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Lectures on ancient ethnography and geography, comprising Greece and her colonies online

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LECTURES ON



CLINICAL MEDICINE,



DELIVERED AT THE HOTELDIEU, PARIS.



A. TROUSSEAU,



Late Professor of Clinical Medicine in the Faculty of MeUietue, Paris ; Physician to the Hdlel-Dien ;

Member of the Imperial Academy of Medicine ; Commander of the Legion of Uonour ;

Grand Officer of the Order of the Lion and the Sun of Persia; Ex-represenlAlive

of the People in the National Assembly ; jrc. ire. /■<:.



VOLUME FOURTH.
TRANSLATED FROM THE EDITION OP 1868.

Being the 't%ird Revised and Enlarged Edition ;



JOHN B08E COBMACK, M.D. Emk., M.D. Paeis,
F.B.S.E.,

Pfil^w of M« R0j/al Collt^ of Ph^tieiaiu of Bdimburghj formn-ly Lecturer on Porenue MtdkiM in tk« Mtdieml

School of BimbHrgh^ and formerly Pkyneian to th* Royal Infirmary and Pewr HotpitnU of BdMmrfA{

Correipondinf Memdtr oftko Acmdrmy of 8urg«ry of Modridy /fe. ife.



PHILADELPHIA:
LINDSAY AND BLAKISTON.

HOCCCLXXI.



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PBINTBD BY
J. E. ADIABD. BAKTFfOI^OMKW CL08K.

BOSTON MEDICAL LIBRARY

IN THE

FRANCIS A. COUNTWAY

LBRARY OF MEDICINE



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CONTENTS.



LECTUEE LXVIII.

DYSPEPSIA.

Djspepsit 18 not 80 mnoh a Di8ea8e as a Phenomenon common to manj Dis-
eases. — ^In the cases in which, from its predominance, it seems to consti-
tnte a Morbid Species, it is subordinate to nnmerons different conditions.
— General Considerations upon Aptitudes of the Organism, and Manner in
which particular Organs accommodate themselves to the Stimulants which
act upon them. — ^Application of this fact to the question of Dyspepsia. —
Dyspepsia, the consequence of Increased Excitation of the Gastrio Secre-
tions and Muscular Movements of the Stomach. — Reflections upon that
Neurosis, which I have called ** exhaustion of indtability '' [^puisement de
rindtabilit^]. — Asthenia consecntire upon very prolonged excitation. —
Dyspepsia the result of Sympathy with diseases of the Uyer, stomach, in-
testines, and other organs .... i — 15

Forms of Dyspepsia. — ^Dyspepsia associated with Chronic Gastritis. — ^Boulimic
I>y8pepsia.-~Ilatulent Dyspepsia.— Acid Dyspepsia. — General Disturbance
of the System caused by I^spepsia, such as Anaesthesia, partial Analgesia,
Neuralgia, and Disturbance of the Intellectual Faculties. — ^Disturbance of
the Ciiculation.-^Annmia .... 16 — 34

Treatment of Dyspepsia. — ^The most important part of the Treatment is the
Begimen. — ^The best Regimen is that which the patient has learned by ex-
perience agrees best with him. — ^The Specific Character of the Phlegmasia
must be taken into account. — Connection of Dyspepsia with the Herpetic
Diathesis.— Remedies which produce a Local Modification of the Gastric
Inflammation, such as Emetics, Purgatives, Mercurials, Subnitrate of Bis-
muth, Precipitated Chalk, Alcalies, Lactic Acid, and Hydrochloric Add. —
In Bulimic Dyspepsia, are given Opium and Belladonna in small doses.
Zinc, and Antispasmodics.— In Add Dyspepsia, both Acids and Alcalies
available, as they do not act as Chemii»l Remedies : Narcotics, Mineral



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VI CONTENTS.

Waters. — In Flatulent Dyspepsia, use of Alcalies : Bitters, Quassia, &c. :
Tonics, Cinchona, &c. : Aromatics : Mineral Waters, containing Chlorides
of Soda : Hydrotherapy : Sea-bathing. — ^In Dyspepsia connected with Dis*
eased Liver, use of Alcalies, Alcaline Mineral Waters : sometimes. Acids. —
Acids particularly indicated in Dyspepsia associated with a Chronic Morbid
Diathesis, particularly in fully declared Phthisis. — ^In Dyspepsia connected
with Marsh Cachexia, Alcaline Mineral Waters, and other weak Mineral
Waters are of great use.— Dyspepsia connected with Affections of the
Uterus is beneficially treated by the Local Treatment suitable to such
affections, and also by General Treatment, particularly by Sea-bathing and
Hydrotherapy. — ^Li Dyspepsia resulting from Habitual Constipation, ad-
vantage derived from Belladonna, certain Purgatives, Mineral Waters con-
taining Sulphate of Magnesia and other Sulphates. — In certain severe
cases of Dyspepsia, the Inhalation of Oxygen Gas is resorted to 34—56



LECTURE LXIX.

