his two remarkable works, "Mécanisme de la Physionomie Humaine " (Paris: 1862), and "Physiologie des Mouvements" (Paris: 1867). By this method the state of motility of paralysed muscle can alone be determined in reference to the therapeutical application of electricity, and that application effectively carried out.

As regards the muscles, the method may be employed either directly or indirectly, that is to say, in the former case by applying the conductors directly over the belly of the muscle; in the latter, by acting upon its motor nerve when accessible. The direct method is that chiefly followed by Duchenne. He uses as conductors (or rather directors) instruments of various forms. These include a pair of sponge-holders for directing the current upon the larger muscles; a pair of button-headed directors covered with several layers of leather for localising the currents on smaller muscles; and an olive-shaped and a conical director, the heads also sheathed with leather, for localising the currents on the individual muscles of the face. In addition, he uses a brush of fine wire for localising the current in the skin. The form of the handles is such as to permit each pair of directors being manipulated by one hand so as to leave the other free. The directors are connected with the volta-faradaic apparatus by very flexible wires covered with silk, or cotton, or india rubber. Before being used, the sponges or leather coverings

are saturated with warm water in which a little salt has been dissolved. For therapeutical purposes, each muscle, or group of muscles, should be acted upon for about thirty seconds at a time, with intervals of a few seconds, and the whole period of application should extend from ten to twenty minutes as a rule.

The therapeutical uses of faradisation arise directly out of the physiological properties of faradaic currents. In respect of the muscular system they rest entirely upon the power possessed by these currents of exciting muscular contraction, and the physiological consequences of such contraction, namely, increased growth and aptitude to action of the muscular tissue. The reaction of muscles against a faradaic current--the electro-motility so called-is unaffected, or it is variously modified in certain paralytic affections. When the electro motility is normal, as in paralysis of cerebral origin, faradisation cannot make the contractility of the muscles more normal; and, as a rule, it is useless. When the electro-motility is diminished or exhausted, as in certain forms of spinal and local paralysis, faradisation may reinvigorate or recall the defective or lost motility. The broad rule for the application of faradisation in the treatment of paralysed muscles is, indeed, this-when the electro-motility is diminished or exhausted, then faradisation will be of service; when the electro-motility is unaffected it will not prove of any use. The question then, of the use or not of faradisation in a given case of paralysis, involves a primary question of diagnosis; and this diagnosis is altogether special, and can be determined only by the systematic examination of the affected muscles. Such an examination excepting only in the ordinary forms of paralysis of cerebral origin, should be made in every case. The examination, however, it is to be repeated, must be of individual muscles, for in the forms of paralysis in which faradisation proves most beneficial, not all the muscles of au affected limb may be equally paralysed, and some may be unaffected while the motility of others is seriously damaged. To faradise equally the affected and the unaffected muscles-those muscles which are slightly and those which are much injured,-would be to do harm rather than good, and at the best would be a haphazard practice. The condition of muscle in which faradisation is found chiefly beneficial most commonly exists in paralysis following certain lesions of the substance of the spinal cord, the paralysis of infancy, and local palsies arising from injury of a nerve, or which are classed as rheumatic palsies. If, however, the practitioner follows the rule of guidance given above, he will have no difficulty in any given case of determining whether faradisation is needed or not in its treatment. The chief caution to be borne in mind is that in cases of centric origin faradisation should not be had recourse to—or, indeed, any method of electrisation—so long as active mischief exists.

Space does not permit me to do more than refer to the faradisation of the muscular tissues of particular organs, as of the bladder, the rectum, the uterus, the eyes, and the larynx, when the contractility of those tissues is impaired.

There are certain forms of quasi-paralysis in which the electro-motility is intact, in which faradisation is of much benefit, although not so certainly or so surely as in cases of paralysis in which the electro-motility is impaired. The quasi-paralytic affections referred to are the so-called wasting palsy (progressive muscular atrophy) and local atrophy of muscles. In these cases. the paralysis of movement depends upon the loss of muscular tissue, that which remains acting normally under the faradaic contact, and as a rule responding to the volition. In some of these cases faradisation is an invaluable remedy, staying the onward progress of the wasting, and promoting the growth of the affected muscles.

