that when the skin and the conductors are both quite dry, a Faradaic
current of moderate power (and practically this form of electricity
is always employed in cutaneous electrization) does not penetrate the
skin, but is localized upon its surface. There are three methods of
applying cutaneous Faradization--the method that we employed--that
of “_Metallic Conductors_;” the “_Electric Hand_,” as it is called,
in which the operator having applied one conductor to some little
sensitive part of the patient’s body, holds the second in his left, and
passes the back of his right hand over the points he wishes to excite,
these points of the patient’s skin and the back of his hand being dry,
and sprinkled with absorbent powder; and the “_Wire Brush_,” a brush
of metallic wire, which replaces one of the conductors, and which is
moved over the skin. With a strong Faradaic current this wire brush
becomes the most powerful of all the excitants of the skin which do not
disorganize its structure; in fact it was proposed by some scientific
parliamentary philanthropist as a substitute for flogging in the navy,
and I have no doubt that more intense pain may be produced by it than
by any application of the cat, however well laid on!
[SN: Electrization of Internal Organs.]
The methods of electrizing internal organs need not detain us long.
The rectum and muscles of the anus may be electrized by introducing
into the rectum the rectal rheophore, a metallic stem insulated by gum
elastic, and moving it over the internal surface, bringing it also into
contact with the levator and sphincter ani. A well-moistened sponge
connected with the other pole may be applied to the abdominal muscles
or to the neighbourhood of the anus. The rectum must be first freed
from fæcal matter.
The bladder is most readily electrized by the introduction into the
rectum of the rectal rheophore, and into the bladder--previously
emptied--of a curved metallic sound insulated by an elastic catheter
to within an inch of its vesical extremity. This sound must be brought
into contact successively with all points of the neck of the bladder.
The uterus by the introduction of the rectal rheophore, connected
with one pole, to the os uteri, and by the application of two sponges
from the other pole, one to the abdominal parietes, the other to the
lumbar region. The larynx, externally by one sponge to the nape of the
neck, and the second to the exterior of the larynx; or, internally, a
sponge to the neck as before, and the introduction by the aid of the
laryngoscope of a small bit of sponge at the end of a curved metallic
stem, insulated by a gum-elastic catheter, the current not being
allowed to pass until it is seen by the laryngeal mirror that the
sponge is in the desired position. The male genital organs by moist
rheophores to the scrotum over the testicle; but if it be desired to
excite the vesiculæ seminales, the bowel is first emptied, the rectal
rheophore is then introduced and so directed that its olive-shaped
termination may be brought into relation with the vesiculæ. For this
purpose it is sufficient to move the rheophore from right to left and
_vice versá_. A powerful current will penetrate the intestine and reach
the vesiculæ, exciting them energetically. The circuit is completed by
a second rheophore placed on an unsensitive part of the body.
[SN: Electrization of the Central Organs.]
In electrization of the central organs of the nervous system, the
Voltaic current is alone used, and in its application to the brain,
the sympathetic nerves, or the organs of the senses, especial
circumspection must be employed. As a general rule it should not be
had recourse to when central excitement is contra-indicated, and
in _all cases_ the minimum dose should be commenced with, and the
application discontinued upon the occurrence of giddiness, nausea, or
cerebral symptoms. With these precautions the brain may be electrized
by well-moistened sponges applied to each mastoid process, to each
temple, or to the frontal and occipital protuberances. The sponges
must be held immovable. To galvanize the superior cervical ganglion of
the sympathetic, one electrode of small size must be deeply pressed
into the auriculo-maxillary fossa, and the other with a good-sized
sponge applied over the sixth or seventh cervical vertebra, or to the
manubrium sterni, close to the border of the sterno-mastoid. The spinal
cord may be electrized by keeping one sponge, usually the positive,
stationary, and moving the other up and down by the sides of the
vertebræ, or one pole may be applied to the spine, and the other held
to a nerve or muscle. The retina by a moistened conductor to the closed
eye, and the second to the temple or to the mastoid process of the
same side. The auditory nerve by one conductor tipped with sponge and
inserted to the bottom of the meatus, the second being held in the hand
of the opposite side; or the meatus may be filled with tepid water, and
a metallic wire traversing the axis of a vulcanite tube may be immersed
in the water, the second conductor being a well-moistened sponge to
the nape of the neck. Direct application to the ocular muscles or to
the conjunctiva is usually inadmissible, but one pole may be placed
over the facial nerve below the ear, and the other applied to the
closed eyelid, or the operator may use the forefinger of his right
hand, covered by a finger-stall of wet linen as an electrode, passing
the current through his own body by holding a moistened sponge from
one pole in his left hand, the conductor from the second pole being
similarly held in one of the hands of the patient. This application
is not only convenient, but it is calculated to allay the fears of a
sensitive patient: or a pointed conductor, covered with wet leather,
may be connected with one pole, and its point held immovable and
firmly pressed down upon the orbital margin, as near as possible to
the position of the muscle it is desired to excite, while the patient
touches at intervals the sponge from the second pole held by its
insulating handle in the operator’s disengaged hand.
