The following cases must be now added to those recorded in my list of private patients whose family history has been ascertained with reliable accuracy.

Case I. is that of a gentleman, aged forty-seven, the subject of lumbo-abdominal neuralgia: no history of nervous disease in the family; his mother, however, was of a "nervous" temperament.

Case II.—A gentleman, aged sixty-four, suffering from angina. His family nervous history is fearful. On the father's side it is not possible to get a clear account. But on the maternal side there has been a strong tendency to insanity and suicide; and in the patient's own generation one brother committed suicide from insanity, and one sister is still alive, insane. An interesting fact is, that the mother's family have shown an extraordinary proclivity to erysipelas.

Case III.—The young gentleman, whose single but extremely severe attack of angina is previously described, comes of a family in whom the tendency to neuralgia is undoubtedly very strongly inherited. His father is frequently and very severely migraineux, and in early life suffered cardiac symptoms not unlike his son's. A brother was also liable to attacks of true migraine between puberty and the age of twenty-one.

Case IV.—On the other hand, a case of angina which I saw in the country, last year, occurred in a gentleman, aged fifty, whose family presented no traceable neurotic history. But the damage inflicted upon his nervous system by various external influences was quite extraordinary. In some way or other he got some attacks of migraine at the age of fifteen or sixteen; for these he was treated with bleeding, and with a most savage antiphlogisticism generally. From that time he never got free of the neuralgic tendency. He used to have not only facial, but intercostal neuralgia; for this last he was repeatedly bled, under the idea that it was pleurisy. Added to all this he habitually did an immense deal of brain-work in his study, and for years had performed clerical duties of the most exacting and exhausting character. It is not much wonder that these combined circumstances had sufficed to generate the neurotic temperament.

In the present transitional state of opinion concerning the mode in which the phenomena are produced that are popularly known under the name of "reflex paralysis," I cannot pass without notice the doctrines of these two observers. The reader will have perceived that, as regards the secondary paralytic symptoms observed in neuralgias, I explain the phenomena mainly on the theory of a process which is central, and not peripheral, in origin. And, even where, as in some few instances, it seems possible that the starting-point was an organic affection of some viscus, we must always consider the possibility that the link between this and the neuralgia and paralyses was a neuritis migrans travelling inward to the sensory centre, and from that passing over to motor centres and thus producing paralysis; or that, without the intervention of any truly inflammatory process, the continual impressions streaming in upon the cord from the original seat of organic disease may damage the nutrition of the sensory nerve-root, producing a partial atrophy, and that this process may extend to the motor root.

It remains, however, to inquire whether the influence of powerful peripheral agencies may not, in a purely "functional" manner, disable the nerve-centres for a time, causing paralysis with or without neuralgia. The main supporters of such a doctrine are Dr. Handfield Jones[46] and M. Jaccoud.[47]

Dr. Handfield Jones expressly rejects the theory of Brown-Sequard, as to spasm of the vessels in the nerve-centres, and we need not repeat his arguments on that head, because it seems to be generally felt that the vascular spasm theory will not account for the facts. Jones believes that the state produced in the nerve-centre by the peripheral influence is one of paresis from shock-depression, and that from the sensory centre this state can communicate itself to motor and vaso-motor centres, though commissural fibres. He does not believe in the existence of a special inhibitory portion of the nervous system: he believes that an impression may prove stimulating when it is mild, or paralyzing when it is strong; and that any afferent nerve may convey either the one influence or the other to the centres and thus produce secondary stimulus or secondary paralyses in various efferent nerves. Jones has the distinguished merit of being one of the first authors distinctly to perceive that pain must rank on the same level with paralysis: hence he sees nothing unintelligible in the communication of paralysis to a motor centre from a sensory centre that was in the state which the mind interprets as pain.

The theorie d'epuisement of Jaccoud (Erschopfungs-theoric) also denies the possibility of Brown-Sequard's idea of prolonged spasm of the vessels of the centres. It imagines that powerful peripheral excitements exhaust the irritability of the nerve, and through that of the centres, and induce a state of unimpressibility—analogous to that which exists in a nerve or nerve-centre, which is included in the circuit of a constant current. The nervous force is wasted, and, until an opportunity of repose is afforded to the centre, the faculty of impressibility cannot again revive.

I must say that of these two theories I decidedly incline to that of Handfield Jones (though I imagine that in reality the cases are extremely rare, if there be any, in which the change in the centres is really only functional and non-organic), I prefer the idea of paralyzing shock to that of exhaustion from over-excitement, from a consideration of the nature of that form of peripheral influence which has been specially mentioned by authors as competent to produce this sort of "reflex" affections, namely, intense and persistent cold. It seems to me a mere abuse of words to speak of this as an agent that could exhaust the nerve by over-stimulation; it must surely exhaust it in a much more direct manner than this, namely by the direct physical agency of withdrawing heat from the nerve, and spoiling its physical texture, pro tanto. If such an effect as that which must thus be produced on the nerve, and through it on the centre, is to be looked on as a case of over-stimulated function, then, it seems to me, there is no meaning in language, and no possibility of attaining to clear ideas on the subject of nervous influence.

Since writing the above chapter on the Treatment of Neuralgia, I have had two fresh and very striking examples, in private practice, of the power of arsenic to break the morbid chain of nervous actions in angina pectoris.

