The Project Gutenberg eBook of A Treatise on Acupuncturation, by James Morss Churchill.

A TREATISE
ON
ACUPUNCTURATION, &c.
DEDICATED, BY PERMISSION,
TO
ASTLEY COOPER, Esq. F. R. S.

A TREATISE
ON
ACUPUNCTURATION;

BEING
A DESCRIPTION OF A SURGICAL OPERATION ORIGINALLY PECULIAR
TO THE JAPONESE AND CHINESE, AND BY THEM
DENOMINATED

Now introduced into European Practice,
WITH

DIRECTIONS FOR ITS PERFORMANCE,

AND

CASES ILLUSTRATING ITS SUCCESS.

BY

JAMES MORSS CHURCHILL,

MEMBER OF THE ROYAL COLLEGE OF SURGEONS IN LONDON.

SOLD BY E. COX AND SON, ST. THOMAS’S STREET; J. CALLOW, PRINCE’S STREET, SOHO; MESSRS. UNDERWOOD, FLEET STREET; BURGESS AND HILL, WINDMILL STREET; AND J. COX, BERNERS STREET, OXFORD STREET.

TO
ASTLEY COOPER, ESQ.
THE STEADY FRIEND AND PATRON OF HUMBLE MERIT,
THE AUTHOR RESPECTFULLY INSCRIBES
THIS LITTLE TREATISE;
LESS FROM PRESUMPTION OF ITS DESERVING
HIS APPROBATION,
THAN
AS A MARK OF RESPECT
FOR SPLENDID ACQUIREMENTS,
AND OF
GRATITUDE,
TOWARDS A GREAT MASTER.

Preliminary Remarks.

IF the medical profession merit the reproach, of being easily deluded into an admiration of novelty, then I need use no apology for introducing the following pages to notice, nor will my subject stand in need of prefatory allurements to obtain attention; but if on the other hand, a rational theory, built on4 sound logical reasoning, be the only evidence to which any value can be attached, then will my efforts have been unavailing and fruitless. Under the impression, however, that there exists a desire for speculation and discovery on the one hand, regulated and qualified by a moderate and proper degree of scepticism on the other, I shall presume a medium of the two extremes, and proceed without apology or preface to my subject, trusting, that the interesting facts which I have to relate, will elicit such attention and investigation, as will kindle a desire in some men, at least, to become acquainted with a process, which appears to rival the most successful operations for the relief of human sufferings.

I should not have taken the tales which are told of the wonderful cures effected by this operation amongst the original founders of it, as sufficient authority for recommending it, nor would I admit the fables which are promulgated by these people, as evidence of its efficacy, had not this efficacy been witnessed by European spectators on its native soil, and at length experienced in our hemisphere; and even, latterly, in our own country.

The operation of acupuncturation has been seen by so few Europeans, that our books have made us acquainted with little more than its name. It is of6 Asiatic origin, and China and Japan peculiarly claim it as their own. A writer in the year 1802, mentions a discovery of its having been practised by the natives of America, and refers to Dampier’s voyages for an account of it; but I have in vain followed Capt. Dampier’s relation of his adventures, in crossing from the South to the North Sea, over the Isthmus of Darien, for any account of the operation, for he does not so much as name it. He speaks of a work intended to be published by his surgeon, Mr. Lionel Wafer, who accompanied the expedition, and to which he refers his readers for an account of the manners and customs of the interior of the country. Mr. Wafer was detained, from an accident, a considerable time7 amongst the Darien Indians, and did, on his return to England, publish this book, which I have therefore been at the trouble of perusing, but do not learn from it, that the operation of acupuncturation was practised in that part of America: it is true, Mr. Wafer describes a method of blood-letting employed by the natives, which is somewhat correspondent to acupuncturation, but both the intention and the effect are widely different. This operation is effected in the following manner: the patient is taken to a river, and seated upon a stone in the middle of it. A native, dexterous in the use of the bow, now shoots a number of small arrows into various parts of the body. These arrows are prepared purposely for this operation,8 and are so constructed, that they cannot penetrate beyond the skin, the veins of which, opened by the puncturation, furnish numerous streams of blood, which flow down the body of the patient. If this be the operation which has given rise to the idea, that acupuncturation is practised by the American natives, the conclusion is evidently erroneous, as it is simply a method of blood-letting, and is generally resorted to for the cure of fever. Now, acupuncturation has no reference whatever to bleeding, and it is rare, that even a drop of blood follows either the introduction or withdrawing of the needle; nor does it appear, that the Chinese and Japanese, with whom it originated, intended it as a method of abstracting blood,9 which is proved, not only by the consequences of the operation, but by the manner in which it is performed, and the nature of the diseases to which it is applied. If it could have been established, that the natives of the American Isthmus were acquainted with it, it would have been a curious, as well as an interesting enquiry, to ascertain whence they derived it.

It is a little strange, that the surprising efficacy, of which so much has been boasted by its eastern professors, and the safety, at least, with which acupuncturation may be performed, having been so fully demonstrated; it is strange I repeat, that it has not met with an earlier encou10ragement amongst us. It is probable, that the hyperbole in which it has been related, has induced the sober minds of our Northern soil, to treat these relations as the fictions of Eastern imagination, and to reject them without examination, as fables calculated only for amusement. There have not, however, been wanting sensible minds, and men of talent and reputation, to recommend this operation; and the names of Ten-Rhyne, Bidloo, Kœmpfer, and Vicq-d’Azyr, stand conspicuous on the list of those who speak in its favour; but still, neither of them had undertaken to put its merits to the test, by actual experiment. Several practitioners in France, however, have now taken up this neglected operation, and11 their report verifies the praises which have been bestowed by others upon it. My attention was lately directed to it by my friend Mr. Scott, of Westminster, who, as far as my knowledge goes, was the first who performed it in England, and some successful cases which I witnessed in his practice, assured me of its efficacy, and led me to its adoption. The success of my own subsequent practice, warrants a recommendation of it, in almost any terms I could give it; but I shall content myself in laying before my readers, the opinion and experience of some physicians of eminence, accompanied by a relation of some cases of my own, where the benefit of the operation has been decidedly successful; upon a better foundation than12 which it cannot at present rest for public examination; it remains for the medical profession to ascertain its claims to attention by the test of experience, and having undergone the ordeal of experimental enquiry, it will, I have no doubt, so fully develope its merit, as to obtain a conspicuous rank in medical estimation, as a valuable curative measure.

ACUPUNCTURATION.