[SN: Electrolysis Needles.]
The chemical action of a continuous Voltaic current is sometimes useful
in the removal or dispersal of tumours, and in the consolidation of
aneurisms, one or more needles being introduced into the tumour, and
connected with a Voltaic battery. I shall discuss this subject in our
next Lecture, but I have here some of the most generally useful needles
(Fig. 16), and I have had made for them holders with eyelet-holes
for the attachment of conducting wires which render the operator
independent of special conducting cords, for with a coil of insulated
wire and a pocket knife he can fit up his needles in a few minutes in
any way best adapted to his proposed operation.
[Illustration: FIG. 16. Electrolysis Needles and Needle-holders. By
pressing the spring side B, the holder opens as shown in C, to grasp
the needle D. The wire is twisted into the eyelet hole-A.]
[SN: Precautions in mode of Application.]
Having now considered the more generally useful methods of application,
it may perhaps not be out of place to remind you in concluding this
part of our subject that certain precautions are necessary to be
observed. We must keep constantly before our attention that we are
prescribing or administering an exceedingly powerful remedy, and
with all new patients we should commence with a minimum dose, watch
its effect, and if we need to increase it, do so gradually--_e.g._,
muscular contraction being sought we must use the power just sufficient
to produce it and _no more_--and so on with other applications; and it
is especially necessary to use care in applying the Voltaic current to
the face, neck, or any part of the head. Duchenne blinded a patient by
suddenly applying a current from 40 cells to the facial muscles, and
he had the candour to publish his misfortune. Sudden applications and
sudden cessations should especially be guarded against. The cessation
shock can, of course, only occur in cases where the conductors having
been held immovable, and the current gradually increased, one or both
of them has been abruptly, and it may be inadvertently, removed; and
I have known a patient so frightened by such a cessation shock as to
decline further treatment. The negative pole of a Voltaic battery
will, if frequently applied to the same spot, soon cause a sore,
and to avoid this the point of application should be slightly varied
occasionally; and let me impress upon you, Gentlemen, the importance
of always testing electricity upon yourselves before applying it to
a patient. Use as many galvanometers, or so-called “instruments of
precision,” as you like, but use in addition the back of your left
hand as a convenient approximate test for the Voltaic, and your
thumb muscles for the Faradaic current, except when about to apply
electricity to your patient’s head or face, and make it then an
invariable rule to first apply to your own face the same strength
of current you are about to administer to your patient’s. If you
authorize your patient to have treatment carried out at home impress
this rule upon whosoever electrizes him. Under such circumstances
it is especially imperative, for there is great belief, even with
educated persons who ought to know better, that the benefit derived
from electrization is in exact proportion to the pain given by it, and
a little personal experience is a very wholesome corrective to such
a notion. Graduate your dose, then, by the number of cells employed
checked by testing its effect, and do this upon each application, for
there is no certain means of securing that the strength of either a
Voltaic or a Faradaic current shall not have varied from day to day.
We have now studied, Gentlemen, medical electricity, electrical
instruments, and methods of application. In our next and concluding
Lecture I propose to discuss the assistance that electricity affords us
in diagnosis, prognosis, and treatment.
FOOTNOTES:
[10] See pages 6-17.