The first example was that of a medical man, aged seventy-five, in whom a neuralgia, originally malarial in origin, and of some years' duration, had fixed itself for some time in the fifth and sixth left intercostal spaces, and of late had become complicated with anginoid attacks of an unmistakable character, though not of the highest degree of severity. The case certainly seemed very unpromising, looking at the patient's age and the consequent high probability that there was much arterial degeneration. However, the use of Fowler's solution (five minims three times a day) was commenced and steadily pushed. The anginoid attacks rapidly diminished in frequency and at the end of ten days' time were entirely gone, and after one month of treatment he still had no return of them, although they had previously been of daily occurrence. It is a curious fact, whether a mere coincidence or not I cannot say, that, some few days after the anginoid attacks ceased, he began to experience somewhat severe pains, rheumatic in feeling, but unattended with heat or swelling, in the elbows, wrists, and fingers, symmetrically. This has nearly disappeared, but he is still free from angina. There is no discoverable heart-lesion in this patient.

The other case was that of a fine old man of sixty-four, who, but for some few slight attacks of gout, a few small calculi, and a troublesome prostatic affection, had always enjoyed remarkably good health, until about five months ago, when he began to notice tightness across the chest, etc., when he walked uphill. About a fortnight before he came to me, he was seized with very violent and alarming paroxysms of pain across the chest and running down both arms, extreme intermittence of pulse, and a sense of impending dissolution. The attack had recurred daily, at the same hour (6 p. m.), ever since; besides which there was an abiding sense of uneasiness in the cardiac region, and a consciousness that the least excitement or exertion would bring on the paroxysm. I put the patient on five minims of Fowler, three times a day, with directions to take ether when the paroxysms came. At the end of the first week there was already much improvement, the paroxysms having been both less frequent and less severe. At the end of a fortnight's treatment he reported that there had been nothing like a paroxysm for the last eight days, although there was still a good deal of uneasiness from time to time. The hour at which the attack was expected passed by absolutely without a trace of angina. It remains to be seen how long this improvement will last, but the altered state of things, and particularly the suddenness of the change, cannot be overlooked, and has very much struck the patient himself. It is now six weeks since he had any paroxysm.

It becomes more and more apparent that arsenic is generally applicable to neuroses of the vagus. In asthma, I have long held it to be the most powerful prophylactic tonic that we possess. It is also an excellent remedy in gastralgia; although I have rather dwelt (in the text of this work) on the action of strychnia in this disease, I would not omit my testimony to arsenic. Dr. Leared has related some exceedingly interesting cases bearing on this point. (See British Medical Journal, November 23 and 30, 1867.)

Dr. Reynolds pointed out to me the exceedingly curious fact, which I have several times verified, that the constant current, in relieving facial neuralgia, not unfrequently disperses, almost instantaneously, the brown skin-pigment that has collected in the painful region; e. g., near the orbit.

A remedy for inveterate neuralgia which of late years I had almost discarded—the actual cautery—has quite recently yielded me very good palliative results in two cases. Its omission from the text of the chapter on Treatment was an accident due to the effect of habit in making one, half unconsciously, reckon this remedy as a "counter-irritant." The longer I practise, however, the more decidedly I am convinced that the actual cautery, if properly applied, does not act as an irritant at all; and this fact was sufficiently in my mind, when writing of irritant remedies, to make me omit the cautery from that section. I should have inserted it under the heading of remedies that interrupt the conductivity of nerves, and thus give the centres temporary rest. The only useful way to apply it is, to make an iron white hot, and very lightly brush the skin over so as to make an eschar not followed by suppuration. The galvano-cautery (Stohrer's Bunsen) is the best for the purpose, but I have made the flat-iron cautery serve very well.

PART II.

The clinical history of the different varieties of myalgia absolutely requires this key for its interpretation; otherwise, the appearance of the sufferers from different kinds of myalgia is so widely dissimilar that we should be exceedingly likely to miss the important features of treatment, which must be applied to them all in common. Nothing, for instance, can be more strikingly unlike than the appearance of the pallid, stunted, under-nourishment cobbler who complains of epigastric myalgia, and that of the ruddy and muscular navvy who suffers from acute lumbago, or the similarly plethoric-looking country commercial traveller, who has been driving in his gig against wind and rain, and complains of violent aching pains in one or both shoulders; yet one and all of these individuals are suffering from precisely the same cause of pain, viz., a temporarily crippled muscle or set of muscles which has been compelled to work against the grain. Why this state of things should invariably be interpreted as sensation in the form of acute pain never absent, but severely aggravated by every movement of the affected part, is a matter beyond our powers of explanation, we must accept it as an ultimate fact for the present.