As regards the nervous system, the most marked use of faradisation is in cases of local anesthesia, particularly the local anesthesia apt to occur in hysteria. In such cases the application of the electrical brush, or "whip,” as some writers term it, is of great value.

The use of faradisation in certain perverted states of nervous and museular action (neuralgia and spasm) is governed by general therapeutical principles rather than by any special remedial indication.

For a detailed account of the pathological and clinical conditions in which faradisation is useful either for the purposes of diagnosis or treatment, I must refer to the great work on "Localised Electrisation," by Duchenne (de Boulogne.)-Practitioner, July 1868, p. 18.

A healthy looking lad aged 14, was seized with lockjaw and severe pain in the cervical and dorsal regions, with fever, a few days after jumping from a coal-waggon. Ou my visit (fourth day of symptoms), I noted well marked risus sardonicus; incisors separable for less than half an inch; masseters rigid; cervical and dorsal vertebræ arched forwards; sterno-mastoids and muscles of back rigid; abdomen flat and hard; legs and feet rigidly extended; tenderness along spine; arms free from tetanic symptoms; paroxysms of severe general spasms every few minutes; pulse 140; sleepless. I ordered one-sixtieth of a grain of atropia every three hours; and linimentum belladonna to be well rubbed over the spine and rigid muscles every six hours.

Within twenty-four hours, the physiological action of atropia showed itself; then the clonic spasms became less severe, and of shorter duration; and the tonic rigidity gave way, first in the legs and neck, then in back, and last of all in abdomen and masseters. On the sixth day of treatment by atropia, rigidity of the masseters alone remained. He was kept under the influence of atropia for three weeks. He then quickly and completely recovered his usual health under steel and quinine.

It is said by Brown Séquard, that belladonna reduces congestion of the blood-vessels of the spinal cord and its membranes; that its principal physiological action is "spinal anæmia." I believe that the tetanic symptoms in this case depended on an excitability of the spinal cord, probably caused by "spinal congestion"-a derangement of the vaso-motor nerves of the cord and its membranes, which allowed more blood than normal to circulate through the contents of the spinal canal. If so, we have the rationale of the therapeutic action of atropia in this and allied cases.--British Med. Journal, August 22, 1868. p. 184.

18.-ON THE

EMPLOYMENT OF PHYSOSTIGMA (CALABAR

BEAN) IN THE TREATMENT OF TETANUS AND CHOREA. By Dr. THOMAS R. FRASER, F. R. S. E, Assistant to the Professor of Materia Medica in the University of Edinburgh.

Ex

Tetanus appears to be, essentially, a disease characterised by an exaggeration of the reflex function of the medulla spinalis, medulla oblongata, and certain lobes at the base of the brain. A close analogy exists between it and that condition of exaggeration of reflex excitability which is produced by the action of strychnia. This supports the idea that, although tetanus may be often due to appreciable lesions of the central nervous system, either connected with, or independent of, irritating diseased conditions of the peripheral nerves, it may also exist without any discoverable central lesions aggeration of the reflex function of the central nervous system, resulting in spasmodic contractions, appears to constitute its essential character. Hence its most successful treatment seems to have been by the employment of such means as remove the condition of exaggerated reflex excitability, or oppose its manifestation. Warm baths, sudorifics, and the application of ice to the spine have been used at various times and with varying success; and numerous cases have been recorded in which sedative drugs were used, such as opium, aconite, belladonna, tobacco, and curare, and the active principle of these. None of these drugs has, however, produced such successful results as to become the established remedy for tetanus. A presumption of success might be supposed to exist in favour of several of them, and perhaps more especially in favour of those which powerfully impair and destroy the conductivity of motor nerves, such as belladonna and curare, or of those which combine a somewhat feeble paralysing effect on motor nerves with a more decided paralysing action on voluntary muscular fibre, such as tobacco; but they fail in this, that none of them possesses a primary and energetic sedative action on the diastatic function of the spinal cord. Opium, in certain circumstances, produces this effect, but it cannot be looked upon as one of its primary or leading actions, and it is complicated and even opposed by its other actions; for, with the exception of narceia, all the opium alkaloids produce more or less marked convulsant effects. It is probable, therefore, that its spinal sedative action, only exceptionally observed, is dependent on the narceia, but it is doubtful if this alkaloid would be of any use in tetanus, as the powerful soporific action it is reputed to possess would obscure the effect on the spinal cord that is wished for.

