Part 4

Indirect, or extra-muscular electrization, next claims our attention. You will recollect that it is produced by acting upon the special nerve trunk and its branches, instead of by placing the rheophores upon the muscle itself. We may thus call a motor nerve into action without affecting the cutaneous nerves, and with a minimum of power of current, and necessarily a minimum of sensation which hardly ever need amount to actual pain. This method is preferable, therefore, in cases where we desire to produce muscular contraction and as little sensation as may be, and again when the sedative influence of the constant Voltaic current is required to be localized in any special nerve. In its application it is convenient to place a good-sized sponge connected with one pole upon an indifferent part of the body, such as the sternum, and to apply a pointed conductor from the second pole directly over the course of the nerve it is desired to act upon. Speaking generally, these motor points as they are called may be selected by reference to a good anatomical plate, but only approximately, for we know that it is common to find variations in the course of the nerves and in the mode of their distribution among the muscles, and this being so, it is well when we propose to act upon a motor or mixed nerve (which is not paralyzed), to make sure that we are localizing the current in it by producing for a moment the contraction of its muscles and then marking the spot by touching it with a pencil of nitrate of silver. This, of course, is only necessary where in our subsequent electrization we do not wish muscular contraction, as in the treatment of neuralgia.[12] I will demonstrate indirect electrization by Faradizing the median nerve in my left forearm above the wrist, and before it passes beneath the annular ligament of the carpus. It lies a little below the surface, between the tendons of the flexor carpi radialis and palmaris longus. You observe that its muscles powerfully contract and oppose the thumb to the other fingers, at the same time abducting it. There occurs also a slight flexure of the first phalanges of the index and middle fingers. Professor Ziemssen in his work on Medical Electricity has published some extremely accurate plates of the motor points of the body, and I have grouped together the more important of them in a chart or map for convenient reference.[13] Ziemssen’s method of procedure was to find out experimentally the points where the application of electricity most readily produced muscular contraction. He then marked these points with coloured chalk, and after a sufficient number of trials with nitrate of silver. Photographs of the parts thus marked were taken and afterwards transferred to the wood blocks. These figures may therefore claim to be true to Nature, although they may not be absolutely correct for every individual. Ziemssen verified their approximate exactitude by following the course of the nerves very accurately in the dissecting-room and observing their points of entrance into, and their course within, their muscles, with constant reference to the surface of the body; but he was not completely satisfied until he had determined the motor points upon the skin immediately after death, and before the reaction to electricity had disappeared, and submitted these points to the scalpel. The results of the three methods coincided perfectly.

[SN: Cutaneous Electrization.]

We will next consider cutaneous electrization. I have already shown you 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.

[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._