There is scarcely any need to describe the pain of myalgia, since almost every one has suffered either from lumbago, or from a stiff neck produced by cold. The pain is essentially the same in all cases; it is an aching actually felt either in or toward the tendinous insertions of the affected muscles, and sharply renewed by every attempted contraction of those muscles. The variations in the character and severity of the pains are really entirely due to the greater or the less opportunity for physiological rest which the muscle can obtain. Thus the most obstinate and the most severe, kind of myalgic pain is undoubtedly that of pleurodynia—pain in the intercostal muscles and their fibrous aponeuroses—a fact which depends on the incessant movements which these muscles are compelled to perform in the act of respiration. And next to this in severity and obstinacy are myalgias of the great muscles which are incessantly engaged in maintaining, by their accurately opposed contraction, the erect position of the spinal column and of the head. This rate of proportional frequency and severity, however, must be taken as strictly relative; i. e., it is correct upon the supposition that the different sets of muscles were equally worked and that the state of nutrition was equal in the different parents. It is otherwise when the conditions are reversed. Thus, the unfortunate cobbler or tailor, who sits for long hours in one cramped and bent posture, is continuously exerting his recti abdominales (probably suffering from an under-nutrition common to all his tissues) to a degree perfectly abnormal, and out of all proportion to the functional work he is getting out of any other part of his muscular system. The consequence is, that he comes to us complaining of acute epigastric, and sometimes pubic, pain, rising to agony when he assumes his ordinary sitting posture, and only reduced to any thing moderate by the most complete extension of the whole trunk in the supine posture.

There is no need to dilate at greater length upon the varieties in the symptoms of myalgia, according as it affects one or another part of the body. We must consider, briefly the different kinds of cause that produce it. The immediate source of the pain being, as we have seen, the sense of embarrassment in a muscle obliged to contract when unfit for the work, we have to ask what are the remoter causes that can produce this special unfitness for the work of contraction. They are three: (a) Overlabor pure and simple (i. e., in proportion to the existing bulk and quality of the muscle); (b) cold, and especially damp cold, producing a semi-paralyzing effect on the vaso-motor nerves, and causing congestion and sometimes a little effusion among the fibres or within the sheath of the muscle; (c) fatty degeneration of muscle which is exposed to inevitable and incessant work. Either of these conditions may so disable the muscle that its unavoidable contractions will set up the myalgic state.

Undoubtedly however there is something further, in the shape of a natural predisposition not yet understood, which makes some patients so much more liable to suffer myalgic pain as a consequence of this sort of influences than other persons are. I am in no condition to decide what the nature of this predisposition is; I feel sure it is heightened by an inherited or acquired gouty taint, but I have seen it in people whom there is no reason to suspect of gouty tendencies. It appears to have no connection with true rheumatism.

Still after all that can be said, myalgia remains a disease chiefly of local origin, and depending for nine-tenths of its causation upon a derangement between the balance of work and nutrition in the muscle.

As regards the diagnosis of myalgia from neuralgia, which is a very important matter, the following are the main points that we should recollect:

The treatment of myalgia is not only satisfactory in itself, but often affords, in its results, a very desirable confirmation of diagnosis.

For a very large number of cases, all that is required is (a) to put and keep the affected muscle in a position of full extension, which is only to be changed at somewhat rare intervals; (b) to cover the skin all over and round it with spongio-piline, so as to maintain a perpetual vapor-bath; (c) on the subsidence of the acutest pain and tenderness, to complete the treatment by one or two Turkish baths, to be taken in the manner that I have recommended by speaking of the prophylaxis of neuralgia.

When treatment such as this cures a pain which was greatly aggravated by muscular movement, we may be sure that pain was myalgic and not neuralgic.

The pain, however, is not unfrequently rebellious to such simple remedies as these, more especially when (as in pleurodynia) we are not able to enforce complete physiological rest of the part. When this is the case, we shall find the internal use of twenty and thirty grain doses of muriate of ammonia by far the most effective remedy. In the first very acute stage of a severe case it may be advisable to inject morphia hypodermically; but this is seldom necessary. The muriate-of-ammonia treatment may be usefully accompanied by prolonged gentle frictions, three or four times a day, with a weak chloroform liniment.

When there is visibly a very great deficiency in the general nutrition, we shall often fail to obtain a cure until we have remedied this defect; and accordingly, in the majority of cases of half-starved and overworked needle-women, cobblers, tailors, and the like, who present themselves in the out-patient room, I accompany the above-named treatment with the steady administration of cod-liver oil for three or four weeks or more.

There is one remedy for this pain which I have myself seen used in only a few cases, but which I believe promises exceedingly well for the treatment of obstinate myalgia; viz., acupuncture. I have not even mentioned it as a remedy for neuralgia, for I believe it to be totally useless in true cases of that disease, whether applied in the simple form or in that of galvano-puncture. I think very differently of its use in myalgia; and I venture to believe that it is entirely to cases of this disease that the exceedingly interesting observations of Mr. T. P. Teale, in a recent number of the Lancet, apply. Where (after the usual remedies for myalgia have been applied) we are unable to get rid of a deep-seated and fixed muscular pain, I believe it to be excellent practice to plunge two or three long needles deeply into the muscle near its tendinous attachment.

CHAPTER II.

The more typical cases of so-called "hysterical hyperæsthesia" present the following phenomena: Along with the general symptoms of the hysterical temperament (tendency to causeless depression, variable spirits, sensation of globus, semi-convulsive attacks terminated by the discharge of a great quantity of pale, limpid urine) there is commonly a marked superficial tenderness of the surface everywhere, and an exaggeration of reflex irritability. The general tenderness is so far merely cutaneous that deep pressure is ordinarily borne better than the lightest finger-touch. But besides this there are usually one or several spots in which the tenderness is more profound and genuine. There is almost sure to be some point in the spinal column where firm pressure not merely evokes a complaint of pain, but also induces secondary objective phenomena connected with distant organs, such as nausea and vomiting when the cervical vertebræ are tender, severe gastric pain when the dorsal vertebræ are tender, etc. In such cases there is not only spinal tenderness, but very usually also a well-marked tenderness in the epigastrium and the left hypochondrium, the trepied hysterique of Briquet. The reader must, however, be warned that the whole of these three tender points may be merely myalgic, and it is necessary very carefully to observe whether local movements do or do not seriously aggravate the pain in them. And, on the other hand, the spinal tender point may be merely the "point apophysaire" of a true neuralgia which exhibits no other symptoms of the so-called hysteric constitution.