Physostigma has the great advantage over all these substances of directly and powerfully diminishing the reflex activity of the cord. A description of the various data on which this conclusion is founded would occupy too much of the space at my disposal. I shall therefore, assume that the evidence I have elsewhere published is sufficient to establish this effect of physostigma. The following experiments illustrate the power of this drug to counteract the tetanic symptoms of strychnia poisoning; and it is generally admitted that a very close analogy exists between these symptoms and those of tetanus itself.

"I placed a small drop of solution of strychnia (Brit. Pharm.) on the back of a frog. This produced tetanus in four minutes. When a considerable dose of physostigma extract was inserted into the animal's mouth, the manipulations necessary for its introduction excited a series of violent emprostho tonic spasms. Four minutes after the Calabar bean was exhibited, a decided diminution occurred in the frequency and severity of the convulsions; and, in nine minutes, they had lost their tetanic character. In forty minutes, it was difficult to excite even a faint reflex movement by pretty strong galvanism of any part of the body; and, soon after, reflex action had completely disappeared, even when the exposed sciatic nerves were galvanised."

The part which physostigma played in counteracting the tetanic effects of strychnia, may be readily shown by comparing this experiment with one in which the strychnia effects were not interfered with.

A frog was selected of the same weight as the last, and in every other respect as nearly resembling it as possible, and a small drop of solution of strychnia (Brit. Pharm.) was placed on its back. Tetanus occurred in four minutes; and violent convulsions of a tetanic character followed each other at intervals, and could be excited by the slightest touch, during the next six hours, after which the observations were stopped."

In addition to this paralysing action on the spinal chord, physostigma diminishes and even destroys the conductivity of motor nerves. It thus includes among its therapeutic properties that which has recommended curare as a remedy for tetanus. It is, therefore, peculiarly suited to counteract such convulsive movements as results from an exaggeration of the reflex function of the spinal system. It is true, that it does not influence the afferent, or sensory, nerves, and probably its value would be enhanced if it diminished the activity of these. This effect might especially be valuable in such cases of tetanus as manifestly depend on an irritation of peripheral nerves. But there can be little doubt, that in these the primary irritation constitutes but a portion of the disease. The symptoms prove undoubtedly that the spinal chord is sooner or later affected. Tetanic convulsions or exacerbations of existing convulsions may be produced by sudden sounds, by unexpected sights, or by gentle touches of any portion of the skin, proving the existence of an abnormally excitable condition of the reflex centres, the result, possibly, but now independent, of persistent irritation localised in an injured afferent nerve. It cannot be ignored, however, that a persistent local irritation may occupy a position of such importance in the disease as either to interfere greatly with the prospects of successful treatment by such a remedy as physostigma, or altogether to prevent success. Several cases have been recorded where tetanus has followed injuries and surgical operations, and where important nerve lesions have afterwards unmistakeably indicated its cause. No great benefit can rationally be looked for in these cases from the employment of any drug. A necessary preliminary must always be the discovery of the lesions and their removal by surgical means Shortly after the recommendation of physostigma as a remedy for tetanus, a French practitioner, M. Lemaire, employed it in a case of the spontaneous or idiopathic variety of the disease. This was in 1864. It appears to have been the first example of this treatment, and was fortunately a successful one. In the same year, M. Giraldès the accomplished surgeon of l'Hôpital des Enfants at Paris, narrated before the Surgical Society a case in which he had successfully used physostigma in tetanus. About two years after this, the value of physostigma in tetanus was successfully tested, for the first time in this country, by Dr. Eben Watson, of Glasgow,-a gentlemen who deserves great credit for the ability with which he has investigated some of the physiological effects of this drug, and for the energy and skill with which he has advocated its application to the treatment of tetanus. Other nine cases have since been recorded.

[Dr. Fraser then relates twelve cases in which physostigma was used. Of these one was too far advanced before the treatment was commenced, but of the remaining eleven, nine recovered.]

