m
 
 THE PHENOMENA

 
 Pig 1
 
 THEjPHENOMENA 
 
 SPINAL IRRITATION 
 
 Q'mmts of % $fcrtoras I&gsiem, 
 
 EXPLAINED, 
 
 A RATIONAL PLAN OF TEEATMENT DEDUCED. 
 
 \ BY 
 
 \k 
 
 THOMAS INMAN, M.D. LOND. 
 
 LECTURER ON THE PRINCIPLES AND PRACTICE OF MEDICINE AT THE 
 LIVERPOOL ROYAL INFIRMARY SCHOOL OF MEDICINE; 
 
 PHYSICIAN TO THE NORTHERN HOSPITAL; 
 
 PRESIDENT Or THE LIVERPOOL LITERARY AND PHILOSOPHICAL 
 SOCIETY. 
 
 LONDON: 
 JOHN CHURCHILL, NEW BURLINGTON STREET. 
 
 MDCCCLVIII.
 
 LONDON : 
 
 frAVILL AND EDWARDS, PRINTERS, CHAXDGs SIBEKI, 
 COVEXI GiEDEX.
 
 TO 
 PROFESSOR GEORGE BUDD, M.D., 
 
 A LECTURER WHO 
 PRE-EMINENTLY TEACHES STUDENTS TO THINK FOR THEMSELVES; 
 
 AND TO 
 
 DR. R. B. TODD, 
 
 WHOSE PERSISTENT KINDNESS TO HIS CLASS 
 
 WAS ONLY EQUALLED BY THE PROFOUNDNESS OF HIS KNOWLEDGE 
 AND THE STRENGTH OF HIS JUDGMENT, 
 
 THIS ESSAY 
 
 s jes 
 
 BY THEIR LATE PUPIL, 
 
 THE AUTHOR.
 
 PKEFACE. 
 
 THE subject of Spinal Affections in general is one 
 which, for many years, has been of surpassing in- 
 terest both to the Medical Profession and the 
 public. 
 
 At one period it was supposed that tenderness 
 of any portion of the spinal column indicated in- 
 cipient disease in the bones, in the cord, or its mem- 
 branes; and thirty years have barely elapsed since 
 these presumed spinal complaints were so common, 
 that a young lady was considered fortunate if she 
 escaped without an attack. The patient was com- 
 monly laid up in bed or on a sofa ; leeches, or cup- 
 ping-glasses, or blisters, or issues, or moxas, or 
 setons were applied near the seat of pain ; and the 
 progress of the patient towards convalescence was 
 measured by the effect of pressure used on the spine 
 from time to time. In the progress of the case it 
 was not uncommon to find new symptoms arise of 
 s the most alarming nature, and of the most wonder- 
 ful class frightful pain would alternate with, or 
 
 accompany, terrific spasms ; and as the tender spot 
 
 62 
 
 ^3173
 
 PREFACE. 
 
 in the spine was still present, and as the effect of 
 pressure upon it became more startling inTtS ef- 
 fects, it was a natural conclusion to draw, that the 
 disease was becoming graver, more difficult to 
 cure, and more inscrutable in its nature. By-and- 
 bye, weary of unsuccessful efforts at home, the 
 patient would go elsewhere to seek relief; and, 
 throwing physic to the dogs, would try and regain 
 the health which had been shattered by so many 
 onslaughts of pain, spasm, bleeding, blistering, and 
 the like. As the influence of change of air and 
 scene was felt by the constitution, the symptoms 
 began to give way; and as roses returned to the 
 cheeks, misery left the back. A little tenderness 
 on pressure might yet remain, but the electrical 
 results that used to attend manipulation had 
 ceased. 
 
 A great step was considered to have been made 
 in our knowledge of spinal disorders when a dis- 
 tinction could readily be drawn between organic 
 and functional diseases. 
 
 . But with this era a new theory set in respecting 
 the latter. 
 
 This was marked at first by the words " spinal 
 irritation " being employed, instead of " spinal 
 disease " or inflammation. By-and-bye, however, 
 it was apparent that the symptoms of so-called 
 spinal irritation occasionally presented themselves 
 without spinal tenderness, and that there were 
 other cases in which spinal tenderness existed
 
 PREFACE. ix 
 
 without any special symptoms. The next con- 
 clusion drawn was, that the symptoms were due 
 to " hysteria "- the Medical Refuge for the Desti- 
 tute and that " spinal tenderness " was nothing 
 more than one of the forms assumed by that Pro- 
 teus. Having been educated in that belief, I was 
 content with the theory for a number of years, 
 although there were many points that seemed 
 vague and uncertain. 
 
 But when I had to lecture upon hysteria, and 
 explain it to others, I found that there were a 
 number of refractory symptoms of which I could 
 give no reasonable account. With the difficulty 
 surrounding the subject of diseases of the nervous 
 system, my interest in them increased, and they 
 formed a special object of reading, thought, and 
 clinical observation. During the winter of 1856, and 
 when lecturing on the subject, some very remark- 
 able cases, supposed to be hysterical, came under 
 my notice, in which the sufferings of the patients 
 had been violent, at times indescribably intense, 
 and extending over a great number of years. The 
 symptoms were both neuralgic and spasmodic, and 
 the spine was tender. Not paying much attention 
 to the latter, I closely investigated the former, and 
 was enabled to convince myself that the severe 
 pain complained of had a common origin with 
 the spasms, and that the symptoms were all refer- 
 rible to the muscular system. The idea once 
 started was followed up with extreme interest ; and
 
 X PREFACE. 
 
 it was not long before I had furnished myself with 
 convincing proofs that I had struck a mine of the 
 greatest value, and case after case came before my 
 notice in which symptoms once anomalous were 
 now clear as daylight. Anxious to impart to my 
 medical brethren the knowledge I had gained, I 
 read a paper to the Liverpool Medical Society, en- 
 titled " Certain painful Muscular Affections simu- 
 lating Inflammatory, Neuralgic, or Organic Dis- 
 ease." This was subsequently printed for private 
 circulation. Some of the friends to whom I sent 
 it remarked that symptoms similar to those I had 
 described were to be found recorded in works on 
 spinal irritation ; and that, had I examined the pa- 
 tients with special reference to that, I should have 
 found that spinal tenderness existed, and in that I 
 ought to have recognised the explanation of the 
 sufferings. Others "had calculated upon finding 
 some notices of a class of distressing and often 
 alarming diseases traceable to spinal disorders." 
 In consequence of these friendly criticisms, I de- 
 termined to re-peruse the volumes on spinal irri- 
 tation to which I had been referred. 
 
 Aided by an experience in " muscular pains," 
 already vastly extended by the kindness of my 
 colleagues at the school, the hospital, and else- 
 where, I was enabled to recognise in the so-called 
 spinal disorders the same classes of symptoms with 
 which I was already familiar. 
 
 I could readily recognise the cause of the ten-
 
 PREFACE. XI 
 
 derness; I could see in the aggravation of the 
 symptoms the result of a false plan of treatment ; 
 I could deduce the broad principle of cure. But 
 as the inventor of a new theory is very apt to seize 
 points of resemblance too hastily, I was determined 
 to keep the matter in abeyance until I could ex- 
 plain to my own satisfaction the connexion of 
 spinal tenderness and spinal disorders with hys- 
 teria, could fairly lay down a principle of treat- 
 ment equally applicable to all and consonant with 
 the present state of our knowledge, and could also 
 show, on the same principles, why the older plan of 
 treatment was so often unfortunate. 
 
 Whether I have been successful in my efforts 
 time will show. I can scarcely expect to convince 
 those who have long looked upon the nervous sys- 
 tem as the chief source of pain in hysteria and 
 spinal affections, that the muscles and their ten- 
 dinous prolongations or parts are far more fre- 
 quently the cause of suffering than the nerves ; for 
 when once a definite opinion is formed by an adult 
 upon any subject, it is against human nature to 
 change it. A new theory requires a new genera- 
 tion before it is generally adopted. There are, 
 however, in the ranks of the Profession, many dis- 
 tinguished exceptions to this rule men who are 
 habitually exercising their minds, examining every 
 theory, whether new or old, adopting what is good 
 and rejecting what is bad. Should the following 
 pages come under the eyes of such, I shall be both
 
 PREFACE. 
 
 proud and happy to receive such criticism as they 
 think fit to bestow. 
 
 An author working in a new field cannot see at 
 once either all the flowers or the weeds that lie 
 around him; he may readily mistake one for the 
 other, and like the Australian miner, may fancy he 
 has found a golden treasure when he has turned up 
 a mass of iron pyrites alone. I am painfully con- 
 scious of this, and therefore look with eagerness 
 for the opinions of others. 
 
 It is only right to make some apology to my 
 readers for the title of the book. It was adopted 
 simply because it was more likely to give an idea 
 of the nature and bearing of its contents than if 
 it had been designated what it really is, a " Trea- 
 tise on Muscular Affections, and their Bearings 
 upon Nervous Disorders." 
 
 I have adopted the order of time, that my 
 readers might form their own opinions much in 
 the same gradation and manner that I formed my 
 own. The Essay on " Muscular Affections" was 
 written in November, 1856, that on the " Nature of 
 Spinal Irritation" in August, 1857 ; but I have not 
 scrupled to add to the first such other observa- 
 tions and cases as have come under my notice 
 since it was written, so as to make it as complete 
 as possible.
 
 . -6-
 
 
 
 -ff Bgg , lei. et ~Ut>i
 
 EXPLANATION OF THE PLATES. 
 
 FIG. 1, FBONTISPIECE, 
 
 INDICATES the situations in which we most commonly meet 
 with muscular pains. 
 
 The oval marks occupy the fibrous parts, or else the origins 
 or insertions of muscles. Pain in these localities is often severe, 
 but is not constantly aggravated by pressure. 
 
 The circular dots indicate the fleshy parts of muscles ; they 
 are occasionally the seats of " tumours," i. e., more or less per- 
 sistent cramp. At these parts it is that we have most commonly 
 severe pain and extreme tenderness on pressure. 
 
 The mark on the shoulder is intended to represent the inser- 
 tion of " trapezius " and the origin of the greater pectoral and 
 deltoid. 
 
 The mark across the mammae marks the origin of the lesser 
 pectoral. 
 
 The long one at the side is intended to mark the extent to 
 which we may have pain in the intercostal muscles. 
 
 That in the loins is due to over-exertion of the obliquus 
 externus, internus, and transversalis. 
 
 The position of the infra-mammary pain corresponds with the 
 lower origin of the pectoral, or with the commencement of the 
 linea semilunaris. It is commonly connected with pain referred 
 to the origins of serratus magnus and external oblique. 
 
 FIG. 2 
 
 Indicates the most frequent situations of pain in the back. 
 
 The whole length of the spine may be tender, but it was not 
 considered necessary to mark it throughout. The most common
 
 XIV EXPLANATION OF THE PLATES. 
 
 seats alone have been selected. As in the preceding figure, the 
 oval lines correspond with fibrous structures, and the circular 
 ones indicate the seat of spasm. Those in the middle of the 
 loins indicate the fleshy part of longissimus dorsi. 
 
 FIGS. 3, 4, 5, 6 
 
 Are intended to show the origin and insertion of those muscles 
 and fibrous parts which are the most common seats of pain. 
 Figs. 4 and 5 are intended specially to show the number of 
 muscles which are inserted into the spinous processes. 
 
 The Author has at present a young woman under his care at 
 the Northern Hospital, Liverpool, with painful tender persis- 
 tent cramp in the external and internal oblique, and probably the 
 transversalis, produced by excessive exertion in washing with a 
 " dolly." In company with a medical friend, he took the oppor- 
 tunity of referring in succession to all the points indicated in 
 Figs. 1 and 2 ; and the patient was found to have, or to have 
 had, pain referred to them all, with the sole exception of those 
 marking the transverse lines of the rectus abdominis.
 
 Printed VyHuDmstnael i. "WiJtc.
 
 Bagg del et litk. 
 
 ruimaal t~vValtMi.
 
 
 ;. 

 
 I tw s 
 fis:
 
 CONTENTS. 
 
 CHAPTEE I. 
 
 Introduction Muscular affections well known in the healthy Ignored 
 in the delicate Eeason why The word muscle denned Reason 
 why pain is so frequently referred to the fibrous portion Case of 
 Mrs. I., illustrative of the danger attending non-recognition of mus- 
 cular pains Familiar examples of muscular affections in healthy 
 individuals Various names given to degrees of stiffness, &c, 
 Their mode of invasion Cramp The circumstances under which 
 it comes on pp. 1-13 
 
 CHAPTEE II. 
 
 " Unusual exertion" defined and explained Ordinary exertion in the 
 strong is extraordinary in the weak Examples Habitual prac- 
 tice does not necessarily give strength Case of Mrs. T. Its long 
 duration Diagnosis of muscular pains Cases illustrative of the 
 various points of diagnosis pp. 14-32 
 
 CHAPTEE III. 
 
 The parts of the body most commonly affected The occipital region 
 Extension of pain along the occipito-frontalis The sterno- 
 mastoid and temporal sometimes affected Pain in sterno-clavicular 
 insertion of trapezius Case of Miss I. Pain in interscapular 
 aponeurosis, and attachment of ligamentum nuchae Longissimus 
 dorsi affected Cases of Nurse and Mrs. W. I. Causes some- 
 times difficult of detection Case of Mrs. L. Advantage of stays 
 in giving artificial support Quadratus lumborum affected with 
 others Gives rise to suspicion of disease of liver Case of Mrs. N. 
 
 Glutei muscles and erectores spinse affected Case of Mrs. B. 
 
 Mr Pectorals and intercostals affected Stitch in side
 
 XVI CONTENTS. 
 
 Its cause Pleurodynia Diagnosis from pleurisy Case of 
 Mr. E. Diaphragm affected The symptoms Abdominal walls 
 
 Pain under mamma, right or left, accounted for Epigastric 
 pain Its cause Case of I. W. Danger of mistaking these 
 pains for inflammation, &c. Pain in side of abdomen during preg- 
 nancy Its cause assigned Case Question whether the fibrous 
 tissue is not more " stretchable" in the weak than in the strong 
 Points bearing on the inquiry Varicose veins Pain in the pubic 
 region Eeferred in women to the hypogastric Its cause 
 Illustrative cases Mental depression common in these affections 
 
 The reason why Pains produced in muscular system from 
 excessive vomiting Case of Mrs. L. Distinction between neu- 
 ralgic, hysterical, and muscular (or fibrous) pains Cramp in the ab- 
 dominal walls Case of Ann B. Case of pubic pain, Sarah M'G. 
 
 Painful affection of abdominal walls Case of Miss M. Mus- 
 cular pains in the extremities Case of Miss L. C. . pp. 33-74 
 
 CHAPTEE IV. 
 
 Causes which predispose to muscular disorders Aphorisms The 
 irritability of a muscle is proportionate to its debility Muscular 
 action exhaustive Various causes of muscular exhaustion or de- 
 bility Uterine disease a common concomitant, not a cause, of 
 muscular disorders Hysteria, the vague use of the term Its 
 necessary connexion with the uterus doubted Can gout be referred 
 to the testes ? Comparison of reasons The nature of chorea 
 and convulsive diseases hinted at Palpitation a proof of cardiac 
 debility pp. 75-80 
 
 CHAPTEE Y. 
 
 Cramp The circumstances under which it comes on Case of Mrs. 
 E., affected when support of " stays" withdrawn Cramp simu- 
 lates "tumour" cases Occasional influence of galvanism in cramps 
 
 Severity of pain Its comparatively transient character 
 Cases pp. 81-88 
 
 CHAPTEE VI. 
 
 Are the heart and involuntary muscles affected in a similar way to the 
 voluntary ? The heart Its muscular fibres those of animal life 
 Meaning of palpitation Irregular action Angina Cause of 
 sudden death in disease of heart Principles of treatment discussed 
 
 The value, influence, and effect of digitalis The intestines and 
 uterus affected Anteversion Eetroversion ... pp. 89-94
 
 CONTENTS. XV11 
 
 CHAPTER VII. 
 
 The plan of treatment proposed Artificial support General tonics 
 
 Sedatives, general and local Case of laryngismus stridulus 
 cured by the latter Galvanism Exercise Its value discussed 
 
 The necessity for pure air Local depletion Its doubtful 
 value pp. 95-98 
 
 CHAPTEE VIII. 
 
 Spinal disorders Their nature, as defined by recent writers : as 
 Dr. Copland, Dr. Griffin, Mr. Teale, Dr. Brown Similarity of 
 the symptoms described by them to those we have described and 
 ascribed to another source Cases quoted Duration of symptoms 
 
 Days, months, or years Exciting and predisposing causes 
 Treatment recommended pp. 99-109 
 
 CHAPTEE IX. 
 
 General sketch of the proposed explanation 1. What spinal tender- 
 ness is not 2. What it is 3. True explanation of the pheno- 
 mena 4. Treatment deduced The tenderness no proof of 
 organic spinal disease, either in the bones or in the spinal cord 
 Arguments Its connexion with hysteria What hysteria is not 
 
 What it is pp. 110-113 
 
 CHAPTEE X. 
 
 What spinal tenderness is Anatomical relations of the spinous pro- 
 cesses They form the starting-point for almost every muscle of 
 the back, and, to a great extent, of the trunk, head, and extremities 
 
 Examples Strain upon the more moveable insertions of muscles 
 produces pain and tenderness on pressure It may do so equally 
 on the more fixed insertion Eeason why the cause of spinal ten- 
 derness may be traced in some and ignored in others Why the 
 symptoms of spinal irritation may be present without spinal ten- 
 derness, and vice versd Why pressure on certain regions produces 
 apparently definite symptoms Effect of the examination on the 
 patient's equilibrium Recapitulation pp. 114-123 
 
 CHAPTEE XI. 
 
 Why spinal irritation has been considered a symptom or phase of hys- 
 teria Definition of hysteria, quoted from Dr. Copland Consti- 
 tutional debility the cause of hysterical phenomena Constitutional 
 debility defined Consequences of constitutional debility Law 
 The more debilitated the individual the greater is the irritability of
 
 XVlll CONTENTS. 
 
 the nervous system How irritability of the nervous system shows 
 itself Multifarious functions of the nervous system Artificial 
 division into mental, sensitive, motor, and organic functions One 
 of these or more may be affected There may be rapid transitions 
 from one to the other Sometimes all may be affected Over- 
 action a cause of exhaustion in muscle May be so in nervous affec- 
 tions Over-action in one part of nervous system is not always 
 followed by symptoms referrible to that particular division. 
 
 pp. 124-129 
 
 CHAPTEE XLT. 
 
 Insanity an affection of the mental nervous system Its alliances 
 Its causes : shipwreck, hunger, misery Experience drawn from 
 asylums Influence of generous diet on the insane Dr. Conolly's 
 opinion of cod-liver oil, &c. Mania not a disease of strength 
 Sensitive nervous system Its susceptibility increased by exhaus- 
 tion Effect of noise, light, strong odours, &c., on those weakened 
 by losses of blood Sensibility of the skin in hysteria explained 
 Cases Neuralgia Its causes Its proper treatment Musciilar 
 nervous system Cause of tetanus Fatal case of idiopathic tetanus 
 
 Epilepsy May be produced by bleeding or excessive debility 
 
 Case of Mrs. T. Infantile convulsions Its chief victims 
 Its causes The danger The cure Chorea Its cause Its 
 victims Their condition of health The danger The cure 
 Cases Influence of a tonic plan of treatment Influence of 
 mental emotion on a weakened heart Organic nervous system 
 Effects of debility on the milk On digestion Emotion produces 
 vomiting Question how far anxiety operates in the production of 
 tubercle or cancer pp. 130-143 
 
 CHAPTEE XIII. 
 
 Application of foregoing observations Law The word irritability 
 defined Corollary when there is debility The symptoms will be 
 referrible to the muscular or nervous systems according to circum- 
 stances; or the two may be combined Case from Griffin, in which 
 both muscular and nervous systems were intensely affected Anno- 
 tations Summary of views pp. 144-161 
 
 CHAPTEE XIV. 
 
 The value of a medical theory judged by the treatment it involves 
 The treatment proposed in accordance with recognised facts 
 Sydenham's maxim Danger of departing from it Embraced by 
 the homceopathists Principle embodied in their theory Eeference 
 to " sympathetic powder" Law enunciated Treatment in recent
 
 CONTENTS.- XIX 
 
 cases In confirmed In recent cases, to husband strength To 
 increase it Difficulty in persuading patients to do so Causes 
 The amount of labour or exertion is to be reduced An increased 
 amount of rest is to be enforced Amount of work gone through 
 by women in their households Rules regarding rest It must be 
 in the recumbent posture and not too prolonged Opiates, if neces- 
 sary, at night Elastic belt or corset Any drain upon the system 
 to be checked The strength to be increased Change of air 
 Its value considered Change of habits as well as of scene required 
 
 Exercise in the open air Its importance discussed Difference 
 between the open air of towns and the country The diet must be 
 generous and nutritious The supply of food should equal the 
 demand of the system A weak stomach cannot digest strong foods 
 
 Influence of tonics, wine, steel, &c. Wine assists the vital 
 powers Is not a substitute for food Food recommended 
 Things to be avoided Tea often prejudicial Why Baths, &c. 
 Purgatives to be shunned as a rule They produce flatulence 
 Observations on their use A daily motion unnecessary Cod-oil, 
 steel, bitters; quinine and opium combined Any special sources of 
 irritation are to be investigated, and if possible cured, pp. 162-184 
 
 CHAPTEE XV. 
 
 Treatment of confirmed cases Necessity for tact, knowledge, expe- 
 rience, and confidence The advantage of giving definite hopes 
 To impart these the doctor must have definite ideas Influence of 
 hope and despair Examples Influence of new remedies in the 
 hands of their discoverers Of their adopters Application Rest 
 of body Mind The senses Rest for the bowels The stomach 
 
 The uterus Nausea and vomiting to be relieved by champagne, 
 chloroform, &c. Antispasmodics are only of temporary utility 
 The mind is to be supported Method of management The pro- 
 posed, treatment in a bad case detailed Conclusion . pp. 185-201

 
 TREATISE 
 
 ON CERTAIN 
 
 PAINFUL MUSCULAR AFFECTIONS, 
 
 ETC. 
 
 fart tty |irst. 
 
 CH-A.FTEE I. 
 
 INTRODUCTION. 
 
 Introduction Muscular affections well known in the healthy Ignored 
 in the delicate Reason why The word muscle defined Reason 
 why pain is so frequently referred to the fibrous portion Case of 
 Mrs. I., illustrative of the danger attending non-recognition of mus- 
 cular pains Familiar examples of muscular affections in healthy 
 individuals Various names given to degrees of stiffness, &c. 
 Their mode of invasion Cramp The circumstances under which 
 it comes on. 
 
 HAVING had my notice directed, both frequently 
 and forcibly, of late, to certain painful affections 
 of the muscular* system, I venture to call the 
 attention of the Profession to the subject. I am 
 the more desirous to do this, as I have met with 
 many cases where deplorable results have followed 
 the non-recognition of the phenomena referred to, 
 and as I am not aware that any medical writer has 
 treated of them systematically. 
 
 The affections I allude to are particularly com- 
 mon few persons, if indeed any, escaping them 
 altogether. 
 
 * It must be understood that, in using the word muscle, I con- 
 sider it includes tendon, fibre, or fascia, as the case may be. 
 
 B
 
 2 INTRODUCTION. 
 
 In the healthy individual they are spoken of 
 under different names cramp, spasm, stiffness, 
 soreness, or aching. In the invalid they are 
 always designated under the generic term of pain. 
 
 In the former, it is so common an occurrence to 
 be stiff, or sore, after exertion, that the phenomena 
 is never examined into, the connexion between 
 cause and effect is so clear, that as soon as the one 
 is felt, inquiry is instituted into the other; and 
 after a few years' experience, even the schoolboy 
 knows how to estimate the duration of his stiff- 
 ness, by comparing it with the muscular efforts he 
 has made. 
 
 In the weakly and invalid, on the contrary, where 
 there does not appear to be any unusual exertion 
 made, the idea of soreness from muscular fatigue 
 occupies no place ; and even if it did, the difference 
 of sensation arising from similar causes in a strong 
 man and a delicate woman would be sufficient to 
 make the majority of persons believe that they could 
 have nothing in common. It is easy therefore to 
 see how, though clear in the one, they may be 
 obscure in the other. 
 
 The pain complained of is supposed to indicate 
 neuralgia, inflammation, indigestion, or disease of 
 some internal organ ; and, in the endeavour to 
 cure it, the practitioner too often treats it in a 
 way to insure its continuance. There is scarcely 
 any part of the body which is absolutely free 
 from these affections, for they are to be met with
 
 SEATS OF PAIN. 3 
 
 wherever there are voluntary muscles or their ten- 
 dinous prolongations. Some parts are more fre- 
 quently attacked than others. The trunk more 
 commonly than the extremities. The abdominal 
 walls oftener than the thoracic, and the legs more 
 constantly than the arms. 
 
 On the whole, the tendinous parts are more 
 frequently the seat of pain than the fleshy, but 
 where the affection is of a spasmodic nature, the 
 fleshy parts alone are implicated. The reason for 
 this is to be sought by inquiry into the minute 
 anatomy of muscle. We know that every mus- 
 cular fibre terminates at each end in being attached 
 to a tendinous fibre ; that these, again, are, singly 
 or collectively, inserted directly into the bones. 
 Whenever a muscle contracts, there is a strain 
 upon all parts of it, and a direct effort to tear it 
 from the bone, or to separate itself into its inte- 
 gral parts. There are, therefore, two strains upon 
 the tendinous fibre, at each end of the muscle; 
 one where it joins the muscular fibre, the other 
 where it is inserted into the bone. In addition, 
 however, to this consideration, it must be borne in 
 mind that (speaking generally) the muscular fibre 
 is much longer than the tendinous one, and the 
 strain which is divided over a long space in the 
 former, is concentrated in a small space in the 
 latter. In corroboration of this view we may add 
 that, where the muscle has a long tendon attached 
 to it, as the gastrocnemius for example, the pain 
 
 B 2
 
 4 PAIN FROM STRETCHING FIBROUS STRUCTURES. 
 
 arising from over-stretching or over-exertion is 
 confined almost exclusively to the origin and in- 
 sertion of the tendon, as in tendo-Achillis, at the 
 lower end of the calf of the leg and in the heel, 
 the intermediate parts being free from pain. Any 
 one who wishes to ascertain for himself the pain 
 attendant upon the stretching of a fibrous struc- 
 ture, should stand with his feet close together, and 
 then, without bending the knee, try and stoop for- 
 wards until he can touch the ground with the tips 
 of the fingers. When first this is tried success- 
 fully, the pain in the popliteal region is excessive ; 
 by practice the feat can be performed with scarcely 
 any suffering. 
 
 If farther illustration were wanting, I would 
 point to the excessive pain complained of by the 
 parturient female, from the terrible strain upon 
 the sacro-sciatic ligaments, and the relief given by 
 counteracting the pressure in front, by pressure of 
 a firm hand to the back of the sacrum ; and I may 
 add, that the common reason alleged for the pain 
 of the lower animals during parturition being less 
 than in our own species is, that in the former there 
 is a relaxation of the ligaments tying the pelvis 
 together, while in the latter this provision is absent. 
 
 As an illustration of the importance of a due 
 recognition of muscular pains, I give the following 
 case the first that I met with and one which 
 naturally laid the foundation for more extensive 
 inquiries :
 
 CASE. 5 
 
 A very near and dear relative, a lady, a3t. forty- 
 four, or thereabouts, had been confined to bed a 
 long time for what was said to be congestion or 
 inflammation of the liver. For this she was 
 cupped and leeched, blistered, purged, and starved 
 on low diet ; and, as she was able to leave her bed 
 at the end of two months, it is charitable to con- 
 clude that the diagnosis was correct, and the treat- 
 ment unimpeachable. Unfortunately new troubles 
 arose. The first day she sat up, she began to 
 suffer pain between the shoulders, and in the head. 
 These being mentioned to the doctor, were pro- 
 nounced to be proofs of a relapse ; " bile was at the 
 bottom of them," and it would be necessary again 
 to bleed, blister, give blue pill, and to confine the 
 patient to bed. The treatment seemed triumph- 
 antly successful, for the pain did not return 
 during the week, and the patient, consequently, 
 once more ventured to sit up. But, alas! the 
 symptoms returned with increased severity, and 
 she was once more condemned to bed, bleeding, 
 blistering, and blue pill. The pain once more was 
 cured, and the patient was allowed to get up 
 again. The attempt was more disastrous than 
 before. The suffering returned with renewed vio- 
 lence, and her friends now despaired of her re- 
 covery. The husband, however, seeing that his 
 wife only rose to be knocked down again, and had 
 less and less strength at each attack, determined 
 to try change of air, and to see what nature, un-
 
 6 CASE CONTINUED. 
 
 aided, could perform. Though he was satisfied, 
 she was not, and confided all her troubles to the 
 ear of her relative, who was then in his " second 
 medical year." The terrible pain in the head, and 
 between the shoulders, was the most complained 
 of; she could not read in consequence of strabis- 
 mus ; vision was double from the same cause ; 
 and it did not require any information to show 
 that the patient was in a deplorable state of de- 
 bility. On being requested to point to the chief 
 seat of suffering, the aponeurosis of the trapezius, 
 and the occipital insertion of the same muscle, 
 were mapped out. It was soon ascertained that 
 the pain came on only after the patient had been 
 sitting up, with the head unsupported that it went 
 away as soon as she lay down, or rested her head 
 on her hand. 
 
 In consequence of its continuance, she could not 
 be induced to give up the use of aperients and low 
 diet, and these, combined with a very natural de- 
 pression of spirits, almost brought her to the grave. 
 I succeeded, however, at last, in inducing her to 
 believe that the pain was entirely muscular, and 
 had nothing whatever to do with the liver. I pre- 
 scribed the almost habitual use of a high-backed 
 arm-chair ; frequent rest in the recumbent posture ; 
 an abstinence from everything but kitchen physic ; 
 a generous diet; a liberal use of wine, porter, or 
 ale ; and had the satisfaction of seeing the patient 
 mend at a rapid rate. She had been, however,
 
 MUSCULAR PAINS IN THE BACK. 7 
 
 reduced to such a pitch of weakness, that many 
 months elapsed ere she was able to support the 
 weight of her head without pain. 
 
 Since then, I have had abundant opportunities 
 to learn that this pain in the trapezius muscle is 
 an almost constant concomitant on convalescence, 
 unless care is taken to provide the patient with a 
 comfortable arm-chair, on which he can rest the 
 head and arms. The weight of the shoulders being 
 almost equally onerous with that of the head. 
 
 Returning from this digression, let us consider 
 the phenomena presented in a healthy individual 
 exposed to unusual and excessive muscular exer- 
 tion. We are familiar with the expression, " laugh- 
 ing till our sides ache;" and I need not remind 
 you' of the soreness, pain, or abdominal tenderness 
 that follow on the next day after a night spent with 
 Buckstone, or any other irresistibly comic actor; 
 yet I have often found the cause ignored, and the 
 individual unable to see the connexion between the 
 two whenever the soreness has occurred in an 
 unusual place. Everybody is familiar with the 
 stiffness that follows- a first fencing, dancing, or 
 broadsword lesson. The schoolboy remembers 
 his first ride, the athlete his first day's training. 
 The seaman remembers how his eyes have " burned" 
 after many an hour's weary lookout for land, espe- 
 cially at night. The seamstress, too, often stitches 
 till her eyes ache with watching her needle i. e., 
 until the muscles that move the ball are thoroughly
 
 8 MUSCULAR PAINS. 
 
 weary. The traveller remembers the weariness he 
 experienced at the termination of a long journey 
 in a jolting carriage ; and the enthusiastic card- 
 player may be able to recal the burning ache he 
 has felt at the pubic insertion of the rectus ab- 
 dominis as the morning approaches. 
 
 Those who have visited mountainous districts 
 for the first time, and ascended some conspicuous 
 height, in which, of course, they have made extra- 
 ordinary use of the abdominal muscles, will recal 
 the soreness they feel in the same muscles in the 
 descent. When going up the hill, they were con- 
 tracting them; in corning down, their attitude ne- 
 cessarily stretches them; and the two effects com- 
 bined leave a painful ache for at least two days. 
 
 To take familiar examples from the other sex, 
 let me remind you of the back-ache complained of 
 by the pregnant woman, who has to keep erect all 
 day with an extra burden to support ; of the severe 
 pain known by many ladies as a " cutting-out pain," 
 because it is produced by the unusual strain thrown 
 upon the erector muscles of the back, while they 
 are leaning over a table to cut out patterns. 
 
 Every midwife is familiar with the excessive 
 soreness complained of after delivery, and which 
 arises from the immense muscular exertion required 
 to propel the child into the world ; yet few, when a 
 similar pain is complained of by the virgin, see any 
 relation between one and the other. 
 
 Speaking from personal knowledge, I would say,
 
 VAEIETIES OF MUSCULAR PAIN. 9 
 
 that if any one is desirous of knowing to what a 
 pitch of severity this muscular ache will reach if 
 he wishes to know what is meant by the expres- 
 sion, a " burning pain between the shoulders," let 
 him sit for fourteen hours consecutively, working 
 with the microscope, making specimens, taking 
 notes, raising and lowering the head continually, 
 and he will then find that not even a new beauty, 
 of intense interest, can keep him from his arrn-chair, 
 the sofa, or some other contrivance for supporting 
 the head. 
 
 If we analyse particularly the phenomena to 
 which I have alluded, we find that there are varie- 
 ties or degrees of the aching pain. 1. That which 
 we feel after unusual exertion, though the muscle 
 is in a state of repose. 2. That which we expe- 
 rience, under the same circumstances, when the 
 muscle is in a state of activity every one knows, 
 for example, how much pleasanter it is to get over 
 the stiffness produced by a long day's walk, on a 
 sofa, rather than by a second day's exertion. 
 
 These sensations are of greater or less duration, 
 according to circumstances, but are always most 
 severe on the day following the unusual effort ; 
 and we may remark, in passing, that they rarely, 
 if ever, come on until after a period of complete 
 repose and sleep. 3. They differ from the burning 
 ache, which is produced by long-continued action 
 in any muscle, and which goes off as soon as 
 the muscle returns to a quiescent state. 4. As a
 
 10 PAIN FOLLOWS CRAMP. 
 
 general rule, when the sensation is referred to a 
 tendinous part, it is spoken of as pain when to 
 a fleshy part, as an ache. 
 
 If we examine into the circumstances under 
 which these sensations are produced, we shall be 
 able, in all cases, to trace them to severe and un- 
 usual exercise of a muscle or set of muscles. The 
 well-tried pedestrian can laugh at the stiffness 
 the sedentary student experiences when he sud- 
 denly throws off his quiet habits for more active 
 work. The mason and the blacksmith work with 
 ease for a period quite impossible to the unini- 
 tiated. But, set the first upon horseback, and the 
 last to do duty as hod-carriers, and they all will 
 experience some stiffness next day.* 
 
 The muscles are severely exercised during the 
 occurrence of cramp in them, and soreness follows 
 this as surely as after a more prolonged but gentler 
 use. 
 
 As a general rule, the more perfect the develop- 
 
 * The habit of muscular exertion does not always give immunity 
 from ill effects in man any more than it does in women. We shall 
 speak elsewhere of the assistance given by a corset or elastic belt to the 
 abdominal and other muscles of the trunk in women. We wish here 
 to call attention to the frequency with which workmen employ artificial 
 supports to assist those muscles or fasciae that are violently strained in 
 their occupation. Navvies, who have to wheel heavy barrow-loads of 
 earth, place a strap round their wrists to assist the annular ligament. 
 Washerwomen who have much wringing of clothes adapt a piece of 
 ribbon to the same place and the same purpose. Labourers who have 
 much standing-work employ a belt ; and the pedestrian uses a strap 
 or handkerchief round his waist to prevent stitch (or cramp). The 
 swimmer will use a tight garter round his calf, with the same intention.
 
 CRAMP. 11 
 
 ment of the muscular system, the less is the 
 amount of stiffness following exertion ; and the 
 feebler the individual, the greater the pain. Thus, 
 the hardy countryman can go through an amount 
 of labour with comparative ease, which would lay 
 up his town cousin for a week. The records of 
 the guides to Mont Blanc, or any other mountain, 
 infallibly show a similar result. Of five gentlemen 
 who go up, apparently under similar circumstances 
 of previous training, &c., one will be unaffected, 
 while the others will have various degrees of stiff- 
 ness during one or more days. The question, 
 " upon what does this condition of soreness and 
 stiffness depend ?" is one of tempting interest ; 
 but, as I have not yet anything beyond conjecture 
 and analogy to offer, I must omit it for a time, and 
 consider another phenomenon arising from exces- 
 sive muscular exertion, to which we have already 
 alluded, viz. cramp. 
 
 Cramp is an intense spasm or contraction of a 
 muscle. It comes on suddenly, and is attended, 
 as in all muscular contraction, with apparent 
 swelling and great hardness. It is usually accom- 
 panied with severe pain, is of variable duration, 
 and passes off slowly, with a vibrating, twitching, 
 or creeping sensation. During its continuance, 
 the same action is produced that would be by a 
 voluntary use of the muscle, but the sufferer has 
 no power to suspend or modify its condition 
 directly.
 
 1 2 CRAMP. 
 
 Experience shows that a forcible extension is 
 more efficacious than anything else in relaxing the 
 spasm. Shampooing is next in value. 
 
 When a muscle has been once seized with cramp, 
 it is very liable to other similar attacks. 
 
 Experience still farther teaches and the lesson 
 is of great importance that cramp rarely, if ever, 
 comes on in a muscle until it has been in some 
 way debilitated. That condition may have been 
 produced by unusual, excessive, or too long sus- 
 tained exertion, or by long inaction, or the whole 
 system may have been " pulled down " by loss of 
 blood, or food, or rest, by diarrhoea, or other causes 
 of weakness. Thus, for example^ after walking for 
 a whole day, we are attacked with cramp just as 
 we point the toe to take off our boots. And when 
 it attacks the bather, it is not until he has been 
 swimming for a long time, and is, too often, far 
 from land. It is to be remarked, too, that the 
 victims of cramp are commonly persons whose 
 frames are not inured to the immense and con- 
 tinued exertion put forward in swimming. It is 
 more common in the townsman who visits the sea 
 or river side, and indulges in a bath after long 
 inaction, than in the countryman who has a daily 
 swim, and whose muscles are more developed and 
 more accustomed to fatigue. 
 
 I shall have, in the ensuing pages, many oppor- 
 tunities to show that constitutional debility predis- 
 poses to the occurrence of " cramp.' '
 
 CRAMP. 13 
 
 I am, of course, aware that cramp may be pro- 
 duced by what, for want of a better term, we must 
 call nervous irritation, as in tetanus, &c. ; but I 
 hope, hereafter, to show that, even in these cases, 
 the condition of the muscles, as regards vital 
 power or vigour, has a great deal to do with the 
 phenomenon. 
 
 I purposely, too, omit all those cases in which 
 cramp is produced by some peculiar condition of 
 the blood as in cholera, scurvy, and other 
 diseases.
 
 14 WHAT IS UNUSUAL EXERTION. 
 
 CHAPTER II. 
 
 " Unusual exertion" denned and explained Ordinary exertion in the 
 strong is extraordinary in the weak Examples Habitual prac- 
 tice does not necessarily give strength Case of Mrs. T. Its long 
 duration Diagnosis of muscular pains Cases illustrative of the 
 various points of diagnosis. 
 
 IT cannot fail to be remarked, the great stress we 
 have laid upon the fact, that the soreness, &c., de- 
 pends upon a severe, excessive, or unusual exer- 
 tion of the affected muscles. 
 
 It is now necessary that we call particular 
 attention to what we mean by excessive or un- 
 usual exertion, and how it bears upon our subject. 
 
 As long as a man is in a healthy condition, and 
 is not subjected to extraordinary exercise, he is 
 almost unconscious that he has any muscles at all. 
 Each one performs its duty quietly and silently 
 (so to speak). The muscles are equal to the work 
 they have to do the work is constant the head 
 and the shoulders are always of the same weight, 
 or nearly so the abdomen contains an almost un- 
 varying amount, and the trunk does not change its 
 relative weight to the limbs. As long as the rela- 
 tion between the work to be done and the power to do 
 it remains the same, the exertion of the muscles 
 is not unusual. But whenever muscles reduced in
 
 ORDINARY EXERTION MAY BE EXCESSIVE. 15 
 
 power are obliged to do the same work as when they 
 were strong, the exertion they put forth is unusual, 
 and the violence of the exertion is proportionate to the 
 weakness of the muscles. 
 
 It must at once be apparent, that what is an 
 ordinary exercise for the muscles of a healthy man, 
 would be extraordinary to the same man when just 
 recovering from typhus, or any other debilitating 
 disease. In the first case, the heart can propel the 
 blood to the brain in an erect posture, without any 
 difficulty; in the second, the exertion may prove 
 beyond its strength, and the erect posture will pro- 
 duce fatal syncope. 
 
 So again, we can in health support the head, 
 during the day, without fatigue ; but, when debili- 
 tated in any way, we can no longer do so, for the 
 head remains the same, while the muscular fibre is 
 reduced in power. This is familiar to us all by 
 the manner in which a " heavy head" and " heavy 
 eyelids" are used as symbolical of fatigue i. 0., the 
 head feels heavy, not because it has increased in 
 weight, but because the power to support it is 
 diminished. The country people have a proverb, 
 " that if you carry a lamb all day it becomes a 
 sheep by night," which they explain in the same 
 way. 
 
 It costs us no suffering, while we are in good 
 health, to walk erect, or to sit over our books and 
 papers ; but when illness has reduced our powers, 
 when a refractory stomach has refused the neces-
 
 16 WEAEINESS GOES ON TO PAINFULNESS. 
 
 sary supplies of food, or when we have been brought 
 low by accidents and loss of blood, we find the 
 exertion excessive, painful, or too great for our 
 powers. As long as the school-girl is healthy and 
 strong, she can sit erect for hours, and at the end 
 feel weary only; but as the influence of sedentary 
 life, mental exertion, deficient appetite and diges- 
 tion, a crowded sleeping apartment and school, 
 begins to be felt, the weariness is changed to pain- 
 fulness; she is no longer fatigued, she is suffering. 
 We shall give many instances of this truth here- 
 after. We wish now to show, that even though 
 the habit of erect sitting may be continued for a 
 number of years with impunity, the exertion may 
 become too great at last. The following case, 
 which suggested the writing of this essay, illustrates 
 this point forcibly : 
 
 Mrs. T., aged about fifty-four, came under my 
 care, suffering from bronchitis and asthma. She 
 had been under medical treatment thirteen years, 
 and informed me that she had, in addition to her 
 other ailments, enlargement of the liver, and a 
 tumour in the uterus. Her severest sufferings, 
 however, arose from intense pain between the 
 shoulders, and in the occipital region of the head ; 
 it was, she said, for all the world as if somebody 
 was burning her with a hot iron. She had, too, 
 pain in the loins and small of the back; and, she 
 added, suiting the action to the word, there was a 
 continual grasping pain all over the abdomen, as if
 
 CASE CONTINUED. 17 
 
 somebody was always drawing her up, and so 
 severe was this when she walked, that she was 
 often obliged to lay hold of the palisades in the 
 street, to draw herself up by, and relieve the pain. 
 Bed alone gave her a degree of ease, but her trou- 
 bles pursued her there, for, at every turn, the abdo- 
 minal walls were drawn up into lumps on one side 
 or the other. A severe nettle-rash, for the last 
 two years, added to her suffering. Life was a 
 burden to her; during the day her wish was, 
 " would to God it were evening," and then, " would 
 to God it were morning." She had a fixed idea 
 that her case was hopeless, and that -she would 
 die ere the year was out, and she was nothing 
 loth. 
 
 It was not until my third visit that I obtained 
 all these particulars, from the disinclination she 
 felt to talk of them, and some further time elapsed 
 ere she spoke to me of the treatment that had been 
 adopted. She told me that she had been blistered 
 on almost every part of the back and head; had 
 had leeches to the nape, between the shoulders; 
 that the abdomen had been covered with them, in 
 different batches. She had, she said, had blisters 
 by dozens, and leeches by hundreds; and that she 
 had been kept^low in consequence of the presumed 
 disease of the liver. In fine, all the usual counter- 
 irritants had been used, in abundant succession, 
 whenever the pain became more than ordinarily 
 severe, or was more than usually complained of. 
 
 c
 
 18 SYMPTOMS EXPLAINED. 
 
 On one occasion the uterus had been considered the 
 seat of the mischief, and she had been examined 
 with the speculum ; and on some abnormal appear- 
 ance being found around the os, it was thought her 
 sufferings were due to uterine sympathy, and a 
 gloomy prognosis was given. After two or three 
 visits, however, I had seen sufficient of her habits 
 to account for the majority of her symptoms, Ori- 
 ginally, a healthy woman from the country, she 
 had married a gentleman who had a profound con- 
 tempt for any lady who indulged in luxurious 
 habits. She had ever after acted as affection dic- 
 tated, and sat erect, without using any artificial 
 support. As long as she was strong, the exertion 
 brought no suffering ; but when menorrhagia, diar- 
 rhoea, and the like had pulled her down, the 
 muscles refused to do their work without pain. 
 The bronchitis kept up debility; wine and other 
 stimuli were not adequate to give the necessary 
 strength, and she neither had the inclination, nor 
 had she even been directed, to give her muscles 
 less work to do. The pulse was feeble, respiration 
 gasping, there was frequent and distressing cough, 
 and an occasional expectoration of tenacious mucus ; 
 the appetite was poor, digestion bad, flatulence 
 occurred nightly, and the bowels were torpid. 
 There were the usual physical signs of bronchitis 
 over the lower halves of both lungs, but percussion 
 showed that the liver was natural in size, and it 
 seemed possible that the supposed enlargement had
 
 TREATMENT RECOMMENDED. 19 
 
 been nothing more than a cramped state of the 
 external oblique, on the right side.* 
 
 I ventured to assure her that all her pains were 
 muscular, that they were to be cured by indulging 
 in a greater amount of repose, and by a still further 
 development of the strengthening plan of treat- 
 ment. 
 
 A sofa, and comfortable arm-chair, were to be 
 frequently used during the day tea was to be 
 eschewed steel took the place of some of the wine 
 a mild expectorant relieved the cough; colchi- 
 cum diminished the urticaria, and cod-liver oil 
 gave strength rapidly, and at the end of a month, 
 
 * The subject of tumours from muscular over-exertion is one of great 
 interest. I have attributed the one here to simple cramp in the fleshy 
 fibres, and there is no doubt this is a frequent cause ; but it will be 
 seen (Part II. p. 150) that the characters assumed are different to those 
 we should anticipate in cramp. On mentioning this subject to a non- 
 medical friend who has been all over the world, mingled with all sorts 
 of people, and who was for many months a miner at the Australian 
 diggings, he assured me that he had very frequently seen large and 
 painful swellings white and shining as if they were going to form ab- 
 scesses situated over the radial insertion of the pronator quadratus. 
 The swelling followed severe twisting or wringing motions, and went 
 away entirely after rest. He had heard it attributed by surgeons on 
 the spot to effusion under the periosteum. The use of a strap round 
 the wrist used to prevent its recurrence. It is tolerably clear in this 
 case that the swelling could not have been from cramp in the fleshy 
 fibres of a muscle, for none exist at the point indicated. The appear- 
 ance of whiteness negatives the idea of the swellings being purely, if at 
 all, inflammatory. Their tenderness and painfulness would lead to the 
 belief that there was great stretching of some fibrous structure. I have 
 not any personal experience on the subject, but I would suggest the 
 possibility that, in these cases, the periosteum has in reality been torn 
 from the bone, and an effusion of serum and blood poured out between 
 the two, which is readily absorbed under favourable circumstances. 
 
 c2
 
 20 DIAGNOSIS. 
 
 the lady was once more able to enjoy life, and enter 
 into its pleasures. A party of attached relatives, 
 who had come to condole with her, remained to con- 
 gratulate. The pains, and aches, and spasms had 
 all gone; the cough was all but well; and she, who 
 had previously risen at eleven and retired at eight, 
 now rose at eight o'clock and retired at eleven. 
 She has since had attacks of bronchitis, but the 
 cramps in the abdominal walls have never returned. 
 It will naturally be expected that I should say 
 something about the diagnosis of muscular (and 
 fibrous) pains. 
 
 1. They are almost always described as hot or 
 burning. 
 
 2. They are absent in the morning on getting 
 up, and go on increasing in severity till bed-time, 
 when they cease. If they follow excessive exer- 
 tion, they come on first thing in the morning, and 
 subside gradually. 
 
 3. The pain is referred to some muscle, or to 
 some part where it is fibrous, and is aggravated by 
 bringing it into increased action. At first, and as 
 a general rule, the pain is relieved by the steady 
 pressure of the hand, but after it has continued 
 for some time, the parts become tender to the touch, 
 and pressure cannot be borne. A similar result 
 follows, if the exertion of the muscles has been 
 absolutely as well as relatively excessive. There is 
 great variety in this symptom, according to the 
 condition of the patient, and whether the pain is
 
 DIAGNOSIS. 21 
 
 the result of a strain upon the fibrous, or cramp in 
 the fleshy part of the muscle. As far as my expe- 
 rience goes, it appears that in nineteen cases out of 
 twenty, the patient tries to relieve and sometimes 
 even to describe the pain to another person by 
 pressure upon its ordinary seat.* 
 
 4. It can be traced to unusual exertion in a 
 strong person, or to a weak muscle having to do 
 the work of a strong one. 
 
 I do not know any point in the diagnosis that 
 requires a more ready power of appreciation than 
 this. Unless the mind is imbued with the possi- 
 
 * My friend who furnished matter for the last note made some valu- 
 able observations on this point. He said it was very common to find 
 many persons in an Australian journey suffer intensely from muscular 
 pains. " We scarcely ever thought of calling anything a journey," he 
 remarked, " unless it lasted at least a week or ten days. They were 
 made in drays, carts, or waggons, with the men, mostly on foot, carry- 
 ing their guns, revolvers, or other light things. The tracks were so 
 heavy, that he could only compare the fatigue to that experienced in 
 walking over a newly-ploughed field after rain, or over deep dry sand. 
 The travellers planted their feet apart, and walked with a rolling gait. 
 The first day all went well : people were tired, and that was all. Next 
 day, those not inured to fatigue had frequent stitches in the side, and 
 could not make a long day's walk. At night they could not sleep on 
 the side, only on the back ; and ideas of liver disease and pleurisy were 
 discussed at the camp fire. The next day the pain in the side terribly 
 augmented, and the day's work was shortened accordingly. By this time, 
 the whole sides were so tender that all sorts of plans were resorted 
 to to keep off the shirt from touching the skin (of course, had this 
 been met with in a woman, it would at once have been called hysterical 
 by the doctor). Those who had previously led a sedentary life were the 
 greatest sufferers. Many threw away all the goods they had to carry. 
 Two or three days' rest, without other appliances, completely cured 
 them." 
 
 In Part II. will be given the case of a housemaid who had similar 
 cutaneous tenderness from over-exertion.
 