The kind of hysteria that is joined with the existence of fixed tender spots in definite points of the vertebral column is not commonly distinguished by the occurrence of cutaneous anæsthesia; but those writers are certainly wrong in saying that such a combination never takes place. I have seen examples of the most marked union of the two classes of symptoms in the same person.

These cases of so-called spinal irritation with general hysteric manifestations are very commonly attended with paroxysmal pains that approach true neuralgia in character. Nor is it to be denied that we sometimes meet with the combination of general hysteria, spinal tenderness in definite points (with secondary spasmodic or paralytic phenomena always following pressure exerted on the latter), and true neuralgia limited to one nerve. But the more typical spinal irritation cases are merely complicated with a tendency to vague pains which are shifting both in character and position, not with definite unilateral neuralgia always haunting the same nerve and exhibiting more or less of the same type. In fact, as far as one can judge in the absence of any precise information as to the condition of the nervous centres in such cases, it would seem likely that the ordinary cases of spinal irritation differ from the true neuralgias chiefly in this—that the injury, or inherited weakness of organization, or both, which is at the root of the malady, is at once slighter in degree, and spread over a larger tract of the nervous centres, than that which produces a true neuralgia. I believe that Dr. Radcliffe is right in supposing it to be probable that a blow or other injury to the back producing general spinal shock, is the original but unsuspected cause of a large proportion of these cases. One of the most perfect examples of spinal irritation that I have ever seen (and which also contrasts keenly with the commoner hysteric affections on the one hand, and the true neuralgiæ on the other) was that of a girl whom I examined together with Dr. Walshe, Dr. Reynolds, and Dr. Bridge. This young lady was a most intelligent person, and not in the slightest degree inclined to the apathy and idleness so often seen in hysterical people. She had received what was thought at the time to be a very slight contusion in a railway collision, in which, however, her sister, who was in the same carriage, had been severely injured. She nursed this sister assiduously, and it was not till three or four months later that her own health began to fail seriously; but she then became anæmic and extremely depressed. About six months after the accident it was quite casually discovered that there was a spot over the lowest cervical vertebra, pressure on which gave her exquisite pain and a sensation of extreme nausea; and the very curious observation was made that such pressure instantaneously produced extinction of the right pulse, the left pulse remaining unaltered. In this case it cannot be doubted that a serious shock had been communicated to a lateral segment of the cord involving chiefly the vaso-motor nerve fibres, in which probably some decided material lesion had been gradually set up; and besides this there was probably slighter damage to the spinal cord generally, as there was great general feebleness of movement, though no actual paralysis of the limbs.

Along with the phenomena of fixed spinal tenderness, without distinct neuralgia of any particular nerve, we not unfrequently observe the development of more or less decided tenderness of some of the internal surfaces of the body. I have recently had under my care a young woman in whom a very tender point was developed over the second cervical vertebra, and who suffered from such persistent tenderness of the whole posterior part of the pharynx, that I was for some time seriously apprehensive of the existence of spinal caries and post-pharyngeal abscess. The general character of her symptoms, however, induced me to hope that the case was one of spinal irritation merely, and the event proved that this was the case, for under the use of iron and small doses of strychnia she recovered completely in about three weeks. In another patient who came under my care about twelve months ago, there was extraordinary sensitiveness of the gastric mucous membrane, causing exquisite pain after she had eaten almost any thing: there was only occasional vomiting, however, and there had never been any hæmorrhage, so that the evidence for gastric ulcer, which I otherwise inclined to think existed, was insufficient. I discovered that pressure on the third or the fourth dorsal vertebra gave great pain, and produced a strong inclination to vomit; this made it probable that the affection was spinal, and accordingly all treatment addressed to the stomach was abandoned. Flying blisters to the neighborhood of the painful spinal points quickly relieved all the symptoms.

Another distressing class of symptoms, which is very commonly observed in connection with these cases of spinal irritation, is that of abnormal arterial pulsations: I am not sure whether even severe neuralgia produces more distress than does this pulsation. I have repeatedly seen abnormal pulsation of the carotids in connection with fixed tender-points over the cervical or the upper dorsal vertebræ; and still more commonly pulsation of the abdominal aorta in connection with tenderness over one or two of the upper dorsal vertebræ. Spasmodic cough and spasmodic dyspnœa frequently accompany tenderness of points in the upper half of the spinal column; and in one instance I have seen pressure on the lowest cervical vertebræ produce a paroxysm which looked alarmingly like angina pectoris. A case of singularly prolonged and obstinate spasmodic hiccough which came under my notice was distinguished by the presence of a fixed tender spot over the third dorsal vertebra.

