REVIEW VI.

Clinique Médicale de l'Hôtel-Dieu de Paris. Par M. TROUSSEAU, Professeur de Clinique Médicale de la Faculté de Médecine de Paris, &c. Tome II.-Paris, 1863.

Clinical Lectures on Medicine delivered at the Hôtel-Dieu, Paris. By A. TROUSSEAU. Vol. II.

AMONG the multitude of medical publications issued of late years there are but few which are devoted to the details of clinical medicine. The task is, indeed, one of the most difficult that a medical author can undertake-a long familiarity with disease, an extended acquaintance with remedies and their application, and a readiness to accept and put to the test new views and proposals, all these are essentials to a successful bedside teacher, and with them must be combined in a high degree the faculties of observation and close comparison.

M. Trousseau has repeatedly indicated his possession of these acquirements, and we would welcome as a valuable addition to professional literature this second volume of his Clinique Médicale.'

Like its predecessor, noted in the pages of this Review for April, 1862, this book is devoted to the close consideration of distinct diseases, each one in a separate chapter. Throughout there exists a special charm for the practitioner, of medicine; the work is essentially practical; we meet with no elaborate straining to reduce diseases to one system or another, no deep inquiry into the dim arcana of an eclectic pathology, but a simple statement is afforded to the reader of morbid processes as they have appeared to a thoroughly competent observer, with a clear enunciation of the best mode of dealing with each separate affection.

The volume includes forty chapters. We propose to direct attention to some which have, either from their subject-matter or from the treatment suggested, an especial claim.

Chap. XXXIX., and the first in this treatise, is devoted to the consideration of epilepsy. Occurring in the first instance not infrequently only during sleep, the attacks may for years even pass unnoticed. A symptom of their presence not very commonly recognised is thus referred to:

"If you examine attentively an epileptic after his attack-better still on the following day-you will find very frequently on his forehead, on his neck, on his chest, little red spots resembling flea-bites, not disappearing under the pressure of the finger, and presenting all the characters of ecchymotic stains. The existence of these ecchymotic stains is a certain sign of an attack of epilepsy." (pp. 9, 10.)

Fear, so frequently stated by the relatives or by patients themselves to have been the immediate cause of the seizures, is so employed, in the author's opinion, merely to give an apparent external cause to a morbid condition far more often dependent on hereditary or other taint.

Epileptic vertigo may show itself in endless forms. Usually preceding, it is found occasionally to succeed on the severe convulsive type. This condition has been said to be the most frequent precursor of mental alienation-it would be more correct to speak of the sequence as more rapid rather than as being absolutely more certain. As a curative agent it is best to employ belladonna, given for some time, and in doses steadily increased. Metallic remedies-the salts of silver, zinc, &c.-have their value, and may be used either conjoined with atropine or alone.

The proposal to perform tracheotomy, which originated with the late Dr. Marshall Hall, is named only to be strongly reprehended.

The next chapter takes cognizance of epileptiform neuralgia, seated, as a rule, in the branches of the trifacial nerve, and rising at times to the most intense agony. By our own writers this most painful affection has been usually referred to the nerve-disorders especially due to organic intra-cranial changes. Distinct analogies are stated by M. Trousseau to link it with positive epilepsy. It is thoroughly incurable. Section of the affected nerve has sometimes given relief, transient only too often, while long continued and very large doses of opium have seemed to be most deserving of trial.

Chap. XLI. Apoplectiform cerebral congestion, if not indeed thoroughly a misnomer, is yet a term given to a series of cases truly epileptic in character. They exhibit at their onset nervous or irregular convulsive movements of the limbs, vertigo more or less marked, and very commonly manifest some tendency to delirium. The local epileptic ecchymotic patches will be found on a close inquiry.

The medico-legal relations of epilepsy are then considered. It is not to be assumed that an epileptic is to be held irresponsible for acts of violence, because at times he is from his disease blind to the result of his deeds. To quote the author's own words on this matter:

"Yet if this same epileptic has committed a murder without purpose, without possible motive, without profit for himself or any other person, without premeditation, without passion, in the sight and knowledge of all, consequently under conditions differing from those under which murders are committed, I have the right to affirm before the magistrate that the impulse to the crime has been almost certainly the result of the epileptic seizure.