 22 CASE. 
 
 bility of such and such an occurrence being " too 
 much" for the abdominal walls unless it is pre- 
 pared to believe that a walk of a few yards would 
 overpower them that sitting or standing may 
 produce epigastric or pubic pain the real cause of 
 the complaint will not be discovered. Many of the 
 cases I shall hereafter detail will illustrate this 
 point. I append three here, which are the more 
 interesting as two occurred in physicians, one of 
 whom was in full possession of my views on the 
 subject; the last of the three occurred in a per- 
 sonal friend of Mrs. T., and in the practice of a 
 medical man with whom I had had many a dis- 
 cussion on muscular pains : 
 
 G. 0. F., a young medical man, set. twenty-six, 
 tall and healthy-looking, though with a contracted 
 chest, came to consult me at the North Hospital, 
 Liverpool, respecting a severe and harassing pain 
 two or three inches on the right side of the lower 
 end of the sternum. I learned that two years ago 
 he had had measles, which left him weakly : he had 
 then what he assured me was pleuro-pneumonia, for 
 which he had taken a great deal of mercury; he 
 had continued very weak for some time, but in 
 other respects had recovered perfectly ; he re- 
 mained well until six months ago, when he had an 
 attack of influenza, which was attended with some 
 cough and expectoration; since then he has been 
 getting thinner, and has suffered much from pain 
 in the side. To regain his strength he had been
 
 CASE. 23 
 
 travelling, being always on the move for the last 
 two months. His daily average of travelling was 
 about eight hours, and his longest rest two or three 
 days, but that was only when he felt knocked up. 
 He had latterly been pedestrianizing in Scotland. 
 His diet was bread and milk : stimulants he fancied 
 made his side worse. His family connexions were 
 all healthy. His pulse was eighty-four (standing), 
 his breathing easy, and his complexion healthy. A 
 careful examination of his chest failed to detect 
 any abnormal phenomenon. A farther investiga- 
 tion elicited that the pain was worst after a day's 
 fatigue that it was relieved by pressure (although 
 the part seemed very tender when percussion was 
 made over it) by pressing with a firm hand over 
 the place a deeper breath could be taken than 
 without : the stitch-like pain only came on when 
 the intercostal muscles were strongly contracted, 
 and it went off just in the same way as cramp 
 elsewhere does. I farther ascertained that while 
 pedestrianizing he had made very free use of a 
 walking-stick, which he was often obliged to transfer 
 from the right-hand to the left on account of the 
 fatigue of the shoulder it produced. He was 
 always better on Sunday and on Monday morning. 
 I ventured to assure him that the pain was purely 
 muscular, and required little more than generous 
 living, tonics, and rest, with the addition of some 
 local anodyne liniment. 
 
 Another case of a precisely similar description
 
 24 CASE. 
 
 occurred in a distinguished physician who had been 
 threatened with phthisis. The pain in this case was 
 referred to the same part as in the preceding one, 
 but it was supposed to be more formidable, as it 
 was accompanied by a considerable amount of ex- 
 pectoration, and perspiration at night. The pulse, 
 however, was only 80. The skin was cool. The 
 nature of the pain was similar to that in the last 
 case. There was no physical sign of pleurisy, but 
 the patient had been for some days living very 
 abstemiously, and had been occupied for many 
 hours daily in overlooking and arranging papers, 
 &c., in which he had, of course, to employ his 
 right arm principally. A few glasses of wine 
 extra, and some steel, with more rest, set him right 
 again in a day or two. Here, as in so many other 
 instances, there was no suspicion that the pain 
 might be muscular, because it was supposed that 
 there had not been unusual exertion. The exer- 
 tion had in reality been unusual only because the 
 muscles had been, when weak, called upon to do 
 the same duty as when they were strong.* 
 
 * A day or two after this case was seen, I was called in to see a 
 gentleman who had a cavity under the left clavicle, and was exceedingly 
 anxious about the right side, as he had had severe pain in it, which I 
 could not refer to any one spot. There was no physical sign of pleurisy 
 or disease of the lung, and no tenderness on pressure. He had had 
 it only after a long railway journey but it " caught his breath." 
 " I think, however," added his ordinary attendant, " that it is only a 
 muscular pain, for if he draws in his breath slowly through the nostrils, 
 lie does not have the stitch ; but if he opens his mouth and takes in a 
 full breath rapidly, he is at once drawn on one side, with his hand on 
 the seat of pain." This medical case is well worth remembering.
 
 CASE. 25 
 
 The following case illustrates the severity of the 
 suffering, and the uselessness of antispasmodics to 
 relieve it : 
 
 Mr. B., set. forty, of sedentary habits, very thin 
 and pale, and of small build, consulted me for a 
 distressing spasmodic affection. The history was 
 this. About five weeks ago he had a serious 
 attack of haemoptysis, which reduced him conside- 
 rably. He took for it some turpentine, which 
 checked the bleeding, but its administration was 
 followed by intense pain in the right hypochon- 
 drium, vomiting, and constipation. These symp- 
 toms were relieved by copious enemata, and he 
 then began to suffer from spasms, referred to both 
 sides. He had been suffering latterly from irri- 
 table cough, and had not been able to lie down 
 for three weeks, the attempt producing violent 
 cough and spasmodic action of all the muscles of 
 respiration ; and during the whole of that time he 
 had not had an hour's continuous sleep. His ordi- 
 nary attitude was sitting in the erect posture, or 
 stooping forwards. On examination, I found faint 
 crepitation under the left clavicle, and absence of 
 any respiration over the lower lobe of the right 
 lung. The pulse was feeble, the voice weak, the 
 appetite gone, and the bowels, as was to be ex- 
 pected, sluggish and constipated. As there were 
 no signs of inflammation present as there were 
 all the requisites to produce muscular pain and 
 spasm, i. e., a debilitated frame and unusual exer-
 
 26 DIAGNOSIS CONTINUED. 
 
 tion of the muscles, in keeping the body constantly 
 erect, and in the action of coughing frequently and 
 as the spasmodic nature of the affection was well 
 marked, the diagnosis appeared easy, and the indi- 
 cations of treatment plain, morphia was given in 
 quarter-grain doses, to reduce the irritability of the 
 chest and of the muscles, and a liniment, composed 
 of laudanum and camphorated oil, was used freely 
 over both sides, from the arms to the pelvis. The 
 treatment was eminently successful. He slept 
 four hours the first night without awaking. The 
 next night he was able to go to bed. The cough 
 ceased, the spasms left the intercostals, and were 
 confined now to the external oblique, &c., and 
 were reduced greatly in intensity. In ten days he 
 slept in bed for the whole night without awaking, 
 had a return of appetite, and increased strength, and 
 was declared convalescent, and able to go into the 
 country for the benefit of change of air. The phthi- 
 sical symptoms, however, shortly returned, and he 
 succumbed under them. It is worth noting in this 
 case that ether, chloroform, and assafoetida had been 
 freely tried before the morphia was used, but they 
 had not given relief after the second day's use. 
 
 5. The pain is relieved by relaxation, or artificial 
 support. The assistance which this observation 
 gives to the diagnosis is immense, though, as may 
 readily be understood, it is not always available. 
 The following case was one of great uncertainty, 
 until it was cleared up by attention to this sign.
 
 CASE. 27 
 
 J. G. 0., a?t. forty-eight, a gentleman of stout, 
 tall frame, strong looking, and of great energy, com- 
 plained of severe and sometimes intense pain, re- 
 ferred to a small spot corresponding with the tendi- 
 nous portion of the rhomboideus major on the left 
 side. This was at times so agonizing as to preclude 
 any attention to business. He then went to bed, and 
 almost immediately "felt himself in heaven " the 
 relief was complete. He was the editor of a news- 
 paper, and worked indefatigably with his pen ; had 
 suffered from this symptom for many years ; had had 
 it referred by one medical adviser to the liver, by an- 
 other to the gall-bladder, by another to indigestion, 
 &c. A close examination could detect nothing wrong 
 in the chest, in the region of the liver, &c. The 
 pain was described as frequently changing its seat, 
 now being on the right side, now on the left, but 
 always confined to a space between the spine and 
 scapulae. He had pain sometimes, though rarely, 
 in the spine and occiput: there was no tenderness 
 on pressure. Blisters, opiates, &c., gave no per- 
 manent relief. I considered it to be muscular in 
 its nature, arising from the contraction of the 
 rhomboids, a thing of which every one must be 
 painfully conscious who writes for a long period 
 without resting; but the case was by no means 
 clear. I was called in a second time, and made 
 still fuller inquiries than before. The only new 
 fact I could elicit was that there was loss of appe- 
 tite and great abstinence from stimulants, and that
 
 28 DIAGNOSIS CONTINUED. 
 
 the time occupied in writing was at least twelve 
 hours a day. The pain had shifted once or twice 
 since my first visit, from the left to the right side, 
 and back again, and once again to the right ; and 
 he had tried change of air, without any advantage. 
 I found him writing in bed, lying on his side 
 the only position, he said, in which he could now 
 do so comfortably. Being a man of great intel- 
 ligence, he was asked to put himself into the atti- 
 tude which gave him the most relief. He imme- 
 diately threw his head and arms back as far as he 
 could, and said, " There, that position gives me in- 
 stant relief." It was thus clear that his sufferings 
 
 O 
 
 arose from too great and constant a strain upon 
 the trapezius and rhomboid muscles; but when the 
 cause was detected, we were still a long way from 
 the cure. The patient could not give a sufficient 
 amount of rest to the muscles without injuring his 
 business ; and we were obliged to content ourselves 
 with recommending such means as we could sug- 
 gest for relieving the habitual strain on the muscles, 
 and improving the general tone of the system. 
 
 6. However severe the pain, the pulse is unaf- 
 fected, although it may be softer and weaker than 
 natural. This is a point of no small assistance in 
 our diagnosis, especially in some of those cases 
 where the pain is so severe and persistent as to 
 lead to a doubt respecting the presence of inflam- 
 mation, as the following case will show: 
 
 Mr. M., ret. 28, a student in medicine, and in
 
 CASE. 29 
 
 business as a druggist, of strong frame, and of per- 
 fectly correct and temperate habits, sent for me 
 one day, under the impression that he was suffering 
 from peritonitis, affecting the caacum and the as- 
 cending colon principally. The following was the 
 history he gave : A few weeks preceding my visit 
 he had had sore-throat, which ended in quinsy; 
 for this he took aperient medicine, and lived very 
 abstemiously. As soon as he was able, he went, as 
 usual, to attend lecture, walking about two miles 
 and a half; and this, in addition to a good deal of 
 standing, necessitated by his business, was too 
 much for him in the impoverished condition of his 
 system. At night he was seized suddenly with 
 pain in he right iliac region and in the loins. He 
 now put himself under the care of a surgeon, who 
 treated him as for inflammation, with mercury to 
 salivation, low diet, &c. He was confined to bed, 
 but was after a short time able to go about. He 
 then went again to lecture, in a car. He was only 
 able to stand it for three days, and was then as 
 bad as at first, and in very low spirits. Without 
 farther advice, he applied a blister to the seat of 
 pain, took more mercury, purged himself dutifully, 
 and continued on low diet. I found him pale, with 
 anxious features, perspiring freely, with a clean 
 tongue, and a pulse sixty-four when lying down, 
 seventy-four when sitting up. The seat of pain 
 was the junction of the right obliquus externus, with 
 its aponeurosis. There was some pain on the left
 
 30 DIAGNOSIS CONTINUED. 
 
 side, but not much. The pain had always been 
 relieved by lying down, but it came on as bad as 
 ever after he had been sitting up, or going about 
 for a few hours. He felt so weak, " that if he had 
 had any cough he would have fancied he was going 
 into decline." His appetite was good, but he dared 
 not to indulge it. Whenever he had taken a good 
 meal, " he always fancied he was better for it." 
 I easily persuaded him that his pain was entirely 
 due to over-exertion of the abdominal muscles 
 while he was in a weakly condition. Steel, cod-oil, 
 moderate exercise in the open air, and as full a diet 
 as his digestion would bear, were recommended. 
 The freedom from his fear of peritonitis acted at 
 once as a stimulant, and ere my visit was over 
 there was a change for the better in his features, 
 and in a week he was perfectly restored. 
 
 7. The patient, in describing the seat of pain, 
 almost invariably, though of course unconsciously, 
 moves the hand in the course of the fibres of the 
 affected muscles. It was this that, in the case of 
 Mrs. T., afforded me the clue to the cause of her 
 suffering. In giving me an account of the way the 
 pains ran, her hand mapped out, as clearly as if she 
 had been an anatomist, the ascending, descending, 
 and horizontal fibres of the trapezius, the perpen- 
 dicular fibres of the quadratus lumborum and 
 rectus abdominis, the oblique course of the external 
 oblique, and the horizontal course of the transver- 
 salis. With the idea of spinal disorder before his
 
 DIAGNOSIS CONTINUED. 31 
 
 judgment, the practitioner would seek to find in the . 
 nerves supplying these parts the true cause of the 
 peculiar sensations, and would be puzzled how to 
 account for them on any adequate hypothesis, but 
 on a muscular hypothesis they are as plain as pos- 
 sible. 
 
 Where the pain is a fixed one, it almost invari- 
 ably occupies a spot which is more or less tendinous, 
 and this should at once enable us to distinguish it 
 from neuralgia. There is, however, one exception 
 to this point of diagnosis, to which I shall hereafter 
 refer. A woman cannot be expected to point to 
 the pubic insertion of the rectus she always points 
 to the hypogastric region instead but, as far as 
 my experience goes, the practitioner will have no 
 difficulty in gaining the information he requires by 
 indicating on his own person the precise seat of 
 pain. I find, too, that many women suffer pain at 
 the origin of the lesser pectoral, which they do 
 not tell of, lest it should necessitate an examination 
 of the mammaB. 
 
 8. The pain of cramp often comes on suddenly 
 during the night, while the patient is moving. 
 
 This point is one of great physiological interest, 
 as well as of pathological importance. It is curious 
 that a muscle which has been thoroughly fatigued 
 should not become cramped until it had been rested 
 to a greater or less extent by sleep. 
 
 The explanation of this is not perfectly satisfac- 
 tory; but we may refer to the fact that cramp is
 
 32 CEAMP. 
 
 often produced during sleep from some cerebral 
 cause, that there is generally a faint general con- 
 vulsion as soon as sleep comes on (as many persons 
 nodding in church discover to their annoyance), 
 and, as we have before noticed, stiffness rarely 
 comes on after great exertion until sleep has inter- 
 vened. 
 
 But, whatever the explanation, it is, as far as my 
 experience extends, an undeniable fact, that in a 
 weakly person cramp will come on in a fatigued 
 muscle during sleep ; and that the pain attending it 
 will be more excessive, and its duration generally 
 intermitting for a few minutes at a time will be 
 more considerable than if it had come on by day. 
 
 I have known a lady affected in this manner 
 after a comparatively short railway journey, and 
 be almost on the scream from three o'clock one 
 morning to the ensuing midnight, and that in spite 
 of large doses of morphia. A similar instance where 
 the lady had been only riding about four miles in 
 a car will be given by and bye.
 
 PARTS AFFECTED, 33 
 
 CHAPTER III. 
 
 The parts of the body most commonly affected The occipital region 
 
 Extension of pain along the occipito-frontalis The sterno- 
 mastoid and temporal sometimes affected Pain in sterno-clavicular 
 insertion of trapezius Case of Miss I. Pain in interscapular 
 aponeurosis, and attachment of ligamentum nucha? Longissimus 
 dorsi affected Cases of Nurse and Mrs. W. I. Causes some- 
 times difficult of detection Case of Mrs. L. Advantage of stays 
 in giving artificial support Quadratus lumborum affected with 
 others Gives rise to suspicion of disease of liver Case of Mrs. N. 
 
 Glutei muscles and erectores spinse affected Case of Mrs. B. 
 
 Mr Pectorals and intercostals affected Stitch in side 
 
 Its cause Pleurodynia Diagnosis from pleurisy Case of 
 Mr. B. Diaphragm affected The symptoms Abdominal walls 
 
 Pain under mamma, right or left, accounted for Epigastric 
 pain Its cause Case of I. W. Danger of mistaking these 
 pains for inflammation, &c. Pain in side of abdomen during preg- 
 nancy Its cause assigned Case Question whether the fibrous 
 tissue is not more " stretchable" in the weak than in the strong 
 Points bearing on the inquiry Varicose veins Pain in the pubic 
 region Referred in women to the hypogastric Its cause 
 Illustrative cases Mental depression common in these affections 
 
 The reason why Pains produced in muscular system from 
 excessive vomiting Case of Mrs. L. Distinction between neu- 
 ralgic, hysterical, and muscular (or fibrous) pains Cramp in the ab- 
 dominal walls Case of Ann B. Case of pubic pain, Sarah M'G. 
 
 Painful affection of abdominal walls Case of Miss M. Mus- 
 cular pains in the extremities Case of Miss L. C. 
 
 WE have said that every part of the body is liable 
 to muscular pains. We will select now those that 
 are the most common seats; premising that we 
 shall notice them in the order of convenience, 
 rather than of their frequency. 
 
 D
 
 34 TRAPEZIUS MUSCLE AFFECTED. 
 
 As we have already given some illustrations of 
 the pain referred to the interscapular aponeurosis, 
 we may pass on to other parts of the same muscle. 
 The first case recorded will serve to show that the 
 occipital attachment is often the seat of pain : I 
 would invite particular attention to this, for in- 
 stances are perpetually occurring where, during 
 convalescence, or under other circumstances, the 
 patient complains of severe headache, and the prac- 
 titioner is misled, especially if his mind is preoccu- 
 pied with some particular idea ; the danger is the 
 greater inasmuch as the pain, which commences 
 in the occipital region, sometimes seems to be pro- 
 longed into the " occipito-frontalis." The pain is 
 sometimes referred to the insertion of the sterno- 
 mastoid, and the origin of the temporal. Mistakes 
 may readily be avoided by requesting the patient 
 to put her fingers on the seat of pain. 
 
 Pain is also referred to the claviculo-scapular 
 insertion of the trapezius, and it is exceedingly 
 probable that this occurs to a far greater extent 
 than we have hitherto supposed. How many must 
 have noticed the frequent occurrence of pain in 
 the shoulder in phthisical subjects so common 
 indeed as to be considered by many as a charac- 
 teristic sign of chronic local pleurisy and yet how 
 strong must have been the feeling of surprise in 
 many to find that the patient refers the pain to a 
 part distant from the apex of the lung. I must 
 confess to having long known the symptom, yet
 
 CASE. 35 
 
 never recognised its significance until the following 
 case came under my care. 
 
 Miss I., aet. twenty-three, a milliner of very 
 spare frame, came to consult me with all the symp- 
 toms of incipient phthisis. There were, however, 
 no well-marked physical signs to be detected on 
 an examination of the chest. She was very weak, 
 and unable to pursue her occupation. Under 
 the use of steel, cod-oil, &c., she improved con- 
 siderably. But she now began to complain of 
 pain in the shoulder, similar to what she had 
 when first she had been taken ill. I at once ex- 
 amined the thorax, and finding no sign of pleu- 
 risy, made farther inquiry respecting the pain. 
 She pointed out as its seat the trapezius muscle in 
 its course from the occiput to its claviculo-scapu- 
 lar attachment. My next inquiry was, what had 
 she been doing? She had been able to return to 
 sewing and knitting! and both of them brought 
 on the pain. When the pain came on, which it 
 never did till an hour or two after she had got up, 
 she commonly laid her work down and went out 
 for a walk : this increased her sufferings the pain 
 increased till bed-time, and was not easy in bed un- 
 less she lay with her head still. She did not use an 
 arm-chair, never went to rest during the day, &c. 
 Here it was evident that the trapezius was over- 
 worked in having habitually to support the weight 
 of the head and shoulders in knitting, &c. I scarcely 
 need add that my only prescription was the use of 
 
 D2
 
 36 LONGISSIMUS DORSI AFFECTED. 
 
 an arm-chair. Pain in the infra-clavicular region 
 is also common from excessive use of the pectoral 
 muscle. I can scarcely leave this point without 
 recalling to those of my own sex the difficulty 
 they have in reading in a carriage for any length 
 of time, walking arm-in-arm, with a friend, carry- 
 ing a gun, a great-coat, or any other thing which 
 brings the trapezius into action, without feeling 
 thoroughly weary in the " shoulder." Is it, then, 
 to be wondered at that females, whose sensibility 
 is so much more exalted than ours, should have 
 pain from similar causes? 
 
 Next to the trapezius, the longissimus dorsi, or 
 erector spinae, is the most frequently affected as 
 might readily be anticipated by the work which it 
 has to perform in keeping the body erect during 
 sitting, standing, and walking. We are all familiar 
 with pain in this muscle after having had a long 
 ride in a railway-carriage, a long stand in a crowd, 
 and the like. It is to be noted, too, that a con- 
 tinued stretching of its strong fibrous aponeurosis 
 is productive of as much inconvenience as over- 
 exertion of the muscular structure, thus, digging 
 or weeding in a garden, or working in any position 
 that requires much stooping, becomes almost in- 
 tolerable after a certain time. 
 
 In practice I have found pain in this muscle is 
 brought on by railway travelling, by having to 
 carry a heavy infant or other great weight a large 
 portion of the day ; and, as might be expected, it
 
 CASE, 37 
 
 is extremely common in pregnant women, upon 
 whom there is so great an additional burden 
 thrown. Referring to works on spinal irritation, 
 and reading cases detailed there, we may add, that 
 the practice of carrying heavy weights upon the 
 head, such as water, stones, fish, &c., have been a 
 very fertile source of pain in the lumbar muscles. 
 
 The following are good illustrations of the 
 phenomena resulting from excessive action of the 
 erectores spinaB, &c. 
 
 I was consulted, a few days ago, by a lady, 
 respecting her nurse, an elderly woman, upwards 
 of fifty, who had been brought home in a sort of 
 fit, and who had ever since been complaining of 
 severe pain in the back. Inflammation of the 
 spine had been feared, and she had been recom- 
 mended to apply blisters, and to take aperient 
 medicines. The woman had taken the latter, but 
 refused to apply the former, till she had seen me. 
 A short inquiry elicited that she had lost her 
 appetite for some time back; that the child she 
 had to carry was very heavy ; that the fit resem- 
 bled an ordinary fainting one, and that the pain in 
 the back had existed long before the fit, but had 
 been more severe afterwards. It was compared to 
 hot water poured down the back, getting hotter and 
 hotter, till bed-time. It rarely came on before noon, 
 was always relieved by throwing the head and 
 shoulders back, and was well the instant she lay 
 down. The pain, I found by manipulation of
 
 38 CASE. 
 
 various parts, was the worst in the erector spinse, 
 on both sides, and in the aponeurosis of the tra- 
 pezius muscle. I recommended simply a tonic, 
 rest during the day, in the recumbent posture, for 
 half an hour, and an abstinence from all depressing 
 agents, and when I next heard of her she was 
 perfectly well. 
 
 Mrs. W. J., set. thirty, of spare build, of very 
 active habits, and living in a healthy part of the 
 country, was suddenly seized with intense pain in 
 the small of the back, on the right side. Her 
 husband, fearing some deep-seated inflammation, 
 sent for me. I elicited the following account : 
 She had been, for the last ten days, complaining of 
 lumbar pain, which was especially severe at night, 
 but went off when she lay down. She had been 
 exerting herself, more than usual, in carrying 
 water to her husband's room, who was laid up 
 with an accident, and had much stooping over him. 
 There was company in the house, and she could 
 take no rest during the day. Her appetite failed. 
 On the night in question, she had been carrying 
 away a heavy slop-pail, and, on her putting it 
 down and rising again, a sudden and intense pain 
 in the right lumbar region seized her; a lump 
 came, the size of a small lemon, in the fleshy part 
 of the longissimus dorsi, evidently cramp ; she al- 
 most fainted; was pulled by her husband on to the 
 bed, and was then seized with a severe rigor. On 
 rising for a necessary purpose, the pain returned
 
 CASE. 39 
 
 with renewed violence, and it was with difficulty 
 another fainting fit and rigor were staved off. By 
 rest the pain was relieved, but did not go away 
 entirely; coughing, laughing, and any attempt to 
 turn, brought it on again. The pulse was quiet. 
 It was not difficult to explain the phenomena, and 
 to prescribe for the cure. 
 
 Rest in bed for a few hours, a more frequent re- 
 course during the day to the sofa, and a diminution 
 of work, together with a few doses of steel, brought 
 the patient round directly. 
 
 In this case the cause was readily detected; in 
 others it is a little more difficult to find. This 
 arises chiefly from the preconceived notion that 
 the exertion must necessarily appear to the patient 
 and the doctor as extraordinary. If, however, we 
 bear in mind that the commonest efforts may be- 
 come excessive, in consequence of diminished 
 strength, we shall never be at a loss. Who, for 
 example, would consider that riding four miles in 
 a car would prove an extraordinary exertion to one 
 who had been riding almost daily for a week ; yet, 
 that it was so, the following case will prove, in 
 which the abdominal muscles were implicated, as 
 well as the erector spinae, &c. : 
 
 Mrs. L., aet. thirty-eight, a lady of somewhat 
 delicate constitution, but of active habits, and one 
 who had never worn stays,* came under my care 
 
 * I mention this circumstance because it is evident, from another 
 case which I shall relate, that a well-made corset does give a great
 
 40 CASE. 
 
 for hemicrania. She had been much harassed by 
 servants leaving her, and had to undergo great 
 exertion in managing her large family and house- 
 hold. She had also at the time profuse menor- 
 rhagia, and subsequently an attack of diarrhoea. 
 She had every morning a very suspicious cough 
 and distressing sickness, and was in very low 
 spirits, as she dreaded an attack similar to a pre- 
 ceding one, which nearly brought her to the 
 grave. She gradually grew worse, and lost all 
 appetite ; the cough increased, and there were fits 
 of excessive despondency. Change of air was re- 
 commended, and she went out daily for a drive, 
 but came back exhausted. She then went for a 
 time to Bootle. She felt revived at first, and 
 slept comfortably for a few hours, but was then 
 awakened by intolerable pain in the right flank, 
 and a swelling, the size of an egg, attended with 
 vibrating sensations. The acute pain left her, but 
 was constantly recurring in mitigated degrees, 
 
 deal of artificial support to the body. This is evident from the greater 
 length of time that women can sit npright compared with our own sex 
 from the atrophied condition of the longissimus dorsi in the female 
 compared with the male from the excessive difficulty women accus- 
 tomed to stays have in dispensing with them during the day and the 
 frequency with which spasm or cramp comes on in some of the erect- 
 keeping muscles when the stays are laid aside. An individual, there- 
 fore, without any artificial support, is more obnoxious to muscular 
 pain in the trunk than one who does not attempt to keep the body up- 
 right without assistance. When stays are not worn, a simple elastic 
 belt is of great service. It has been objected, that stays impede respira- 
 tion by interfering with the action of the diaphragm ; but this does not 
 hold in the female sex, for, as Dr. Walshe has shown, they breathe with 
 the upper part of the chest habitually, and not like man, with the lower.
 
 CASE. 41 
 
 both when she moved and lay still. She tried 
 chloroform externally, and sinapisms, without 
 effect. No position could be found which gave 
 relief, except the curious one of lying across the 
 bed with the face over one side and the feet over 
 the other, or with a hard pillow under the affected 
 side (i. e., to stretch the cramped muscles as much 
 as possible). The pain now extended towards the 
 median line, with a swelling under the right ribs, 
 and a drawing or grasping feel in the external 
 oblique. From previous experience, she felt as- 
 sured that the pain was inflammatory. I had no 
 hesitation in assuring her that the pain was mus- 
 cular, that it was on the right side only, because 
 she had used that side most in leaning against the 
 car (her husband sat on the left). It was, how- 
 ever, with great reluctance that she accepted this 
 solution of her case. Instead of punishing her 
 with severe remedies, I applied a strong solution 
 of morphia sprinkled on cotton wool to the part 
 affected, and kept it in its place by a long roller 
 towel applied as it is after confinement. A sooth- 
 ing and tonic plan of treatment was kept up, and 
 this, with the rest, quiet, and change, speedily re- 
 stored her to comparative health. I have since 
 ascertained that she had previously been a victim 
 to muscular pains in many other parts. Her first 
 attempt at walking, after her long illness, was at- 
 tended with intense cramp in the rectus abdominis 
 and external oblique, which came on immediately
 
 42 QUADRATUS LUMBORUM AFFECTED. 
 
 on leaving a car in which she had been taking an 
 airing, and for some time prevented progression. 
 She had suffered habitually during pregnancy from 
 aching in Poupart's ligament, and has often had 
 to rest her head for an hour at a time to escape 
 from spasm or burning ache in the trapezius. She 
 has had pain in the tendinous expansion of the tri- 
 ceps extensor cubiti, from resting her head on her 
 hand, &c., and is no stranger to pain in the pubic 
 insertion of the rectus. Having never recognised 
 the cause of these pains, she had been labouring 
 under the idea that she had a disease that medicine 
 could not touch. The dissipation of this perpetual 
 dread formed no slight element in the cure. 
 
 The quadratus lumborum is sometimes the seat of 
 pain, and from its position, both patient and doctor 
 too often assume the existence of disease of the liver. 
 
 The following illustrates the amount of mischief 
 produced by such a mistaken diagnosis : 
 
 Mrs. N., set. sixty-four, came to consult me one 
 day respecting the manner in which she was to 
 take a mercurial pill and saline aperient that had 
 been prescribed for her by her last medical adviser, 
 but which had been accompanied by rather ambi- 
 guous directions. Having known her for many 
 years, and being greatly shocked by her altered 
 appearance and extremely feeble voice and man- 
 ner, and having heard much from her relatives 
 about the pertinacious manner in which she had 
 dosed herself with aperients, I took the oppor-
 
 CASE. 43 
 
 tunity of inveighing against so much medicine, and 
 pointed out a variety of mischiefs that had already 
 occurred to her, and others which might be anti- 
 cipated. She was, however, for a long time deaf 
 to my advice, for she was convinced, from certain 
 sensations in her right leg and thigh, that she was 
 threatened with apoplexy. She suffered, too, from 
 pain in the right side, which all her doctors, and 
 she had had many, assured her was "liver;" and 
 to crown all, these pains were always improved, she 
 assured me, the day after she had taken her pills, fyc. 
 I told her she ran a risk of purging herself into an 
 apoplexy rather than out of one, and ended by 
 recommending cod-liver oil. Circumstances gave 
 me full opportunities for noticing her habits, and 
 in them I fancied I could see the cause of her ail- 
 ments. I found her sensibly weakened in voice 
 and muscular power after every pill she took, and 
 that on that day, as a natural consequence, she 
 passed an unusual long time on the sofa. In about 
 a fortnight she began to take the oil and leave off 
 blue pill, &c., and in another fortnight there was 
 so wonderful a change that she was never tired of 
 talking of it. She could now dress in one hour 
 instead of two, and Avalk four miles instead of one. 
 The oil came in for unbounded praise, and she 
 again came to consult me, to ascertain whether I 
 could effectually convince her of the non-existence 
 of disease of the liver and threatened apoplexy 
 the ghosts that had been so long haunting her.
 
 44 CASE. 
 
 Her first question was, " Do you think that I have 
 not diseased liver. I have so much pain here," 
 (placing her hand over the right quadratus lum- 
 borura muscle,) "and every doctor I have yet 
 consulted, has told me that I had?" My answer 
 was a decided no. I ran over, rapidly, the signs 
 of real disease of the liver, none of which she pre- 
 sented. I told her that there was no liver at the 
 part she pointed to, and then seeing her sitting in 
 her usual posture, I told her that the cause of all her 
 suffering was the habit she had of sitting erect, with- 
 out assistance or sufficient support. I told her she 
 would always find relief from lolling in an easy 
 chair, or lying on a sofa called to her memory 
 how that her medicine days were always followed 
 by this increased repose of body. I expatiated on 
 the freedom from pain in the morning, and its 
 steady increase till bed -time; and then its sudden 
 cure, and was proceeding to further demonstration, 
 when I was interrupted by the remark, " You're 
 right; and now I can explain the pain in my thigh 
 and leg, which I so long supposed was a sign of 
 apoplexy. I am, she continued, in the habit when 
 I sit of balancing myself just on the edge of my 
 chair, and rocking myself towards the right side, 
 and am constantly using the right leg to steady 
 myself, and when the pain is very bad I sit back, 
 and throw my foot on to a stool, and it always re- 
 lieves me; how stupid never to have thought of 
 this before." My patient left me as light-hearted
 
 GLUT7EI MUSCLES AFFECTED. 45 
 
 as she had become strong-bodied, and, in the 
 warmth of her feelings, told me that she had 
 thought she was corning to Liverpool to die, an 
 idea that was now dissipated. She left with a 
 large bottle of cod-oil, and bore a long journey 
 better than she had done for twelve years or more, 
 and has continued well up to the present time. 
 
 The glutaei muscles, which have a great deal to 
 do in keeping the body erect, and raising it up 
 after stooping, &c., may be affected in the same 
 way as others, as the following case will show : 
 
 Mrs. B., get. forty-five, summoned me to see her 
 for what she deemed was an attack of inflammation 
 of the spine, &c. I found her confined to bed, 
 with intense pain at the lower part of the back and 
 over the left glutseal region, and from her history 
 I learned that the complaint had come on two days 
 before during sleep, that it had gone off again ere 
 morning, but had returned with such violence at 
 the end of a long walk in the evening, that she had 
 been for two hours unable to move. She had 
 reached home, in a car, with great pain. She had 
 had a painful night, the suffering returning with 
 every turn she made. Towards morning the pain 
 left the one side and attacked the other, though 
 with less severity. She was easy when she lay 
 still, but the slightest movement brought on her 
 suffering. There was no fever; the pulse was 
 quiet, eighty ; the tongue was clean and moist, and 
 the appetite good. On making particular inquiry,
 
 46 CASE. 
 
 I found that the day before the attack she had been 
 for some hours engaged in rubbing down tables, 
 chairs, &c., a thing she was not accustomed to, and 
 which, of course, involved frequent stooping and 
 rising. She had been living more poorly than 
 usual for a week before, and she had felt knocked 
 up ere she went to bed, and had been much jaded 
 by her walk. I ascertained the seat of the pain 
 to be the glutaei, and that when the suffering 
 was at its height she was obliged to lie in such a 
 position as would best relax their fibres. I had no 
 scruple in assuring her that the pain was not in- 
 flammatory, that it entirely arose from the peculiar 
 nature of her exertions, and that it would soon go 
 off. I prescribed more generous living, an opiate 
 at night to procure sleep, an opiate liniment for 
 local use, and complete rest, and I had the satis- 
 faction of knowing that my patient had recovered 
 by the next evening. 
 
 This case is another illustration of the severity 
 of the crampy symptoms when they first come on 
 during sleep. 
 
 In July, 1857, I was consulted by a gentleman 
 attending the hospital and my class in medicine, 
 respecting what he feared was a disease of the liver. 
 The following was the history he gave : He was a 
 druggist, and had served his time with a surgeon. 
 His hours then were from seven in the morning to 
 eleven at night. After he had been at it for three 
 or four years he had an attack of black jaundice,
 
 CASE. 47 
 
 which was attributable to hard work, and he was 
 cured soon by aperients and tonics. After about 
 another three years he began to suffer from pain 
 in the right hypochondriac and epigastric region, 
 for which he consulted a physician, who told him 
 that he had considerable enlargement of the liver, 
 and had ordered blue pill, &c., which made him 
 worse. He had then gone away for change of 
 air, and recovered. He was married, and had 
 always lived in every respect a very temperate, 
 well-regulated life. At present his chief com- 
 plaint was referred to the region of the right 
 quadratus lumborum, &c. His urine was high- 
 coloured and lithatic. He was half " moidered" 
 on lying down in bed, and felt faint and dizzy 
 wTien he got up in the morning, and saw in the 
 glass that he looked yellow about the eyes. He 
 was not overworked now, as he had an assistant in 
 his business. His skin was sallow, cool, and moist; 
 the tongue particularly clean, the pulse small, 
 eighty-five when standing. He had been taking 
 soda powders regularly, and the bowels were open, 
 and the motions healthy. He had lost all appetite, 
 and was doing the same work as usual on a diet of 
 tea and an occasional sup of ox-tail soup! The 
 pain I ascertained rarely came on early in the day; 
 it increased in severity towards evening; it was 
 always relieved by lying down, though it sometimes 
 caught him in his sleep, and when turning in bed. 
 I had little difficulty in convincing him that his
 
 48 PLEURODYNIA. 
 
 sufferings arose from the muscles of the back, &c., 
 being called upon to perform, in a weakly condition, 
 what they were barely able to do when he was 
 strong. I recommended rest, a frequent recourse to 
 egg and brandy beaten up together (" cock-a-doodle 
 broth," as Peter Crawley calls it, in Reade's Never 
 too late to Mend}, until the healthy appetite re- 
 turned, the use of quinine as a tonic, and, if that 
 was not sufficiently strengthening, to take steel 
 and cod-oil, and by all means to have some pure 
 fresh air as soon a$ possible. Under this treatment 
 the symptoms rapidly disappeared. 
 
 I have already referred to pain affecting the pec- 
 toral muscles, and possibly the serrati. There is 
 another form of extreme interest, and one which, 
 from its close resemblance to pleurisy, might 
 readily be, as indeed it too frequently is, mistaken 
 for pleurisy. Its ordinary name is pleurodynia, 
 and it consists essentially of muscular pain, and 
 frequently cramp in the intercostal muscles. There 
 are few individuals who are not acquainted with it 
 under the name of " stitch in the side ;" and there 
 are few who do not know that it is brought on by 
 running, an exertion that involves the fullest action 
 of which the intercostals are capable, both in the 
 "working" (to borrow a nautical term) of the 
 body, as it sways about with the alternate flinging 
 of arms and legs, and from the great efforts made 
 to aerate, by full respirations, the increased quan- 
 tity of blood thrown upon the lungs. There are
 
 STITCH IN THE SIDE. 49 
 
 few, too, who do not know that stitch is most com- 
 mon in growing lads, and those who are not strong ; 
 that it does not come on till the muscles have been 
 long worked, and that as they increase in vigour 
 by practice the tendency to stitch diminishes. 
 
 But there are few who recognise the fact that 
 the intercostals have a great deal of work to do in 
 keeping the body erect, and turning it from side to 
 side, as well as in assisting respiration, and that 
 this business may be too much for them to perform 
 without pain, when they are reduced in power from 
 any general debility. Persons threatened with 
 phthisis are in a state of great weakness, and are 
 therefore particularly obnoxious to these pains; 
 and the same remark applies to growing persons, 
 delicate individuals, and others pulled down by 
 any exhausting discharge. 
 
 These pains commonly come on at night, or 
 towards evening, or after some unusual exertion, 
 such as sneezing, coughing, laughing, &c. ; they 
 are not severe at first, but are " wearing ;" and 
 as they often come on in the act of turning 
 round in bed, they interfere with sleep. They 
 resemble the pain of genuine pleurisy, inasmuch as 
 they are always aggravated, and often induced 
 sharply by taking a deep inspiration, the sudden 
 catch being decidedly marked. They differ, how- 
 ever, from pleurisy in being relieved by pressure, 
 and rarely produced by percussion (except it is 
 made directly in the intercostal space, when it will 
 
 E
 
 50 CASES OF PLEURODYNIA. 
 
 sometimes produce cramp). Of course there are 
 no physical signs of pleurisy present, but we must, 
 in making the diagnosis, ever bear in mind that 
 there may have been pleurisy years or months ago, 
 the physical signs of which are still remaining, and 
 these may, with the pain, lead to the belief in pre- 
 sent existence of disease. ( Vide note, p. 24.) 
 
 How intensely severe these intercostal pains may 
 become the following case will show : 
 
 Mr. R., set. thirty, an attorney's clerk, who had 
 been for some time under my care, with all the 
 symptoms of incipient consumption, summoned me 
 at five o'clock one morning. I found him in in- 
 tense suffering, from pain referred to both sides of 
 the thorax. The pain had come on during sleep, 
 and was so severe that he could not take a breath 
 or answer a question without its returning. He 
 kept his hands firmly fixed on both sides, as if to 
 stay its acuteness while he was in the act of speak- 
 ing. To attempt to take a deep inspiration was 
 agony. The apparent dyspnoea arid pain led me to 
 anticipate the occurrence of pleurisy, but there was 
 not a single physical sign of its existence. A 
 farther investigation proved that the intercostal 
 muscles were the seat of pain ; and the next inquiry 
 into the probable cause of this elicited the fact, 
 that after his usual day's work was over, at ten 
 o'clock at night, he had gone out at midnight to 
 join a set of " choice spirits," with whom he had 
 remained till three, and they were all such " funny
 
 DIAPHKAGM AFFECTED. 51 
 
 dogs," that he had been in a constant roar of 
 laughter all the time. He had felt nothing on his 
 return, soon fell asleep, and awoke in an hour in 
 the condition in which I found him. It was toler- 
 ably clear that he was suffering from intercostal 
 cramp ; but in spite of antispasmodics, aether, and 
 hot fomentations, some hours elapsed ere he got 
 any relief. Had I been then more experienced 
 in these affections, I should have applied a ban- 
 dage to the thorax, and given an overpowering 
 dose of opium. 
 
 Leaving for a time the consideration whether 
 the heart, an organ with all the characters of 
 voluntary muscle, may or may not be affected in 
 a manner analogous to others, we come to the 
 diaphragm, and inquire whether it is subject to 
 muscular pain, or other affections similar to the 
 intercostals, which it resembles in being a muscle 
 of respiration. 
 
 Our first consideration is, what are the diseases 
 in which the diaphragm is unusually exerted? 
 The reply is, asthma, in which it has to work with 
 greatly increased force to distend the chest ; bron- 
 chitis, in which the same phenomenon is to be 
 noticed, and some other diseases of the lungs, 
 attended with dyspnoea, &c. ; excessive cough, 
 vomiting, difficulty of defaecation, parturition, &c. 
 Our next investigation is, whether in all these 
 cases there is any symptom not fairly traceable to 
 the diseased condition of the organs themselves, to 
 
 E 2
 
 52 ABDOMINAL MUSCLES AFFECTED. 
 
 neuralgia, or to other muscles. We find it in the 
 constrictive pain round the body, the pain shooting 
 from back to epigastrium, and from side to side; 
 in the painful respiration referred to every part of 
 the diaphragm's insertion, and the sudden catch in 
 the breath following a full inspiration a catch not 
 refer rible to the inter costals or the abdominal walls. 
 
 The abdominal muscles are very commonly the 
 seat both of pain and cramp or spasm as much 
 so, probably, as those of the back. The locality 
 and intensity of the affections vary with the 
 strength and occupation of the patient. Com- 
 plaint in some is most urgent at the epigastrium ; 
 in others on the left side ; in others on the right ; 
 some complain equally of all these spots. In other 
 instances, the suffering is referred to the iliac 
 and hypogastric regions ; and in others, the hypo- 
 chondria and the umbilical regions are the seat of 
 pain, &c. 
 
 When the pain occurs on the left side, it is 
 commonly pooh-poohed, for the spleen is not very 
 liable to inflammation, or it may be called neuralgia ; 
 but when it occurs on the right side, where there is 
 .a large organ, it is supposed to indicate disease of 
 the liver, inflammation, congestion, or abscess; 
 faecal or other distension of the colon; or a new 
 growth, cancer, hydatids, &c. 
 
 When the pain occurs at the epigastrium, it is 
 referred to inflammation of the stomach, gastro- 
 t dynia, dyspepsia, spinal irritation, or some other
 
 CASE. 53 
 
 cause. The following is a good example of this 
 form of the complaint, and its origin : 
 
 John Williams, get. forty-five, labourer in a 
 white-lead works, and of tall, spare build, and 
 sallow complexion, was admitted into the Northern 
 Hospital, complaining of severe pain at the epigas- 
 trium, supposed to be the result of the baneful in- 
 fluence of lead. The pain was described as a 
 dreadful weakness, and was referred entirely to 
 the ensiform cartilage. He had been repeatedly 
 under treatment for it, and had been blistered and 
 leeched without relief. At his admission he was 
 wearing a large strengthening plaster. A close 
 examination of the heart, lungs, and abdomen failed 
 in detecting any disease. There was no blue line 
 round the gums, the tongue was clean, digestion 
 indifferent, the bowels regular, both legs were 
 very remarkable from the number and size of vari- 
 cosities in the veins. Failing to ascertain any 
 serious complaint, I asked him how he was on 
 Monday morning (i. e., after the rest of Sunday). 
 " Quite well, sir," was the answer. "And on Satur- 
 day night?" "Quite done, sir; so bad, I can 
 scarcely reach my home; it often takes me half an 
 hour " (to go half a mile), " and I am sometimes 
 fairly doubled up with pain." I next inquired 
 what his work consisted in ; and found that it was 
 to raise from the ground and throw up to a stage 
 above him heavy materials, which involved fre- 
 quent contraction, and a frequent stretching of the
 
 54 INFRA-MAMMARY PAIN: 
 
 recti muscles of the abdomen. I ascertained that 
 towards the end of the week the different segments 
 of the rectus were frequently cramped, that he had 
 about the same period " lumps " i. e., isolated 
 cramps in the left external oblique, and that he 
 had occasionally pains in the region of the erec- 
 tores spinae. I considered the case one of simple 
 over-exertion, directed the man to remain in bed, 
 gave him steel and cod-liver oil, and on my next 
 visit, two days after, the man declared himself quite 
 well. He remained in the house, however, until 
 he was sufficiently improved in health to bear the 
 hard work he had to get through without painful 
 results. 
 
 The pain complained of in the side is so very 
 common that there is scarcely one young woman 
 in three who escapes it altogether. It is, as we 
 have mentioned, sometimes situated on the left and 
 sometimes on the right, and is occasionally met 
 with on both. It may or may not be attended 
 with swelling i. e., muscular cramp. The suffer- 
 ings it involves are often very severe, and occupy 
 the patient's thoughts, to the exclusion of every- 
 thing else. By some the pain is considered to be neu- 
 ralgic, and it is constantly adduced as one of the 
 symptoms of spinal irritation. It has its seat under 
 the mamma,* at a spot corresponding to the com- 
 
 * This infra-mammary pain well deserves the closest examination by 
 the practitioner. I would suggest the following experiment : Let any 
 one stand or sit before a mirror with the chest and abdomen bare, and then
 
 ITS NATURE MISTAKEN. 55 
 
 mencement of the sheath of the rectus muscle, but it 
 is also to be met with along the margin of the ribs 
 extending along the origin of the external oblique. 
 
 I have already spoken so fully of the diagnosis 
 of this form of pain, that I need not recapitulate 
 the grounds on which the opinion of its being mus- 
 cular is based. 
 
 I have met with many instances in which an 
 inflammatory origin has been assigned, and the 
 unfortunate patient has been bled from the arm, 
 leeched, cupped, or blistered, purged with blue 
 pill, and starved on water-gruel. As from the 
 severity of the supposed disease, and the qua- 
 lity of the treatment, the patient has been confined 
 to bed, an apparent cure has followed, and the suc- 
 cess of the treatment is so marked, that when the 
 symptoms occur on the invalid's moving about as 
 usual, the same treatment is insisted on ; it is again 
 successful, and from the same cause, and this may 
 go on until the health is broken altogether. I have 
 
 attempt to approach the ribs as closely as possible to the crest of the ilium 
 a position always assumed by an individual who has become weary of 
 standing or sitting upright. He will see one spot, corresponding with 
 one of the interdigitations of the serratus magnus and external oblique, 
 where the skin seems more firmly adherent to the parts below than at 
 any other spot. This spot is precisely the one to which the pain is 
 always referred. The left is more frequently complained of than the 
 right side, because a person naturally leans more towards the former 
 than the latter. The tenderness on pressure is not genuine, for in de- 
 scribing the pain the patient almost always presses on it herself, and 
 finds relief therefrom. It is to be explained by reference to the facts 
 recorded in the notes pp. 19 and 21, to the effect that a long-continued 
 strain on a tendinous part will produce tenderness on pressure as well 
 as steady pain.
 
 56 PAIN IN THE SIDE DURING PREGNANCY. 
 
 myself had a patient who was so firmly convinced 
 of the value of the plan, that, though already anemic 
 from repeated bleedings, she came to me to be bled 
 again. It was in vain I urged that every bleeding 
 had really made her worse; she persisted in her 
 view, and went elsewhere. 
 
 Pain referred to a small spot below the mamma, 
 commonly the right, is frequently complained of by 
 women during pregnancy. The spot is about the 
 size of a shilling, and is very tender on pressure. 
 It corresponds with the upper termination of the 
 " linea semilunaris." The pain is pretty constant, 
 slightly relieved by the recumbent posture, but 
 greatly increased by lying on the affected side ; it 
 may come on during the third month, and con- 
 tinue to the time of parturition, its " wearing " 
 character greatly depressing the patient's spirits. 
 It is not relieved by leeches, blisters, or sinapisms ; 
 warm fomentations do some good, but rest is of the 
 utmost importance. Occasionally a similar pain 
 is felt in the lower end of the linea semilunaris, 
 and apparently from the same cause. It seems to 
 be due to a stretching of the fibrous tissue, from 
 the gradual enlargement of the uterus, unattended 
 with any inflammatory condition. 
 
 One case has come under my notice where a 
 lady suffered most severely from it during one 
 pregnancy, considerably during the next, and not 
 at all on a third; and the only difference that 
 could be detected was, that on the first occasion she
 
 THE FIBROUS TISSUES ARE STRETCHABLE. 57 
 
 was very weak, on the second was stronger, and on 
 the third was in good health throughout. 
 
 And here, without violating materially the plan 
 we have laid down for ourselves, we may enter 
 upon the question Are not the fibrous and other 
 tissues more easily " stretchable" when an indi- 
 vidual is in a weakly condition than in a strong? 
 We see, for example, the strong ligaments of the 
 knee-joint give way in the weakly children of 
 strumous parents, and the individuals become 
 ;t in-kneed" or "bow-legged." We see in the 
 same class the powerful ligaments of the spine give 
 way, and allow the person to have great lateral 
 curvature. From a similar cause we find the bones 
 yield to pressure and become unusually curved: 
 we find the skin give way, and the scrotum become 
 unusually long from any debilitating agency. The 
 bowels readily allow themselves to be distended by 
 flatus in the weak a most unusual occurrence in 
 the strong. The veins are no exceptions to this 
 rule, for we find them distended and varicose in 
 those only whose constitutions lack vigour ; and 
 we farther find that an individual will suffer from 
 painful distension when they are weakly, while a 
 restoration to firm health will, while it enables the 
 fibrous coats of the veins to resist more, reduce the 
 pain complained of. In illustration of this par- 
 ticular consideration, it may be added that the 
 lady whose case has just been recorded suffered 
 during the first and second pregnancies most
 
 58 HYPOGASTRIC PAIN. 
 
 severely from excessively distended veins in and 
 about the vulva ; but on the third occasion 
 there was scarcely any distension and no suf- 
 fering. 
 
 Pain in the plantar fascia, and sometimes so com- 
 plete a stretching of the fascia and the ligaments 
 of the foot as to destroy the plantar arch and make 
 a person flat-footed, is common in the weak from 
 too much walking. Weakness of the ankle is not 
 unusual from a similar cause; and I have heard 
 many pedestrians complain of the frequency with 
 which they " put their ankle out" on descending a 
 mountain at the end of a long day. It is remark- 
 able that in these circumstances, though the pain 
 is very intense for a time, it goes off without other 
 symptoms of sprain. 
 