The method of performing the operation of acupuncturation is simple and easy, requiring neither practice to give dexterity, nor adroitness that it may be done with propriety. Anatomical knowledge of the human body is, however, necessary; as an imprudent application of it, by an operator ignorant of the structure of the part into which he introduces his needle, might be productive of bad consequences. To a surgeon, however, properly qualified, (and no other ought to perform this or14 any operation) no danger can arise; as the cautions are but few, and no risk is incurred, if they are attended to. It is only necessary that the operator, in introducing the needle, should avoid the course of large vessels, of nervous trunks, and of the tendons of muscles. It is not, however, proved, that the latter sustain injury from the puncture of the needle; but it is as well to avoid the possibility of mischief, by such a cautious mode of introducing the instrument, as shall be divested of risk. I cannot better familiarize my subject to the reader, than by a sketch of it in its native state; and as an excellent description of the operation, as performed by the Japonese natives, is given in the ninth volume of the “Mo15dern part of an Universal History, from the Earliest Account of Time,” I shall extract it, as containing all that is known of its original practice.

“The place made choice of for the puncture, is commonly at a middle distance between the navel and the pit of the stomach, but often as much nearer to, or farther from either as the operator, after a due scrutiny, thinks most proper; and in this, and the judging rightly how deep the needle must be thrust below the skin, so as to reach the seat of the morbific matter, and giving it a proper vent, consists the main skill of the artist, and the success of the operation is said to depend. Each row hath its particular name,16 which carries with it a kind of direction, with regard to the depth of each puncture, and the distance of the holes from each other, which last, seldom exceeds half an inch in grown persons, in the perpendicular rows, though something more in those which are made across the body, thus,

The needles which perform the operation are made, as was hinted at first, either of the finest gold, or silver, and without the least dross or alloy. They must be exquisitely slender, finely polished, and carry a curious point, and with some degree of hardness, which is17 given by the maker by tempering, and not by any mixture, in order to facilitate their entrance, and penetrating the skin. But, though the country abounds with expert artists, able to make them in the highest perfection, yet none are allowed, but such as are licensed by the emperor.

“These needles are of two sorts with respect to their structure, as well as materials; the one, either of gold or silver indifferently, and about four inches long, very slender, and ending in a sharp point, and have at the other end a small twisted handle, which serves to turn them round with the extremity of the middle finger and thumb, in order to sink them into the flesh with greater ease and safety;18 the other is chiefly of silver, and much like the first in length and shape, but exceedingly small towards the point, with a short thick handle, channelled for the same end of turning them about, and to prevent their going in too deep; and for the same reason, some of them are cased in a kind of copper tube, of the bigness of a goose quill, which serves as a sort of guage, and lets the point in, just so far as the operator hath determined it. The best sort of needles are carefully kept in a case made of bull’s horn, lined with some soft downy stuff. This case is shaped somewhat like a hammer, having on the striking side a piece of lead, to give it a sufficient weight, and on the outside a compressed round piece of lea19ther to prevent a recoil, and with this they strike the needle through the thickness of the skin; after which they keep turning the handle about with the hand, till it is sunk to the depth they design it, that is, till it is thought to have reached the seat of the morbific virus, which in grown persons is seldom less than half, or more than a whole inch: this done, he draws it out, and compresses the part, in order to force the morbific vapour or spirit out.

“The directions and nice rules for the performing of this curious operation are many, and require great skill and attention in the operator; and when duly performed, may be of excellent use, not only20 against the excruciating distemper, called Senki, but against many other topical ones, which are most commonly cured by the Indian Moxa, and other caustics. On the other hand, these last are often tried against the distemper above mentioned, by applying the caustic to the belly, on each side of the navel, and about two inches from it, but mostly without any success, it being very unlikely that such an application should reach the seat of the distemper; whereas, the benefit which has accrued from the acupuncture, in that one disease, hath encouraged others to apply it indifferently to other parts of the body, where the moxa is used, and by a due care and precaution not to prick any nerves, tendons, or other21 considerable blood vessels, have cured their patients by it, without putting them to the excruciating torture which attends that of the Moxa, or other caustics.”

From the little we have learned of the practice of this operation amongst the Asiatics, it would seem, that it was chiefly diseases of the abdominal cavity and viscera, which afforded opportunities for its performance, such as Colic, Tympany, &c. It is not in such diseases, however, that I have any experience of its use, but it is questionable, whether it might not be beneficial, particularly in the latter, and I would beg to recommend it as a matter of interesting experiment, to be tried in this malady;22 such an opportunity, should it fall in my own practice, I shall take advantage of.

The Indians, however, do not confine their practice of Acupuncturation (or Zin-king, as they call it) to diseases of this kind. They puncture the head in all cases of Cephalalgia, in Comatose affections, Ophthalmia, &c. They puncture the chest, back, and abdomen, not only to relieve pain of those parts, but as a cure for Dysentery, Anorexia, Hysteria, Cholera Morbus, Iliac Passion, &c. Local diseases of the muscular and fibrous structures of the body, also often afford them occasions for its performance; and it is for diseases of this class only, that I have hitherto practised23 it, and for which I would expressly recommend it.

Neither sufficient time has elapsed, nor a proper selection of cases been made since this operation has been known to me, to have afforded me, either a large number of experiments, or a great variety of diseases on which to try the effects of it: it is true I have employed it on some few, and I have it in contemplation to encrease the list, by giving my experiments a wider range, but at present I should not be doing justice to my subject, to form conclusions on such imperfect evidence; I shall therefore confine myself, merely to the description of the good effects, which I have witnessed24 in diseases of a rheumatic character, and in those injuries of the fibrous structures of the body, which are often observed to arise, (particularly in labouring persons) from violent exertion. This circumstance must be ever in view, and if it be not fully impressed on the mind, I doubt not but many who may be induced to try the effect of the operation, may be disappointed in it; viz. that acupuncturation does no good, nor does it produce even a temporary alleviation, when the disease for which it is used, is of an inflammatory character. This distinction seems to have regulated the practice of those, who have experimented on the subject, and to have decided them in their selection of cases for the operation. Mr. Berlioz,25 of Paris, has practised it extensively, and has recently published an account of the success which it has had in his hands.1 He says,

“The eulogia given to acupuncturation by Kœmpfer and Ten-Rhyne, are just and merited. We have reason to feel surprized, that although an age or more has elapsed, since this curative measure has been known in Europe, no physician has made trial of its efficacy. The practice of the operation is attended with but little pain, and the success of it is so prompt, that the disease is alleviated or entirely ceases, as soon as the needle has been introduced the depth of a few lines; 26most frequently, however, the pain is not removed by the first introduction of the instrument, and it is not until after the use of it for a second, third, or fourth time, that the cure is completed. Simple nervous affections, especially demonstrate how much acupuncturation merits the attention of physicians, for there are but few remedies possessed of such prompt activity, and which produce such wonderful effects.

