cal student. There is another class of persons to whom we would recommend it-those out of the pale of the profession, who impru dently consult medical books, impelled either by an apprehension of the disease, or by being already afflicted with it; and for this reason, that in the work of Dr. Garrod they will find the malady so well described in all its afflicting issues and its causes, whether predisposing or exciting, so well pointed out, that they will be fully indoctrinated in the formidable nature of the malady, and disposed to receive, not the congratulations, as of old was the fashion, but rather the condolence of friends on experiencing a fit of it; and further, whilst they will be put on their guard as to the bad habits and excesses on which the gouty habit so much depends, they will be enabled to see the folly of having recourse either to empirical medicines or to the empiric, or to becoming, except in the safe way of prevention, their own physician.

Before concluding, we will give two extracts from the work, which may be useful to those of our readers who may not possess or have an opportunity of consulting it:

Summary of Treatment.-"The management required in an ordinary attack of acute gout may be thus shortly summed up:

The diet should be very light, and chiefly amylaceous, diluents freely used, but no alcoholic stimulants allowed, unless in exceptional cases.

"The medical treatment should consist in the administration of some simple alkaline saline, combined with a moderate dose of colchicum. If necessary, purgatives may be given, selected according to the habit and condition of the patient. In the majority of cases, this will be found to be all that is necessary, but in some instances certain modifications may be essential; for example, if there be plethora, the question of the abstraction of a few ounces of blood may possibly arise; on the other hand, if the vital powers are at a low ebb, and great vascular and nervous depression exists, it may be desirable to give aminonia in addition to other salines; at the same time the colchicum should be either omitted or used with the greatest caution.

"The only local application required in the majority of cases is cotton-wool, covered lightly with oiled silk; but now and then an anodyne may be advantageously used, and a small blister is occasionally of service." (p. 364.)

Diagnosis of Gout and Rheumatism." Gout cannot easily be mistaken for acute rheumatism when each malady is exhibited in its typical form. The subjects in which the diseases usually occur differ considerably, the first being most common in men after middle age, and in those who have lived freely; the second is at least as frequent in females, usually in the young and those of enfeebled powers. The characters of the diseases are also dissimilar. Gout, in its early seizures, ordinarily affects but one or two joints, and commonly the ball of the great toe, and the inflammation is accompanied with comparatively little fever, but with much local pain, cedema, and subsequent desquamation of the cuticle; the attacks are for the most part periodic, and gradually implicate a larger number of the joints. Rheumatism, on the contrary, generally affects many and large joints, even at first, and the upper extremities equally with the lower; the fever is likewise out of proportion to the local inflammation; and although the disease is apt to return upon re-exposure to its exciting causes, still no periodicity can be traced in its visitations. Gout may be further separated from rheumatism by the study of hereditary influence of the predisposing and exciting causes of the two diseases, as likewise of the great tendency to acute cardiac affection in the latter. Notwithstanding the great apparent facility in the diagnosis of typical cases, there are others very difficult to separate;

some such we have given in our description of acute gout, and these require different methods of analysis, involving a knowledge of their more intimate pathology.

"In gout we have proved beyond question that the blood is invariably impregnated with uric acid, and we are in a position equally to prove that in genuine acute rheumatism this principle is absent. In an examination of forty cases of the latter disease, exhibiting all its typical peculiarities, the salient points of which will be found in the Appendix, no trace was discovered by the process before detailed.

Furthermore, we have demonstrated that true gouty inflammation is always accompanied with the deposition of urate of soda in the structures primarily inflamed; and from the examination of the joints of numerous subjects who had suffered during life from acute rheumatism, I can testify that no such alteration ever ensues.

"In the chronic stage of the diseases, the separation of gout and rheumatism by the ordinary symptoms which present themselves, becomes in some instances a difficult task even to those who have given special attention to the subject. The forms most apt to be mistaken are chronic gout affecting both the large and small joints, and unaccompanied with any external deposits or chalk-stones, and certain forms of acute rheumatism, where the same structures are implicated. The external phenomena are then almost the same, probably but little febrile disturbance is present, the joints are but slightly swollen,

and there is no redness of surface.

"A careful investigation of the history of the cases will do much if the disease originally commenced in the great toe, and gradually became more extended in after attacks; if it began about the middle age, or bordering upon this, and the patient had lived freely, indulging in wine or malt liquors, then it is in all probability a case of gout. In many subjects the examination of the external ear will throw considerable light, and I have often been able to arrive quickly at a correct diagnosis by finding the presence of a spot or two upon the helix. . Instances occasionally occur in which the history, from peculiar circumstances, is of little value or cannot be procured, and where there are no external signs on which the diagnosis can be founded; these are rare, but any one frequently consulted on such subjects must have now and then felt a difficulty. In some of these cases I have derived much assistance from the examination of the blood or blister fluid; and a careful attention of the effects of drugs has often afforded much additional aid, as the inflammation of gout is relieved by the administration of colchicum in an infinitely more decided manner than that dependent on rheumatism." (p. 524.)

Not the least valuable portions of Dr. Garrod's work are its concluding chapters those on rheumatic gout and rheumatoïd arthritis, especially the last, in which, as the name implies, there is a similarity of symptoms and dissimilarity of nature-an essential difference, and requiring necessarily a different mode of treatment. As the skill of the navigator is best displayed amidst hidden rocks and shoals, so is that of the physician in diseases such as those just mentioned, the obvious phenomena of which are not to be trusted to these can be successfully diagnosed and treated only by means of such aids as advanced medical science affords, and which are described with much clearness aud precision in our author's pages.

* In Dr. John Davy's 'Physiological Researches,' of which a review was given in our last number, an instance is mentioned (note, p. 372), of urate of ammonia having been found in the blood of a man labouring under acute rheumatism.

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 anthor 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. Paris, 1861..