drachms of fluid, and probably a displacement of not less than two to four ounces is required for compression. I have, of course, seen plenty of cases of depressed fractures with head symptoms; but in all, the symptoms were those of severe concussion, or of lacerated brain, and not those of compression. The practice of trephining and elevation is, I think, strongly to be recommended in all cases of compound fracture with depression; but it is in order to prevent inflammatory symptoms, not to relieve an imaginary state of compression of the brain.-Clinical Lectures and Reports of the London Hospital, 1867-8, p. 10.

15.-ON DELIRIUM TREMENS.

By Dr. SAMUEL WILKS, Physician to, and Lecturer on the Practice of Medicine at, Guy's Hospital. Now, after speaking of the slow destruction of the brain-tissue by a chronic inflammatory process, let us look at the case of a more simple atrophy. In the disease we have just left-the general paralysis of the insane there is not only loss of bodily and mental power, but the manifestations of the latter are peculiar. In simple wasting of the brain, however. there appears to be only a gradual failing of the physical and intellectual functions. See a man, for example, tottering along, scarcely able to support himself, or "all of a tremble," and his mind at the same time impaired; that man, if the symptoms have existed for any period, has an atrophic brain. This may have been the result of age, and he may be approaching a second childishness or mere oblivion; but if he be a young man, it arises from disease, and in all probability, from intemperance. Certainly one of the causes most frequently instrumental in the production of an atrophy of the brain is drunkenness or the excessive use of alcoholic drinks. Alcohol, as you know, causes a degeneration of all the tissues of the body. By its direct effect on particular organs, you may find an increase of the connective or fibrous tissues, and then a cirrhosis of the liver, a Bright's kidney, or a so-called chronic pneumonia may arise; in other instances a fatty degeneration of the tissues occurs, and thus death by diseased heart is very frequent in the drunkard. These two morbid processes are, however, often combined; but, whatever may be the exact pathological change, the result is the decay of all the tissues and organs of the body. It is remarkable how many morbid processes resemble those which naturally take place in advancing age, and thus a disease will by its effects, add so many years to a person's life. A drunken man is literally living too fast.

There are of course other circumstances which tend to this general and nervous decay; but I think in most instances, as you have often heard me say, if you see a man come staggering in amongst our out-patients, the probability is that he has been taking too many so-called "strengthening things" all his life. If you find this so, and he is bodily and mentally incapacitated, that man has assuredly an atrophied brain. If you examine the body of a man who has died of delirium tremens, you find the effects of the long-continued stimulus on his organs; and, as regards his brain, that has a very striking appearance-the membranes are thickened, and the convolutions are much shrunken, so that there are deep sulci on the surface, and in these a quantity of fluid. Sometimes three or four ounces of serum are seen, taking the place of so much good brain which has disappeared. The figurative expression which Cassio makes use of when speaking to Iago contains a solid and substantial fact-" O God! that men should put au enemy in their mouth to steal away their brains!" The brain, then, of a confirmed drunkard is an organ which is shrunken, and weighs so many ounces less than it did when healthy. All its functions, also, are becoming enfeebled, and those qualifications which should have preserved to its owner the name of lord of the creation have disappeared, and he has become, in common parlance, a good-natured fool. Call such a man a brainless sot, and you have his exact condition-the sot implying a man stupid with drink, and the "brainless" imparting to the term his true pathological condition. It

is such a brain as I have mentioned that you find in those who have died of delirium tremens. The earlier attacks of the drunkard are recovered from ; but there comes a time when the last and fatal one arises. But then his death is really due to the degeneration of tissues which long-continued habits of intemperance have entailed.

Take a man who, from his addiction to alcoholic drinks, has the weakened brain that I have described, and let any unusual stimulus act upon it, he loses his balance, and he is thrown into the state known as delirium tremens. This is my idea of the disease. I believe some medical books state that delirium tremens is a train of morbid phenomena produced by the slow and cumulative action of alcohol. This, however, I cannot admit without some modification, for it might imply that delirium tremens was due directly to stimulation of the brain. There is, no doubt, a morbid condition set up by alcohol, but this would be delirium é potu, or simply intoxication, or poisoning by spirit. I believe, however, that such an opinion as I have mentioned does largely prevail-i. e., that the brain is over-stimulated by the artificial excitement, and that a sudden deprivation of this starts the disease into life. My own strong conviction is, that such an opinion is highly erroneous, as well as the treatment which it necessarily involves-viz., that the stimulus must be restored, and the excitement abated by opium. I believe firmly that such opinion and the conclusions which flow from it are erroneous and mis

chievous.