CHRONIC GASTBITIS.

Existence of Chronic Gastritis improperly denied in the present day. — ^Pituitous
Vomiting attributable to it .... 57 — 63



LECTURE LXX.

SIMPLE CHRDNIC ULCER OF THE STOMACH.

Gastralgia with Stitch in the Ensiform and Rachidian Regions is not exclusively
a Symptom of Simple Ulcer of the Stomach. — ^It may be absent in this
affection, and it may also be met with in Diseases of the Stomach of very
different Characters. — ^The same is true in respect of HsBmorrhage from the
Stomach and Intestines independent of Organic Change (in supplementary
Hsematemesis, for example), and in Chronic Gastritis. — Hsemorrhage, a
character common to Simple and Cancerous Ulceration, may be absent. —
In Cauoer, Hemorrhage is sometimes as profuse as in Simple Ulceration,
although generally the Hnmatemesis of Cancer is less than the Hsema-
temesis of Simple Ulceration.— The positive Diagnosis of Simple Ulcera-
tion ia enveloped in much obscurity. — ^Treatment . . 64—93



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CONTENTS. Vll

LECTUEE LXXI.

DIARRHCEA.

Classification according to Proximate Cansee, that is to say, according to the
Mechanism by which the Diarrhoea is produced . — Catarrhal Diarrhoea .
this may be a Specific Affection. — Sudoral Diarrhoea [Diarrh6e Sudorale]]
— Nenroos Diarrhoea. — Catarrhal Diarrhoea^ in which the Affection is con-
secutive npon increased Secretion from the Digestive Canal or its Append-
ages. — ^Diarrhoea, resulting from Increased Tonicity. — ^Diarrhoea resulting
from Indigestion. — Diarrhoea associated with (^ganio Disease. — ^This
Classification is Artificial: the different kinds are blended with one
another ...... 94 — 118

CHRONIC DIARRHCEA.
Diarrhcea complicated with Fever and Nocturnal Sweats is almost always asso-
ciated with Tubercle. — Chronic Syphilitic Diarrhoea* — Herpetic Diarrhoea.
— Chronic piarrhoea depending upon Simile Chronic Catarrh of the Intes.
tines. — Chronic Diarrhoea, the result of Insufficiency of Food. — ^Treatment
varie according to the Cause. — The Use of Raw Meat . 119— 130



LECTUBE LXXn.

INFANTILE CHOLERA :— DIARRHCEA OF CHILDREN.

Infsntfle Cholera is different from Asiatic Cholera-Morbus. — Conditions under
which it is developed : influence of Season. — Particukrly occurs at the
period of Weaning. — Symptoms. — Prognosis. — ^Treatment. — ^Diarrhoea of
Weaning Infants treated by Raw Meat . . . 131 — 145

LECTUBE LXXm.

LACTATION, FIRST DENTITION, AND THE WEANING OF
INFANTS.

ItAxmnoa : natural, artificial and mixed.— Lactation in respect of the Woman.
— Conditions essential to a Good Nurse. — Infiuenoe on the Lacteal Secre-
tion of Menstruation, Conjugal Relations, Preguancy, and Intercurrent
Diseases. — Lactation in relation to the Nursling. — ^Weighing the Infant is
the only means of ascertaining whether it is sufficiently suckled. — ^First
Dentitiov : — Mode of Evolution of the Teeth in Groups. — Order of Suc-
cession in which thoy appear. — Casualties of Dentition. — ^Febrile Discom-
fort.— Convulsions.— Diarrhoea.— Wbaninq . 146 — 164



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Vm CONTENTS.

LECTUEE LXXIV.

DYSENTERY.

Most formidable of all Epidemic Diseases. — ^Its Causes unknown. — ^Eating
Fruit blamed without reason. — Opinion of the ancients on this point —
Different Forms of the Disease.— Character of the Stools : Tenesmus. —
Bilious, Inflammatory, Bheunuitic, Putrid, and Malignant Forms of Dysen-
tery. — Anatomical Lesions. — ^Treatment : Evacuant the most useful : Em-
ployment of Saline Purgatives, Calomel, Emetics, Topical Remedies, and
Caustic Injections. — ^Dangers of Opium. — Sequels of Dysentery, tiz.
Dropsy, Paralysis, and Abscess of the Li?er.— Intractable Diarrhcoa. —
Intestinal Perforation .... 165—183

LECTUEE LXXV.