“But acupuncturation does not appertain in any respect to sanguineous evacuations,2 it can only contribute sometimes 27to establish the indications for them. This operation is not indeed followed by any success, when the disease depends upon sanguineous turgescence and inflammation.

“In contrary circumstances, Acupuncturation, by dissipating the symptoms, demonstrates, that disorder of the nervous system only had given rise to them.”

The only cases of Rheumatism in which I have been successful with the operation, 28have been of the Rheumatalgic form, or that which is divested of external inflammation; characterised by pain upon motion, stiffness and coldness of the part; the disease having a disposition to change its place; is aggravated by atmospheric changes, and relieved often by stimulant Diaphoretics, Narcotics and external warmth: but I have yet met with success in some cases where the intensity of the pain would have led me to believe, that considerable inflammatory action must have given rise to such exquisite nervous sensibility.

Mr. Berlioz in speaking of the diseases to which this remedy is applicable, says, “vague and wandering Rheumatism sometimes attacks the external muscles subser29vient to respiration; the patient is obliged to remain motionless; every motion of the trunk compels him to cry out; a deep inspiration is very difficult, and coughing occasions such cruel pains, that expectoration is impossible. Acupuncturation dissipates instantly this state of distress, and renders to the muscles their full liberty of action. In the space of one or two minutes, a patient whose sufferings drew from him tears, exclaims he is quite cured.”

These observations of Mr. Berlioz are fully substantiated by the experience of Dr. Haime of Tours, who has devoted much time and attention to the operation of Acupuncturation, and has lately published a most interesting paper upon the30 subject in the 13th volume of the “Journal Universel des Sciences Medicales,” at Paris.3

The doctor declares that his own practice bears evidence of the fidelity of the preceding remarks of Mr. Berlioz. He accuses the Japonese and Chinese, (to whom this operation he says is peculiar practising,) practising it too extensively, which has been partly the cause of its being disregarded by Europeans, and acknowledges that it was to Mr. Berlioz’s cases, which he has related in his “estimable work,” that he owed the fortunate application which he has made of this measure.

The following cases are given by Dr. Haime, which he says support the Theory of Mr. Berlioz.

“Antoinette Boulard, 38 years of age, had experienced in April 1818, a severe attack of Rheumatism, which fixed on the inferior part of the left side of the chest; it gave way in 48 hours to the use of some sedatives, the tepid bath, and the application of a blister to the part in pain.

“Six weeks afterwards I was called to see this woman, who had fallen again into the same state. I found her with the trunk in a state of inability of action, the motion of the respiratory muscles extremely difficult, and the plaintive tone of voice indi32cated the violence of the pain, which drew from her cries on the least motion. The pulse was small and concentrated, but without sensible acceleration; the body was covered with cold sweats; and the unhappy patient, altogether, was in a state of inexpressible anguish. I thought it right to have recourse to the same remedies which had been successful on former occasions; but my hopes were deceived. Three days were passed in this state, and Antoinette obtained no relief: I determined therefore to practice acupunctuation. I introduced a needle 4 at the inferior margin of the cartilages of 33the false ribs. The instrument had hardly passed to the depth of a few lines, when the patient said the pain had changed its seat, and was descended into the abdomen, at the same time that it had lost much of its violence. I continued the introduction to the depth of an inch; by this means the pain was driven from the abdomen, and permitted the patient to breathe freely: however I maintained the needle in its place for five minutes, and then made a second puncture, and successively a third, in the place where the disease had taken refuge. This third puncture made the pain totally disappear, and the patient cried out that I had restored her to life. Sleep of eight hours duration and a state34 of perfect calmness succeeded this operation.

“However Antoinette sent for me on the following day, saying her sufferings had returned, but with less violence, and entreated me with much earnestness that I would repeat the operation “seeing” she said, “that it was only the sound,” (for so she named the needle) “which gave her relief.” The operation was this time still more successful. The treatment was now continued for four days, and the last puncture so entirely relieved the pain, that it has not since returned.”

“A woman had suffered for several days with wandering Rheumatic pains, which continued daily to encrease in violence; there were however at all times fixed pains in the shoulder and in the right arm, which acquired such a degree of intensity by intervals, that the patient could not refrain from crying out. She was in this state when she came to consult me: finding, however, neither alteration in the pulse, nor encrease of heat, nor redness of the skin, nor tension, nor swelling in the part affected, I considered the case to be simple Rheumatalgia, and passed the needle to the middle of the arm, between the fibres of the Triceps Brachialis muscle; the place designated by the patient as the seat of the pain.36 The pain was driven into the fore arm, and the second puncture caused it to descend into the hand, and a third being made in this part, caused it totally to disappear, and the patient said with delight and astonishment, she was cured; and was so satisfied with this treatment, that she spoke of it to every body. I have not since seen her, although I requested her (and she promised) to return in the event of a relapse.” But the most remarkable case which has occurred to exemplify the triumphant effects of acupuncturation, was that of a girl of 24 years of age. She was naturally healthy and robust, and had enjoyed good health till she was 15 years old, at which time the signs of puberty were manifested.37 At this period the system became much disturbed, menstruation was established with difficulty, and continued with irregularity; she lost her cheerfulness, and symptoms of the nervous temperament became predominant.—Various nervous symptoms now evinced themselves, and amongst others an obstinate vomiting occurred, which subsided only during very short intervals. She continued in this state for two years 5. From this time she gradually got worse, and in addition to the habitual vomiting which she had endured from the age of 16, she suffered extremely from violent general convulsions. Some medicines were now 38given which relieved the sickness, and the use of the cold bath suspended the convulsions. After the treatment had been continued two months, she was visited by Dr. Haime, (to whose description of this interesting case, I am indebted for these particulars,) who found her labouring under partial convulsions, with a disposition to vomit occasionally. The means which had been before employed were still continued, but the symptoms became more aggravated, but were a little subdued by blood-letting from the saphena vein. The convulsions were almost wholly removed, at least had become only partial; the spasmodic efforts being concentrated on the diaphragm and stomach; but a nervous hiccup supervened39 which acquired such a degree of intensity, that the unhappy patient experienced no intervals of ease. All the known antispasmodic remedies were now tried during the space of six months without any benefit. Blisters to the pit of the stomach afforded no sort of relief, and the cold bath gave but a short and temporary alleviation. Scarifications followed by the application of a cupping glass were made on the side of the Dorsal Vertebræ, and the situations corresponding to the pillars of the Diaphragm, which suspended the symptoms but for a few days: relief was only partially obtained by the cautery, and the hiccup returned with its original force accompanied with such a convulsive affection of the stomach, that this organ40 appeared to act like a pair of bellows, alternately receiving and expelling large quantities of air. At length when the hiccup ceased, it was replaced by partial convulsions or some other symptoms, and vice versa.