My own idea is that the brain has been previously brought into an impoverished state by the continued debauchery, and that, thus weakened, it is ready to be further disturbed by any fresh excitant, whether this be a mental trouble, an accident, or, more probably, an extra amount of the alcoholic stimulus. I am led to this opinion because, in the intervals of the attacks of delirium tremens, the patients present the symptoms I have before mentioned, a mental and physical weakness as a result of the chronic pernicious effects which are being produced on the brain, and also because I observe the circumstances which excite the attack. The cause may be an accident or an acute disease suddenly set up, but more generally we find that the patient has been out with his friends drinking for two or three days in succession, and if he has had any troubles in business this would only be a still further excitant cause. On the other hand, I never hear of a man suffering delirium tremens from having got drunk only once, nor do I hear of it in the habitual drunkard from his having left off the accustomed stimulus. I have never witnessed such a case myself, and I have taken the trouble of inquiring of those who have had an opportunity of seeing persons habitually intemperate, and who have been placed on a bread-and-water diet, and I am informed that such persons do not have delirium tremens. I have myself on several occasions recommended or insisted upon the withdrawal of ale, wine, and spirits from those who had been endeavouring to live upon these stimulants, but never witnessed anything like delirium tremens result. Why I insist more especially upon the importance of having a true conception of the disease is that an erroneous one carries with it a very harmful treatment. The one theory suggests a continuance of the accustomed stimulus; the other its withdrawal and repose for the excited and wearied brain. Delirium tremens is not so simple a disorder as you may imagine; each caso requires a study and its appropriate remedies.

Having given you a clue to its pathology and treatment, I have said all that is important. As regards the symptoms several very graphic accounts have been written, and some by those who have suffered all its horrors. I might say in a few words that a man suffering from delirium tremens has generally already shown symptoms of a weakened brain by his tremor and want of mental vigour. When you are called to see him in the attack, you generally at once see the nature of the case; he is probably up and dressed; he may indeed be attempting to conduct his usual business-in fact, he generally has a great desire to be about his accustomed avocations; he is constantly moving and wanting to go somewhere or do something which his friends are as constantly desirous of preventing. As you speak to him he is suffiLVIII.-4

ciently intelligent to know you and sit down for a moment and converse, but it is only for a moment; his restlessness prevents him remaining quiet, and his mind then rambles on all kinds of subjects. If you place him in bed, he constantly jumps up, and is suspicious of those around him, or fancies that he sees objects in the corners of the room; if the bed be surrounded by a screen, then he sees imaginary cats and dogs on the bedclothes, and will attempt to stroke them, or sees creeping things like spiders; or he stretches out of bed to look beneath, fearing there are persons hidden there. All this time he is constantly fidgetting his hands, and perpetually jumping up and lying down again; his pulse is quick, his tongue is furred, and he is bathed in perspiration.

When I say such a case is easily recognised, I mean with care, for I have constantly seen mistakes made with reference to diagnosis. I have seen general paralysis of the insane styled delirium tremens by the same physician on two different occasions. In the surgical ward of a hospital, cases of injury to the head, followed by arachnitis, or effusion of blood on the surface of the brain, are extremely likely to be called by this name. Acute disease, as pneumonia, occurring in a person of intemperate habits, is masked by the delirium, and the primary disease may be overlooked. Typhus fever I have seen styled delirium tremens; and there is one disease which certainly puts on an outward form very like it-I allude to the case where cerebral symp. toms accompany pericarditis. A patient, for example, has acute rheumatism, followed by inflammation of the heart, and, in some cases, most remarkable nervous symptoms ensue-the patient is delirious, is in constant movement, and bathed in perspiration--he resembles exactly, indeed, the case of delirium tremens. In this case the stethoscope placed over the heart would insure to the listener a true knowledge of its nature,

It is important also to know what is the condition of the patient generally who suffers from delirium tremens, for on the state of the organs the prognosis mainly depends. He may have cirrhosis of the liver, or, what is not uncommon, Bright's disease of the kidney. If the patient have convulsions, you may find that the urine is albuminous, and this of course must endanger the case, Convulsions, I might say, however, often occur independently: they may be due to the wasted brain, or be temporary and due to the recent debauch.

