u- * / UNIVERSITY OF CALIFORNIA CALIFORNIA COLLEGE OF MEDICINE JUL241975 WINE, CAUfOftNIA 92664 USE A HAMMER ON SPINAL COLUMN TO CURE ORGANS Tack Driver Used at Philadelphia Hospital to Overcome Lung, Heart and Other Troubles SCIENTIFIC hammering of certain vertebrae of the spinal column with an ordinary tack hammer has brought relief to scores of patients at the Philadelphia Hospital suffering with lung, heart, stomach and liver troubles. The novel treatment is being applied at the institution with remark- able success almost daily by Dr. Myer Soils Cohen, of 4102 Girard avenue. If you 'have lung trouble, and it ia essential to have a contraction of those important organs, wonders can be worked in that direction by a little intelligent pounding of your fourth and fifth cervical vertebrae, Doctor Cohen ho>s. If your liver is out of kilter, a few well directed thumps on the eleventh dorsal vertebrae will aid greatly in re- storing the organs to their normal condi- tion. Many patients who h;|d given up hope until they were hammered can testify to it. The "tack hammer treatment 1 ' bears the scientific name of "Spondylc-therapy." It was discovered by Dr. Albert Abrams, a noted nerve specialist of San Fran- cisco. Recently Doctor Abrams demon- strated his discovery at the PhiLadelphda Hospital with the X-ray. Since Doctor Abrams' clinic, several leading Philadel- phia vhysicians, including Doctor Cohen, have applied the treatment. "Spondylotherapy," acording to Doctor Cohen ds based upon a sensible and scientific understanding of the various nerve centers that gather about the spinal cord. Nerve centers that control the hearfc the stomach, the lungs, liver and spleen are all found in the spinal canal. The vertabrae of the spinal columr serve as sort of guide posts in the loca- tion of the nerve centers. When these vertabrae are struck with a hamme* they cause a vibration of the nerves am a reflex action is produced on the organ ! which the physician is attempting to treat." " 'Spondylotlierapy,' " said Doctor Cohen, "is not so much for the treat- ment of disease as it is for the treat- ment of the condition of the various in- ternal organs of the body. "I was present at Doctor Abram' demonstration in this city and was as- tonished at the result. The subject was placed under the X-ray so that the effect on the various organs could be observed plainly. "For instance if a patient has a di- lated heart, the organ can be contracted by the hammering of a certain vertebrae which is in proximity to the nerves that control that organ. A patient suffering with asthma or a spasm of the bronchial tubes can be greatly helped by thumping the vertebrae nearest the nerve center that controls th bronchial tubes. The thumping causes a reflex action and! con- tracts the tubes. "Some physicians who have adoptd the new treatment use a pounding instru- ment called a "plessor," but I use an or- dinary tack hammer with the head cov- ered with rubber. "Xow, if I wish to contract the heart of a patient, I hammer the seventh cervi- cal vertebrae. That produces a reflex action on the organ and brings the de- sired result almost immediately. If it is necessary to dilate the heart, I pound with my hammer on the spinal column from the eighth to the twelfth dorsal vertebrae. The treatment rarely fails. "To contract 'the lungs I thump the fourth and fifth cervical vertebrae, and to dilate the lungs I do a little sharp hammering from the third to the eighth dorsal vertigrae. "To contract the stomach, liver and spleen, it is necessary to gently pound the first and third lumbar vertebrae. To dilate those 01 grans I pound the eleventh dorsal vertebrae. "The treatment seema even arore won- derful when it is .demonstrated under the X-ray. When Doctor Abraras gave hi& clinic I could see the heart a;Jjd the arota, the largest blod vessel coming from the heart of the subject, contracting when Doctor Abrams hammered the. seventh ervical vertebrae. "It is safe to say that 'Spondylotherapy' is yet in its Infancy and that we may ex- pect more wonderful results from the treatment in the future. The relief it has given patients at he Philadelphia Hospital has convinced me of its scien- tific value." Spondylo therapy BY THE SAME AUTHOR NEW CONCEPTS IN DIAGNOSIS AND TREATMENT; Physico-Clinical Medi- cine, 1916 The practical application of the Electronic Theory in the inter- pretation and treatment of disease. The author is sponsor for the visceral reflexes bearing his name and is the originator of methods in which reflexes are utilized in diagnosis. "It is an erudite, elaborate study of new conceptions" "and the applica- tion of physico-clinical facts to human considerations and needs." The British Journal of Tuberculosis. SPONDYLOTHERAPY ; Physio and Pharmacotherapy and Diagnostic meth- ods based on a study of what the author has first called Clinical Physiol- ogy Sixth Edition, 1913. "The author gives evidence of high scholarly attainments" "The result is a treatise of extraordinary interest and usefulness." New York Medical Journal, May 8, 1912. PHYSICO-CLINICAL MEDICINE; A Quarterly Journal devoted to the study of the Electronic Reactions of Abrams and the Visceral' Reflexes of Abrams, in the diagnosis, treatment and pathology of disease. All ad- vances made in electronic medicine and spondylotherapy are reported in this Journal. Philopolis Press, 2135 Sacramento Street, San Francisco. CLINICAL DIAGNOSIS ; Fourth Edition. AUTO- INTOXICATION; Causes, symptoms and treatment. SPLANCHNIC NEURASTHENIA (The blues) ; Fourth Edition. The author was the originator of this neologism, describing this variety of neuras- thenia. "It is a long time since we have read a medical book with such interest and real enjoyment." Medical Record. TRANSACTIONS OF THE ANTISEPTIC CLUB E. B. Treat & Co., New York. DIAGNOSTIC THERAPEUTICS; A pioneer work dealing with drugs and remedial measures in the diagnosis of disease. Rebman Co., New York. "Dr. Abraras has produced a book along new lines, a thoughtful philo- sophical exposition of a much neglected subject. The text is presented in plain, charming English and deals with a unique aspect of medicine."- Maryland Medical Journal. SCATTERED LEAVES FROM A PHYSICIAN'S DIARY. DISEASES OF THE LUNGS AND PLEURA Fortnightly Press Co., St. Louis. NERVOUS BREAKDOWN. CONSUMPTION. DOMESTIC AND PERSONAL HYGIENE; Cohen's System of Physiologic Therapeutics. >P. Blakiston's 'Son and Co. ELECTRONIC REACTONS OF ABRAMS; International Clinics, Vol. 1, 27th series. J. B. Lippincott Co. SPONDYLOTHERAPY; Reference Handbook of the Medical Sciences, Vol. vii, 3rd edition. Wm. Wood and Co. PREFACE TO THE SIXTH EDITION *T HE visceral reflexes of ABRAMS have been firmly entrenched * in medical literature and, respecting Spondylotherapy, the re- port of the committee on Standardizaton of the American Electro- Therapeutic Association, is as follows : "In Spondylotherapy. the employment of mechanical vibration fills one of the most useful roles in therapeutics. It is easily controlled and is practical and effective of application in the hands of those familiar with the meth- ods of employing it as spinal percussion." Incorporated in the present edition are chapters on, The Elec- tronic Reactions of Abrams reprinted with additions from "Inter- national Clinics," and a summary of Spondylotherapy, which is reprinted from "Reference Handbook of the Medical Sciences" (3d edition). This work on Spondylotherapy has been translated into the French and Japanese languages. In Spondylotherapy, 1914 (page 96 et. seq.), the polarity of the reactions should be reversed as fol- lows: Positive should read negative and negative should read positive. Neutral, and positive and negative reactions, are correct. These reactions only hold when a male subject is used and who during the time of the examination faces the west. A. A. 2135 SACRAMENTO STREET, SAN FRANCISCO, CAL. FEBRUARY, 1918. tSPONDYLOTHERAPY ~7 PHYSIO AND PHARMACO-THERAPY AND DIAGNOSTIC METHODS BASED ON A STUDY OF CLINICAL PHYSIOLOGY BY ALBERT ABRAMS, A.M., LL.D., M.D. DR. MED. (HEIDELBERG), F. R. M. S., (LONDON). HONORARY PRESIDENT OF THE AMERICAN ASSOCIATION FOR THE STUDY OF SPONDYLOTHERAPY; FORMERLY PROFESSOR OF PATHOLOGY AND DIRECTOR OF THE MEDICAL CLINIC COOPER MEDICAL COLLEGE (DEPARTMENT OF MEDICINE, LELAND STANFORD JUNIOR UNIVERSITY); CONSULT- ING PHYSICIAN TO THE MOUNT ZION AND FRENCH HOSPITALS, SAN FRANCISCO; PRESIDENT OF THE EMANUEL SISTERHOOD POLYCLINIC; PRESIDENT OF THE SAN FRANCISCO MEDICO-CHIRURGICAL SOCIETY; PRESIDENT OF THE ALUMNI ASSO- CIATION OF COOPER MEDICAL COLLEGE; FELLQW OF THE AMERICAN MEDICAL ASSOCIATION, ETC. SIXTH EDITION PHILOPOLIS PRESS 2135 SACRAMENTO STREET, SAN FRANCISCO, CAL. 1918. (Us Copyright, ipro by Albert Abrams Copyright, 1912 by Albert Abrams Copyright, 1918 by Albert Abrams TO THE MEMBERS OF THE FACULTY OF MEDICINE, PARIS, IN RECOGNITION OF THEIR DISTINGUISHED SERVICES IN THE ADVANCEMENT OF MEDICINE AND FOR MANY ACTS OF COURTESY THIS BOOK IS DEDICATED BY THE AUTHOR PREFACE TO THE FIFTH EDITION THIS represents the fifth edition of Spondylotherapy, the first edition of which was published in 1910. This edition has been enlarged to include Progressive Spondylotherapy for the years 1913 and 1914 and an address, Human Energy. The author ventures to hope that his new physico-clinical methods which appear in the latter address may be the means of attaining greater precision in diagnosis. A translation of this work into French is now in the course of preparation. A. A. 291 GEARY STREET, SAN FRANCISCO, CAL., JANUARY, 1914. Preface to the First Edition THE subject of spinal therapeutics has received less attention from the medical profession than it deserves. Even the laity know that cold applied to the back of the neck may arrest hemorrhage from the nose, and that heat applied to the small of the back may hasten menstruation. The profound and far-reaching physiologic truths which underlie these simple phenomena have either been ignored or only given inconsiderate attention. Others, less scientific but more astute, have determined empiric- ally that manipulation of the spine does sometimes cure conditions that have failed of cure in the hands of experienced physicians. So it has come to pass that schools of practice exploiting spinal man- ipulation as a cure-all have arisen. Neifher the fury of tongue nor the truculence of pen can gainsay the confidence which these systems of practice have inspired in the community. The author was led to a deeper study of spinal therapeutics in investigating various visceral reflexes which bear his name. As the years passed on, he ascertained that a number of pathologic con- ditions could be more easily and certainly controlled by spondylo- therapeutic means, than by the conventional measures. Some physicians may consider the remedial methods discussed in this book to be unduly and unworthily simple, on the principle that what is obvious can hardly compete with what is obscure in the treatment of disease. The most mystifying phenomena rest upon the least complex causes; and the simpler a thing is, the harder it is to understand. Anybody, however, who investigates the study of spinal thera- peutics in earnest, will discover that the simplicity is only apparent. The successful practice of spondylotherapy requires knowledge, observation and experience of the highest kind, and is comparable to the best effort in any other department of scientific medicine. Indeed, one of the author's truest motives has been to lift this whole subject of spinal therapy out of the low state in which it blunders onward, hitting or missing as the case may be, and rescuing it from the lowly esteem which physicians as a class have thus felt for it. He has endeavored to put it in a place befitting its scientific impor- tance, and to emphasize its great practical helpfulness in disease. VII P r e fa c e to the First Edition Any method of cure that is more or less new is inclined to be viewed critically by the formalist and traditionalist, and so it should be. The writer knows better than any one else can the incompleteness and imperfections of his work. It is really a pioneer effort and he only asks that it be judged as such. Indeed, the author hopes to receive many suggestions and if need be, corrections, and to profit by them. One word concerning the cases cited in illustration of the methods which the author has described in various parts of the book. These may seem more or less incredible, the outcome of enthusiasm, bias, of some defect of the power of scientific observation, or of judgment. Yet the cases cited are not the most remarkable that the author has encountered in his practice. Some of these cases have been deliber- ately suppressed with a feeling that many readers are hardly prepared to appreciate or to credit the results which may be achieved by an earnest study and practice of spondylotherapy. To eschew a remedy because we cannot gauge its material properties may be an act worthy of the scientist, but the aim of the physician is to cure disease. In the presence of a sick man, two questions are to be answered: "What is the matter with him, and what will do him good?" Neither the pragmatical doctrinaire who accepts nothing but what is demonstrated morphologically, nor the representative of an exclusive system of practice, with his introspective reasoning, can aid therapeutics. The former forgets that the crucial test for the action of remedial measures is in their clinical application and that many of our most potent drugs have been inherited from the therapeutic acumen of our medical ancestors. "The diseases of which we know the least pathology are the diseases which we treat successfully." Cure, as conceived by the introspectionist, cannot merit the imprimatur of the scientist, and for this reason, the author has endeavored to justify his con- clusions by demonstrable evidence. ALBERT ABRAMS. 