Seeing the want of success of all attempts to cure this obstinate disease, and reduced to the necessity of remaining a mere spectator of its dreadful effects, Dr. Haime consulted every book which he conceived might give him some information by which some other curative measure might be suggested; but his researches were totally unsatisfactory, until he met with Dr. Berlioz’s observations upon Acupuncturation, when, not less41 struck with the curious facts which Dr. Berlioz relates, than with the efficacy which it was reported to possess in nervous diseases, he resolved to try it as a sort of forlorn hope, upon his present patient: he accordingly proposed it to her, and readily obtained her consent to its performance. He communicated his intention to Doctor Bretonneau, Physician to the general hospital, who had seen the case with him, and had often spoken of it; and in his presence he performed the operation for the first time. A needle was introduced perpendicularly at the centre of the Epigastrium, and the two physicians soon became convinced of the astonishing promptitude of the remedy; for the instrument had hardly42 passed to the depth of a few lines, when the symptoms vanished as it were by enchantment. The operation not appearing to be painful to the patient, the introduction of the needle was continued to half its length, in depth from twelve to fifteen lines, where it was suffered to remain for five minutes. The result was a perfect calmness, and a total suspension of the hiccup for three days, when the same symptoms returning, the needle again was had recourse to, and with the same efficacious effect as at first; and the operation was performed again and again, at longer or shorter intervals, according as the symptoms re-appeared, and always with the same advantages. Dr. Bretonneau became convinced of its efficacy by43 himself performing it several times. The treatment of the case was thus continued, selecting the part for the introduction of the needle, according to the situation of the symptoms which each operation was intended to alleviate; and Dr. Haime asserts, it never once failed of success; for the convulsive motions of the head, the instrument was passed into the muscles of the neck; into the masseter muscle, to relieve constant gaping; and into the fore arm when these muscles were affected; and thus, by pursuing the disease as it were, the convulsive disposition was entirely removed, and the patient restored to health.

For the fidelity with which I have reported this case, I refer the reader to44 Dr. Haime’s own record in the 13th volume of the “Journal Universal des Sciences Medicales,” and should further evidence of the efficacy of this remedy be necessary from other authority, I have but to mention the experience of Dr. Demours of Paris, who has recently confirmed 6 the report of Messrs. Berlioz and Haime. He dwells with particular force upon its good effects in Ophthalmia, for which he directs five or six needles to be passed between the fibres of the supraspinatus muscle. His method of performing the operation I shall presently notice when describing this part of my subject. The following cases which have occurred in my own practice, I shall now 45lay before my readers, and I doubt not but I shall make it appear that the beneficial effects of the remedy employed, are sufficiently flattering to deserve the esteem I hold it in, and to justify me in bringing the subject into general notice.

CASE I.

George Mc’Laughlan, about 30 years of age, a Bricklayer by employment, came to my house in November last, supporting himself by a stick in one hand, and resting the other against the wall, as he proceeded. The body was bent at nearly right angles with the thighs, and his countenance indicated acute suffering. He had been attacked, he said, three days before, with darting excruciating pains in the loins and hips; every motion of the body produced an acute spasmodic pain, resembling47 an electric shock; and the attempt to raise the body to an upright position was attended by such insupportable agony, as obliged him to continue in this state of flexion rather than encounter it by altering his position. There was no more constitutional disturbance than was to be expected from three days and nights of constant pain; the pulse was a little quickened, and the tongue white, but I attributed this derangement to the irritation set up by the pain and loss of rest. I directed him to place himself across a chair for support during the operation, and I immediately introduced a needle of an inch and a half in length into the lumbar mass on the right side of the spine; in two minutes time I observed48 that he seemed to rest the weight of his body more on his limbs, and in the next instant, without any enquiry being made, he observed, that he felt his limbs stronger from the “pain having left his hips.” He next plainly indicated that the disease was lessened, by raising his body; from which he only desisted, by being desired to remain at rest, through fear of the needle being broken. The instrument having remained in its place about six minutes, the patient declared he felt no pain, and could, if he were permitted, raise himself upright; it was then withdrawn; the man arose, adjusted his dress, expressed his astonishment and delight at the sudden removal of his disease, and having made the most grateful acknow49ledgements, left the house with a facility as though he had never been afflicted. The relief was no doubt permanent, as he did not return, which he would most probably have done, had he suffered a relapse.

CASE II.

William Morgan, a young man in the employment of a timber merchant, felt a violent pain suddenly attack the loins whilst in the act of lifting a very heavy piece of mahogany. The weight fell from his hands, and he found he was incapable of raising himself. He was immediately cupped and blistered on the part; but two days had passed and he was still labouring under considerable pain, augmented violently by every motion of the body. On the third day the51 operation of Acupuncturation 7 was performed upon the part of the loins pointed out as the seat of the injury, which, as in the former case, dissipated the pains in five or six minutes, and restored the motions of the back. He returned, however, the next day, with the same symptoms as at first, but in a mitigated degree. A needle was now passed to the depth of an inch on each side of the spine, which, as I expected, terminated the disease in a few minutes, and it was with pleasure that I understood the next morning, that the man had gone to his usual employment.

This case illustrates the observations of the French physicians before cited, as 52to the efficacy of the remedy in injuries of this description: it is true that in my own practice it is a solitary example; but so decisive was the benefit derived from it, that the case proves a powerful corroboration of both Mr. Berlioz’s theory and practice.

CASE III.

Elizabeth Jacks, a married woman, aged 44 years, was admitted into one of the public hospitals of London, in the year 1817, for an enlarged Bursa situated under the Rectus Femoris muscle. Soon after her admission she was attacked with violent pains in the limbs, which continued to affect her with greater or less violence, till the month of October, 1820, when a severe rheumatic state of the back of the head and of the loins supervened; the one preventing flexion of the neck,54 the other of the back. Her digestion continued unimpaired, the pulse about its natural standard, without hardness or acceleration. Her nights were passed without sleep, and every motion of the body was performed with pain and reluctance. In this state she applied to me, and I gave her antimonials combined with opium, keeping the bowels open with gentle aperients. Under this treatment, she was in some degree relieved, but as she laboured under the impression that nothing could be done to eradicate the disease, she discontinued it after a short time, but in a few days afterwards (Nov. 4th,) Mr. Carpue was requested to see her; he prescribed ten grains of Dover’s powder, to be taken every night at bed55 time: this dose she took twice without any benefit. The pains had now entirely left the parts they at first occupied, and had fixed on the intercostal muscles above and below the seventh and eighth ribs on each side of the chest; whence, to avoid the insupportable anguish occasioned by the action of these muscles in the process of respiration, this function was (or at least appeared to be) wholly supported by the Diaphragm, the abdominal muscles, and the large external muscles of the neck, chest and back. No other force but that of pressure upon the situation corresponding with the interstices of the ribs gave any uneasiness, but on these parts, the slightest pressure produced intolerable pain: this plainly56 proved that the disease affected the intercostal muscles alone. Peritonœal inflammation ensued, and the suffering which this occasioned, banished for the time, all attention to the original disease; but no sooner was this removed, (which was effected by the most active means) than the patient found that she was still the victim of an unrelenting malady, which had now pursued her upwards of three years. Acupuncturation now recurred to me as a probable mean of relieving her from her sufferings. I accordingly introduced a needle between the sixth and seventh ribs, and another between the seventh and eighth of the right side; in two minutes the patient became sensible of relief, and in two or57 three minutes more, that side of the chest was emancipated from the disease.