CONSTIPATION.

Constipation is not necessarily a state of impaired health. — Cases. Treat-
ment : Influence of Will and Habit : Cold Lavements : Suppositories of
cacao-nut butter, soap, and hardened honey: Mucilaginous Lavements:
Belladonna, with or without small doses of Castor-Oil. — ^In Obstinate Con-
stipation have recourse to Drastic Purgatives. — Hygienical Measures:
Eqg;imen, Bran-bread «... 184 — 194

LECTUEE LXXVI.

FISSURE OP THE ANUS.

Treatment by Rhatany. — Constriction of the Sphincter of the Anus is the
Effect and not the Cause of Fissure. — ^Fissure is very common in Women
Recently Delivered: why it is so. — ^The Curative Effect of Rhatany
depends on its modifying the character of the ulcerated surfaces, and
tonifying the parts. — ^Its action ought to be promoted by Belladonna,
which is a remedy for constipation. — When Rhatany fails, recourse must
be had to a Surgical Operation ; tliat which seems the best is Forcible
Dilatation ..... 195—204



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CONTENTS. IX

LECTUEE LXXVII.
INTESTINAL OCCLUSIONS.

1\Max Canaes. — ^Their Mechanism.— Their extreme Gravity.— Treatment bj
medical men. — Qastrotomy may be reaorted to in serioiu oasea 305—225

LECTUEE LXXVm.

HEPATIC COLIC: BILIAEY CALCULUS.

More common in Women than in Men. — ^Rardy oconra in Children. — Compoai-
tion. Form, and Yolome of the Calculi.— Biliary Grarel. — Canse of the
disease is not known. — Sometimes hereditary. — ^May be coincident with
Urinary Gravel, and be a manifestation of the Gouty Diathesis. — Hepatic
CoHc — ^Diagnosis often very difiKcult. — ^May be mistaken for Gastralgia,
Colalgia, and Heptalgia. — ^Pain and Jaundice are not essentially pathogno-
mcmic signs ; and may be absent.— They may be the symptoms of other
affections, as of hepatitis, heptalgia, or of the hepatic colic caused by
ascarides or hydatids. — ^Presence of calculi in the stools is the only positiTe
diagnostic sign. — Symptomatic affectiona caused by the calculi: Acute
Hepatitis : Betention of bile m the liver, in the gall-bladder : Dropsy of
the Gall-Bladder : Rupture of Gall-Bladder and its excretory ducts. —
Biliary Fistulc.— Paraplegia, reflex and consecutive.— Treatment of
Calculous Disease of the Liver . . 226 — 262

LECTUEE LXXIX.

HYDATIC CYSTS OP THE LIVER.

Case occurring in a child six years of age. — ^Two cases in which Hydatid Cysts
opened into the Thoracic Cavity.— Hydatids : their mode of development.
— ^Hydatida of the Liver. — Symptoms. — At first, nothing characteristic,
except sometimes the appearance of a Tumour in the region of the Liver.
— General symptoms : Disturbance of the Digestive Functions : tendency
to Hemorrhages and Ghingrene. — ^Functional Disturbance of Neighbouring
Organs. — ^Hepatitis. — ^Purulent Infection.— Spontaneous Opening of Cysts
into different passages; through the abdominal walls; into the blood-
vessels ; into the biliary ducts ; into the digestive canal ; into the pleural
cavity ; and into the bronchial tubes. TKB ATMENT :— Simple Puncture
with tiie Exploratory Trocar. — ^Puncture with the Permanent Canula. —
Brim's Method of Successive Incisions. — ^R^camier's Method of opening
bj Caustics. — Opening the Cyst by the Trocar, after establishing adhesions
by Acupuncture^^Iodised Injections . 263—296



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CONTKNT8.



LECTUBELXXX.

MALIGNANT JAUNDICB,

Malignant Janndioe [Ictke Gra^e] is a general disease— iotioa subatantia —
analogous to Typhoid Fever, and the BiHoas Fever of Tropical Climates.
— ^Retention of Bile in the biliary ducts does not constitute Malignant
Jaundice.~l?yphoid Symptoms at the beginning of the attack.— lellow
colour, and Ghreen odour of Skin and Oonjunctifn. — ^Hemorrhages from
the mucous membranes : Epistaxis, Gastrorrhagia, Melosna. — ^Hemorrhages
from the l^dn: Eoohymosis, Purpura.— Decrease in sise of Liver not
constant. — Secondary Nervous Symptoms. - «Death the most common
termination. — ^Morbid Anatomy: Change in Structure of Liver not
constant. — ^Primary Alteration of Blood.^-Notice of the Fatal Janndioe of
Infants.— Mal^nant Jaundice is not Yellow Fever . . 397—323



LECTUEE liXXXI.
SYPHILIS US INFANTS.