 In many instances this facility of distension is 
 unaccompanied by pain, but when the distension is 
 in a fibrous tissue, and suddenly produced, the 
 suffering is often severe. Whether the greater 
 pain complained of by those of weakly condition 
 in the fibrous structures, from a muscular strain, is 
 due to their being more stretched, or to their being 
 
 O ' cj 
 
 in a more exalted state of sensibility, or from both 
 causes combined, it is difficult to say with cer- 
 tainty ; but the broad fact is certain, that pain in 
 the tendinous parts of muscles is both more com- 
 mon and more severe in direct proportion to the 
 debility of the individual. 
 
 This pain in the side is commonly accompanied
 
 PUBIC PAIN. 59 
 
 with another, referred to the hypogastric region; 
 and these, singly or combined, are most common 
 in housemaids, milliners, seamstresses, and others, 
 who have much stooping and using of the right 
 hand and arm. The symptoms which accompany 
 the pain are usually loss of appetite, palpitation, 
 failing strength, sometimes diarrhoea, more com- 
 monly constipation ; some disorder of the uterine 
 function is usually to be detected, the discharge 
 being either painful, scanty, absent, or profuse, and 
 there is abundant secretion of urine. Were it not 
 for the pain, the case would seem one of atonic 
 dyspepsia only, or simple debility. It was a long 
 time before I could fully comprehend the nature 
 of the hypogastric pain. I could not satisfactorily 
 refer it to the bladder, uterus, colon, or small 
 intestines. The difficulty was at last solved by a 
 young medical man who came to consult me for 
 what he considered was inflammation of the 
 bladder. " The pain," he said, "is here (pointing 
 to the pubis), right in the bone at the top." A 
 careful examination of all the other signs showed 
 that there was nothing wrong in the bladder, and 
 that the pain was confined to the insertion of the 
 rectus and the inner end of Poupart's ligament. His 
 case was one of great interest : he had had gonor- 
 rhoea, but had been perfectly well for months when 
 he began to feel this pubic pain ; but he was so 
 convinced that it was produced by vesical inflam- 
 mation that he became perfectly miserable. He
 
 60 CASE. 
 
 was house surgeon, however, to a dispensary, and 
 had an amazing amount of work to do both in 
 the surgery and visiting patients: he lived abste- 
 miously, and was low in health and spirits. The 
 pain only came on in the evening, and it made him 
 wretched, for that was the very time when he was 
 the least able to forget it, and unable from fatigue 
 to take up any active exertion. I recommended 
 tonics, and rest during the middle of the day, and 
 he soon forgot the pain ; but his mind had dwelt so 
 long upon the one idea, that a long period elapsed 
 ere he recovered perfectly the mens sana in cor- 
 pore sano. Since then I have had several opportu- 
 nities of finding that female patients, from natural 
 feelings of modesty, point to the hypogastric in- 
 stead of the pubic region, and that in a great 
 number of instances the existence of the pain is 
 suppressed altogether from a similar cause. The 
 following case illustrates the connexion between 
 the lateral and pubic pain : 
 
 Mrs. P., set. twenty-seven, came under my care 
 for severe pain in the right side, which she con- 
 sidered to be inflammatory. On examination, I 
 found that it was confined to the costal origin of 
 the external oblique; that she was free from it 
 (except in certain positions) while in bed; that it 
 came on after she had been walking, standing, or 
 sitting; that it was always worse at night, and 
 sometimes prevented her sleeping ; that when 
 severe, it came on suddenly, and went off with a
 
 MENTAL DEPKESSION. 61 
 
 twitching sensation ; pressure and warmth relieved 
 the pain ; the pulse was weak and quiet ; the 
 bowels rather confined; the tongue was slightly 
 furred and indented at the edges by the teeth ; the 
 catamenia were regular. The appetite had entirely 
 failed, and she had for some time been low and 
 easily excited to tears. I informed her that the 
 pain was not a mark of inflammation ; that it arose 
 from weakness, and endeavouring to make a debili- 
 tated muscle do the work of a strong one. I pre- 
 scribed tonics and a very generous diet, with daily 
 rest and gentle exercise in the open air, and soon 
 found the pains disappear. When subsequently 
 conversing on this subject with my patient, with a 
 view to ascertain whether she had had any other 
 pains of a similar origin, I found out that she had 
 two years previously been under medical care for 
 severe pain referred to the region of the groins and 
 the pubis; that she had been repeatedly leeched 
 under the impression that it was inflammatory; 
 that the leeches had done no good ; that the pain 
 was of a hot, aching, or burning character, and was 
 of such daily occurrence that it seemed to wear 
 her down with low spirits. On particular inquiry, 
 it appeared that the pain was confined to Poupart's 
 ligament and the insertion of the rectus muscle, 
 and she was always relieved by rest in bed or 
 lolling in an arm-chair with the legs raised. 
 
 In narrating the case, she laid peculiar stress on 
 the mental depression produced by the perpetual
 
 62 EXPLANATION. 
 
 recurrence of the suffering, and this forms a not 
 uninteresting feature in this class of cases gene- 
 rally. The despondency does not arise simply from 
 the pain, but from that condition of body upon 
 which the pain depends. We all know that when 
 an individual is weakly, either from loss of blood, 
 diarrhoea, or dyspepsia, low spirits are as common, 
 if not as constant, as are joyousness, enthusiasm, 
 and exuberance of spirits when a person has re- 
 covered health after fever, or when emancipated 
 from town influences he breathes the pure air of 
 the Cumberland or Switzerland mountains. The 
 effects of tonics are not confined simply to im- 
 proving the condition of the muscular system : they 
 affect, to a similar extent, the mental nervous sys- 
 tem, and thus the patient experiences a twofold 
 advantage ; but this advantage can never be fully 
 consummated until the patient is able to under- 
 stand thoroughly the cause of the pain; for if she 
 remain ignorant of this, at every return of the suf- 
 fering there is an increased depression of spirits, 
 from a mental being superadded to a physical cause. 
 In consequence of the character of the pain and 
 the appearance of the patient, a neuralgic origin is 
 frequently supposed, and, speaking generally, where 
 such a view gives rise to the adoption of a tonic 
 plan of treatment, little harm is done, and the 
 patient will get slowly better. The advantage, 
 however, of increased rest is such that a correct 
 diagnosis materially hastens the cure.
 
 PAIN FOLLOWS PROTRACTED VOMITING. 63 
 
 The nature of the pain in the pubis can readily 
 be understood by any one who has sat up all night 
 reading, writing, or playing at any game. Few 
 enthusiastic travellers escape it, and the accoucheur 
 who sits for many a weary hour at his patient's 
 bedside is constantly its victim. They suffer from 
 the unusual strain upon the muscle which is re- 
 quired to keep the trunk erect or bending forwards ; 
 and can we wonder, if the strong man feels pain, 
 that the poor milliner, the ill-fed seamstress, the 
 chlorotic or weakly housemaid, or sickly cook, 
 whose muscles are badly developed, suffer from a 
 similar cause? Not knowing the origin of the 
 pain, they take either no measures to relieve it, or 
 those measures are misdirected ; they try aperients, 
 leeches, and low diet; they fancy the womb is 
 at fault, and perchance get examined with the 
 speculum and duly causticed by some one who 
 sees the uterus in every female ailment ; they grow 
 miserable with the continued ache ; their mornings 
 are bearable, their evenings are all but intolerable. 
 Once explain the cause, however, and improve the 
 patient's strength, and relief soon follows by simple 
 indulgence in the recumbent posture, or supporting 
 the back in a comfortable chair. 
 
 Perhaps the most serious form in which we meet 
 with intense muscular pains, is that occurring after 
 prolonged and excessive vomiting. The healthy 
 man may feel something of this after a voyage in 
 which he has suffered from much sea-sickness. He
 
 64 CASE. 
 
 speaks of it only as extreme soreness; and he is 
 tolerably able, from having had similar pains else- 
 where, to trace it to its true cause ; but where 
 violent sickness comes on under other circum- 
 stances, and is followed by severe pain, the con- 
 nexion is too often either unsuspected or ignored. 
 The violence of the suffering suggests the idea of 
 its being dependent upon inflammation, neuralgia, 
 or hysteria ; and it is looked upon as a symptom 
 of great importance, as it is attended with rapid 
 pulse, strong evidence of disorder of the stomach 
 and bowels, and great tenderness of the parietes 
 of the abdomen. 
 
 The following is an instructive example of a 
 case of this kind, in which the sufferings were said 
 by the patient to be far more severe than those she 
 had undergone in any of her confinements : 
 
 I was called in consultation to see Mrs. L., aet. 
 thirty-eight, the lady whose case I have pre- 
 viously referred to, p. 39, and the history I ob- 
 tained was the following : After being unusually 
 well, she was induced to take a drive on a cold 
 day, by which she was thoroughly starved, and the 
 catamenia, which were "on" at the time, were 
 stopped abruptly. On her return, she had sat by a 
 warm fire, and taken some hot negus ; but the 
 discharge did not again come on, and she gradually 
 became weak, faint, and sickly, and when I saw 
 her, she was vomiting almost incessantly. She 
 seemed low and extremely weak; the pulse was
 
 CASE. 65 
 
 fluttering and variable, at one minute 104, at 
 another 120 and upwards. There was great rest- 
 lessness the patient constantly moving from bed 
 to a couch, and changing her position on each every 
 few minutes. She only spoke in whispers. It was 
 with difficulty we could see the tongue. The 
 vomiting and retching came on every half hour, 
 and were aggravated by the patient putting her 
 finger to the fauces. The ejecta were small, con- 
 sisting of mucus only. Nothing she took remained 
 on the stomach, and she had not had any sleep for 
 some time. Champagne, brandy and soda-water, 
 and morphia, were prescribed, with arrowroot and 
 brandy, in small quantities, every hour. Next day 
 the symptoms had undergone only the slightest 
 amelioration; the arrowroot alone stayed on the 
 stomach; and there was superadded severe pain in 
 the left hypochondriac region, and some tenderness 
 at the epigastrium. For this a strong solution of mor- 
 phia was applied, and subsequently a large poultice, 
 consisting of scalded hops. This produced com- 
 plete numbness of the parietes and some cessation 
 of pain. Some sleep was procured; the restless- 
 ness diminished; the pulse became stronger and 
 less variable ; the sickness abated ; and the bowels 
 were relieved by an injection of warm mutton- 
 broth : the arrowroot and brandy still stayed, and 
 beef-tea could be taken pretty well. On the fifth 
 day the vomiting had ceased entirely; but the 
 patient complained of intense pain in the trunk,
 
 66 CASE. 
 
 which shot up to the neck and head, and down the 
 hips to the knees. She was constantly moaning 
 from its severity. She described it as if starting 
 from a focus ; it rushed along in radiating lines to 
 all parts and in all directions. Up and down along 
 the erector spinae, vibrating, twitching, and tearing, 
 the pain was constant, but there were exacerbations 
 of increased severity. It was also described (by 
 the motions of the patient's hand and the words 
 she employed) as being equally severe in the ex- 
 ternal oblique, the internal oblique, the transver- 
 salis, the rectus abdominis, the quadratus lumbo- 
 rum, the latissimus dorsi, the pectorals, and the 
 gluteal and crural muscles. The attachments of 
 the diaphragm were also mapped out by the painful 
 spots. There was soreness of the skin, and tender- 
 ness on pressure. The pulse, however, was reduced 
 to 98, and was steady, and there was some refresh- 
 ing sleep at night. The lady had considerable em- 
 bonpoint, and seemed to be in good condition. 
 
 The question now to be decided was Are the 
 pains hysterical, or are they muscular? It was 
 clear that they were not inflammatory. If the 
 former, experience would lead us to expect that 
 they would be difficult to cure, and that the 
 effect of direct and active local treatment would 
 be prejudicial. If, on the other hand, they were 
 muscular, there was reason to believe that they 
 would soon wear themselves out, now that the 
 vomiting had ceased. Considering that all the
 
 CASE. 67 
 
 seats of pain complained of were occupied by volun- 
 tary muscles brought into operation by severe 
 vomiting; that the pains had not come on until 
 these muscles had been unusually, and even in- 
 tensely, exerted; that the pain was described as 
 following the course of the fibres of different 
 muscles, rather than the course of any nerves; 
 that even the pharyngeal muscles did not escape ; 
 that there was no neuralgic pain in the face or 
 head ; that the pain was moreover paroxysmal, and 
 existed in the intervals as intense soreness; that it 
 was aggravated by any motion, as, for example, 
 the effort to expel flatus ; and comparing all these 
 symptoms with those that follow prolonged sea- 
 sickness, I ventured to predict that the pain would 
 be gone, or nearly so, by the next day, and that its 
 nature was analogous to the soreness that a strong 
 man feels after unusual exertion. A mild tonic 
 was ordered as medicine, and a stimulating and 
 strongly odorous liniment was prescribed, with 
 directions for it to be used in shampooing and 
 friction frequently. In twenty-four hours the 
 pains had all but disappeared, and I took my leave 
 on the seventh day, the patient then being conva- 
 lescent. She died shortly after of inanition arising 
 from a total absence of digestive power. The em- 
 bonpoint, however, continued to the end of her life. 
 The following are cases, by no means uncommon, 
 of cramps in the abdominal muscles productive of 
 great suffering : 
 
 r2
 
 68 CASE. 
 
 Ann B., set. thirty, an exceedingly delicate-look- 
 ing woman, who had been confined about two 
 months, and was still nursing, was admitted into 
 the Northern Hospital, March 29th, 1857, with 
 "tumour of the abdomen, situated at the right 
 side." On examining her by percussion no tumour 
 could be detected, but I noticed that every stroke 
 of Piorry's hammer on the pleximeter produced 
 local spasm. I found that she had a severe cough, 
 and that when this had lasted a little time there 
 was such an intense pain in the abdomen that it 
 doubled her up, and she had to go upon her hands 
 and knees for relief. On asking her to describe 
 the seat of pain, she mapped out all the fleshy 
 parts of the abdominal muscles and the course of 
 their fibres in her description of the accession and 
 departure of the pain. The severe pain was always 
 attended with " a lump," which went away with a 
 beating sensation. The woman had no appetite; 
 had been living very badly; perspired freely, and 
 had still a profuse lochial discharge; she was 
 intensely weak, and could with difficulty move 
 about except when under the influence of the 
 terrible pain. 
 
 There was little difficulty in the diagnosis. The 
 abdominal muscles had been overworked. The 
 treatment adopted was rest in bed, cod-oil, steel, a 
 cessation from nursing, &c. The severe pains 
 never came on after the second day of her admis- 
 sion; but the first day after she was able to sit
 
 CASE. 69 
 
 up, she had pain at the epigastrium, the pubis, on 
 both sides at the infra-mammary regions, in the 
 loins, at the back of the head, between the scapula, 
 and at the shoulders. As she slowly gained 
 strength these subsided, and she left the hos- 
 pital entirely free from them at the end of two 
 months. 
 
 Here is another case, in which the sufferings 
 were less severe : 
 
 One of the nurses of the Hospital was admitted 
 as a patient into the ward, July 27, 1857; her 
 appearance and manner were nervous and hyste- 
 rical. For the last four days she had had diarrhoea, 
 attended with violent abdominal pain, and fre- 
 quent " cramps, which had made her roll about in 
 every direction for ease," they had, however, 
 ceased since she had been confined to bed. On 
 making definite inquiry, I found that she had for 
 some time had a burning or hot pain at the epi- 
 gastrium, at the right infra-marnmary region, at the 
 pubis, and along Poupart's ligament ; the catamenia 
 were all right, the appetite good, tongue clean, and 
 pulse natural. There were no special signs of hys- 
 teria. It was tolerably clear that she had been for 
 some time only just equal to her daily toil, and 
 that as soon as she was pulled down still more by 
 diarrhoea, the muscles had become more irritable 
 than before, and had suffered from cramp where 
 they had previously only been weary. 
 
 The following is a somewhat amusing instance
 
 70 CASE. 
 
 of that pain which is referred chiefly to the pubic 
 insertion of the rectus muscle : Sarah McG., aet. 
 twenty-eight, a tall, well-made Irishwoman, with 
 considerable embonpoint, and at the time acting as 
 maid-of-all-work in a house where the duties were 
 very severe, and who had been a former patient in 
 the Northern Hospital, where she had suffered from 
 intense debility, called upon me, complaining of a 
 " burning pain at the bottom of her belly, which 
 seemed as if a hot coal were always there." " Her 
 changes, too, were of a bad colour, and she could 
 not tell what was amiss with her." She attributed 
 everything to " having sat down in the dark on a 
 very dirty privy." As I had some doubts about her 
 moral propriety, I imagined that she had con- 
 tracted venereal disease, and made an examination. 
 Everything being perfectly correct, I instituted 
 further inquiries, and satisfactorily ascertained that 
 the burning pain was confined to the tendinous 
 insertion of the rectus and inner end of Poupart's 
 ligament ; that it came on towards night, and was 
 not present in the morning, &c. It was evidently 
 due to exertion beyond her strength. Of course I 
 recommended tonics, rest when practicable, &c. ; 
 but I subsequently ascertained that she had retired 
 from " service" to the " streets," and never heard 
 anything more of the case. 
 
 The following is a case in which the sensibility 
 of the abdominal parietes was raised to an extra- 
 ordinary pitch, but which does not seem to have
 
 CASE. 71 
 
 followed the ordinary course of muscular affec- 
 tions : Miss M.,set. twenty-one, of pale complexion, 
 delicate appearance, and consumptive family, yet 
 of remarkably active habits, and taking horse ex- 
 ercise for some hours daily, complained of a severe 
 paroxysmal pain in the abdomen, for which she 
 took a satisfactory amount of opening medicine. 
 As this produced no abatement, I was summoned. 
 The strictest examination could detect nothing 
 beyond pain and loss of appetite. There was no 
 feverishness, no spinal tenderness, no uterine dis- 
 order, no flatulence or indigestion ; the bowels were 
 habitually regular; there was no blue line round 
 the gums, and there were no signs of hysteria; 
 there had not been any unusual bodily exercise, or 
 any exciting mental emotion. She slept well, and 
 seemed cheerful. There was little difficulty in 
 ascertaining that the suffering was confined to the 
 abdominal muscular parietes (including the levator 
 ani) ; but it differed from the ordinary hysterical 
 pain, inasmuch as there was no shrinking from 
 pressure in any form, until it had attained suffi- 
 cient force to stretch the muscles, and it was 
 increased by any twisting motion. Warmth and 
 antispasmodics were prescribed, but without 
 marked effect, and the pain gradually increased in 
 intensity. The efforts of talking, coughing, sneez- 
 ing, defaecation, and micturition became all more 
 or less acutely painful, and she could only speak in 
 whispers. The pain was now referred principally
 
 72 CASE. 
 
 to the groins and Poupart's ligament. Any pres- 
 sure was unbearable ; she was unable to get any 
 rest; the respiration was entirely thoracic; the 
 pulse remained steady at 84 ; the tongue clean and 
 the skin natural. The ordinary position of the 
 body was extended and supine. The pain and 
 loss of sleep produced great debility. The treat- 
 ment consisted of anodynes locally applied, large 
 doses of morphia internally, nourishing diet, and 
 tonics. After having increased in severity during 
 the first four days, the pain became stationary ; in 
 two days more it began to subside. The bowels 
 were now relieved, the dose of opiates was dimi- 
 nished, the tonics were continued, and in eighteen 
 days from the commencement she was perfectly 
 cured. 
 
 As her mother had previously had a similar but 
 milder attack, which yielded to morphia in a few 
 days, the drinking water they used was analysed 
 to ascertain if it contained lead. None of this 
 metal was found, nor could the closest inquiry 
 point to any other mode in which it could have 
 been introduced. 
 
 It is not often that we are consulted respecting 
 muscular pains in the lower extremities. I have, 
 however, met with an instance where there was 
 such acute suffering in the back of both legs as to 
 lead the patient to the belief that she was begin- 
 ning with rheumatic fever. The cause was simply 
 in her having walked a long way to church on a
 
 CASE. 73 
 
 wet Sunday in a new dress and petticoats for, to 
 save these, she had gone on tiptoes ! 
 
 The following, of a different class, was one in- 
 volving very severe suffering : 
 
 Miss L. C., set. twenty-one, stout, and florid, 
 and healthy-looking, and who, I was told, had long 
 suffered from a curious affection of the knee-joint, 
 came to consult me respecting a pain referred to 
 the posterior part of the knee. The affection had 
 come on suddenly during the night. I ascertained 
 that the day before she had been quite well, en- 
 joying herself at a pic-nic party, to which she had 
 gone and returned in a pleasure-boat, having had, 
 in all, six hours' sitting in a cramped position in a 
 boat, and three hours' sitting in a carriage where 
 there was no room to stretch the legs. On exa- 
 mination, I found intense tenderness over the ten- 
 dinous portion of the biceps cruri, and that any at- 
 tempt either to bend the knee or to extend the leg 
 produced increase of pain. She had been wearing 
 a knee-cap, tightly laced, and that joint was less 
 than the other by an inch and a half. The pain 
 was constant; but, at times, there was a twitching 
 or creeping referred to the fleshy part of the 
 muscles. 
 
 I found that she was not constitutionally strong, 
 and that she was living rather low, to prevent too 
 great embonpoint. On learning these particulars, 
 I considered that the complaint was due to an un- 
 usually long sitting, in a cramped position, in a
 
 74 CASE. 
 
 pleasure-barge that it was muscular, and not 
 nervous, and that it would soon go off. I ordered, 
 locally, a strong solution of hydrochlorate of mor- 
 phia, to be used like water-dressing, an opiate pill 
 at night, quinine, and generous diet. The pain 
 was relieved by the anodyne in half an hour ; and 
 in two or three days the patient was perfectly 
 recovered, and gave up, at my request, the use of 
 the knee-cap. 
 
 She had previously suffered, she informed me, 
 from similar attacks, and had been repeatedly 
 leeched in consequence, and laid up for some 
 time. 
 
 When once, however, she understood their na- 
 ture, she avoided the causes producing them; or, 
 when present, cared little for them. At any rate, 
 she has never complained of them since to me or 
 any of her friends, though nearly six months have 
 elapsed since the last attack.* 
 
 * Since the above was in type I have been told of three cases of great 
 interest : 
 
 One occurred in a gentleman who, on visiting the Lakes, had a long 
 row in a pleasure-boat. The next day he was so ill as to summon his 
 medical attendant from a distant town, under the notion that he had 
 acute rheumatism. 
 
 A second was in a bricklayer, who, after six weeks' illness from 
 bronchitis, did a day's work at digging. On the morrow he suffered so 
 severely that rheumatic fever was suspected. In both instances there 
 was tenderness on pressure over the abdomen : in the latter this was 
 excessive and universal. 
 
 The third was a case of intensely painful cramps in the lower ex- 
 tremities. It occurred in a delicate young lady who had just returned 
 from a ball, where she had been dancing with great animation the 
 greatest part of five hours.
 
 APHORISMS. 75 
 
 CHAPTER IV. 
 
 Causes which predispose to muscular disorders Aphorisms The 
 irritability of a muscle is proportionate to its debility Muscular 
 action exhaustive Various causes of muscular exhaustion or de- 
 bility Uterine disease a common concomitant, not a cause, of 
 muscular disorders Hysteria, the vague use of the term ; its 
 necessary connexion with the uterus doubted Can gout be referred 
 to the testes ? Comparison of reasons The nature of chorea 
 and convulsive diseases hinted at Palpitation a proof of cardiac 
 debility, 
 
 LEAVING for a time these special manifestations of 
 muscular disorder, let us examine into the causes 
 which predispose to them. 
 
 In doing so, I must acknowledge my obligation 
 to Dr. A. Wood, of Edinburgh, who has so ably 
 handled the subject in the " Monthly Journal" for 
 February, 1853. The following are the most im- 
 portant of his aphorisms : 
 
 1. Contractility is the function of a muscle 
 the more perfect the organ the more perfect the 
 function, and vice versd. 
 
 2. A muscle is exhausted by action; it therefore 
 requires an adequate amount of nutrition (i.e., the 
 harder a man works the more food he requires). 
 
 3. It receives its nutrition from the blood; the 
 healthier, therefore, the blood, the more complete 
 the nutrition. There must be, then, a direct rela-
 
 76 IMPORTANT APHORISMS. 
 
 tion between the supply and healthy quality of the 
 blood sent to a muscle and its power. 
 
 4. A supply of pure air is of importance in 
 keeping up the healthy condition of a muscle in 
 man. 
 
 5. The law of reaction on a stimulant is the 
 reverse of the law of contractility. That is to 
 say the stronger the muscle, the more firmly it will 
 contract the weaker the muscle, the less its contractile 
 power, but the greater its irritability or tendency to 
 contract. 
 
 A stimulus which scarcely affects a strong muscle 
 will produce spasm or cramp in a weakly one. 
 
 This, which is the most important of all the laws 
 which govern muscular action, richly deserves every 
 embellishment that experience can heap upon it. 
 
 It would be easy to show that it is not the 
 strong-limbed, firm-fleshed child of the country 
 which is the most frequent victim to convulsive 
 disease ; but that the mortality from this cause is 
 greatest amongst the puny, weak, soft-fleshed, ill- 
 fed denizens of our crowded courts and narrow 
 alleys. 
 
 It is easy to show why, when fed with colocynth, 
 calomel, and Epsom salts, and a diet that would 
 suit a juvenile Brahmin, the sufferer from chorea 
 continues ill for weeks and months, and even ulti- 
 mately dies ; while, on a generous and tonic treat- 
 ment, he or she recovers rapidly. With increased 
 muscular power comes less muscular irritability.
 
 IRRITABILITY IMPLIES DEBILITY. 77 
 
 If we turn to the epileptic, we find the same law 
 carried out; the feebler the muscular system the 
 more severe and frequent the fits. 
 
 How often do we find a child, ill with convul- 
 sions, recover immediately on being taken to a 
 pure air, where its blood is duly oxygenated, and 
 relapse again the day he returns to town. 
 
 Tempting as this subject is, we must not pursue 
 it, but continue the special subject of our paper. 
 
 If it be true that muscular action is exhaustive, 
 it necessarily follows that any muscle which has 
 been severely tried is pro tanto in a weakened 
 condition, until it has had a period of repose, and 
 an adequate supply of nutrition; it follows that if, 
 in addition to this natural exhaustion, any depress- 
 ing drugs are used, and nourishing food denied, 
 the muscle will be more and more exhausted. 
 
 With increased exhaustion comes greater irri- 
 tability. Great muscular irritability must then be 
 considered as being caused by, and dependant upon, 
 great general and local debility, and demands, for its 
 cure, a generous diet, tonic medicines, and pure air. 
 
 The predisposing causes, then, of the muscular 
 affections we have spoken of, are a want of tone in 
 the system, and a diminished strength in the muscles. 
 In these cases we find plenty of other proofs of 
 debility, a quick, weak, or irritable pulse; a ten- 
 dency to sigh frequently, a disposition to cry on 
 the slightest occasion, a difficulty in restraining 
 laughter, snoring during sleep, with heaviness on
 
 SIGNS OF DEBILITY. 
 
 awaking, giddiness on turning out of bed, yawning 
 while at the toilette, &c. ; anorexia, or irregularity 
 in appetite or digestion, torpid bowels, lithatic or 
 phosphatic urine, which speedily becomes ammo- 
 niacal, foul breath, bad taste in the mouth, head- 
 ache, languor and lassitude during the day, and 
 perhaps nervous excitement at night. If the 
 patient be a female, there is almost sure to be, if 
 she have arrived at the age of puberty, some ute- 
 rine disorder added to the other symptoms.* Yet, 
 
 * It is this which has, for so long a period, kept the Profession on 
 the wrong scent. The reasoning of the majority of writers seems to 
 be something like this : Hysteria and hysterical affections are more 
 common in women than in men ; women have an uterus and men have 
 none ; women are more frequently affected by hysteria after the age of 
 puberty than before, and, when they have hysteria, the doctor can find, 
 in three cases out of seven, something wrong with the catamenia in 
 one case out of seven, an ulcer on the os uteri in another, engorge- 
 ment and in the other two, although he can find nothing wrong, he 
 concludes that it is only because he is not clever enough ! ! As long as 
 there is an uterine affection, it matters little to such reasoners what its 
 real nature is ! whether ulcer, congestion, leucorrhcea, meuorrhagia, 
 dysmenorrhcea, or chlorosis ; whether the discharge is too profuse or 
 too scanty ; whether the woman is a virgin or a wife. If there are 
 hysterical symptoms, the womb has produced them ! The proof is 
 irrefragable, for if you cure the uterus you cure the other symptoms ! 
 Every now and then it is true that hysteria occurs in the male sex, and 
 in the female who has never menstruated, and possibly has no womb ; 
 but these exceptions are too few and too insignificant to upset the beau- 
 tiful uterine theory ! and the womb is still to be the organ blamed for 
 everything, although it may only be suffering in common with all 
 others in the body. By-and-by, we may expect to have a theory that 
 the beard and whiskers are the cause of gout ! We know that men 
 have gout far more frequently than women ; that these have no whis- 
 kers ; that men rarely have it until after the beard has begun to grow ; 
 that those of the male sex who never have beards have gout as rarely as 
 females ; and that, when gout is not inherited, it does not come on until 
 the whiskers have begun to grow grey, indicating that they are not as
 
 DEDUCTIONS. 79 
 
 as a general rule, the severity of the muscular pain 
 is so great, that it alone engrosses the patient's 
 feelings, and the practitioner too often prescribes 
 for it, without considering the totality of the symp- 
 toms and their significance. 
 
 Guided by the light of these principles, we 
 can thus see our way through many a path that 
 once was dark, and elicit a definite principle 
 where all before was empiricism. We see why 
 chorea is not relieved by a diet of rhubarb and 
 magnesia ; why leeches so often kill, and so 
 rarely, if ever, cure the patient in infantile con- 
 vulsions; why hysteric spasms are so common in 
 the weak, and so rare in the strong woman; 
 and why excessive drinking, " all sack and no 
 bread," produces a trembling hand and shaky 
 muscles. 
 
 We can understand how it is that a growing 
 that is to say (for the two words are in this re- 
 spect practically synonymous), a weakly child 
 has " growing pains " (i. e., muscular aches.) ; why 
 it is that palpitation always accompanies debility, 
 and prostration is marked by an irregular pulse.* 
 
 In speaking thus we must guard ourselves from 
 
 young as they used to be ! And when it is farther urged, that the first 
 paroxysm often comes on after a debauch in which the beard has been 
 plentifully manured by wine or porter, the train of argument may be 
 considered complete ! 
 
 * As palpitation of the heart is a constant sign in spinal irritation, 
 we shall take a future opportunity of explaining its phenomena.
 
 80 DEDUCTIONS. 
 
 the imputation that we are forgetting the influence 
 of the nervous system in the production of spasms. 
 All we wish to urge is that, cceteris paribus, a 
 weakly muscle is more excitable than a strong 
 one. To consider the nervous stimuli, in obe- 
 dience to which the muscles contract, would be 
 quite foreign to our present purpose.* 
 
 * I have at present under my care an elderly lady who has suffered 
 much from muscular pains. She was originally attacked with diarrhoea, 
 which confined her to bed. This left behind it excessive irritability 
 of the rectum and bladder, with discharge of bloody mucus. The 
 "calls" were so frequent and imperious that she had to start out of bed 
 every half hour to go to the night-chair. In two days after this there 
 was pain and tenderness over the whole abdomen, which was especially 
 severe at the insertions of " rectus and oblique." In two days more, 
 intense pain in the calf of both legs came on whenever she left the bed ; 
 it was referred to the origin of the " solceus," and the part was tender 
 on pressure. This was relieved by strapping from the toes to the knee. 
 The abdominal pain was not relieved by anything I could suggest. 
 The irritation was at last subdued, and five days elapsed without the 
 bowels being moved ; during this period the abdominal tenderness, &c., 
 disappeared. The bowels were then naturally opened, and there was for 
 thirty-six hours a partial diarrhoea. The patient persisted in using the 
 night-chair instead of a bed-pan, and the exertion required in getting 
 in and out of bed, and sitting up so often, brought back the abdominal 
 pain. The diarrhoea again subsiding, this gave way. 
 
 The strapping appeared to prevent a recurrence of the pain in the 
 calf of the leg. I am also attending a lady four months pregnant, in 
 whom it was supposed that symptoms of peritonitis had set in, from 
 the severe pain complained of in the abdomen, and the extreme tender- 
 ness on pressure. The pain came on after the action of a purgative, 
 and was kept up by straining to micturate. The debility was extreme. 
 A careful investigation proved it to be a case of muscular soreness, ana- 
 logous to that of Mrs. L., p. 65. 
 
 I scarcely need add, that the attention of the practitioner ouo-ht 
 always to he called to the possibility of the abdominal tenderness pre- 
 sent in diarrhoea, &c., being due to the muscular exertion required in 
 leaving hed, defecating, sitting up, or micturating in the recumbent 
 posture.
 
 CRAMP. 8 1 
 
 CHAPTER V. 
 
 Cramp The circumstances under which it comes on Case of Mrs. R., 
 affected when support of "stays" withdrawn Cramp simulates 
 " tumour" cases Occasional influence of galvanism in cramps 
 Severity of pain Its comparatively transient character Cases. 
 
 WE have hitherto spoken chiefly of muscular 
 aching pain, which is relieved by suspension of 
 action. We now come to speak of cramp, and the 
 circumstances under which it comes on. We have 
 already given some cases, in which it accompanied 
 other muscular pains ; we will now give a few, in 
 which it was the prominent symptom. The most 
 remarkable I have met with, was in Mrs. L., 
 whose case I have before given. Three years ago 
 she was the subject of a severe accident, which 
 bruised the back considerably, and materially de- 
 bilitated its muscles. One morning, shortly after- 
 wards, as she was stooping forward, to arrange 
 her hair, the head bended on the chest, and both 
 hands at the back of the head, a painful cramp 
 seized the muscles, and in that condition she re- 
 mained for three days, in great suffering.* 
 
 * I have since met with another instance where cramp has seized a 
 lady while arranging the back hair. In this case the patient was a 
 school-girl, and the suffering was intense and prolonged. 
 
 G
 
 82 CASE. 
 
 The following cases illustrate the exciting causes 
 of cramp : 
 
 Mrs. R., set. thirty-eight, a well-made, strong- 
 looking woman, above the medium height, after 
 two or three miscarriages, which had pulled her 
 down considerably, was obliged to nurse a sick 
 child on her knee for three days, during which 
 time she never took her stays off, and never lay 
 down. The child being out of danger, she took 
 off her stays, and went to bed the artificial support 
 of the corset being now taken away, she felt exces- 
 sively weakened arid weary. At the first attempt to 
 turn, the whole of the abdominal w T alls became the 
 seat of cramp, one muscle after another taking up 
 the spasm. The muscles of the back were affected 
 in turn, and she spent a night of the utmost agony, 
 which profuse inhalation of chloroform failed to 
 relieve. There was a suspension of her sufferings 
 when the stays were again put on, and a renewal 
 of them on undressing. Her husband now con- 
 sulted me, and I suggested the habitual use of an 
 elastic belt, more frequent rest during the day, 
 and as generous diet as possible ; and, under this 
 plan, the cramp almost immediately left her. 
 
 The next case shows the persistence of the 
 crampy condition, when due care is not taken to 
 improve the muscular tone. Some years ago, a 
 middle-aged woman called upon me, with a ho- 
 moeopathic dispensary " paper" and a polite mes- 
 sage from one of the doctors, that she had come to 
 give me an opportunity of seeing a very interesting
 
 EXPLANATION. 83 
 
 case. She told me she had a tumour in the abdo- 
 men the ticket indicated the same, and I learned 
 that she had been under treatment for about eight 
 months. On making percussion, however, on the 
 abdomen, over her dress, I found it resonant every- 
 where, and I could make a tolerably deep thrust 
 without meeting with resistance. When I ex- 
 pressed a doubt about there being a tumour, she 
 made the remark, " That it was not always there." 
 This gave me a clue, and after a lengthened in- 
 quiry, I elicited the following facts : 
 
 The woman had a great deal of washing to do 
 once a fortnight, or thereabouts, and used a high 
 tub, over which she Avas then constantly stooping ; 
 the tumour occupied the position of the rectus 
 abdominis, sometimes one segment, sometimes an- 
 other it was attended with pain, and seemed to 
 double her up ; stretching backwards, and strong 
 pressure, gave it relief. Any heavy-day's work 
 would bring it on. If she had been reduced by 
 diarrhoea, or any other cause, it was always more 
 severe and long continued; it was independent of 
 the bowels, except that, if they were costive, the 
 effort of defecation would bring it on. Its size 
 was always the same, and its hardness considerable. 
 
 I could, under these circumstances, have no 
 reasonable doubt, that the case was one of cramp 
 in the rectus abdominis, produced by a debilitated 
 condition of the muscle and too great an amount of 
 work. The sequel I am unable to give. 
 
 G2
 
 84 CASE. 
 
 The following case occurred in the Liverpool 
 Infirmary during the time I was house-surgeon : 
 
 A young woman was admitted, under one of the 
 then physicians, with what was represented as a 
 tumour in the abdomen. On making an exami- 
 nation, I found a swelling about the size of the 
 palm of the hand, occupying the left hypochon- 
 driac region ; it was elevated above the surrounding 
 level, very firm, and painless to the touch, though 
 the patient declared it hurt her when it first ap- 
 peared. Percussion showed some dulriess, but not 
 much. I considered that it was not a tumour, but 
 could not form a definite idea of what it was. She 
 remained in the ward some six weeks, during 
 which time no change was apparent, and she was 
 then transferred to the surgeon's care. A blister 
 was now applied, and the tumour left that spot; 
 but another appeared on the opposite side, and 
 again succumbed to a blister, and the so-called 
 tumour travelled, successively, over every part of 
 the fleshy walls of the abdomen ; blisters pursued 
 them unrelentingly, and at last the patient was 
 cured. There could then be no doubt that the 
 tumour was nothing more than cramp in isolated 
 parts of the external oblique rectus, and probably 
 other muscles. 
 
 About two years ago, a man, aet. twenty-four, 
 entered the North Hospital, suffering acutely from 
 cramp in the abdominal muscles, and occasionally 
 in the arms and legs. He told us he had had a 
 similar attack previously. He had been much
 
 CRAMP. 85 
 
 exposed to cold and privation. A variety of anti- 
 spasmodics, sinapisms, &c., were tried without re- 
 lief. On the third day, galvanism was adopted, 
 and with such complete success that he went out 
 next day cured. 
 
 Not long after, an Italian, set. twenty-five, came 
 in. From what I could make out, he was a sea- 
 man, and had suffered from abdominal pain for six 
 weeks. He looked feeble, and had no appetite. 
 The recti muscles were excessively irritable, any 
 manipulation produced a painful contraction, and 
 sitting up, or walking, gave rise to decided cramp, 
 almost doubling him up. Best, cod-oil, steel, and 
 full diet, restored him in twelve days. 
 
 The sufferings from cramps are often very se- 
 vere. I was once summoned in great haste to the 
 Waterloo Hotel to see a gentleman, aet. about forty, 
 whom I found in bed writhing in agony; he was 
 half tipsy; could scarcely speak three words con- 
 secutively, from a fresh accession of cramp; the 
 abdominal muscles were contracting and relaxing 
 with amazing rapidity, and the appearance was as 
 if some large ball was rolling about, bulging all 
 parts successively. I could get no history. I 
 recommended hot bags of scalded bran to be pre- 
 pared and applied, and in the mean time strong 
 friction to be used. The patient refused to take 
 anything. I called next morning, and found him 
 dressing, and quite well ; but so apparently uncon- 
 scious of ever having seen me before, and so in- 
 dignant that T should have entered his room, that
 
 86 CASE. 
 
 I felt rather happy to make my escape without any 
 farther explanation, and with nothing but my 
 labour for my pains. 
 
 Mrs. C., aat. thirty, of great stoutness, after 
 having been well for many years, consulted me for 
 severe pain in the loins and left groin. She had 
 previously been under my care for what was then 
 considered atrophy or fatty degeneration of the 
 heart; she had also had erysipelas of the face and 
 head, followed by dropsy and albuminous urine, 
 and during this last attack had complained much 
 of the same kind of lumbar pain. She was appre- 
 hensive that disease of the kidney had returned,* 
 and was naturally very anxious about herself. The 
 pain in the groin I ascertained had come on sud- 
 denly in the evening, when she had been sitting up 
 for some time teaching a child its lessons ; it drew 
 her downwards, was relieved by pressure, went off 
 with a twitching sensation, and left her sore next 
 day: it extended towards the ribs. The pain in 
 the back came on while she was sitting up playing 
 at whist, and was very acute, drawing her back- 
 wards; it was relieved by stretching to the other 
 side. The urine was healthy. I found that she 
 had been weaker than usual of late, from loss of 
 appetite, and that she still, though feeling unable 
 to do it with comfort, went through the same 
 
 * There is strong reason to believe that the pain in the back so 
 frequently met with in renal disease is due entirely to a muscular cause 
 (excepting, of course, cases of renal calculi, &c.), and indicates general 
 debility rather than a specific alteration in the kidney.
 
 .CASE. 87 
 
 amount of exertion as when she was strong. This 
 was the origin of the suffering ; wishing to keep 
 down her size by continued exertion, she taxed her 
 muscles beyond their strength, and they became 
 irritable, cramped, and sore. Tonics and rest re- 
 lieved her, and a knowledge of the cause of her 
 symptoms took away all anxiety from her mind. 
 
 Mrs. G., set. thirty-four, a publican's widow, 
 above the medium height, but thin and pale, sent 
 for me one evening for what she thought was an 
 attack of pleurisy. She informed me that she had 
 had pain in the right side for some days, which 
 had been gradually increasing until it had been so 
 severe as to prevent her sleeping. The night before 
 she had been awaked by it, and was unable to find 
 a sufficiently easy posture to sleep again. The 
 pulse was very weak, her voice was feeble, the skin 
 perfectly cool, and there were no physical signs of 
 inflammation. She had had a similar attack ten 
 years previously, for which she had been bled 
 and confined to bed for a fortnight. I ascertained 
 that the pain came on towards evening, gradually 
 increasing in severity; that when severe it was 
 twitching or pulsating; that it was always relieved 
 by rest ; that it extended to the abdominal parietes, 
 and to the groin, and to the " latissimus dorsi" pos- 
 teriorly. I found that she had been greatly ha- 
 rassed by having to attend both to her family and 
 " the bar ;" that she had lost all appetite, and was 
 almost living upon tea and muffins ; that she 
 had been " unwell" rather profusely, and that
 
 88 CASES. 
 
 when the pain was present it was increased by 
 using the beer engine. There was no difficulty in 
 recognising the milder pain as muscular, the severe 
 pain, as cramp in the intercostal muscles. More 
 frequent rest was prescribed, with tonics and gene- 
 rous diet ; but some time elapsed ere she was strong 
 enough to be free from pain and fatigue. 
 
 In all cases where we meet with cramp in the 
 extremities it is necessary to make particular in- 
 quiries as to whether it is due to a muscular or 
 a nervous cause. 
 
 R. H., set. forty-three, cook, entered the Northern 
 Hospital, with a painful swelling in the right leg; 
 it was simply cramp in the calf, arising from too 
 much standing; she was weak, but otherwise 
 healthy. Rest in bed for a few days, and a few 
 doses of steel enabled her to go out cured. 
 
 Miss D., a tall, overgrown young lady, a3t. seven- 
 teen, consulted me, through a friend, respecting 
 severe cramp she suffered in the calf of the leg and 
 in the thigh. The nervous system w r as healthy, 
 and all the functions correct ; but she was a great 
 walker, very active, and fond of standing instead 
 of sitting. I recommended steel and quiet, and in 
 a fortnight she ceased to complain. It is worthy 
 of calling attention here to the fact we elsewhere 
 allude to, that cramp is rarely ever so severe when 
 it invades its victim during the waking hours as 
 when it comes on during sleep.
 
 THE INVOLUNTARY MUSCLES. 89 
 
 CHAPTER VI. 
 
 Are the heart and involuntary muscles affected in a similar way to the 
 voluntary ? The heart Its muscular fibres those of animal life 
 
 Meaning of palpitation Irregular action Angina Cause of 
 sudden death in disease of heart Principles of treatment discussed 
 
 The value, influence, and effect of digitalis The intestines and 
 uterus affected Ante version Retro version. 
 
 AN inquiry of great interest now forces itself upon 
 us, which is, do the heart and other muscles re- 
 moved from the influence of volition, participate in 
 the affections we have been describing? 
 
 Let us commence with the heart. We know 
 that in its minute structure it resembles voluntary 
 muscle, that its fibres are striped, and that many 
 of them terminate in tendinous prolongations. Is 
 it affected by debility in the same way as the mus- 
 cles of the abdomen for example? We have seen 
 that constitutional or local debility produces irre- 
 gular action in a muscle, and that when excessive, 
 cramp is the result. The irregularity of action in 
 the voluntary muscle shows itself by pain and 
 spasm; but as the heart cannot feel the former, 
 we can only anticipate the latter. In reality this 
 is the case. First, we know that the most com- 
 mon cause of palpitation is constitutional debility ; 
 we know, too, that an irregular pulse coming on at
 
 90 PALPITATION. 
 
 the termination of an illness is looked upon as a 
 proof that exhaustion has reached the heart; we 
 find this irregularity cease under the influence of 
 stimulants, and if the patient regains strength it 
 does not return. Still farther, we find that in the 
 debilitated we have the heart beating regularly 
 enough as long as it has only its ordinary work to 
 do; but as soon as a small additional labour is 
 imposed upon it, as in fast walking, going up 
 stairs, &c., its action at once becomes irregular, its 
 contractions are strong and impetuous, and some- 
 times for a time terminate altogether, producing 
 faintness. So generally now is this fact under- 
 stood, that it only remains for us to recal to re- 
 collection the law, " The feebler a muscle, the 
 greater its irritability" to gain for it an unhesi- 
 tating assent. 
 
 It has long appeared to me that it is of the ut- 
 most importance to bear this law in mind in cases 
 of organic disease of the heart, and especially of the 
 valves. It is impossible to be long in practice with- 
 out remarking the fact that a great number of per- 
 sons die suddenly from disease of the heart struck 
 down in an instant while others die a death of 
 lingering pain. It is clear that there must be 
 some reason for this which we ought to discover. 
 In our inquiries we must necessarily include angina 
 pectoris, a complaint characterized by the sudden- 
 ness of the attack. We find the following facts to 
 guide us in our judgment :
 
 REMARKS ON CARDIAC DISEASE. 91 
 
 1. Individuals may have valvular or other dis- 
 ease of the heart, and yet be unconscious of any 
 inconvenience from it. 
 
 2. They may live many years in this condition. 
 
 3. They may have symptoms of cardiac disease, 
 recover from them, and again continue a long 
 period unaffected. 
 
 4. In those cases where people live comfortably 
 with valvular disease, there is almost always 
 hypertrophy. 
 
 5. Hypertrophy signifies an increase of power 
 to make up for loss. 
 
 6. The causes that determine a paroxysm of 
 cardiac disease, are 
 
 a. An excessive action of the organ itself; 
 
 b. Something which diminishes the power of the 
 
 system e.g., diarrhoea, loss of blood, loss 
 of appetite, anxiety of mind, &c. ; 
 
 and both of these may be included in the terms 
 
 " local and general debility." 
 
 7. The plan of treatment most successful in 
 cardiac disease is one which restores the heart to 
 its usual tone 
 
 a. By diminishing the resistance it has to over- 
 
 come and the work it has to do; 
 
 b. By increasing its power through the consti- 
 
 tution generally. 
 
 8. The spasm in angina pectoris is produced by 
 unusual exertion. These considerations induce us 
 to believe
 
 92 INFERENCES. 
 
 a. That as long as the constitution is sound, and 
 the muscular system is in good condition, that dis- 
 ease of the heart may be compatible with tolerable 
 health. 
 
 b. That when the heart is diseased, and the 
 person debilitated, death may be sudden, or other- 
 wise, according to the work the heart has to do : 
 where the heart is much enfeebled, the task of 
 driving the blood to the head in an erect posture 
 may be too much for its powers. 
 
 c. That the proper treatment is rest and quiet, 
 as far as possible, the removal of obstructions, 
 and the administration of such tonics as are avail- 
 able.* In a great number of instances I have 
 found that rest and adequate nutrition alone suffice 
 for (relative) cure. 
 
 The other involuntary muscles, such as the sto- 
 
 * Digitalis is a favourite remedy in disease of the heart. It is a very 
 depressing drug, and can only be judiciously employed when the patient 
 is quiet and in the recumbent posture. If used in full doses while the 
 patient goes about as usual, it produces faintness, irregularity of the 
 heart's action, and frequently sudden death (from spasm of the ven- 
 tricles ?). I have known calomel and opium, given for endocarditis 
 (in rheumatic fever), produce great faintness and irregularity of the 
 heart's action, which went off on the administration of brandy and the 
 suspension of the drug. They returned when the mercury was again 
 employed, and went off finally when it was abandoned. 
 
 I may also remind my readers of Mr. Pearson's cases of mercurial 
 erethism, in which it is evident that the drug had produced intense 
 general debility, and where a sudden and violent exertion of the animal 
 power, especially in the erect posture, was frequently fatal. Similar 
 phenomena used to be common in scurvy. The most probable cause of 
 death in these cases would be spasm of the ventricle, or what would 
 have the same effect, an inability of the ventricle to overcome the
 
 IS THE UTERUS AFFECTED? 93 
 
 mach, small and large intestines, appear to suffer 
 from debility much in the same way as the volun- 
 tary, with the exception of pain, which is seldom, 
 if ever, present, except when there is spasm. The 
 proofs of this are necessarily somewhat insuffi- 
 cient, inasmuch as it is difficult to separate the 
 intestinal muscular system from the mucous mem- 
 brane. Yet it is a generally received opinion 
 that the weaker the individual, the greater is the 
 tendency for any indigestible substance to pro- 
 duce cramp in the stomach or griping pain in the 
 bowels. 
 
 We cannot say much about the uterus, but there 
 is one point connected with it of great interest 
 i.e., that whenever a pregnant woman is jaded by 
 fatigue, or weakened by diarrhoea, &c., the motions 
 of the foetus become more lively. This results 
 evidently not from increased vigour in the infant, 
 but from increased irritability of its muscles, the 
 effect of a transient want of tone. 
 
 It is a matter for speculation whether the uterus, 
 in an unimpregnated condition, may or may not 
 be the subject of temporary, or more or less per- 
 sistent, spasm. But when we consider the symp- 
 
 weiglit of a column of blood. It is surprising, when the patient is in a 
 state of extreme debility, how very slight an exertion proves too much 
 for the heart to overcome. Sitting upright in bed, adjusting the bed 
 linen, turning round in bed, and even talking for a long duration, will 
 sometimes be enough to produce very severe dyspnoea and palpitation, 
 or a fatal syncope.
 
 94 ANTE VERSION. 
 
 toms of " irritable uterus" described by Gooch and 
 Churchill, and then refer to the causes assigned 
 for the complaint, it seems quite as rational to 
 assign a muscular origin to the pains, &c., as a 
 nervous one. 
 
 On mentioning this subject to my friend, Mr. 
 Grimsdale (who has made for some years a special 
 study of uterine disease), he informed me that he 
 had long considered that the phenomena of retro- 
 version and anteversion of the unimpregnated 
 womb was due to irregular contraction of its 
 walls. I have not been able to ascertain whether, 
 in those persons who suffer from the disease, there 
 is a condition of system likely to predispose to 
 muscular irregularities. 
 