Prolonged spastic contraction of voluntary muscles, going on, sometimes for weeks, and even months, is a phenomenon that has often been observed; it may attack the arm only, or may affect all the limbs, and the muscles of the trunk and of the neck: it is for the most part symmetrical, but is occasionally unilateral. It begins in the extremities, and is very commonly limited to them; it is much more gentle than tetanic spasm, and is also painless, or nearly so; but the contraction is often strong enough to resist very vigorous efforts at artificial extension.

Paralyses, both of bowel and bladder, have been recorded among the occasional phenomena of spinal irritation with fixed tender points; but I cannot say that I have ever seen such an occurrence. On the whole, I must say that by far the most frequent phenomena of spinal irritation that I have seen have been somewhat diffuse cutaneous or mucous tenderness and irritability (without acute pain) and the presence of tormenting arterial throbbings; also a marked tendency to aggravation of some symptoms, especially the gastric, when firm pressure is made upon the tender spinal points. For a further and fuller account of the phenomena of spinal irritation I may refer the reader to the able article of Dr. Radcliffe,[48] and the work of the brothers Griffin, already quoted; adding the suggestion, however, that both these authorities, and especially the Griffins, appear to me not to draw a sufficiently clear distinction between the class of cases that I have been attempting to describe and the true neuralgias.

After what has been said, there is no need to draw out a formal list of the points of diagnosis between spinal irritation and neuralgia. It must be admitted, moreover, that the two forms of diseases have a strong connection in the fact that they are each of them most frequently developed in the descendants of neurotic families. It is by the more generalized character of the symptoms, and the absence of the tendency to perpetual recurrence of paroxysmal pain in one definite nerve, that spinal irritation is mainly distinguishable from true neuralgia. I may add that there is a marked distinction, also, in the results of treatment.

The treatment of spinal irritation is, it must be confessed still in an unsatisfactory position; and I believe that a good deal of unnecessary discouragement has been occasioned to physicians by their failures to cure supposed neuralgias which really belonged to the spinal irritation class. I would assuredly by no means assert that genuine neuralgia is not frequently intractable, or even incurable; but it is certainly much more curable than spinal irritation; and for this reason, mainly as I believe—that there is much more possibility of aiming our remedies at the actual seat of the disease. On the other hand, in spinal irritation we are confused and distracted with a variety of phenomena for which even the most subtle analysis will frequently fail to trace a common origin. It is true that the existence of definite tender spots in the spine apparently suggests a strictly local application of remedies; and it true also that medication based upon this fact is sometimes very effective; but this is, in my experience, only an occasional result, and the practitioner who trusts to local measures will frequently be disappointed. And, on the other hand, the general tonic treatment, and the use of special medicines, like quinine and arsenic, or the hypodermic injection of morphia oratropia, have nothing like the extensive utility in the treatment of spinal irritation that they possess in that of true neuralgia. Of internal remedies, by far the most useful in my hands have been sesquichloride of iron with small doses of strychnia, and the milder vegetable bitters, especially calumba.

There is one special phase, however, of spinal irritation which is very amenable to the direct, treatment, viz., cutaneous and mucous tenderness. Whatever the "hyperæsthetic" part is within reach, so that we can apply Faradization, we can almost certainly eradicate the morbid sensibility very quickly. The secondary current of an electro-magnetic or volta-electric induction apparatus is to be employed; the conductors should be of dry metal and the negative one, which is to be applied to the painful surface, should be in the form of the wire brush. The positive pole is to be placed on some indifferent spot, and the negative is to be stroked briskly backward and forward over the sensitive skin, a pretty strong current being employed. The process is painful so much so that it will often be advisable, with delicate patients, either to administer chloroform or to inject morphia subcutaneously before the Faradization. A very few daily sittings of four or five minutes length will generally remove the morbid tenderness completely. Where the tender part is within one of the cavities, at the rectum, bladder, vagina, or pharynx, we must of course use a solid negative conductor of appropriate form, and must content ourselves with applying it steadily to one point after another of the sensitive surface.

The fact that Faradization proves so remarkably useful, in these cases of spinal irritation with diffuse cutaneous or mucous tenderness, is in itself a strong diagnostic between this sort of affection and the true neuralgiæ, which, as I have stated are seldom benefited, and are often made worse, by the interrupted current, though the constant current frequently mitigates or cures them.

Sometimes where it is not possible to apply the remedy directly to the sensitive surface, we may nevertheless do great good by sending the interrupted current through it. Thus, in gastric sensitiveness connected with spinal tenderness in the upper dorsal region, I have seen very great relief afforded by sending a current from the positive pole, placed on the tender vertebræ, to a broad, negative conductor placed on the epigastrium. And similarly, I have seen an acutely sensitive condition of the neck of the bladder greatly soothed by the passage of a current from a painful lumbar vertebra to the perinæum immediately behind the scrotum.

Undoubtedly, however, the more serious cases of spinal irritation will yield only (if they yield at all) to a prolonged treatment in which very skilful use is made of general hygienic measures, and especially of morbal influences. As the brothers Griffin long ago pointed out, although rest is useful in the early stages of this malady, if the disease does not quickly yield to this and to appropriate tonic medication, and perhaps local applications to the spine, it will not do to keep the patient recumbent and confined to the house; on the contrary at whatever cost of immediate discomfort, he (or she for these patients are by far the most frequently females) must be roused up, and persuaded or compelled to take out-door exercise, and if possible to travel, and divert the mind by complete change of scene. When such expensive remedies are out of the question, it seems better that patients, even seemingly very feeble, should take to their ordinary avocations in life again, and fight down the tendency to invalidism. But of course, the decision on such a point must rest with the tact and judgment of the practitioner in each individual case, for there are, doubtless, instances in which the attempt to carry out such a plan, even moderately, would break down the remaining strength, and make matters worse than they were before.