Stphilib or fHX Fomrs: — ^Abortion: Pempfa^;us: Suppuration of the Thymus
GUnd and Lungs.

Syphilis in thb Iotakt:— Pox rarely shows itself before the second week,
or after the eighth mootL — Slow Form: Subacute Form: Symptoms:
Corysa : Fissures : Ulcerations and Mucous Crusts at the mouth, anus,
and folds of the skin : Cutaneous Eruptions, Roseola, &c.^Peculiar Tint
of the Face: Characteristic Physiognomy of the Syphilitio Infant. —
Cachexia. — Visceral Lesions. — ^Pathogenic Conditions of Syphilis in the
Hecently Bom Infant.

Hebxditaet Stphiub:— Transmission by the Mother : by the Father.

AcQUiBED Syphilis :— Syphilis may be transmitted to Nurse by Syphilitio
Nursling. — ^Has the Norse been infected in coiiu, or by her Nursling P —
Transmission of Syphilis bj Vaccination.— Transmission of Syphilis from
the Foetus to the Mother. — ^Treatment of Congenital Syphilis . 334 — 353



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CONTjBNTS. XI

LECTUEE LXXXII.

GOUT.

Prellmioarj Gonsideratioiis. — ^The word ''Goaf is much to be preferred to
any of the other names which hare been proposed in pkce of it. — Gont,
acute and reg;uUr. — ^Premonitory phenomena. — ^Dbtnrbanee of Digestion :
Disturbance of the .Nenrous System : Disturbance of the Urinary Organs.
— Gatarrfaa], Urethral, and Ocular Affections. — ^Arthritis, its progress and
appearances. — ^Acate Gout in the form of short Paroxysms which either
sneceed to, or ran into one another. — The paroxism may snperfene under
the influence of an immediate appreciable cause . 354 — 368

Regular Chronic Gout. — Consecutive Deformities of Joints.-^Tophus, a mani-
festation only met with in Gk)ut. — The Visceral Complications are very
different from those which constitute Anomalous Gout and Paludal
Gout . . ... 369 — ^376

Larraceous Gout. — Comparison of it with Palustral Lanraceous Fevers. —
Megrim: Asthma: Neuralgia in various forms: Gravel: Hemorrhoids:
Cutaneous Affections : Anomalous or Visceral Gout. — Bright* s Disease. —
Pulmonary Catarrh. — Suppressed Gout . • . 376 — ^386

fiuallel between Gout and Rheumatism.— Articuhir Rheumatism: Chronic
Rheumatism: Nodular Rheumatism. — Nature of Gont . 386—396

TREATMENT OF GOUT .... 396-407

LECTUEE LXXXm.

NODULAR RHEUMATISM, ERRONEOUSLY CALLED RHEUMATIC

GOUT.

The disease is very rare in men : it is more common in women.— -Generally
chronic, supervening all at once. — Sometimes subacute at the commence-
ment. — It is a manifestation of the rheumatic diathesis. — Pains and Mus-
cular Retractions.— The Heart is seldom affected. — Rheumatic Complica-
tions, however, have been observed in the heart, pleurs, lungs, brain, and
kidneys. — ^Essentially a chronic disease in respect of its duration. —
Successful Treatment by different medicines. — Tincture of Iodine, given
internally, ought to be preferred . 408—431



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Xll CONTENTS.



LECTURE LXXXIV.

ACUTE ARTICULAR RHEUMATISM AND ULCERATING
ENDOCARDITIS.

Very great frequency of Acute Articular Rheamatism. — A Diathesic Disease.
— ^Peculiarly an affection of the Fibro-Serous Tissue. — ^Rheumatism of the
Large and Small Joints. — ^Primary or Secondary Rheumatism. — ^Rheu-
matism of the Heart, the origin of organic diseases of the organ. —
Rheumatism of the Pleurs, Lungs, and Membranes of the Brain and
Spinal Marrow. — ^Rheumatic Metastases. — No Specific Treatment for
Acute Articular Rheumatism. — ^Rheumatic Ulcerative Endocarditis. —
Ulcerative Endocarditis Independent of the Rheumatic Diathesis. —
Atheromatous Endocarditis. — ^Visceral Emphraxis. — Capillary Embolism
^Alteration of the Blood consequent upon Ulcerative Endocarditis. —
Typhoid Symptoms ..... 432—470



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LECTUEE LXVm.