The same operation was now performed on the other side, though the good effect was not equally extensive on this as on the right; yet the patient respired now with so much comparative freedom and ease, that she exclaimed, she should “soon be quite well.”—The following day but one, there was a little augmentation of the pain on both sides of the chest, but a single needle introduced into each part, entirely removed it. No return of pain after this time visited the right side, but the left, still continued to be attacked; until at length the third introduction of the needle, dissipated it58 permanently, and the patient has since remained free from the disorder. The needles in every instance were suffered to remain in the part about five or six minutes.

CASE IV.

Hannah Howard (a female servant in my house) aged 25 years, became in September last the subject of Rheumatalgia. The shoulders, arms, back and hips, were the parts selected by the disease for its wandering peregrinations. Antimonials, Opium, Guaiacum, Hyosciamus, &c. relieved her occasionally, but at the end of three months, metastasis to the heart suddenly took place. I was called hastily to her at this time; she had fainted, and when recovered from60 the syncope, complained of violent pain about the region of the heart, which she informed me had troubled her more or less for several hours. Her pulse was hard, and beat somewhat about 106 in a minute; but from its extreme irregularity, it could not be measured with exactness; nor if it might, would it have been found, I believe, to have preserved an uniformity within any two given periods; as both its intermissions and its actions of rapid velocity were produced at uncertain and variable intervals. Copious bleeding, blistering, cupping, with the use of digitalis and colchicum, at length removed the disease; and in three weeks she was able to leave London, to try the effect of country air in restoring her61 health and strength. She returned to town after a short time, perfectly recovered; and continued so, until an exposure to wet brought on another attack of rheumatalgia; which, after variously shifting its seat for several days, now fixed itself on the left side. The remedies which had formerly been of service, were now taken without relief; and the colchicum 8 (which in most cases of rheumatism will be found, after bleeding, more valuable than any other article of the materia medica) was totally inert. The 62pain had now acquired such a degree of violence, that the slightest motion of the body gave the most exquisite agony; and so intense was this state of suffering, that the patient could not be urged to speak in a tone loud enough to be conveniently heard, through the fear of exciting an exacerbation of pain, which even such slight motions occasioned. I now had recourse to acupuncturation; having introduced a needle through the integuments covering the interstice of the 8th and 9th ribs, at the part corresponding to the junction, with their cartilaginous epiphises, I continued to press it gently forward, by rolling it freely between my fingers. When it had penetrated to about two thirds, its whole depth (an inch)63 I enquired if she experienced either pain from the puncture, or relief from the disease; she replied, “she scarcely felt the instrument, but that her rheumatism had suddenly abated of its violence;” and to my surprise, this reply was expressed in her natural tone of voice. She added, “that she could now speak and breathe freely,” so that I now found her former taciturnity, which I had attributed to moroseness, was banished. I continued the introduction of the needle, and in a few minutes the disease was dislodged, and fled to the back of the chest, near the angle of the ribs. The motions of the shoulder were now restored to their utmost freedom, and I withdrew the needle, and inserted it into64 the part which had become the seat of the pain, about two inches from the spinal column. The disease soon began to dissipate itself totally; the patient said she was free from uneasiness, and could make a deep inspiration without pain. The instrument having been retained in its place five or six minutes, was withdrawn; the chest had regained its full liberty of action, and the utmost variety of flexion of the body could be used, not the slightest inconvenience ensuing. The next day, however, the pain again visited the anterior part of the chest, and I again had recourse to the needle. The operation was completely successful; for excepting a slight darting pain, which occasionally troubled her for a few days after65wards, no symptoms of the disorder remained, and she continues at this time to attend to the duties of her station in my family.

Whilst occupied with the preceding pages, I received the following communication from my friend, Mr. Jukes; which I subjoin as the strongest corroborative evidence of the efficacy of the practice under our consideration.

“Great Peter-Street, Westminster,
xxxxxFebruary 27, 1821.

My Dear Sir,

In compliance with your request, I send you an account of the effect of Acupuncturation 66 on our friend Mr.Scott.9 I received an urgent message on the morning of the 18th inst. from that gentleman, requesting I would visit him instantly. I found him in bed; and, with a countenance expressive of much anguish, he informed me, that for three days he had been suffering severely from pain in the loins, which he attributed to leaving a warm room during one of the late foggy nights. Within the last 12 hours it had acquired such a degree of violence that even respiration was insupportable, except the body were fixed in such positions as permitted the least possible motion. An attempt to resume the erect posture, produced violent spas67modic action of the muscles of the back, which appeared to be communicated by sympathy to those of the abdomen and chest, impeding respiration with a convulsive effort; nor could any motion of the body be made without producing this distressing effect. Neither fever nor general derangement was present; the secreting organs of the body properly performing their function, proved the external locality of the disease. In this state of things, Acupuncturation presented itself to us as likely to afford relief, and it was therefore immediately resorted to.

“I applied an exhausted cupping glass upon the integuments, opposite to the 68second lumbar Vertebra, and midway between this bone and the edge of the Latissimus Dorsi muscle of the right side, which was the part referred to as the most concentrated spot of the disease. As soon as a needle had penetrated to the depth of an inch, a sensation arose, apparently from the point of the instrument, which the patient described as resembling that which is produced by the passage of the electric aura, when elicited to a metallic point, diffusing itself at first to some distance around the part, and then extending itself up the side to the Axilla. This sensation continued to be felt for the space of a minute, when a violent pain struck into the right iliac region, immediately above, and corresponding with the line of, the 69Crista of the Ilium. No pain was now felt in the back, except a dull aching of about two inches in breadth on the right side of the spine, extending from the lower part of the neck to the Sacrum; corresponding with the situation and course of the Longissimus Dorsi Muscle. The pain above the hip now began to subside and in the space of three minutes from its commencement, had ceased altogether.