 I have met with four or five cases in which in- 
 tense suffering has been produced from spasm or 
 cramp in the sphincter ani, and probably in the 
 rectum, in all there has been some direct cause 
 of irritation ; but as the same causes are in opera- 
 tion more or less in the majority of individuals, 
 and continued to be in operation in the cases 
 named after the cure was effected, we cannot con- 
 sider that those alone produced the complaint. All 
 the patients I refer to were greatly " out of con- 
 dition," and were improved by a tonic plan, com- 
 bined with opiates, &c., applied to the bowels and 
 external parts.
 
 TREATMENT. 95" 
 
 CHAPTER YIT. 
 
 The plan of treatment proposed Artificial support General tonics 
 
 Sedatives, general and local Case of laryngismus stridulus 
 cured by the latter Galvanism Exercise Its value discussed 
 
 The necessity for pure air Local depletion Its doubtful value. 
 
 THE remarks we have already made are sufficient 
 to indicate the plan of treatment to be generally 
 adopted in all these painful muscular affections. 
 
 1. For immediate relief the muscles must have 
 rest or some artificial support, such as a bandage, 
 elastic or otherwise, strapping, and the like. 
 
 2. For a permanent cure the whole system must 
 be strengthened; and where it agrees there is no 
 medicine which fulfils this indication like cod-liver 
 oil, with or without tincture of iron in full doses. 
 
 3. Where the cramps are severe, morphia in- 
 ternally and externally is of the greatest benefit. 
 
 The most interesting example I can give of the 
 value of this remedy is the following : 
 
 I was called in consultation during May last to 
 see a child who was suffering severely from con- 
 vulsions. I found that it was one of twins, and 
 that the two had been nursed by the same woman ; 
 that they had often suffered from flatulence; that 
 the motions had been intolerably fetid, and that
 
 96 CASE. 
 
 this symptom was always worse whenever the 
 nurse was unwell. They were eight months old ; 
 no teeth were near ; they had been weaned a few 
 days at the time I saw them ; one was pretty well, 
 but whooped at times as in hooping-cough; the 
 other child was large, pallid, and lay on its back 
 with the eyes half open, but did not scream or 
 show any marked symptoms of disease of the head. 
 The head was, however, of large size, and the an- 
 terior fontanelle projecting. Ten or twelve con- 
 vulsions occurred daily, and they seemed to be 
 gaining ground. Prior to my seeing her the treat- 
 ment had been directed to improving the secre- 
 tions, and giving an adequate amount of digestible 
 food ; the secretions had come right, but the symp- 
 toms remained unabated. During our visit we 
 witnessed a fit, and it was clear that it was "laryn- 
 gismus stridulus"* the child was suffering from, 
 and that complete closure of the glottis took place 
 for a few seconds. The treatment was not mate- 
 rially altered, but a solution of morphia (a grain to 
 the ounce) was directed to be applied as water- 
 dressing to the throat, and kept on pretty con- 
 stantly. The child was relieved within half an 
 hour of the first application, and had no more con- 
 vulsions; it was subsequently applied in the same 
 way to the other, and was equally successful in pre- 
 venting the whoops. A few days sufficed to prove 
 that the children had not caught hooping-cough; 
 
 * I.e., cramp or spasm of laryngeal muscles.
 
 TREATMENT. 97 
 
 and the good diet used soon put the parents out of 
 anxiety.* 
 
 Forcible extension of the affected muscles gives 
 almost immediate relief if the cramp is recent. 
 
 4. Galvanismf is sometimes of service in restor- 
 ing "tone;" friction does little good; shampooing 
 relieves, but rarely cures; strychnine is too slow 
 in its operation to be trusted to. 
 
 5. Exercise is of no use unless combined with 
 fresh air, generous diet, and such medicines as 
 tend to improve the digestive powers. For though 
 
 * While on this subject I may add, that I have known both laryn- 
 gismus stridulus and general convulsions, of an extremely formidable 
 nature, come on in young infants and children from beef-tea, meat- 
 gravy, and even from the single yolk of an egg. In some instances 
 the convulsions have been fatal. I have met with two cases of epi- 
 leptic seizures coming on in patients (adult males) who had been too 
 well-fed after surgical operations. A cessation of the diet was followed 
 by a cessation of the fits, and a return to the good living by a return of 
 the convulsions. In none of the cases was there any predisposition to 
 the complaint. I was reminded of these facts by an observation I eli- 
 cited from the mother of the little child whose case is detailed above. 
 The twin sister of the patient saw some beef-tea brought for an elder 
 brother, and insisted on having some ; she took a good drink, and in a 
 quarter of an hour a severe attack of general convulsions came on ! 
 the only one she had ! It would be out of place to pursue the subject 
 farther. 
 
 f I have in the hospital had, on three occasions, to resort to a 
 series of galvanic shocks to restore the tone of the affected muscles, 
 when other means have failed. The most striking one was that of a 
 servant who suffered from cramps in the abdominal walls. Kest in bed, 
 opiates, tonics, friction, morphia locally applied, &c., were adopted with- 
 out any abatement of the symptoms. The first application of galvanic 
 shocks was followed by relief, and in three days she was free from 
 spasm. At the same period I had another young patient, who had 
 cramps in the back from excessive labour as a washerwoman. These 
 had to be treated with galvanism ere they gave way. I have already 
 alluded to a third. 
 
 H
 
 98 TREATMENT. 
 
 exercise improves the muscles in the country, 
 yet it commonly debilitates in a town like Liver- 
 pool. 
 
 6. Local depletion, blisters, or sinapisms, very 
 rarely if ever give relief; if they do it is only 
 temporary, and the next attack is more severe; 
 the exception is when the spasmodic condition is 
 permanent.
 
 OTHER FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM 
 
 EXPLAINED. 
 
 fart 
 
 C H A. I T E K 
 
 Spinal disorders Their nature, as defined by recent writers : as 
 Dr. Copland, Dr. Griffin, Mr. Teale, Dr. Brown Similarity of 
 the symptoms described by them to those we have described and 
 ascribed to another source Cases quoted Duration of symptoms 
 Days, months, or years Exciting and predisposing causes 
 Treatment recommended. 
 
 HAVING now attempted to demonstrate that the 
 muscles and their fibrous prolongations may be, 
 and very frequently are, the seat of severe pain 
 having stated the characters by which those pains 
 are distinguished, the circumstances under which 
 they arise, the causes which determine their occur- 
 rence, and the individuals in whom they are most 
 commonly met with we now proceed to investi- 
 gate the manner in which they bear upon that 
 class of diseases known under the name of " Spinal 
 Disorders," " Spinal Irritation," and " Functional 
 Diseases of the Spine." 
 
 Before anything satisfactory can be said upon 
 this topic, it will be necessary at the commence- 
 
 H2
 
 100 SYMPTOMS OF SPINAL IRKITATION. 
 
 ment to examine into and define what are the phe- 
 nomena we have to explain. 
 
 Lest I should be suspected of colouring the 
 views of various authors, to suit my own conve- 
 nience, I shall take the liberty of quoting their 
 own words. I do this the more readily, as it was 
 in consequence of the expressions they employed 
 that I was enabled to seize the thread by which so 
 many apparently discordant elements were joined 
 together. Referring to Dr. Copland's "Dictionary," 
 as being the best enunciator of the present state of 
 our knowledge, we find the following definition : 
 " Pain in some part of the spinal column, generally 
 accompanied by neuralgic or hysterical affections, 
 unattended by fever or by other indications of in- 
 flammation, injury, or structural change of the ver- 
 tebral column or its contents." 
 
 Further on, in the same article (" Functional Dis- 
 eases of the Spine," vol. iii. p. 862) we read, "It is 
 characterized by pain, increased by pressure on the 
 spinous processes, in the chief seat of pain, and 
 often accompanied by painful, anomalous, or hyste- 
 rical symptoms in parts supplied with nerves from 
 the seat of pain in the spine." 
 
 In speaking of the diagnosis, quoting from Dr. 
 Griffin, he says : 
 
 " The complaints, whatever they may be, are 
 usually relieved by the recumbent posture (the italics 
 are our own), always increased by lifting weights, 
 bending, stooping, or twisting the spine, and amongst
 
 SYMPTOMS CONTINUED. 101 
 
 the poor classes often consequent on the labour of 
 carrying heavy loads, as in drawing water, carting 
 manure, &c." 
 
 We find Dr. Griffin remarking (" Observations on 
 Functional Affections of the Spinal Cord," p. 202), 
 " Spinal tenderness is seldom or never met with in 
 cases of pure inflammation The functional dis- 
 orders connected with spinal tenderness are very 
 often attended by some disturbance of the func- 
 tions of the uterus, but they are by no means 
 always so, since they occur in those who are 
 regular in this respect in girls long before the 
 menstrual period of life, in women after it has 
 passed, and, lastly, in men of nervous, susceptible 
 
 habit, and in boys They are not necessarily 
 
 dependent upon the disorder of any one organ, 
 since they are found indifferently co-existing with 
 disturbance of the digestive organs solely, or the 
 uterus solely, or of the circulating or respiratory 
 
 systems Affections are occasionally met with, 
 
 presenting all the marks of the hysteric character, and 
 perfectly resembling cases described as those of spinal 
 irritation, but unattended by spinal tenderness or any 
 other direct indication of a morbid state of the cord." 
 
 In a treatise upon neuralgic diseases dependent 
 upon " Irritation of the Spinal Marrow and Ganglia 
 of the Sympathetic Nerve," by T. P. Teale, we 
 read in the introduction, " The term neuralgia, 
 which was originally employed to designate certain 
 affections of nerves, attended with severe pain, has
 
 102 SYMPTOMS CONTINUED. 
 
 of late, with great propriety, been extended .... 
 to many other morbid affections of nerves, which 
 are not characterized by pain, but by some other 
 perverted state of their functions." 
 
 " The skin, for instance, may be the seat of 
 every degree of exalted or diminished sensibility. 
 .... The voluntary muscles may indicate in a 
 variety of ways a morbid condition of the nerves 
 with which they are supplied. They may be 
 affected with weakness, spasms, tremors, or a va- 
 riety of other disordered states, within the two ex- 
 tremes of convulsions and paralysis The 
 
 secretions may also undergo alterations both in 
 quantity and quality, from a perverted agency of 
 the nerves upon which they depend."* 
 
 Quoting from Dr. Brown's essay, he continues, 
 " The spinal affection may perhaps be considered 
 as the consequence of disease, but of its existence 
 at the commencement any one may satisfy him- 
 self; and this circumstance, combined with the suc- 
 cess which has attended the employment of topical 
 applications to the tender parts about the vertebra?, 
 appears to indicate that the cause may (sic in orig. ) 
 exist there." After a few more remarks, he gives 
 a case in illustration: "A young lady, ast. seven- 
 teen, had for more than a year complained of pain, 
 
 * The reader is particularly requested to keep these quotations in 
 mind, as they will be referred to hereafter. They all unequivocally 
 prove that muscular pains, and those arising from the stretching of 
 fibrous tissue, have been completely ignored.
 
 SYMPTOMS CONTINUED. 103 
 
 situated below the left mamma. This had been 
 fixed to one spot during the whole time. It was a 
 gnawing, bruised feeling, increased materially by 
 fatigue of any kind, and after fatigue was attended 
 with restlessness. It was relieved by reclining in 
 the horizontal posture. It was not sore to the touch.' 11 
 These very terms at once suggest the idea that 
 the pain was muscular, and not in any sense neu- 
 ralgic. 
 
 Again, "When the affection of the spinal nerves 
 is situated in the lumbar vertebra, it is apt to 
 occasion severe pain in some part of the abdomen. 
 I have seen it of a spasmodic nature, attended 
 with flatulency, and occupying apparently the arch 
 of the colon ; and in one case it seemed to be fixed in 
 the caput coli" (i.e., transverse fibres of rectus, 
 linea semilunaris). 
 
 Another case is given of pain below the mamma, 
 "sometimes extending down the side to the crest of the 
 ilium. It was accompanied with pain at the top, 
 and towards the back part of the left shoulder (i. e., 
 insertion of trapezius), which she described as a 
 sensation of burning, not interfering with the move- 
 ments of the joint, but so tender to the touch that she 
 could not rest on that side in bed," &c. These pains 
 were clearly muscular. 
 
 Again, quoting Dr. Darwall, Mr. Teale remarks, 
 " The following is the description of a form in 
 which cerebral and spinal irritation is frequently 
 exhibited, particularly in young females: It is
 
 104 SYMPTOMS CONTINUED. 
 
 attended by severe and constant pain in one or 
 both hypochondria, extending to the shoulder and 
 arm of the affected side, not always aggravated by 
 pressure, and ceasing immediately upon, or in a 
 short time after lying down. It is this pain of 
 which the patients generally complain, and it fre- 
 quently endures for several years. 1 " 1 After giving a 
 number of symptoms, all referrible to debility, it 
 is added, " Attending these affections are pain in 
 ike side in the course of the descending colon, and 
 difficulty of breathing, sometimes so great as to in- 
 duce fear of organic mischief having taken place in 
 the lungs" (i. e., muscular pains or cramp in the 
 abdominal and intercostal muscles, stretching of 
 the linea semilunaris). 
 
 Again, and the words are pregnant with 
 meaning :* 
 
 " Many individuals, as young females and mo- 
 thers, are often accused of indolence when labour- 
 ing under the state of muscular debility to which I 
 have alluded. They have felt an unconquerable 
 disinclination to exertion, &c., without even them- 
 selves being aware of the cause of this inertness." 
 
 Again, " These neuralgic diseases frequently as- 
 sume an intermitting form, the paroxysms generally 
 occurring in the evening."^ Pain in the insertion of 
 the trapezius is described, though not sufficiently 
 distinctive for quotation ; and it is added in a note, 
 
 * Vide Aphorism 5, p. 76. f Vide p. 20, Rule 2, ante.
 
 SYMPTOMS CONTINUED. 105 
 
 "Vertigo frequently attends this neuralgia of the 
 scalp, and is sometimes accompanied with tinnitus 
 aurium" (a tolerably good sign of debility). 
 
 " Occasionally the pain is fixed at some point 
 near* the clavicle, scapula, or shoulder joint, at the 
 insertion of the deltoid, or near the elbow" (triceps 
 extensor). "Females of sedentary habits appear 
 to be particularly subject to these affections of 
 the upper extremities; and it is not uncommon 
 for them to complain of being scarcely able to feel 
 the needle, when it is held in their fingers," &c. 
 (a tolerably good proof of their great exhaustion, 
 and that an overpowering amount of stitching, &c., 
 has been the cause of their upper extremities being 
 the chief seat of pain). u There is often a fixed 
 pain in some part of the intercostal muscles . . . .f 
 and when this has existed a long time there is 
 tenderness on pressing the part. The pleurodynin, 
 when it exists, is felt in the lower intercostal 
 muscles ; frequently there is a sensation of a cord 
 tied round the waist ; various pains, fixed and fugi- 
 tive, are also felt in the parietes of the abdomen ; 
 the pain is frequently fixed in some portion of the 
 rectus muscle, and not unfrequently in the ob- 
 lique muscles and transversalis. The patients 
 
 * Vide pp. 34-5-6, ante. 
 
 f It is particularly requested that this and similar observations will 
 be borne in mind. It is quite evident from these remarks that a pro- 
 longed stretching of the fibrous portion of the muscles will ultimately 
 produce tenderness on pressure.
 
 106 CASE FROM MR. TEALE. 
 
 also complain of instability in walking, their knees 
 totter, and they feel scarcely able to support the 
 weight of the body. In some cases very conside- 
 rable relief is found from recumbency, the pain fre- 
 quently being diminished as soon as the patient 
 retires to bed, independently of any paroxysmal 
 remission." This paragraph might almost have 
 been dictated by ourselves, so pregnant is it with 
 meaning when rightly interpreted. 
 
 Mr. Teale then records cases of spinal irritation 
 characterized by pain in the occipital insertion of 
 the trapezius, in the occipito-frontalis, in the tem- 
 poral muscle, the mastoid origin of the sterno- 
 mastoid. The following might, mutatis mutandis, 
 have served for an illustration of pain and cramp 
 in the muscular syste^n : Mrs. B., aet. fifty-three, 
 mother of a large family, and long afflicted with 
 rheumatism, now suffers from pain in the neck and 
 head, pains about the clavicles, difficulty in moving 
 the arms, which feel fixed at the shoulder-joints; 
 the pain in the neck and between the shoulders is 
 fixed and constant, being nearly the same both day 
 and night; it is a little alleviated by supporting 
 the back against a chair. There are also dart- 
 ing pains, extending from the cervical portion of 
 the spine upwards over the occiput, and downwards 
 across the neck and over each shoulder. Both arms 
 are affected with aching pains over their whole 
 extent, and with a sense of soreness on pressing or 
 rubbing the skin, pricking sensations, cramps and
 
 CASE. 107 
 
 numbness in the fore-arms, hands, and fingers, fre- 
 quent sudden twitching pains in the neck, arms, 
 and trunk, occasional pains in the abdominal mus- 
 cles, relieved by recumbency ; appetite poor ; there 
 was tenderness of two lower cervical and six upper 
 dorsal vertebras. Leeches, a blister, and recumbency 
 were enjoined, and in three weeks she was well. 
 
 Other cases are given. One headed " Intercostal 
 Neuralgia" is worth extracting : Mr. H., aet. forty, 
 had been out of health for several months. He 
 complained of a constant pain in the right side of 
 the chest, occupying the intercostal spaces between 
 the fourth and seventh ribs. These spaces were 
 tender on pressure, and the pain was increased by 
 deep inspiration. The intercostal muscles at this 
 part were occasionally affected with spasm. His 
 most intense sufferings, however, were caused by 
 acute pains shooting through this part of the chest, 
 extending to the back and darting thence towards 
 the shoulder ; these would sometimes dart through 
 the left side also, and then the chest felt completely 
 encircled by the pain. The dull, fixed pain was 
 constant during the day, and became a little re- 
 lieved by recumbency ; there were anorexia, flatu- 
 lence, and cough. Has had the pain in the side 
 for ten years, off and on; has been leeched and 
 blistered frequently, without relief. There was 
 tenderness of third and fourth dorsal vertebra?, and 
 he recollected that it had often been the seat of a 
 sensation of heat, and of some uneasiness. The
 
 108 SPINAL DISORDERS. 
 
 treatment was local depletion, antiphlogistic reme- 
 dies to the tender spine, and recumbency subse- 
 quently quinine. The duration of treatment was a 
 month ; recovery was perfect. 
 
 I had marked many other cases and observations 
 for quotation, but these will probably be deemed 
 sufficient. 
 
 Dr. Copland remarks, respecting the duration 
 and cause of functional spinal disorders : " The 
 duration of this disorder may be only three or four 
 days, or as many months, or even years, according 
 to the severity, causes, and treatment of individual 
 cases. There is every reason to infer that the 
 more obstinate cases, especially where the treat- 
 ment has been judicious, are perpetuated, either by 
 the continuance of their causes, or some chronic 
 or recurring inflammatory condition of the spinal 
 cord. . . . The most common exciting causes are ex- 
 cessive sexual intercourse, uterine disorder, sudden 
 muscular efforts, &c. It is, too, most common in 
 the nervous and lymphatic temperaments ;" and, we 
 may add, from other sources, in those who from any 
 cause are weakly or delicate. 
 
 The treatment recommended as most judicious is 
 " local bleeding by a few leeches, or cupping, occa- 
 sional blisters, liniments, &c., applied to the spine 
 about the tender spot, medication of the uterus 
 where necessary, chalybeates where the neuralgic 
 affections predominate, and in severe cases a general 
 tonic and restorative plan of diet" &c.
 
 REMARKS. 109 
 
 Such is a short epitome of the views held by 
 many distinguished authors and practitioners on 
 the subject of functional disorders of the spinal 
 cord. Those who have done me the honour to fol- 
 low my observations thus far, will not fail in reco- 
 gnising in the prominent symptoms all the charac- 
 ters I have assigned to affections of the muscular 
 system ; they will readily recognise, under the word 
 neuralgia, the pain due to overstretching of the 
 fibrous element of the muscles ; and in the twitching 
 spasms, the convulsive movement so common when 
 these organs are in action after fatigue, or when 
 the body generally is weak. 
 
 It may, however, be readily understood that a 
 simple similarity of symptoms is not sufficient to 
 establish so important a change in medical belief, 
 as that spinal disorders are almost entirely inde- 
 pendent of the nerves;* it will therefore be neces- 
 sary to address ourselves to a more cogent line of 
 argument. 
 
 * I have hitherto assumed that the pain in the tendinous or fibrous 
 portions of muscles, which is produced by stretching, is to a great 
 extent independent of the nerves. By some this may be considered a 
 physiological heresy. The subject is too long for discussion here, and I 
 shall not enter upon it. It will be quite sufficient for all practical pur- 
 poses if it be conceded that the pain arising from the stretching of a 
 fascia, or other fibrous structure, is essentially distinct and different 
 from the pain of tic- douloureux, or other genuine neuralgia. Different 
 in its cause, different in its history, and different as regards the treat- 
 ment required for its cure.
 
 110 EXPLANATION. 
 
 CHAPTER IX. 
 
 General sketch of the proposed explanation 1. What spinal tender- 
 ness is not 2. What it is 3. True explanation of the pheno- 
 mena 4. Treatment deduced The tenderness no proof of or- 
 ganic spinal disease, either in the bones or in the spinal cord 
 Arguments Its connexion with hysteria What hysteria is not 
 What it is. 
 
 THE main points we have to explain are the spinal 
 tenderness, the occurrence of certain symptoms 
 when the tender spot is touched, the occurrence of 
 similar symptoms when there is no spinal tender- 
 ness, and the bond of union that joins spinal dis- 
 orders to hysteria. 
 
 Bearing in mind that spinal tenderness has been, 
 and still is considered as the chief and character- 
 istic symptom of functional disease of the spine, we 
 will consider it first, and we shall most probably 
 find that, in explaining it, the explanation of the 
 other phenomena will naturally arise. 
 
 I propose to consider 1. What spinal tender- 
 ness is not; 2. What it is; 3. To show how the 
 various symptoms attributed to it may be explained 
 on a strictly physiological basis, quoting and annotat- 
 ing a severe case from Mr. Griffin's book ; 4. To de- 
 monstrate the plan of treatment necessarily deduced 
 from the new considerations, and to show that this
 
 WHAT SPINAL TENDERNESS IS NOT. Ill 
 
 is the only one which has hitherto commanded the 
 confidence of the medical profession, or rather the 
 one which has been successful when all other things 
 had failed. 
 
 1. What spinal tenderness is not. Our task 
 here is lightened by the fact that those systematic 
 writers who have made it their study, frankly 
 allow that the tenderness is no proof of real disease. 
 
 It is not due to any inflammatory affection of the 
 vertebrae themselves. Its invasion is too sudden, 
 its duration too fleeting, its seat far too migratory, 
 and the pain on pressure far too severe to allow us 
 to believe that it has anything in common with 
 genuine disease of bone. It is not due to inflam- 
 mation, congestion, or other affection of the spinal 
 cord. We conclude this (1.) Because the pain is 
 superficial, and confined almost exclusively to the 
 spinous processes of the vertebrae ; (2.) Because the 
 spinal column is so strong, the arch so formed, the 
 length of the spinous process so considerable, the 
 cord so cushioned in fat, that no pressure on the 
 spinous process with the finger could produce any 
 effect on the cord or its membranes. 
 
 It is not due to caries of the spine ; for we know 
 from experience that when real disease in the bones 
 does exist, it is neither attended with the signs of 
 spinal irritation or tenderness externally. 
 
 It is not due to conjoint inflammation of the 
 canal and its contents ; for where these exist, though 
 pain is the rule, tenderness on pressure is the ex-
 
 112 SPINAL TENDERNESS. 
 
 caption ; and in many instances where the inflam- 
 mation has been excessive, the tenderness has been 
 insignificant. In these instances, too, we do find, 
 as Dr. Copland remarks, " that the motions of the 
 spine, by perpetuating and aggravating the inflam- 
 mation of the spinous membrane covering the bones, 
 cause thickening or swelling of it," &c., but in 
 spinal irritation these motions of the body have no 
 such result. 
 
 Again, it is to be remarked that the spinal 
 tenderness, superficial as it is, is not accompanied 
 by redness, heat, or swelling (the sensation of heat 
 spoken of by the patient is altogether different 
 from genuine increase in temperature) ; the pain, 
 when it exists, is hot and aching, not throbbing, &c., 
 and local bleeding unaccompanied by rest is of no 
 service. 
 
 But perhaps the best arguments we can make 
 use of are the statements of the authors we have 
 quoted, " that we may have spinal tenderness with- 
 out any marks of spinal irritation, and symptoms of 
 spinal irritation without spinal tenderness." No- 
 thing could more emphatically prove that the various 
 spasmodic arid neuralgic phenomena spoken of, do 
 not depend upon " a peculiar condition of some 
 portion of the spine." 
 
 There are, however, those who hold that spinal 
 tenderness and its concomitant symptoms are 
 nothing more than signs of hysteria. Ere we can 
 combat this idea, we must form some definite notion
 
 HYSTERIA ITS NATURE. 113 
 
 of what hysteria is. Hysteria is not a disease in- 
 tended by nature to include every curious symptom 
 in the female which we are not able definitely to 
 explain ; nor can we allow ourselves, without great 
 detriment to our mental powers, to attribute every 
 pain, spasm, or ache which occurs in a delicate 
 virgin to something wrong in her womb, depraved 
 in her mind, or faulty in her education. Hysteria, 
 as a word, ought to be restricted to that congeries 
 of symptoms which betoken a peculiar condition of 
 the system generally, and of the nervous system in 
 particular; and as soon as any symptom once sup- 
 posed to be hysterical can be explained without 
 any special reference to the nerves it ought to be 
 removed from that congeries. Whether we can re- 
 move spinal tenderness in that manner it remains 
 now to be discussed. We have already demon- 
 strated that many spasmodic and painful affections, 
 once considered hysterical, and still spoken of as 
 such by the vast majority of practitioners, are due, 
 in reality, to over-exertion of certain sets of mus- 
 cles, and have no more connexion (necessarily) 
 with the uterus in the female than they have with 
 the whiskers of the male ! and we hope to show 
 that spinal tenderness itself is nothing more than 
 the result of over-exertion of those very muscles, 
 whose aches and pains we have already described 
 in their more moveable insertions.
 
 114 WHAT SPINAL TENDERNESS IS. 
 
 CHAPTER X. 
 
 What spinal tenderness is Anatomical relations of the spinous pro- 
 cesses They form the starting-point for almost every muscle of 
 the back, and, to a great extent, of the trunk, head, and extremities 
 Examples Strain upon the more moveable insertions of muscles 
 produces pain and tenderness on pressure It may do so equally 
 on the more fixed insertion Reason why the cause of spinal ten- 
 derness may be traced in some and ignored in others Why the 
 symptoms of spinal irritation may be present without spinal ten- 
 derness, and vice -versa Why pressure on certain regions pro- 
 duces apparently definite symptoms Effect of the examination on 
 the patient's equilibrium Recapitulation. 
 
 WE proceed now to examine what spinal tender- 
 ness is. We inquire 
 
 First, into the anatomical relations of the spinous 
 processes of the vertebra?. 
 
 Secondly, whether there is anything in those 
 relations which will explain the pain. 
 
 When we rake up our reminiscences of the dis- 
 secting-room, and refresh our memories with any 
 work on anatomy, we find that the chief, if not 
 the sole use of the spinous processes is for the 
 insertion of muscles. The spine forms the point 
 d'appui for nearly every muscle in the body. Is 
 the head to be kept erect, the muscle springs from 
 the spine ; are the scapula to be drawn back, the 
 arm to be raised, the shoulder to be moved, the 
 muscles by which the operation is effected have 
 the spinous process for their "stand-point." Is
 
 MUSCLES ATTACHED TO SPINOUS PROCESSES. 115 
 
 the body to be kept erect or to be turned, still the 
 muscles use the spine for their centre of operations. 
 Are the thighs to be raised by the psoas, the anta- 
 gonistic muscles on the other side the vertebras 
 must be brought into operation, that the spine 
 may be fixed (if not, the body would be bent on 
 the thighs). In fine, there is scarcely a single 
 motion of the body in which one or more muscles 
 attached to the spinous processes are not brought into 
 operation, and there is, therefore, throughout the whole 
 day (except during absolute rest) a constant and 
 unintermitting strain upon the fibres by which the 
 muscles are inserted. 
 
 We know, as a law of dynamics, that when a 
 strain is laid on any cord, or similar material 
 uniting a moveable to a fixed body, the same effect 
 is produced in the one as in the other attachment, 
 but that the heavier body will not move towards 
 the light one with the same velocity as the light 
 one goes to the heavy one. In the same way, 
 when the shoulder is moved by the trapezius 
 muscle, as great an eifect is produced by the mus- 
 cular strain on the origin as on the insertion of 
 the muscle; but the shoulder is the most move- 
 able the lightest so to speak, and it moves while 
 the back remains still. This can readily be de- 
 monstrated to the tyro, for he has only to fix the 
 shoulder-joint artificially, and he may then move 
 the trunk by the same muscle. 
 
 Whenever a muscle makes a feeble effort, as, for 
 i2
 
 116 SPINAL TENDERNESS OF FIBROUS ORIGIN. 
 
 example, in carrying a hat on the head, the strain 
 is so small as to be imperceptible; but when it 
 makes an unusual exertion, as in carrying a canful 
 of water on the head, the stress is tremendous. 
 
 The strain, then, laid upon any muscle, i.e., the 
 force it exerts, is to be measured by the result 
 produced. 
 
 But we have attempted to show that what was 
 an ordinary and easily borne effort, when an indi- 
 vidual was strong, became a severe and extraor- 
 dinary exertion when he was weak.* 
 
 We have shown that a large amount of suffer- 
 ing, often of a very intense kind, arises from 
 muscular strains in various parts of the body. 
 We have shown, and might still farther illustrate 
 the fact from histories of torture by the rack and 
 by strappado, that the fibrous portions of the 
 muscles are the chief seat of pain, and that after 
 the strain has been long continued there is abso- 
 lute tenderness on pressure.f 
 
 Is there, therefore, anything extraordinary in 
 the assertion, that the spinous origins of various 
 muscles are as frequently and as painfully affected 
 as are their insertions elsewhere? 
 
 We have shown that the pain, either in the 
 fleshy or the fibrous parts, has been in some cases 
 produced by long-continued exertion of a debili- 
 tated muscle, in others by excessive exertion in 
 
 Vide pp. 14 and 15. f Vide notes, pp. 19, 21, and 74.
 
 SPINAL IRRITATION WITHOUT TENDERNESS. 117 
 
 one of ordinary strength. We ought, therefore, to 
 be able to recognise the same phenomena in cases 
 of spinal tenderness. We ought to have one class 
 of patients tracing their complaints to some power- 
 ful muscular exertion, and another unable to give 
 any account of its origin; as they would not be 
 aware that they had been doing anything out 
 of the common way. I need only refer to what 
 Dr. Copland says respecting the causes of spinal 
 disorders (p.* 101, ante} to show that this is prac- 
 tically the case. 
 
 It is farther to be noticed that we may have all 
 the symptoms of spinal irritation without spinal 
 tenderness. This is readily explained by the con- 
 sideration that other muscles may have borne the 
 chief brunt of the bodily exertion employed, while 
 the spine, either from the use of well-made stays, 
 or from the use of an arm-chair, has not been 
 extraordinarily taxed. I am conscious that this 
 suggestion alone is by no means sufficient to 
 account for the fact alluded to; I shall, therefore, 
 refer to this question again by-and-by. I merely call 
 attention to it here in a " muscular" point of view. 
 
 Again, we may have spinal tenderness without any 
 sign of spinal irritation : a fact which is explained 
 by stating that it is most probable that in these in- 
 stances the trapezius, latissimus dorsi, rhomboidei, 
 splenii, and erector spin as, have been more used 
 than the muscles elsewhere. A glance at Fig. 4 
 will at once show the value of this explanation.
 
 118 WHY CERTAIN SYMPTOMS FOLLOW 
 
 There is another thing to be explained, and one on 
 which the authors of books on functional diseases 
 of the spine lay great stress: viz., that certain 
 symptoms attend pressure in the cervical region, 
 certain others in the lower cervical and upper 
 dorsal, others in the dorsal, lower dorsal and 
 lumbar, and lumbar and sacral, &c. 
 
 The first answer we give is to deny the fact, 
 not in the general sense, but in the particular one ; 
 that is to say, we assert that an invariable set of 
 symptoms do not attend tenderness in any one 
 spot, for the same set may be found where there is 
 tenderness in the cervical, or dorsal, or lumbar, in 
 all of them, and in none ! That, as stated above, 
 there may be tenderness, and no other marked 
 symptoms, and vice versa. 
 
 The next answer is, that it is natural, when the 
 cervical region is the one in which the tenderness 
 exists (which we attribute to excessive use of the 
 trapezius, rhomboid, and splenii muscles), that the 
 other (muscular) pains of which the patient com- 
 plains, should be in the upper parts of the body, 
 with which the head and arms are intimately con- 
 nected in motion. Thus, for example, we anti- 
 cipate that with pain referrible to the trapezius, 
 we may have pain in the " occipito-frontalis," in 
 the sterno-mastoid, in the splenius colli, and capitis, 
 in the shoulder, in the pectorals, probably in the 
 deltoid, in the serratus magnus, and in the abdo- 
 minal muscle?.
 
 PRESSURE ON THE SPINOUS PROCESSES. 119 
 
 Is the tenderness in the dorsal region, the cause 
 may be in the body itself, rather than in the 
 extremities, and we shall have pain in the inter- 
 costals, the abdominal muscles, the diaphragm, the 
 serratus magnus, &c. 
 
 Is the tenderness in the lumbar vertebras, the 
 cause may be presumed to be connected with the 
 lower extremities ; the patient probably has much 
 stooping and rising, is fond of gardening, dancing, 
 organ* or pianoforte playing, &c. The exertion 
 required in all these exercises necessitates the 
 lower part of the spine to be fixed, and this as 
 certainly produces pain and tenderness at the 
 insertion of the muscles into it, as we have pain at 
 the pubic insertion of the rectus from frequent 
 stooping. 
 
 It may still be objected, that when certain im- 
 portant symptoms, such as palpitation, pain arising 
 
 * I have had numerous instances brought under my notice in which 
 considerable suffering (of a muscular character) has arisen from excessive 
 practice at the pianoforte, and can readily understand how organ-playing 
 must be much more severe. The individual commonly sits upright on 
 a stool, without the slightest artificial support (except the corset in 
 women) ; both hands are in perpetual motion ; the body is swayed from 
 side to side, according to the exigencies of the tuue and " time ;" the 
 legs are called into exertion to work the pedals ; and as singing is often 
 joined to playing, the muscles of ordinary and extraordinary respiration 
 are forcibly occupied. The interest of the musician during the practice 
 diverts her thoughts from herself ; and it is not, usually, until she has 
 long left the piano, and has begun to exercise herself in another manner, 
 that she is conscious of pain, aching, or fatigue. In these cases, the 
 presence of spinal tenderness is the rule, and it is generally in the cer- 
 vical region.
 
 120 SUBJECT CONTINUED. 
 
 with telegraphic rapidity, and shocks comparable 
 only to those produced by powerful batteries, do 
 arise instantly upon pressure on a tender spot, it 
 must be conceded that there is a direct connexion 
 between the cause (spinal tenderness or disorder) 
 and effect. 
 
 To this mode of putting the argument, our 
 answer differs little from that given before. In 
 the first place, it is not true in the main, and when 
 true, a different and far more satisfactory explana- 
 tion may be given. 
 
 It is not true in the main; for out of every 
 twenty cases of spinal irritation not more than one 
 has any result follow from pressure upon the 
 tender spot, except local pain. We find, also, both 
 Teale and Griffin themselves laying great emphasis 
 upon the fact that where the electric-like results 
 do follow pressure on the tender vertebrae, they 
 follow equally from pressure on any other tender 
 spot. 
 
 That in these points we have not been guilty of 
 misstatements, we quote the following from Dr. 
 Griffin, p. 217, "With respect to the tenderness of 
 the spine in diseases of irritation, we have been 
 anxious to ascertain what symptoms might be 
 considered as peculiarly belonging to any one por- 
 tion of the cord ; but in- this we have found much 
 difficulty, and have not had in fact a sufficient 
 number of cases before us to draw absolute con- 
 clusions from." Yet he had 148 in all ! !
 
 EXPLANATION OF PHENOMENA. 121 
 
 "In examining the spine, we shall often find 
 that the tenderness does not reach so high up or 
 so low down as the symptoms would lead us to 
 expect," p. 218. 
 
 " It happens that when great tenderness prevails 
 at a particular part of the spine, pressure on which 
 excites cough, or oppression, or distant pain, these 
 symptoms may be equally brought on by pressure 
 for some distance above or below the tender 
 point."* 
 
 * It would be almost impossible for any one who has not closely 
 watched all the phenomena of muscular action, and the excessive irri- 
 tability to which the muscles are sometimes brought, to seize the truth 
 contained in this paragraph, and some others of a similar import a 
 truth evidently hitherto unrecognised. Let me ask my readers to re- 
 quest a medical friend to examine whether their spine is tender, and to 
 note, most closely and minutely, the effect produced on the trunk and 
 extremities by pressure upon the various parts of the spine. Supposing 
 that the examination is made in any of the usual ways, either by direct 
 pressure upon each spinous process, or by a thump on many at once, or 
 by stroking the finger heavily and continuously over each, it will be 
 found, whether the patient is sitting, standing, or lying when the exa- 
 mination is made, that pressure in the cervical region has a tendency to 
 bring the head back or push the body forwards, and excite the trapezius, 
 splenii, sterno-mastoid, &c. ; in the dorsal region, to push the body for- 
 wards or to bring the shoulders back, and to irritate the trapezius, the 
 rhomboids, the pectorals, the serratus magnus, and abdominal walls in 
 the lumbar region ; to bring the latissimus and longissimus dorsi, the 
 quadratus lumborum, psose, rectus abdominis, obliqui, &c. &c., into 
 action. After this examination, it will not be difficult to see that the 
 results following pressure on the tender spine may be simply the effect 
 of the patient naturally moving in some way or shrinking from the 
 painful infliction, a motion which calls into sudden operation muscles 
 rendered peculiarly irritable from the effects of general debility. It 
 would be difficult to make any examination of the spine in which this v 
 source of fallacy would not have to be borne in mind. I may add, that 
 it is only in cases of extreme debility that the electric-like results 
 follow.
 
 122 ARGUMENTS CORROBORATIVE. 
 
 " Instances may even be met with of such extra- 
 ordinary susceptibility, that pressure on any of the 
 large nervous trunks, or any portion of the person 
 which happens to be morbidly irritable, may ex- 
 cite or aggravate the same symptoms (as those pro- 
 duced by pressure on the spine). A case is de- 
 tailed where pressure behind the trochanter, or the 
 knee, excited distressing pain at the ensiform carti- 
 lage,* with a disposition to syncope !" 
 
 Supposing, however, that these explanations 
 may not be satisfactory to every one, and wishing 
 to heap up proofs of the truth of our position, we 
 may add that the electric-like shocks produced by 
 pressure on a tender vertebra may be simply due 
 to the fact that the spot is tender, and the system 
 in a peculiarly excitable condition. The practi- 
 tioner is no stranger to the probability of such an 
 occurrence. How often, for example, do we read of 
 a breath, a footfall, a whisper exciting the most dis- 
 tressing paroxysms in hydrophobia ! How common 
 in tetanus is it for the spasms to be reinduced by 
 a current of cold air, or by the faintest touch! 
 When a frog has been dosed with strychnia, how 
 it starts at a prick of his toes ! Even man, when 
 
 * Does not this pain, evidently referrible to the insertion of the 
 rectus abdominis, lead us to infer that, in making the pressure de- 
 scribed, the body of the patient was involuntarily pushed forwards, thus 
 suddenly irritating the excitable muscle. The disposition to syncope 
 may have been from the upright posture, supposing, as seems probable, 
 that it had been adopted during the examination ; but we have not 
 data enough to explain it thoroughly.
 
 RECAPITULATION. 123 
 
 under the influence of the same drug, may have a 
 spasmodic exacerbation, produced by a touch at 
 any spot. Dr. Abercromby " relates the case of a 
 lady who was subject for two years to convulsive 
 action of the muscles of the back, and twitchings 
 of the arms and legs. These were much increased 
 by touching her, especially on any part of the 
 lack. After describing more extraordinary con- 
 vulsions, &c., it is remarked " that if the head or 
 neck were touched, the motions were increased to a 
 most extraordinary degree of rapidity." (Quoted 
 from Dr. Watson's " Practice of Physic.") 
 
 To recapitulate 
 
 We believe that the vast majority of the symp- 
 toms considered the result of spinal irritation arise 
 from over-exertion of one or more portions of the 
 muscular system in debilitated subjects. 
 
 That the spinal tenderness has a similar origin ; 
 
 That the other symptoms, commonly considered 
 as resulting from spinal tenderness, are concomi- 
 tants only, and referrible to a common cause. 
 
 It remains for us next to show the connexion 
 between hysteria and spinal irritation. 
 
 We anticipate that it will be found in the con- 
 stitutional debility which is common to both.
 
 124 CONNEXION WITH HYSTERIA. 
 
 CHAPTER XL 
 
 Why spinal irritation has been considered a symptom or phase of hys- 
 teria Definition of hysteria, quoted from Dr. Copland Consti- 
 tutional debility the cause of hysterical phenomena Constitutional 
 debility defined Consequences of constitutional debility Law 
 The more debilitated the individual, the greater is the irritability 
 of the nervous system How irritability of the nervous system 
 shows itself Multifarious functions of the nervous system Arti- 
 ficial division into mental, sensitive, motor, and organic functions 
 One or more of these may be affected There may be rapid transi- 
 tions from one to the other Sometimes all may be affected Over- 
 action, a cause of exhaustion in muscle ; may be so in nervous affec- 
 tions Over-action in one part of nervous system is not always fol- 
 lowed by symptoms referrible to that particular division. 
 
 ERE we attempt to demonstrate the connexion be- 
 tween spinal disorders and hysteria, let us turn to 
 Dr. Copland (article Hysteria), and take the mea- 
 sure, as it were, of the latter the disease we have 
 to fit. Definition " Nervous disorder, often as- 
 suming the most varied forms, but commonly pre- 
 senting a paroxysmal character ; the attacks usually 
 commencing with a flow of limpid urine, with un- 
 easiness or irregular motions, and rumbling noises 
 in the left iliac region, or the sensation of a ball 
 rising upwards to the throat, frequently attended 
 by a feeling of suffocation, and sometimes with 
 convulsions, chiefly affecting females from the pe- 
 riod of puberty to the decline of life, and princi- 
 pally those possessing great susceptibility of the ner- 
 vous system.'" (The italics are our own.)
 
 HYSTERIA DEFINED. 125 
 
 We continue the same article, and find that we 
 have to account for " Altered sensibility or pain, 
 of a truly hysterical character in the head;* below 
 the left mamma, or at the margin of the ribs; in the 
 region of the stomach and spleen; in the course of the 
 descending colon; and in the left iliac region; above 
 the pubes ; in various other parts of the abdomen, or 
 in the abdomen generally ; in the region of the kid- 
 neys, sometimes extending in the course of the ureters; 
 in one or more of the lower dorsal or lumbar ver- 
 tebras; in the sacrum, f in the hip, or knee-joint; 
 in the pharynx and larynx; in one or both 
 mammae ; or in the region of the liver. 
 
 Again, Dr. Copland remarks 
 
 " Hysteria will give rise to and simulate various 
 spasmodic affections asthma, cough, hiccough, 
 sneezing, dysphagia, colic, hydrophobia, trismus, 
 opisthotonos, or pleurosthotonos." " It gives rise to 
 various comatose, cataleptic, or soporific states." 
 " It may simulate paralytic affections." " It may 
 manifest itself chiefly by disorder of the mental 
 emotions and faculties." Further quotations would 
 
 * The author has placed in italics all those pains, &c., which he con- 
 siders have a muscular origin. He must refer his readers to the article 
 itself for corroborative proof that the view that he has taken of these 
 pains is the only one which is consonant with facts. 
 
 f The pain in the sacrum is not strictly hysterical, whatever its 
 proximate cause. It is common in males who have oxaluria, and invo- 
 luntary discharge of semen, and in women who have leucorrhcea, or 
 some disorder of the os uteri. It may exist without other symptoms of 
 hysteria.
 
 126 IMPORTANT LAW. 
 
 weary the attention of the reader, and divert him 
 from the main question. 
 
 The connecting link between hysteria, muscular 
 affections, and spinal irritation in general is, that 
 there are in all cases, general and very readily re- 
 cognised constitutional or acquired debility.* In 
 hysteria the debility shows itself by disorder of the 
 nervous system. In the other instances we have 
 described, debility has shown itself by disorders of 
 the muscular system. 
 
 We have already enunciated the law that 
 
 " The more debilitated the individual, the greater 
 is the irritability of his muscular system." We now 
 enunciate the corresponding one " The more debi- 
 litated the individual, the greater is the irritability of 
 the nervous system." 
 
 To many this may seem a truism, but we en- 
 treat their attention while we try to develope the 
 
 * I have so frequently used the words constitutional or acquired de- 
 bility, that it is necessary, to prevent misunderstanding, to state the 
 meaning I assign to them. 
 
 Constitutional debility is used to indicate the deficiency of strength 
 in the system, rather than of strength in the will, the mind, or the 
 muscles. The debility is inherited from one or both parents, and is 
 necessarily inseparable from the strumous, scrofulous, tubercular, and 
 gouty diatheses. In short, wherever there is hereditary disease, there 
 must be constitutional debility, as disease cannot exist without the vital 
 powers having been overcome. Constitutional debility is persistent 
 through life. Acquired debility is more or less transient, according to 
 its cause. It may be produced by bad air, poor diet, exhausting dis- 
 eases, excessive discharges, loss of blood, loss of appetite, indigestion, 
 depressing drugs, incessant mental or bodily labour, prolonged grief, 
 mental excitement, loss of sleep, and any other circumstance, hygienic 
 or otherwise, likely to deteriorate the vital powers.
 
 BEARING OF THE LAW. 127 
 
 important bearings it should have upon pathology 
 and practice. 
 
 We may assume it as a medical axiom, That when 
 an organ is in a state of disease, the disorder shows 
 itself in some modification of its special function 
 i.e., if the eye is diseased, sight is affected ; if the 
 ear, hearing; if the lungs, the breathing; if the 
 heart, the circulation; the liver, the secretion of 
 bile, &c. &c. 
 
 We have seen how when a muscle, whose special 
 business is contraction, is disordered, spasms fre- 
 quently ensue (it is out of our province to refer 
 to paralysis, except when it occurs, as it some- 
 times does, from over-stretching or from very pro- 
 longed exercise). 
 
 But when the nervous system is diseased, in 
 what way are we to anticipate that its functions 
 will be affected? 
 
 The cerebro-spinal nervous system has not a 
 simple function, like the heart, the stomach, the 
 liver, kidneys, &c. On the contrary, its functions 
 are at least fourfold. 
 
 1. It has to originate, direct, control, &c., 
 thought, memory, the will, &c. 
 
 2. It has to appreciate impressions, special or 
 otherwise, and interpret them to the mind as sen- 
 sations. 
 
 3. It has to generate, use, or direct the applica- 
 tion of that " something " which, when it reaches a 
 muscle, compels it to contract.
 
 128 FUNCTIONS OF NERVOUS SYSTEM. 
 
 4. It has an influence over the body generally, 
 assisting or modifying in some way secretion, assi- 
 milation, growth, &c. &c. 
 
 To save time and circumlocution, we propose de- 
 signating these different functions as 1. Mental; 
 2. Sensitive; 3. Muscular; 4. Organic. 
 
 Whenever the system generally is debilitated 
 from any cause, any one or all of these functions 
 may be affected. The affection, whatever it may 
 be, shows itself first in one, then in another; in 
 two simultaneously or alternately, and in every 
 variety of combination.* 
 
 It is this which has given to hysteria the desig- 
 nation of the Protsean malady. Yet when we look 
 upon its symptoms in this light, it loses this cha- 
 racter, and becomes amenable to the same laws 
 which guide us in our recognition of diseases of 
 other organs. 
 
 In our inquiry into the causes of muscular weak- 
 ness, we were able to trace over-action as one ; and 
 
 * This observation is one of extreme interest to the philosophical 
 physician, and I doubt not that many of my readers will be able to 
 recal cases like the following : M. C., aet. 25, had hysterical attacks, 
 characterized chiefly by laughing, shouting, and crying, during a period 
 of about ten months ; by the treatment adopted, these were cured in 
 three days, but (according to prophecy) they were followed by tic-doulou- 
 reux. J. H. had fits of a convulsive nature, which were mistaken for 
 epileptic. She came into hospital ; their nature was ascertained ; they 
 were cured in a day, but the next day they were replaced by tic-doulou- 
 reux. These are only very small illustrations of the Protsean character 
 of hysteria, and the rapidity with which its symptoms may be trans- 
 ferred from one portion of the nervous system to another.
 
 OVER- ACTION A CAUSE OF DEBILITY. 129 
 
 in our remarks upon cramp, we showed that it was 
 due to excessive previous exertion in a muscle as 
 well as to general debility.* 
 
 We ought, then, to be prepared for the fact that 
 excessive nervous action (whatever its nature) will 
 produce nervous exhaustion. 
 
 Theory might lead us to infer that excessive 
 mental action, or emotion, would produce excita- 
 bility of mind, but experience shows us that it may 
 produce any or all of the following viz., Insanity, 
 spectral or aural illusions, tic, chorea, convulsions, 
 catalepsy, corna, urination, vomiting, diarrhoea, or 
 jaundice; theory might say that intense sensitive 
 emotion, whether arising from the eye, the ear, or 
 other parts, should produce some disorder of sen- 
 sibility; experience tells us that it disorders the 
 mind. Whether, then, we have exhaustion of the 
 nervous system, from general debility or from over- 
 action, it shows itself by disorder of one or other 
 of the nervous functions, or of all. 
 
 Let us see how the remarks of modern autho- 
 rities bear us out in this view, as regards the 
 nervous system. 
 
 * Vide p. 12. 
 
 K
 
 130 INSANITY. 
 
 CHAPTER XII. 
 
 Insanity an affection of the mental nervous system Its alliances 
 Its causes : shipwreck, hunger, misery Experience drawn from 
 asylums Influence of generous diet on the insane Dr. Conolly's 
 opinion of cod-liver oil, &c. Mania not a disease of strength 
 Sensitive nervous system Its susceptibility increased by exhaus- 
 tion Effect of noise, light, strong odours, &c., on those weakened 
 by losses of blood Sensibility of the skin in hysteria explained 
 Cases Neuralgia Its causes Its proper treatment Muscular 
 nervous system Cause of tetanus Fatal case of idiopathic tetanus 
 Epilepsy May be produced by bleeding or excessive debility 
 Case of Mrs. T. Infantile convulsions Its chief victims 
 Its causes The danger The cure Chorea Its cause Its 
 victims Their condition of health The danger The cure 
 Cases Influence of a tonic plan of treatment Influence of 
 mental emotion on a weakened heart Organic nervous system 
 Effects of debility on the milk On digestion Emotion produces 
 vomiting Question how far anxiety operates in the production of 
 tubercle or cancer. 
 