246 POWELL STREET, SAN FRANCISCO, CAL., JANUARY, 1910. vin Preface to the Third Edition THE favorable reception accorded to the previous editions, has induced the author to undertake the enlargement of this work by the addition of seven chapters (xii xviii) and fifty new illustrations. When the first edition of this book was published, nearly two years ago, it was a pioneer effort and only the cognoscenti could correctly interpret its real significance, viz., that spondylotherapy was suggested by the study of human physiology, on the principle that, "The proper study of mankind is man." After this manner, clinical physiology is made the basis of clinical pathology. To launch an innovation in medicine, with its surfeit of theories and theorists, is fraught with much risk to the innovator and the author anticipated the usual fate accorded to the originator, viz., condemnation, discussion and possibly acceptance. Neither fear of difficulty, nor adverse criticism, deterred him from regarding scepticism as an argument against the truth of his observations. It is indeed unfortunate that our medical journals have not yet attained that Utopian condition, when they are eager to give space to the protestations of an author, who feels that his work has been misinterpreted or unjustly criticised. For the latter reason, the author may be pardoned for utilizing the bulk of this preface in refuting some reviews of the previous edition. The review of "The Journal of the American Medical Association," is discussed on page 387. Occasionally, a reviewer has sat in the scorner's seat and hurled the cynic's ban. "There is a principle which is a bar against all information, which is proof against all argument and which cannot fail to keep a man in everlasting ignorance ; this principle is con- tempt prior to examination." A reviewer asseverated that the book contained nothing that was particularly new. The latter conflicted with another reviewer who said, "There are fifty pages scattered throughout the volume, any one of which could be torn out and be used as a starting point and an in- spiration for most valuable research work. The possessor of this book has a rich mine of startlingly suggestive knowledge .... and to the man of study who strives to reach ever better and more fruitful IX Preface to Third Edition methods of investigation and, cure of disease, this book will be most welcome" In another publication a prominent surgeon commented as follows: "Probably the most startlingly radical stand ever taken within the ranks of the medical profession was that announced this very year by DR. ALBERT ABRAMS, of San Francisco, in his remarkable book, 1 Spondylotherapy.'' ' An eminent French clinician, in commenting on "Spondylotherapy," says: "Some of my results and those of my colleagues in Paris, by the methods of Spondylotherapy are positively miracles. 11 Those "in. authority"? who regard innovation from the view- point of heresy, recalls the ban mot by a witty compatriot of Talley- rand, who, in commenting on the conservatism of the latter said, if Talleyrand, had been present at the creation he would have exclaimed: "Good gracious! Chaos will be destroyed." "He who dreads new remedies must abide old evils." Yet another reviewer who questioned the right of a clinician to digress from traditional methods in the investigation of facts physio- logic, must be answered. It is not now unusual for the laboratory- physiologist, to preside at the birth of his theory one day, and for the clinicist to officiate at its burial on the morrow. Pavloff observes, "The physician gives a more correct verdict concerning physiologic processes than the physiologist himself." Hughlings Jackson, was one of the greatest scientific neurologists, yet he never performed an experiment but formulated his conclusions in the wards of a hospital. Some of his enthusiastic proselytes have arrogated to the author the questionable honor of having created a new system of medical practice. No system can exclusively preempt the field of thera- peutics, which is a composite practice founded on empiricism and the practical application of pharmacology and other sciences in the treatment of disease and the innovationist must create no discon- tinuity in the transition to new knowledge. As an emphatic protest to such an assumption, ^the author has incorporated many facts relating to the employment of drugs in the treatment of disease and refers to his monograph, "Diagnostic-Therapeutics." When the author employed the neologism, Spondylotherapy (G. Spondylos, vertebra + therapeia, treatment), he advocated no exclusive methods in spinal therapeutics, but employed all the resources of Preface to Third Edition scientific medicine bearing on the treatment of disease. Since the publication of his work, the author regrets that, some so-called "drug- less healers" are exploiting the term spondylotherapy to abet their exclusive methods of practice. For the benefit of physicians who cannot master some of the details of spondylotherapy, a practical course is given on this subject by the author from time to time. ALBERT ABRAMS. 246 POWELL STREET, SAN FRANCISCO, CAL., FEBRUARY 1912. Contents CHAPTER I. HISTORICAL. Page Primitive Era of Spondylotherapeutics . . i The Griffin Brothers ..... 2 Swedish Gymnasts . . . . . . . 4 Osteopathy . . rV ... 4 Chiropractic . . . . . . .5 Dana . . . . . . . 7 Quincke . . . . . . .7 Head ....... 7 The Vertebral Reflexes . . . . .7 CHAPTER II. ANATOMIC, TOPOGRAPHIC AND PHYSIOLOGIC DATA. Structure of the Spinal Cord . . . i. 1 7 Roots and Distribution of the Spinal Nerves '" . ' 18 Anatomic Landmarks . . . ~U 19 Sympathetic System . * * . - 24 Physiology of the Spinal Cord . . . . .26 Localization of the Functions in Different Segments of the Spinal Cord ....... 30 CHAPTER III. SYMPTOMATOLOGY. Examination of the Back . . . . -38 The Normal Spine . . . 38 Spondylography . . . - .42 Examination of the Muscles of the Back ... 46 Stiff Back . . . - ' 5 Muscular Hypotonia . . . . 5 2 XIII C o n t e n t s Page Pain and Tenderness of the Spine . . . -55 Sympathetic Sensations . . . . -57 Dermatomes of Head . . . . , 58 Vertebral Pain . . . . . . 66 Vertebral Tenderness . . . . . 71 Vertebral Percussion . . . . .79 Vibrosuppression . . ... . .80 CHAPTER IV. SUMMARY OF SPINAL DISEASES AND SYMPTOMS. Backache . . . . . . 83 Chest Deformities . . . . . . 94 Coccygodynia - , . ... . -95 Faulty Attitudes . . . . 96 Litigation Backs . . . . -97 Lumbago ....... 99 Neurotic Spine . . . . . . 103 Osteo- Arthritis i . . . . . 105 Pott's Disease of the Spine ..... 108 Sacro- Iliac Disease . . . . . .in Sacro- Iliac Relaxation . . . . . .in Spinal Curvatures . . . . . .113 Scoliosis . . . . . . i J 3 Kyphosis and Lordosis . . . . .115 Angular Curvature . . . . . . 117 Spondylitis ....... 117 Spondylolisthesis . . . . . .118 Traumatism of the Spine . . . . . 118 Tumors of the Spine . . . . . .121 Typhoid Spine . . . . . .121 Vertebral Insufficiency . . . . . .122 Diagnosis of Spinal Diseases . . . .126 Pains . . . . . . . .128 Deformity .... ... 131 Compression of the Spinal Cord . . . . 133 xiv C o n t e n t s Page Paraplegia . . . . . .134 Tuberculosis . . . . . . - I 37 Syphilis . . . . . . . 139 Gonorrhoea ....... 141 Rheumatisin ...... 141 Rickets ....... 143 Spinal Meningitis - . . . . . .144 CHAPTER V. GENERAL SPONDYLOTHERAPY. Abdominal Supporters . . . . . -145 Acupuncture . . . . . .146 Counter-irritation ...... 148 Electrotherapy . . . . '. . . 151 Exercises . . . . . . . 159 Re-education of Co-ordinated Movements . . . 165 Spinal Hydro-Therapy . . . . . . 166 Lumbar Puncture . . . . . .167 Massage . . . . . 168 Psychrotherapy . . . . .172 Thermotherapy . . . . . . 174 Vibratory Massage . . . . .. 175 CHAPTER VI. PSEUDO-VISCERAL DISEASES. Neuralgia ...... ..182 Intercostal Neuralgia . . . . .186 Differential Diagnosis ...... 189 Pseudo-Appendicitis ..... 191 Pseud o- Cerebral Disease . . . . .192 Pseudo-Angina Pectoris . . ~ . .194 Pseudo- Arrhythmia . . . . . . 195 Pseudo-Esophagismus . . . . .196 XV O o n t e n t s Page Pseud o-Nephrolithiasis . . . . . . 197 Pseudo-Dyspepsia . . . . . .197 Pseudo-Cholelithiasis ....... 197 Pseudo-Mammary Neoplasms . . . .198 CHAPTER VII. THE CIRCULATORY SYSTEM. The Heart Reflex . . . . . - 199 Cardiac Sufficiency . . . . .210 Differential Table of Asthma . . . . .212 Tests for Heart Sufficiency . . . . .215 Angina Pectoris . . . . . .221 The Heart Reflex of Dilatation . . . , 221 Differential Table of True and False Angina . . .224 Functional Affections of the Heart . . . .228 Inhibition of the Heart ..... 228 Physiology and Pathology of the Blood-Vessels . . 231 Blood-Pressure ....... 234 Vaso-Motor Factor in Blood-Pressure . . . 239 Sphygmomanometry ...... 244 Hypertension and Hypotension .... 246 The Aortic Reflexes . . . . . . 254 Aneurysm of the Thoracic Aorta . . . .254 The Vaso-Motor Apparatus . . . . .272 Vaso-Motor Neuroses . . . . .275 CHAPTER VIII. THE RESPIRATORY APPARATUS. Physiology ....... 288 Histology ....... 289 Postural Lung-Dullness . . . .290 Lung Reflex of Dilatation . . 294 Lung Reflex of Contraction ..... 298 xvi c n t e n Page Pulmonary Atelectasis ..... 299 Bronchial Asthma . ,> .... 303 Spasmodic Bronchostenosis . . . 311 Tuberculosis . . . . . . 315 Hemoptysis . . . . . 315 CHAPTER IX. THE DIGESTIVE SYSTEM. The Stomach . . . "* '. ? . . . . 316 The Stomach Reflexes . ; , . . 316 Percussion of the Stomach . . . . . 321 Treatment of Diseases of the Stomach . . .324 The Intestine . . . c . . . 325 The Intestinal Reflexes . . . . .325 Diseases of the Intestines . . . . . 326 Treatment of Constipation . 'V . . . 329 The Intestinal Neuroses ..... 330 The Liver . . .. . . . .331 Hepatic Toxemia ...... 334 Splanchnic Neurasthenia ..... 345 CHAPTER X. MISCELLANEOUS REFLEXES. The Spleen ....... 351 Reflexes of the Spleen . . . m 352 Splenic Reflexes in Treatment ..... 352 Uterus Reflex . . . . 358 Dysmenorrhea . . . . . . -358 The Bladder Reflex . . . . .358 The Kidney Reflexes . . . . -359 Nervous Symptoms . .362 Paralysis, Contractures, Ataxia . . . . . 362 XVII Contents CHAPTER XI. THE THERAPEUTICS AND DIAGNOSIS OF PAIN. Page Segmental- Analgesia . . . . . . . 366 Concussion- Analgesia . . . . . .367 Segmental-Localization . . . . . -367 The Trigeminus Nerve . . . . . . 371 Sinusoidal- Analgesia . . . . . . -374 Segmental-Psychrotherapy . . . . ' . 375 Segmental-Analgesia of the Viscera . . . . . 376 Segmental- Analgesia in Diagnosis . . . . 377 Physiology of Spondylotherapeutic Methods . . - 379 Spinal Nerve-Trunk Analgesia . . . . .382 Cortical Sinusoidalization . . . . . . 383 CHAPTER XII. THE REFLEXES AND THE PERIPHERAL SYMPTOMATOLOGY OF VISCERAL DISEASE. Purport of Spondylotherapy ...... 387 General Features of Reflexes ..... 390 Therapeutics of Reflexes ...... 392 Therapeutics of Concussion ..... 394 Comparison of Methods . . . . . 397 Trophic Functions of Cord ..... 400 Trophic Diseases . . . . . ..401 Peripheral Reflex Phenomena . . . . . 411 Insufficiency of the Foot . . . . . .421 Test for the Splanchnic Circulation . . . . 427 Reflexes of the Cranial Nerves ..... 440 CHAPTER XIII. TONUS OF THE VAGUS AND PHARMACOLOGY OF THE REFLEXES. Tonus of the Vagus ....'... 446 Anatomy of the Vagus ...... 446 Physiology and Clinical Physiology of the Vagus . . . 448 XVIII c n t e n Diagnosis of Vagus-Tonus . /'. '" . . . 453 Vagus-tone and the Sense Organs ...... 462 Psychovagus Tone ...... 466 Methods for Increasing and Decreasing Vagus-tone - . . 469 Therapeutic Results ...... 474 Diseases Caused by Vagus-hypertonia and Vagus-hypotonia . 479 Phylogenetic Diseases . . ' 4 i . . . 500 Vagal Hyperesthesia ....... 504 Clinical Pharmacology . . . . . 504 CHAPTER XIV. FURTHER ADVANCES IN THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE CIRCULATORY SYSTEM. Tests For Heart-Sufficiency . . . . . .510 Kuatsu ..... !.. . . 515 Heart-Failure . . . . . . . . 523 Functional Cardiac Murmurs . . "..-.. . . 525 Reflex of the Pulmonary Artery . . . . . 526 Inhibition of the Heart . . . . . . 528 Cardioptosis . . ' . . . . . . 529 Subclavian Murmurs . . ... . 533 Angina Pectoris . . . . . . 539 Anginoid Pains ....... 540 Phrenic Nerve ........ 549 Diaphragm Reflex . . . ". . 550 Aneurysm ........ 550 Fluoroscopy of the Aorta . . . . . .561 CHAPTER XV. FURTHER ADVANCES IN THE DIAGNOSIS OF DISEASES OF THE DIGESTIVE SYSTEM. Percussion of the Stomach ...... 584 Diagnostic Data ....... 588 Percussion of the Intestines . . . . . . 591 The Gall-Bladder . . . . . .597 Diagnostic Data ....... 599 The Pancreas ....... 600 XIX Contents Page CHAPTER XVI. PHYSIO-THERAPY OF PULMONARY TUBERCULOSIS. Anemic Theory ....... 602 Clinical Evidence ....... 603 Triangles of Grocco ....... 606 Methods for Eliciting Lung-Hyperemia ... 608 Resume ......... 608 Treatment ........ 609 Author's Treatment . . . . . . .612 Visceral Vascularity . . . . . .614 Blood- Volume . . . . . ... .617 CHAPTER XVII. TREATMENT OF WHOOPING COUGH. Pertussis ........ 619 Author's Conception of Pertussis ..... 620 Author's Treatment ...... 624 Results of Treatment . . .... . . . 624 Analysis of Treatment . . . . . .627 CHAPTER XVIII. MISCELLANEOUS DATA. Further Advances in the Utilization of the Kidney Reflexes . 629 Prostatic Hypertrophy . . . . . .634 Reflexotherapy . . . . . . . . 636 Spondylotherapy in the Etiology of Disease . . . 640 Synoptic Table of Spondylodiagnosis . . . .642 Synoptic Table of Spondylotherapy .... 644 Synoptic Table of Pharmacology of the Reflexes . . . 644 Spondylotherapeutic Armamentarium .... 646 Bibliography . . . . . . . -657 Index ..... 661 xx Illustrations Figure. Page 1. Illustrating the Chiropractor's Conception of Disease . 6 2. Plexor and Pleximeter for the Vertebral Reflexes . 9 3. Concussing the Spines with the Hands . . .10 4. Spinal Muscular Reflexes ... . . . 13 5. Viscero-Motor Reflexes . , L , _.{ . . 14 6. Babinski Toe-Reflex ._ ... . . . 16 7. Conducting Paths in the Spinal Cord . . 17 8. A Spinal Nerve . . f . . . . . 18 9. Composition of a Peripheral Nerve-Trunk . 19 10. Relations of the Segments of the Spinal Cord . . 20 11. Posterior Aspect of the Thorax and Abdomen . .22 12. Sympathetic and Cerebro- Spinal Nervous System . 25 13. Mechanism of the Knee-jerk > . . . . 27 14. Showing Spinal Segments for Motion and Sensibility 31 15. Segmental Skin Fields ,,,. .,.,: ;.,. (;'' 35 16. Normal Vertebral Curves . :, 4 ?-..-' ;'-,-' 4 17. Spondylograms . . ; .,.. . .., v -[., r - 42 18. Apparatus for Taking a Spondylogram --. '. : - 43 19. Vertebral Areas of Muscular Spasm . . . ij>Ji' 49 20. Plan of the Cervical Plexus . }>-:. '.-. 5 1 21. Diagrams of Transferred Pains ... 56 22. Illustrating Cutaneous Tenderness . . 58 23. Sensory Areas of the Skin (Anterior View) . -).;. i 61 24. Sensory Areas of the Skin (Posterior View) , ,./. . 61 25. Sensory Areas of the Skin .... 