In the worse case of spinal irritation that I ever saw, that of a young lady, aged twenty-eight, there were pronounced anæmia and general feebleness, the true hysteric trepied of tender points, painful irritability of the stomach, which baffled all medical advisers and resisted almost every possible form of tonic and nervine medicines, counter-irritation to the spine, and, in fact every thing that one dared attempt with so feeble-looking a patient, but at once cleared up and was quite cured after marriage. And there can be no question that a very large proportion of these cases in single women (who form by far the greater number of subjects of spinal irritation) are due to this conscious or unconscious irritation kept up by an unsatisfied sexual want. In some patients there cannot be a doubt that this condition of things is indefinitely aggravated by the practice of self abuse; but it would be most unjust to think that this is a necessary element in the causation; on the contrary, it is certain that very many young persons (women more especially) are tormented by the irritability of the sexual organs without having the least consciousness of sensual desire, and present the sad spectacle of a vie manquee without ever knowing the true source of the misery which incapacitates them for all the active duties of life. It is a singular fact, that in occasional instances one may even see two sisters inheriting the same kind of nervous organization, both tormented with the symptoms of spinal irritation, and both probably suffering from repressed sexual function, but of whom one shall be pure-minded and entirely unconscious of the real source of her troubles, while the other is a victim to conscious and fruitless sexual irritation.

I have already causally alluded to the danger of mistaking mere myalgia for spinal irritation and must again enforce this consideration upon the reader. Myalgic tender points in the region of the spine are common enough; and it would be easy without careful attention, to mistake them for the deeper-seated vertebral tenderness which is truly characteristic of spinal irritation. Hence the utmost care must be taken to ascertain the true history of the commencement of the disorder whether it succeeded to great and long continued fatigue of particular sets of muscles, and whether it is specially aggravated by contractions of those muscles, and relieved by their full extension. The differences of treatment which depend on the diagnosis are too obvious to need dwelling upon.

The question of administering remedies with the direct intention of procuring sleep, for patients suffering from spinal irritation, often becomes an important and a very difficult one. It is, for the most part, highly objectionable to commence the use of such remedies; and yet sleeplessness is a very distressing symptom with many patients, and is, of course in itself exhausting and deleterious. For as long as we possibly can, we should content ourselves with efforts to produce sleep by the timely administration of nourishment. The same general rule of a very generous (though not very stimulating) diet to be enforced as carefully as in the case of sufferers from neuralgia. But it is especially advisable in spinal irritation; that the patient should take some food shortly before bedtime; and it is well, also to place food within reach at the bedside, so that if he wakes up he may take some. If, however, we are absolutely driven to employ hypnotics, we must commence with the very mildest. The popular remedy of a pillow stuffed with hops will sometimes suffice; and a better way of administering the volatile principle of hops is to scatter a few hops on hot water in an inhaler, and let the patient breathe the steam. Hot foot-baths, with mustard, are also very useful. If these fail, chloral, in moderate doses is probably the best and safest remedy, and, with care not to give too much, we may go on using the same dose without increase for a good many times.

CHAPTER III.

Hypochondriasis is not insanity, if by insanity we mean intellectual perversion dependent mainly or entirely on the state of the higher nervous centres. But it is closely allied to insanity in its phenomena, only that these are, as it were, manifested in a scattered form, unequally distributed over the whole central nervous system, and especially affecting the spinal sensory centres. And its radical relationship to true insanity is strongly indicated by the fact that the sufferers from hypochondriasis are nearly, if not quite, always members of families in which distinct insanity has shown itself; indeed, more often than not, of families which have been strongly tainted in this way. In the majority of instances there are psychical peculiarities of a marked kind which accompany or precede the development of the abnormal sensations which form the especial torment of hypochondriacs. Without apparent cause, they begin to evince a heightened self-feeling and an anxious concentration of their thoughts upon the state of one or more of their bodily organs. Or it may be that, before any such definite bias is given to their thoughts, they simply become less sociable and more self-centred, and are subject to fits of indefinite and inexplicable depression, or at least to great variability of spirits. But before long they begin to experience definite morbid sensations, most commonly connected with the digestive organs, and very often accompanied by positive derangement of digestion of an objective character; such as flatulence, sour eructation, spasmodic stomach-pain, etc. Along with these phenomena, or soon afterward (and not unfrequently before the patient has acquired that intensity of morbid conviction of his having some special disease which is afterward so marked a peculiarity of his mental state), he very often becomes the subject of the kind of pains which it is the special purpose of this chapter to describe.