 WE commence with insanity, a disease showing 
 itself principally in the mental nervous system, 
 although we find it affecting, to a greater or less 
 extent, both the sensitive, muscular, and organic, 
 as is evidenced by the aural and ocular delu- 
 sions, the catalepsy, the convulsive diseases, and 
 the modified secretions so common in that com- 
 plaint. 
 
 What are the common causes of insanity? Dr. 
 Copland sums them up thus : "A certain confor- 
 mation derived from parents, an original predispo-
 
 CAUSES OF INSANITY. 131 
 
 sition not so derived, a state of the constitution 
 gradually acquired, or arising out of the continued 
 operation of causes which deteriorate, or otherwise 
 change, the organic, nervous, and vital powers " We 
 turn to the accounts of shipwreck, and other ter- 
 rible scenes, when human beings have been long 
 subject to anxiety, labour, distress, cold, and starva- 
 tion, and we find that most of those who succumb 
 "go mad" ere they die, and that many of the sur- 
 vivors never recover their reason. The form of 
 their insanity is various ; sometimes there are optical 
 delusions, at others a raving mania. We turn to 
 the individuals who are the victims of insanity in 
 our asylums, and we find that they are chiefly poor 
 people who have long suffered privation. Misery 
 and drink are the causes assigned for a full half of 
 those attacked ; others assign prolonged lactation, 
 sexual excess, loss of rest, incessant toil, losses of 
 blood, loss of health, &c. In the " Report of the 
 Commissioners of Lunacy for 1844," p. 118, we 
 read : " It is indeed evident that nothing can be 
 effected without an ample supply of proper food, in 
 the restoration of the patients from that state of 
 physical weakness and exhaustion which is the con- 
 dition of the majority among the inmates of pauper 
 asylums. 
 
 " It is worthy of remark, that in Middlesex and 
 Dorset Asylums the diet of the patients was some 
 time since improved by an increased allowance of 
 food, and that in both of these asylums there was 
 
 K2
 
 132 INSANITY A DISEASE OF DEBILITY. 
 
 recorded after this alteration an increase in the 
 number of recoveries." 
 
 We find Dr. Conolly, than whom few men have 
 laboured harder, observed closer, or reasoned more 
 philosophically, writing thus : 
 
 " It is desirable to keep in view that the preter- 
 natural excitement of a patient affected with acute 
 mania, his violent action, and his loud voice, are 
 not indications of strength, and that the more vio- 
 lent the symptoms, the greater is the danger of 
 sudden prostration and death. In young persons, 
 maniacal symptoms are not unfrequently the first 
 in the train of those belonging to pulmonary dis- 
 ease. In old persons, an outbreak of mania is often 
 the mere precursor of general decline and death." 
 (Conolly on the " Treatment of the Insane," pp. 69, 
 70.) Again, p. 76 : " There will soon be accumu- 
 lated, I believe, in many asylums, very singular 
 proofs of the general benefit of a tonic and nutritive 
 plan of treatment, in most of the forms of chronic 
 insanity, and in all cases attended with debility, in 
 consequence of the recent extensive introduction of 
 cod-liver oil into practice." Again, pp. 77-8 : 
 " All practitioners in medicine, whose experience 
 extends, as my own does, to more than thirty 
 years, must have observed, even within that short 
 period, a striking change in the extent to which 
 ordinary means, formerly considered remediable 
 and even indispensable, are employed. Large and 
 frequent bleedings, once so common as almost to be
 
 DELIRIUM TREMENS. 133 
 
 universal, are now wholly unknown. Violent pur- 
 gative medicines, and the excessive employment of 
 mercury, have been desisted from in all climates 
 where scientific practice prevails." The " Medico- 
 Chirurgical Review" remarks, in addition: "Many 
 instances (of mania) have come to our knowledge, in 
 which, to the best of our judgment, acute and once 
 hopeful cases have been rendered the reverse by 
 general bleeding, into which the surgeon has been 
 misled probably by delusive appearances of ple- 
 thora," &c. 
 
 From insanity we turn to a peculiar form of it, 
 delirium tremens, in which we have both the 
 mental, sensitive, and muscular nervous systems 
 affected. We find that this is produced by debility, 
 the debility commonly arising from deficiency of 
 food and the abuse of ardent spirits ; a fit is often 
 determined by diarrhoea, loss of blood, an acci- 
 dent, &c. The danger is death from exhaustion ; 
 and the best treatment is, opiates to procure rest, 
 combined with appropriate food and stimulants to 
 support strength. 
 
 When we leave the mental for the sensitive ner- 
 vous system, we see the same' law hold good: 
 " The greater the debility, the greater the irrita- 
 bility." We are all of us familiar with the fact, 
 that when a person has suffered from an exhaust- 
 ing illness, from haemorrhage, or other causes of 
 debility, the sensibility becomes wonderfully ex- 
 alted ; one patient faints at a strong odour, another
 
 134 SENSITIVE IRRITABILITY. 
 
 cannot bear the light of day, or the common sounds 
 that go on hourly in our working-day world. A 
 woman, after menorrhagia or miscarriage, cannot 
 endure the prattle of her children, once her greatest 
 delight ; she is sensible to a footfall, and can 
 scarcely bear contact with her clothes. This ex- 
 treme sensibility of the skin has long been known 
 as a symptom of hysteria, and has commonly been 
 considered an almost certain diagnostic mark. Its 
 true signification has been overlooked. We have con- 
 tented ourselves with establishing the diagnosis 
 rather than investigating the connexion. How im- 
 portant does the sign become when we recognise 
 in the preternatural irritability of the skin a proof 
 of general and special debility. 
 
 The following cases are interesting specimens of 
 this form of sensitive nervous irritability. The first 
 I met with casually in conversation, the second 
 occurred in my own practice : 
 
 A lady in wealthy circumstances, not subject 
 to any particular emotion, excitement, mental or 
 bodily labour, passing her time, in fact, almost 
 exclusively in bed or on the sofa, was the victim 
 of most extraordinary sensitiveness of the skin ; to 
 such a degree did this extend, that a touch on any 
 part of the body would produce paroxysms, which 
 could only be compared to those resulting from a 
 touch or current of air in hydrophobia. The very 
 idea that she was going to be touched produced a 
 fit of shuddering, as does sometimes the sound of
 
 CASE. 135 
 
 runninsr water in canine madness. There was no 
 
 o 
 
 exhausting disease, but the patient lived almost 
 exclusively on tea and toast-and-water ! a diet 
 certainly by no means sufficient to keep up the 
 natural or vital powers. There was exhaustion 
 from deficient supply, not from excessive demand. 
 
 M. I., ast. twenty-seven, of delicate appearance, 
 came under my care for pain and tenderness of the 
 whole of the back. She was a housemaid, had an 
 easy place, and a kind mistress, who gave her every 
 facility for relief. She was chlorotic, but there was 
 no sign of organic uterine disease, or other depress- 
 ing disorder. There was complete loss of appetite, 
 the bowels were inclined to be costive, the pain was 
 so severe she could not sleep, contact with her 
 clothes was painful, and it required all her energies 
 to go through the smallest exertion. The spine 
 was exquisitely tender throughout its whole extent, 
 there was soreness over the abdomen and chest 
 to a limited degree, she had pain in the hypochon- 
 dria, the epigastrium, the iliac regions, and in the 
 pubis. Had cramps in the rectus, oblique, longis- 
 simus dorsi, &c. 
 
 My recommendations, which were strictly fol- 
 lowed, were a belladonna plaster along the spine, 
 morphia at night, rest for an hour or so in the 
 afternoon, with steel, cod-oil, and generous living. 
 The oil soon disagreed; the other remedies seemed 
 powerless. The sensibility increased to such a 
 degree that she could not "sleep a wink" day or
 
 136 CAUSES OF GENUINE NEURALGIA. 
 
 night. She was obliged at last to leave her place, 
 and took lodgings with the full intention of taking 
 care of herself. She abandoned all medicine, in- 
 dulged in bed for the greatest part of the day, lived 
 as well as her means would permit, and at the end 
 of six weeks was perfectly recovered. As I did 
 not attend her after she left her place, I can give 
 no history of the gradual cessation of any special 
 symptom. I can scarcely refrain from adding 
 that, had she placed herself under the care of a 
 homoeopathist, she would have formed a most 
 astonishing (though of course fallacious) proof of 
 the value of the new over the old style of medicine. 
 When we consider the causes of those painful 
 diseases of the nervous system, to which the word 
 neuralgia ought specially to be confined, as " tic," 
 " sciatica," " megrim," &c., complaints which so 
 often baffle our best-directed efforts, and subse- 
 quently go away of themselves (resembling in 
 this respect the fury of a maniac, which continues 
 intense as long as he is coerced by gyves and 
 other restraints, but goes off at once when he is 
 placed alone and unshackled in a padded room), 
 we find them to exist chiefly in local or general 
 debility. Dr. Copland thus sums them up, vol. ii. 
 p. 884 : " Chronic or prolonged debility, the ex- 
 haustion consequent upon acute diseases (and 
 influenza), prolonged or neglected dyspepsia, the 
 puerperal states, exhausting discharges, prolonged 
 or improper lactation, excessive venereal indul-
 
 CAUSES OF SPASMODIC AFFECTIONS. 137 
 
 gences, anxiety of mind, menorrhagia, &c., are 
 amongst the most influential of predisposing causes." 
 
 We see the same broad truth evinced in the 
 influence of treatment upon these diseases. What- 
 ever tends to keep up or increase debility keeps 
 up or aggravates the pains : whatever tends to 
 invigorate the system, such as quinine, steel, cod- 
 oil, &c., has a direct tendency to cure them. 
 
 From diseases of the sensitive, we may pass to 
 the muscular nervous system. We have already 
 considered the muscles themselves as being ren- 
 dered more irritable by debility : we have now to 
 consider the nervous stimulant which impels them 
 to contract, being rendered irregular, excessive, or 
 deficient from the same cause. We have little that 
 is satisfactory to say of tetanus, except that it is 
 most common in those who, after having been 
 exposed to great heat, exertion, and probably loss 
 of blood, are exposed for a considerable period to 
 severe cold. How potent is this cause, the follow- 
 ing case of idiopathic tetanus will show : 
 
 " Mrs. G., set. thirty-eight, of nervous tempera- 
 ment, mother of seven children (the youngest of 
 whom was twenty-two months old, and still at the 
 breast), and residing in a crowded, unhealthy street, 
 lost her appetite a fortnight ago, was languid, and 
 suffered from palpitation; in a week she had "flood- 
 ing" and faintness, was laid up a few days, and 
 then resumed her domestic duties; on the 2nd of 
 August went to rest on her bed in the afternoon,
 
 138 CASE. 
 
 and fell asleep with the window open, the left side 
 of the neck being exposed to a current of cold air 
 and the body exposed to the full influence of a 
 powerful sun. She had giddiness on rising; on 
 the next evening the neck was stiff; on the 4th all 
 the signs of tetanus were well marked; and she 
 expired on the evening of the 5th." (Sinclair, in 
 No. I. of the "Liverpool Medico-Chirurgical 
 Journal," p. 130.) 
 
 If we turn to epilepsy, we see the same fostering 
 effect of debility on the growth and severity of the 
 complaint. We find that patients may be bled 
 into epilepsy; that it is the most severe in the 
 poor, the ill-fed, and weakly; that it occasionally 
 accompanies exhausting diseases; and that when 
 it is dependent upon some organic cause in the 
 brain, the number and severity of the fits depend 
 upon the general health of the system. 
 
 The following case is useful as illustrating many 
 of the points we have brought forward and some 
 which we shall hereafter refer to : 
 
 I was called in consultation to see Mrs. T., 
 set. thirty-eight, who was at the time insensible, 
 and had just suffered from severe epileptic fits. 
 She had been ailing a long time, and was supposed 
 to be under the influence of lead. The most pro- 
 minent symptoms were intense pain in the head, 
 strabismus, partial loss of sight, daily bilious 
 vomiting the bile being of a bright grass-green, 
 pulse 84, skin cool and pale ; at times she was sufli-
 
 CASE. 139 
 
 ciently well to sit up, but soon relapsed, becoming 
 weaker on every occasion. A variety of treatment 
 had been resorted to, including a blister to the 
 nape, and aperients. The epileptic seizure came 
 on after the administration of a turpentine enema 
 (which was retained). The treatment now adopted 
 was to abandon medicine, and support the system ; 
 as the stomach refused to retain food or stimuli, 
 injections of beef-tea were given : in four days the 
 patient returned to full consciousness. Morphia 
 appeared now to relieve the headache; food was 
 cautiously given, and everything seemed to go on 
 well for a time; a relapse, however, ensued, at- 
 tended with the same bilious vomiting; another, 
 and another, and at last one with a slight return of 
 the epilepsy, insensibility, and delirium. By a very 
 close attention to the circumstances under which 
 these came on, they were clearly traceable to mental 
 emotion in a terribly debilitated frame, or to the 
 exertion of talking for a short period to sympa- 
 thising friends. Comparative seclusion was then 
 adopted in the sick-room, for a week, and as 
 generous a diet given as the stomach would bear, 
 and from this time the patient steadily recovered, 
 until she was perfectly restored. The headache 
 and strabismus diminished in direct proportion to 
 her gain of strength. The weak vision (due to 
 dilatation of the pupil) went with the other symp- 
 toms, and the " biliousness" disappeared. 
 
 From epilepsy we pass on to infantile convul-
 
 140 CHOREA. 
 
 sions. Who are its chief victims? Those who 
 inherit consumption, struma, or debility the de- 
 nizens of our crowded courts and alleys the pale, 
 puny, and ill-fed. They carry off those who have 
 been weakened by diarrhea or loss of blood. They 
 are the bane of the town -infants ; but rare amongst 
 the families of the healthy, well-to-do peasantry. 
 What is the danger? Death by exhaustion. What 
 is the cure? Good air, good diet, comfortable con- 
 dition. When does subsultus tendinum a variety 
 of convulsions come on? When the patient is 
 dying of weakness. What is its cure? Wine and 
 other stimuli. 
 
 Again, in chorea and allied disorders; what is 
 the most common cause? Excessive fright. And 
 what is fear? The most depressing of all the mental 
 emotions (people die of fright sometimes without 
 any farther cause). What are the individuals it 
 chiefly attacks? The weakly and delicate, whose 
 flabby muscles give tolerable evidence of their 
 want of tone. What is its cure? The most power- 
 ful tonics, the most digestible and generous food it 
 is possible to employ. What is the danger? Death 
 by exhaustion. 
 
 The two following cases are of great value in 
 illustrating these points : 
 
 M. A. R., aet. thirteen, was admitted into the 
 Liverpool Infirmary, July 20, 1843, under the 
 care of one of the then physicians; said she had 
 always been well till she had been thrown violently
 
 CASES OF CHOREA. 141 
 
 against a wall by her father a month ago; twitch- 
 ing came on the next day, and continued increasing 
 in severity up to the time of her admission. The 
 motions were excessive, and the laryngeal muscles 
 were affected in common with others. As she had 
 once passed worms, castor-oil was ordered, which 
 operated unsatisfactorily, and calomel and jalap, 
 with another dose of oil to follow, were prescribed. 
 The jactitation was so incessant that she had no 
 sleep, and the skin of the nates became excoriated. 
 On the night of the 21st the motions ceased; 
 she fell asleep about five o'clock of the morning 
 of the 22nd, and was dead at seven. The post- 
 mortem showed, as healthy a body as it was 
 possible to examine. She had died of simple 
 exhaustion. 
 
 M. J., set. thirteen, was brought into my con- 
 sulting-room one morning, August, 1847, in the 
 arms of her mother. She was suffering so severely 
 from chorea that she could not be retained upon 
 the knee, and was utterly unable to walk. The 
 history was similar to the last. (Dr. Todd had, 
 however, in the meantime, published a case in 
 which a tonic, &c., plan of treatment had been 
 most conspicuously successful.) I recommended 
 full doses of the tincture of iron, and as much egg 
 and wine as the stomach would bear. In three 
 days my patient walked into my room without a 
 greater amount of "nervousness" than many 
 healthy girls would show on visiting a stranger.
 
 142 INFLUENCE OF EMOTION ON THE HEART. 
 
 There is scarcely a muscle in the human body 
 so much influenced by mental emotion as the 
 heart; and in this, as in every other instance, we 
 recognise the influence of debility. The fact is so 
 well known, that I shall only bring forward one 
 illustration, which, though it borders on persiflage, 
 yet contains " a moral." 
 
 One young man, timid and diffident, when he 
 "pops the question," finds his heart palpitate from 
 the combined influence of fear and mental emotion ; 
 another, under the Bacchic influence of wine, goes 
 through the same ceremony without a qualm, and 
 has the palpitation the next day when he thinks 
 over what he has done. 
 
 We turn, lastly, to the organic nervous system, 
 and inquire into the results of debility upon it. 
 Our ground here, unfortunately, is somewhat 
 treacherous, as we are not sufficiently acquainted 
 with the real influence the nerves exercise over the 
 different organs of the body. 
 
 We therefore put the following forward with 
 diffidence and hesitation. Debility deteriorates 
 the quality of the milk in a nurse, and makes it 
 " windy" for the child. Intense mental emotion 
 will make the milk absolutely poisonous, and pro- 
 duce convulsions or death. 
 
 Debility, fear, anxiety, or other intense de- 
 pressing mental emotions, check digestion, produce 
 vomiting often of a severe type, purging, profuse 
 urination, lacrymation, &c. Disgust will check an
 
 ORGANIC NERVOUS SYSTEM. 143 
 
 erection. Anger or anxiety may produce jaundice. 
 I have known a bride on the wedding morning 
 delay the ceremony from an attack of vomiting, 
 and a bridegroom who could only attend to busi- 
 ness under the influence of brandy and water. 
 Vexation will produce asthma. Fright suspends 
 the secretion of saliva; and there can be no doubt 
 that debility is a fruitful source of dyspepsia, 
 flatulence, menorrhagia, &c. ; and that grief and 
 anxiety have much to do in the formation of 
 tubercle and cancer.* 
 
 * Ten years ago I had two cases of cancer under my care. The 
 patients were elderly ladies of about the same age. In both the disease 
 occupied the mamma, and was in its earliest stage. There was no ap- 
 parent diiference in the constitution of the two, and their position in 
 life was a comfortable one. One, however, was not only excitable, but 
 suffered from a constantly-operating cause of deep anxiety ; the other 
 was composed, and had no cares beyond what her complaint produced. 
 
 They were both treated in the same way, simply by a belladonna 
 plaster over the seat of the disease, good and generous diet, and an occa- 
 sional tonic. The first steadily got worse, and died in a few months. 
 The second is at this moment perfectly well. The scirrhus mass slowly 
 withered, and after a lapse of five or six years separated from the rest 
 of the mamma like a huge black wart. This at last fell off, leaving a 
 deep depression in the mamma, and giving it the appearance of an in- 
 verted cone. 
 
 There was little reasonable doubt that the wearing anxiety to which 
 the other patient had been subject was the reason for the rapid march 
 of her complaint.
 
 144 IRRITABILITY DEFINED, 
 
 CHAPTER XIII. 
 
 Application of foregoing observations Law The word irritability 
 defined Corollary when there is debility The symptoms will be 
 referrible to the muscular or nervous systems according to circum- 
 stances ; or the two may be combined Case from Griffin, in which 
 both muscular and nervous systems were intensely affected Anno- 
 tations Summary of views. 
 
 AFTER these remarks, we venture once more to 
 enunciate the following law, which deserves the 
 highest place that memory can assign to it : 
 
 The greater the debility of a patient, the greater is 
 the irritability of his nervous and muscular systems. 
 
 By irritability, we mean propensity to take up 
 diseased action, or tendency to perverted function. 
 It would not be difficult (though foreign to our 
 present purpose) to show that this law is capable 
 of more extended application ; for we think that 
 there is not any philosophical physician who would 
 deny the truth of the proposition 
 
 " The healthier the individual, the less he is pre- 
 disposed to disease." Or the converse, " When an 
 individual is not in perfect health (i. e., when his 
 natural or vital powers are deteriorated), he is pre- 
 disposed to disease of one or more organs." 
 
 Having thus shown that when any individual is
 
 VARIED EFFECTS OF DEBILITY. 145 
 
 in a debilitated condition, he is subject to affections 
 of the nervous or muscular system, or both to- 
 gether and that they do not come on unless there 
 is some constitutional or acquired debility, or re- 
 duction of the vital powers it remains for us to re- 
 mark that the symptoms of one or other will pre- 
 dominate, according to the circumstances in which 
 the patient is placed. Is she a servant, a milliner, 
 a sempstress, the mother of a family, or otherwise 
 actively engaged, the muscular system will be chiefly 
 affected. If, on the other hand, he or she be in 
 a good position in life, sedentary in habit of body, 
 but active hi mind, the result of debility will be 
 shown in some form of hysteria. It may be that 
 the complaint may manifest itself by some curious 
 crotchet of the mind (i. e., in the mental nervous 
 system), a morbid appetite, a vitiated taste, the 
 love of sympathy, feigning disease, &c. ; or by 
 neuralgia (i. e., in the sensitive nervous system), 
 ocular spectra, strange noises in the ears; or in 
 strange contortions of the body (i. e., in the mus- 
 cular nervous system), in tremendous fish-like 
 springs, in curious antics, in gyrations, dancing or 
 leaping ; or in the total absence of muscular power, 
 in spasm of the oesophagus, "globus," and the 
 like. Or we may have the organic nervous system 
 affected chiefly, as evidenced by the sudden gene- 
 ration of flatus in the stomach and intestines, in 
 excessive urination, in the production of strange 
 pigment in the face, strange smells from the 
 
 L
 
 146 SUFFERING PRODUCED BY DEPLETION, ETC. 
 
 uterus and lungs, simulation of disease of large 
 joints, of apoplexy, and the like. 
 
 If mental labour and great anxiety are com- 
 bined with bodily fatigue, we shall have painful 
 muscular affections added to the hysterical ones, 
 thus complicating the symptoms, but not ob- 
 scuring for a moment either the diagnosis or the 
 plan of treatment. 
 
 The intense amount of suffering occasionally 
 produced by a non-recognition of the principles we 
 have laid down, is well shown in the following case, 
 which we quote from Dr. Griffin's work (" Spinal 
 Irritation," p. 7, et seq.). We place in italics such 
 comments as will serve to show the reading we 
 should give to the symptoms described. As might 
 naturally be supposed, we consider the report of 
 the case incomplete, many important points (in our 
 estimation) being omitted. 
 
 A young lady, aet. twenty-one, who had always 
 before enjoyed good health, received a slight blow 
 on the chest from her mother, during her convulsive 
 struggles while dying of apoplexy. She spit up a 
 little blood at the time, and felt pain for some 
 days. ( Was she phthisical ? Had she been exerting 
 herself to hold her mother? Had she nursed her 
 long, and had she been much shocked or agitated at 
 the sudden death of her mother ? Had she lost her 
 appetite? Where was the pain in the side in the 
 pectorals, the intercostals, or the oblique ? Most pro- 
 bably the former, as they would be greatly strained in
 
 CASE. 147 
 
 lifting the sick woman.) After this it suddenly re- 
 moved to the abdomen, affecting the left side, 
 about the situation of the descending colon, and was 
 accompanied by frequent pulse, tenderness, and the 
 most incessant vomiting. ( The sequence of symptoms 
 is probably not strictly maintained here. The first 
 would be pain in the left external oblique, vomiting 
 from anxiety or mental emotion, then tenderness of 
 the muscles, one or more, from the effort of vomiting, 
 rapid pulse from debility.) The pain was abated 
 by bleeding, blistering, and aperients, but nothing 
 could allay the vomiting, which was brought on by 
 the smallest quantity of anything solid or liquid 
 taken into the stomach. (The vomiting produced 
 by excitement is now kept up by debility. The pain 
 is diminished by blisters, fyc., whose soreness is such 
 that they compel muscular quiescence below them for 
 a time. Rest in bed, though not mentioned, was 
 coincident with the blister, fyc. In the bleeding, blis- 
 tering, and purging we have direct means adopted 
 for debilitating the vital powers. We anticipate, 
 therefore, to meet with disorders of the nervous 
 system in their fullest extent, and painful muscular 
 affections in addition. We have them in the suc- 
 ceeding symptoms.) This came to be attended 
 with flitting pains in the head, with throbbing of 
 the temples and intolerance of light, attributed to 
 the straining, the continuance of which made it 
 difficult to move the bowels. Even when medi- 
 cine did operate, it gave no relief. (Sensitive 
 
 L2
 
 148 CASE CONTINUED. 
 
 nervous system now very irritable, organic muscles 
 weak, purgatives increasing the mischief.} 
 
 She remained many days in this state, suffering 
 much from the want of rest and the distressing 
 retching (both exhaustive), after which she was 
 attacked with frequent oppression, occurring at 
 intervals through the day, and usually terminating 
 in fits of insensibility. (Respiratory muscles are 
 now so feeble as to be inadequate to perform the ordi- 
 nary motions of respiration well* and the imperfectly 
 aerated blood produces partial coma.) In these 
 she usually lay for ten or fifteen minutes, with her 
 hands fast clenched (the muscular nervous system is 
 now affected), or sometimes shutting and opening 
 them with great rapidity. There was considerable 
 rigidity of the tendons of the wrist while the fit 
 lasted, and the first symptom of amendment was 
 always a gradual relaxation and opening of the 
 fingers, when she fetched a long, deep sigh (fully 
 aerating the blood), and recovered. These oppres- 
 sions proved as intolerable as the vomiting, and 
 were very distressing. Repeated blistering (still 
 farther diminishing power and increasing irrita- 
 bility), ether, asafoetida, opium, and other anti- 
 spasmodics were had recourse to without relief, 
 
 * As women naturally breathe with the upper part of the chest, and 
 not with the diaphragm as men do, they experience a far greater sense 
 of " oppression," or difficulty of breathing, when the muscles are weak, 
 than we; for it is far more difficult to move the whole thorax in 
 every inspiration than to move the soft bowels, &c., as any one may 
 satisfy himself from the smallest experiment.
 
 CASE CONTINUED, 149 
 
 except of the most temporary kind. (None of these 
 gave more than transient strength the other reme- 
 dies! were diminishing the permanent strength.} At 
 the end of three weeks, however, the more severe 
 symptoms of the complaint, without any very 
 obvious cause, and after resisting every kind of 
 treatment, began gradually to decline, the oppres- 
 sions, throbbing at the temples, fits of insensibility, 
 and vomiting manifestly abated, and the digestive 
 organs, the state of which had never been lost 
 sight of, improved rapidly under mild aperients 
 and bitters. In short, she soon after recovered a 
 sufficient degree of health to permit her going to 
 a party, and even joining in the amusements (we 
 have here the jirst indication of a correct plan of 
 treatment, but unfortunately the "principle" is not 
 recognised, the success seems to have been considered 
 as accidental: a flaw now ensues in the philo- 
 sophical history of the case, and we are left to ima- 
 gine there may be a period of activity, and possibly 
 gaiety before a relapse comes on), at any rate. 
 
 The reprieve was but of short continuance. A 
 return of the oppression brought with it cough, 
 pain in chest and left side; the former slowly dis- 
 appearing as the latter symptoms advanced and 
 became more formidable. The cough was loud, 
 dry, convulsive, and became at last so incessant 
 that she had no intermission of the fits day or 
 night. (Irritation of organic nervous system, fol- 
 lowed by symptom.s evincing excessive irritability of
 
 150 CASE CONTINUED. 
 
 muscular system, both in the larynx, diaphragm, and 
 other respiratory muscles. ) The convulsive expira- 
 tions followed one another with such rapidity, that 
 one can only conceive the suffering by imagining 
 the fits of a severe chincough following one another 
 without interval. To heighten the distress, it in- 
 creased considerably the pain in the chest and sides 
 (pectorals and inter costals), and the respiratory 
 muscles became so sore and tender from the eternal 
 convulsive action, that she could scarcely bear to 
 have a finger touch them.* 
 
 After much time had passed in vain attempts to 
 remove or alleviate it, she became affected with 
 swelling and pain in the anterior part of the pight 
 lobe of the liver, which increased rapidly, and 
 formed a round circumscribed shining tumour, 
 bearing all the appearance of an abscess (cramp in 
 the oblique muscles}. This was very painful, and 
 the torture produced by the constant coughing 
 was extreme. f 
 
 A course of blue-pill was now prescribed at a 
 consultation . . . copious ptyalism followed . . . the 
 cough was now first relieved, and in a week or two 
 ceased altogether. (Query from the blue-pill?) 
 
 The young lady, however, remained in a very 
 
 * The reader is particularly requested to notice this fact, as affording 
 a clue to the cause of the spinal tenderness afterwards discovered. 
 
 t This answers the description given me by Mrs. L. (p. 40), of a 
 tumour she once had in the back, which was in like manner considered 
 an abscess. Vide case of Mrs. T., p. 16, and the note, p. 19.
 
 CASE CONTINUED. 151 
 
 weak, complaining state, troubled much with occa- 
 sional pain in the head (occipito-frontalist), intole- 
 rance of light (irritability of sensitive nervous sys- 
 tem}, and eventually, as the soreness of the gums 
 diminished, the terrific cough evinced a disposition 
 to return. (Query is it possible the uvula was re- 
 laxed?) It was not considered advisable to perse- 
 vere in the mercurial pill, which seemed to be the 
 only preventive likely to be employed Avith success, 
 as she had suffered much from the salivation, and 
 was greatly debilitated. ( We anticipate now a great 
 aggravation of symptoms, as increased debility must 
 have produced increased irritability, both in the ner- 
 vous and muscular systems.) The consequence was 
 a renewal of her sufferings, if possible, to a more 
 intense degree than before. New symptoms week 
 after week supervened, or alternated with the old, 
 and were only more distressing on account of their 
 strangeness and suddenness of attack; at one time 
 she had oppressions, at another headache with fits of 
 insensibility ; at a third, the old pains traversing dif- 
 ferent parts of the colon and ileum with their former 
 violence. She was attacked, too, with severe pain 
 and tenderness in the hypogastric region, followed 
 by retention of urine (debility of the bladder), oblig- 
 ing the introduction of a catheter. But little was 
 drawn off, however, as the secretion was almost 
 entirely suppressed, and did not return for three or 
 four days (disorder of organic nervous system), when 
 the soreness and pain in the hypogastric region
 
 152 CASE CONTINUED. 
 
 subsided. During all this time the pain and ten- 
 derness of the chest and the dry, loud cough were 
 never for a moment absent. (It will be scarcely 
 considered necessary that these symptoms should be 
 explained at length after what has gone before. ) 
 
 The case was now looked upon as quite hopeless ; 
 the distress occasioned by such complicated disorder 
 destroyed all rest and appetite, and induced ex- 
 treme emaciation. Solid food could no longer be 
 borne; it was either instantly rejected, or excited 
 violent spasmodic pain in the stomach, and some- 
 times the oppression. (How can we expect a debili- 
 tated stomach to do the work of a strong one?} 
 The slightest motion (she was now continually 
 confined to bed) brought on similar paroxysms; 
 after which she usually became almost insensible, 
 with suppressed convulsive efforts at coughing, her 
 voice gone, and her pulse rapid (inanition]. This 
 state generally lasted for some hours, sometimes 
 much longer; and as the strength gradually re- 
 turned, the hacking eternal cough resumed its attack. 
 
 It would be tedious to enter into a minute his- 
 tory for the succeeding two or three years. The 
 disease successively assumed the appearance of 
 organic disease of the lungs, heart, and abdominal 
 viscera. . . . On an accidental visit of the medical 
 attendant he was struck with the connexion be- 
 tween the pains and the distribution of the spinal 
 nerves. ( Query did he think at all of the muscles ?) 
 An examination of the spine was made. There was
 
 CASE CONTINUED. 153 
 
 neither deformity, unevenness, nor prominence. 
 There was tenderness over the whole column. 
 Pressure on any of the spinous processes excited 
 instant convulsive fits of coughing, and pain at the 
 corresponding point anteriorly, or oppression.* ( We 
 presume the tenderness is from constant strain upon 
 the tendinous fibres of muscles attached to the spine. 
 We "query" whether the act of pressure shook the 
 body, and with it a relaxed uvula, of which we have 
 no notice. The oppression is due to the fatigue of 
 sitting up, <$c. We shall see from other symptoms 
 whether this interpretation is borne out. ) The slightest 
 curvature in any direction was intensely painful; 
 attempting to turn in bed during the examination 
 (which, however, she could never acccomplish or 
 permit) (a good proof that the spinal tenderness was 
 due to the cause we assign to it) occasioned a sensa- 
 tion as if her back was breaking ; raising the head 
 from the pillow and bending the neck forwards 
 brought on a burning! pain at the middle of the 
 dorsal vertebrae, which shot down to the extremity 
 of the spine (we surely need not explain this /), and 
 thence to the limbs, knees, and toes, followed by a 
 sort of general cramp !| 
 
 It seemed extraordinary how little the patient 
 directed attention to the back in so intense a case 
 
 * Vide note, p. 121, ante. f Vide p. 20, No. 1, ante. 
 
 J It must be remarked here that a person cannot bend the head for- 
 wards, when sitting up in bed, without stretching not only the fasciae, 
 &c., of the back, but of the buttocks, thighs, and legs as well as any one 
 may convince himself of by a ten minutes' experiment of the position.
 
 154 CASE CONTINUED. 
 
 of spinal disease; she frequently complained of 
 pain there, but as it was never constant like those 
 felt at the extremities of the nerves, and was only 
 excited by pressure or motion of the spine, and 
 was then generally accompanied by or occasioned 
 extreme sickness of stomach, retching, and even- 
 tual insensibility (was the patient told to sit up in 
 bed when the examination was made? if so, these 
 symptoms are readily accounted for), it claimed 
 little notice in the train of symptoms. (It is, of 
 course, an assumption that spinal tenderness existed 
 from the commencement of the complaint, but the 
 assumption once being established as a matter of fact, 
 we are not surprised to read the following :) The 
 complaint now clearly developed itself. ( ! ) The 
 various affections to which she had so long been a 
 sufferer were obviously attributable to some disease 
 of the medullary column ! ! (/ need not copy the 
 rest of the paragraph, with the exception of the last 
 sentence. ) All the complicated, and it would appear 
 whimsical, attacks of this strange malady seemed 
 now simple and necessary results, and their alter- 
 nations with one another merely indicated the 
 shifting of the diseased action to new points of the 
 vertebral chain. ( As we dare not suppose that the 
 present generation is more infallible than the last, 
 we leave the appreciation of this medical reasoning to 
 each individual reader.") As issues or blisters to 
 the spine were almost the only untried remedies 
 which the state of the patient suggested, and these
 
 CASE CONTINUED. 155 
 
 seemed wholly inadmissible, &c., the case was 
 again left to the efforts of nature. 
 
 ( The disease now slowly progressed, and as it did 
 so the "nerves" became irritable to an almost incre- 
 dible degree, the sensitive, mental, and organic being 
 all affected; the muscular system was affected equally 
 and to such a degree, that any unusual or unantici- 
 pated motion produced a new and painful symptom.} 
 The bowels were attended to, and narcotics w r ere 
 used for violent pain. The disease was, never- 
 theless, slowly progressive, and as it advanced 
 declared its true seat to the most careless observer ; 
 the whole spinal column was, if possible, more 
 acutely tender; the slightest pressure or motion 
 brought on pain, cramps, or fits of retching ; draw- 
 ing the sheet or arranging the bed, or the sudden 
 falling of a piece of furniture, excited an instant 
 paroxysm, commencing with cramps of the chest, 
 sense of suffocation in the throat, with low, crowing 
 inspiration (spasm of laryngeal muscles), not ring- 
 ing and stridulous as in croup, and terminating in 
 extreme debility, with total loss of power and 
 tremulous, convulsive motion of almost every 
 muscle in the frame. The affection of the head 
 and pain in the throat became more tormenting; 
 there was a constant distressing pain of stomach, 
 with rawness, soreness, and sometimes a burning 
 feeling extending up the trachea to the larynx 
 (muscular pains in the sterno-thyroidei, and sterno- 
 hyoidei, and others, induced either by talking or
 
 156 CASE CONTINUED. 
 
 by the habitual or instinctive act of swallowing}. 
 There was a variable pain in the chest or left side, 
 and a sore sensation as of a cord or band stretched 
 across from the superior bone of the sternum to a 
 point corresponding with the anterior part of the 
 fifth rib on the left side (insertion of the lesser 
 pectoral}. This never permitted her stretching 
 back and making the chest prominent : she had 
 also apprehensions that it would rend or snap in 
 the violent fits of coughing. She had also a fre- 
 quent feeling as if the spine were seized internally 
 and drawn to the sternum or stomach (spasm of the 
 diaphragm) : when to the former, the sensation was 
 succeeded by convulsive spasms with oppression; 
 when to the latter, by violent cramp extending 
 upwards to the sternum and shooting down to the 
 limbs, knees, and toes. At times, when the cough 
 was extremely violent, and shook the frame much 
 (ample cause for fatiguing the muscles^ or when the 
 patient was lifted on a sheet to have her bed ar- 
 ranged, she felt as if the articulating surfaces of 
 the spinal bones were inflamed, sore, and glided or 
 rubbed upon one another in the loose ligaments. 
 This feeling was so excruciating, that whenever 
 she was about to be removed on a sheet, she was 
 accustomed to throw all the extensor spinal mus- 
 cles into action, and by a violent effort bring the 
 whole spine into a state of rigid extension, to pre- 
 clude the possibility of the slightest motion. An 
 approach to syncope always followed the exertion,
 
 CASE CONTINUED. 157 
 
 in which she lay on the bed for days, unable to 
 speak, or swallow, or even move, though conscious 
 of what was passing around her (good evidence of 
 her deplorable state of debility]. Although so seem- 
 ingly still and breathless, that it might have been 
 imagined she lay in an utter state of relaxation 
 and exhaustion on these occasions ; if a hand was 
 laid on hers it was found in rigid spastic action, 
 and instead of reposing quietly on the chest, as it 
 appeared, pressed firmly and almost convulsively 
 against it, as one does to prevent the elevation of 
 the ribs in painful breathing (persistent spasm after 
 the effort to make the body rigid). The breathing, 
 too, although so apparently easy as to be almost 
 imperceptible, was found oh close observation diffi- 
 cult and suffocating. There was a subdued work- 
 ing of the muscles of the throat, and inspiration 
 was either wholly suspended at times, or occurred 
 in short and indistinguishable catches, until a deep 
 sigh brought with it general relaxation and relief. 
 It was usually a full week before she recovered 
 from the ill effects of these attempts to move her 
 from her bed, but even turning her head on the 
 pillow for a few minutes brought on such convulsive 
 coughing and subsequent sinking, that she could 
 not utter an audible whisper, and would lie for 
 hours in a state of the most extreme exhaustion. 
 
 As it seemed that her sufferings could now at 
 all events admit of little increase, an issue was in- 
 serted at each side of the second cervical vertebra,
 
 158 CASE CONTINUED. 
 
 by which the pain of the forehead, face, and scalp 
 was considerably relieved. All the parts, she re- 
 marked, above the issue were better, the other 
 symptoms were little altered. The fourth year of 
 her sufferings, while drinking one evening, she 
 felt a sensation as if something gave way in her 
 chest as if the band from the upper part of the 
 sternum, before spoken of, had snapped (paralysis 
 of lesser pectoral?). She was instantly attacked 
 with oppression, a sense of burning and pain in 
 the throat and chest, croupy breathing, total loss of 
 speech, and blindness of the left eye, with numbness 
 and paralysis of the left arm ; she had also a sense 
 of numbness extending from the point in the chest 
 where she felt the band snap, across to the 
 shoulder, and down the left arm to the fingers. 
 She had, too, difficulty in swallowing (pharyngeal 
 muscles affected}, and violent pain, straining, and 
 retching when the smallest quantity of food or 
 drink reached the stomach. There was some 
 swelling and excessive tenderness of stomach, with 
 violent cramp at intervals, which extended down 
 to the limbs and knees. The secretion of urine 
 was suppressed, no more than half an ounce 
 having passed in twenty -four hours (organic ner- 
 vous system affected}. There was no tenderness or 
 fulness in the pubic region. 
 
 After the lapse of some days, during which 
 croton oil and other diuretics had been freely used, 
 the eye partly recovered its power, and the action
 
 DEDUCTIONS FROM PREVIOUS CASE. 159 
 
 of the kidney was restored. Blisters to the throat 
 
 tf 
 
 and neck were of very little advantage ; but on ap- 
 plying one 'to the occiput, some degree of voice was 
 manifestly recovered, and the power of swallowing 
 perfectly; the fingers of the paralysed arm also 
 seemed to acquire a little motion. The paralysis 
 had been discovered to affect the whole side. In 
 six months the arm had attained much strength, 
 and she could speak in a low whisper, though with 
 pain and difficulty, &c. &c. Five years after this, 
 the lady was mending, and spoke well, was cheer- 
 ful, and anticipated a perfect recovery. 
 
 I have quoted this case at great length, because 
 it shows, better than any other I could meet with, 
 the immense amount of suffering entailed on a 
 patient by a false view of the case, and of course 
 a non-recognition of the correct principles of 
 treatment. The symptoms become aggravated by 
 the means adopted for cure, and the patients get 
 at last into such a deplorable state of weakness, 
 that the vital powers are unable easily to bring 
 them round. With the exhaustion comes defi- 
 cient nutrition in every organ, the stomach is too 
 weak to digest well, the wear and tear of the body 
 exceed the supply, the frame is gradually con- 
 suming, and in the process it often happens that 
 an amount of suffering is undergone, almost, if 
 not quite, equal to what would be felt if the body 
 was to be really burned up with fire. 
 
 We have thus attempted to show
 
 160 RECAPITULATION. 
 
 1. That the symptoms attributable to " spinal 
 irritation" have nothing to do with the spinal cord, 
 or the nerves arising from it. 
 
 2. That the majority, if not the whole of them, 
 are due essentially to the same cause which pro- 
 duces the spinal tenderness. 
 
 3. That the spinal tenderness results from over- 
 straining of the fibrous origins of the muscles at- 
 tached to the spinous processes. 
 
 4. That the spinal tenderness is analogous to 
 that experienced at the origin and insertion of 
 muscles in other parts. 
 
 5. That the weaker the individual is, the greater 
 is the tendency to fibrous pain. 
 
 6. That the most common causes of the pain and 
 tenderness, in any part of the muscles, are consti- 
 tutional or acquired debility. 
 
 7. That debility increases equally the irrita- 
 bility of the muscular and the nervous systems. 
 
 8. That before hysteria can manifest its pre- 
 sence there must be debility from some cause or 
 other. 
 
 9. That that debility may show itself in the 
 muscular or nervous system, or both. 
 
 10. That debility affects the nervous system as a 
 whole or in sections i.e., mental, sensitive, motor, 
 organic. 
 
 11. That functional affections in any one or 
 more of these parts have long been recognised as 
 emanating from deficient vital power.
 
 RECAPITULATION. 161 
 
 12. That anything which deteriorates the vital 
 power has a direct tendency to aggravate the com- 
 plaints referred to. 
 
 13. That muscular and nervous irritability are 
 subject to the same laws, and that the remarks 
 applicable to the one are, mutatis mutandis, appli- 
 cable to the other. 
 
 14. That the link connecting hysteria with 
 spinal disorders is constitutional or acquired de- 
 bility. 
 
 15. That, as regards curious mental phenomena, 
 excess of sensibility in the nerves of common or 
 special sensation, a propensity to spasmodic actions 
 and to irregular organic phenomena, there is no 
 essential distinction, they are simply different facets 
 of the same die. 
 
 16. That the essential distinction between ge- 
 nuine hysterical and muscular affections is, that a 
 large amount of bodily rest is necessary for the 
 cure of the latter, while it is not so absolutely 
 requisite for the former. 
 
 17. That, for the future, it will be necessary to 
 discriminate between pain arising from muscular 
 fatigue, cramp, or fibrous stretching and genuine 
 neuralgia, and that there will be neither precision 
 in diction nor a clear idea of treatment until the 
 distinction is made. 
 
 We may now proceed to consider the plan of 
 treatment necessarily resulting from these views. 
 
 M
 
 162 TREATMENT 
 
 CHAPTER XIV. 
 
 The value of a medical theory judged by the treatment it involves 
 The treatment proposed in accordance with recognised facts 
 Sydenham's maxim Danger of departing from it Embraced by 
 the homceopathists Principle embodied in their theory Reference 
 to "sympathetic powder" Law enunciated Treatment in recent 
 cases In confirmed In recent cases, to husband strength To 
 increase it Difficulty in persuading patients to do so Causes 
 The amount of labour or exertion is to be reduced An increased 
 amount of rest is to be enforced Amount of work gone through 
 by women in their households Rules regarding rest It must be 
 in the recumbent posture and not too prolonged Opiates, if neces- 
 sary, at night Elastic belt or corset Any drain upon the system 
 to be checked The strength to be increased Change of air 
 Its value considered Change of habits as well as of scene required 
 
 Exercise in the open air Its importance discussed Difference 
 between the open air of towns and the country The diet must be 
 generous and nutritious The supply of food should equal the 
 demand of tbe system A weak stomach cannot digest strong foods 
 
 Influence of tonics, wine, steel, &c. Wine assists the vital 
 powers Is not a substitute for food Food recommended 
 Things to be avoided Tea often prejudicial Why baths, &c. 
 Purgatives to be shunned as a rule They produce flatulence 
 Observations on their use A daily motion unnecessary Cod-oil, 
 steel, bitters, quinine, and opium combined Any special sources of 
 irritation are to be investigated, and if possible cured. 
 
 WHENEVER any author propounds a new medical 
 theory, the Profession commence their examina- 
 tion into its value by ascertaining the influence it 
 has upon "treatment;" and if the latter seems to 
 be inconsistent with previously reliable knowledge, 
 they reject the former almost without a single con- 
 sideration. If the new theory merely leads to a
 
 THE TEST OF A THEORY. 163 
 
 novel classification of facts, or a fresh nomenclature 
 of disease, without attempting to meddle with 
 treatment, the speculations of the author fall upon 
 equally careless ears. But where the treatment 
 proposed is one evidently based upon principles of 
 known worth and universal application, the theory 
 generally receives a fair hearing, and is discussed 
 in an anxious spirit of inquiry. 
 
 It was not, therefore, until I had made a full 
 investigation of the bearing of the preceding views 
 upon the treatment of nervous affections, and a 
 careful annotation of the plan proposed, with the 
 circumstances under which bad nervous complaints 
 have hitherto received their cure, that I ventured 
 to indulge the idea of promulgating them to my 
 professional brethren. 
 
 I have already so frequently referred to the 
 present most approved modes of treating neuralgia, 
 insanity, convulsions, chorea, hysteria, and the like, 
 that I need only recapitulate and "codify" them, 
 by saying that they all are intended to give vigour 
 to the constitution. 
 
 This is precisely the plan to which the foregoing 
 observations and reasoning tend. We must medicate 
 the constitution and restore it to health. This must 
 be the great end always in our minds, rather than 
 the conquering of some particular symptom. 
 
 At the risk of being thought irrelevant, I will 
 tell the following anecdote, as illustrating a frame 
 of mind we frequently meet with in practice : A 
 
 M 2
 
 164 IMPORTANT MAXIM. 
 
 late physician in this town, of great reading, and 
 one who aspired to literary fame, was called in 
 consultation to see a patient who was very ill. 
 The tongue was greatly furred. " We must clean 
 the tongue" was the medical dictum. Some medi- 
 cine was ordered with that special end. In three 
 days after, the surgeon meeting the physician, re- 
 marked, "Well, doctor, our patient is dead!" 
 "Never mind," was the reply, "we cleaned the 
 tongue ! ! " 
 
 I believe it to be by no means an uncommon 
 thing for the practitioner, in his attempt to cure a 
 symptom or a disease, to lay the foundation of 
 another, and the patient actually dies that he may 
 live ! Thus, for example, I have heard a sexagena- 
 rian surgeon remark of a mutual friend, deceased, 
 " Ah, poor fellow, he had an attack of pneumonia ; 
 you know I was obliged to bleed him, and he had 
 not stamina for it, so he sank under it !" 
 
 It is a maxim in the world, " Don't kill yourself 
 to keep yourself;" it certainly ought to be so in 
 physic (reading " your patient" for "yourself). 
 Sydenham, the English Hippocrates, laid down 
 the law " Primum est ut non nocere ;" or, to 
 translate freely, the physician must do as little 
 harm to the constitution as he possibly can. 
 
 Unfortunately for the advancement of true 
 medical science, the so-called allopathists have 
 neglected this principle too much, and a most 
 formidable heresy has consequently sprung up, the
 
 HOMOEOPATHY EXAMINED. 165 
 
 more dangerous as it comes under a semi-scientific 
 garb. In it the patient is left to nature, but not 
 to poor unaided nature, whose propensity during 
 illness is to despond and make matters worse, but 
 to bright, sparkling, hopeful nature, whose fond 
 propensity it is to see, in every "medicine" swal- 
 lowed, a step made in advance towards health. 
 " A rose by any other name would smell as sweet;" 
 and to a sick man " medicine" is still " medicine," 
 whether it be a grain of mercury, or its twentieth 
 dilution by the homoeopathists. " Graphite" and 
 " calx carbonica'' of any dilution will operate as 
 "medicine," if ordered by a "doctor" and dis- 
 pensed by a "chemist;" but the same dose taken 
 by licking a smooth oyster-shell or a bit of mother- 
 of-pearl, or by touching the tongue with a lead 
 pencil, would be utterly inert ! 
 
 But the homoeopathists not only do no mischief 
 (of course I am speaking generally), they attempt, 
 in addition, to do good, by giving cod-oil and other 
 tonics, which are introduced under the specious 
 pretence of getting the patient into condition for 
 the other medicines to operate ! The result is a 
 great amount of success; and this is attributed 
 to the drugs, notwithstanding their infinitesimal 
 dilutions. But false as is the theory, it enwraps a 
 great truth a truth which must force itself, ere 
 long, on the minds of all thinking people. The old 
 " weapon-salve" was used with wonderful and mys- 
 terious success for a whole century r ere the prin-
 
 166 IMPORTANT PRINCIPLE. 
 
 ciple of healing wounds by the first intention was 
 recognised; and it may be a century from the 
 rise of the system of homoeopathy before its prin- 
 ciple is understood namely, that as deficient or 
 defective nutrition, or overpowered vital force, is the 
 cause of the manifestation of disease, so a restoration 
 of the healthy tone is necessary for recovery ; and that 
 everything which deteriorates the constitutional powers 
 necessarily protracts the period required for restora- 
 tion* 
 
 * In speaking thus of homoeopathy, I wish to steer equally clear of 
 the appearance of ridiculing it on the one side, and of the idea that I 
 have the smallest leaning towards it on the other. In my capacity of 
 lecturer, first on materia medica and therapeutics, and subsequently on 
 the principles and practice of medicine, I honestly endeavoured to study 
 the subject, both by reading, and conversation with its professors. I 
 ascertained, that where I had been in the habit of administering no 
 medicine at all, "the doctrine" prescribed globules; where I recom- 
 mended generous living and tonics, "the doctrine" did so too; where there 
 was a possibility of art doing good and not harm, I found that art was 
 used, quite irrespective of Hahnemann. I also found that the principle 
 of " laissez aller" was frequently productive of great evil ; but these cases 
 were so numerically few, in comparison with the others, that they were 
 considered as deplorable accidents (as are deaths by chloroform), and not 
 necessary occurrences. It was clear that homoeopathy shone brightly 
 only when it was contrasted with the so-called heroic treatment of the 
 hospital, army, and naval doctors of its early days. Its own light re- 
 sembled the electric one, which requires a constant adjustment of the 
 charcoal points to keep it up. At one time the infinitesimal dose, with 
 the " virtue of the drug, magnified by trituration," was the sun of the 
 system ; but by-and-by it paled its fire, and gave way to another, which 
 is already on the wane. Harvey's memory, and the opposition made to 
 Jenner's views, were used as a lever to move the world ; but a recollec- 
 tion of Sir Kenelm Digby (vide " Lay of the Last Minstrel," note 8 to 
 canto iv.) broke the fulcrum. Nevertheless, it was clear that there was 
 a trxith to be sought, as a diamond amongst quartz pebbles. What was 
 it ? It was this : Did we know, in reality, as much as we ought of the 
 natural history of disease ? This seemed to afford a clue by which to
 
 GENERAL REMARKS. 167 
 
 In the treatment of affections of the nervous 
 system these principles must never be lost sight of. 
 They must form the main trunk, and all other 
 things must be considered as branches solely. The 
 physician must resemble a guide who has to con- 
 duct his patient across a difficult country to a cer- 
 tain goal health ; it may be that his route will at 
 times deviate, as he has to turn this rock, or cross 
 that river, but every detour ought to be subser- 
 vient to the end in view. How miserable the 
 guide who leaves his convoy farther away from his 
 destination at the end than at the beginning ! 
 
