Electrotherapeutics
ELECTROTHERAPEUTICS, a general term for the use of electricity in therapeutics, i.e. in the alleviation and cure of disease. Before the different forms of medical treatment are dealt with, a few points in connexion with the machines and currents, of special interest to the medical reader, must first be given.
Faradism. - For the battery required either for faradism or galvanism, cells of the Leclanché type are the most satisfactory. Being dry they can be carried in any position, are lighter, and there is no trouble from the erosion of wires and binding screws, such as so often results from wet cells. The best method of producing a smooth current in the secondary coil is for the interruptor hammer to vibrate directly against the iron core of the primary coil. For this it is best that the interruptor be made of a piece of steel spring, as a high rate of interruption can then be maintained, with a fairly smooth current in the secondary coil. This form of interruptor necessitates that the iron core be fixed, and variation in the primary induced current is arranged for by slipping a brass tube more or less over the iron core, thus cutting off the magnetic field from the primary coil. The secondary current (that obtained from the secondary coil) can be varied by keeping the secondary coil permanently fixed over the primary and varying the strength of the primary current. Where, as suggested above, the iron core is fixed, the primary and secondary induced currents will be at their strongest when the brass tube is completely withdrawn. As there is no simple means of measuring the strength of the faradic current, it is best to start with a very weak current, testing it on the muscles of one's own hand until these begin to contract and a definite sensory effect is produced; the current can then be applied to the part, being strengthened only very gradually.
Galvanism. - For treatment by galvanism a large battery is needed, the simplest form being known as a "patient's battery," consisting of a variable number of dry cells arranged in series. The cells used are those of Leclanché, with E.M.F. (or voltage) of 1.5 and an internal resistance of .3 ohm. Thus the exact strength of the current is known; the number of cells usually employed is 24, and when new give an E.M.F. of about 36 volts. By using the formula C = E/R, where E is the voltage of the battery, R the total resistance of battery, electrodes and the patient's skin and tissues, and C the current in amperes, the number of cells required for any particular current can be worked out. The resistance of the patient's skin must be made as low as possible by thoroughly wetting both skin and electrodes with sodium bicarbonate solution, and keeping the electrodes in very close apposition to the skin. A galvanometer is always fitted to the battery, usually of the d'Arsonval type, with a shunt by means of which, on turning a screw, nine-tenths of the inducing current can be short-circuited away, and the solenoid only influenced by one-tenth of the current which is being used on the patient. In districts where electric power is available the continuous current can be used by means of a switchboard. A current of much value for electrotherapeutic purposes is the sinusoidal current, by which is meant an alternating current whose curve of electromotive force, in both positive and negative phase, varies constantly and smoothly in what is known as the sine curve. In those districts supplied by an alternating current, the sinusoidal current can be obtained from the mains by passing it through various transformers, but where the main supply is the direct or constant current, a motor transformer is needed.
Static Electricity. - For treatment by static electricity the Wimshurst type of machine is the one most generally used. A number of electrodes are required; thus for the application of sparks a brass ball and brass roller electrode, for the "breeze" a single point and a multiple point electrode, and another multiple point electrode in the form of a metal cap that can be placed over the patient's head. The polarity of the machine must always be tested, as either knob may become positive or negative, though the polarity rarely changes when once the machine is in action. The oldest method of subjecting a patient to electric influence is that in which static electricity is employed. The patient is insulated on a suitable platform and treated by means of charges and discharges from an electrical machine. The effect is to increase the regularity and frequency of the pulse, raise the blood pressure and increase the action of the skin. The nervous system is quieted, sleep being promoted, the patient often becoming drowsy during the application. If while the patient is being treated a point electrode is brought towards him he feels the sensation of a wind blowing from that point; this is an electric breeze or brush discharge. The breeze is negative if the patient is positively charged and vice versa. The "breeze discharge" treatment is especially valuable in subduing pain of the superficial cutaneous nerves, and also in the treatment of chronic indolent ulcers. Quite recently this form of treatment has been applied with much success to various skin lesions - psoriasis, eczema and pruritus. Static electricity is also utilized for medical purposes by means of "sparks," which are administered with a ball electrode, the result being a sudden muscular contraction at the point of application. The electrode must be rapidly withdrawn before a second spark has time to leap across, as this is a severe form of treatment and must be administered slowly. It is mainly employed for muscular stimulation, and the contractions resulting from spark stimulation can be produced in cases of nerve injury and degeneration, even when the muscles have lost their reaction to faradism. The sensory stimulation of this form of treatment is also strong, and is useful in hysterical anaesthesia and functional paralysis. Where a milder sensory stimulation is required friction can be used, the electrode being in the form of a metal roller which is moved rapidly outside the patient's clothing over the spine or other part to be treated. The clothing must be dry and of wool, and each additional woollen layer intensifies the effect.