63 26. Sensory Areas of the Skin . . . -63 27. Painful Head-Areas Related to Visceral Disease . 65 28. Hyperalgesic Zones . . . . . 67 29. Hyperalgesic Zones . . . . .68 30. Areas of Vertebral Tenderness . . . - 75 31. Areas of Vertebral Tenderness ... 78 32. The Vibrosuppressor . . . . .81 33. Effects of a Dilated Stomach on the Heart . . 85 34. Area of Lung-Dullness in Dislocation of the Heart . 86 35. Sites of Indurations ..... 90 XXI Illustrations Figure. Page 36. Electric Massage-Apparatus . . . . 101 37. Curves in Kyphosis and Lordosis . . . 116 38. Relation of the Spinal Cord . . . .119 39. Spinal veins . . . . . .127 40. Areas for Counter-Irritation . . . .148 41. Areas for Counter-Irritation .... 149 42. A Sine Curve . . . . . . . 152 43. The Author's Sinusoidal Apparatus . . .153 44. Kellogg's Sinusoidal Apparatus . . . . 154 45. The Victor Sinusoidal Apparatus . . .155 46. Interrupting Electrodes . . . . . 156 47. Electro-Motor Points of the Muscles of the Back . 157 48. Vertebral Areas for Eliciting Visceral Reflexes . . 1 70 49. Cutaneous Areas for Influencing the Viscera . . 174 50. Pneumatic Hammer . . . . . 177 51. Electric Concussion-Hammer . . . 179 52. Diagram of a Thoracic Nerve . . . . 183 53. Cutaneous Nerves of the Thorax and Abdomen . 184 54. Illustrating the Heart Reflex .... 200 55. Illustrating the Heart Reflex .... 201 56. Sphygmogram After Inhaling Ammonia . . . 202 57. Illustrating the Heart Reflex .... 206 58. Illustrating the Heart Reflex . . . .206 59. Sphygmogram After Straining at Stool . . 208 60. Illustrating the Heart Reflex in Myocarditis . .220 61. Illustrating the Heart Reflex in Myocarditis . . 220 62. Illustrating the Heart Reflex After Using Digitalis . 225 63. Position of Leg for Palpating the Tibial Artery . 226 64. Demonstrating the Amplitude of the Heart Reflex . 227 65. Position of Head to Inhibit the Heart . . .228 66. Sphygmomanometer ..... 245 67. Rubber-Ring for Excluding Auto-Pulsations . . 246 68. Relation of Heart and Aorta to the Chest- Wall . 254 69. Aortic Reflex of Contraction in Aneurysm . . 255 70. Aortic Reflexes in Aneurysm (Posterior View) . 255 71. Aortic Reflexes ...... 260 72. Aortic Reflexes of the Abdominal Aorta . . 263 XXII I I I u a t i o n Figure p age 73. Reflex of the Abdominal Aorta .... 265 74. Path of a Vasoconstrictor Nerve . . . .273 75. Photograph of Exophthalmic Goitre . . . 282 76. Photograph of Exophthalmic Goitre . . . 283 77. Types of Breathing ...... 289 78. Diagram of the Respiratory Center . . . 290 79. Atelectatic Zones . . . . . .300 80. Atelectatic Zones . . . - . . . 300 81. Illustrating the Bronchial Tubes in Asthma . . 308 82. Arrangement of Bottles for Promoting Lung-Contraction 314 83. Nerves of the Stomach ' . . . . - 317 84. Illustrating Traube's Space . . . . 318 85. Effects of Ether-Inhalation on the Stomach . . . 319 86. Percussion of Stomach by the Vago- Visceral Reflex . 322 87. Liver Reflex of Contraction ..... 332 88. Liver Reflex of Dilatation . . ".' . . 333 89. Cardio-Splanchnic Phenomenon T . . . 346 90. Splenic Reflexes . . '.-. . . 353 91. Kidney Reflexes . . ; i . . . 360 92. Skin-Areas Related to Spinal Segments . . . 368 93. Skin- Areas Related to Spinal-Segments . . . 368 94. Peripheral Distribution of Sensory Nerves . . 372 95. Peripheral Distribution of Sensory Nerves . . . 373 96. Location of the Gasserian Ganglion . . . 374 97. Localization of the Motor Area .... 384 98. Concussor ....... 396 99. Mclntosh Polysine Generator .... 398 100. Double Vacuum Electrode . . . .399 101. Illustrating Origin and Distribution of Autonomic Fibers 412 102. Course of Autonomic Fibers .... 426 103. Patches of Dullness of the Splanchnic Vessels . . 433 104. Dullness in Insufficiency of the Splanchnic Vessels . 433 105. Diagram of Pilo-Motor Reflexes .... 436 106. Illustrating Mechanism of Reflexes . . . . 438 107. Diagram of a Spinal Nerve ..... 440 108. The Ocular Nervous System .... 442 109. Diagram of the Vagus Nerves .... 447 XXIII I I I u a t i o 71 Figure Page 1 10. Illustrating the Effects of Pilocarpin on an Aneurysm 458 in. Illustrating the Action of Adrenalin on an Aneurysm . 459 112. Radicularpressor ...... 468 113. Cardiac Nerves in the Rabbit .... 469 114. Base-Knob ....... 476 115. Heart Reflex by Extension of Cervical Muscles . - 477 116. Apparatus for Paravertebral Pressure . . . 478 117. Tracings in Exophthalmic Goitre .... 493 118. Illustrating Threshold Percussion . . . 511 119. Cardiac Nerves ....... 519 120. Illustrating the Rose Bandage . . . .531 121. Method for Supporting the Abdomen . . . 532 122. Contents of the Mediastina . . . .554 123. Boundaries of Heart and Great Vessels . . - 557 124. Percussion-Zones of the Spine .... 559 125. Postural Method of Percussing the Aorta . . 560 126. Fluoroscopy of the Aorta ..... 561 127. Radioscopy of the Aorta ..... 563 128. Percussion-Areas of an Aneurysm . . . 565 129. Apparatus for Taking Tracings of the Aorta . . 566 130. Aortograms ....... 567 131. Aneurysm of the Thoracic Aorta .... 571 132. Intrathoracic Shadow (Misinterpreted) . . . 576 133. Primitive Apparatus for Concussion .... 582 134. Radioscopy of the Stomach .... 584 135. Diagrammatic Outline of the Stomach . . . 585 136. Percussion of the Stomach (Vago- Visceral Method) . 587 137. Intestinal Areas of Dullness by Paravertebral Pressure . 593 138. Topography of the Alimentary Canal . . . 594 139. Gall-Bladder (Method of Locating) .... 598 140. Vascular Supply of an Alveolus .... 602 141. Vascular Parallelogram and Triangles of Grocco . . 607 142. Arrangement of the Pulmonary Blood-Vessels . . 609 143. Mask of Kuhn ....... 610 144. Reclining Chair of Jacoby . . . . 611 145. Tracheo-Bronchial and Broncho-Pulmonary Glands . 622 146. Posterior View of the Opened Head, Neck and Trunk 631 SPONDYLOTHERAPEUTIC Armamentarium . . . 648 XXIV SPONDYLOTHERAPY CHAPTER I. HISTORICAL. PRIMITIVE ERA OF SPONDYLOTHERAPEUTICS THE GRIFFIN BROTHERS SWEDISH GYMNASTS OSTEOPATHY CHIROPRACTIC DANA QUINCKE HEAD THE VERTEBRAL REFLEXES. TN the primitive era of hydrotherapy, the application to the spinal region of the hot-water bag and ice-bag was a conventional procedure dictated by empiricism with little physiologic knowledge concerning the action of water on the spinal centers. Even at the present day, our thera- peutic armament embraces various physical methods which are indiscriminately employed with neither rhyme nor reason. Thus therapeutics is discredited and any good results achieved from treatment are attributed to suggestion. We dare not wholly ignore the physical methods of treatment even though there is no physiologic reason to justify their employment, although it should be the constant effort of the physician to rationalize his methods. We are not justified in discrediting clinical observations because they have not been confirmed in the laboratories. Gowers observes, "The diseases of which we know the least pathology are the diseases which we treat successfully." We should be prepared to welcome new truths, even, though, as Gcethe observed, they threaten to overturn beliefs which we have entertained for years and have handed down to others. One must not forget, however, the unconscious tendency of specialists to exaggerate the importance of some special method of treatment. Spondylotherapy In the presence of abdominal pain, the surgeon who uses his head as well as his knife thinks of appendicitis, but when he uses his knife to the exclusion of his head, he thinks of nothing else. There is the gynecologist whose conception of disease is limited to the uterus and adnexa, and there is the oculist with mental astigmatism, who reflects his sub- jectivity in the examination of his patients. We all know the tendency to patronize special organs, diseases or remedies, and the poet Crabbe, in verse, thus immortalizes this tendency: "One to the gout contracts all human pain, He views it raging in the frantic brain; Finds it in fevers, all his efforts mar, And sees it lurking in the cold catarrh. Bilious by some, by others nervous seen, Rage the fantastic demons of the spleen; And every symptom of the strange disease, With every system of the sage agrees." THE GRIFFIN BROTHERS. In 1834 William and Daniel Griffin, physicians, respect- ively, of Edinburgh and London, published a work in which 148 cases were analyzed showing the relation of certain symptoms to definite spinal regions. These symptoms were associated with spinal tenderness in fixed regions. They concluded that the tenderness in question was either primary in the spinal cord or secondary to visceral or other diseases. The Griffin Brothers queried as follows: "We should like to learn why pressure on a particular vertebra increases, or excites, the disease about which we are consulted, why it at one time excites headache or croup or sickness of the stomach." "Why, in some instances, any of these complaints may be called up at will bv touching a corresponding point 2 The G r i ffi n Brothers of the spinal chain?" The following table by the Griffin Brothers 1 demonstrates the tender areas of the spine: CASES. Twenty-eight cases of cervical tenderness, 8 men; 8 married, 12 unmarried. Forty-six cases of cer- vical and dorsal tenderness, 7, 15 married, 24 un- married. Twenty-three cases of dorsal tenderness, 4, o - - 6 married, 1 6 unmarried. Fifteen cases of dorsal and lumbar; i man; ii married, 3 un- married. Thirteen cases of lum- bar tenderness. Twenty-three cases, all of the spine, 4, o 4 married, 15 un- married. Five cases; no tender- ness of the spine. PROMINENT SYMPTOMS. Headache, nausea or vomiting, face-ache, fits of insensibility, af- fections of the upper extremities. In 2 cases only, pain of stomach ; In 5, nausea and vomiting. In addition to the foregoing symptoms, pain oi stomach and sides, pyrosis, palpitation, op- pression. In 34 cases, pain of stomach. In 10 cases, nausea or vomiting. Pain in stomach and sides, cough, oppression, fits of syn- cope, hiccough, eructations. In. one case only, nausea and vomit- ing. In almost all, pain of stomach. Pain in abdomen, loins, hips, lower extremities, dysury, isch- ury in addition to the symptoms attendant on tenderness of the dorsal. In i case only, nausea. Pains in lower part of abdo- men, dysury, ischury, pains in testes or lower extremities, or disposition to paralysis. In i case only, spasms of stomach and retching. Combines the symptoms of all the foregoing cases. Cases resembling the foregoing. 3 Spondylotherapy At this period (1834) Swedish gymnasts, notably Ling, observed among cardiopaths, tenderness over the 4th or 5th dorsal nerves when this region was subjected to friction. The Swedish school recognizes definite areas of spinal ten- derness identified with the various organs. Thus, in affec- tions of the stomach, tenderness is observed in the region of the 6th, yth and 8th dorsal nerves on the left side, and man- ipulation of the region in question often evokes eructations of gas. In 1841 Marshall Hall published his memorable work which established the importance of the spinal reflex. OSTEOPATHY. In 1874 osteopathy was founded. It was based on the theory that health signifies a natural flow of blood and that the bones may be employed as levers to relieve pressure on nerves, veins and arteries. The pressure is assumed to be caused by dislocated bones, and, when the osteopath refers to a "lesion," he intimates malposition of a bone. The theory of the osteopath may be at variance with our accepted views of etiology, yet the latter, by his manipu- lations, unconsciously evokes reflexes which are cogent factors in favorably influencing disease. The osteopath indignantly resents any comparison of his system to massage. The following statement occurs in a representative work on this system by G. D. Hulett 2 : "Masseurs are aware of the fact and the possible significance of tender points in the tissues along the spine over the area from which the nerves are given off to the organs which are in a diseased condition; evidently, however, they have con- sidered these tender points as always secondary to the dis- eased viscus." "The essential distinction between osteop- athy and all other systems of healing," continues the same 4 Chiropractic writer, "based on manipulation, clusters around the etiology of disease." In other words, in disease of an organ, the masseur acts directly upon the organ; but the osteopath taking into consideration what he regards as a fact "The ability of nature to functionate properly, treats the central force." According to the foregoing, the osteopath regards disease from a central and not from a peripheral standpoint. CHIROPRACTIC. This system was founded in 1885. The theory sustaining this system presumes that, in consequence of displaced vertebrae, the intervertebral foramina are occluded through which the spinal nerves pass (Fig. i). In this way the nerves are pinched and chiropractors assume that such pinching is responsible for 95 per cent of all diseases. Chiropractic concerns itself with an "adjust- ment" of the subluxations, thus removing pressure on the nerves. What the chiropractor calls "nerve-tracing," consists of following a sensitive nerve from its vertebral exit to and from the affected organs. The chiropractor differentiates, his method from osteopathy by the following asseverations : 1. The hands are used in a different manner and the movements are dissimilar; 2. The etiology of disease is unlike that accepted by osteopathy; 3. Chiropractors "adjust" for more diseases than osteo- paths and the results are immediate. It is known that pain may be felt at a point distant from the actual site of a lesion. Such pains are know as TRANS- FERRED PAINS. Thus the pains sometimes felt in the 5 Spondyloth a p y FIG. i. Illustrating the chiropractor's conception of disease. A, the vertebrae are in the normal position with the spinal window open (SWO); B, showing that with an open spinal window the nerve is not compressed. The dotted lines show the correct alignment of the spinous processes; C, the spinal window is closed (SWC) owing to displaced vertebrae and in consequence the nerve at its exit is pinched (D). (After Palmer.) The Vertebral Reflexes mammary gland in uterine disease and in the knee in hip- joint disease are transferred or referred pains. The well-known illustrations of Dana (page 56) represent the location of transferred pains. In 1890 Quincke studied the sites of SYMPATHETIC SENSATIONS (page 57). Still later, in 1893, Henry Head, of London, demonstrated that in visceral disease, pain and disturbed sensation may be referred to definite cutaneous areas (vide page 58). THE VERTEBRAL REFLEXES. In medical literature the author has referred repeatedly to certain VISCERAL REFLEXES elicited by cutaneous irritation, viz., the lung reflexes of dilatation 3 and contraction 4 , the heart reflex 5 , liver reflex 6 , stomach and intestinal reflexes 7 , and the aortic reflexes 3 . The reflexes in question are endowed with more than mere physiologic interest. They yield unequivocal demon- stration of the fact that the sensory peripheral nerve ter- minations receive impressions which are conducted, com- municated or reflected by aid of the nervous system. Such impressions react on the viscera and the manifesta- tions of the reaction may be utilized in a diagnostic and therapeutic direction. The evidence heretofore adduced in explanation of the results achieved by electric, hydriatic, mechanic and bal- neary treatment of disease was naught else than a mere array of words conceived only in conjecture. The cutaneous visceral reflexes referred to, suggest the rationale of the different peripheral methods of treatment. Visceral reflexes may be evoked not only by cutaneous irritation but likewise by concussion and the application of 7 Spondylotherapy the sinusoidal current to the spinous processes of the verte- brae. Reflexes elicited from the spinous processes have been specified by the author as VERTEBRAL REFLEXES. 