 The broad stream, the main channel of " prin- 
 ciples " is easily discovered; it is far more difficult 
 to steer with a pilot's nerve through all the varied 
 shoals so constantly occurring in the nervous branch 
 of the river of life. 
 
 We propose, in the first place, to consider the 
 principal line of treatment to be adopted in ordi- 
 nary cases; 
 
 And, secondly, the one most likely to be suc- 
 cessful in cases like the one we have quoted from 
 Griffin; or where the' practitioner is not consulted 
 
 enter the labyrinth of error. I sedulously followed it ; and I can assure 
 those who choose to take up the same thread, that it will bring them 
 out at last into a fair hall, where there are no " Mene Mene Tekels" 
 which require a Daniel to interpret ; where the cobwebs of false theories 
 cannot thrive; and where the most stylishly-dressed system must 
 immediately depose its finery, and stand in naked guise of truth or 
 falsehood. Outside that hall many a " pathy" will stand and look in, 
 but never enter.
 
 168 CAUSES OF FAILUKE. 
 
 until the disease is fairly rooted, and the strength 
 of the constitution greatly impaired. 
 
 1. The broad principles of treatment to be 
 adopted in the affections we have referred to are 
 
 a. To husband the existing amount of consti- 
 
 tutional strength as far as possible. 
 
 b. To increase it. 
 
 a. It is far easier to know the desiderata than to 
 induce our patients to comply with our recommen- 
 dations. For this we must be prepared. One, can- 
 not take sufficient rest, for the household duties 
 fall upon her, and she is unable to give them up, 
 or too poor to provide a substitute. Another will 
 continue to nurse till she is physically incapaci- 
 tated, putting, in her own estimation, present suffer- 
 ing against a probable future contingency, involving 
 greater pain and more expense. Another patient 
 (a very common occurrence) has formed her 
 notions from some domestic medicine-book, some 
 nurse, or some newspaper paragraphs, whilst she 
 has been in health. When she is in any way de- 
 bilitated, she is too weak to think the mental 
 labour required to take up a new train of thought, 
 hopes, and confidence is too great. In her own 
 idea, the patient is firm, in the opinion of the 
 healthy lookers-on she is obstinate, in her resolves, 
 and actually prefers pain and mental quiescence to 
 relief and mental violence. Those who have had 
 much practice will readily recognise this as a main 
 obstruction to complete success.
 
 VALUE OF REST. 169 
 
 (1.) The strength is to be husbanded by dimi- 
 nishing the amount of labour undertaken, whether 
 that is mental or bodily, or both. 
 
 In this the physician can do little more than 
 advise with the utmost weight of his professional 
 character; but he may effect the same object by 
 insisting upon an increased amount of rest. 
 
 Few persons, till they give their unbiassed atten- 
 tion to it, have any definite idea of the amazing 
 amount of work, women in the middle and lower 
 classes of life get through day by day. From six or 
 eight in the morning till ten or twelve at night they 
 are incessantly at work, washing, dressing, scour- 
 ing, carrying, cleaning, making beds, shaking carpets, 
 sweeping floors, ironing, sewing, darning, knitting, 
 nursing, playing with children, teaching infants to 
 walk, carrying them in their arms, cooking, &c. 
 All these require muscular exertion, and this is 
 sometimes excessive in degree their very insig- 
 nificance and their daily occurrence cause them to 
 be ignored. The labourer, the man of business, 
 the doctor, know little of them, for they are per- 
 formed out of his sight. They all see their rooms 
 pretty nearly in the same condition, their linen, 
 &c., in the proper state, and never care about, for 
 they do not know, the trouble required even in 
 these small details.* A woman herself, knowing 
 
 * As the proverb says 
 
 " Man's labour ends at set of sun, 
 But woman's work is never done."
 
 170 RULES FOR REST. 
 
 that some of her companions in sex get through 
 their duties without suffering, imagines that the 
 same duties can have no influence over her health 
 or feelings, and she attributes her complaints not to 
 what she has to do, but to something that prevents 
 her doing them, and which may be removed by 
 art or skill; and as the abdominal muscles are 
 commonly affected, the patient takes blue pill and 
 other aperients, and thus makes matters worse. 
 The only way to lighten labour under these cir- 
 cumstances is to insist on a daily rest in the re- 
 cumbent posture for at least half an hour, and more 
 if necessary, in the middle of the day. 
 
 Rest, like all other means of cure, is liable to 
 abuse in various ways. 
 
 When excessive and long-continued, it weakens 
 the muscular system from simple want of exercise 
 (e. </., the muscles of a paralysed limb ultimately 
 become fat, and lose all contractility whatever, 
 when they are allowed to remain quiet, but con- 
 tinue healthy if they are stimulated daily by gal- 
 vanic shocks). 
 
 Rest, on the other hand, may be insufficient ; it 
 may be taken in a chair, or on a sofa, instead of on 
 a bed, and with such a style of reading, writing, 
 or conversation, to fill up the time, that the mental 
 exertion is actually greater in its effects on the 
 system than the bodily fatigue it supplants. For 
 rest to be of any use, the patient should retire to 
 her bedroom, at two o'clock every day, and lie on
 
 STRENGTH TO BE INCREASED. 171 
 
 her back on the bed for a good half-hour, with no 
 other companion than a readable book. If there 
 is much constitutional debility, another such rest is 
 required about seven o'clock. 
 
 This method of husbanding strength is the 
 greatest possible assistance and comfort to those 
 who are nursing or are pregnant. 
 
 The use of a well-made corset or elastic waist- 
 belt gives great support and assistance. 
 
 Sleep at night is indispensable, and, if necessary, 
 must be promoted by opiates. 
 
 The use of an arm-chair during the day should 
 be recommended. 
 
 (2.) The strength is to be husbanded by dimi- 
 nishing discharges of any kind, such as diarrhoea, 
 diuresis, menorrhagia, loss of blood in any way, 
 leucorrhcea, prolonged lactation, and the like, into 
 the particulars of which it is not necessary to 
 enter. 
 
 b. The strength must be increased if possible. 
 To effect this the means we have at our command 
 are comparatively few; they consist 
 
 (1.) Change of air and scene, which operates 
 in two ways, by removing the patient from ex- 
 hausting labour, and by placing her or him in the 
 most favourable condition for improving health. 
 It is the common opinion, and in the main the 
 most correct one, that the change must be from a 
 bad air, as that of a town, to the purer air of the 
 country or the seaside ; but experience shows that
 
 172 EXERCISE IN PUKE AIR. 
 
 a change from the country to a comparatively un- 
 healthy town is productive of good, whenever it 
 is attended with absence of excessive mental or 
 bodily labour, and the presence of pleasant asso- 
 ciations and companions. Change of air is of little 
 use when the patient carries with him all the 
 habits, &c., of home. It is of small advantage for a 
 worn-down mother to go to the seaside for her own 
 health, and to take with her the most chargeable 
 of her younger ones ; or for an author to resort to 
 the Lake district with his pens and ink in undi- 
 minished array. Equally useless is it for the vic- 
 tim of hysteria to change the assemblies, concerts, 
 &c., of the town, for the assemblies, dinner parties, 
 picnics, &c., of the country. 
 
 (2.) Adequate exercise in the open air, and in 
 a locality where the atmosphere is pure, is ad- 
 visable. 
 
 Every clause in this sentence is important, for 
 if the exercise be excessive, the strength is over- 
 taxed, the power of digestion reduced, old mus- 
 cular pains increased, and new ones produced; if 
 the exercise be taken in the house, it is simply 
 exhaustive, and of course likely to increase the 
 troubles already existing. There is no difficulty 
 in persuading oneself of this fact, for amongst the 
 chief sufferers from spinal irritation, and other 
 nervous and muscular affections, housemaids are 
 the most prominent, and the amount of exercise 
 they have daily is almost proverbial. Exercise in
 
 TOO MUCH EXERCISE EXHAUSTS. 173 
 
 the open air of a large town is equally exhausting 
 with that in the house, as is readily proved by the 
 lassitude and debility shown by most of those who 
 lead an active life in towns. In Liverpool there 
 must be many who have felt jaded and tired-out 
 while walking in the streets, but who, as soon as 
 they have reached New Brighton, or have " topped" 
 the Bidston range of hills, away from town smoke, 
 immediately forget their fatigue, and enjoy an 
 evening stroll. They may then come home, 
 pleased with their excursion, and meditating a 
 return; but as soon as they enter the town, weak- 
 ness seizes them, and they recognise at once 
 the difference between town and country air. 
 Exercise in a town produces loss of appetite, in- 
 digestion, and a craving for stimulants. In the 
 country it produces a healthy appetite and a good 
 digestion; it promotes the circulation, increases 
 the oxygenation of the blood, and exalts the vital 
 powers. 
 
 Exercise must invariably be adapted to the con- 
 dition of the patient, and where walking is too 
 much, a carriage or quiet horse must be used. 
 
 (3.) The diet must be generous, ample, and diges- 
 tible, with such intervals between meals that, while 
 there is sufficient time on the one hand for the 
 stomach to rest, there is not sufficient to enfeeble 
 it on the other. Long fasts are very prejudicial. 
 This rule is of the utmost importance, and well 
 deserves all the attention the profession can bestow
 
 174 INFLUENCE OF WINE. 
 
 upon it. Nothing is of greater moment than so to 
 regulate the supply of food that it may equal the 
 demand created by muscular exertion and the 
 other exigencies of the body. A young lady 
 whose habits are sedentary requires far less food 
 than another whose habits are active to a high de- 
 gree ; and yet it too often happens that the former 
 feeds largely, and the latter very sparingly. When 
 the body is exhausted by labour, the stomach takes 
 part in the debility, and is unable to digest the 
 ordinary food employed ; the want of appropriate 
 nourishment, in its turn, increases the patient's 
 weakness, and thus the two may go on gradually 
 aggravating each other. 
 
 Whenever the stomach is thus weakened, it 
 must be our endeavour to try and increase its 
 digestive power, and to employ such food as will 
 be both nutritious and digestible. 
 
 The first end is best attained by the use of 
 wine, steel, bitters, &c.* The administration of 
 wine must ever be regulated by the effect it pro- 
 duces. At first, when the patient is exhausted, a 
 very small quantity is sufficient to produce un- 
 comfortable feelings in the head, and it is, there- 
 fore, too often cast aside as "not agreeing;" this, 
 however, forms no impediment against its conti- 
 
 * When there is indigestion as a prominent symptom, it will be well, 
 in addition to other means, to administer a dose of pepsin with each 
 meal. That made from the stomach of the pig is considered, from phy- 
 siological considerations, to be the best.
 
 CHOICE OF FOOD. 175 
 
 nued employment, but it must be combined with 
 water, or given with some comparatively solid food. 
 The most favourite plan appears to be to beat it 
 up with the yolk of an egg and a little sugar. 
 This makes the wine less likely to intoxicate, as 
 the patient is taking food as well as stimulus. 
 
 It must ever be borne in mind that wine alone 
 is not strengthening it is simply heating or sti- 
 mulating. It is given to assist the powers of 
 nature, not as a substitute for food; to effect this, 
 a certain amount, varying in every patient, is ne- 
 cessary; beyond that amount, wine is of no ser- 
 vice. As a medicine, wine is to be used quite irre- 
 spective of the time of -day or common conven- 
 tional rules; it should be taken shortly after the 
 morning meal, before or at the noon meal, and 
 again at or after the evening one. 
 
 The choice of the wine may safely be left to the 
 patients; but it must be borne in mind that, as a 
 general rule, the French and Rhenish wines are 
 not sufficiently strong to be stimulating.* 
 
 Where wine "turns sour" on the stomach, a 
 proportionate quantity of brandy with water may 
 be used instead. 
 
 On the whole, wine or other alcoholic stimulant 
 is preferable to, and far more palatable than steel 
 or bitters. 
 
 * Whenever there is much flatulence and a tendency to vomiting, 
 Champagne or other sparkling wines are preferable to any others. The 
 amount required varies from a pint to a quart bottle daily.
 
 176 TEA. 
 
 With regard to the choice of food, it is to be re- 
 
 o ' 
 
 marked that eggs, bread, and milk, in the various 
 forms that the artistic cook is able to present 
 them, are the most digestible and nutritious; that 
 soups* are preferable to farinaceous slops, and solid 
 food to liquid nourishment. But there are certain 
 things to be avoided, amongst which, unfortu- 
 nately, comes woman's greatest luxury tea; of 
 all the articles of diet in common use, tea is the 
 most prejudicial to the delicate stomach. It pro- 
 duces flatulence, and weakens the digestive powers. 
 It is to be doubted whether this effect is due to 
 the heat at which the fluid is generally im- 
 bibed, to the milk, the sugar, or to the tea itself. 
 The first is the most probable ; for, as far as my 
 experience has gone, those who have suffered most 
 
 * Of all fluid nutriments, beef-tea is the most popular ; but it is one 
 which varies in value according to the skill and experience of the cook. 
 After having given great attention to the subject, I venture to put for- 
 ward the following directions as being the most certain of success ; they 
 were communicated by a young lady who was nursing her delicate 
 mother with consummate judgment : 
 
 Two pounds of. good lean beef-steak are to be minced small and placed 
 in a brown jar ; two pints of boiling water are then to be poured over 
 them, and the whole well stirred : add nothing more. Cover the jar, 
 and stew in a slow oven, stirring frequently : an hour or two suffices. 
 If the beef-tea is required very strong, the water is allowed to evapo- 
 rate, and the stewing process is prolonged, say six to ten hours. Stir 
 up and pour off the fluid, not straining. Skim off the fat. 
 
 To prepare for use, add salt and an onion to the quantity required, 
 and raise it to the boiling point. 
 
 If an onion is unpalatable, celery, ketchup, or any other flavour may 
 be added; or salt alone may be used. 
 
 The deliciousness of beef- tea thus prepared exceeds anything I have 
 yet seen in a sick-room.
 
 BATHING CONSIDERED. 177 
 
 from tea have taken it very hot and very weak. 
 Cocoa, or coffee, or inilk-and- water answer for sub- 
 stitutes. 
 
 It is very prejudicial to drink large quantities of 
 cold water, which has a direct tendency to pro- 
 duce emaciation. 
 
 (4.) There are few things more popular for in- 
 creasing the tone of the system than baths, and the 
 variety of these is infinite. We find persons 
 advocating sea-bathing, bathing in salt or sea- 
 water, the plunge-bath, the sitz-bath, the douche, 
 the wet sheet, the hot-bath, the warm-bath, the 
 cool-bath, the vapour-bath, and the like. Others 
 eschew bathing and plead for cold-sponging 
 daily. 
 
 All do good when appropriate, and when not 
 carried too far : they do positive harm when 
 abused. Thus one lad gains benefit from a plunge- 
 bath when he remains in it a few minutes only; 
 another, who remains in it for an hour, swimming 
 or otherwise exerting himself, is positively injured. 
 The same may be said of sea-bathing ; one lady has 
 her single dip, and feels a warm glow follow; an- 
 other enjoys, like a modern Venus, a closer ac- 
 quaintance with the waves, and does not leave 
 them till starved and blue with cold. 
 
 Cold-sponging is open to the same remarks ; it 
 does good to the strong, but is prejudicial to the 
 weak, whose small natural heat it diminishes for 
 half the day. If there is much vigour in the sys- 
 
 N
 
 178 THE SHOWER-BATH. 
 
 tern, judicious bathing will increase it; if there is 
 little, it will reduce it still more. 
 
 Of all baths, the shower-bath is the most useful, 
 especially in hysteria. A person cannot immo- 
 derately indulge in it it is soon over; it produces 
 a gentle shock to the nervous system, is commonly 
 followed by a pleasant glow, and tends more than 
 any other thing to restore tone to the general 
 system. 
 
 It never, however, does good when the patient is 
 habitually " cold-blooded" and is made colder by 
 its use. 
 
 In general terms, we may say that the value of 
 any bath is proportionate to the reaction it pro- 
 duces; it will improve constitutional power, but 
 will not generate it. 
 
 c. With respect to medicines we need not say 
 much; purgatives are to be scrupulously avoided, 
 or if administered, they must be of the mildest 
 form and combined with bitter tonics, and not 
 given oftener than once in three or four days ; they 
 may for a time relieve the bowels, but after their 
 stimulus, comes corresponding debility, and the 
 patient suffers from flatulence and intestinal atony.* 
 
 * It was my lot, two winters ago, to travel on the Continent with a 
 gentleman who was in search of health. He had been seriously threatened 
 with phthisis, and suffered frequently from spasmodic asthma. His ap- 
 petite was good, but his stomach and bowels were flatulent. As long 
 as we were quiet at any town the asthma was absent, but it came on 
 invariably the first night after we had migrated to another locality, and 
 then subsided. At first he used to treat himself by aperients and
 
 PUKGATIVES PREJUDICIAL. 179 
 
 If the bowels are extremely torpid, they must be 
 "solicited" by large draughts of slightly saline 
 water taken in the morning on an empty stomach, 
 
 meagre fare, and with apparent success, but the influence of this gra- 
 dually diminished, and at last, during a "vetturino" journey of ten 
 days' duration, it was clear, even to himself, that the principle adopted 
 was unsound, for the asthma was habitual and the weakness extreme. 
 By this time I had learned to read the symptoms right. A day's 
 journey fatigued the system, without, however, inducing the sensation 
 of weariness ; the debilitated stomach could not do its ordinary busi- 
 ness ; the French wines were not stimulating enough to give it tran- 
 sient tone (brandy was distasteful). The result was flatulent indiges- 
 tion. His purgatives were irritants, and compelled intestinal contraction 
 and the evacuation of the flatus and fseces ; with diminished flatulence, 
 came increased mobility of the diaphragm and less distress in breathing. 
 But the second, third, and fourth days after the aperients, the amount 
 of general flatulence increased, being the greatest at first, and gradually 
 going away. At first the milder food, being easily digestible, prevented 
 the recurrence of flatulence and asthma ; but when the use of purgatives 
 had been continued for some time, everything was too much for the 
 debilitated digestion. Despairing now of his own plan, my companion 
 adopted mine. After each meal he was to have a glass of brandy-and- 
 water as a " dram," to give up aperients, and live generously. Fortu- 
 nate circumstances enabled him to substitute port wine for brandy, and 
 the benefit of the change of plan was immediate. A residence for a few 
 weeks at Nice repaired his strength, and for the next eight months, 
 though our amount of travelling was undiminished, he had neither 
 indigestion nor asthma, except on one occasion when, after having had a 
 long day's sight-seeing, he followed it by a good dinner and twenty 
 hours' riding over a long and rugged mountain-pass. 
 
 After his return to England he remained well for about five months, 
 but his vigour slowly diminished. After a dinner-party a fit of asthma 
 came on with great severity, and he resorted to aperients once again ; 
 they gave him a day's comfort, but were followed by three days' dis- 
 comfort. He took more pills, had a few hours' relief, and then so 
 serious an attack that he sent for me to meet his ordinary attendant. 
 It was the old story over again. We "tided over" the bad days pro- 
 duced by the medicine, with fetid spirit of ammonia, &c., began cau- 
 tiously with generous diet, and had the same success as before. 
 
 Irritating aperients are to weakly bowels as a spur is to a jaded 
 horse they give a momentary briskness, to be followed by increased 
 exhaustion. 
 
 N2
 
 180 TONICS. 
 
 and by kneading or shampooing after breakfast; 
 by the use of bran-bread, figs, or oatmeal ; or they 
 may be relieved at stated intervals by warm-water 
 enemata. 
 
 The dogma of the ancients, that the bowels ought 
 to be open daily, is one applicable to men rather 
 than to women; and a large and enlightened ex- 
 perience will prove to every thoughtful mind, 
 not only that an interval of three or four days 
 may be allowed to pass without any ill effects 
 whatever, but that a persistence in medicine to 
 procure the daily visit will occasionally end in very 
 marked debility. 
 
 Constipation is not of itself a disease, it is only 
 a symptom, and as such must be considered as 
 supplementary to others. 
 
 Tonics are of more general application, but they 
 are, at best, mere substitutes for such hygienic 
 remedies as change of air, &c. 
 
 Amongst the most valuable are cod-oil and steel, 
 singly or combined. Where the stomach can bear 
 their united administration there is no medicine at 
 all to be compared with them. 
 
 It may not be considered impertinent if I give 
 an account of the manner I recommend for their 
 conjoint use : One wine-glass is to be prepared 
 with fifteen minims of the tincture of the sesqui- 
 chloride of iron and an ounce and a half of water, 
 and another with five minims of the tincture with 
 tibout six drachms of water, and the dose .of oil
 
 QUININE AND OPIUM. 181 
 
 (varying from a tea to a table-spoonful). The 
 patient is then to sip from the first glass, swallow 
 the contents of the second, and then finish off the 
 first. In this way the oil is taken without leaving 
 any disagreeable taste, &c., in the mouth. "Where 
 the steel is not borne in any quantity, brandy and 
 water may be advantageously substituted. The dose 
 should be taken three times a day, and shortly after 
 a meal. 
 
 Next to these two remedies comes quinine ; when 
 genuine neuralgia is present, it may be advanta- 
 geously combined with opium or morphia. In the 
 use of these remedies there is still room for con- 
 siderable improvement. In small doses they will 
 produce their effect slowly; in full doses, such as 
 three grains of quinine, and a quarter or a third of 
 a, grain of morphia, repeated every six hours, they 
 will commonly cure simple neuralgia in a day. If 
 they fail to cure in two days, or if from any cause 
 the complaint returns after apparent cure, the ulti- 
 mate recovery will be slow, and the cause of the 
 neuralgia is to be sought in an offending tooth or 
 some local irritation. 
 
 Opium is a debilitating drug, as is evidenced by 
 the " seediness," nausea, and fairitness which follow 
 its primary action, by the general condition of 
 opium-eaters, and the intense and sometimes fatal 
 exhaustion that follows a day or two after a poi- 
 sonous dose has been taken and recovered from. 
 It must not, therefore, be indulged in more than
 
 182 MORPHIA EXDERMICALLT. 
 
 can be helped, and when administered, must be 
 combined with stimuli and nutriment. 
 
 Hyoscyamus, conium, belladonna, &c., are by 
 no means equivalent to opium ; they are useful as 
 outward applications. 
 
 A strong solution of morphia one, two, three, 
 or four grains to the ounce of water applied as 
 " water dressing," is of great service in the relief 
 of local pain. If a blister be previously produced, 
 and morphia be applied to the raw surface, the 
 effect is greater, for the patient is often narcotized, 
 but the pain is considerable in the sore, and lasts 
 for half an hour or more. An injection of the 
 solution beneath the cutis has been recommended, 
 and may be adopted with advantage when lighter 
 means have failed. When there is no horror of "in- 
 struments" it would be well to commence with it. 
 
 After these remedies come the more indifferent 
 ones, tannin, gallic acid, zinc, valerian, manga- 
 nese, &c. &c. 
 
 The next point to be attended to, is to remove 
 any morbid condition of the uterus, or any other 
 thing that may act as an irritant. 
 
 Bad teeth are very common causes of neuralgia. 
 The following is an instructive case, in which are 
 exemplified some points we have before laid stress 
 on ; for here was a lady with an ever-present cause 
 of irritation, suffering at long intervals only, and 
 cured for a time by medicating the constitution, 
 the irritation still remaining. A married lady, of
 
 CASE. 183 
 
 somewhat delicate constitution, complained of 
 hemicrania ; no cause could be detected ; there 
 was no loss of appetite, no exhausting discharge. 
 Under the use of quinine she was cured in twenty 
 hours. In a few weeks she had tic-douloureux in 
 the eyeball, which assumed an intermitting cha- 
 racter. This gave way to warmth, steel, and the 
 use of Pulvermacher's chain. In a few weeks 
 more the tic attacked first one cheek and then the 
 other. A tooth was now found to be tender, but 
 to the eye it appeared perfectly healthy, and there 
 was no purulent discharge from the alveolus. Qui- 
 nine and galvanism again effected a cure. In a 
 few weeks more the tic affected the lower jaw, and 
 was cured in an instant by an electric shock. By- 
 and-by the whole teeth ached, and were exces- 
 sively tender. Steel in full doses cured this 
 (morphia was tried, but disagreed with the sto- 
 mach). At the end of about two years, from the 
 time the first symptoms Avere complained of, the 
 patient was induced to part with the tender tooth, 
 a back molar; a curious round, smooth hole was 
 found on the posterior aspect, and out of sight, 
 which went as far as the pulp. The pains at once 
 disappeared, and never returned. 
 
 If any organic uterine affection exists, appro- 
 priate remedies must be employed ; but as a gene- 
 ral rule, constitutional means are to be preferred 
 to local ones, and the latter only resorted to when 
 the former have failed.
 
 184 LEUCOKRHCEA. 
 
 Profuse leucorrhoea is a common cause of de- 
 bility, muscular and nervous affections. This is 
 best treated, when habitual, by the cold hip-bath 
 and the daily use of astringent applications. The 
 best method to employ these is to use a sponge 
 fastened on a sufficiently strong rod of gutta- 
 percha, having a button at the end like that of a 
 fencing-foil; the gum being yielding, is far pre- 
 ferable to a piece of wood ; the button prevents the 
 sponge coming off. The instrument is first to be 
 introduced moistened only with water, so" as to clean 
 the passage of all mucus ; it is subsequently to be 
 immersed in a strong solution of alum (an ounce 
 to a pint of water), and slowly passed to the end 
 of the vagina and withdrawn. The advantage of 
 this plan over the use of injections is very marked. 
 
 Where the leucorrhoea comes on after the cata- 
 menial discharge, and is very profuse, a blister to 
 the sacrum, and the internal use of copaiba in full 
 doses, will often operate an immediate cure. 
 
 For fuller information on all these points we 
 must refer to obstetric writers.
 
 TREATMENT CONTINUED. 185 
 
 CHAPTER XV. 
 
 Treatment of confirmed cases Necessity for tact, knowledge, expe- 
 rience, and confidence The advantage of giving definite hopes 
 To impart these the doctor must have definite ideas Influence of 
 hope and despair' Examples Influence of new remedies in the 
 hands of their discoverers Of their adopters Application Rest 
 of body Mind The senses Rest for the bowels The stomach 
 The uterus Nausea and vomiting to be relieved by champagne, 
 chloroform, &c. Antispasmodics are only of temporary utility 
 The mind is to be supported Method of management The 
 proposed treatment in a bad case detailed Conclusion. 
 
 WE now come to speak of the treatment of those 
 cases in which the patient has been a long time 
 suffering before coming under our care, and is in 
 an extremely enfeebled condition, or the victim of 
 some sort of indigestion, vomiting, &c. 
 
 Our mission here is one of extreme difficulty, 
 and requires the greatest tact, knowledge, and 
 firmness in its execution. 
 
 We must form to ourselves as accurate an esti- 
 mate as possible of what art and medicine can 
 effect; we must form a similar estimate of what 
 medical science cannot do; and, above all things, 
 we must consider the duration of time which must 
 elapse ere the patient can be restored to perfect 
 health ; in other words, the physician must make 
 a survey of the ground, and, like a medical Tod-
 
 186 JUDGMENT. 
 
 leben, make his dispositions accordingly. As the 
 engineer knows that fortifications or siege-works 
 require time for their execution, which time he can 
 estimate with tolerable precision, making all allow- 
 ances for sallies from the enemy, so the practitioner 
 ought to be able to tell with comparative accuracy 
 the length of time required to regain health, even 
 making allowances for accidental or new symptoms. 
 
 When this estimate has been made the patient 
 should be informed of it ; and the grounds on which 
 the judgment is formed should be explained. The 
 advantage of this straightforward plan of proceed- 
 ing has scarcely been sufficiently recognised. The 
 practitioner has been contented with the expres- 
 sion of vague hopes of recovery ; he says, per- 
 chance, to the sufferer, " You will be better soon" 
 if you do this or that. His interpretation of the 
 word, however, differs from that of the patient; 
 she anticipates a restoration in a week, a fortnight, 
 or a month. He has no fixed limit at all. With 
 her, to-morrow is the day after the one in which 
 the word was uttered ; with him, to-morrow always 
 means a day in prospect. 
 
 The effect of this practically is, that as long as 
 the supposed definite period has not been reached, 
 there is hope, confidence, and bright anticipation ; 
 as soon as it has passed without marked relief, 
 there is distrust, depression, and distress. 
 
 If you tell the sufferer that she must expect one, 
 two, or three months to elapse ere she recover,
 
 INFLUENCE OF HOPE. 187 
 
 sketch the various phases of the complaint likely 
 to be noticed; tell her the difficulties attending 
 each new symptom, and the determination you 
 have of still piloting her in an almost undeviating 
 line to health, you will receive a sustained con- 
 fidence up to the period you have named. With a 
 definite end in our own mind, you will soon gene- 
 rate a similar steadfastness in your patient, and 
 this of itself is no slight element of cure. 
 
 The importance of the two opposite emotions, 
 hope and despair, have long been recognised in the 
 abstract; but they have not hitherto been suffi- 
 ciently regarded in the treatment of disease. 
 
 We could give cases from our own experience 
 in which patients given over, by their own doctor, 
 to death, have gone steadily on the road thither, 
 sped chiefly by his dictum, but who, on the appa- 
 rition of another, whose face, at first grave, has 
 become bright and confident, have incontinently 
 left their beds, and entered with joyous vigour into 
 the world again. 
 
 We could tell of the mortality of retreating 
 armies, the tenacity of life in the victorious sol- 
 diery. We might recal to memory the wonderful 
 influences of fanaticism and saintly intervention in 
 the arrest of plague, fever, and " black death," and 
 the heart-thrilling accounts of Lieutenant Pirn's 
 arrival on the scurvy-stricken seamen of M'Clure's 
 ship ; but we prefer dwelling on the more strictly 
 practical points which so nearly concern " the Pro- 
 fession."
 
 188 INFLUENCE OF CONFIDENCE. 
 
 Let us turn to any book we will, which promul- 
 gates a new doctrine, or proposes a new means of 
 curing disease, and we invariably find that the 
 author has a larger amount of success than any of 
 his followers. No matter what the medicine used, 
 whether it is hemlock, creosote, antimony, calomel, 
 prussic acid, aconite, lobelia, ipecacuanha, cotyle- 
 don, brandy-and-salt, taraxacum, or the like, 
 whether the system adopted is a new one, such as 
 metallic tractorism, animal magnetism, -electricity, 
 galvanism, hypnotism, mesmerism, homoeopathy, 
 hydropathy, kinesipathy, the grape cure, the 
 rarefied or condensed-air cure, Coffinism, Moriso- 
 nianism, &c., whether it is a reference of all com- 
 plaints to a want of bile, or of gastric juice, or to a 
 redundance of bile, to irritation of the kidney or 
 disease of the heart, to repressed itch or ulcer of 
 the uterus, it is of no matter whatever, as long as 
 the patient is ignorant of the theory (or at any 
 rate unable to judge correctly about its truth or 
 falsehood), and the apostle of the new doctrine is 
 ardent, enthusiastic, and confident! But when 
 the theory is no longer a novelty, and its ex- 
 pounder lacks the fanatic energy of its founder, 
 it naturally sinks, and often never to rise again. 
 The unbounded trust reposed in every new doc- 
 trine is a frailty so well known, that it is a source 
 of astonishment that so few practitioners reco- 
 gnise the truth it contains, or, if they do, act in 
 accordance therewith.
 
 SOURCES OF DISAPPOINTMENT. 189 
 
 They visit their patients as a veterinary surgeon 
 does a horse; they examine the symptoms, say a 
 few words stereotyped on their tongue " Oh, you 
 will soon be better; I am going to send you some 
 physic, which you will take according to direc- 
 tions;" and then, after having said to the friends 
 whether or not there is danger to life, go away, 
 thinking that the medicine is to do the rest. The 
 patient, knowing nothing herself of the cause of 
 her suffering, and getting no explanation of it, 
 broods over her troubles in her mind, and at the 
 first failure of the drugs gives way to a species of 
 despair. 
 
 No wonder that disappointment follows. 
 
 For a doctor to be successful in nervous affec- 
 tions, he must be bright, firm, confident, and ex- 
 plicit; he must show that he knows the value of 
 every symptom, and is able to explain it without a 
 mist of words that mean nothing ; he must prove 
 that he knows what he has to do, that he knows 
 how to do it, the time it will require, and the 
 difficulties he will meet with. 
 
 Such an one gains unlimited confidence ; and his 
 voice, his face, his manner, are all of them worth 
 many a dose of the most vivifying medicine. 
 
 Without this confidence success is extremely 
 doubtful. 
 
 The bearing of this view is not, in some points, 
 so satisfactory as could be wished for our profes- 
 sion, for it would dictate that the doctor who has
 
 190 VALUE OF MEDICAL FAITH. 
 
 not the power to inspire his patient with confi- 
 dence, whether in himself or his art, is bound at 
 once to consign him to another in the same or in a 
 different line who has the envied faculty. The 
 allopath must be willing to give way to the hydro- 
 path, the homoeopath, or the Coffinite ; and he will 
 sometimes have to swallow the bitter pill of know- 
 ing that they have succeeded where he has failed. 
 Under these circumstances, however, it is no small 
 consolation to know that the confidence of a pa- 
 tient in a new system affords no valid argument 
 in favour of its truth.* 
 
 * An amusing proof of this is to be seen in an episode in the 
 history of nitrous oxide, or laughing-gas. Its wonderful properties 
 led to a very natural expectation that it would be useful in medicine. 
 A very distinguished physician, having first well primed his patient 
 with accounts of the amazing results to be expected, brought a para- 
 lytic to the laboratory of Dr. Priestley, its discoverer. Many learned 
 men were present, and amongst others (if I remember rightly) Dr. 
 Wollaston. He wanted to ascertain if there would be any increase of 
 temperature in the blood or body by the inhalation of a large dose of 
 oxygen, and placed, for this purpose, a thermometer under the man's 
 tongue. He, thinking that this was the process he had come for (it 
 was in A.D. 1776), started, and said he felt the influence already, and 
 could move his arm slightly. The doctors "tipped the wink" all 
 round, and looked on with increasing interest and gravity. The seance 
 lasted fifteen minutes, the thermometer was then removed, and the man 
 went away improved. Every second day he came to have the same 
 process repeated, and in six weeks was considered cured. Of course, 
 had the man happened to have inhaled the gas, that would have got the 
 credit. 
 
 The homceopathists are constantly putting forward the success at- 
 tending their plan of treatment as a proof of the value of the globules 
 they employ. But a great many instances have come to the author's 
 knowledge where waggish friends have substituted inert globules for 
 those the patient was in the habit of taking. 
 
 In one instance success followed the cheat for three months. The
 
 VALUE OF REST. 191 
 
 In the treatment, then, of confirmed nervous 
 affections, we consider that confidence and hope 
 hold the foremost place. 
 
 It is so difficult to assign the second place, that 
 we must give the heads of other supplemental 
 plans of treatment, without any very definite 
 order. 
 
 Rest is of great importance rest of body even 
 from conversation; rest of mind, rest for the 
 nerves of special sensation, and rest from all irri- 
 tants whatever ; rest for a time from medicine. 
 
 For the first week " kitchen physic" alone is to 
 be resorted to, and this is to be of the most judi- 
 
 inert globules were made potent \>j faith. The patient was then told 
 of the deceit; her faith was gone, and the potent globules became 
 inert. 
 
 In another instance a cheat was announced, and the globules at once 
 lost their power ; but no substitution had been made ! The infinitesimal 
 dose was there in reality, but \hefaith in its value had departed. 
 
 In a third, a friend, weary of hearing the virtues of "mix" and 
 " calx carbonica," and " mercurius," provided himself with a lot of 
 sugar-of-milk globules, and took an opportunity to empty the whole of 
 the medicine armoury of his friend, and to replace the stock with his 
 equally harmless supply. The zest with which he now listens to the 
 marvels of " bryonia," " graphite," " arnica," is a rich treat, and one 
 that he has not yet spoiled by telling the secret. 
 
 The impossibility of really knowing whether globules are potent or 
 not i. e., whether they really contain any of the medicine supposed, 
 will, when the world has had a little more time to get reasonable, 
 afford a strong argument against the claims of so extraordinary a doc- 
 trine as that the value of a medicine increases in proportion to its 
 proximity to nonentity ! 
 
 It is an interesting fact that the most ardent disciple of one new 
 "pathy" becomes, after a variable period, equally ardent respecting 
 another, and another ; showing that his confidence in each wanes in 
 direct proportion to his familiarity with it and the amount of pre- 
 tensions of the new one.
 
 292 MANAGEMENT. 
 
 cious kind. Egg and wine, soup, beef-tea, fruits, 
 good toasted cheese, madeira, champagne, ice, soda- 
 water and brandy, cream, jelly, blanc-mange, tipsy 
 cake ; anything tasty, light, and digestible is to be 
 adopted in small quantities and at short intervals. 
 
 If the stomach is irritable, it must have a rest 
 too, and the patient be sustained by enemata of 
 beef-tea, mutton-broth, &c. 
 
 The bowels, too, must be let alone; and if the 
 vagina or uterus have been invaded with the spe- 
 culum and caustics, they, too, must have a holiday. 
 Opiates are for a time to be shunned. Entertain- 
 ment is to fall to the lowest point of dulness. 
 Excitement is to be quenched by "wet blankets." 
 Sympathy is to be frozen up; complaints are to 
 fall on serpents' ears which are deaf to pity ; and, 
 to sum up, the patient must be put into nearly the 
 same position as a plant. She must be tended, 
 cherished, fed, and watched. At the end of a few 
 days the powers remaining in the system may be 
 estimated, and the tendencies of the constitution 
 ascertained. 
 
 When medicines are administered, they must be 
 confined to the tonic class, five minims of tinc- 
 ture of the sesquichloride of iron in plenty of 
 water, about every four hours; cod-oil in such 
 quantities as the stomach will tolerate ; or any other 
 medicine not peculiarly unpalatable. Mercury is 
 to be carefully avoided. When there is nausea 
 and vomiting, champagne, brandy and soda-water,
 
 MENTAL CONTROL. 193 
 
 chloroform with or without an alkali, or opium, 
 are of great service. Special medicines are to be 
 shunned, as distracting attention from the main 
 point. Anti-spasmodics will relieve stomachic or 
 intestinal cramp or spasm, but are only of tempo- 
 rary utility; by repetition they lose their efficacy, 
 and they should therefore be reserved for great 
 occasions. We have already stated that, where 
 there is a tendency to muscular affections, great 
 relief is obtained from artificial support; mutatis 
 mutandis, the same is true of nervous affections, 
 especially of a mental kind. The patient must not 
 be left to herself; her will, though it may be obsti- 
 nate, is actually weak; it must not be expected 
 to originate a change. She is essentially to be 
 compared to a naughty or wayward child, who, as 
 long as he is unchecked, is unhappy in himself 
 and a burden to others; but who, as soon as he 
 feels under the eye of a strict parent or school- 
 master, can and does check himself, and follow any 
 lead proposed to him. He requires the support of 
 a stronger mind, and is not comfortable till he has 
 it. So it is with the so-called hysterical people ; they 
 suffer in many a form, painful alike to themselves 
 and others, until some master-mind teaches them 
 unequivocally that they are under control; they 
 are like young saplings, which require the help of 
 a stake to keep them upright till they are strong 
 enough to stand alone. 
 
 How this control is to be acquired and exercised 
 
 o
 
 194 A CASE SUPPOSED. 
 
 must necessarily vary with the nature of the symp- 
 toms and the tact and experience of the medical 
 man. The great point to be attained (as it is 
 with children) is that the doctor must be superior 
 to the patient in every point where they come in 
 contact, and let it be well known too. He must 
 be able to read the truth or the falsity of every 
 new symptom; detect and punish every attempt 
 at imposition; never give way while administer- 
 ing the cold-douche, &c., until he is victorious; his 
 word must be law; he must show little medical 
 sympathy, and that of the most patronizing kind : 
 in fine, he must be metaphorically the strict 
 father, and he will soon influence his patient to be 
 the happy child. The remarkable success of the 
 late Dr. Jephson, of Leamington, is to be mainly 
 attributable to the power he had in this respect. 
 
 To pass from generalities to particulars, let us 
 inquire into the treatment most likely to be suc- 
 cessful in the case we quoted from Dr. Griffin's 
 work. We will take it up at the period when 
 lifting the patient in a sheet produced such in- 
 tense suffering as to make her half insensible for a 
 week (p. 156). 
 
 We have to manage an intensely irritable cough, 
 a very delicate stomach, and an extraordinary ten- 
 dency to spasm in the voluntary muscles ; we have 
 so much agony from motion that the administra- 
 tion of enemata is out of the question. We ex- 
 amine the throat, and anticipate finding a relaxed
 
 THE CASE TREATED. 195 
 
 uvula, or some other affection capable of local 
 medication ; we find no evidence of disease of the 
 lungs, of the heart, &c. 
 
 Once satisfied on these points, we assure our 
 patient with all the earnestness and confidence 
 that our complete understanding of the case en- 
 titles us to use, that she will be perfectly well in 
 three months, if she will obey our orders implicitly ; 
 that the complaint arises entirely from the state of 
 debility in which she is; that as her system re- 
 gains its powers, her sufferings will lose their hold : 
 but that, as she has doubtless read of persons who 
 have been nearly dead of starvation, and who have 
 really died from overgorging when they were in a 
 land of plenty, so, she must expect that for her 
 own sake, the progress towards restoration should 
 not be too rapid ; that it will be very slow at first, 
 progress only being perceptible from week end to 
 week end, or even at a longer interval, but that 
 when once begun it will go on with gradually in- 
 creasing rapidity, until she will be able to say she 
 is better and better every day. 
 
 She must remain perfectly quiet in bed, without 
 talking or other excitement. She is to have the 
 throat medicated (by a solution gr. x. to %i. of 
 nitrate of silver, applied every day, if anything is 
 found which requires such treatment) by a solution 
 (gr. ij. to 3i) of muriate of morphia applied over 
 the larynx, to reduce the irritability of glottis, &c. 
 A piece of lint wetted with the solution is to be
 
 196 A FEEDING TUBE DESCRIBED. 
 
 covered with gutta-percha and applied to the un- 
 abraded skin. For medicine, two minims of the 
 tincture of iron is to be given every four hours in 
 half an ounce of water. 
 
 The yolk of an egg is to be beaten up with 
 equal parts of water and half an ounce of sherry 
 or Madeira, and the half to be administered every 
 hour and half, or two hours, both day and night. 
 In a day or two, as the egg palled upon the taste, 
 a thin gravy soup should be substituted, care 
 being taken to avoid all very decided flavours. In 
 a few days more, indeed, at any period the patient 
 fancied it, cream and water sweetened should re- 
 place the other aliment, the quantity given at 
 each time being kept very small. The wine, in 
 half-ounce doses, should be continued at intervals, 
 as it seemed to be required. When given alone, 
 champagne should have the preference. Jelly, 
 blanc-mange, &c. &c., might at any time replace 
 any of the above. No matter what the aliment, it 
 should be administered without the slightest fatigue 
 to the patient. The medicine-spoon, or cup, answers 
 well, but in practice I have found a long tube, bent 
 at right angles, to answer better (they can be pro- 
 cured at any glass-blower's) : the long leg should 
 be about a foot long, the short four inches; the 
 diameter of the tube one-third of an inch. To use 
 it, the short leg is placed in the cup or glass, held 
 above the level of the mouth, the long leg in the 
 mouth. The smallest amount of suction converts it
 
 ENEMATA PRACTICAL HINT. 197 
 
 into a syphon, and the patient drinks without 
 greater trouble than an infant at the breast when 
 " the flow" comes. 
 
 In addition, we should suggest gentle friction of 
 the body with cod-liver oil, having first ascertained 
 that the odour did not nauseate. 
 
 If vomiting come on, the stomach must have a 
 rest, and then we must begin again with cham- 
 pagne, or sparkling hock or Moselle, or brandy 
 and soda-water, or ice. If persistent, opium in- 
 ternally and an epithem of solution of morphia to 
 the epigastrium will be most appropriate. 
 
 We should be content to leave the bowels alone 
 for the first fortnight, or even a longer period. 
 
 As the patient increased in strength, she should 
 increase the quantity of food taken, and increase 
 the intervals between the meals. The dose of iron 
 should be augmented. Solid food, well mixed, 
 would at last take the place of liquids. The wine 
 would be increased in quantity, and reserved for 
 meal-times. Longer sleep would be allowed, and 
 visitors to the sick-room might be encouraged. 
 
 The doctor's visit should be a daily one for the 
 first week, that he might cheer up his patient, and 
 encourage her through the first dreary steps of re- 
 covery; afterwards he must act according to his 
 discretion. 
 
 As soon as the body could be moved without 
 pain, enemata of beef-tea, &c., might be used ; and 
 here we must suggest a modification of the ordi-
 
 198 CHANGE OF AIR. 
 
 nary apparatus, which is of the greatest conve- 
 nience ; it is simply to substitute for the ordinary 
 pipe and nozzle a tube of vulcanized india-rubber 
 of the same diameter, but at least a yard in length, 
 and a bulbous ivory nozzle. The bulb at the end, 
 being passed beyond the sphincter, is retained by 
 it, and the length of tube attached enables the 
 attendant to give an injection without the patient 
 turning on her side, the tube passing over or under 
 one thigh ; the water-basin may be on an adjoining 
 table, and the bed-pan, if necessary, may be intro- 
 duced ere the instrument is withdrawn. 
 
 As soon as the stomach was likely to bear it, 
 cod-liver oil should be tried in full doses with the 
 steel; or, dropping this, with brandy and water. 
 When the patient could bear to be moved, she 
 should have complete change from one room to 
 another, and, if possible, have a different room for 
 day and night. The old bed-chamber, associated 
 with so much misery, should be discarded alto- 
 gether. At first any attempt at exercise should 
 not exceed such as an infant takes when learnino- 
 
 o 
 
 to walk, and it should be increased very slowly, 
 for the smallest over-exertion would reproduce the 
 cramps. When the patient was able to sit -up for 
 a few hours, and the weather was fine, a short 
 drive would be of service, but it must be in the 
 recumbent posture. As soon as short drives could 
 be borne, a complete change of air might be 
 adopted ; and where such a spot is accessible, there
 
 SUMMARY. 199 
 
 is no watering-place near here so favourable as 
 New Brighton, where, in addition to pure air, there 
 is the mild excitement of seeing ships perpetually 
 passing by day, and listening to the steamers 
 thrashing the water at night. With the change of 
 air, the tonics may probably be suspended, the 
 food will gradually be increased in quantity, and 
 ale or porter substituted for wine. The bowels 
 must now be regulated by some very mild ape- 
 rient and bitter. The daily amount of exercise 
 may be increased, care being taken to alternate 
 with it rest in the recumbent posture. If the pa- 
 tient is a female, exercise is to be moderated 
 during the presence of the catamenia. Pleasant 
 occupation is to be found, if possible, which will in- 
 terest without exciting the mind, or will occupy the 
 hands without fatiguing the arms, shoulders, or back. 
 When the Profession shall have recognised the 
 principles we have attempted to lay down when 
 they begin to look with jealousy at every dose 
 of calomel, antimony, or digitalis that they order 
 when they take for a starting-point the axiom 
 that "disease implies debility," and "that every- 
 thing which weakens a patient must impede his 
 restoration to health" when bleeding shall have 
 been dismissed to the limbo of scientific fallacies, 
 to be recalled only by some medical judge of 
 supreme knowledge when blisters become the 
 rifle-shot of the experienced hunter, who never 
 fires without a definite aim, rather than the
 
 200 CONCLUSION. 
 
 grape, canister, or the shrapnel-shot of the artil- 
 lerist, who fires them comparatively at random 
 when purgatives are not considered panaceas, 
 and salivation is not a refuge for the destitute 
 of ideas when active treatment gives way to 
 scientific, and the general health is considered su- 
 perior to the apparent health of any one organ 
 when medicines are considered as means to an end, 
 and not as so many doses of bottled comfort 
 when the doctor recognises in recovery the result 
 of a natural process rather than the imbibition of so 
 many ounces of physic when there is a thorough 
 knowledge of what medicine can do, as well as 
 what it cannot when a discrimination is made 
 between the effects of a disease and the effect of 
 presumed remedies when the natural history of 
 each complaint becomes more generally known, 1 
 not only will the science of medicine be fixed upon 
 a firm basis, but it will command a confidence that 
 it has never yet fully deserved. 
 
 Heresies may be possible, but they never will 
 be captivating. 
 
 At present the tendency of medical authors is to 
 hold a magnifying-glass before particular organs, 
 to discriminate between the minutest phases of 
 their complaints, and to discuss the best plans for 
 the relief of this or that symptom. What is wanted 
 is a broad and comprehensive classification, in 
 which life, health, vitality, and nutrition will form 
 the genera, and diseases the species only.
 
 CONCLUSION. 201 
 
 The question that the physician will then pro- 
 pose to himself will be, how shall I restore the 
 patient to health? not how shall I attack the 
 complaint. When an organ has gone wrong, or an 
 inflammation has set itself up, instead of punishing 
 the former, and knocking down the latter, the 
 system will be helped to put the one right and to 
 get over the other. A difficulty will be "tided 
 over" instead of being crushed, rapidity of cure, 
 rather than an ultimate result will be the test of 
 successful theory, and, oh! conclusion most disas- 
 trous, the more scientific the physician the smaller 
 will be his emoluments ! 
 
 THE ENl).
 
 LONDON: 
 
 8AVILL AND EDWABDS, PEINTEBS, CHAND03 STREET, 
 COVENT GARDEN.
 
 London, New Burlington Street, 
 November, 1850. 
 
 MEDICINE, SURGERY, 
 
 AND 
 
 SCIENCE. 
 
 " It would be unjust to conclude this notice without saying a few words in favour of 
 Mr. Churchill, from whom the profession is receiving, it may be truly said, the most 
 beautiful series of Illustrated Medical Works which has ever been published." Lancet. 
 