Another method of employing electricity at high potential is by the employment of high frequency currents. There are two methods of application: that in which brush discharges are made use of, with undoubtedly good effects in many of the diseases affecting the surface of the body, and that in which the currents of the solenoid are made to traverse the patient directly. The physiological value of the latter method is not certain, though one point of interest in connexion with it is that whereas statical applications raise the blood pressure, high frequency applications lower it. It has been used in the case of old people with arterio-sclerosis, and the reduction of blood pressure produced is said to have shown considerable permanence.
The Faradic Current. - G.B. Duchenne was the first physician to make use of the induced current for treatment, and the term "faradization" is supposed to be due to him. But in his day the differences between the two currents available, the primary and the secondary, were not worked out, and they were used somewhat indiscriminately. Nowadays it is generally accepted that the primary current should be used for the stimulation of deep-lying organs, as stomach and intestines, etc., while the secondary current is employed for stimulation of the limb muscles and the cutaneous sensory nerves. The faradic current is also used as a means of diagnosis for neuro-muscular conditions. When the interrupted current is used to stimulate the skin over a motor nerve, all the muscles supplied by that nerve are thrown into rapid tetanic contraction, the contraction both beginning and ceasing sharply and suddenly with the current. This is the normal reaction of the nerve to faradism. If the muscle be wasted from disuse or some local cause unconnected with its nerve-supply, the contraction is smaller, and both arises and relaxes more slowly. But if the lesion lies in the nerve itself, as in Bell's palsy, the muscles no longer show any response when the nerve is stimulated, and this is known as the reaction of degeneration in the nerve. It is usually preceded by a condition of hyperexcitability. These results are applied to distinguish between functional paralysis and that due to some organic lesion, as in the former case the reaction of faradism will be as brisk as usual. Also at the beginning of most cases of infantile paralysis many more groups of muscles appear to be affected than ultimately prove to be, and faradism enables the physician to distinguish between those groups of muscles that are permanently paralysed owing to the destruction of their trophic centre, and those muscles which are only temporarily inhibited from shock, and which with proper treatment will later regain their full power. In the testing of muscles electrically that point on the skin which on stimulation gives the maximum contraction for that muscle is known as the "motor point" for that muscle. It usually corresponds to the entry of the motor nerve. Faradic treatment may be employed in the weakness and emaciation depending on any long illness, rickets, anaemia, etc. For these cases it is best to use the electric bath, the patient being placed in warm water, and the two electrodes, one at the patient's back and the other at his feet, being connected with the secondary coil. The patient's general metabolism is stimulated, he eats and sleeps better and soon begins to put on weight. This is especially beneficial in severe cases of rickets. In the weakness and emaciation due to neurasthenia, especially in those cases being treated by the Weir Mitchell method (isolation, absolute confinement to bed, massage and overfeeding), a similar faradic bath is a very helpful adjunct. In tabes dorsalis faradic treatment will often diminish the anaesthesia and numbness in the legs, with resulting benefit to the ataxy. Perhaps the most beneficial use of the faradic current is in the treatment of chronic constipation - especially that so frequently met with in young women and due to deficient muscular power of the intestinal walls. In long-standing cases the large intestine becomes permanently dilated, and its muscular fibres so attenuated as to have no power over the intestinal contents. But faradism causes contraction at the point of stimulation, and the peristaltic wave thus started slowly progresses along the bowel. All that is needed is a special electrode for introduction into the bowel and an ordinary roller electrode. The rectal electrode consists of a 6-inch wire bearing at one end a small metal knob and fitted at the other into a metal cup which screws into the handle of the electrode. The only part exposed is the metallic knob; the rest is coated with some insulating material. The patient reclines on a couch on his back, the rectal electrode is connected, and having been vaselined is passed some three inches into the rectum. A current is started with the secondary coil in such a position as to give only an extremely weak current. The roller electrode is then wetted with hot water and applied to the front of the abdomen. At first the patient should feel nothing, but the current should slowly be increased until a faint response is perceptible from the abdominal muscles. This gives the required strength, and the roller electrode, pressed well into the abdominal wall, should very slowly be moved along the course of the large intestine beginning at the right iliac fossa. Thus a combination of massage and faradic current is obtained, and the results are particularly satisfactory. Treatment should be given on alternate days immediately after breakfast, and should be persevered with for six or eight weeks. The patient can be taught to administer it to himself.