Dr. Bouchut's case is one that shows the urgent necessity of commencing the administration of this drug as early as possible, and of boldly increasing the dose until some decided effect is produced. Physiological chemistry teaches us that muscle itself produces, during its contraction, substances that cause it to contract. When the contraction is extremely energetic and continuons, these substances so accumulate as to cause a condition of persistent tetanus, independent of the nervous system for its persistence. Possibly the continuous rigor, especially marked in the muscles of the back, and occasionally described, in fatal cases, as passing directly into the condition of rigor mortis, may be greatly due to this circumstance. Our knowledge of this disease teaches us that the abnormally excitable condition of the reflex centres first manifests itself in limited portions, and gradually extends until it involves their whole extent. It is, therefore, of the greatest importance to diminish the frequency of the tetanic convulsions at as early a stage as possible. This,

it is only rational to suppose, will be best done by the use of a substance that diminishes the reflex excitability of the spinal chord. Physostigma possesses such an action, and the experience gained in these cases proves that it efficiently exerts it in tetanus. I extract, in illustration, the following details from the account of Mr. Ashdown's case (Case 9):

"October 6th.--. One-third of a grain of extract of Calabar bean, dissolved in eighteen minims of water, ordered to be injected every two hours under the skin. The effect of the first subcutaneous injection was very marked. In about five minutes, the legs, which had been previously perfectly rigid and immoveable, became flaccid and freely moveable by the patient; the abdominal muscles became lesss tense, and the arching of the spine disappeared. The pupils also contracted, and the pulse sank to 82. The effects lasted two or three hours, and all the symptoms then reappeared." "October 7th.--. . . Every subcutaneous injection, which had been given regularly every three hours during the night, had been followed by an almost complete remission of the symptoms. lasting about two hours.

October 10th.-During the night, as the patient was very delirious, and the pulse had risen to 148.-effects supposed to depend on an overdose of the medicine, the injections were stopped for seven hours. This morning, the vessels were as rigid as ever; and the paroxysms, which had almost ceased, again increased in frequency. The injection was ordered to be continued as before. In the evening, the pulse had fallen to 125, but the injections had been required every two hours, the effect not lasting so long as previously."

In the cases I have mentioned, physostigma was administered in very varying doses, and in numerous forms. Little benefit would, therefore, be derived from an attempt to establish any rules for its administration from the experience of these cases alone. I prefer to use this experience as merely a guide in preparing the recommendations I venture to make on the employment of this remedy in tetanus.

The British Pharmacopoeia contains two preparations of physostigma, the powder and the extract. I think the powder should not be used, as there is considerable evidence to show that the functions of the stomach are impaired in this disease. By giving it we not only increase this evil, but we fail, on account of the comparatively slow action of the powder, in securing the important object of affecting the system as rapidly as possible. The extract should be always used, as it is the most concentrated preparation, and one on whose constancy we may rely. It may be given in the form of pill, or of solution and suspension in water (mixture), or of solution in weak spirit of sp. gr. 0.920 thirty-two grains to the fluid ounce). I prefer the first and last of these forms, as that with water decomposes in a few days.

Physostigma may be administered by the mouth, anus, or subcutaneously; and the special peculiarities of each case will be the best guide in determining which of these should be used. I should myself feel inclined always to commence the treatment by subcutaneous injection, to repeat such injection until the system is decidedly affected, and then to administer the remedy by the mouth, in a dose three times as large as is found necessary by subcutaneous injection. Such a plan might be quite safely followed in a child of even nine years. If the remedial effects continue to be produced by administration by the mouth, it should be persevered with, for such administration has obvious advantages as far as the convenience of the practitioner is concerned. In the more severe cases, however, I believe subcutaneous injection should be alone employed. The distress and the increase of spasm caused by swallowing, or the impossibility of introducing substances by the mouth, will render this necessary. I cannot, also, urge too strongly that subcutaneous injection should always be used when severe and continuous spasms occur, when a fatal result is imminent from the exhaustion caused by prolonged and frequent convulsions, and when apnoea threatens at once to close the tragic scene. By it we obtain the quickest and most powerful effects. Administration by the anus will be rarely necessary. It may, however, be employed to relieve the stomach, and will then be occasionally useful.