DYSPEPSIA.

Dyspepsia is not so much a Disease as a Phenomenon common to many
Diseases. — In the cases in which^from its predomitiance, it seems
to constitute a Morbid Species, it is subordinate to numerous
different conditions. — General Considerations upon Aptitudes
of the Organism, and Manner in which particular Organs
accommodate themselves to the Stimulants which act upon them. —
Application of this fact to the question of Dyspepsia. — Dyspepsia,
the consequence of Increased Excitation of the Gastric Secretions
and Muscular Movements of the Stomach. — Reflections upon that
Neurosis, which I have called^' exhaustion of incitabilitif^ [Spuise-
ment de VincitabilitS^. — Asthenia consecutive upon very pro-
longed excitation. — Dyspepsia the result of Sympathy with
diseases of the liver, stomach, intestines, and other organs.

Gentlemen : — ^We nearly always have some dyspeptic patients in
the clinical wards. You sometimes see me prescribe alcalies^ and at
other times acids^ to relieve the symptoms from which these persons
are suffering. There are also cases in which I order preparations of
cinchona, quassia, or strychnine; and there are others, in which I
order opixun, belladonna, and antispasmodics. In fact, I vary my
treatment in an infinity of ways.

The reason of my thus actmg, as if I had no fixed rules to guide
me, really arises from there being nothing determinate in dyspepsia
itself. In it, more than in any other morbid condition, the physi-
cian, free to act on the suggestions of the moment as they arise, is
forced to feel his way as he proceeds, inquiring into the indications,
which vary with the case, with the person, and which may also
differ in the same person at different times. There is nothing sur-
prising in this, when it is remembered that difficulty' of digestion

1



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2 DYSPEPSIA.

— for that is the etymological meaning of the word dyspepsia, derived
from the Greek word Sucnrc^m — is a symptom common to a host of
acute and chronic diseases; and that it is subordinate to morbid
conditions differing very much from one another, even when it is so
predominant a feature as to seem to be entitled to be regarded as a
pathological species.

I take up this subject to-day, without the least intention of
attempting to give you a complete account of dyspepsia. I only
propose to enter into some general considerations, to lay before you
some of the cases which I have seen, and to formulate some of the
indications which most frequently present themselves at the bedside.
I shall not shrink from going into details, which, in a subject so
vast and so obscure, appear to me to be of greater practical utility
than a dogmatic description however elaborate.

A short preliminary excursion into the domain of normal physi-
ology is requisite, to enable you to understand the facts which I
shall have to lay before you.

There are three things which have to be considered in the per-
formance of every function, as has been said by Professor Beamier,
one of my most illustrious predecessors in this chair; viz. the
stimulus, the support of the stimulus, and that which he called
reciprocal capacity [capacite reciproque\ This last expression is
not, perhaps, very clear; and I shall, therefore, substitute for it
functional relation [relation /onctionelle"], which is more intelligible.
By *' support of the stimulus,'' E^camier understood the organ in
its totality with its anatomical and physiological accessories, the
functional apparatus which ought to be in communication with its
physiological excitant, its stimulus, the excitant of the stomach
which is all that brings the support into operation. Aliment is
the stimulus, the excitant of the stomach which is the support of
the stimulus : and light is the normal excitant of the eye. The
'* reciprocal capacity,'' which I propose to call the '' functional
relation," is the mutual bearing on each other of the support of the
stimulus and of the stimulus itself; and it is from this mutual bear-
ing that there results the normal performance of the function.

Having made good this position, let us endeavour to study the
different modifications which may take place in the support, and in
the stimulus : let us see what are the results and modifications in
relation to the function.

Suppose^ for a moment, that the support of the stimulus is normal,



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DYSPEPSIA. 8

and the organ healthy; and suppose^ at the same time^ that the
stimulus is abnormal^ it is evident that there will be disturbance of
the function. Take the eye, for example, and apply to it light
differing in quality and in quantity from that which it habitually
supports, and you will produce functional disturbance of vision. Or,
make your experiment on the stomach — give it aliment of abnormal
quantity or quality — and you will induce a perturbation of its
functions.

Suppose, on the contrary, that there is an abnormal disposition of
the normal stimulant, and also of the support of the stimulant. In
the case of the eye, suppose the light, sufficient in quantity and
normal in quality, acting upon the morbid organ in one or another
mode : in the case of the stomach, suppose food to be given normal
in quantity and quality, but that the organ from some cause or
another is not in a proper state to receive it, and the functional rela-



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