"I say almost certainly if I have not seen the attack; but if I have seen it, if eye-witnesses have noticed the complete paroxysm or the epileptic vertigo immediately precede the criminal act, I affirm then, in an absolute manner, that the prisoner has been impelled to the crime by a force which he has not been able to resist." (p. 59.)

Chap. XLII. Convulsions occurring in childhood may be primary, showing themselves at the commencement of some exanthem or acute febrile affection, or secondary, appearing at the close. These latter are of much the most serious significance. It must not be supposed that the convulsions are dependent upon the organic changes in the nerve-centres revealed by post-mortem examination; they rather precede, or indeed may be instrumental in the production of, the local congestions, &c., so found to exist.

Hereditary predisposition may induce their appearance, so too, and

this we would note with especial satisfaction, the causal influence is recognised of "all these conditions which tend to weaken the whole economy," insufficient food, loss of blood, diarrhoea, &c.

In the treatment of this class of affections antispasmodics have a real value, such as chloroform, musk, belladonna, &c.; the older and severe plans of treatment have no praise. "I believe very strongly that the less we do, the better in general will be our course of action, and that our treatment ought to be expectant." (p. 99.)

In the convulsions of pregnant and lying-in women, depletion is condemned, and the use of such agents as chloroform, &c., is strongly insisted upon.

XLV. Chorea and its allied affections form the subject-matter of this chapter.

The close connexion existing between this neurosis and rheumatism is strongly pointed out; they are mutually interdependent, sometimes even appear to be convertible, and manifest a common tendency to induce endocardial mischief and deposits in the heart-valves.

The administration of the potassio-tartrate of antimony after the manner recommended by M. Gillette, is referred to as of possible advantage in those severer cases of choreic movement hitherto almost intractable. In some instances the free administration of opium is of material service, bearing in mind always that "when one administers opium, it is less the dose of the drug than the effects which one has to consider." (p. 160.)

Hysterical cough, that bête noire of daily practice, is referred by the author to the anomalous forms of hysterical chorea.

Chap. XLVII. The strange nerve-disorder known by our neighbours as the "maladie de Duchenne," is thus defined: "progressive abolition of the co-ordination of movement and apparent paralysis, contrasting with the healthy condition (integrité) of the muscular force."* (p. 181.)

Cases of this description, until lately grouped en masse with paraplegics, commence by symptoms of disturbance of the nervous system, the first being usually pain of a peculiar, severe, flash-like character, frequently returning upon changes of temperature, and as a rule occupying only circumscribed spaces. Subsequently are noted various paralyses, which may be either transitory or persistent, often indeed disappearing with great rapidity, and so conferring a false reputation on the medical treatment which may have been instituted.

Men are most frequently affected, and about the middle period of life. On first starting, the invalid totters, especially if he have been seated for some little time before attempting to move; then, after steadying himself by some fixed body, he is able to move on. The progression, at first slow and uncertain, becomes more hurried, and the legs are thrown forward hastily and convulsively, yet with all these symptoms, much muscular exertion in walking is quite compatible. As the disease advances the violence and irregularity of the movements increase and weary out the powers of the patient before he has Duchenne, M. De l'Electrisation Localisée, &c. &c. Seconde édition.

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proceeded very far. Later on still, not one step is possible without falling; the unfortunate subject constantly sits or lies, and sloughs over the ischia or trochanters hasten the inevitable termination.

An aid to the diagnosis may be found in directing the patient to stand or attempt to walk with his eyes closed. The small amount of co-ordinating control still possessed is at once lost, and a fall, unless additional support be at once given, is inevitable. The malady may remain stationary for some time; one case is reported where it existed for twenty years; but it is never cured.

The consideration of this disease is again taken up in Chapter LXXIX., the last in the volume. Subsequent inquiries by several other observers are referred to, specially on the question of the anatomical changes found on post-mortem examination. Softening of the posterior columns of the cord and coincident atrophy of the posterior roots of the spinal nerves have usually been met with.