9 The manipulation of definite vertebrae corresponds with the elicitation of specific reflexes, but, if the spinous processes are promiscuously manipulated, counter-reflexes are evoked which nullify the reflexes sought. As we proceed with our subject, we will determine that vertebral manipulation is influential for weal or woe in the treatment of disease and it will be the endeavor of the author, to endow spondylothera- peutics with some scientific accuracy and thus substitute order for chaos. To excite the vertebral reflexes for therapeutic purposes, concussion by means of an apparatus (page 176) or the sinusoidal current (page 151) is employed. For diagnostic purposes, either the sinusoidal current or simple concussion after the manner to be described is used. When the current is employed, the moistened, indifferent pad (usually large) is placed over the sacral region, whereas an interrupting electrode (Fig. 46), which permits one to close and open the circuit, is placed over definite spinal processes. For simple concussion the author employs a piece of soft rubber or linoleum about 6 inches long, i^ inches wide, and about a \ of an inch in thickness as a pleximeter for receiving the stroke and a plexor with a large piece of thick rubber for delivering the blow (Fig. 2). The plexor used by the author is similar to that employed by French clinicians for obtaining the knee-jerk and is known as the plexor of Dejerine. In the absence of the latter, a mallet or even an ordinary tack-hammer will suffice. One may also strike the spinous processes with the 8 The Vertebral Reflexes FlG. 2. Plexor and pleximeter employed for eliciting the vertebral reflexes. knuckles or better still, the ringers may be used as a plexi- meter and the clenched fist as a plexor. In the latter instance, the palmar surfaces of the fingers are applied to the spinous processes to be concussed, and, with the clenched fist, the dorsal surfaces of the fingers are struck a series of short and vigorous blows (Fig. 3) . The use of a pleximeter and plexor is decidedly more effective than the latter method which is only employed in an emergency. Here the strip of linoleum or rubber is applied to the spinous process or processes to be concussed, and, with the hammer, a series of sharp and vigorous blows are allowed to fall upon the pleximeter. S p o ndylotherapy FIG. 3. Showing the method of concussing the spinous processes with the hands for eliciting the vertebral reflexes. Naturally, the blows jar the patient somewhat, but be- yond this no inconvenience is suffered. The vertebral reflexes, when the stimulant is concussion, are probably due to transmitted mechanic stimulation of the roots of the spinal nerves, insomuch as many physiologists contend that the spinal cord does not react to direct stimuli. In some instances concussion is more effective than the sinusoidal current in eliciting certain vertebral reflexes, whereas, in other instances, the current supersedes concus- sion. The relative value of these methods, however, will be studied in detail in succeeding chapters. There is yet an- other method for eliciting the vertebral reflexes by means of 10 The Vertebral Reflexes pressure at the vertebral exits of definite spinal nerves (page 169). Reference to Fig. 4 shows the spinal muscular reflexes thus far elicited by the author, whereas, Fig. 5 represents the viscero-motor reflexes of spinal origin. The latter, with the exception of the aortic reflexes, probably act on the muscu- lature of the organs independently of the vaso-motor system. Unstriped or involuntary muscular fibers are present in practically all the organs of the body. Even the liver is not exempt. Here the muscular fibers contained in the fibrous coat of the organ enter the organ at the transverse fissure. The viscera, even in health, vary in size, and this alter- nate enlargement and diminution in bulk is due in part to variations in the supply of blood and in part to the contract- ility of the visceral musculature. If I am permitted to digress for a moment to give expres- sion to my prejudiced conception of many morbid manifesta- tions, I witness muscular tissue in a state of incoordination j uncontrolled by will and subordinated to the vagaries of un- disciplined reflex centers, the muscular orgy presents the tableau of muscles gone mad. Practically everywhere throughout the organism where muscle is found, fibers co- exist which dilate or contract. When neither function pre- dominates there are no morbid manifestations; in other words, a normal function is a question of muscular equilib- rium. The moment one set of fibers gains the ascendancy over its antagonist the symptomatic picture is made up of spasm or paralysis (vide Asthma, page 303). SPINAL MUSCULAR REFLEXES. These reflexes are best elicited by means of a powerful sinusoidal current after the manner already described (page u). Concussion by means of the plexor and pleximeter 11 S p ondyloth e r a p y will also excite some of them. It will be observed that the reflexes in question are bilateral, in contradistinction to the conventional cutaneo -peripheral reflexes, which are unilateral. For the convenience of their clinical elicitation they have been studied with relation to definite vertebral spinous processes. It must be observed, however, that the areas in question may vary in different patients, but, as here cited, the areas are approximately correct. Like all reflexes, the degree of stimulation necessary for their excitation varies with the indi- vidual, but, as a rule, powerful currents are necessary. Practi- cally every muscle, or group of muscles, may be brought to contraction, but, insomuch as this work is designed for a utilitarian rather than an academic purpose, only a few mus- cular reflexes thus far elicited by the author will be cited. 1. STERNO-CLEIDO-MASTOID REFLEX. This is best ob- served when the head is flexed and when the interrupting electrode is fixed over the spinous process of the yth cervical vertebra. Concussion of the latter will also evoke the reflex. This bilateral reflex is most pronounced at the sterno -clavicular attachment of the muscles. 2. BICEPS, TRICEPS, AND WRIST-JERK. Elicited by concussion of the spinous processes of the 5th and 6th cervical vertebrae or by application of the current to the same proc- esses. Here the processes are concussed in succession or the electrode used is large enough to embrace both spinous processes. The upper extremities must be placed in a state of flexion, with muscles absolutely relaxed and the elbows resting in either hand of an assistant. The elbows may also rest on a table in the flexed position and relaxed. 3. PALMAR REFLEX. This consists of a contraction of two or more fingers when the interrupting electrode is ap- plied over the spinous process of the 6th cervical vertebra. 12 T h Vertebral Reflexes 4. PECTORAL REFLEX. The patient lies on his side with arms elevated to bring the pectoral muscles into slight prominence, after which the dorsal spinous processes (3d to the 6th) are either concussed or sinusoidalized. 5. SCAPULAR REFLEX. Concussion or sinusoidalization of the 5th cervical spinous process. ****& FIG. 4. The spinal muscular reflexes. 6. EPIGASTRIC REFLEX. Concussion or sinusoidaliza- tion of the dorsal spinous processes (yth to the Qth). 7. GLUTEAL REFLEX. When the patient is on his side sinusoidalization or concussion of any of the lumbar verte- brae. The reflex is accentuated as the last lumbar vertebra is attained. 8. CREMASTERIC REFLEX. When the ist, 2nd and 3d lumbar vertebrae are concussed or sinusoidalized. 13 WES. BARRETT S p o n d y I t h r a p y 9. SPHINCTER ANI REFLEX. Sinusoidalization with a small electrode at a point corresponding to the sacro-coccy- geal articulation. 10. ADDUCTOR REFLEX. Adduction of both lower ex- tremities when the spinous processes of all the lumbar verte- brae are sinusoidalized or concussed. The patient sits on a chair, with both lower extremities extended and relaxed. Br ^fS?s FIG. 5. Viscero-motor reflexes of spinal origin. . ii. QUADRICEPS REFLEX. With the patient seated and legs extended, concussion or sinusoidalization of the spinous process of the 2nd lumbar vertebra will produce a decided contraction of the quadriceps femoris. It may be noted that it is a contraction of this muscle which is responsible for the patellar reflex (knee-jerk). When one leg is crossed upon the other (the conventional position for eliciting the knee- jerk), a knee-jerk can be obtained in the norm. In 14 The Vertebral Reflexes several tabetics in whom the knee-jerk was absent (by tapping the patellar tendon) it was very much exaggerated in either one or the other leg when one leg was crossed upon the other during sinusoidalization (with the interrupting electrode) of the spinous process of the 2nd lumbar vertebra. The foregoing phenomenon is discussed on page 28. 12. ACHILLES REFLEX. The patient rests on his knees on a chair, with feet projecting over the edge of the latter. In the conventional way, striking the Achilles tendon results in flexion of the foot. With the patient in the same position the interrupting electrode is fixed over the sacrococcygeal articulation, where- as the large pad is applied in the lumbar region. Here, like- wise, the current evokes flexion of the foot. 13. PLANTAR REFLEX. Evoked by sinusoidalization of the ist and 2nd sacral segments. 14. BABINSKI REFLEX. If, in the norm, we irritate the inner side of the sole of the foot from the heel to the toes by stroking with a moderately sharp object, all the toes undergo plantar flexion ; but, if the great toe (and perhaps the other toes) undergoes dorsal flexion (Fig. 6), the Babinski reflex or phenomenon is present. As a rule the latter phenomenon indicates a lesion of the pyramidal tract. The observations of the author show that the Babinski reflex may be elicited in the norm by applying the interrupting electrode (large electrode over the sacrum) over the spinous process of either the 3d or 4th lumbar vertebra. Schneider's explanation of the Babinski reflex is as follows ; Plantar flexion of the toes (the normal reflex) de- pends upon a cortical component of the reflex, whereas dorsal flexion of the toes (Babinski reflex) depends on the spinal component. If then, there is a lesion of the pyramidal tract, the reflex for the plantar flexion is interrupted, whereas 15 S p o n d y I o t h e r a p y the spinal component for dorsal flexion is retained. In several cases with lesions of the pyramidal tract observed by the author, and in all of whom the Babinski reflex was present by irritating the sole of the foot, the same reflex could not be elicited as in the norm by sinusoidalization of the spinal column. In these cases, however, the plantar reflex was elicited by sinusoidalization in lieu of the Babinski reflex, FIG. 6. The Babinski toe-reflex (Hutchison and Rainy). which occurs in the normal subject. The latter observation would seem to show in part the correctness of Schneider's explanation of the Babinski reflex. The occurrence of the plantar reflex in these cases suggests that it is likewise a spinal and not a cortical reflex and that its occurrence in lieu of the Babinski by sinusoidalization is equally diagnostic of a lesion of the pyramidal tract. The physician will observe that the spinal muscular reflexes (provided the current remains in action for several seconds) consist of clonic rather than tonic contractions, and, furthermore, that the spinal reflexes may be elicited even though the ordinary cutaneo -peripheral reflexes are absent. Anatomic, Topographic and Physiologic Data CHAPTER II. ANATOMIC, TOPOGRAPHIC AND PHYSIOLOGIC DATA. STRUCTURE OF THE SPINAL CORD ROOTS AND DISTRIBUTION OF THE SPINAL NERVES LOCATION OF THE SPINAL NERVES ANATOMIC LANDMARKS SYMPATHETIC SYSTEM PHYSIOLOGY OF THE SPINAL CORD LOCALIZATION OF THE FUNCTIONS IN DIFFERENT SEGMENTS OF THE SPINAL CORD. A transverse section of the spinal cord (Fig. 7) shows it to consist of central gray matter containing nerve -cells and .Jl FIG. 7. Illustrating the conducting paths in the spinal cord at the level of the third dorsal nerve. The black part represents the gray matter; V, anterior, and HW, posterior root; A, direct, and G, crossed pyramidal tracts; B, anterior, column ground bundle; C, Goll's column; D, postero-external column; E and F, mixed lateral paths; H, direct cerebellar tracts (Landois). surrounding white matter made up of nerve-fibers. The gray matter is divided into the anterior and posterior horns. The SPINAL NERVES take their origin from the spinal cord and on either side make their exit through the intervertebral foramina. There are 31 pairs of spinal nerves: Cervical nerves 8 pairs Dorsal " 12 " Lumbar " 5 " Sacral " 5 " Coccygeal " i pair 17 S p o n d y loth a p y ROOTS OF THE SPINAL NERVES. The anterior or ventral roots arise from the motor cells in the anterior horn of the gray matter and are motor in function. The posterior or dorsal roots arise from the nerve-cells of the spinal ganglia from which they can be traced into the cord and are sensory in function. 