The pains of hypochondriasis, when they assume any more definite form than that of mere dyspeptic uneasiness, present many analogies with neuralgia. They are not, usually, periodic in any regular manner, but they have the same tendency to complete intermission, and they frequently haunt some one or more definite nerves for a considerable period of time. Of all nerves that are liable to this kind of affections the vagus is undoubtedly the most susceptible; hypochondriac patients very frequently complain of pseudo-anginoid and pseudo-gastralgic pains; next in frequency are nervous pain in the region of the liver, or in the rectum or bladder. The main distinctions by which they are separable from true neuralgia are two: in the first place, the character of the pain nearly always is more of the boring or burning kind than of the acutely darting sort which is most usual in true neuralgia; and, secondly, the influence of mental attention in aggravating the pain is far more pronounced than in the latter malady; indeed, it is often possible, by merely engaging the patient in conversation on other topics, to cause the pain to disappear altogether for the time. But in hypochondriasis it is not often that we are left, for any long time, to these means of diagnosis only; the special character of the disease is that the morbid sensations shift from one place to another, in a manner that is quite unlike that of the true neuralgias. The patient who to-day complains of the most severe gastralgia, or liver-pain, will to-morrow place all his sufferings in the cardiac region, or in the rectum, or will complain of a deep fixed pain within his head; and these changes are often most rapid and frequent. Frequently there are also peculiar skin sensations, which usually approach formication in type, and these, like the pains, are apt to shift with rapidity from one part of the body to another. Later on in the disease, especially in those worst cases which approach most closely to the type of true insanity, there are often hallucinations of a peculiar and characteristic nature, such as the conviction of the patient that he has some animal inside him gnawing his vitals, that he is made of glass and in constant danger of being broken, and a variety of similar absurdities. In short, it is not the fully-developed cases of hypochondriasis that need puzzle us, these are usually distinct enough; but the earlier and less characteristic stages in which pain may be nearly the only symptom that is particularly prominent.

In hypochondriasis, as in hysteria, there is often great sensitiveness of the surface; and, as in hysteria, this sensitiveness is found to be very superficial, so that a light touch often hurts more than firm, deep pressure. As in hysteria, too, the tenderness is a phenomenon so greatly affected by the mind, that, if we can divert the patient's attention for a moment, he will let us touch him anywhere, without noticing it at all.

It is a marked peculiarity of hypochondriasis that it is far more common in men than in women; a relation which is precisely the opposite to that which rules in neuralgia. Hypochondriasis is also pre-eminently a disease of adult middle life; it is scarcely ever seen in youth, except as the result of excessive masturbation acting on a temperament hereditarily predisposed to insanity.

The results of treatment frequently assist our diagnosis in difficult cases. Almost any medicine will relieve the pains of the hypochondriac for a time, and it is generally far easier to do him good, temporarily, than it is to relieve a neuralgic patient; but, en revanche, every remedy is apt to lose its affect after a little while. The only chance of producing permanent benefit in hypochondriasis is by the judicious combination of remedies that remove symptoms (especially dyspepsia, flatulence, etc.), which mischievously engage the patient's mind, with general tonics, and, above all, which such alterations in the patient's habits of daily life as take him out of himself and compel him to interest himself in the affairs of the world around him. And, after all, our best efforts will frequently lead to nothing but disappointment.

It is notoriously the fact that hypochondriasis especially affects the rich and idle classes; but it would be a great mistake to suppose that it never attacks the poor or the hard-worked: only, in the latter instances, it apparently needs, for it development, the existence of strong family tendencies to neurotic disease, and especially to insanity. Among the numerous debilitated persons who attend the out-patient rooms of our hospitals we every now and then encounter as typical a case of hypochondriasis as could be found even among the rich and gloomy old bachelors who haunt some of our London clubs. I have one such patient under my care now, who has been a repeated visitor at the Westminster Hospital during many years: he has had pseudo-neuralgic pains nearly everywhere at different times; but his most complaint has been of pain in the groin and scrotum of the right side. The existence of what seemed, at first, like the tender points of lumbo-abdominal neuralgia, at one time led me to believe it was a case of that affection; but I was soon undeceived by finding that the tenderness did not remain constant to the same points, but shifted about. This man has professed, by turns, to derive benefit from nearly all the drugs in the Pharmacopœia; but the only remedies that have done him good, for more than a day or two at a time, have been valerian and assafœtida, with the prolonged use of cod-liver oil. He will never be really cured; and I suspect that the secret of his maladies is an inveterate habit of masturbation acting on a nervous system hereditarily predisposed to hypochondriasis.

Sometimes it happens that the starting-point of hypochondriac pains, simulating neuralgia, is a blow, or other bodily injury acting on a predisposed nervous system. Another of my patients at the Westminster Hospital was a policeman, who had received a severe kick in the groin; he suffered pains which at first seemed to wear all the characters of true neuralgia in the pudic nerve, but afterward shifted to other places and exhibited all the intractability of hypochondriasis; the patient also developed the regular appearance and the characteristic hallucinations of the latter disease. On the last occasion when I saw him, he struck me as likely to become really insane, in the melancholic form; and the probability is that the casualty which he suffered was only accidentally the starting-point of a malady which was inherent in him since birth, and would have been developed, in any case, at some period of his life.

CHAPTER IV.

Considering the vast amount that has been written about this disease during the last few years, it might be thought superfluous for me to give any description of its general features. But it unfortunately happens that there is still great divergence of opinion among authorities as to the true limitation of the group of cases that can properly be ranked under this title, and, indeed, as to the propriety of employing the title at all. The phrase ataxie locomotrice progressive, as every one knows, was applied by Duchenne de Boulogne to a class of cases which really only form a subdivision of the group known under the older title of tabes dorsalis and the most advanced German pathologists maintain that the old word was better, and that Duchenne was altogether wrong in making the one symptom, ataxy of locomotion, the bases of a new phraseology;[49] more especially as his theory as to the seat of the morbid changes was undoubtedly erroneous.