[11] See Duchenne (de Boulogne) “On Localized Electrization and its
Applications to Pathology and Therapeutics” (English Edition). Part I.,
pp. 38-40. London: Churchill.
[12] It is often of imperative importance in the administration of
the “constant” current that we should really localize it--not in name
only, but in fact--in some special nerve; and this is not always quite
so easy in practice as in theory. [SN: Importance of exactitude in
administering a constant current.] To secure the result we desire, we
must see that the cord or wire from the terminals of the battery to
the electrodes is without flaw; that the electrodes are well moistened
and placed firmly in the position determined upon; and especially
that they are held quite immovable during the entire application, for
if not maintained immovable, we shall be using not a “constant” but
an “interrupted” current with totally dissimiliar physiological and
therapeutical effects! We must satisfy ourselves that the current from
our battery is also constant, and that we so apply it to our patients
that the affected nerve shall be--as it is called--included in the
circuit--that is, between the poles, and that the current circulates
through this nerve as perfectly and continuously as it would through a
piece of wire connecting the terminals of the battery.
[13] Published by Churchill.
LECTURE III. ELECTRICITY IN DIAGNOSIS AND TREATMENT.
A.--_Electricity in Diagnosis._
GENTLEMEN,
[SN: Electro-Diagnosis.]
Our first two Lectures were devoted to a consideration of electrical
instruments; the different varieties of electricity; and the most
approved methods of applying them in therapeutics. To-day we have to
study their uses in diagnosis, prognosis, and treatment.
[SN: Test of Electro-Irritability.]
The chief use of electricity in diagnosis is dependent upon its power
of evolving muscular contraction. We have seen--as I demonstrated
to you upon my left forearm--that both muscles and nerves, when
in a normal condition, respond to the stimulus of electricity. In
disease this response, or irritability, may remain unaltered, or it
may be increased, decreased, or abolished; and our first step in
electro-diagnosis should therefore be to ascertain the exact condition
of electro-contractility. As in practically almost all our cases we
have to do with altered reaction existing only in one nerve or muscle,
or in one of two symmetrical groups of nerves or muscles, we possess
a ready means of testing irritability by ascertaining its relative
condition upon opposite sides of the body, as, for example, in an
ordinary case of hemiplegia. [SN: Test of Farado-Irritability.] In
examining such a case electrically--and the principles of procedure are
the same in all cases--it is convenient to commence our investigation
with the Faradaic current, and to ascertain the _lowest_ power which
will call into action any one of the muscles of the healthy side,
and then to apply this same strength of current _to identical points
of the corresponding muscle on the diseased side_, noting whether
it causes contraction. If so, we decrease the power of the current,
when if contraction still occurs there is increased irritability, or
_vice versá_, as the case may be. Having ascertained the condition
of the muscle we proceed similarly to test its motor nerve, for
we shall see hereafter that in certain diseased conditions muscle
and nerve irritability are affected unequally. One conductor being
held to an indifferent part of the body we apply a fine-pointed
conductor to the most superficial point in the course of the nerve,
in the way that, as you will recollect, I electrized my left median
nerve. [SN: Test of Voltao-Irritability.] We next submit the muscle
and nerve to similar examination with the Voltaic current. Holding
both conductors immovable, we interrupt the current for a moment
by moving the “key” of our battery, or if it is not provided with
a key, while one conductor is stationary, we break the current by
lifting and reapplying the other. It is essential that on both sides
there should be exact similarity in the application, and that the
electrodes should be placed on identical points of the muscle, and
this is especially important with the Voltaic current, for healthy
muscle responds to it more readily when it flows down the limb, that
is, with the positive pole nearest to the spine, and the negative
farther from it than when it flows up, and consequently a reversal
of the poles will influence the result. [SN: Rule for strength of
Current.] In testing a case in which there is equal disease upon
both sides--as in some cases of paraplegia--we must be guided by
a knowledge of the strength of current usually required to induce
contraction. As a general rule, unless a current that causes energetic
and painful action in the muscles of the ball of the thumb produces
some contraction, irritability is impaired. If, in our examination of
the muscle, we find irritability normal to both currents, we have proof
of the integrity of the muscular tissue. If the muscle also responds
by contraction to electrization of its nerve, we have further proof
that the nerve is healthy, and also the spinal cord at the point of
origin of the nerve. [SN: Electro-Irritability diminished.] If we find
the irritability lessened, there is disease of either muscular tissue,
nerve or cord; and, as a rule, this will be in direct proportion
to the amount of diminished irritability. [SN: Electro-Irritability
increased.] Increased irritability points to increased vascularity
or irritative lesion; but in such cases we very seldom require the
aid of electricity to complete our diagnosis. [SN: Voltao-Irritability
increased.] The reactions of Faradism and Voltaism are usually
equal, but in some cases in which muscular response to Faradism is
diminished or abolished the muscular reaction to an interrupted
Voltaic current is not only preserved but increased. The diseased
muscle will respond much more readily to the Voltaic current than the
corresponding muscle of the healthy side; while at the same time it
will be found on examining the nerve that there is equal diminution
to both currents. [SN: Diagnosis of Peripheral from Central Disease.]