 " All the publications of Mr. Churchill are prepared with so much taste and neatness, 
 that it is superfluous to speak of them in terms of commendation." Edinburgh 
 Medical and Surgical Journal. 
 
 " No one is more distinguished for the elegance and recherclii style of his publica- 
 tions than Mr. Churchill." Provincial Medical Journal, 
 
 "Mr. Churchill's publications are very handsomely got up: the engravings are 
 remarkably well executed." Dublin Medical Press. 
 
 "The typography, illustrations, and getting up are, in all Mr. Churchill's publi- 
 cations, most beautiful." Monthly Journal of Medical Science. 
 
 " Mr. Churchill's illustrated works are among the best that emanate from the 
 Medical Press." Medical Times. 
 
 " We have before called the attention of both students and practitioners to the great 
 advantage which Mr. Churchill has conferred on the profession, in the issue, at such a 
 moderate cost, of works so highly creditable in point of artistic execution and scientific 
 merit." Dublin Quarterly Journal.
 
 MR. CHURCHILL is the Publisher of the following Periodicals, offering to Authors a 
 wide extent of Literary Announcement, and a Medium of Advertisement, addressed to 
 all Classes of the Profession. COMMUNICATIONS, BOOKS for REVIEW, addressed to the 
 respective Editors, are received and duly forwarded by Mr. Churchill. 
 
 THE BRITISH AND FOREIGN MEDIGO-GHIRURGICAL REVIEW; 
 
 OR, 
 
 QUARTERLY JOURNAL OF PRACTICAL MEDICINE. 
 
 Price Six Shillings. Nos. I. to XLVIII. 
 
 THE QUARTERLY JOURNAL OF MICROSCOPICAL 
 SCIENCE. 
 
 Edited by EDWIN LANKESTER, M.D., F.R.S., F.L.S., and GEORGE BUSK, F.R.C.S.E., 
 F.R.S., F.L.S. Price 4s. Nos. I. to XXIX. 
 
 THE MEDICAL TIMES AND GAZETTE. 
 
 Published Weekly, price Sevenpence, or Stamped, Eightpence. 
 Annual Subscription, 1. 10s., or Stamped, 1. 14s. Kd., and regularly forwarded to all parts 
 
 of the Kingdom. 
 
 The MEDICAL TIMES AND GAZETTE is favoured with an amount of Literary and Scientific 
 support which enables it to reflect fully the progress of Medical Science, and insure for it a 
 character, an influence, and a circulation possessed at the present time by no Medical Peri- 
 odical. 
 
 THE HALF-YEARLY ABSTRACT OF THE 
 MEDICAL SCIENCES. 
 
 Being a Digest of the Contents of the principal British and Continental Medical Works ; 
 together with a Critical Report of the Progress of Medicine and the Collateral Sciences. 
 Edited by W. H. RANKING, M.D., Cantab., and C. B. RADCLIFFE, M.D., Lond. Post 8vo. 
 jcloth, 6s. Gd. Vols. I. to XXIX. 
 
 THE JOURNAL OF PSYCHOLOGICAL MEDICINE 
 AND MENTAL PATHOLOGY. 
 
 Being a Quarterly Review of Medical Jurisprudence and Insanity. Edited by FORBES 
 WINSLOW, M.D. Price 3s. 6d. Nos. I. to XVI. New Series. 
 
 THE PHARMACEUTICAL JOURNAL. 
 
 EDITED BY JACOB BELL, F.L.S., M.R.I. 
 
 Published Monthly, price One Shilling. 
 *** Vols. I. to XVIII., bound in cloth, price 12s. 6d. each. 
 
 THE BRITISH JOURNAL OF DENTAL SCIENCE. 
 
 Published Monthly, price One Shilling. Nos. I. to XXXIX. 
 
 THE DUBLIN MEDICAL PRESS. 
 
 Published Weekly, Stamped, price Sixpence, free to any part of the Empire. 
 
 Jj THE LONDON AND PROVINCIAL MEDICAL DIRECTORY. 
 
 |f Published Annually. 12mo. cloth, 8s. 6<Z.
 
 A CLASSIFIED INDEX 
 
 Ml. 
 
 ANATOMY. 
 
 PAGE 
 
 Anatomical Remembrancer . . 3 
 Beale on Liver 5 
 Hassall's Micros. Anatomy .. 14 
 Holden's Human Osteology . . 15 
 
 DISEASES of the URINARY 
 and GENERATIVE ORGANS, 
 and SYPHILIS. 
 
 MATERIA MEDICA and 
 PHARMACY. 
 
 Bateman's Magnacopia . . . . 4 
 Beasley's Formulary 5 
 
 Do. on Dissections . . . . 15 
 Jones' and Sieveking's Patho- 
 logical Anatomy 17 
 Maclise's Surgical Anatomy .. 19 
 Paget's Catalogue 21 
 Sibson's Medical Anatomy . . 25 
 Wheeler's Handbook 30 
 Wilson's Anatomy 30 
 
 CHEMISTRY. 
 
 Abel & Bloxam's Handbook . . 3 
 Bowman's Practical Chemistry 7 
 Do. Medical do. ..7 
 Chalmers' Electro-Chemistry . . 8 
 Fownes' Manual of Chemistry . . 12 
 Do. Actonian Prize .. ..12 
 Do. Qualitative Analysis .. 12 
 Fresenius' Chemical Analysis . . 12 
 Galloway's First Step . . . . 12 
 Do. Analysis 12 
 Griffiths' Four Seasons . . . . 13 
 Horsley's Chem. Philosophy . . 16 
 Jones. Mulder on Wine .. .. 17 
 Odling's Practical Chemistry .. 21 
 Plattner on Blowpipe . . . . 22 
 
 Acton on Reproductive Organs 3 
 Coote on Syphilis 10 
 Coulson on Bladder 10 
 Do. on Lithotomy .. .. 10 
 Egan on Syphilis 11 
 Gant on Bladder 13 
 Judd on Syphilis 17 
 Maunder on Chancre . . . . 20 
 Milton on Gonorrhoea . . . . 20 
 Parker on Syphilis .21 
 Todd on Urinary Organs . . . . 28 
 Wilson on Syphilis 31 
 
 DISEASES OF WOMEN 
 AND CHILDREN. 
 
 Barker on Children 4 
 Bennet on Uterus 5 
 Do. on Uterine Pathology.. 5 
 Bird on Children 6 
 Brown on Women 7 
 Do. on Scarlatina 7 
 Eyre's Practical Remarks . . 11 
 Hood on Crowing 16 
 Lee's Ovarian & Uterine Diseases 18 
 Lee on Diseases of Uterus 18 
 
 Do. Receipt Book . . . . 5 
 Do. Book of Prescriptions 5 
 Lane's Materia Medica .. ..18 
 Pereira's Selecta e Prsescriptis 22 
 Pharmacopoeia Londinensis . . 22 
 Prescriber's Pharmacopoeia . . 22 
 Royle's Materia Medica . . . . 24 
 Spurgin's Materia Medica.. .. 20 
 Steggall's Materia Medica . . 25 
 Do. First Lines for Chem ists 26 
 Stowe's Toxicological Chart . . 28 
 Taylor on Poisons 27 
 Wittstein's Pharmacy . . . . 31 
 
 MEDICINE. 
 
 Acland on Cholera 3 
 Adams on Rheumatic Gout . . 3 
 Addison on Supra-Renal Capsules 3 
 Addison on Cells 3 
 Alexander on Rheumatism . . 3 
 Baly and Gull on Cholera . . 4 
 Barclay on Diagnosis . . . . 4 
 Barlow's Practice of Medicine 4 
 Basham on Dropsy 4 
 
 Speer's PathoL Chemistry . . 26 
 
 Do. on Speculum 18 
 Roberton on Women 23 
 Rowe on Females 24 
 
 Billing's First Principles . . . . 6 
 Bird's Urinary Deposits . . . . 6 
 Bird on Charcoal 6 
 
 CLIMATE. 
 
 Francis on Change of Climate . . 12 
 Hall on Torquay 14 
 Haviland on Climate 14 
 Lee on Climate 18 
 McClelland on Bengal . . . . 19 
 Martin on the Undercliff . . . . 19 
 Martin (J. R.) on Tropical . . 20 
 
 DEFORMITIES, &c. 
 
 Bigg on Deformities 6 
 Bishop on Deformities . . . . 6 
 Do. Articulate Sounds . . 6 
 Brodhurst on Spine 7 
 Do. on Clubfoot . . . . 7 
 Hare on Spine 14 
 Hugman on Hip Joint . . . . 16 
 
 Smith on Leucorrhoea . . . . 25 
 Tiit on Diseases of Women . . 27 
 Do. on Change of Life . . . . 27 
 Underwood on Children . . . . 29 
 West on Women 30 
 
 HYGIENE. 
 
 Armstrong on Naval Hygiene 4 
 Beale's Laws of Health . . . . 5 
 Do. Health and Disease . . 5 
 Bennet on Nutrition 5 
 Blundell's Medicina Mechanica 6 
 Carter on Training 8 
 Cornaro on Long Life . . . . 10 
 Granville on Vichy 13 
 Hartwig on Sea Bathing .. .. 14 
 Do. Physical Education 14 
 Hufeland's Art 16 
 
 Brinton on Stomach 7 
 Do. on Ulcer of do 7 
 Budd on the Liver 8 
 Do. on Stomach 8 
 Camplin on Diabetes 8 
 Chambers on Digestion . . . . 9 
 Davey's Ganglionic 10 
 Eyre on Stomach 11 
 Fuller on Rheumatism .. ..12 
 Gairdner on Gout 12 
 Granville on Sudden Death . . 13 
 Gully's Simple Treatment . . 13 
 Habershon on Stomach .. ..13 
 Hall on Apncea 13 
 Hall's Observations 13 
 Harrison on Lead in Water . . 14 
 Hassall on Urine 14 
 Headland on Medicines .. ..15 
 Hooper's Medical Dictionary .. Hi 
 Hooper's Physician's Vade- 
 Mecum 13 
 
 Inman on Spine 16 
 Tamplin on Spine 26 
 
 DENTISTRY. 
 
 Blundell's Painless Extraction . 7 
 Clark's Odontalgist 9 
 Gray on the Teeth 13 
 Odontological Soc Transactions 21 
 Tomes' Dental Surgery . . . . 28 
 
 :fe> *-S4 
 
 Lee's Watering Places of England 18 
 Do. do. Germany, 
 France, and Switzerland .. 18 
 Lee's Rhenish Watering Places 18 
 Parkin on Disease 21 
 Pickford on Hygiene . . . . 22 
 Robertson on Diet 24 
 Rumsey's State Medicine . . . . 24 
 Van Oven's Decline of Life . . 29 
 Wilson on Healthy Skin .. ..31 
 Do. on Mineral Waters . . 31 
 
 Hughes on Blood Disease . . 16 
 Jones' Animal Chemistry .. 17 
 Lugol on Scrofula 19 
 Peacock on Influenza . . . . 21 
 Pym on Yellow Fever . . . . 23 
 Roberts on Palsy 23 
 Robertson on Gout. 24 
 Savory's Compendium .. ..24 
 Semple on Cough 24 
 Shaw's Remembrancer . . . . 25 
 Smee on Debility 25 
 
 >**, - -Sx-SU* 
 
 f
 
 CLASSIFIED INDEX. 
 
 MEDICINE continued. 
 
 Steggall's Medical Manual . . 26 
 
 SteggalTs Gregory's Conspectus 26 
 
 Do. Celsus 26 
 
 Thomas' Practice of Physic . . 27 
 
 Thudichum on Urine . . . . 28 
 
 Wegg's Observations 2<J 
 
 Wells on Gout 29 
 
 What to Observe 19 
 
 Whitehead on Transmission . . 30 
 
 Williams' Principles 30 
 
 Wright on Headaches . . . . 31 
 
 MICBOSCOPE. 
 
 Beale on Microscope in Medicine 5 
 
 Do. How to Work . . . . 5 
 
 Carpenter on Microscope . . . . 8 
 
 Schacht on do. . . . . 24 
 
 MISCELLANEOUS. 
 
 Acton on Prostitution . . . . 3 
 
 Atkinson's Bibliography . . . . 4 
 
 Bascome on Epidemics ... . . 4 
 
 Bryce on Sebastopol 7 
 
 Cooley's Cyclopedia 9 
 
 Davy's (Sir H. ) Remains . . ..11 
 Forbes' Nature and Art in Disease 12 
 
 Guy's Hospital Reports . . . . 13 
 
 Haycock's Veterinary . . . . 14 
 
 Lane's Hydropathy 18 
 
 Lee on Homoeop. and Hydrop. 18 
 
 Marcet on Food 19 
 
 Massy on Recruits 20 
 
 Part's Case Book 21 
 
 Pettigvew on Superstitions . . 22 
 
 NERVOUS DISEASES AND 
 INDIGESTION. 
 
 Carter on Hysteria 8 
 
 Child on Indigestion . . . . 9 
 Downing on Neuralgia .. ..11 
 
 Hunt on Heartburn 16 
 
 Lobb on Nervous Affections .. 19 
 Radcliffe on Epilepsy . . . . 23 
 Reynolds on the Brain . . . . 23 
 Rowe on Nervous Diseases . . 24 
 Sieveking on Epilepsy . . . . 25 
 Todd on Nervous System . . . . 28 
 Turnbull on Stomach . . . . 28 
 
 OBSTETRICS. 
 
 Barnes on Placenta Prsevia . . 4 
 
 Davis on Parturition 11 
 
 Lee's Clinical Midwifery .. ..18 
 Pretty's Aids during Labour . . 22 
 Ramsbotham's Obstetrics . . . . 23 
 Do. Midwifery.. .. 23 
 
 Sinclair & Johnston's Midwifery 25 
 Smellie's Obstetric Plates . . . . 25 
 Smith's Manual of Obstetrics . . 25 
 
 Swayne's Aphorism's 20 
 
 Waller's Midwifery 29 
 
 OPHTHALMOLOGY. 
 
 FACE 
 
 Cooper on Inj uries of Eye . . 9 
 Do. on Near Sight . . . . 9 
 
 Dalrymple on Eye 10 
 
 Dixon on the Eye 11 
 
 Hogg on Ophthalmoscope . . 15 
 
 Holthouse on Strabismus . . . . 15 
 
 Do. on Impaired Vision 15 
 
 Jacob on Eye-ball 16 
 
 Jago on Ocular Spectres .. ..16 
 
 Jones' Ophthalmic Medicine . . 17 
 
 Do. Defects of Sight .. ..17 
 
 Do. Eye and Ear 17 
 
 Nunneley on the Organs of Vi- 
 sion 21 
 
 Walton on Ophthalmic . . . . 29 
 
 PHYSIOLOGY. 
 
 Carpenter's Human 8 
 
 Do. Comparative . . . . 8 
 
 Do. Manual 8 
 
 Cottle's Human 10 
 
 Heale on Vital Causes .. ..15 
 Hilton on the Cranium .. ..15 
 Richardson on Coagulation . . 23 
 
 PSYCHOLOGY. 
 
 Arlidge on Lunacy 3 
 
 Austin on Paralysis 4 
 
 Bucknill and Tuke's Psycholo- 
 gical Medicine 8 
 
 Burgess on Madness 7 
 
 Burnett on Insanity 9 
 
 Conolly on Asylums 9 
 
 Davey on Nature of Insanity . . 10 
 Dunn's Physiological Psycho- 
 logy 11 
 
 Hood on Criminal Lunatics . . 16 
 Jacobi on Hospitals, by Tuke . . 28 
 Millingen on Treatment of In- 
 sane 20 
 
 Monro on Insanity 20 
 
 Do. Private Asylums . . . . 20 
 Noble on Psychology . . . . 20 
 
 Do. on Mind 20 
 
 Williams (J.) on Insanity . . 30 
 Williams (J. H) Unsoundness of 
 
 Mind 30 
 
 Winslow's Lettsomian .. ..31 
 
 PULMONARY and CHEST 
 DISEASES, &c. 
 
 Addison on Healthy and Dis- 
 eased Structure 3 
 
 Billing on Lungs and Heart . . 6 
 Blakiston on the Chest . . . . 6 
 
 Bright on the Chest 7 
 
 Cotton on Consumption .. ..10 
 
 Do. on Stethoscope .. ..10 
 
 Davies on Lungs and Heart . . 11 
 
 Dobell on the Chest 11 
 
 Fenwick on Consumption . . ..11 
 Laennec on Auscultation .. .. 17 
 
 Markham on Heart 19 
 
 Richardson on Consumption . . 23 
 Skoda on Auscultation .. ..19 
 Thompson on Consumption . . 27 
 Turnbull on Consumption . . 28 
 Weber on Auscultation . . . . 29 
 
 SCIENCE. 
 
 PAGE 
 
 Bird's Natural Philosophy . . 6 
 Burnett's Philosophy of Spirits 8 
 Craig on Electric Tension . . 10 
 Garner's Eutherapeia .. .. 13 
 Hardwich's Photography . . .. 14 
 
 Hinds' Harmonies 15 
 
 Jones on Vision 17 
 
 Do. on Body, Sense, and Mind 17 
 
 Mayne's Lexicon 20 
 
 Nourse's Students' Tables . . 21 
 Price's Photographic Manipula- 
 tion 22 
 
 Rainey on Shells 23 
 
 Reymond's Animal Electricity 23 
 Taylor's Medical Jurisprudence 27 
 
 Vestiges of Creation 28 
 
 Sequel to ditto 28 
 
 Unger's Botanical Letters . . 29 
 
 SURGERY. 
 
 Ashton on Rectum 4 
 
 Bellingham on Aneurism . . . . 5 
 Bigg on Artificial Limbs . . . . 6 
 
 Bishop on Bones 6 
 
 Bryant on Joints 7 
 
 Chapman on Ulcers 9 
 
 Do. Varicose Veins . . . . 9 
 Cooper (Sir A.) on Testis . . . . 9 
 
 Do. (S.) Surg. Dictionary 9 
 Curling on Rectum 10 
 
 Dp. on Testis 10 
 
 Druitt's Surgery 11 
 
 Fergusson's Surgery 12 
 
 Fraser on Chest 12 
 
 Harrison on Stricture .. ..14 
 Higginbottom on Nitrate of Silver 15 
 
 Hodgson on Prostate 15 
 
 James on Hernia 17 
 
 Jordan's Clinical Surgery . . 17 
 
 Laurence on Cancer 18 
 
 Lawrence on Ruptures .. ..18 
 
 Listen's Surgery 18 
 
 Macleod's Surgery of the Crimea 19 
 
 Maclise on Fractures 19 
 
 Nunneley on Erysipelas .. ..21 
 Pemberton on Melanosis . . . . 22 
 
 Pirrie on Surgery 22 
 
 Smith on Stricture 25 
 
 Snow on Chloroform 25 
 
 Steggall's Surgical Manual . . 26 
 Teale on Amputation . . . . 27 
 Thompson on Stricture . . . . 27 
 
 Do. on Prostate 27 
 
 Watson on the Larynx . . . . 29 
 Williamson on Gunshot Injuries 30 
 Wilson on the Skin 30 
 
 Do. Portraits of Skin Diseases 31 
 Yearsley on Deafness .. ..31 
 
 Do. on Throat 31 
 
 -H
 
 MR. CHURCHILLS PUBLICATIONS. 
 
 MR. F. A. ABEL, F.C.S., &> MR. C. L. BLOXAM. 
 
 HANDBOOK OF CHEMISTRY: THEORETICAL, PRACTICAL, 
 
 AND TECHNICAL. Second Edition. 8vo. cloth, 15s. 
 DR. ACLAND. 
 
 MEMOIR ON THE CHOLERA AT OXFORD IN THE YEAR 
 
 1854; with Considerations suggested by the Epidemic. 4to. cloth, with Maps, 12s. 
 
 MR. ACTON, M.R.C.S. 
 
 I. 
 
 THE FUNCTIONS AND DISORDERS OF THE REPRODUC- 
 TIVE ORGANS IN YOUTH, IN ADULT AGE, AND IN ADVANCED 
 LIFE. Considered in their Physiological, Social, and Psychological Relations. Second 
 Edition. 8vo. cloth, 7s. 
 
 ii. 
 
 PROSTITUTION : Considered in its Moral, Social, and Sanitary Bearings, 
 with a View to its Amelioration and Regulation. 8vo. cloth, 10s. 6d. 
 
 DR. ADAMS, A.M. 
 
 A TREATISE ON RHEUMATIC GOUT; OE, CHRONIC 
 
 RHEUMATIC ARTHRITIS. 8vo. cloth, with a Quarto Atlas of Plates, 21s. 
 DR. ADDISON. 
 
 ON THE CONSTITUTIONAL AND LOCAL EFFECTS OF 
 
 DISEASE OF THE SUPRA-RENAL CAPSULES. 4to. cloth. Coloured Plates, 2 Is. 
 DR. WILLIAM ADDISON, F. R.S. 
 
 CELL THERAPEUTICS. 8vo. cloth, 4*. 
 ON HEALTHY AND DISEASED STRUCTURE, AND THE TRUE 
 
 PRINCIPLES OF TREATMENT FOR THE CURE OF DISEASE, ESPECIALLY CONSUMPTION 
 AND SCROFULA, founded on MICROSCOPICAL ANALYSIS. 8vo. cloth, 12s. 
 
 DR. ALEXANDER, F.R.C.S. BY EXAM. 
 
 RHEUMATISM : its Nature, Causes, and Cure. 
 GOUT : its Nature, Causes, Cure, and Prevention. 
 
 Post 8vo. cloth, 7s. 6d. 
 
 THE ANATOMICAL REMEMBRANCER; OE, COMPLETE 
 
 POCKET ANATOMIST. Fifth Edition, carefully Revised. 32mo. cloth, 3s. 6d. 
 
 DR. ARLIDGE. ~( 
 
 ON THE STATE OF LUNACY AND THE LEGAL PROYI- 
 
 SION FOR THE INSANE ; with Observations on the Construction and Organization 
 of Asylums. 8vo. cloth, 7s.
 
 MR. CHURCHILL'S PUBLICATIONS. 
 
 DR. ALEXANDER ARMSTRONG, R.N. 
 
 OBSERVATIONS OX NATAL HYGIENE AND SCURYY. 
 
 More particularly as the latter appeared during a Polar Voyage. 8vo. cloth, os. 
 
 MR. T. J. ASHTON. 
 
 ON THE DISEASES, INJURIES, AND MALFORMATIONS 
 
 OF THE RECTUM AND ANUS. Second Edition. 8vo. cloth, 8s. 
 
 MR. ATKINSON. 
 
 MEDICAL BIBLIOGRAPHY. Vol. i. Royal 8vo. ie. 
 
 MR. THOS. J. AUSTIN, M.R.C.S. ENG. 
 
 A PRACTICAL ACCOUNT OF GENERAL PARALYSIS: 
 
 Its Mental and Physical Symptoms, Statistics, Causes, Seat, and Treatment. 8 vo. cloth, 6s. 
 DR. WILLIAM BALY, F.R.S., &, DR. WILLIAM W. GULL. 
 
 REPORTS ON EPIDEMIC CHOLERA; its Cause and Mode of 
 
 Diffusion, Morbid Anatomy, Pathology and Treatment. Drawn up at the desire of the 
 Cholera Committee of the Royal College of Physicians. With Maps, 8vo. cloth, 16s. 
 
 DR. BARCLAY. 
 
 A MANUAL OF MEDICAL DIAGNOSIS. Second Edition. 
 
 Foolscap 8vo. cloth, 8. Qd. W 
 
 DR. T. HERBERT BARKER. 
 
 ON THE HYGIENIC MANAGEMENT OF INFANTS AND \ 
 
 CHILDREN. 8vo. cloth, 5s. 
 
 DR. BARLOW. 
 
 A MANUAL OF THE PRACTICE OF MEDICINE. Fcap. Svo. * 
 
 cloth, 12s. 6d. 
 
 DR. BARNES. 
 
 THE PHYSIOLOGY AND TREATMENT OF PLACENTA 
 
 PR.3SVIA; being the Lettsomian Lectures on Midwifery for 1857. Post 8vo. cloth, 6s. 
 
 DR. BASCOME. 
 
 A HISTORY OF EPIDEMIC PESTILENCES, FROM THE 
 
 EARLIEST AGES. Svo. cloth, 8*. 
 
 DR. BASHAM. 
 
 ON DROPSY, CONNECTED WITH DISEASE OF THE 
 
 KIDNEYS (MORBUS BRIGHTII), and on some other Diseases of those Onrr.ns, 
 associated with Albuminous and Purulent Urine. Illustrated by numerous Drawings 
 from the Microscope. Svo. cloth, 9s. 
 
 MR. BATEMAN. 
 
 MAGNACOPIA : A Practical Library of Profitable Knowledge, commu- 
 nicating the general Minutiae of Chemical and Pharmaceutic Routine, together with the 
 generality of Secret Forms of Preparations; including Concentrated Solutions of Camphor 
 and Copaiba in Water, Mineral Succedanemn, Marmoratum, Silicia, Terro-Metallicum, 
 Pharmaccutic Condensions, Prismatic Crystallization, Crystallized Aromatic Salt of Vine- 
 gar, Spa Waters ; newly-invented Writing Fluids ; Etching on Steel or Iron ; with an 
 extensive Variety of et ccetera. Third Edition. I8mo. 6s.
 
 MR. CHURCHILL'S PUBLICATIONS. 5 m 
 
 *. ^ f 
 
 MR. LIONEL J. BEALE, M.R.C.S. 
 
 THE LAWS OF HEALTH IN 'THEIR RELATIONS TO MIND 
 
 AND BODY. A Series of Letters from an Old Practitioner to a Patient. Post !5vo. 
 cloth, 7s. 6c/. n 
 
 HEALTH AND DISEASE, IN CONNECTION WITH THE 
 
 GENERAL PRINCIPLES OF HYGIENE. Fcap. 8vo., 2s. 6d. 
 DR. BEALE, F.R.S. 
 
 HOW TO WORK WITH THE MICROSCOPE. Crown 8vo. cloth, 5,. 
 
 ILLUSTRATIONS TO THE ABOVE, WITH DESCRIPTION, Is. Gd. 
 
 THE MICROSCOPE, IN ITS APPLICATION TO PRACTICAL 
 
 MEDICINE. With a Coloured Plate, and 270 Woodcuts. Second Edition. 8vo. 
 cloth, 14s. 
 
 in. 
 
 ON THE ANATOMY OF THE LITER, illustrated with 66 Pho- 
 
 tographs of the Author's Drawings. 8vo. cloth, 6s. 6d. 
 
 ILLUSTRATIONS OF THE SALTS OF URINE, URINARY 
 
 DEPOSITS, and CALCULI. 37 Plates, containing upwards of 170 Figures copied 
 from Nature, with descriptive Letterpress. 8vo. cloth, 9s. 6d. 
 
 MR. BEASLEY. 
 
 THE BOOK OF PRESCRIPTIONS; containing 3000 Prescriptions. 
 
 Collected from the Practice of the most eminent Physicians and Surgeons, English 
 and Foreign. Second Edition. 24mo. cloth, 6s. 
 
 THE DRUGGIST'S GENERAL' RECEIPT-BOOK : comprising a 
 
 copious Veterinary Formulary and Table of Veterinary Materia Medica ; Patent and 
 Proprietary Medicines, Druggists' Nostrums, &c. ; Perfumery, Skin Cosmetics, Hair 
 Cosmetics, and Teeth Cosmetics ; Beverages, Dietetic Articles, and Condiments ; Trade 
 Chemicals, Miscellaneous Preparations and Compounds used in the Arts, &c. ; with 
 useful Memoranda and Tables. Fourth Edition. 24mo. cloth, 6s. 
 
 in. 
 
 THE POCKET FORMULARY AND SYNOPSIS OF THE 
 
 BRITISH AND FOREIGN PHARMACOPOEIAS ; comprising standard and 
 approved Formulae for the Preparations and Compounds employed in Medical Practice. 
 Sixth Edition, corrected and enlarged. 24mo. cloth, 6s. 
 
 DR. O'B. BELLINGHAM. 
 
 ON ANEURISM, AND ITS TREATMENT BY COMPRESSION, 
 
 12mo. cloth, 4s. 
 
 DR. HENRY BENNET. 
 
 NUTRITION IN HEALTH AND DISEASE. Post 8vo. cloth, 5,. 
 A PRACTICAL TREATISE "'ON INFLAMMATION AND 
 
 OTHER DISEASES OF THE UTERUS. Third Edition, revised, with Additions. 
 8vo. cloth, 12s. 6d. 
 
 in. 
 
 A REVIEW OF THE PRESENT STATE OF UTERINE 
 
 PATHOLOGY. 8vo. cloth, 4s. 
 
 4
 
 DR. JOHN W. F. BLUNDELL. 
 
 MEDICINA MECHANICA ; or, the Theory and Practice of Active and 
 Passive Exercises and Manipulations in the Cure of Chronic Disease. Post 8vo. cloth, 6s. 
 
 e MR. CHURCHILL'S PUBLICATIONS. 
 
 +&i 
 
 MR. HENRY HEATHER BIGG. 
 
 THE MECHANICAL APPLIANCES NECESSARY EOE THE 
 
 TREATMENT OF DEFORMITIES. Post 8vo. cloth, 4s. 
 
 ARTIFICIAL LIMBS; THEIlTcONSTRUCTION AND APPLI- 
 
 CATION. With Engravings on Wood. 8vo. cloth, 3s. 
 DR. BILLING, F.R.S. 
 
 ON DISEASES OE THE LUNGS AND HEART. 8vo. cloth, e. 
 
 FIRST PRINCIPLES OF MEDICINE, Fifth Edition, Revised and 
 Improved. 8vo. 10s. 6d. 
 
 DR. GOLDING BIRD, F.R.S. 
 
 URINARY DEPOSITS; THEIR DIAGNOSIS, PATHOLOGY, 
 
 AND THERAPEUTICAL INDICATIONS. With Engravings on Wood. Fifth 
 Edition. Post 8vo. cloth, 10s. 6d. 
 
 ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental 
 Introduction to the Study of the Physical Sciences. Illustrated with numerous Engrav- 
 ings on Wood. Fourth Edition. By GOLDINQ BIRD, M.D., F.R.S., and CHARLES 
 BROOKE, M.B. Cantab., F.R.S. Fcap. 8vo. cloth, 12s. 6d. 
 
 MR. P. HINCKES BIRD, F.R.C.S. 
 
 PRACTICAL TREATISE ON THE DISEASES OF CHILDREN 
 
 AND INFANTS AT THE BREAST. Translated from the French of M. BOUCHUT, 
 with Notes and Additions. 8vo. cloth. 20s. 
 
 MR. JAMES BIRD. 
 
 VEGETABLE CHARCOAL : its MEDICINAL and ECONOMIC PRO- 
 
 PERTIES; with Practical Remarks on its Use in Chronic Affections of the Stomach 
 and Bowels. Second Edition, 8vo. cloth, 3s. 6d. 
 
 MR. BISHOP, F.R.S. 
 
 ON DEFORMITIES OF THE HUMAN BODY, their Pathology 
 
 and Treatment. With Engravings on Wood. 8vo. cloth, 10s. 
 
 ON ARTICULATE SOUNDS, AND ON THE CAUSES AND 
 
 CURE OF IMPEDIMENTS OF SPEECH. 8vo. cloth, 4s. 
 
 in. 
 
 LETTSOMIAN LECTURES ON THE PHYSICAL CONSTI- 
 TUTION, DISEASES AND FRACTURES OF BONES. Post 8vo., 2s. 6d. 
 
 DR. BLAKISTON, F.R.S. 
 
 PRACTICAL OBSERVATIONS ON CERTAIN DISEASES OF 
 
 THE CHEST; and on the Principles of Auscultation. 8vo. cloth, 12s. 
 
 e>t
 
 MR. CHURCHILL S PUBLICATIONS. 
 
 *- 
 
 MR. WALTER BLUNDELU. 
 
 PAINLESS TOOTH-EXTRACTION WITHOUT CHLOROFORM ; 
 
 with Observations on Local Anaesthesia by Congelation in General Surgery. Second 
 Edition, 2s. Gd. cloth. Illustrated on Wood and Stone. 
 
 MR. JOHN E. BOWMAN. 
 I. 
 
 PRACTICAL CHEMISTRY, including Analysis. With numerous Illus- 
 trations on Wood. Third Edition. Foolscap 8vo. cloth, 6s. Gd. 
 
 ii. 
 MEDICAL CHEMISTRY ; with Illustrations on Wood. Third Edition. 
 
 Fcap. 8vo. cloth, 6s. Gd. 
 
 DR. JAMES BRIGHT. 
 
 ON DISEASES OF THE HEART, LUNGS, & AIR PASSAGES; 
 
 with a Review of the several Climates recommended in these Affections. Third Edi- 
 tion. Post 8vo. cloth, 9s. 
 
 DR. BRINTON. 
 I. 
 
 o THE DISEASES OF THE STOMACH, with an Introduction on its $ 
 
 Anatomy and Physiology; being Lectures delivered at St. Thomas's Hospital. Post 8vo. 
 cloth, 10s. 6d. 
 
 THE SYMPTOMS, PATHOLOGY, AND TREATMENT OF 
 
 ULCER OF THE STOMACH. Post 8vo. cloth, 5s. 
 
 MR. BERNARD E. BRODHURST. 
 I. 
 
 ON LATERAL CURVATURE OF THE SPINE: its Pathology and 
 
 Treatment. Post 8vo. cloth, with Plates, 3s. 
 
 ON THE NATURE AND TREATMENT OF CLUBFOOT AND 
 
 ANALOGOUS DISTORTIONS involving the TIBIO-TARSAL ARTICULATION. 
 
 With Engravings on Wood. 8vo. cloth, 4s. Gd. 
 
 MR. ISAAC BAKER BROWN, F.R.C.S. 
 
 ON SOME DISEASES OF WOMEN ADMITTING OF SUR- 
 
 GICAL TREATMENT. With Plates, 8vo. cloth, 10s. Gd. 
 
 ii. 
 
 ON SCARLATINA : its Nature and Treatment. Second Edition. Fcap. 
 8vo. cloth, 3s. 
 
 MR. THOMAS BRYANT, F.R.C.S. 
 
 ON THE DISEASES AND INJURIES OF THE JOINTS. 
 
 CLINICAL AND PATHOLOGICAL OBSERVATIONS. Post 8vo. cloth, 7s. Gd. 
 
 DR. BRYCE. 
 
 ENGLAND AND FRANCE BEFORE SEBASTOPOL, looked at ; 
 
 from a Medical Point of View. 8vo. cloth, 6s.
 
 MR. CHURCHILL S PUBLICATIONS. 
 
 DR. BUDD, F.R.S. 
 
 ON DISEASES OF THE LITER. 
 
 Illustrated with Coloured Plates and Engravings on Wood. Third Edition. 8vo. cloth, 16s. 
 
 ON THE ORGANIC DISEASES AND FUNCTIONAL DIS- 
 ORDERS OF THE STOMACH. 8vo. cloth, 9s. 
 
 DR. JOHN CHARLES BUCKNILL, &, DR. DANIEL H. TUKE. 
 
 A MANUAL OF PSYCHOLOGICAL MEDICINE: containing 
 
 the History, Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of 
 Insanity. 8vo. cloth, 15s. 
 
 DR. BURGESS. 
 
 THE MEDICAL AND LEGAL RELATIONS OF MADNESS; 
 
 showing a Cellular Theory of Mind, and of Nerve Force, and also of Vegetative Vital 
 Force. 8vo. cloth, 7s. 
 
 DR. BURNETT. 
 
 THE PHILOSOPHY OF SPIRITS IN RELATION TO MATTER, 
 
 8vo. cloth, 9s. n. 
 
 INSANITY TESTED BY SCIENCE. 8vo. cloth, 5*. 
 
 DR. JOHN M. CAMPLIN, F.L.S. 
 
 ON DIABETES, AND ITS SUCCESSFUL TREATMENT. Fcap. 
 
 8vo. cloth, 3s. 
 
 MR. ROBERT B. CARTER, M.R.C.S. 
 
 ON THE INFLUENCE OF EDUCATION AND TRAINING 
 
 IN PREVENTING DISEASES OF THE NERVOUS SYSTEM. Fcap. 8vo., 6s. 
 
 THE PATHOLOGY AND TREATMENT OF HYSTERIA. Post 
 
 8vo. cloth, 4s. 6d. 
 
 DR. CARPENTER, F.R.S. 
 
 PRINCIPLES OF HUMAN PHYSIOLOGY, with numerous uius- 
 
 trations on Steel and Wood. Fifth Edition. 8vo. cloth, 26s. 
 
 PRINCIPLES OF COMPARATIVE PHYSIOLOGY, illustrated 
 
 with 300 Engravings on Wood. Fourth Edition. 8vo. cloth, 24s. 
 
 in. 
 
 A MANUAL OF PHYSIOLOGY. With numerous Illustrations on 
 
 Steel and Wood. Third Edition. Fcap. 8vo. cloth, 12s. Gd. 
 
 IV. 
 
 THE MICROSCOPE AND ITS REYELATIONS. With mime- 
 
 rous Engravings on Wood. Second Edition. Fcap. 8vo. cloth, 12s. Gd. 
 
 MR. CHARLES CHALMERS. 
 
 ELECTRO-CHEMISTRY, with Positive Ptesults; and Notes for Inquiry on 
 
 the Sciences of Geology and Astronomy: with a Tract of Miscellanies. 8vo. cloth, 3s. 6d.
 
 MR. CHURCHILL S PUBLICATIONS. 
 
 DR. CHAMBERS. 
 
 DIGESTION AND ITS DERANGMENTS. Post 8 vo. cloth, 10s. 6d 
 
 DR. G. C. CHILD. 
 
 ON INDIGESTION, AND CERTAIN BILIOUS DISORDERS 
 
 OFTEN CONJOINED WITH IT. Second Edition. 8vo. cloth, 6s. 
 
 MR. W. WHITE COOPER. 
 
 ON WOUNDS AND INJURIES OF THE EYE. illustrated b y 
 
 17 Coloured Figures and 41 Woodcuts. 8vo. cloth, 12s. 
 
 ON NEAR SIGHT, AGED "SIGHT, IMPAIRED VISION, 
 
 AND THE MEANS OF ASSISTING SIGHT. With 31 Illustrations on Wood. 
 Second Edition. Fcap. 8vo. cloth, 7s. 6d. 
 
 MR. COOPER. 
 
 A DICTIONARY OE PRACTICAL SURGERY; comprehending ail 
 
 the most interesting Improvements, from the Earliest Times down to the Present Period. 
 Seventh Edition. One very thick volume, 8vo., 11. 10s. 
 
 * Oi 
 
 MR. H. T. CHAPMAN, F.R.C.S. 
 
 THE TREATMENT OF OBSTINATE ULCERS AND CUTA- 
 
 NEOUS ERUPTIONS OF THE LEG WITHOUT CONFINEMENT. Third 
 Edition. Post 8vo. cloth, 3s. 6d. 
 
 ii. 
 
 VARICOSE VEINS : their Nature, Consequences, and Treatment, Pallia- 
 tive and Curative. Post 8vo. cloth, 3s. 6d. 
 
 MR. J. PATERSON CLARK, M.A. 
 
 THE ODONTALGIST; OR, HOW TO PRESERVE THE TEETH, 
 
 CURE TOOTHACHE, AND REGULATE DENTITION FROM INFANCY 
 TO AGE. With plates. Post 8vo. cloth, 5s. 
 
 DR. CONOLLY. 
 
 THE CONSTRUCTION AND GOVERNMENT OF LUNATIC 
 
 ASYLUMS AND HOSPITALS FOR THE INSANE. With Plans. PostSvo. 
 cloth, 6s. 
 
 5MR. COO LEY. 
 
 COMPREHENSIVE SUPPLEMENT TO THE PHARMACOPOEIAS. 
 
 $ THE CYCLOPEDIA OF PRACTICAL RECEIPTS, AND COL- $ 
 
 LATERAL INFORMATION IN THE ARTS, PROFESSIONS, MANU- 
 FACTURES, AND TRADES, INCLUDING MEDICINE, PHARMACY, AND 
 DOMESTIC ECONOMY ; designed as a Compendious Book of Reference for the 
 Manufacturer, Tradesman, Amateur, and Heads of Families. Third and greatly 
 enlarged Edition, 8vo. cloth, 26s. 
 
 SIR ASTLEY COOPER, BART., F.R.S. 
 
 ON THE STRUCTURE AND DISEASES OF THE TESTIS. 
 
 Illustrated with 24 highly finished Coloured Plates. Second Edition. Royal 4to. 
 Reduced from 3. 3s. to l. 10s.
 
 MR. CHURCHILL S PUBLICATIONS. 
 
 ^f 3o 
 
 MR. HOLMES COOTE, F.R.C.S. 
 
 * A REPORT ON SOME IMPORTANT POINTS IN THE * 
 
 TREATMENT OF SYPHILIS. 8vo. cloth, 5s. 
 
 
 V 
 
 LEWIS CORNARO. 
 
 SURE METHODS OF ATTAINING A LONG AND HEALTH- 
 
 FUL LIFE. Thirty-eighth Edition. 18mo., Is. 
 DR. COTTLE. 
 
 A MANUAL OF HUMAN PHYSIOLOGY FOR STUDENTS; 
 
 being a Condensation of the Subject, a Conservation of the Matter, and a Record of 
 Facts and Principles up to the present Day. Fcap. 8vo., 5s. 
 
 DR. COTTON. 
 
 ON CONSUMPTION: Its Nature, Symptoms, and Treatment. To 
 which Essay was awarded the Fothergillian Gold Medal of the Medical Society of 
 London. Second Edition. 8vo. cloth, 8s. 
 
 PHTHISIS AND THE STETHOSCOPE; OK, THE PHYSICAL 
 
 SIGNS OF CONSUMPTION. Second Edition. Foolscap 8vo. cloth, 3s. 
 MR. COULSON. 
 
 ON DISEASES OF THE BLADDER AND PROSTATE GLAND. 
 
 The Fifth Edition, revised and enlarged. 8vo. cloth, 10s. 6d. 
 
 II. 
 
 ON LITHOTRITY AND LITHOTOMY; with Engravings on Wood. 
 
 8vo. cloth, 8s. 
 
 MR. WILLIAM CRAIG, L.F.P.S. GLASGOW. 
 
 ON THE INFLUENCE OF VARIATIONS OF ELECTRIC 
 
 TENSION AS THE REMOTE CAUSE OF EPIDEMIC AND OTHER 
 DISEASES. 8vo. cloth, 10s. 
 
 MR. CURLING, F.R.S. 
 
 OBSERVATIONS ON DISEASES OF THE RECTUM. Second 
 
 Edition. 8vo. cloth, 5s. 
 
 A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, 
 
 SPERMATIC CORD, AND SCROTUM. Second Edition, with Additions. 8vo. 
 cloth, 14s. 
 
 MR. JOHN DALRYMPLE, F.R.S., F.R.C.S. 
 
 PATHOLOGY OF THE HUMAN EYE. Complete in Nine Fasciculi: 
 imperial 4to., 20s. each; half-bound morocco, gilt tops, 91. 15s. 
 
 DR. D A V E Y. 
 
 THE GANGLIONIC NERVOUS 1 " SYSTEM: its Structure, Functions, 
 
 and Diseases. 8vo. cloth, 9s. 
 
 ON THE NATURE AND PROXIMATE CAUSE OF IN- 
 SANITY. Post 8vo. cloth, 3s.
 
 MR. CHURCHILLS PUBLICATIONS. 
 
 DR. HERBERT DAVIES. 
 
 ON THE PHYSICAL DIAGNOSIS OF DISEASES OF THE 
 
 LUNGS AND HEART. Second Edition. Post 8vo. cloth, 8s. 
 DR. HALL DAVIS. 
 
 ILLUSTRATIONS OF DIFFICULT PARTURITION, Post 8vo. 
 
 cloth, 6s. 6d. 
 
 DR. JOHN DAVY, F.R.S. 
 
 FRAGMENTARY REMAINS, LITERARY AND SCIENTIFIC, 
 
 of SIR HUMPHREY DAVY, Bart., LL.D., late President of the Royal Society; 
 with a Sketch of his Life, and Selections from his Correspondence. 8vo. cloth, 10s. 6d. 
 
 MR. D IXO N. 
 
 A GUIDE TO THE PRACTICAL STUDY OF DISEASES OF 
 
 THE EYE. Second Edition. Post 8vo. cloth, 9s. 
 DR. DOBELL. 
 
 v DEMONSTRATIONS OF DISEASES IN THE CHEST, AND 
 
 THEIR PHYSICAL DIAGNOSIS. Illustrated with Coloured Plates. 8vo. cloth, 
 12s. 6d. 
 
 DR. TOOQOOD DOWNING. 
 
 NEURALGIA: its various Forms, Pathology, and Treatment. THE 
 JACKSONIAN PKIZE ESSAY FOR 1850. 8vo. cloth, 10s. 6d. 
 
 DR. DRUITT, F.R.C.S. 
 
 * THE SURGEON'S YADE-MECUM; with numerous Engravings on A 
 Wood. Eighth Edition. Foolscap 8vo. cloth, 1 2s. 6d. 
 
 MR. DUNN, F.R.C.S. 
 
 AN ESSAY ON PHYSIOLOGICAL PSYCHOLOGY. 8vo. cloth, 4,. 
 
 DR. JOHN C. EGAN. 
 
 SYPHILITIC DISEASES: THEIR PATHOLOGY, DIAGNOSIS, 
 
 AND TREATMENT : including Experimental Researches on Inoculation, as a Diffe- 
 rential Agent in Testing the Character of these Affections. 8vo. cloth, 9s. 
 
 SIR JAMES EYRE, M. D. 
 
 THE STOMACH AND ITS DIFFICULTIES. Fourth Edition. 
 
 Fcap. 8vo. cloth, 2s. 6d. 
 
 PRACTICAL REMARKS ON" SOME EXHAUSTING DIS- 
 
 EASES. Second Edition. Post 8vo. cloth, 4s. 6d. 
 DR. FENWICK. 
 
 ON SCROFULA AND CONSUMPTION. Clergyman's Sore Throat, 
 Catarrh, Croup, Bronchitis, Asthma. Fcap. 8vo., 2s. 6d.
 
 MR. CHURCHILL S PUBLICATIONS. 
 
 MR. FERGUSSON, F.R.S. 
 
 A SYSTEM OF PRACTICAL SURGERY; with numerous nius- 
 
 trations on Wood. Fourth Edition. Fcap. 8vo. cloth, 12s. 6d. 
 
 SIR JOHN FORBES, M.D., D.C.L. (OXON.), F.R.S. 
 
 NATURE AND ART IN THE CURE OF DISEASE. Second 
 
 Edition. Post 8vo. cloth, 6s. 
 
 MR. FOWNES, PH.D., F.R.S. 
 
 I. 
 
 A MANUAL OF CHEMISTRY; with numerous Illustrations on Wood. 
 
 Seventh Edition. Fcap. 8vo. cloth, 12s. 6d. 
 Edited by H. BENCE JONES, M.D., F.R.S., and A. W. HOFMANN, Pn.D., F.R.S. 
 
 CHEMISTRY, AS EXEMPLIFYING THE WISDOM AND 
 
 BENEFICENCE OF GOD. Second Edition. Fcap. 8vo. cloth, 4s. 6d. 
 
 in. 
 
 INTRODUCTION TO QUALITATIVE ANALYSIS. Post 8vo. cloth, 2*. 
 
 DR. D. J. T. FRANCIS. 
 
 CHANGE OF CLIMATE ; considered as a Remedy in Dyspeptic, Pul- 
 
 monary, and other Chronic Affections; with an Account of the most Eligible Places of 
 Residence for Invalids in Spain, Portugal, Algeria, &c., at different Seasons of the Year; 
 and an Appendix on the Mineral Springs of the Pyrenees, Vichy, and Aix les Bains. 
 Post 8vo. cloth, 8s. 6d. 
 
 DR. PATRICK FRASER. 
 
 A TREATISE UPON PENETRATING WOUNDS OF THE 
 
 CHEST. 8vo. cloth, 5s. 
 
 C. REMIGIUS FRESENIUS. 
 
 ELEMENTARY INSTRUCTION IN CHEMICAL ANALYSIS, 
 
 AS PRACTISED IN THE LABORATORY OF GIESSEN. Edited by LLOYD 
 BULLOCK, F.C.S. 
 
 QUALITATIVE. Fifth Edition. 8vo. cloth, 9s. 
 QUANTITATIVE. Second Edition. 8vo. cloth, 15s. 
 
 DR. FULLER. 
 
 ON RHEUMATISM, RHEUMATIC GOUT, AND SCIATICA: 
 
 their Pathology, Symptoms, and Treatment. Second Edition. 8vo. cloth, 12s. 6d. 
 
 DR. GAIRDNER. 
 
 ON GOUT ; its History, its Causes, and its Cure. Third Edition. Post 
 
 8vo. cloth, 8s. 6d. 
 
 MR. GALLOWAY. 
 
 THE FIRST STEP IN CHEMISTRY. Second Edition. Fcap. Svo. 
 
 cloth, 5s. 
 
 II. 
 
 A MANUAL OF QUALITATIVE ANALYSIS. Second Edition. 
 
 Post 8vo. cloth, 4s. 6d.
 
 MR. CHURCHILLS PUBLICATIONS. 13 
 
 MR. F. J. GANT. 
 
 THE IRRITABLE BLADDER : its Causes and Curative Treatment. 
 
 Post 8vo. cloth, 4s. Gd. 
 
 MR. ROBERT GARNER, F.L.S. 
 
 EUTHERAPEIA; or, AN EXAMINATION OF THE PEINCIPLES 
 
 OF MEDICAL SCIENCE, including Researches on the Nervous System. Illustrated 
 with 9 Engravings on Copper, and Engravings on Wood. 8vo. cloth, 8s. 
 
 DR. GRANVILLE, F.R.S. 
 
 THE MINERAL SPRINGS OF VICHY : their Efficacy in the 
 
 Treatment of Gout, Indigestion, Gravel, c. 8vo. cloth, 5s, 
 
 ON SUDDEN DEAm^Post 8vo., 2*. 6rf. 
 
 MR. GRAY, M.R.C.S. 
 
 PRESERVATION OE THE TEETH indispensable to Comfort and 
 
 Appearance, Health, and Longevity. 18mo. cloth, 3s. 
 
 MR. GRIFFITHS. 
 
 CHEMISTRY OF THE FOUR SEASONS -Spring, Summer, 
 
 Autumn, Winter. Illustrated with Engravings on Wood. Second Edition. Foolscap 
 8vo. cloth, 7s. 6d. 
 
 DR. GULLY. 
 
 THE SIMPLE TREATMENT OF DISEASE; deduced from the 
 
 Methods of Expectancy and Revulsion. 18mo. cloth, 4s. 
 
 DR. GUY. 
 
 HOOPER'S PHYSICIAN'S VADE-MECUM; OR, MANUAL OF 
 
 THE PRINCIPLES AND PRACTICE OF PHYSIC. New Edition, considerably 
 enlarged, and rewritten. Foolscap 8vo. cloth, 12s. 6d. 
 
 GUY'S HOSPITAL REPORTS. Third Series. Vols. I. to V., 8vo., 
 
 7s. 6d. each. 
 
 DR. HABERSHON. 
 