Now, as regards treatment, the most important instruction I can give you is what not to do. Do not, in the first place, regard delirum tremens as a disease due to the sudden withdrawal of an accustomed stimulus, and therefore commence the treatment with the administration of wine or spirits—you will by so doing add fuel to the fire-but look upon the attack as due to excitement acting on a previously weakened brain. Then your mode of treatment is obvious and rational. In one word, get your patient repose. Now I do not mean by this that your remedy is simply opium to procure sleep, but I use repose in a much larger sense. I have frequently seen a patient, probably a publican, sitting in a large room surrounded by a dozen friends, male and female, who are talking to him or holding him in restraint. He is bathed in perspiration, his pulse is very quick and feeble; the doctor says he has not slept for two or three nights, and he dare not give any more opium, as the pupils are already contracted. His fears that the man will die seem not illgrounded, since it is impossible to suppose that any mortal man could go to sleep under such circumstances. I have seen such a patient then removed to a small room, put to bed, and go off to sleep in half an hour. Therefore I say that the most judicious treatment is required for delirium tremens, and do not go away with the notion that all you have to do is to give opium to procure sleep. I have many times seen the last sleep produced by it. And do not, as I before said, continually give stimulants to "keep up" the patient, for I have constantly seen the complaint strengthened by these means. I do not wish to reflect on the opinion of others, because I state strongly my impression that the disease is not to be cured off hand by medicine. I see a great deal of this disease, and the time at which I am called in is about the third day, when, all means have been found unavailing in checking the com

plaint, another opinion is sought; after this time the patient usually sleeps and does well. I think then, except in very slight cases where a single dose of opium procures rest, that a certain interval must elapse before the commotion subsides; that in a bad example of the complaint the symptoms will continue without abatement for three days at least. This is my experience under all modes of treatment. I have no objection to opium, but it must be administered judiciously; if you act on the principle that sleep must be procured at all hazards and as soon as possible, you will without doubt kill many of your patients. In the first instance you should place your patient in a small quiet room, and get rid of a number of officious friends.

As regards medicines, you must be guided by circumstances. I have often prescribed with advantage the well-known mixture of twenty drops of antimony wine and tincture of opium every four hours, keeping up the patient's strength by beef-tea. If you can give a glass of wine or beer in the form of nourishment without its producing any injurious stimulating effects, I have no objection; but, as a rule, I advocate the plan of giving none. Instead of administering antimony, you might give the laudanum, or small doses of morphia with ether or ammonia, and, at the same time, support the strength of the patient. By judicious management of this kind you will find your patient recover in three or four days, unless, indeed, he be extremely diseased in consequence of his former dissipations. As regards restraint, I have often heard objections made to it, but I believe it is often necessary, and its adoption is a real kindness to the patient. He may wander about his house until he drops dead from exhaustion, when a forcible restraint in bed by a sheet across the chest might procure rest for the body, and often for the brain. Remember, then, your patient wants repose; do not be content with administering opium and neglecting every measure which common sense would say was necessary to give any man a night's rest. As regards chloroform, you may quiet the patient by it for a time, but you do not in any way influence the disease. Other remedies are advocated. When digitalis was first proposed, I gave it to a man in large doses, and, he having unfortu nately died, I have never felt myself justified in administering it again. I have seen enough of the sedative effects of the wet sheet to fully believe the statements which have been made as to its efficacy. You strip the patient naked, roll around him a wet sheet until he looks like a mummy, then a blanket around this again. In many cases of delirious excitement, you will find that, as soon as a hot vapour surrounds the patient, he sinks into a quiet sleep. Med. Times and Gazette, Sept. 19, 1868, p. 327.

16.-FARADISATION IN THE TREATMENT OF PARALYSIS. By J. NETTEN RADCLIFFE, Esq., Medical Superintendent of the National Hospital for the Paralysed and Epileptic.

[Of the three forms of electricity used in medicine, viz., frictional, chemical, and induced, the nomenclature has given rise to a good deal of discussion.]