9' FlG. 8. A spinal nerve with its anterior and posterior roots (Testut). i, a portion of the spinal cord viewed from the left side; 2, anterior median fissure; 3, anterior horn; 4, posterior horn; 6, formatio reticularis; 7, anterior root; 8, posterior root with 8 1 , its ganglion; 9, spinal nerve; g 1 , its posterior division. On the posterior root of each of the spinal nerves, a gang- lion is found which is located in the intervertebral foramen external to the point where the nerve perforates the dura mater (Figs. 8 and 38). DISTRIBUTION OF THE SPINAL NERVES. Just beyond the ganglion, the roots of the spinal nerves unite to form a trunk which constitutes the spinal nerve. After the latter passes out of the intervertebral foramen, it divides into a posterior division for the supply of the pos- 18 Anatomic Land mar terior part of the body and an anterior division which supplies the anterior part of the body. In each division there are fibers from the roots of both nerves. Each spinal nerve receives a branch from the sympa- thetic (Fig. 9). FlG. 9. Diagram after Bohm and Davidoff to show the composition of a peripheral nerve-trunk, i, axon of ganglion-cell; 2, spinal ganglion; 3, dendrite of ganglion-cell; 4, anterior horn of gray matter of spinal cord; 5, axon of motor nerve-cell; 6, sympathetic ganglion; 7, axon of sympathetic neuron; 8, nerve-trunk. The roots of the majority of spinal nerves pass obliquely downwards and outwards to their points of exit from the intervertebral foramina, hence the level of their emergence from the cord does not correspond to that of their exit from the intervertebral foramina (Fig. 10). ANATOMIC LANDMARKS. There is usually a furrow or medium groove in the back, at the bottom of which lie the spinous processes. In 19 Spondyloth r a p y S. to rectut laterallt _ _ _^.;i to rectut antic. minor . _, Aruutomotit t"lth _ .Anastomosis atth pntumogastria .V. to rectut antle.major. "2. _~.y. to mastoid region. ,_ __|.Or>t auricular . ' 5rronoerK cervui. Internal cutaneout n. V. (a ophincttr ani _ _ _ _ Coccy^eai n_ _ _ _ _ _ _ -, External eufatwoK* . --Qcntto-cruraln. interior eruratn. - _ - -^OMurator n. Superior gluteal n. If. to ptHformlt . .If. to gcmcllus super. -V to gcmflhts infer. N. to guadratui FIG. 10. The relations of the segments of the spinal cord and their nerve- roots to the bodies and spines of the vertebrae (Dejerine et Thomas, modified by Starr). 20 Anatomic Landmarks emaciated individuals the spinous line replaces the groove. The spinal furrow is less evident in the cervical than in the lumbar region; in the former situation it is between the trapezii and between the larger erector spinae muscles in the dorsal and lumbar regions. Palpation and definition of the vertebral spinous processes are facilitated by directing the patient to lean far forward or the processes may be rubbed with the hand, thus evoking a spot of hyperemic redness over the tip of each spinous process. The 5th lumbar spine (marked by a depression) is used for measuring the external conjugate diameter of the pelvis. The latter diameter from the depression to the upper border of the symphysis pubis measures 2o| cm. or 8| inches. The two posterior superior spinous processes of the ilium are on a line with the 3d sacral spine below which lie the sacro-iliac joints. PETIT' s TRIANGLE is a triangular space corresponding to the central point of the crest of the ilium (Fig. 47). This triangle is the occasional site of a lumbar hernia and is also a convenient region for relieving congestion of the kidney by local bleeding. Deep pressure made in the neck in the direction of the carotid artery and opposite the cricoid cartilage detects a tubercle belonging to the transverse process of the 6th cervical vertebra and is known as CHASSAIGNAC'S TUBERCLE. Against the latter the carotid artery may be compressed by the finger. The VERTEBRAL ARTERY may be compressed in the suboccipital region, the thumb and finger of one hand being placed in the hollows behind the mastoid process, while counterpressure is made by the other hand on the forehead. As the arteries lie under the complexus muscle, the pressure 21 S p o n t h r a p y must be rather firm. If such pressure inhibits pulsating noises or vertiginous feelings, the inference is that, these are caused by congestion in regions supplied by branches of the FIG. n. Diagram of the posterior aspect of the thorax and abdomen and showing the relation of the viscera to the surface. Liver (L) ; spleen (S) ; kidneys and ureters (KU). basilar artery (internal ear). If noises in the ear are dimin- ished by compression of the carotid artery, they are prob- ably caused by congestion in the middle or external ear, and are often synchronous with the pulse. L a n d m a SPINES OF THE VERTEBRAE. Atlas. Axis. 4th cervical vertebra. 6th cervical vertebra. 7th cervical vertebra (Vertebra prominens) 2d dorsal spine. 36 dorsal spine. 4th dorsal vertebra. 7th dorsal spine, roth dorsal vertebra. 1 2th dorsal spine. 4th lumbar spine. LANDMARKS. RELATION. On a line with the hard palate. The trans- verse process is just below and in front of the tip of the mastoid process. Felt beneath the occiput and is on a level with the free edge of the upper teeth. Opposite the hyoid bone. On a line with the cricoid cartilage. Esoph- agus commences. Easily recognized, owing to its prominence and serves as a guide for counting the proc- esses downwards. Location of the in- ferior cervical ganglion. Corresponds to the head of the 3d rib. The scapula covers the ribs from the 2nd to the yth, inclusive. The apex of the lower lobe of the lung is at the lev el of the 3d rib behind. Corresponds to the inner edge of the spine of the scapula. Termination of the arch of the aorta on the left side. Opposite the junction of the ist and 2nd section of the sternum. Thoracic aorta commences to the left. Trachea bifurcates midway between the 3d and 4th dorsal spines, the roots of the lungs thus lying a little below and external. Corresponds to the inferior angle of the scap- ula when the patient is sitting with the arms hanging at the side. Corresponds to the tip of the ensiform cartil- age. Lower edge of lung posteriorly. Car- diac orifice of the stomach. Corresponds to the head of the last rib. Aortic orifice in diaphragm. Highest point of the crest of the ilium. The umbilicus is near the same plane. Division of the aorta. Below the tip of this spine, point of election for lumbar puncture. The disk of this vertebra corresponds to the ileo-cecal valve. 23 S p on d y I o t h e r a p y LOCALIZATION OF THE SPINAL NERVES. In the adult, as a rule, the spinal cord extends from the lower surface of the foramen magnum to the lower edge of the ist lumbar vertebra, and only exceptionally as far as the 2nd lumbar vertebra. The position of the cord shows slight alterations in posi- tion in the movements of the body. Thus it rises during spinal flexion. The root -origin of the spinal nerves may be determined as follows (Consult Fig. 10) : For the upper 4 CERVICAL NERVES Thus the root-origin of the 3d subtract i from the number of cervical is opposite the 2nd cer- the nerve. vical spine. For the 4 lower cervical nerves and Thus the root-origin of the 8th upper 6 DORSAL NERVES, sub- cervical nerve corresponds to tract 2 from the number of each the 6th cervical spine. nerve. For the lower 6 dorsal nerves sub- Thus the root-origin of the gth tract 3 from the number of the dorsal is opposite the 6th dorsal nerve. spine. The LUMBAR NERVES take their origin contiguous to the loth and nth dorsal spines and the SACRAL NERVES between the nth dorsal and ist lumbar spines. THE SYMPATHETIC SYSTEM. This portion of the nervous system is concerned in the distribution of impulses to the glandular structures, cardiac muscle and the non-striated muscular tissue of the body. While this system is not supposed to be independent in action of the cerebro -spinal system, Langley employs the term autonomic to indicate that the efferent fibers of the sympathetic are endowed with a certain independence of the central nervous system. The autonomic fibers are removed from the control of the will and preside over unconscious 24 Internal Carotid plezus ffami communicantts ot tit/fen yangliated ford and Ga/iylioa juyu/are N. Vagi* To Ganglion petrosum N. Glosso-pharyngei Cervical nerve Caverxotap/aal FlaasakoutVertebral art.-- t Plata atattSidclapian art. Thoracic Herat JT jr ^Connections with Vagus Glosso-pAarynytal fojbrm f/iarynyeal plexus. f Submajcillartf (faxalion Superior' \ f Mid die \ ' jlnjeriof) f ^Connections with Vayus and V f'\ Recurrent larynqeal nent% "l left Pulmonary plucus CARDIAC PLEXUS ^InfenorMesenteric plans \ I Auerbach flenuesof J an ^ ( Meissner ff V Coctyyeal neroe ic plexus mpocAsmic PLEXUS Ganglion Coccygeum impar FIG. 12. Illustrating the principal communications between the sympathetic and cerebro-spinal nervous system (Flower, modified by Morris). Spondylotherapy reflexes like intestinal peristalsis, contraction and dilation of the arteries and the secretory activity of the digestive glands. The sympathetic system communicates with the cerebro- spinal system, by means of efferent and afferent nerves. Fig. 12 shows the principal communications between the two systems. The sympathetic nerves are now regarded as carrying chiefly motor fibers, and their cell-origin is most probably the lateral horns on the same side of the spinal cord. THE PHYSIOLOGY OF THE SPINAL CORD. The spinal cord has a dual function; it acts as an inde- pendent central organ and as a conductor of nervous im- pulses. Reference will be made primarily to the spinal cord as a REFLEX CENTER. A reflex refers to involuntary production of activity in a part brought about by conduction of a stimulus along an afferent (sensory) nerve to the motor cells in the cord or medulla. This stimulus is converted into an impulse by the motor cells, which impulse is then conducted to a part by means of an efferent (motor) nerve. The mechanism of the reflex known as the knee-jerk is illustrated in Fig. 13. To elicit this reflex, it is neces- sary to have an intact REFLEX ARC, otherwise the reflex is abolished. The reflex arc is made up as follows : 1 . A healthy tendon which, when struck with a hammer, constitutes the peripheral stimulus which is then conducted by- 2, an afferent (sensory) nerve along the posterior roots to the anterior horn of the spinal cord where, by means of the motor cells, it is converted into an impulse which is then conducted by means of 26 T h K n J INHIBITING FIBRES FROM J CEREBRUM. ) DISEASE AFFECTING > -(m THESE ALLOWS I EXAGGERATED REFLEXES I f CORTICAL I LESIONS. 1 SPASTIC [PARALYSIS ATAXA, _ ^te. * DISEASED OF MOTOR END-PLATES SHOWING THE MECHANISM OF THE DEEP REFLEXES AND EXAMPLES OF THE LESIONS WHICH MAY INCREASE OR ABOLISH THEM AS ILLUSTRATED BY THE KNEE-JERK. DOTTED CIRCLES LESIONS ABOLISHING THE REFLEXES. BLACK CIRCLES = LESIONS EXAGGERATING THE REFLEXES. ,13- Showing the -mechanism of the knee-jerk; also the two chief types (spastic and flaccid) of paralysis (Butler). S p o n d y I o t h e r d p y 3, an efferent (motor) nerve to a healthy muscle. The text-books usually describe the following reflexes : 1. Superficial or cutaneous elicited by irritation of the skin or a mucous membrane resulting in contraction of the muscles contiguous to the site of irritation; 2. Deep or tendon reflexes elicited by striking a tendon, muscle or periosteum near the tendon; 3. Organic or visceral reflexes which result in special acts like urination and defecation. The reader is referred to page 7, where consideration was given to the vertebral reflexes. The latter are essentially central and are elicited by concussion or sinusoidalization of the spinous processes of definite vertebrae and by pressure at the vertebral exits of the spinal nerves. A single paradigm may be cited to show the importance of the central vertebral reflexes in diagnosis. In LOCOMOTOR ATAXIA the posterior root-fibers in the posterior columns in the lumbar region are involved, in consequence of which the knee-jerk* is diminished or usually abolished. The knee-jerk would be similarly influenced in lesions involving the anterior horns of the gray matter by cutting off the motor path. In other words, to elicit the knee-jerk the reflex arc in the lumbar cord must be intact. Reference to Fig. 14 shows that the center for the knee-jerk is located in segment III, of the medulla lumbalis and reference to Fig. 4, shows that the quadriceps reflex (central vertebral reflex) corresponds practically to the same site. *The knee-jerk reflex arc is made up of nerve-fibers which pass to and from the crureus (one of the four muscles constituting the quadriceps extensor) by the anterior crural nerve and to and from the hamstrings by the sciatic nerve. The nerves to the crureus arise from the spinal nerve-roots corresponding to the 3rd and 4th lumbar; the hamstring supply is from the 5th lumbar and ist and and sacral roots. It will be noted that concussion will not elicit the knee- jerk. Here it is necessary to sinusoidalize simultaneously the 2nd lumbar vertebra and the sacral region. 28 The K n e e - J e r Now, in locomotor ataxia, the knee-jerk is abolished, owing to involvement of a part of the reflex arc (the afferent or sensory path), and when the knee-jerk is elicited in the usual way, it may be difficult to say whether any other part of the arc in question is implicated. If one can provoke the central quadriceps reflex, one can at least conclude that the descending paths (efferent or motor) are intact. For a like reason a peripheral neuritis may be difficult to differen- tiate from locomotor ataxia owing to involvement of the peripheral sensory nerves. In a number of patients with locomotor ataxia examined by the author, a quadriceps reflex was usually present, and in a number of instances an exaggerated knee-jerk was obtainable on either one or the other leg. Usually it was absent in the more atactic leg or in advanced stages of the disease. Here one was constrained to conclude that when the knee-jerk was obtainable, the posterior root-fibers were not entirely destroyed. It was also found that the Achilles reflex could be elicited (corresponding to segment V of the medulla lumbalis, Fig. 14) in a number of cases of loco- motor ataxia by sinusoidalization over the sacrococcygeal articulation. The elicitation of the vertebral reflexes directs reference to a mooted point in physiology, viz., whether the tendon reflexes are or are not true reflexes. According to the prevailing opinion, they are not true reflexes but are due to direct stimulation of the muscle itself. The author questions the correctness of the latter observation insomuch as a veritable Achilles reflex and knee-jerk can be elicited in the norm by vertebral stimulation.