The opposition thus marked out between the results of disease and the teachings of experiment with regard to the functions of the posterior columns is fairly stated. As yet no adequate explanation is available.

Very little can be said on the question of treatment; MM. Charcot and Vulpian have obtained good results from the administration of nitrate of silver, so following the plan of M. Wunderlich, a remedy available on à priori grounds, since it has been proved of material use in other disorders of the nervous system.

Chap. XLVIII. Alcoholism has been by common consent transferred to the domain of physicians who study mental disorders alone. Yet there are in this pathological condition many points of interest for those who practise general medicine.

An especial reference is made to these cases in which, from slow saturation of the system with alcohol, delirium is impending to break out furiously when the individual shall have become the subject of any acute disease. Decisive signs of this character of delirium are as yet wanting.

Chap. L. enters on the consideration of Nocturnal Incontinence of Urine, dependent on an excess of tonicity and irritability about the muscular structure in the walls of the bladder, on this idea most satisfactorily treated by the slow and long-continued administration of belladonna, given for a time in full doses and then slowly diminished.

In those cases of nocturnal and diurnal incontinence due to the opposite condition, atony of the bladder, the preparations of strychnine are of most value.

Progressive Muscular Atrophy occupies the next Chapter, LI., known more familiarly under the name of wasting palsy. It is characterized anatomically by a diminution in size of the muscular fasciculi from which, as the disease gains ground, the transverse striæ are found to disappear, while fatty granules take their place.

The earliest symptom would seem to be that of local muscular weakness, limited at first to some one single member, increased by muscular exertion and under the influence of cold, the difficulty of

movement ending in complete failure of power. Cramps are frequently met with; the muscles affected often become the seats of slight fibrillar contractions, so that they seem to be in continual movement; a sensation of slight shuddering is often complained of in consequence.

According to M. Duchenne, the disease depends not on any defect in nerve-power, but on the physical changes in the muscular structures. Since, however, even in the muscles positively altered in composition, some parts are to be found still possessed of their normal contractility, M. Trousseau leans to the opinion that the peripheral extremities of the nerves undergo some modification by virtue of which they become unable to determine the muscular contraction. Thus, then, the fault in the transmission of nerve-power would precede, and so determine the muscular degeneration.

The muscles first affected are usually those of the upper extremity; and attendant on the affection is well-marked wasting, so that one side, and this usually the right, may be almost deprived of the ordinary muscular prominences, while the other shall have preserved intact its normal outlines. An excess of fat may hide these ravages, but the electro-magnetic current readily decides which muscles are failing in, and which still retain, their functional power.

The rapidity of the course may vary materially, but the disease entails a certainly fatal termination. Examination after death discloses a marked diminution in the size of the anterior roots of the spinal nerves. This must not, however, in the author's opinion, be looked upon as the source of the disease, but rather as an anatomical change, consequent upon the loss of functional power in the muscles-a secondary, therefore, not a primary condition.

Chap. LII. This chapter enters on a question of interest, in these days of scepticism about the propriety of bloodletting, and treats of its value as a remedial measure in cases of cerebral hemorrhage and apoplexy; only, be it understood, to negative the existence of the supposed advantages. The injury is done; no loss of blood will repair it. A softened patch of brain-substance has given way, or some cerebral vessel of greater or less size has poured out blood, the physical and intellectual powers have suffered accordingly; but these are not conditions to be treated by loss of blood, strict confinement to bed, and diminished supply of food. Far greater benefit will be obtained by the administration of food and careful nursing.

"I have the conviction that since I have adopted this expectant plan of therapeutics, my invalids have found themselves much better than those whom formerly I bled, kept on low diet, and confined to bed." (p. 274.)

Chap. LIII. Alternate hemiplegia, the face being paralysed on one side, the limbs on the opposite, is considered by M. Gubler* to indicate lesion of the pons Varolii.

manner.

"The special form of the hemiplegia is explained in the following The lesion affecting the facial nerve in a point where it has accom* De l'Hémiplegie Alterne: Gazette Hebdom. Paris, 1856 and 1859. 65-XXXIII.

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