 OBSERVATIONS ON DISEASES OF THE ALIMENTARY 
 
 CANAL, (ESOPHAGUS, STOMACH, CAECUM, and INTESTINES. 8vo. cloth, 
 10s. 6d. 
 
 DR. MARSHALL HALL, F.R.S. 
 
 PRONE AND POSTURAL RESPIRATION IN DROWNING 
 
 AND OTHER FORMS OF APNCEA OR SUSPENDED RESPIRATION. 
 Post 8vo. cloth. 5s. 
 
 PRACTICAL OBSERVATIONS AND SUGGESTIONS IN MEDI- 
 
 CINE. SeronU Series. Post 8\-o. cloth, 8s. 6d. 
 -<^ *s-
 
 14 MR. CHURCHILL S PUBLICATIONS. 
 
 DR. C. RADCLYFFE HALL. 
 
 TORQUAY IN ITS MEDICAL ASPECT AS A RESORT FOR 
 
 PULMONARY INVALIDS. Post 8vo. cloth, 5s. 
 MR. HARDWICH. 
 
 A MANUAL OF PHOTOGRAPHIC CHEMISTRY. Fifth 
 
 Edition. Foolscap 8vo. cloth, 7s. 6d. 
 
 MR. HARE, M.R.C.S. 
 
 PRACTICAL OBSERVATIONS ON THE PREVENTION, 
 
 CAUSES, AND TREATMENT OF CURVATURES OF THE SPINE; with 
 Engravings. Third Edition. 8vo. cloth, 6s. 
 
 MR. HARRISON, F.R.C.S. 
 
 THE PATHOLOGY AND TREATMENT OF STRICTURE OF 
 
 THE URETHRA. Second Edition. 8vo. cloth, 5s. 
 
 MR. JAMES B. HARRISON, F.R.C.S. 
 
 ON THE CONTAMINATION OF WATER BY THE POISON 
 
 OF LEAD, and its Effects on the Human Body. Foolscap 8vo. cloth, 3s. 6d. 
 
 DR. HARTWIQ. 
 L 
 
 ON SEA BATHING AND SEA AIR. Fcap. 8vo., 2*. e* 
 
 ii. 
 
 ON THE PHYSICAL EDUCATION OF CHILDREN, Fcap. 
 
 8vo., 2s. 6d. 
 
 DR. A. H. HASSALL. 
 I. 
 
 THE MICROSCOPIC ANATOMY OF THE HUMAN BODY, 
 
 IN HEALTH AND DISEASE. Illustrated with Several Hundred Drawings in 
 Colour. Two vols. 8vo. cloth, 1. 10s. 
 
 ii. 
 
 THE URINE, IN HEALTH AND DISEASE ; or, a Simple EX- 
 
 planation of the Physical Properties, Composition, and Uses of the Urine, of the Functions 
 of the Kidneys, and of the Treatment of Urinary Disorders. With Twenty-four En- 
 gravings. Post 8vo. cloth, 5s. 
 
 MR. ALFRED HAVILAND, M.R.C.S. 
 
 CLIMATE, WEATHER, AND DISEASE; being a Sketch of the 
 
 Opinions of the most celebrated Ancient and Modern Writers with regard to the Influence 
 of Climate and Weather in producing Disease. With Four coloured Engravings. 8vo 
 cloth, 7s. 
 
 MR. WILLIAM HAYCOCK, M.R.C.V.S. 
 
 i A TREATISE ON THE PRINCIPLES AND PRACTICE OF 
 
 VETERINARY MEDICINE AND SURGERY. 8vo. boards, 6s. 6rf.
 
 MR. CHURCHILLS PUBLICATIONS. 
 
 DR. HEADLAND. 
 
 ON THE ACTION OF MEDICINES IN THE SYSTEM. 
 
 Being the Prize Essay to which the Medical Society of London awarded the Fother- 
 gillian Gold Medal for 1852. Third Edition. 8vo. cloth, 12s. 6d. 
 
 DR. HEALE. 
 
 A TREATISE ON YITAL^CAUSES. 8vo. cloth, 9,. 
 
 MR. HIGGINBOTTOM, F.R.S., F.R.C.S. 
 
 AN ESSAY ON THE USE OF THE NITRATE OF SILVER 
 
 IN THE CURE OF INFLAMMATION, WOUNDS, AND ULCERS. Second 
 Edition. Price 5s. 
 
 ADDITIONAL OBSERVATIONS ON THE NITRATE OF SIL- 
 
 VER; with full Directions for its Use as a Therapeutic Agent. 8vo., 2s. 6d. 
 MR. JOHN HILTON, F.R.S. 
 
 ON THE DEVELOPMENT AND DESIGN OF CERTAIN POR- 
 
 TIONS OF THE CRANIUM. Illustrated with Plates in Lithography. 8vo. cloth, 6s. 
 DR. HINDS. 
 
 THE HARMONIES OF PHYSICAL SCIENCE IN RELATION 
 
 TO THE HIGHER SENTIMENTS; with Observations on Medical Studies, and on 
 the Moral and Scientific Relations of Medical Life. Post 8vo., cloth, 4s. 
 
 DR. DECIMUS HODGSON. 
 
 THE PROSTATE GLAND, AND ITS ENLARGEMENT IN * 
 
 OLD AGE. With 12 Plates. Royal 8vo., cloth, 6s. 
 MR. JABEZ HOGG. 
 
 THE OPHTHALMOSCOPE : an Essay on its value in the Exploration 
 of Internal Eye Diseases. Second Edition. Cloth, 3s. 6d. 
 
 MR. LUTHER HOLDEN, F.R.C.S. 
 L 
 
 HUMAN OSTEOLOGY : with Plates, showing the Attachments of the 
 Muscles. Second Edition. 8vo. cloth, 16s. 
 
 A MANUAL OF THE DISSECTION OF THE HUMAN BODY. 
 
 12mo. cloth, 14s. 
 
 MR. C. HOLTHOUSE. 
 L 
 
 ON SQUINTING, PARALYTIC AFFECTIONS OF THE EYE, 
 
 and CERTAIN FORMS OF IMPAIRED VISION. Fcap. 8vo. cloth, 4s. 6d. 
 
 LECTURES ON STRABISMUS^delivered at the Westminster Hospital. 
 
 8vo. cloth, 4s.
 
 MR. CHURCHILL S PUBLICATIONS. 
 
 DR. W. CHARLES HOOD. 
 
 SUGGESTIONS FOR THE FUTURE PROVISION OF CRIMI- 
 NAL LUNATICS. 8vo. cloth, 5s. 6d. 
 
 MR. P. HOOD. 
 
 THE SUCCESSFUL TREATMENT OF SCARLET FEYER; 
 
 also, OBSERVATIONS ON THE PATHOLOGY AND TREATMENT OF 
 CROWING INSPIRATIONS OF INFANTS. Post 8vo. cloth, 5s. 
 
 DR. HOOPER. 
 
 THE MEDICAL DICTIONARY; containing an Explanation of the 
 Terms used in Medicine and the Collateral Sciences. Eighth Edition. Edited by 
 KLEIN GRANT, M.D. 8vo. cloth, 30s. 
 
 MR. JOHN HORSLEY. 
 
 A CATECHISM OF CHEMICAL PHILOSOPHY; being a Familiar 
 
 Exposition of the Principles of Chemistry and Physics. With Engravings on Wood. 
 Designed for the Use of Schools and Private Teachers. Post 8vo. cloth, 6s. 6d. 
 
 DR. HUFELAND. 
 
 THE ART OF PROLONGING LIFE. Second Edition. Edited 
 
 by ERASMUS WILSON, F.R.S. Foolscap 8vo., 2s. 6d. 
 
 DR. VAUQHAN HUGHES. 
 
 BLOOD DISEASE, Crown 8vo. cloth, 4s. Gd. 
 
 MR. W. CURTIS HUGMAN, F.R.C.S. 
 
 ON HIP- JOINT DISEASE; with reference especially to Treatment 
 
 by Mechanical Means for the Relief of Contraction and Deformity of the Affected Limb 
 8vo. cloth, 3s. 6d. 
 
 DR. HENRY HUNT. 
 
 ON HEARTBURN AND INDIGESTION. 8vo. doth, 5*. 
 
 DR. INMAN. 
 
 THE PHENOMENA OF SPINAL IRRITATION AND OTHER 
 
 FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM EXPLAINED 
 and a Rational Plan of Treatment deduced. With Plates. 8vo. cloth, 6s. 
 
 DR. ARTHUR JACOB, F.R.C.S. 
 
 A TREATISE ON THE INFLAMMATIONS OF THE EYE-BALL. 
 
 Foolscap 8vo. cloth, 5s. 
 
 DR. JAMES JAGO, A.B., CANTAB.; M.B., OXON 
 
 OC ? S S Am STRUCTURES AS MUTUAL EXPO- 
 
 I b. Illustrated with Engravings on Wood. 8vo. cloth, 5s.
 
 MR. CHURCHILL S PUBLICATIONS. 17 
 
 MR. J. H. JAMES, F.R.C.S. 
 
 PRACTICAL OBSERVATIONS ON THE OPERATIONS FOR 
 
 STRANGULATED HERNIA. 8vo. cloth, 5s. 
 
 DR. BENCE JONES, F.R.S. 
 
 MULDER ON WINE. Foolscap 8vo. doth, 6*. 
 
 II. 
 
 ON ANIMAL CHEMISTRY, in its relation to STOMACH and RENAL 
 DISEASES. 8vo. cloth, 6s. 
 
 DR. HANDFIELD JONES, F.R.S., &, DR. EDWARD H. SIEVEKINQ. 
 
 A MANUAL OF PATHOLOGICAL ANATOMY, illustrated with 
 
 numerous Engravings on Wood. Foolscap 8vo. cloth, 12s. 6d. 
 
 MR. WHARTON JONES, F.R.S. 
 
 A MANUAL OF THE PRINCIPLES AND PRACTICE OF 
 
 OPHTHALMIC MEDICINE AND SURGERY; illustrated with Engravings, plain 
 and coloured. Second Edition. Foolscap 8vo. cloth, 12s. 6<f. 
 
 THE WISDOM AND BENEFICENCE OF THE ALMIGHTY, 
 
 AS DISPLAYED IN THE SENSE OF VISION; being the Actonian Prize Essay 
 for 1851. With Illustrations on Steel and Wood. Foolscap 8vo. cloth, 4s. 6d. 
 
 in. 
 
 DEFECTS OF SIGHT : their Nature, Causes, Prevention, and General 
 
 Management. Fcap. 8vo. 2s. 6d. 
 
 A CATECHISM OF THE MEDICINE AND SURGERY OF 
 
 THE EYE AND EAR. For the Clinical Use of Hospital Students. Fcap. 8vo. 2s. Gd. 
 
 A CATECHISM OF THE PHYSIOLOGY AND PHILOSOPHY 
 
 OF BODY, SENSE, AND MIND. For Use in Schools and Colleges. Fcap. 8vo., 
 2s. Qd. 
 
 MR. FURNEAUX JORDAN, M.R.C.S. 
 
 AN INTRODUCTION TO CLINICAL SURGERY; WITH A 
 
 Method of Investigating and Reporting Surgical Cases. Fcap. 8vo. cloth, 5s. 
 
 MR. JUDO. 
 
 A PRACTICAL TREATISE ON URETHRITIS AND SYPHI- 
 
 LIS : including Observations on the Power of the Menstruous Fluid, and of the Dis- 
 charge from Leucorrhoea and Sores to produce Urethritis: with a variety of Examples, 
 Experiments, Remedies, and Cures. 8vo. cloth, 1. 5s. 
 
 DR. LAENNEC. 
 
 A MANUAL OF AUSCULTATION AND PERCUSSION, Trans- 
 
 lated and Edited by J. B. SHAIIPE, M.R.C.S. 3s. 
 
 ri 
 
 b
 
 Jf 18 MR. CHURCHILL S PUBLICATIONS. 
 
 DR. HUNTER LANE, F.L.S. 
 
 A COMPENDIUM OF MATEEIA MEDICA AND PHARMACY; 
 
 adapted to the London Pharmacopoeia, 1851, embodying all the new French, American, 
 and Indian Medicines, and also comprising a Summary of Practical Toxicology Second 
 Edition. 24mo. cloth, 5s. M. 
 
 _ DR. LANE, M.A. 
 
 HYDROPATHY; OR, HYGIENIC MEDICINE, An Explanatory 
 
 Essay. Second Edition. Post Svo. cloth, 5s. 
 
 MR. LAURENCE, M.B., F.R C S 
 
 THE DIAGNOSIS OF SURGICAL CANCER.' The Lhton Prize 
 
 Essay for 1854. Second Edition. Plates, 8vo. cloth, 7s. (JJ. 
 MR. LAWRENCE, F.R S 
 
 A TREATISE ON RUPTURES. The Fifth Edition, considerably 
 
 enlarged. 8vo. cloth, 1 6s. 
 
 DR. EDWIN LEE. 
 I. 
 
 * THE EFFECT OF CLIMATE ON TUBERCULOUS DISEASE, 
 
 with Notices of the chief Foreign Places of Winter Resort. Small Svo. cloth, 5s. 6d. 
 
 THE WATERING PLACES OF ENGLAND, CONSIDERED 
 
 with^ Reference to their Medical Topography. Fourth Edition. Foolscap 8vo. cloth, 
 
 HI. 
 
 * BATHS OF GERMANY, FIUXCE - & SWITZERLAND. 
 
 Third Edition. Post 8vo. cloth, 8s. 6J. 
 
 THE BATHS OF RHENISH GERMANY. Post Svo. cloth, 4*. 
 HOMEOPATHY AND HYDROPATHY IMPARTIALLY AP- 
 
 PRECIATED. With Notes illustrative of the Influence of the Mind over the Body 
 Fourth Edition. Post Svo. cloth, 3*-. 6</. 
 
 DR. ROBERT LEE, F.R.S. 
 
 A TREATISE ON THE SPECULUM; with Three Hundred Ca 
 
 Svo. cloth, 4s. 6cf. 
 
 CLINICAL REPORTS OF OVARIAN AND UTERINE DIS- 
 
 EASES, with Commentaries. Foolscap Svo. cloth, 6s. 6J. 
 
 HI. 
 
 CLINICAL MIDWIFERY: comprising the Histories of 545 Case* of 
 
 D,rticult, Preternatural, and Complicated Labour, with Commentaries. Second Edition. 
 foolscap Svo. cloth, os. 
 
 Or IHL H 
 
 Plates. Two Parts. Imperial 4to^ 7s. 6d. each Part. 
 
 MR. LISTON, F.R.S. y 
 
 PRACTICAL- SURGERY. Fourth Editioo. 8>-o. cloth, -2^.
 
 MR. CHURCHILLS PUBLICATIONS. 19 
 
 MR. H. W. LOBB, L.S.A., M.R.C.S.E. 
 
 ON SOME OF THE MORE OBSCURE FORMS OF NERVOUS 
 
 AFFECTIONS, THEIR PATHOLOGY AND TREATMENT. With an 
 Introduction on the Physiology of Digestion and Assimilation, and the Generation and 
 Distribution of Nerve Force. Based upon Original Microscopical Observations. With 
 Engravings. 8vo. cloth, 10s. 6d. 
 
 LONDON MEDICAL SOCIETY OF OBSERVATION. 
 
 WHAT TO OBSERVE AT THE BED-SIDE, AND AFTER 
 
 DEATH. Published by Authority. Second Edition. Foolscap 8vo. cloth, 4s. (id. 
 M. LUGOL. 
 
 ON SCROFULOUS DISEASES. Translated from the French, with 
 Additions by W. H. RANKING, M.D., Physician to the Suffolk General Hospital. 
 8 vo. cloth, 10s. 6d. 
 
 MR. M'CLELLAND, F.L.S., F.G.S. 
 
 SKETCH OF THE MEDICAL TOPOGRAPHY, OR CLIMATE 
 
 AND SOILS, OF BENGAL AND THE N. W. PROVINCES. Post 8vo. 
 cloth, 4s. 6rf. 
 
 DR. GEORGE H. B. MACLEOD, F.R.C.S. (EDIN.) 
 
 NOTES ON THE SURGERY OF THE CRIMEAN WAR; with 
 
 REMARKS on GUN-SHOT WOUNDS. 8vo. cloth, 10s. 6d. 
 
 MR. JOSEPH MACLISE, F.R.C.S. 
 I. 
 
 SURGICAL ANATOMY. A Series of Dissections, illustrating the Prin- 
 cipal Regions of the Human Body. 
 
 The Second Edition, complete in XIII. Fasciculi, imperial folio, 5s. each. Bound in 
 cloth, 3. 12s.; or in morocco, 4. 4s. 
 
 ON DISLOCATIONS AND FRACTURES. This Work is Uniform 
 
 with the Author's " Surgical Anatomy;" each Fasciculus contains Four beautifully 
 executed Lithographic Drawings. Complete in Nine Fasciculi, imperial folio, 5s. each. 
 Bound in cloth, 2. 10s.; or in morocco, 2. 15*. 
 
 DR. MARCET. 
 
 ON THE COMPOSITION OF FOOD, AND HOW IT IS 
 
 ADULTERATED ; with Practical Directions for its Analysis. 8vo. cloth, 6s. 6d. 
 
 DR. MARTIN. 
 
 THE UNDERCLIFF, ISLE OF WIGHT: its Climate, History, 
 
 and Natural Productions. Post 8vo. cloth, 1 Os. 6d. 
 
 DR. MARKHAM. 
 I. 
 
 DISEASES OF THE HEART : THEIR PATHOLOGY, DIAG- 
 
 NOSIS, AND TREATMENT. Post. 8vo. cloth, 6s. 
 
 ii. 
 
 SKODA ON AUSCULTATION AND PERCUSSION. Post SVG. 
 
 cloth, 6s. 
 
 -*
 
 20 MR. CHURCHILL'S PUBLICATIONS. 
 
 MR. J. RANALD MARTIN, F.R.S. 
 
 THE INFLUENCE OF TROPICAL CLIMATES ON EUEO- 
 
 PEAN CONSTITUTIONS. Originally by the late JAMES JOHNSON, M.D., and now 
 entirely rewritten ; including Practical Observations on the Diseases of European Invalids 
 on their Return from Tropical Climates. Seventh Edition. 8vo. cloth, 16s. 
 
 DR. MASSY. 
 
 ON THE EXAMINATION OF RECRUITS; intended for the Use of 
 
 Young Medical Officers on Entering the Army. 8vo. cloth, 5s. 
 
 D R. MAYNE. 
 
 AN EXPOSITORY LEXICON OF THE TERMS, ANCIENT 
 
 AND MODERN, IN MEDICAL AND GENERAL SCIENCE, including a com- 
 plete MEDICAL AND MEDICO-LEGAL VOCABULARY, and presenting the 
 correct Pronunciation, Derivation, Definition, and Explanation of the Names, Analogues, 
 Synonymes, and Phrases (in English, Latin, Greek, French, and German,) employed in 
 Science and connected with Medicine. Parts I. to VIII., price 5s. each. 
 
 MR. MAUNDER, F.R.C.S. 
 
 A RICORD'S LECTURES ON CHANCRE. With Remarks on Perinaeal 
 | -Section of Stricture of the Urethra. 8vo. cloth, 8s. 
 
 ?DR. MILLINGEN. 
 . ON THE TREATMENT AND MANAGEMENT OF THE IN- 
 
 ffl SANE; with Considerations on Public and Private Lunatic Asylums. 18mo. cloth, (> 
 
 4s. 6d. 
 
 MR. JOHN L. MILTON, M.R.C.S. 
 
 PRACTICAL OBSERVATIONS ON A NEW WAY OF 
 
 TREATING GONORRH(EA. With some Remarks on the Cure of Inveterate Cases. 
 8vo. cloth, 5s. 
 
 DR. MONRO. 
 I. 
 
 REMARKS ON INSANITY : its Nature and Treatment. 8vo. cloth, 6s. 
 
 REFORM IN PRIVATE LUNATIC ASYLUMS. 8vo. cloth, 4,. 
 
 DR. NOB LE. 
 
 ELEMENTS OF PSYCHOLOGICAL MEDICINE: AN INTRO- 
 DUCTION TO THE PRACTICAL STUDY OF INSANITY. Second Edition. 8vo. 
 cloth, 10s. 
 
 HUMAN MIND IN ITS RELATIONS WITH THE 
 
 BRAIN AND NERVOUS SYSTEM. Post 8vo. cloth, 4s. 6d.
 
 MR. CHURCHILLS PUBLICATIONS. 21 
 
 MR. NOURSE, M.R.C.S. 
 
 TABLES FOE STUDENTS. Price One Shilling the Set. 
 
 1. Divisions and Classes of the Animal Kingdom. 
 
 2. Classes and Orders of the Vertebrate Sub-kingdom. 
 
 3. Classes of the Vegetable Kingdom, according to the Natural and Artificial Systems. 
 
 4. Table of the Elements, with their Chemical Equivalents and Symbols. 
 
 MR. NUNNELEY, F.R.C.S.E. 
 I. 
 
 ON THE ORGANS OF VISION: THEIR ANATOMY AND PHY- 
 
 SIOLOGY. With Plates, 8vo. cloth, 15s. 
 
 A TREATISE ON THE NATURE, CAUSES, AND TREATMENT 
 
 OF ERYSIPELAS. 8vo. cloth, 10s. 6d. 
 
 DR. ODUNQ. 
 
 A COURSE OF PRACTICAL CHEMISTRY, FOR THE USE 
 
 OF MEDICAL STUDENTS. Arranged with express reference to the Three Months 1 
 Summer Course. Post 8vo. cloth, 4s. 6d. 
 
 TRANSACTIONS OF THE ODONTOLOGICAL SOCIETY OF 
 
 LONDON. With Plates. Vol. I., 8vo. cloth, 8s. 6d. 
 MR. P A Q E T. 
 
 A DESCRIPTIVE CATALOGUE OF THE ANATOMICAL 
 
 MUSEUM OF ST. BARTHOLOMEW'S HOSPITAL. VOL. I. Morbid Anatomy. 
 8vo. cloth, 5s. 
 
 DITTO. Vol. II. Natural and Congenitally Malformed Structures, and Lists of the 
 Models, Casts, Drawings, and Diagrams. 5s. 
 
 MR. LANGSTON PARKER. 
 
 THE MODERN TREATMENT OF SYPHILITIC DISEASES, 
 
 both Primary and Secondary; comprising the Treatment of Constitutional and Confirmed 
 Syphilis, by a safe and successful Method. Third Edition, 8vo. cloth, 10s. 
 
 DR. PARKIN. 
 
 THE CAUSATION AND PREVENTION OF DISEASE. 
 
 8vo. cloth, 5s. 
 MR. JAMES PART, F.R.C.S. 
 
 THE MEDICAL AND SURGICAL POCKET CASE BOOK, 
 
 for the Registration of important Cases in Private Practice, and to assist the Student of 
 Hospital Practice. Second Edition. 3s. 6d. 
 
 ON THE INFLUENZA, OR EPIDEMIC CATARRHAL FEVER 
 
 OF 1847-8. 8vo. cloth, 5s. 6d. 
 
 < 
 DR. THOMAS B. PEACOCK. M.D.
 
 e>t --- - - 
 
 22 MR. CHURCHILL'S PUBLICATIONS. 
 
 MR. OLIVER PEMBERTON, M.R.C.S. 
 
 OBSERVATIONS ON THE HISTORY, PATHOLOGY, AND 
 
 TREATMENT OF CANCEROUS DISEASES. Part I. MELANOSIS. With 
 coloured Plates. Royal 8vo. cloth, 4s. 6d. 
 
 DR. PEREIRA, F.R.S. 
 
 SELECTA E PR^SCRIPTIS : with a Key, containing the Prescriptions 
 
 in an Unabbreviated Form, and a Literal Translation. Twelfth Edition. 24mo. cloth, 5s. 
 MR. PETTIGREW, F.R.S. 
 
 ON SUPERSTITIONS connected with the History and Practice of 
 
 Medicine and Surgery. 8vo. cloth, 7s. 
 
 DR. PICKFORD. 
 
 HYGIENE; or, Health as Depending upon the Conditions of the Atmo- 
 sphere, Food and Drinks, Motion and Rest, Sleep and Wakefulness, Secretions, 
 Excretions, and Retentions, Mental Emotions, Clothing, Bathing, &c. 8vo. cloth, 9s. 
 
 MR. PIRRIE, F.R.S.E. 
 
 THE PRINCIPLES AND PRACTICE OF SURGERY, With 
 
 numerous Engravings on Wood. 8vo. cloth, 21s. 
 
 . PHARMACOPEIA COLLEGII REGALIS MEDICORUM LON- 
 
 DINENSIS. 8vo. cloth, 9s.; or 24mo. 5s. 
 IMPRIMATUR. 
 
 Hie liber, cui titulus, PHARMACOPEIA COLLEGII REGALIS MEDICORUM LONDINENSIS. 
 Datum ex ^Edibus Collegii in comitiis censoriis, Novembris Mensis 14 to 1850. 
 
 JOHANNES AYRTON PARIS. Prases. 
 
 PROFESSORS PLATTNER &, MUSPRATT. 
 
 THE USE OF THE BLOWPIPE IN THE EXAMINATION OF 
 
 MINERALS, ORES, AND OTHER METALLIC COMBINATIONS. Illustrated 
 by numerous Engravings on Wood. Third Edition. 8vo. cloth, 10s. 6d. 
 
 THE PRESCRIBER'S PHARMACOPOEIA ; containing all the Medi- 
 
 cines in the London Pharmacopeia, arranged in Classes according to their Action, with 
 their Composition and Doses. By a Practising Physician. Fourth Edition. 32mo. 
 cloth, 2s. 6rf.; roan tuck (for the pocket), 3s. 6d. 
 
 DR. JOHN ROWLISON PRETTY. 
 
 AIDS DURING LABOUR, including the Administration of Chloroform, 
 the Management of Placenta and Post-partum Hsemorrhage. Fcap. 8vo. cloth, 4s. 6d. 
 
 MR. LAKE PRICE. 
 
 PHOTOGRAPHIC MANIPULATION: Treating of the Practice of 
 
 the Art, and its various appliances to Nature. With Fifty Engravings on Wood. Post 
 ovo. cloth, 6s. 6d.
 
 MR. CHURCHILLS PUBLICATIONS. 23 
 
 SIR WM. PYM, K.C.H. 
 
 OBSERVATIONS UPON YELLOW FEVER, with a Review of 
 
 "A Report upon the Diseases of the African Coast, by Sir WM. BURNETT and 
 Dr. BRYSON," proving its highly Contagious Powers. Post 8vo. 6s. 
 
 DR. RADCLIFFE. 
 
 EPILEPSY, AND OTHER CONVULSIVE AFFECTIONS; their 
 
 Pathology and Treatment. Second Edition. Post 8vo. cloth, 7s. Gd. 
 MR. R A I N E Y. 
 
 ON THE MODE OF FORMATION OF SHELLS OF ANIMALS, 
 
 OF BONE, AND OF SEVERAL OTHER STRUCTURES, by a Process of 
 Molecular Coalescence, Demonstrable in certain Artificially-formed Products. Fcap. 8vo. 
 cloth, 4$. Gd. 
 
 DR. F. H. RAMSBOTHAM. 
 
 THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 
 
 CINE AND SURGERY. Illustrated with One Hundred and Twenty Plates on Steel 
 and Wood; forming one thick handsome volume. Fourth Edition. 8vo. cloth, 22s. 
 
 DR. RAMSBOTHAM. 
 
 PRACTICAL OBSERVATIONS ON MIDWIFERY, with a Selection 
 
 of Cases. Second Edition. 8vo. cloth, 12s. 
 
 DR. DU BOIS REYMOND. 
 
 ANIMAL ELECTRICITY ; Edited by H. BENCE JONES, M.D., F.R.S. 
 
 With Fifty Engravings on Wood. Foolscap 8vo. cloth, 6s. 
 DR. REYNOLDS. 
 
 THE DIAGNOSIS OF DISEASES OF THE BRAIN, SPINAL 
 
 CORD, AND THEIR APPENDAGES. 8vo. cloth, 8s. 
 
 DR. B. W. RICHARDSON. 
 
 ON THE CAUSE OF THE COAGULATION OF THE BLOOD, 
 
 Being the ASTLEY COOPER PRIZE ESSAY for 1856. With a Practical Appendix. 
 8vo. cloth, 16s. 
 
 THE HYGIENIC TREATMENT OF PULMONARY CONSUMP- 
 TION. 8vo. cloth, 5s. 6d. 
 
 MR. ROBERTON. 
 
 ON THE PHYSIOLOGY AND DISEASES OF WOMEN, AND 
 
 ON PRACTICAL MIDWIFERY. 8vo. cloth, 12s. 
 
 MR WILLIAM ROBERTS. 
 
 AN ESSAY ON WASTING PALSY; being a Systematic Treatise on 
 the Disease hitherto described as ATROPHIE MUSCULAIRE PROGRESSIVE. 
 With Four Plates. 8vo. cloth, 7s. 6d.
 
 24 MR. CHURCHILLS PUBLICATIONS. 
 
 DR. W. H. ROBERTSON. 
 I. 
 
 THE NATURE AND TREATMENT OE GOUT. 
 
 8vo. cloth, 10*. 6d. 
 ii. 
 
 A TREATISE ON DIET AND REGIMEN, 
 
 Fourth Edition. 2 TO!S. post STO. cloth, 12. 
 
 DR. ROWE, F.S.A. 
 
 I, 
 
 ON SOME OF THE MORE IMPORTANT DISEASES OF 
 
 WOMEN and CHILDREN. Second Edition. Fcap. 8vo. cloth, 4s. d. 
 
 n. 
 
 NERVOUS DISEASES, LITER AND STOMACH COM- 
 
 PLAINTS, LOW SPIRITS, INDIGESTION, GOUT, ASTHMA, AND DIS- 
 ORDERS PRODUCED BY TROPICAL CLIMATES. With Cases. Fifteenth y 
 Edition. Fcap. STO. 2*. 6d. 
 
 DR. ROYLE, F.R.S. 
 
 A MANUAL OF MATERIA MEDICA AND THERAPEUTICS. 
 
 With numerous Engravings on Wood. Third Edition. Fcap. 8vo. cloth, 12*. 6d. 
 
 MR. RUMSEY, F.R.C.S. 
 
 ESSAYS ON STATE MEDICINE, 8vo. cloth, 10*. u. 
 
 MR. SAVORY. 
 
 A COMPENDIUM OF DOMESTIC MEDICINE, AND COMPA- 
 
 NION TO THE MEDICINE CHEST ; comprising Plain Directions for the Employ- 
 ment of Medicines, with their Properties and Doses, and Brief Descriptions of the 
 Symptoms and Treatment of Diseases, and of the Disorders incidental to Infants and 
 Children, with a Selection of the most efficacious Prescriptions. Intended as a Source 
 of Easy Reference for Clergymen, and for Families residing at a Distance from Profes- 
 sional Assistance. Fifth Edition. 12mo. cloth, 5s. 
 
 DR. SCHACHT. 
 
 THE MICROSCOPE, AND ITS APPLICATION TO VEGETABLE 
 
 ANATOMY AND PHYSIOLOGY. Edited by FREDERICK CURREY, M.A. Fcap. 
 8vo. cloth, 6s. 
 
 DR. SEMPLE. 
 
 ON >UGH : its Causes, Varieties, and Treatment. With some practical 
 
 Remarks on the Use of the Stethoscope as an aid to Diagnosis. Post 8vo. cloth, 4s. 6d.
 
 MR. CHURCHILL S PUBLICATIONS. 25 
 
 MR. SHAW, M.R.C.S. 
 
 THE MEDICAL REMEMBRANCER ; OR, BOOK OF EMER- 
 
 GENCIES: in which are concisely pointed out the Immediate Remedies to be adopted 
 in the First Moments of Danger from Poisoning, Apoplexy, Burns, and other 
 Accidents; with the Tests for the Principal Poisons, and other useful Information. 
 Fourth Edition. Edited, with Additions, by JONATHAN HUTCHINSON, M.R.C.S. 32mo. 
 cloth, 2s. 6d. 
 
 DR. SIBSON, F.R.S. 
 
 MEDICAL ANATOMY. With coloured Plates. Imperial folio. Fasci- 
 
 culi I. to V. 5s. each. 
 
 DR. E. H. SIEVEKING. 
 
 ON EPILEPSY AND EPILEPTIFORM SEIZURES: their 
 
 Causes, Pathology, and Treatment. Post 8vo. cloth, 7s. 6d. 
 
 MR. SINCLAIR AND DR. JOHNSTON. 
 
 PRACTICAL MIDWIFERY : Comprising an Account of 13,748 Deli- 
 veries, which occurred in the Dublin Lying-in Hospital, during a period of Seven Years. T 
 8vo. cloth, 15s. 
 
 MR. ALFRED SMEE, F.R.S. 
 
 GENERAL DEBILITY AND DEFECTIVE NUTRITION ; their 
 
 Causes, Consequences, and Treatment. Fcap. 8vo. cloth, 3s. 6d. 
 
 DR. SMELLIE. ~ 
 
 " OBSTETRIC PLATES I being a Selection from the more Important and " 
 Practical Illustrations contained in the Original Work. With Anatomical and Practical 
 Directions. 8vo. cloth, 5s. 
 
 MR. HENRY SMITH, F.R.C.S. 
 
 ON STRICTURE OF THE URETHRA, 8vo. cloth, 7*. M. 
 
 DR. W. TYLER SMITH. 
 
 A MANUAL OF OBSTETRfCS, THEORETICAL AND PRAC- 
 TICAL. Illustrated with 186 Engravings. Fcap. 8vo. cloth, 12s. 6d. 
 
 THE PATHOLOGY AND TREATMENT OF LEUCORRHCEA. 
 
 With Engravings on Wood. 8vo. cloth, 7s. 
 
 DR. S NONA/. 
 
 ON CHLOROFORM AND OTHER ANESTHETICS: THEIR 
 
 ACTION AND ADMINISTRATION. Edited, with a Memoir of the Author, by A 
 Benjamin W. Richardson, M.D. 8vo. cloth, 1 Os. 6d. A 
 
 v
 
 26 MR. CHURCHILLS PUBLICATIONS. 
 
 DR. STANHOPE TEMPLEMAN SPEER. 
 
 PATHOLOGICAL CHEMISTRY, IN ITS APPLICATION TO 
 
 THE PRACTICE OF MEDICINE. Translated from the French of MM. BECQDEKEL 
 and RODIEB. 8vo. cloth, 12s. 
 
 DR. S P U R G I N. 
 
 LECTURES ON MATERIA MEDICA, AND ITS RELATIONS 
 
 TO THE ANIMAL ECONOMY. Delivered before the Royal College of Physicians. 
 8vo. cloth, 5s. 6d. 
 
 DR. STEGGALL. 
 STUDENTS' BOOKS FOR EXAMINATION. 
 
 i. 
 A MEDICAL MANUAL FOR APOTHECARIES' HALL AND OTHER MEDICAL 
 
 BOARDS. Twelfth Edition. 12mo. cloth, 10s. 
 
 ii. 
 
 A MANUAL FOR THE COLLEGE OF SURGEONS; intended for the Use 
 
 of Candidates for Examination and Practitioners. Second Edition. 12mo. cloth, 10s. 
 
 in. 
 
 GREGORY'S CONSPECTUS MEDICINE THEORETICS. The First Part, con- 
 
 taining the Original Text, with an Ordo Verborum, and Literal Translation. 12mo. 
 cloth, 10s. 
 
 IV. 
 
 THE FIRST FOUR BOOKS OF CELSUS; containing the Text, Ordo Verb- 
 
 orum, and Translation. Second Edition. 12mo. cloth, 8s. 
 
 A TEXT-BOOK OF MATERIA-MEDICA AND THERAPEUTICS. I2mo. cloth, 7s. 
 
 VI. 
 
 FIRST LINES FOR CHEMISTS AND DRUGGISTS PREPARING FOR EX- 
 
 AMINATION AT THE PHARMACEUTICAL SOCIETY. Second Edition 
 18mo. cloth, 3s. 6d. 
 
 MR. STOWE, M.R.C.S. 
 
 A TOXICOLOGICAL CHART, exhibiting at one view the Symptoms. 
 
 Treatment, and Mode of Detecting the various Poisons, Mineral, Vegetable, and Animal, 
 lo which are added, concise Directions for the Treatment of Suspended Animation. 
 Lleventh Edition. On Sheet, 2s.; mounted on Roller, 5s. 
 
 DR. SWAYNE. 
 
 OBSTETRIC APHORISMS EOR THE USE OF STUDENTS 
 
 COMMENCING MIDWIFERY PRACTICE. With Engravings on Wood. Fcap. 
 ovo. cloth, 3s. 6d. 
 
 MR. TAMPLIN, F.R.C.S.E. 
 
 LATERAL CURVATURE OE THE SPINE: its Causes, Nature, and 
 
 Treatment. 8vo. cloth, 4s.
 
 MR. CHURCHILLS PUBLICATIONS. 
 
 DR. ALFRED S. TAYLOR, F.R.S. 
 
 A MANUAL OF MEDICAL JURISPRUDENCE, sixth Edition. 
 
 Fcap. 8vo. cloth, 12s. Gd. 
 
 ii. 
 
 ON POISONS, in relation to MEDICAL JURISPRUDENCE AND 
 MEDICINE. Second Edition. Fcap. 8vo. cloth, 12s. 6d. 
 
 MR, TEALE. 
 
 ON AMPUTATION BY A LONG AND A SHORT RECTAN- 
 
 GULAR FLAP. With Engravings on Wood. 8vo. cloth, 5s. 
 
 DR. THEOPHILUS THOMPSON, F.R.S. 
 
 CLINICAL LECTURES ON PULMONARY CONSUMPTION, 
 
 With Plates. 8vo. cloth, 7s. 6d. 
 
 LETTSOMIAN LECTURES ON "PULMONARY CONSUMPTION ; 
 
 with Remarks on Microscopical Indications, and on Cocoa-nut Oil. Post 8vo., 2s. 6d. 
 
 DR. THOMAS. 
 
 THE MODERN PRACTICE OE PHYSIC; exhibiting the Symp- 
 
 toms, Causes, Morbid Appearances, and Treatment of the Diseases of all Climates. 
 Eleventh Edition. Revised by ALGERNON FRAMPTON, M.D. 2 vols. 8vo. cloth, 28s. 
 
 MR. HENRY THOMPSON, M.B. LOND., F.R.C.S. 
 I. 
 
 STRICTURE OF THE URETHRA; its Pathology and Treatment. 
 The last Jacksonian Treatise of the Royal College of Surgeons. With Plates. Second 
 Edition. 8vo. cloth, 10s. 
 
 II. 
 
 THE ENLARGED PROSTATE; its Pathology and Treatment. With 
 
 Observations on the Relation of this Complaint to Stone in the Bladder. With Plates. 
 8vo. cloth, 7s. 6d. 
 
 DR. TILT. 
 
 ON DISEASES OF WOMEN AND OVARIAN INFLAM- 
 MATION IN RELATION TO MORBID MENSTRUATION, STERILITY, 
 PELVIC TUMOURS, AND AFFECTIONS OF THE WOMB. Second Edition. 
 8vo. cloth, 9s. 
 
 THE CHANGE OF LIFE IN HEALTH AND DISEASE: a 
 
 Practical Treatise on the Nervous and other Affections incidental to Women at the Decline 
 of Life. Second Edition. 8vo. cloth, 6s.
 
 MR. CHURCHILL S PUBLICATIONS. 
 
 DR. THUDICHUM. 
 
 A TEEATISE ON THE PATHOLOGY OF THE URINE, 
 
 Including a complete Guide to its Analysis. With Plates, 8vo. cloth, 14s. 
 
 DR. ROBERT B. TODD, F.R.S. 
 I. 
 
 CLINICAL LECTURES ON PARALYSIS, DISEASES OF THE 
 
 BRAIN, and other AFFECTIONS of the NERVOUS SYSTEM. Second Edition. 
 Foolscap 8vo. cloth, 6s. 
 
 n. 
 
 CLINICAL LECTURES ON CERTAIN DISEASES OF THE 
 
 URINARY ORGANS, AND ON DROPSIES. Fcap. 8vo. cloth, 6s. 
 
 MR. TOMES, F.R.S. 
 
 A MANUAL OF DENTAL SURGERY. With 208 Engravings on r 
 
 Wood. Fcap. 8vo. cloth, 12s. 6d. 
 
 MR. SAMUEL TUKE. 
 
 DR, JACOBI ON THE CONSTRUCTION AND MANAGEMENT 
 
 OF HOSPITALS FOR THE INSANE. Translated from the German. With In- 
 troductory Observations by the Editor. With Plates. 8vo. cloth, 9s. 
 
 DR. TURNBULL. 
 I. 
 
 AN INQUIRY INTO THE CURABILITY OF CONSUMPTION, 
 
 ITS PREVENTION, AND THE PROGRESS OF IMPROVEMENT IN THE 
 TREATMENT. Third Edition. 8vo. cloth, 6s. 
 
 II. 
 
 with FERMENTATION; and on the Causes and Treatment of Indigestion, &c. 8vo. 
 cloth, 6s. 
 
 YESTIGES OF THE NATURAL HISTORY OF CREATION. 
 
 Tenth Edition. Illustrated with 100 Engravings on Wood. 8vo. cloth, 12s. 6d. 
 
 BY THE SAME AUTHOR. 
 
 EXPLANATIONS: A SEQUEL TO "YESTIGES." 
 
 Second Edition. Post 8vo. cloth, 5s.
 
 MR. CHURCHILLS PUBLICATIONS. 29 
 
 DR. UNDERWOOD. 
 
 TREATISE ON THE DISEASES OF CHILDREN. Tenth Edition, 
 
 with Additions and Corrections by HENRY DAVJES, M.D. 8vo. cloth, 15s. 
 
 DR. UNGER. 
 
 BOTANICAL LETTERS, Translated by Dr. B. PAUL. Numerous 
 Woodcuts. Post 8vo., 5s. 
 
 DR. VAN OVEN. 
 
 ON THE DECLINE OF LIFE IN HEALTH AND DISEASE; 
 
 being an Attempt to Investigate the Causes of LONGEVITY, and the Best Means of 
 Attaining a Healthful Old Age. 8vo. cloth, 10s. Gd. 
 
 DR. WALLER. 
 
 - ELEMENTS OF PRACTICAL MIDWIFERY; or, Companion to .. 
 
 the Lying-in Room. Fourth Edition, with Plates. Fcap. cloth, 4s. 6d. 
 
 MR. HAYNES WALTON, F.R.C.S. 
 
 OPERATIVE OPHTHALMIC SURGERY, With Engravings on 
 
 Wood. 8vo. cloth, 18s. 
 
 DR. EBEN. WATSON, A.M. 
 
 ON THE TOPICAL MEDICATION OF THE LARYNX IN 
 
 CERTAIN DISEASES OF THE RESPIRATORY AND VOCAL ORGANS. 
 8vo. cloth, 5s. 
 
 DR. WEBER. 
 
 A CLINICAL HAND-BOOK OF AUSCULTATION AND PER- 
 
 CUSSION. Translated by JOHN COCKLE, M.D. 5s. 
 
 DR. WE GO. 
 
 OBSERVATIONS RELATING TO THE SCIENCE AND ART 
 
 OF MEDICINE. 8vo. cloth, 8s. 
 
 MR. T. SPENCER WELLS, F.R.C.S. 
 
 PRACTICAL OBSERVATIONS ON GOUT AND ITS COMPLI- 
 
 CATIONS, and on the Treatment of Joints Stiffened by Gouty Deposits. Foolscap 8vo. 
 cloth, 5s.
 
 MR. CHURCHILL S PUBLICATIONS. 
 
 DR. WEST. 
 
 LECTURES ON THE DISEASES OF WOMEN, Second Edition. 
 
 8vo. cloth, 16s. 
 
 DR. J. HUME WILLIAMS. 
 
 X UNSOUNDNESS OF MIND, m ITS MEDICAL AND LEGAL * 
 
 CONSIDERATIONS. 8vo. cloth, 7s. 6d. 
 
 MR. WHEELER. 
 
 HAND-BOOK OF ANATOMY FOR STUDENTS OF THE 
 
 FINE ARTS. New Edition, with Engravings on Wood. Fcap. 8m, 2s. 6d. 
 
 DR. WHITEHEAD, F.R.C.S. 
 
 ON THE TRANSMISSION FROM PARENT TO OFFSPRING 
 
 OF SOME. FORMS OF DISEASE, AND OF MORBID TAINTS AND 
 TENDENCIES. Second Edition. 8vo. cloth, 10s. 6d. 
 
 DR. WILLIAMS, F.R.S. 
 
 PRINCIPLES OF MEDICINE : An Elementary View of the Causes, 
 
 Nature, Treatment, Diagnosis, and Prognosis, of Disease. With brief Remarks on 
 Hygienics, or the Preservation of Health. The Third Edition. 8vo. cloth, 15s. 
 
 DR. JOSEPH WILLIAMS. 
 
 INSANITY '. its Causes, Prevention, and Cure ; including Apoplexy, 
 Epilepsy, and Congestion of the Brain. Second Edition. Post 8vo. cloth, 10s. Gd. 
 
 DR. WILLIAMSON, STAFF-SURGEON. 
 
 NOTES ON THE WOUNDED FROM THE MUTINY IN 
 
 INDIA: with a Description of the Preparations of Gunshot Injuries contained in the 
 Museum at Fort Pitt. With Lithographic Plates. 8vo. cloth, 12s. 
 
 MR. ERASMUS WILSON, F.R.S. 
 I. 
 
 THE ANATOMIST'S YADE-MECUM: A SYSTEM OF HUMAN 
 
 ANATOMY. With numerous Illustrations on Wood. Seventh Edition. Foolscap 8vo. 
 cloth, 12s. 6d. 
 
 n. 
 
 DISEASES OF THE SKIN: A Practical and Theoretical Treatise on 
 the DIAGNOSIS, PATHOLOGY, and TREATMENT OF CUTANEOUS DIS- 
 EASES. Fourth Edition. 8 vo. cloth, 16s. 
 
 THE SAME WORK ; illustrated with finely executed Engravings on Steel, accurately 
 coloured. 8vo. cloth, 34s.
 
 MR. CHURCHILL S PUBLICATIONS. 31 
 
 -H=H *e^ 
 
 MR. ERASMUS WILSON, F.R.S. (continued). 
 III. 
 
 HEALTHY SKIN I A Treatise on the Management of the Skin and Hair 
 
 in relation to Health. Sixth Edition. Foolscap 8vo. 2s. 6d. 
 
 IV. 
 
 PORTRAITS OF DISEASES OF THE SKIN, Folio. Fasciculi I. 
 
 to XII., completing the Work. 20s. each. 
 
 v. 
 
 ON SYPHILIS, CONSTITUTIONAL AND HEEEDITAEY; 
 
 AND ON SYPHILITIC ERUPTIONS. With Four Coloured Plates. 8vo. cloth, 
 16s. 
 
 VI. 
 
 A THREE WEEKS' SCAMPER - THROUGH THE SPAS OF 
 
 GERMANY AND BELGIUM, with an Appendix on the Nature and Uses of 
 Mineral Waters. Post 8vo. cloth, 6s. Gd. 
 
 DR. FORBES WINSLOW, D.C.L. OXON. 
 
 LETTSOMIAN LECTURES ON INSANITY, 8vo. cloth, 5s. 
 
 DR. Q. C. WITTSTEIN. 
 
 PRACTICAL PHARMACEUTICAL CHEMISTRY: An Explanation 
 
 of Chemical and Phannaceutical Processes, with the Methods of Testing the Purity of 
 the Preparations, deduced from Original Experiments. Translated from the Second 
 German Edition, by STEPHEN DARBY. 18ino. cloth, 6s. 
 
 DR. HENRY Q. WRIGHT. 
 
 HEADACHES ; their Causes and their Cure. Second Edition. Fcap. 8vo. 
 
 2s. Gd. 
 
 MR. YEARSLEY. 
 I. 
 
 DEAFNESS PRACTICALLY ILLUSTRATED; being an Exposition 
 
 of Original Views as to the Causes and Treatment of Diseases of the Ear. Fifth 
 Edition. Foolscap 8vo., 2s. 6d. 
 
 II. 
 
 ON THE ENLARGED TONSIL AND ELONGATED UYULA, 
 
 and other Morbid Conditions of the Throat. Seventh Edition. 8vo. cloth, 5s.
 
 CHURCHILL'S SERIES OF MANUALS. 
 
 Fcap. 8vo. cloth, 12*. 6r/. each. 
 
 " We here give Mr. Churchill public thanks for the positive benefit conferred on the 
 Medical Profession, by the series of beautiful and cheap Manuals which bear his imprint." 
 British and Foreign Medical Review. 
 
 AGGREGATE SALE, 1O5,OOO COPIES. 
 
 The ANATOMIST'S VADE-MECUM. A System of Human Anatomy. 
 With numerous Illustrations on Wood. Seventh Edition. By ERASMUS 
 WILSON, F.E.C.S., F.K.S. 
 
 CHEMISTRY. With numerous Illustrations on Wood. Seventh Edition. 
 By GEORGE FOWNES, F.R.S. Edited by H. BENCE JONES, M.D., F.R.C.P., 
 and A. W. HOFMANN, F.R.S. 
 
 DENTAL SURGERY. With 208 Illustrations on Wood. By JOHN 
 TOMES, F.R.S. 
 
 MATERIA MEDICA. With numerous Illustrations on Wood. Third 
 Edition. By J. FORBES ROTLE, M.D., F.R.S., and FREDERICK W. HEAD- 
 LAND, M.D., F.L.S. 
 
 MEDICAL JURISPRUDENCE. Sixth Edition. By ALFRED SWAINE 
 TAYLOR, M.D., F.R.S. 
 
 PRACTICE OF MEDICINE. By G. HILARO BARLOW, M.D., M.A. 
 
 The MICROSCOPE and its REVELATIONS. With numerous Illus- 
 trations on Wood. Second Edition. By W. B. CARPENTER, M.D., F.R.S. 
 
 NATURAL PHILOSOPHY. With numerous Illustrations on Wood. 
 Fourth Edition. By GOLDING BIRD, M.D., M.A., F.R.S., and CHARLES 
 BROOKE, M.B., M.A., F.R.S. 
 
 OBSTETRICS. With 186 Engravings on Wood. By W. TYLER SMITH, 
 M.D., L.R.C.P. 
 
 OPHTHALMIC MEDICINE and SURGERY. With coloured Engravings 
 on Steel, and numerous Illustrations On Wood. Second Edition. By 
 T. WHARTON JONES, F.R.C.S., F.R.S. 
 
 PATHOLOGICAL ANATOMY. With numerous Illustrations on Wood. By 
 C.HANDFIELD JONES, M.B., F.R.C.P.,aud E.H. SIEVEKING, M.D.,F.R.C.P. 
 
 PHYSIOLOGY. With numerous Illustrations on Steel and Wood. Third 
 Edition. By WILLIAM B. CARPENTER, M.D., F.R.S. 
 
 ^ POISONS. Second Edition. By ALFRED SWAINE TAYLOR, M.D., F.R.S. 
 
 PRACTICAL SURGERY. With numerous Illustrations on Wood. Fourth 
 Edition. By WILLIAM FERGUSSON, F.R.C.S. 
 
 ~ Printed by W. BLANCOARD & SONS, 62, Millbank Street, Westminster.