* *The author is convinced that this subject embraces a field of research of vast im- portance to the neurologist. Man is available for experimentation for, in the study of the vertebral reflexes, they can be evoked with an accuracy almost equal to their elicitation by vivisection. S p o n d y loth e r a p y In eliciting the knee-jerk the large electrode must be placed over the lower sacral region and the interrupting electrode over the spinous process of the 2nd lumbar vertebra and one leg crossed upon the other leg. A strong current is necessary. With some sinusoidal machines the knee-jerk cannot be evoked, but with Kellogg's apparatus (Fig. 44) it can practically always be excited. LOCALIZATION OF FUNCTION IN THE DIFFERENT SEGMENTS OF THE SPINAL CORD. A SPINAL SEGMENT refers to the part of the cord contained between two sets of roots. Each segment must be regarded as a unit endowed with motor, sensory, vasomotor, trophic and reflex functions with regard to the peripheral distribution of the roots of the nerves which emerge from and enter it. A segment is called after the nerve-roots which take their origin from it and not with reference to its relation to the vertebrae. A diagrammatic representation of the spinal cord is shown in Fig. 14. The cord is divided into its four regions. Within each region the spinal segments are indicated by numbers. On the right-hand side of the diagram, muscles or groups of muscles are indicated, and the lines proceeding from them pass to the segments of the cord in which the cell -bodies of origin are located. On the left side of this diagram the sensory regions are indicated and the lines show their relation to the different segments of the cord itself. To determine the condition of the cord at different levels the following table 11 is serviceable. It shows the different segments controlling the skeletal muscles, the reflex centers and the chief location of the segmental skin-field. 30 SENSORY CORD MOTOR Occiput Neck- Shoulder ' Musculo-spiral nerve | Median nerve* Omar nerve Thorax Epigastrium Abdomen Umbilicus Gluteal and in- > guinal regions j f Anterior aspect External > aspect r* Posterior | aspect Internal aspect Anterior aspect Foot* Thign and Hip Leg Scrotum, penis. Rectum, bladder - Anus. Diaphragm Levator anguli scapulae Sternomastoid Scale ni Neck muscles Trapezius *( Supraspinatus Supinator longus Rhomboids Teres minor Deltoid Infraspinatus Biceps Subscapularis Coraco-brachialis Deep shoulder mus- cles Serratus magnus Brachialis anticus [ Pectoralis major [Extensors of wrist and fingers I Teres major [ La t issimus dorsi f Flexors of wrist and fingers I Triceps 1 Extensorsof thumb Muscles of thenar and hypothenar eminences \flnterossei, lumbri- l cales [intercostals ' Muscles of back and abdomen [Adduction of hip [Quadriceps Sartorius [ Dio-psoas External rotators of hip Hamstring muscles Calf muscles Abduction of hip Olutei Peronei Small muscles of foot Anterior tibial mus- cles Perineal muscles Bladder Rectum FIG. 14. Diagrammatic representation of the spinal cord showing the spinal segments for motion and sensibility. Jakob, Starr, Sachs, Dana, Mills and Butler. S p o n d y I o t h e r a p y LOCALIZATION OF THE FUNCTIONS IN THE SEGMENTS OF THE SPINAL CORD. SEGMENT STRIPED MUSCLES REFLEX SKIN-FIELDS I, II, and III C Splenius capitis Hypochondrium ( ?) Sack of head to Hyoid muscles Sudden inspiration vertex. Sterno-mastoid produced by sudden Neck (upper part). Trapezius pressure beneath the Diaphragm (C HI-V) lower border of ribs Levator scapulae (C III- (diaphragmatic) . V) IV C Trapezius Dilation of the pupil Neck (lower part Diaphragm produced by irrita- to second rib). Levator scapulae tion of neck. Reflex Upper shoulder. Scaleni (C IV-DI) through the sympa- Teres minor thetic (C IV-DI). Supraspinatus Rhomboid vc Diaphragm Scapular (CV-DI). Outer side of Teres minor Irritation of skin over shoulder and up- Supra and infra spinatus the scapula produces per arm over del- (C V-VI) contraction of the toid region. Rhomboid scapular muscles. Subscapularis Supinator longus and Deltoid biceps. Biceps Tapping their ten- Brachialis anticus dons produces flex- Supinator longus (C V- ion of forearm. VII) Supinator brevis (C V- VII) Pectoralis (clavicular sart) Serratus magnus VIC Teres minor and maior Triceps. Tapping Duter side of fore- [nfraspinatus elbow tendon pro- arm, front and Deltoid duces extension of back. Outer half Biceps r orearm. of hand(?). Brachialis anticus 3 osterior wrist. Tap- Supinator longus ing tendons causes Supinator brevis extension of hand Pectoralis (clavicular (C VI-VII). >art) Serratus magnus (C V- VIII) ^oraco-brachialis Pronator teres Triceps (outer and long leads) Sxtensors of wrist (C VI-VHI) 32 Segmental Localization LOCALIZATION OF THE FUNCTIONS IN THE SEGMENTS OF THE SPINAL CORD CONTINUED. SEGMENT STRIPED MUSCLES REFLEX SKIN-FIELDS VII C Teres major Scapulo-humeral. Inner side and Subscapularis Deltoid (posterior part) Pectoralis major (costal part) Pectoralis minor Serratus magnus Pronators of wrist Triceps Extensors of wrist and fingers Flexors of wrist Latissimus dorsi (C VI- VIII) Tapping the inner lower edge of scap- ula causes adduction of the arm. Anterior wrist. Tapping an- terior tendons causes flexion of wrist (C VII- VIII). back of arm and forearm. Radial half of the hand. VIII C Pectoralis major (costal Palmar. Stroking Forearm and hand, part) Pronator quadratus Flexors of wrist and fin- gers) Latissimus Radial lumbricales and interossei palm causes closure of fingers. inner half. ID Lumbricales and inter- Upper arm, inner ossei Thenar and hypothenar eminences (C VII-DI) half. II to XII D .. Muscles of back and ab- domen Erectores spinae (D I- LV) Intercostals (D I-D XII) Rectus abdominis (D V- DXII) External oblique (D V- XII) Internal oblique (D VII -LI) Transversalis(D VII-LI). Epigastric. Tick- ling mammary region causes retraction of epigastrium (D IV- VII). Abdominal. Strok- side of abdomen causes retraction of belly (D IX-XII). Skin of chest and abdomen in obli- que dorso-ventral zones. The nipple lies between the zone of D IV and D V. The um- bilicus lies in the field of D X. I L Lower part of external Cremasteric Strok- Skin over lowest and internal oblique and transversalis Quadratus lumborum (L I-II) C remaster Psoas major and minor(?) ing inner thigh caus- es retraction of scro- tum (L I-II). abdominal zone and groin. 33 Spondylotherapy LOCALIZATION OF THE FUNCTIONS IN THE SEGMENTS OF THE SPINAL CORD CONTINUED. SEGMENT STRIPED MUSCLES REFLEX SKIN-FIELDS II L PSOES major and minor Front of thigh. Iliacus Pectineus Sartorius (lower part) Flexors of knee (Remak) Adductor longus and bre- vis Ill L Sartorius (lower part) Patellar tendon. Front and inner Adductors of thigh Quadriceps femoris (L II-L IV) Inner rotators of thigh Abductors of thigh Tapping tendon causes extension of leg. "Knee-jerk" side of thigh. IV L Flexors of knee (Ferrier) Gluteal. Stroking Mainly inner side Quadriceps femoris Adductors of thigh Abductors of thigh Extensors of ankle (tibi- alis anticus) Glutei (medius and mi- nor) buttock causes dimp- ling in fold of but- tock (L IV-V). of thigh and leg to ankle. VL Flexors of knee (ham- Back of leg and string muscles) (L IV-S H) Outward rotators of thigh Glutei Flexors of ankle (gas- trocnemius and soleus) (L IV-S II) Extensors of toes (L IV- si) Peronaei part of foot. I to II S Flexors of ankle (L V-S Foot reflex Exten- Back of thigh leg II) Long flexor of toes (L V- SII) Peronaei Intrinsic muscles of foot sion of Achilles ten- don causes flexion of of ankle (S I-II). Ankle-clonus. Plan- tar. Tickling sole foot causes flexion of toes or extension of great toe and flexion of others. and foot; outer side. IlltoVS 1 'erineal muscles. Levator and sphincter ani (S I- HI) Vesical and anal re- flexes. Skin over sacrum and buttock. Anus. Perinaeum. Geni- tals. S e g m e n t a I K k' i n - F i e Ids .0.67 FIG. 15. Showing the areas on both surfaces of the body which Are related to the different segments of the spinal cord. When a segment of the cord is destroyed, the surface of the body is anesthetic in the area corresponding to that segment. C, cervical; D, dorsal or thoracic; L, lumbar, S, sacral. 35 Spondyloth a p y Fig. 15 shows the segmental skin-fields which assist in determining the segmental level of spinal cord and of dorsal root-lesions. VISCERO -MOTOR CENTERS. It will be noted that the following physiologic location of the viscero-motor cells does not correspond with the clinical localization of the viscero-motor reflexes (Fig. 5). However, the former are cited for the sake of completeness. It will also be observed that the clinical evidence tallies with physiologic observation, viz., that there is usually a double viscero-motor mechanism consisting of excitation and inhibition. TABLE OF THE VISCERO-MOTOR CENTERS. STRUCTURE. LOCATION OF VISCERO-MOTOR CELLS. Pupil (constriction of). Pupil (dilatation of). Nucleus of the 3rd cranial nerve. Between the 6th cervical and 2nd dorsal segments. Bronchi and bronchioles (constric- Nucleus of the loth cranial nerve. tion of). Heart (acceleration of). 6th cervical to the 2nd dorsal seg- ments of the cord. Heart (inhibition of). Nuclei of the loth and nth cra- nial nerves. Alimentary canal (accelerating Nucleus of the xoth cranial nerve. peristaltic movements) . Alimentary canal (inhibition of 4th dorsal to the 2nd lumbar seg- peristaltic movements). ments. Uterus (inhibition of muscular 2nd, 3d and 4th lumbar segments, coat and contraction of the cer- vix and vagina). Dilatation of cervix uteri and 2nd, 3d and 4th sacral segments. vagina. Bladder (contraction of the sphin- 2nd, 3d and 4th lumbar segments. cter) . Bladder (relaxation of the sphin- 2nd, 3d and 4th sacral segments. cter). Relation of Spines to Segments By referring to Fig. 10 the physician will be able to determine the relation of the segments of the spinal cord to the spines of the vertebrae. It may be recalled that a seg- ment is called after the pair of nerves which arise from it and not from its vertebral relation. The following table shows the approximate relation of the spines of the vertebrae to the segments of the spinal cord. APPROXIMATE RELATION OF THE VERTEBRAL SPINES TO THE SPINAL SEGMENTS. CERVICAL SEGMENTS. VERTEBRAL SPINES. TT \ .................. ist cervical spinous process. HI I .................. 2nd cervical spinous process. V .................... 3d cervical spinous process. VI .................... 4th cervical spinous process. TTJ TT I .................. 5th cervical spinous process. DORSAL SEGMENTS. -6th cervical spinous process. III .................... yth cervical spinous process. IV .................... ist dorsal spinous process. V .................... 2nd dorsal spinous process. VI .................... 3d dorsal spinous process. VII .................... 4th dorsal spinous process. VIII .................... 5th dorsal spinous process. IX .................... 5th dorsal spinous process. X .................... 6th dorsal spinous process. XI .................... 7th dorsal spinous process. XII .................... 8th dorsal spinous process. LUMBAR SEGMENTS. 1 .................... 9th dorsal spinous process. TTT \ ................. loth dorsal spinous process. i ith dorsal spinous process. SACRAL SEGMENTS. ' an , \ ................. 1 2th dorsal spinous process. , COCCYGEAL SEGMENT. I .................... ist lumbar spinous process. The vaso-motor apparatus is discussed on page 272. S p ondylotherapy CHAPTER III. SYMPTOMATOLOGY. EXAMINATION OF THE BACK THE NORMAL SPINE DISEASES OF THE SPINE SPONDYLOGRAPHY EXAMINATION OF THE MUSCLES OF THE BACK STIFF BACK MUSCULAR HYPOTONIA PAIN AND TENDERNESS OF THE SPINE SYMPATHETIC SENSATIONS DERMA- TOMES OF HEAD VERTEBRAL PAIN VERTEBRAL TENDERNESS VERTEBRAL PERCUSSION VIBROSUPPRESSION. The VERTEBRAL COLUMN subserves the following objects : 1. It is the central pillar of the body and supports the weight of the head; 2. It connects the upper and lower segments of the trunk and gives attachments to the ribs. 3. It diminishes the effects of shocks conveyed from various parts of the body chiefly by means of its curves and the elastic intervertebral discs which act the part of buffers.* 4. It is endowed with considerable mobility and fur- nishes a solid tube for the spinal cord. The MUSCLES of the back and trunk are the only agents in supporting the spine erect. When the muscles in question are exhausted, relief is involuntarily secured by means of rotation and lateral flexion, thus eventuating in the condition known as scoliosis. THE NORMAL SPINE. The normal spine must be studied with relation to its CONTOUR and FLEXIBILITY. Any deviation of the spinous *If the height of an individual is taken in the morning and again at night a decrease in the total height of the body of from i to 2 cm. during the day will be noted. This fact may be attributed to compression of the intervertebral discs by the weight of the body in the erect posture. 