“The uneasiness along the course of the spine still remaining, a needle was introduced about an inch from one of the upper Dorsal Vertebræ, and another in a corresponding situation to one of the lower Lumbar Vertebræ. The pain in the right70 side was in a few minutes entirely dissipated, and the patient arose, declaring, that, excepting a slight degree of uneasiness on the posterior part of the chest, near the angles of the inferior ribs of the left side, he was completely relieved from the disease. He, however, requested I would pass a needle in this last situation; on effecting which the pain soon left its last refuge, and the patient dressed himself, and left his house in the most perfect health. 1 have this day seen him, and he assures me that he has not experienced any return of the affection.

“I should have stated that the sensation, described as resembling somewhat an electrical effect, was experienced from 71two of the needles only; the first and the last of those which were introduced.

“I send you the history of this case without any comment upon the mysterious nature of this extraordinary operation; yet I am convinced there is something more in it than has been hitherto explained. I have, it is true, some notions (not however fixed) as to its nature; but I would not at present venture to detail them, lest the embers of animal magnetism might be rekindled in the discussion, and the operation from being associated with an ex72ploded theory, sink into undeserved and premature oblivion, from preconceived prejudice.

I am, dear Sir,
xxxxxxxxxxYour faithful friend,
xxxxxxxxxxxxxxxxxxEDWARD JUKES.”

Conceiving that the foregoing cases will be as satisfactory as a larger number would, I shall not trouble my readers with a more minute detail.

I could certainly add many others to the list; but to minds open to conviction73 and truth, no stronger impression would be made by multiplying examples; whilst the sceptical, would “not be persuaded, though one rose from the dead.”

The Operation of Acupuncturation described.

The first step necessary to the performance of this operation, is the selection of a proper apparatus. It is not requisite, however, that our needles be either of gold or silver, as those of the Japonese are; although it is true that the flexibility of these metals prevents the risque of their breaking; but I have not heard of, or seen, any instance of such an accident with the steel needle, which is the material employed in European practice. It may however be left to the discretion of the surgeon, whether he uses the former or not; it is only of conse75quence, that the extremity should be finely pointed, and preserved so.

Mr. Berlioz uses a steel needle, three inches in length, which has a head given to it of melted sealing wax. This needle is introduced to such a depth as the operator thinks proper, depending on the part in which it is used, as well as the nature of the disease which it is intended to remedy. If it be intended to puncture any of the viscera, such a needle will indeed be wanted; but it will be seen by the practice of the French physicians, that though they have sometimes thought it right to penetrate the visceral cavities to the whole depth of this needle, yet it is but seldom that more than one inch of76 it has been sunk into the part. I have not, in my own practice, ventured to use needles of greater length than one inch, and one inch and a half; and the instrument which I use is an ingenious adaptation of a common sewing needle to an ivory handle, constructed by Mr. Edward Jukes, Surgeon Accoucheur to the Westminster Medical Institution (see plate, fig. 1 and 2.)

Dr. Haime, and I believe the French surgeons who practice acupuncturation, use this long needle (three inches) and Mr. Demours, who appears to be a man of considerable mechanical genius, has lately invented a new apparatus for this purpose. An exhausting syringe is fitted77 to the side of a cupping glass, which can be unscrewed and removed after the exhaustion has been effected by a few strokes of the piston, leaving the glass affixed to the part. From the top of the glass proceeds a hollow staff, in which slides (the tube being air tight) a handle, armed with a three inch needle, which is inserted to any depth the operator chuses.

The theory which Mr. Demours gives in defence of this instrument is, that the sensibility of the part is so much lessened by the conjestion occasioned by the suction of the pump, that the instrument passes without producing the least pain, whilst at the same time it penetrates78 deeper, and more readily, through the tumefaction occasioned by the turgescence of the sanguineous capillaries and lymphatics. These advantages, he says, being only obtained by the operators ability of passing the needle whilst the surface of the body remains in the state of tumefaction, he contends they cannot possibly be derived from the simple process of affixing a common glass by the flame of a taper, as the tumor subsides the instant the glass is removed.

I do not think it, however, a matter of any moment, whether a cupping glass be applied or not; it may, certainly, lessen the sensibility of the part, and consequently diminish the pain occasioned by79 the needle; but this is in general so trifling, that no preparatory steps are required to mitigate it; in fact, it deserves so little the name of pain, that the patient is often unconscious of the needle having penetrated.

The Japonese and Chinese drive in the needle by the stroke of a mallet. This instrument, in use amongst the former, is made of ivory, with holes, sunk on its surface in the same manner as a lady’s thimble, which prevent the hammer from sliding off when the stroke is given. Such a method is however objectionable, as well from the danger there would be of breaking a needle not possessing flexibility, as from its being more painful to the patient.

The handle of the needle being held between the thumb and fore finger, and its point brought into contact with the skin, it is pressed gently, whilst a rotatory motion is given it by the finger and thumb, which gradually insinuates it into the part, and by continuing this rolling, the needle penetrates to any depth with facility and ease. The operator should now and then stop to ask if the patient be relieved; and the needle should always be allowed to remain five or six minutes before it is withdrawn. This mode of introducing the needle, neither produces pain (or at least very little) to the81 patient; nor is productive of Hœmorrhiage, which Dr. Haime says arises from the fibres being separated, rather than divided by the passing of the needle; the former of which (the absence of pain) is a point in its favor, which few surgical operations possess.

It is but rare that I introduce more than one needle at the same time, as a greater number does not appear to be more efficacious than a single one. I, however, depart from this rule (as will be seen from some of the cases) when the pain becomes fugitive from the effects of the instrument; which is a most encouraging symptom. In such circumstances, following the disease by introducing the82 needles where the pain has removed to, has always proved ultimately successful.

Where also the disease is seated in such several parts, which from their anatomical situation, are known to receive their nerves from distinct or opposite departments of nervous origin; or if the disease pervades more organs or muscles than one, which are but little connected as to their nervous relations; then I regulate the number of needles, accordingly as I suppose the several parts may be more or less connected with each other.

The perforation made by a sharp smooth instrument like a needle, is of such a simple nature, that there is little83 danger of doing any mischief with one of this kind. Dr. Bretonneau, Physician to the “Hospital Général” of Paris, has made a number of experiments on puppies, the result of which is, that the Cerebrum, the Cerebellum, the Heart, the Lungs, the Stomach, &c. may be penetrated without occasioning the least pain or inconvenience.

In one case, where the heart had been punctured, he afterwards discovered an extravasation of blood into the Pericardium; and Dr. Haime asserts, that his experiments prove the doctrine of Mons. Beclard, respecting the elasticity of the arterial tunics, which may be punctured with impunity. One case of this nature84 occurred to Dr. Bretonneau, where a jet of blood followed the puncture of an artery. The hœmorrhage was immediately stopped, simply by pressure upon the opening. Dr. Haime says, that he has often, when performing this operation upon the human subject, thrust the needle to such a depth into the Epigastrium, that the stomach must have been pierced; but that it was productive of no more inconvenience than the same operation upon the more simple parts of the body. I should, however, contrary to such high testimony, hesitate much to puncture an artery, as an aneurism has been known to result from a small puncture made by an awl, which required the division of the vessel for the cure.