It seems to me that it would be an advantage to have a series of terms which, while securing the object which Duchenne had in view, would be free from the objections referred to. The electricity of chemical action is more correctly and generally designated, after the name of the original discoverer, Volta, voltaic electricity. Faraday suggested that frictional electricity should be termed after the illustrious philosopher, Franklin, whose name is especially connected with its early experimental study, franklinic electricity, and the name is now being widely adopted by physicists. By applying the method of terminology which Duchenne has so happily used in respect of the induced current to the other forms of electricity, a series of terms is obtained which would be accurate in form as the practice of nomenclature goes, true to science in fact, free from confusion, and particularly convenient in usage. The series would be, (1) faradaic electricity, or faradism, and, as respects the pathological and therapeutical application of the agency, faradisation: (2) voltaic electricity or voltaism; voltaïsation: (3) franklinie electricity or franklinism; franklinisation.

Faradisation -A faradaic apparatus, of one kind or another, when the diagnostic and therapeutic value of faradisation are more widely understood, will become as necessary a part of the practitioner's armament as a stethoscope, or an ophthalmoscope, an otoscope, or a laryngoscope. By the aid of such an apparatus certain special peculiarities of several forms of paralysis. a knowledge of which is essential to the proper treatment of the diseased state, can alone be detected. To the right use of faradisation it is necessary that an instrument should possess certain fundamental requisites. These area sufficient range of power, so as to bring at once, and when properly applied, the largest muscles into full and energetic contraction; easiness and a certain niceness of graduation; and immediate readiness for action, and capability of being placed out of action without involving trouble and loss of time. The form of apparatus which is excited by a permanent magnet (magneto-faradaic), possesses the first and last of these requisites, but, except in the more elaborate instruments, is deficient in the second; but the facility of use of a magneto-faradaic apparatus is greatly impeded by the need of a second person to work it. The form of apparatus which is excited by a voltaic cell (volta faradaic), as ordinarily made, possesses the first and second of the requisites named, but is seriously defective in the third. A volta-faradaic apparatus has, however, been constructed by Stöhrer, of Dresden, which possesses to the fullest extent even the last-named requisite, and which is unquestionably the best and most efficient apparatus for medical purposes yet constructed. This apparatus possesses not only the fundamental requisites which have been enumerated, but also the principal refinements which give an apparatus additional value.

The chief peculiarity of Stöhrer's volta-faradaic, or, as he terms it, induction apparatus, consists in the arrangement of the cell. The elements are formed by a hollow cylinder of carbon, surrounded by a cylinder of amalgamated zinc. The hollow of the carbon is partly filled with fine glass sand, charged with from fifteen to twenty drops of a saturated solution of chromic acid. Both elements dip into a glass jar containing diluted sulphuric acid (one part of the acid to six of water). This jar is moveable, and it can be raised so as to immerse the elements or dropped so as to leave them free from the acid. By this ingenious arrangement, the apparatus can be brought into or put out of action at a moment's notice; and there is this that is remarkable about the combination of elements, that even with frequent daily use they retain their power, and act well for from six to eight weeks, and with care for even a longer period. Moreover when the action is exhausted, the re-amalgamation of the zinc and re-charging of the cells are barely a quarter of an hour's work. The induction coils do not differ from those of other well-made volta-faradaic apparatus, except in the mode of packing, and certain elaborations of accessories. Stöhrer makes two kinds of volta-faradaic apparatus, a larger and smaller. Both are excellent instruments, and both are portable, but the larger is by far the best and most complete.

The currents derived from both the magneto-faradaic and volta-faradaic apparatus produce the same physiological effects when transmitted through a part of the human frame. They equally excite the sensitiveness of the sensitive nerves lying in their track, as shown by pain or other modifications of sensation, and bring into action the contractility of the muscles. These physiological phenomena lie at the root of the therapeutical uses of faradisation, and medicine is indebted to Duchenne (de Boulogne) for first showing in what manner they may be best elicited and applied in the treatment of disease. He has shown that when metallic conductors are used, according as they are applied to the surface of the body uncovered and dry, or tipped with layers of moistened leather or sponge, the electrical current may be limited to the skin and tissues immediately subjacent, or made to pass to the deeper-seated structures, and localised in definite muscles or groups of muscles. This constitutes what Duchenne has termed localised electrisation. By this method it is practicable to determine easily and accurately, in the living, healthy subject, the action of the different muscles which can be reached by the electrical current; and this is what Duchenne has done in