In this country, however, there is as yet no disposition to give up the phrase locomotor ataxy, and it only remains to define with sufficient care the class of cases to which the word is here meant to apply. The disease is understood to depend upon a degeneration of the spinal cord, of which the following description is given by Lockhart Clarke:[50] "In true locomotor ataxy, the spinal cord is invariably altered in structure. Its membranes, however, are sometimes apparently unaffected, or affected only in a slight degree; but generally they are much congested, and I have seen them thickened posteriorly by exudations, and adherent, not only to each other, but to the posterior surface of the cord. The posterior columns, including the posterior nerve-roots, are the parts of the cord which are chiefly altered in structure. This alteration is peculiar, and consists of atrophy and degeneration of the nerve fibres to a greater or less extent, with hypertrophy of the connective tissue, which give to the columns a grayish and more transparent aspect; in this tissue are embedded a multitude of corpora amylacea. Many of the blood vessels that travel the columns are loaded or surrounded to a variable depth by oil-globules of various sizes. For the production of ataxy, it seems to be necessary that the changes extend along a certain length, from one to two inches of the cord. The posterior nerve-roots, both within and without the cord, are frequently affected by the same kind of degeneration, which sometimes extends to the surface even of the lateral columns, and occasionally along the edges of the anterior. Not unfrequently the extremity of the posterior cornua, and even deeper parts of the gray substance, are more or less damaged by areas of disintegration. The morbid process appears to travel from centre to periphery, that is, from the spinal cord to the posterior roots. In the cerebral nerves, on the contrary, the morbid change seems to travel in the opposite direction, that is, from the periphery toward the centres. From the optic nerves it has been found to extend as far as the corpora geniculata, but seldom as far as the corpora quadrigemina. With the exception of the fifth, seventh, and eighth pair, all the cerebral nerves have occasionally been found more or less altered in structure."

The symptoms which occur in cases in which the above are the morbid appearances found after death are (roughly speaking) as follows:[51] "A peculiar gait, arising from want of co-ordinating power in the lower extremities, a gait precipitate and staggering, the legs starting hither and thither in a very disorderly manner, and the heels coming down with a stamp at each step."

No true paralysis in the lower extremities or elsewhere. Characteristic neuralgic pains, erratic paroxysmal in the feet and legs chiefly—pains of a boring, throbbing, shooting character, like those caused by a sharp electric shock.

More or less numbness, in the feet and legs chiefly, in all forms of sensibility, excepting that by which differences of temperature are recognized.

Frequent impairment of sight or hearing, one or both.

Frequent transitory or permanent strabismus or ptosis, one or both.

No very obvious paralysis of the bladder or lower bowel.

No necessary impairment of sexual power.

No tingling or kindred phenomenon.

No marked tremulous, convulsive, or spasmodic phenomena.

No marked impairment of muscular nutrition and irritability.

No impairment of the mental faculties.

Occasional injection of the conjunctivæ, with contraction of the pupils.

The probable limitation of the distinctive phenomenon of locomotor ataxy (the want of co-ordinating motor power) to the lower extremities.

The above description includes all the necessary facts for the recognition of the disease, except one, namely, that the use of the eyesight is always needed in order to prevent the patient from falling during progression; and is usually necessary even to enable him to stand upright without falling.

The pains of locomotor ataxy are early phenomena in most cases, and they are usually present, more or less, throughout the course of the disease.

They are often preceded by strabismus, with or without ptosis; the strabismus, is usually accompanied by amblyopia. It may happen, however, that neuralgic pains are, for a considerable time, the only noticeable phenomena; or they may be attended with a certain amount of anæsthesia.

The most frequent type of the pains is lancinating or stabbing; they are like violent neuralgias occurring successively in various nerves; shifting about from one to another. Sometimes it will happen that the pain remains fixed to one particular nerve for hours together; but it never continues long without showing the characteristic tendency to move about. Most commonly our diagnosis is soon assisted by the occurrence of a greater or less degree of ataxy. But, even before the setting in of definite atactic symptoms, the shifting character of the pains, and the development of a very noticeable amount of anæsthesia, together with the absence of anything like positive motor paralysis, will have given us the necessary clew.

The effect of treatment, or rather its want of effect, usually affords powerful assistance in distinguishing the pains of locomotor ataxy from those of true neuralgia. Even where the pain has been fixed for some hours in a single nerve, and has been stopped by some powerful remedy (such as hypodermic morphia), it will be apt speedily to recur, and frequently in some quite distant nerve.

Locomotor ataxy is a disease affecting chiefly the male sex, and occurring in the immense majority of cases between the thirty-fifth and the fiftieth year.

Not merely is it strictly limited to individuals who belong to families with neurotic tendencies, but it is itself frequently seen to occur in several members of the same family, and sometimes of the same generation. When, therefore, we meet with neuralgic pains of the shifting type above described, it is very important at once to make careful inquiries whether any members of the family have suffered from symptoms of ataxy going on to a fatal result. Otherwise, we might be the more readily deceived into the idea that the pains were merely neuralgic, because the symptoms of the disease are not unfrequently provoked by such causes as fatigue and exposure to cold or wet, which are also very ordinary exciting causes of true neuralgia.