38 The Normal Spine processes from the median plane of the body may be deter- mined by marking each spinous process with a pencil while the patient stands erect. In the norm the marks represent a straight line. The median line of the body is obtained by holding a plumb-line behind the patient so that the lower end of the line dips into the groove between the buttocks. In the norm each marked spinous process will lie under the plumb-line. A record may be made by placing crinoline gauze or tracing paper on the back through which the spinal marks may be seen and thus transferring the marks to the gauze or paper. The contour of the spine may be determined by means of a strip of lead or pure tin thick enough so that it can be molded on the spine and still preserve its shape when re- moved. The prominent spinous processes should be indicated upon it. The curves of the spine thus obtained may be transferred to paper for further study. Certain curves are constant, viz. : 1. Forward in the upper; 2. Backward in the middle, and 3. Again forward in the lower region. These curves are fixed in the adult but may be almost annihilated in early childhood by traction in the horizontal position. In the erect posture a normal individual will show the following curves (Fig. 16): 1. Cervical, the convexity of which is forward. It begins at the ist cervical and ends at the 2nd dorsal vertebra; 2. Thoracic or dorsal, the convexity of which is back- ward. It begins at the 3d dorsal and ends at the 39 Spondyloth r a p y 1 2th dorsal vertebra; its most prominent point behind corresponds to the spine of the 7th dorsal. Lumbar, which is convex anteriorly, commences at the middle of the last dorsal vertebra and ends at the sacro-vertebral angle. This curve is more marked in the female than in the male. Pelvic, which is concave anteriorly, commences at the sacro-vertebral articulation and ends at the point of the coccyx. FlG. 16. Normal vertebral curves and divisions of the spine (Whitman). The average length of the spinal column in the male is about 2 feet and 4 inches and the female spine is about 2 feet in length. The length of the individual parts is as follows : 1. Cervical 5 inches 2. Dorsal n " 3. Lumbar 7 u 4. Sacrum and coccyx 5 " 40 The Normal S p / n e In the adult many causes, notably occupations, cause variations of the normal contour of the spine, but in children such variations may be regarded as abnormal. The normal contour results from balancing of the body in the erect posture, and if there is any variation in one part compensation induces a change in another part, eventuating often in a complete reversal of the normal spinal curves. Even in the norm there is a slight lateral convex curve to the right, extending from the 5th dorsal to about the 3d lumbar vertebra, which has been attributed to the following causes : 1. Aortic pressure on the vertebral bodies; 2. Excessive use of the right side of the body; 3. Right-handedness. The FLEXIBILITY of the human spine is largely dependent on movements between the spine and the pelvis and the head. It is evident that exercises destined for the spine only must presume pelvic fixation, for otherwise, as Lovett 12 puts it, "Part of the muscular force is used in displacing the pelvis to the opposite side to balance the body and the movement becomes a general and not a spinal one." The MOVEMENTS of the spine are : 1. Flexion; 3. Lateral flexion; 2. Extension; 4. Rotation. In FLEXION, or forward -bend ing, if extreme and perfect, the spinous processes will describe the arc of a circle and the distance by measurement from the yth cervical vertebra to the sacrum is greater than a like measurement secured in the erect or prone posture. In EXTENSION, or backward -bending, the movement is chiefly limited to the lumbar and the last two dorsal verte- 41 S p o n d y loth a p y brae. In hyperextension, if measurement is made of the distance from the yth cervical vertebra to the sacrum (over the spinous processes), it is decreased when compared with a like measurement in the erect posture. LATERAL FLEXION may be tested by side -bending in the erect posture. In the norm the movement is located at and below the lumbar dorsal junction. ROTATION is most pronounced in the erect posture in the TRANSMITTED AORTIC PULSATIONS DORSAL REGION FIG. 17. Spondylograms reduced one-half. A, taken at the level of the yth cervical spine; B, taken in the dorsal region; C, taken in the lumbar region; D, transmitted aortic pulsations taken in the dorsal region during the time the patient suspends respiration. cervical and dorsal regions ; the maximum is attained at the top of the cervical column extending below to the lower dorsal region where it is no longer evident. SPOND YLOGRAPHY . It is generally contended that the spinal column enjoys a considerable range of motion as a whole, but that the motion between any two individual pieces is extremely 42 S p ondylography limited. It is known that during deep respiration a straight- ening of the vertebral column occurs involuntarily. The author has reason to believe that the vertebrae en joy a greater degree of motion than is usually accepted and to prove this FIG. 18. Apparatus for taking a spondylogram. The position of the patient is adapted for taking tracings of the abdominal aorta. To take a spondylogram the patient must be in the prone position. A, stand with an adjustable rod, B; C, lever; D, tambour for recording. To the short end of lever (C), a string is passed through an opening and the end of the string is fixed by adhesive plaster to a spinous process. contention the accompanying spondylograms are submitted (Fig. 17). They were obtained with the patients in the prone posture during quiet breathing. The serrations noted in 43 Spondylotherapy the tracings are probably transmitted aortic pulsations. The apparatus (Fig. 18) employed for eliciting the spondylo- grams was originally constructed by the author for taking tracings of the abdominal aorta. 32 Spondylography will aid in the early diagnosis of respir- atory vertebral immobility and by furnishing a permanent record, the course of a vertebral disease may be accurately controlled. Here we are in the possession of a method which may be as important to the orthopedist as is the sphygmo- graph to trie clinician. DISEASES OF THE SPINE. SPINAL EXAMINATION FOR DEFORMITY. With the patient in the erect position (heels together and arms hanging) note if the curves are normal or if there is any abrupt projection of one or more spines. Any ROTATION of the vertebrae may be determined by comparing the prominence of the angles of the ribs, the trans- verse processes of the lumbar vertebras, the height and prominence of the scapulae and the prominence of the iliac crests on the two sides. Estimation of rotation or twist is best determined by Adam's position: The patient bends forwards (with unflexed knees) until the trunk is horizontal with the hands hanging down. With the head on a level with the spine the physician notes whether either side of the trunk is more prominent upward. The presence of an up- ward prominence ' indicates rotation or twist. Next, the anterior aspect of the body is inspected and the following noted with reference to the two sides of the body ; deformities of the chest and the level of both anterior iliac spines. Again, inspecting the back, the patient is instructed to bend forward (with knees straight) and note should be made if he bends freely and straight forwards. If the movement, however, is 44 Examination for D efo rmity restricted and oblique and if the angles of the ribs are un- covered by the scapulae and project more on one side, one is dealing with signs of ROTATION OF THE SPINE. The presence and degree of this rotation determine the diagnosis of Scoliosis and not, as Gould 13 emphasizes, the lateral deviation of the tips of the spinous processes. Next, the patient assumes the prone posture on a flat couch. In the latter position the following may be noted : CURVES. Natural curves lost and replaced by a general convexity of the spine backwards altered by movement and disappearing in the recumbent posture. The general convexity of the spine backwards is permanent and un- influenced by movement or the recumbent position and the movements of the spine are diminished. There is an abrupt curve of the spine backwards or several spin- ous processes are projected pos- teriorly. Diminution of the natural curve in the dorsal region with straight dorsal spine sunk in between the scapulae and rotation of the spine. Lateral deviation of the spines without rotation and disappear- ance of the deviation in the re- cumbent position. A permanent (uninfluenced by position) long sweeping curve to one side without rotation of the vertebrae. AFFECTION. Spinal muscular debility from rickets or other causes and in convalescents who have main tained the horizontal posture. Spondylitis deformans. Caries of the spine (Pott's disease). Lateral curvature of the spine (scoliosis) . Weak-spine often present in hys- teria. Retraction of chest observed in pleuritis and empyema. 45 S p o n d y I o the r a p y EXAMINATION OF THE MUSCLES OF THE BACK. "The spine lies at the back of a more or less cylindrical muscular tube of which the abdominal muscles form the front" (Lovett 12 ). There are two kinds of muscles directly attached to the back, one group passing from one part of the spine to another part and to the head and another group running from the spine to the pelvis or shoulder girdle. In diagnosis and in treatment by muscular exercises, the fact must be emphasized that the spinal movements are not affected by an individual muscle but by all the spinal muscles which act in unison. The relative rigidity of the thoracic spine is dependent on the attachment of the ribs behind, between two vertebrae and to the sternum in front. There are two feeble and movable parts of the spine (points where important muscles have a dividing line), viz. : 1. At the cervico-dorsal junction; 2. At the dorsolumbar junction. The ligaments of the spine are loose and the surfaces of the articular processes are only in slight contact, hence the muscles of the back and trunk are the only agents for main- taining the spine erect. The moment the muscles are ex- hausted some relief is obtained by rotation and lateral flexion of the spinal column (which tightens the ligaments and brings the articular processes in closer contact) which eventuates in scoliosis. RIGIDITY OF THE SPINAL MUSCLES. The condition of the spinal muscles may be determined by the movements of the patient and by palpation. The 46 S p in al-Muscles former may be tested by directing the subject to jump, run, walk, pick up objects from the floor, etc. The tests must include movements which necessitate flexion, extension and lateral bending of the spine. By placing the palm of the hand on various parts of the spine and then directing the patient to make different motions, one may note during execution of the latter whether the vertebrae move or are fixed. Special movements exclude definite joint-involvement. Free and painless nodding of the head excludes implica- tion of the occipito-atloid joint. If the face can be easily turned from one side to another the atlo-axoid joint is not involved. The lower cervical spine is not implicated if flexion of the head can be executed freely and painlessly. The various voluntary movements must be adapted to the intelligence of the patient. Thus children who resist passive movements on a table will submit to manipulation in the arms of the mother. A child will walk toward its mother and will incline the head in the direction of the latter a useful test in determining the condition of the cervical spine. By placing the patient in a recumbent position (with head slightly elevated), first on the right and then on the left side, the spinal muscles are relaxed and may be care- fully palpated. In the norm the muscles show no tenderness, are elastic and easily roll under the palpating finger. SPASM OF THE SPINAL MUSCLE. By the term "spasm" one refers to an abnormal muscular contraction due to an augmented reaction of the motor nerves. When the muscular contraction is prolonged it is known as 47 S p ondylotherapy a tonic spasm, in contradistinction to a clonic spasm, in which contractions of brief duration alternate with flaccid conditions of the muscle. Spasm of the spinal musculature such as the author con- ceives the condition must be dissociated by the reader from the conventional twitchings and spasmodic movements of individual muscles or groups of muscles. It is true that, the clinician has long recognized the almost intelligent function of muscles whether displayed in fixing a diseased joint or spine, or in protecting an inflamed serous membrane, but he has neglected to carefully palpate the spinal musculature for localized spasms which are usually tonic in character. To detect such muscular contractions the patient must be placed on a table in the lateral posture to secure muscular relaxation. The investigations of the author show that pressure at the vertebral exits of the spinal nerves will elicit muscular contractions in definite regions, and conversely, that pressure in the latter situations will evoke localized clonic or tonic spasm in definite spinal regions. In disease the peripheral localized spasm may be present independent of -the spinal spasm, but, as a rule, careful palpation of the spinal and peripheral musculature demon- strates that they coexist. In the accompanying illustration (Fig. 19), the author has endeavored to present a composite picture as obtained in the norm. The illustration shows the vertebral area involved in spasm during the time firm pressure is made in definite peripheral regions. Pressure made at these vertebral exits will provoke spasm of the peripheral musculature. The verte- bral areas are only approximately correct insomuch as the 48 S p n a I - M u s c I spasm of the spinal musculature is often diffused and exact localization is often impossible. The palpating finger may only feel a tremor or a sensation like a pulsation in the muscle. Not infrequently the contraction of the spinal muscle may be seen. It will be noted that although pressure is only made on 7M/&H FIG. 19. Vertebral areas involved in muscular spasm when different periph- eral regions are firmly compressed or irritated. one side of the spinal column the muscular contraction is often bilateral. If deep and firm pressure with the fingers of one hand is made on any of the peripheral points of spasm, the other hand will usually detect bilateral localized spasm of the spinal musculature corresponding to the vertebral areas indicated in Fig. 19. While mere cutaneous irritation will induce contraction 49 Spondylotherapy of the spinal muscles, the latter is less evident than when deep pressure is made on the peripheral muscles or when the peripheral area is painful. The recognition of these peripheral and spinal spasms is destined to be of considerable value in diagnosis. Space will not permit the author to descant further on this subject, but he may be permitted to cite meningismus as a paradigm. The latter affection occurs in association with suppurative diseases of the middle ear in children and adults and symp- toms are present (notably rigidity of the neck-muscles) which simulate disease of the brain although no intracranial inflammation exists. If the peripheral source of irritation can be inhibited by means of cocain, the rigidity of the neck -muscles will subside temporarily. Reference to the accompanying illustration (Fig. 20) shows the extensive anastomoses of the cervical plexus and explains the frequency (when sought) of rigidity of the neck muscles in affections of the head and face. There must also be a spasm of the spinal musculature as an expression of visceral disease and this is a subject worthy of investigation. At present, however, we must rely on vertebral tenderness and the dermatomes of Head as indices of visceral disease (page 58). STIFF BACK. Stiffness and lack of mobility of the back may be caused by: 1. Pain (lumbago, vertebral disease, tonic spasm of the muscles) ; 2. Ankylosis of the vertebral column. MUSCULAR RIGIDITY is one of the earliest signs of Pott's disease and persists until cure is effected. It is most pro- 50 Cervical Plexus FIG. 20.