This increased muscle reaction is due to the special irritability of
muscular tissue, and is quite independent of any nerve influence. It
exists only in peripheral and never in central lesion, and by it we
obtain an absolute diagnosis of such cases as local paralysis of the
facial nerve from facial hemiplegia, paralysis of the extensors of the
wrist and fingers, due to lead poisoning, from commencing muscular
atrophy, or progressive muscular atrophy from paralysis from section
of a nerve--all important questions as affecting treatment. [SN: “The
Degenerative Nerve Reaction.”] It is known as the “degenerative nerve
reaction,” as it always follows when a nerve trunk is involved in the
lesion. There is then diminution of Faradaic irritability through both
nerve and muscle, diminution of reaction to the Voltaic current when
the rheophores are applied over the nerve, and increase of reaction
when they are applied over the muscle; but there is no relation between
these interesting variations in the electrical condition of nerve
and muscle, and the degree of paralysis to the will, for there may
be perfect muscular paralysis, as in hemiplegia, when the electrical
condition of both nerve and muscle is unchanged; but, on the other
hand, in muscles equally paralyzed we may find absolute electrical
changes in some, and none in others. We may often positively predict
that these latter will rapidly recover--one instance of the use of
electricity in prognosis.
After long disuse of healthy muscles a slight degree of diminution
of electric irritability may sometimes be present, but this is
always restored by two or three Faradizations, and its existence is
hardly likely to present any difficulty in diagnosis. [SN: Central
Paralysis.] With this qualification we find that in paralysis from
brain disease electric irritability is normal, except when irritative
lesion is present, and then it is increased. [SN: Spinal Paralysis.]
In paralysis from disease of the substance of the cord irritability is
diminished, and this will sometimes aid us in the diagnosis--not always
easy--between commencing paraplegia and locomotor ataxy. In ataxy--at
least in its early stages--irritability is normal. In progressive
muscular atrophy it is normal as long as any muscular tissue remains.
[SN: Hysterical Paralysis.] In hysterical or emotional paralysis
irritability is normal, but electro-sensibility is often much impaired.
[SN: Diagnosis between Real and Feigned Disease.] [SN: Electricity as
Proof Positive of Death.] These variations will sometimes enable us to
distinguish between real and pretended disease; and, finally, absolute
abolition of electric irritability in all the muscles of the body is
proof positive of death, so that those extraordinary people who are
haunted by a fear of being buried alive may rest contented if they
provide that after apparent death, and before burial, their bodies
shall be submitted to thorough electrical examination.
Considered solely as an aid to diagnosis, we can get little more
assistance from electricity than I have pointed out to you.
And now, Gentlemen, we come to the consideration of the last and
most important branch of our subject--electricity as a therapeutic
agent--its scope and its limitations as a remedy.
[SN: Limitation of Electricity as a remedy.]
Is it needful for me to say that there is too much belief and too much
unbelief in its therapeutic power?