I shall here close my subject, not without exciting, perhaps, in the minds of some of my readers, surprise that I have not attempted an hypothesis of the operation. I have by no means made up my mind as to the nature of its action, and rather than venture into speculative reasoning, which may be received as doubtful by some, and visionary by others, I prefer preserving a profound silence. The authors whom I have before referred to, have attempted such an explanation; and should opinions of this kind be considered as deserving attention, the enquirers may find them in the paper upon acupuncturation, in the 13th volume of the “Journal Universel Des86 Sciences Medicales,” published at Paris in 1819.

The needles may be obtained at Mr. Blackwell’s Bedford-Court, and Mr. Laundy’s, St. Thomas’s Street, Borough.

FOOTNOTES:

*** END OF THE PROJECT GUTENBERG EBOOK A TREATISE ON ACUPUNCTURATION ***

Updated editions will replace the previous one—the old editions will be renamed.

Creating the works from print editions not protected by U.S. copyright law means that no one owns a United States copyright in these works, so the Foundation (and you!) can copy and distribute it in the United States without permission and without paying copyright royalties. Special rules, set forth in the General Terms of Use part of this license, apply to copying and distributing Project Gutenberg™ electronic works to protect the PROJECT GUTENBERG™ concept and trademark. Project Gutenberg is a registered trademark, and may not be used if you charge for an eBook, except by following the terms of the trademark license, including paying royalties for use of the Project Gutenberg trademark. If you do not charge anything for copies of this eBook, complying with the trademark license is very easy. You may use this eBook for nearly any purpose such as creation of derivative works, reports, performances and research. Project Gutenberg eBooks may be modified and printed and given away—you may do practically ANYTHING in the United States with eBooks not protected by U.S. copyright law. Redistribution is subject to the trademark license, especially commercial redistribution.

START: FULL LICENSE

PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the free distribution of electronic works, by using or distributing this work (or any other work associated in any way with the phrase “Project Gutenberg”), you agree to comply with all the terms of the Full Project Gutenberg™ License available with this file or online at www.gutenberg.org/license.

Section 1. General Terms of Use and Redistributing Project Gutenberg™ electronic works

1.A. By reading or using any part of this Project Gutenberg™ electronic work, you indicate that you have read, understand, agree to and accept all the terms of this license and intellectual property (trademark/copyright) agreement. If you do not agree to abide by all the terms of this agreement, you must cease using and return or destroy all copies of Project Gutenberg™ electronic works in your possession. If you paid a fee for obtaining a copy of or access to a Project Gutenberg™ electronic work and you do not agree to be bound by the terms of this agreement, you may obtain a refund from the person or entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only be used on or associated in any way with an electronic work by people who agree to be bound by the terms of this agreement. There are a few things that you can do with most Project Gutenberg™ electronic works even without complying with the full terms of this agreement. See paragraph 1.C below. There are a lot of things you can do with Project Gutenberg™ electronic works if you follow the terms of this agreement and help preserve free future access to Project Gutenberg™ electronic works. See paragraph 1.E below.

1.C. The Project Gutenberg Literary Archive Foundation (“the Foundation” or PGLAF), owns a compilation copyright in the collection of Project Gutenberg™ electronic works. Nearly all the individual works in the collection are in the public domain in the United States. If an individual work is unprotected by copyright law in the United States and you are located in the United States, we do not claim a right to prevent you from copying, distributing, performing, displaying or creating derivative works based on the work as long as all references to Project Gutenberg are removed. Of course, we hope that you will support the Project Gutenberg™ mission of promoting free access to electronic works by freely sharing Project Gutenberg™ works in compliance with the terms of this agreement for keeping the Project Gutenberg™ name associated with the work. You can easily comply with the terms of this agreement by keeping this work in the same format with its attached full Project Gutenberg™ License when you share it without charge with others.

1.D. The copyright laws of the place where you are located also govern what you can do with this work. Copyright laws in most countries are in a constant state of change. If you are outside the United States, check the laws of your country in addition to the terms of this agreement before downloading, copying, displaying, performing, distributing or creating derivative works based on this work or any other Project Gutenberg™ work. The Foundation makes no representations concerning the copyright status of any work in any country other than the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other immediate access to, the full Project Gutenberg™ License must appear prominently whenever any copy of a Project Gutenberg™ work (any work on which the phrase “Project Gutenberg” appears, or with which the phrase “Project Gutenberg” is associated) is accessed, displayed, performed, viewed, copied or distributed:

This eBook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is derived from texts not protected by U.S. copyright law (does not contain a notice indicating that it is posted with permission of the copyright holder), the work can be copied and distributed to anyone in the United States without paying any fees or charges. If you are redistributing or providing access to a work with the phrase “Project Gutenberg” associated with or appearing on the work, you must comply either with the requirements of paragraphs 1.E.1 through 1.E.7 or obtain permission for the use of the work and the Project Gutenberg™ trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is posted with the permission of the copyright holder, your use and distribution must comply with both paragraphs 1.E.1 through 1.E.7 and any additional terms imposed by the copyright holder. Additional terms will be linked to the Project Gutenberg™ License for all works posted with the permission of the copyright holder found at the beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project Gutenberg™ License terms from this work, or any files containing a part of this work or any other work associated with Project Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute this electronic work, or any part of this electronic work, without prominently displaying the sentence set forth in paragraph 1.E.1 with active links or immediate access to the full terms of the Project Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary, compressed, marked up, nonproprietary or proprietary form, including any word processing or hypertext form. However, if you provide access to or distribute copies of a Project Gutenberg™ work in a format other than “Plain Vanilla ASCII” or other format used in the official version posted on the official Project Gutenberg™ website (www.gutenberg.org), you must, at no additional cost, fee or expense to the user, provide a copy, a means of exporting a copy, or a means of obtaining a copy upon request, of the work in its original “Plain Vanilla ASCII” or other form. Any alternate format must include the full Project Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying, performing, copying or distributing any Project Gutenberg™ works unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing access to or distributing Project Gutenberg™ electronic works provided that:

• You pay a royalty fee of 20% of the gross profits you derive from the use of Project Gutenberg™ works calculated using the method you already use to calculate your applicable taxes. The fee is owed to the owner of the Project Gutenberg™ trademark, but he has agreed to donate royalties under this paragraph to the Project Gutenberg Literary Archive Foundation. Royalty payments must be paid within 60 days following each date on which you prepare (or are legally required to prepare) your periodic tax returns. Royalty payments should be clearly marked as such and sent to the Project Gutenberg Literary Archive Foundation at the address specified in Section 4, “Information about donations to the Project Gutenberg Literary Archive Foundation.”
• You provide a full refund of any money paid by a user who notifies you in writing (or by e-mail) within 30 days of receipt that s/he does not agree to the terms of the full Project Gutenberg™ License. You must require such a user to return or destroy all copies of the works possessed in a physical medium and discontinue all use of and all access to other copies of Project Gutenberg™ works.
• You provide, in accordance with paragraph 1.F.3, a full refund of any money paid for a work or a replacement copy, if a defect in the electronic work is discovered and reported to you within 90 days of receipt of the work.
• You comply with all other terms of this agreement for free distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project Gutenberg™ electronic work or group of works on different terms than are set forth in this agreement, you must obtain permission in writing from the Project Gutenberg Literary Archive Foundation, the manager of the Project Gutenberg™ trademark. Contact the Foundation as set forth in Section 3 below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend considerable effort to identify, do copyright research on, transcribe and proofread works not protected by U.S. copyright law in creating the Project Gutenberg™ collection. Despite these efforts, Project Gutenberg™ electronic works, and the medium on which they may be stored, may contain “Defects,” such as, but not limited to, incomplete, inaccurate or corrupt data, transcription errors, a copyright or other intellectual property infringement, a defective or damaged disk or other medium, a computer virus, or computer codes that damage or cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the “Right of Replacement or Refund” described in paragraph 1.F.3, the Project Gutenberg Literary Archive Foundation, the owner of the Project Gutenberg™ trademark, and any other party distributing a Project Gutenberg™ electronic work under this agreement, disclaim all liability to you for damages, costs and expenses, including legal fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a defect in this electronic work within 90 days of receiving it, you can receive a refund of the money (if any) you paid for it by sending a written explanation to the person you received the work from. If you received the work on a physical medium, you must return the medium with your written explanation. The person or entity that provided you with the defective work may elect to provide a replacement copy in lieu of a refund. If you received the work electronically, the person or entity providing it to you may choose to give you a second opportunity to receive the work electronically in lieu of a refund. If the second copy is also defective, you may demand a refund in writing without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set forth in paragraph 1.F.3, this work is provided to you ‘AS-IS’, WITH NO OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied warranties or the exclusion or limitation of certain types of damages. If any disclaimer or limitation set forth in this agreement violates the law of the state applicable to this agreement, the agreement shall be interpreted to make the maximum disclaimer or limitation permitted by the applicable state law. The invalidity or unenforceability of any provision of this agreement shall not void the remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the trademark owner, any agent or employee of the Foundation, anyone providing copies of Project Gutenberg™ electronic works in accordance with this agreement, and any volunteers associated with the production, promotion and distribution of Project Gutenberg™ electronic works, harmless from all liability, costs and expenses, including legal fees, that arise directly or indirectly from any of the following which you do or cause to occur: (a) distribution of this or any Project Gutenberg™ work, (b) alteration, modification, or additions or deletions to any Project Gutenberg™ work, and (c) any Defect you cause.

Section 2. Information about the Mission of Project Gutenberg™

Project Gutenberg™ is synonymous with the free distribution of electronic works in formats readable by the widest variety of computers including obsolete, old, middle-aged and new computers. It exists because of the efforts of hundreds of volunteers and donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the assistance they need are critical to reaching Project Gutenberg™’s goals and ensuring that the Project Gutenberg™ collection will remain freely available for generations to come. In 2001, the Project Gutenberg Literary Archive Foundation was created to provide a secure and permanent future for Project Gutenberg™ and future generations. To learn more about the Project Gutenberg Literary Archive Foundation and how your efforts and donations can help, see Sections 3 and 4 and the Foundation information page at www.gutenberg.org.

Section 3. Information about the Project Gutenberg Literary Archive Foundation

The Project Gutenberg Literary Archive Foundation is a non-profit 501(c)(3) educational corporation organized under the laws of the state of Mississippi and granted tax exempt status by the Internal Revenue Service. The Foundation’s EIN or federal tax identification number is 64-6221541. Contributions to the Project Gutenberg Literary Archive Foundation are tax deductible to the full extent permitted by U.S. federal laws and your state’s laws.

The Foundation’s business office is located at 809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up to date contact information can be found at the Foundation’s website and official page at www.gutenberg.org/contact

Section 4. Information about Donations to the Project Gutenberg Literary Archive Foundation

Project Gutenberg™ depends upon and cannot survive without widespread public support and donations to carry out its mission of increasing the number of public domain and licensed works that can be freely distributed in machine-readable form accessible by the widest array of equipment including outdated equipment. Many small donations ($1 to $5,000) are particularly important to maintaining tax exempt status with the IRS.

The Foundation is committed to complying with the laws regulating charities and charitable donations in all 50 states of the United States. Compliance requirements are not uniform and it takes a considerable effort, much paperwork and many fees to meet and keep up with these requirements. We do not solicit donations in locations where we have not received written confirmation of compliance. To SEND DONATIONS or determine the status of compliance for any particular state visit www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states where we have not met the solicitation requirements, we know of no prohibition against accepting unsolicited donations from donors in such states who approach us with offers to donate.

International donations are gratefully accepted, but we cannot make any statements concerning tax treatment of donations received from outside the United States. U.S. laws alone swamp our small staff.

Please check the Project Gutenberg web pages for current donation methods and addresses. Donations are accepted in a number of other ways including checks, online payments and credit card donations. To donate, please visit: www.gutenberg.org/donate.

Section 5. General Information About Project Gutenberg™ electronic works

Professor Michael S. Hart was the originator of the Project Gutenberg™ concept of a library of electronic works that could be freely shared with anyone. For forty years, he produced and distributed Project Gutenberg™ eBooks with only a loose network of volunteer support.

Project Gutenberg™ eBooks are often created from several printed editions, all of which are confirmed as not protected by copyright in the U.S. unless a copyright notice is included. Thus, we do not necessarily keep eBooks in compliance with any particular paper edition.

Most people start at our website which has the main PG search facility: www.gutenberg.org.

This website includes information about Project Gutenberg™, including how to make donations to the Project Gutenberg Literary Archive Foundation, how to help produce our new eBooks, and how to subscribe to our email newsletter to hear about new eBooks.

Page 30, line	8, after the word peculiar, add, of practising.
44,	2, for univerel read universal.
62,	2, from the bottom, a comma after the word Epipheses, instead of a period.
68,	3, after the word muscle, add, of the right side.
70,	5, after the word ribs, add, of the left side.