The Galvanic, Continuous or Direct Current. - In using the galvanic or direct current the electrode must be covered with padded webbing or some other absorbent material, the metal of the electrode never being allowed to come in contact with the skin. The padding by retaining moisture helps to make good contact, and also helps to guard against burning the skin. But when a continuous current of 3 am. or more is passed for more than 5 min. the electrodes must be raised periodically and the skin inspected. If the current be too strong or applied for too long a time, small blisters are raised which break and are very troublesome to heal. Nor does the patient always feel much pain when this occurs. Also the electrodes must be remoistened every five or six minutes, as they soon become dry, and the skin will then be burnt. It is best to use a solution of sodium bicarbonate. Again, the danger of burning the skin depends on the density of the current per sq. in. of electrode, so that a strong current through a small electrode will burn the skin, whereas the same current through a larger electrode will produce a beneficial effect. If the patient be immersed up to his neck in an electric bath, much stronger currents can be passed without causing either pain or injury, as in this case the whole area of the skin in contact with the water acts as an electrode. In passing the current it must be remembered that the negative electrode or kathode is the more painful of the two, and its action more stimulating than the positive electrode or anode, which is sedative. If a muscle be stimulated over its motor point, it will contract with a sharp twitch and then become quiescent. With normal muscle the KCC (kathodal closure contraction) is stronger than that produced by the closure of the current at the anode ACC (anodal closure contraction). And if the muscle be normal the opening contraction KOC and AOC are not seen. When a galvanic current is passed along a nerve its excitability is increased at the kathode and diminished at the anode. The increased excitability at the kathode is katelectrotonus, and the lowered excitability at the anode anelectrotonus. But since in a patient the electrode cannot be applied directly to the nerve, the lines of force from the electrode pass into the nerve both in an upward and downward direction, and hence there are two poles produced by each electrode. If the current be suddenly reversed, so that what was the anode becomes the kathode, a stronger contraction is obtained than by simply making and breaking the current. To avoid the four poles on the nerve to be tested, it is found most satisfactory to have one electrode placed at some distance, on the back or chest, not on the same limb.
As explained above, when the nerve supplying a muscle is diseased it no longer responds to the faradic current. On further testing this with the galvanic or continuous current it responds, but the contraction is not brisk but begins slowly and relaxes slowly, though the contraction as a whole may be larger than that of a normal muscle. This excessive contraction is known as hyperexcitability to galvanism. This form of contraction is that obtained when the muscle fibre itself is stimulated. Again, whereas in normal muscle KCC > ACC, when the nerve is degenerated KCC = ACC or ACC > KCC. Also in the more severe forms of nerve injury tetanic contractions may be set up in the paralysed muscles, by closure of the current either at the anode or kathode. These charges are known as the reaction of degeneration or RD, and are of great value in diagnosis. They occur only after sudden or acute damage to the nerve cells of the anterior horn of the spinal cord, or to the motor nerve fibres proceeding from these cells. Thus RD is present in infantile paralysis, acute neuritis, etc., but absent in progressive muscular atrophy where the wasting of nerve and muscle takes place extremely slowly. The reaction of degeneration in the nerve is shown by disappearance of reaction to either kind of current, preceded for some days by hyperexcitability to either current. Where the muscle wasting is due to a lesion in the muscle alone, as in ischaemic myositis (usually due to injury from tight bandaging or badly applied splints), no reaction of degeneration is found; the only change is a loss of power in the contraction. If the damage to the anterior horn cells be only very slight, there may only be partial RD, and the prognosis is given according to the extent of RD. From this account it is clear that the greatest value of the continuous current lies in its use in diagnosis. But it is also applied extremely successfully, in combination with massage, to cases of infantile paralysis. Wrist drop from lead poisoning and lead neuritis of all kinds, reflex muscular atrophy and the muscular wasting of hemiplegia, are all benefited by the continuous current; the severe pain of sciatica, and the inflammation of the nerve sheath in these cases, can be arrested more quickly by galvanic treatment than in any other way. Nearly all forms of neuritis, both of the cranial and other nerves, are best treated by the continuous current. The action in all cases is to stimulate the natural tendency to repair, very largely by improving the circulation through the injured parts.