The men who estimate it fairly are quite the minority. It is
generally either much undervalued, or else believed to be a sort
of modern “_Elixir Vitæ_,” capable of curing a hopeless hemiplegia
from destruction of brain tissue, or a paralysis agitans from
senile degeneration. Although electricity will do neither of these
impossibilities, yet, considered as a remedy, it is of great value in a
wide margin of diseases. It will either stimulate or soothe both nerve
and muscle, according to its variety and mode of application; it will
frequently restore voluntary movement, it will relieve pain, heighten
temperature, recall sensation, coagulate the blood, and dissolve or
slowly cause the absorption of tumours.
B.--_Electricity in Treatment._
FRANKLINIZATION.
Franklinization as the oldest form of electricity and as partaking more
of a general application than a local, may be conveniently considered
first.
Administered by the various methods described at pages 6 to 17, it has
been found in the practice of the National Hospital for the Paralyzed
and Epileptic, and in private cases coming under my own observation,
of considerable value. [SN: Facial Neuralgia.] _Facial neuralgia_, for
example, which has resisted other modes of treatment, may occasionally
be relieved with rapidity and permanently by drawing sparks along the
track of the affected branch or branches of the trifacial nerve. [SN:
Sciatica.] [SN: Facial Spasms.] Sometimes also _obstinate sciatica_
has been partially or altogether removed; so also _facial spasm_, (tic
convulsif), as in the following instance, for permission to quote
which I am indebted to Dr. Radcliffe. A female, forty-eight years
of age, had suffered for thirteen years from spasm of the muscles of
the left side of the face. The distortion produced by the spasm was
very great, and was apt to be so much exaggerated by slight emotion,
even such as would be caused by having to address a stranger, as
to make speaking difficult, and to prevent proper attention to her
occupation as a small shopkeeper. An experimental trial was made of
electrization by sparks along the lines of the nerves distributed
to the affected muscles. After the third application the spasm was
manifestly relieved, the distortion being diminished, and the paroxysms
occurring less frequently. By persisting with this treatment thrice
weekly over a period of two months, so great an amount of relief was
obtained that little distortion of the face remained, and the patient
was able to pursue her business with comfort. [SN: Emotional Aphonia.]
Electrization by sparks over the larynx has been found so effective
in the relief of cases of hysterical or _emotional aphonia_, even
those of long standing, that it is well to use it in the treatment
of these cases before having recourse to induced electricity. In
six or seven recent cases, this form of application repeated twice
or thrice effected a complete cure. One of these cases was of nine,
another of six months’ duration. The remainder had lasted from four
weeks to three months. The seventh case did not receive any benefit
from the use of static electricity, and the other forms of the agent
proved equally ineffective. The case recovered slowly under general
treatment. [SN: Localized Excessive Sensitiveness.] Electrization by
sparks over the affected spot has often proved of great benefit in
removing the _localized excessive sensitiveness_ not unfrequently found
in hysterical cases, particularly in the spinal region. [SN: Tremor.]
_Tremor_, whether general or local, is sometimes largely relieved by
insulating the patient, and charging him with positive electricity for
a period of twenty minutes to half an hour. Other applications failing,
I would advise always, in cases similar to the above, a fair trial, say
half a dozen sittings, of Franklinization.[14]
ELECTRIZATION.
[SN: Electro-therapeutics.]
We have seen that if we send a shock of electricity through a motor
nerve the nerve becomes excited, and responds by contraction of its
muscles. One form of electricity, then, is a stimulant, but, unlike
other stimulants, it admits of its action being exactly localized and
its influence instantly withdrawn. [SN: Effects upon Nutrition.] There
first results from such an application a larger flow of blood to the
part, with subsequent increase of temperature and general improvement
in nutrition. [SN: Electricity as a Stimulant.] If muscular contraction
results, it acts in addition as an artificial gymnast, imitating
natural muscular action in a way quite impossible to any agency but
electricity. It is in cases where there is muscular response to it,
but not to the will, that it is often of immense service, and it can
then be replaced by no other remedy known to medicine. Need I say that
in such cases its dosage is of importance; that only a certain amount
of stimulation being needed, this may not be carried to the point of
exhaustion, and that the application should not be continued for too
long a time. From ten to twenty minutes for an entire application is
usually sufficient. So much for the stimulant effects of electricity
when administered under either of its forms in a series of intermittent
“shocks.”