Another effect of an electric current is electrolysis, and the phenomena of electrolytic conduction involve not merely the ionization of the compounds, but also the setting in motion of the ions towards their respective poles. Solutions which conduct electric currents are called electrolytes, and in the case of the human body the electrolyte is the whole mass of the saline constituents in solution throughout the body. When a current is passed through an electrolyte, dissociation into ions takes place, the ions which are freed round the anode being called anions and those which are freed round the kathode being called kations. The anions carry negative charges and are consequently attracted by the positive electricity of the anode. The kations carry positive charges, hence they are repelled by the anode and attracted by the kathode. But a certain number of molecules do not dissociate, and hence in an electrolytic solution there are neutral molecules, anions and kations. The chemical actions, and thus the antiseptic, remedial or toxic effects of electrolytes, are due to the actions of their ions. The phosphides and phosphates may be taken as examples. Some are extremely toxic, while others are quite harmless. But it is to the phosphorus ion that the toxic or therapeutic effect is due. In the phosphates the phosphorus is part of a complex ion possessing quite different properties to those of the phosphorus ion of the phosphides. The strikingly different effects of the sulphates and sulphides are due to similar conditions, as also of many other compounds. There are certain solvents, as alcohol, chloroform, glycerin and vaseline which do not dissociate electrolytes, and consequently the latter become inert when mixed with these solvents. These solutions do not conduct electricity, and hence ionic effects are extremely slow. A vaseline ointment containing 5% of phenol makes a good dressing for an ulcer of the leg, and produces no irritant effect, but a 5% aqueous solution may be both caustic and toxic. Since the toxic or therapeutic action of a solution is due to its ions, the action must be proportional to the number of ions in a given volume, that is, the action of an electrolyte depends on the degree of dissociation. Thus a strong acid is one that is much dissociated, a weak acid one that has undergone but little dissociation and so on. In 1896-1897 it was shown that the bactericidal action of salts varies with their degree of dissociation and therefore depends on the concentration of the active ions. In the medical application of these facts it must be remembered that when an ion is introduced into the body by electrolysis, it is probably forced into the actual cellular constituents of the body, whereas the drug administered by one of the usual methods though circulating in the blood may perhaps never gain access to the cell itself. Hence the different effects that have been recorded between a drug administered by the mouth or subcutaneously and the same administered by electrolysis. Thus a solution of cocaine injected subcutaneously produces quite different effects to that introduced by electrolysis. By the latter method it produces anaesthesia but does not diffuse, and the anaesthesia remains strictly limited to the surface covered by the electrode. It would appear that the ion is never introduced into the general circulation but into the cell plasma.
In the technical working of medical electrolysis the most minute precautions are required. The solution of the drug must be made with as pure water as possible, recently distilled. The spongy substance forming the electrode must be free from any trace of electrolytic substances. Hence all materials used must be washed in distilled water. Absorbent cotton answers all requirements and is easily procured. The area of introduction can be exactly circumscribed by cutting a hole in a sheet of adhesive plaster which is applied to the skin and on which the electrolytic electrodes are pressed. The great advantage of electrolytic methods is that it enables general treatment to be replaced by a strictly local treatment, and the cells can be saturated exactly to the degree and depth required. Strong antiseptics and materials that coagulate albumen cannot be introduced locally by ordinary methods, as the skin is impermeable to them, but by electrolysis they can be introduced to the exact depth required. The local effects of the ions depend on the dosage; thus a feeble dose of the ions of zinc stimulates the growth of hair, but a stronger dose produces the death of the tissue. Naturally the different ions produce different effects. Thus the ions of the alkalis and magnesium are caustic, those of the alkaline earthy metals produce actual mortification of the tissue and so on. According to the ion chosen the effect may be caustic in various degrees, antiseptic, coagulating, producing vascular or nervous changes, etc., etc. And again electrolysis can also be used for extracting from the body such ions as are injurious, as uric and oxalic acid from a patient suffering from gout.
One of the latest advances is the treatment of ankylosed joints by the electrolytic method, the electrolyte used being chloride of sodium, and the marvellous results being attributed to the introduction of the chlorine ions. This sclerolytic property of the current is applicable to all parts of the body accessible to the current. Old cases of rheumatic scleritis, entirely unaffected by the routine treatment of salicylates and iodide, have often cleared up entirely under electrolytic treatment. Cases of chronic iritis with adhesions and old pleural adhesions are also suited for this method of procedure. Certain menstrual troubles of women and also endometritis yield rapidly to electrolysis with a zinc anode. Before this method of introduction, the zinc salts, though excellent disinfectants, acted only on the surface in consequence of their coagulating action on the albuminoids, but by the electric current, under the influence of a difference of potential, the zinc iron will penetrate to any desired depth. Cases of rodent ulcer unaffected by all other methods of treatment have been cured by electric kataphoresis with zinc ions, and the method is now being applied to the treatment of inoperable malignant tumours. As very strong currents are required for this latter, the patient has first to be anaesthetized by a general anaesthetic. Another direction in which electric ions are being used is that of the induction of local anaesthesia before minor surgical operations. Cocaine is the drug used, the resulting anaesthesia is absolute, and the operation can be made almost bloodless by the admixture of suprarenal extract.
Note - this article incorporates content from Encyclopaedia Britannica, Eleventh Edition, (1910-1911)