- -Plan of the ceivi al plexus (Gray)- Spondyloth e r a p y nounced in the neighborhood of the disease, but may extend some distance. If the patient is directed to bend forward and no rigidity nor spasm is associated with the movement and the outline of the spinal curve is even and not broken, Pott's disease may be safely excluded. Muscular rigidity dissociated with spinal disease resists motion only in the directions directly opposed by the con- traction of the muscles. If the spasm, however, is associated with spinal disease it resists motion in all directions. A stiff back due to ankylosis of the vertebral column may be caused by any of the following diseases (q. v. ) : Spondy- litis, Pott's disease, paralysis agitans and arthritis deformans. MUSCULAR HYPOTONIA. MUSCULAR FATIGUE is an invariable sign of neurasthenia. Fatigue of muscle is caused essentially by the consumption of material necessary for contraction and the storing up in the muscle of waste -products produced by its 'own activity. Some people tire more easily than others, owing to the fact that the waste -products responsible for the fatigue in the one are less readily removed or accumulate more easily. Massage of the muscles rapidly removes the evidence of fatigue simply because the waste -products are washed into the circulation by this manceuver. The fatigue in neurasthenia probably has its origin in the nervous system and only indirectly in the muscles. If one tests the strength of the muscles in neurasthenia, although a diminished response is shown, it is by no means proportionate to the diminished vigor exhibited by the patient. It has been shown that the time during which an indi- vidual can sustain a voluntary muscular contraction is deter- mined by the endurance of the brain -centers engaged in the 52 Muscular Hypotonia act of volition rather than by that of the muscles themselves. The very moment these centers are exhausted the contraction of the muscle gives way. Volition can be fatigued when exerted in imagination as well as in actual muscle -effort. BACKACHE, or a sensation of weariness, is a frequent symptom of neurasthenia and the older writers referred to this sign as spinal irritation (vide neurotic spine). It is known that when fatigue -signs are exaggerated they become painful and are described as "aches." Many cases of backache in neurasthenics are caused by a faulty spinal attitude. Thus the attitude of chil- dren with round shoulders (page 96) will substitute lig- amentous for muscular support. All our muscular groups are not equally and symmetrically developed and many de- formities such as spinal curvatures, round shoulders, etc., bear witness to the truth of the foregoing statement (vide Exercises). Decrease in the normal tone or elasticity of the muscles is designated by the word HYPOTONIA, and this condition is frequent in many nervous diseases. It is difficult to measure muscular-force. The dyna- mometer and the ergograph yield valuable but inconstant information. The muscles may be tested by noting the strength of the Galvanic current (read in milliamperes) and Faradic current (measurement on the scale of the secondary spiral and expressed in millimeters of coil-distance) necessary to produce the minimal contraction. The muscles of the healthy side may be used as a standard of comparison, otherwise we must be governed by the re- actions observed in the average individual with normal musculature. 53 S p o n d y I o t h e r a p y One notes that when the muscles are weak, with the strongest current the contraction of the muscles may be no greater than with weak currents. The implicated muscles do not contract in ioto, but only a few bundles contract and appear as slightly prominent ridges. The Faradic current provokes no tetany, but only several clonic contractions of the muscle -substance which succeed each other during the closure of the current (myoclonic contractions). For strengthening defective spinal muscles the sinusoidal current (page 151) is very effective. Very frequently individual muscle-groups are involved in hypotonia. Thus a faulty position of the scapulae may be caused by the muscles which maintain the position of the latter. Similarly, scoliosis may be provoked by an heredi- tary hypotonia of the spinal muscles. A lack of tone or relaxation of the muscles is an early sign 14 of LOCOMOTOR ATAXIA. This hypotonia may be estimated as follows : With the patient in the erect position the distance from the floor to the greater trochanter and the yth cervical vertebra is measured. If the patient is now instructed to bend forward (knees stiff) as far as possible and the distance in this position is again estimated from the floor to the yth cervical vertebra, it will be found that in health, and in all affections (excepting tabes), it is impossible to bend the trunk sufficiently forward to permit the yth cervical vertebra to be brought to or below the level of the trochanter. The hypotonia of the muscles in tabes, however, permits the vertebra in question to attain a distance of 21 or more cm. below the level of the trochanter. 54 ain-Perception PAIN. Pain results from powerful stimulation of a nerve, and in accordance with the law of eccentric projection, it is a matter of little moment which part of the nerve is stimulated, the perception of pain being referred to the periphery. According to the prevailing hypothesis pain-perception is the result of individual stimulations which accumulate prob- ably in the cells in the posterior part of the gray substance of the spinal cord and it is the total of such stimulations which eventuates in a discharge which the patient interprets as pain. The intensity of the pain is determined by the duration and amount of the stimulation and by the irritability of the nerve -fibers and ganglion -cells. The expression of pain is no measure of its intensity. Animals as well as men show differences in their sensitiveness to pain. A frequent clinical error is to underestimate the intensity of pain and to question its reality simply because by diverting the attention of the patient the latter exhibits less evidence of his suffering. Pain is usually worse at night for the very evident reason that in the daytime our attention is distracted. It is also evident that the imagination of pain will accen- tuate its intensity. In estimating pain objectively the per- sonal equation must always be taken into consideration, and by aid of the following method 45 one may determine the degree to which an individual is sensitive to pain. With the thumb, pressure is made over the styloid process in the neck. Some patients will complain of the slightest pressure, whereas others will tolerate considerable pressure without a pain-reaction (vide vertebral tenderness on page 71). 55 Spondylotherapy REFLEX PAINS. As a rule the site of pain corresponds to the location of the lesion. An other instances peripheral pains may be caused by diseases of the spinal cord. Reflex or transferred FlG. 21. Diagrams showing the distribution of the cerebro-spinal strands of nerves and the location of transferred pains and neuralgia. pains may be caused by an irritation at the origin of the nerve - trunk and the pain may be referred to its peripheral distribution. The illustrations of Dana (Fig. 21) show the usual location of transferred pains. Dana observed that the sensory nerves of these areas 5b Sympathetic Sensations were correlated with the sympathetic ganglia innervating the areas in question. SYMPATHETIC SENSATIONS. Quincke has collected a number of sympathefic sensations associated with a circumscribed hyperalgesia of the skin, and one is constrained to conclude that the skin-areas are sup- plied by the same nerves as the organs. According to Donaldson the splitting nerve-fiber sends one portion to the organ and one to the skin overlying it. A pertinent illustration of cutaneous hyperalgesia is ob- served in affections of the heart when pressure of the skin over the heart -region elicits sensitiveness. As a rule the skin overlying an organ is associated with it reflexly, and it is for this reason that one can explain how percutaneous therapeutic methods may influence visceral disease. SYMPATHETIC SENSATIONS. AFFECTION. SYMPATHETIC SENSATIONS. Disease of the middle-ear and Parietal pains. mastoid process. Disease of the frontal sinus. Trigeminal pains. Irritation of the posterior wall of Tendency to cough (irradiation the auditory canal. from the auricular branch of the vagus). Pulmonary abscess (percussion of) . Pain in the larynx. Angina pectoris. Pain in the left arm. Diseases of the stomach. Pain in the back. Intestinal worms. Tickling in the nose. Diseases of the liver. Pains in the shoulder. Diseases of the spleen. Pains in the left shoulder. Diseases of the bladder. Pains in the genitalia and lumbar region. Diseases of the uterus. Pain in the epigastrium. Coxitis. Pain in the knee. 57 S p o n d y I o t h e r a p y DERMATOMES OF HEAD. While cutaneous pains are usually projected with great accuracy to the point stimulated, pain originating in the internal organs is located very inaccurately. Head 46 and others have demonstrated that the different visceral organs bear a definite relation to certain areas of the skin, in other words, in visceral disease,* pain and dis- turbed sensation may be referred to definite cutaneous areas. Thus one may have a cutaneous expression of visceral disease FIG. 22. Illustrating cutaneous tenderness and the radiation of pain in visceral disease. which I may call an endogenetic skin reflex. The cutaneous tenderness in visceral disease is explained as follows : When a stimulus is applied to an organ or tissue with diminished sensibility and which is centrally connected with an organ or tissue with a higher degree of sensibility, pain is referred to the organ or tissue which is relatively more sensitive. Reference to Fig. 22 will elucidate this matter. *Kast and Meltzer, 15 found in animal experimentation that the sense of pain is present in normal organs, and that it is considerably augmented in inflamed organs, and that a subcutaneous or intramuscular injection of cocain is capable of completely abolishing the sensation in normal as well as in inflamed organs. They suggest that the anesthesia of the abdominal organs observed by some surgeons was due to the use of cocain. 58 D m a t o m If the viscus is irritated, say as the result of inflammation, sensory impulses which are usually below the threshold of consciousness are conveyed to its sensory center or segment in the spinal cord. Now to the same segment is also con- nected a definite area of skin from which sensory impressions are habitually received, hence the sensations in consciousness are not referred to their true visceral origin but to the surface of the body. Now Head found that in many visceral diseases, if the sensitiveness of the skin were tested by running a pin point over the cutaneous surface, definite areas could be demon- strated showing hypersensitiveness (hyperalgesia) to pain. Such areas on the surface of the body are known as skin- units or dermatomes. The latter correspond to the spinal segments, from which the posterior roots take their origin and not to their peripheral distribution. The dermatomes are hypersensitive to heat and cold, but not to touch. Head concluded that when the dermatomes could be demonstrated they invariably indicated an affection of the organ to which they corresponded. The dermatomes or zones of hyperalgesia appear early and continue through- out the course of a visceral disease. If absent, say in ap- pendicitis, they appear after palpation of the appendix. The author has found that if the zones are present they are practically always exaggerated after manipulation of a given organ. As a rule the disappearance of a zone is associated with relief of a diseased organ. If, however, the symptoms in- crease or persist, the sudden disappearance of a zone is a sign of ill-omen. 45 There is no definite relation between the severity of the visceral lesion and the degree of cutaneous hyperalgesia. The absence of a zone does not exclude a lesion of a given 59 Spondylotherapy organ, but, if demonstrated, it is corroborative evidence that such a lesion is present. It is important to remember that counterirritation over a zone of hyperalgesia is often surprisingly efficient in relieving the pain and underlying condition of the visceral disease. The application of cold to the abdomen in acute abdom- inal affections owing to the anesthesia produced is equally efficient. On the same theory Elsberg and Neuhof, 45 secure relief from pain in acute affections by anesthetizing the hyperalg- esic area with menthol (50 per cent). Reference to Figs. 23, 24, 25 and 26 shows, according to Head and Schmidt, 47 the segmental distribution of referred pain and cutaneous tenderness in visceral disease, and Fig. 27 shows the associated painful areas about the head related to visceral disease and areas of referred pain and tenderness in affections of the head and neck. METHODS FOR ELICITING THE DERMATOMES. Head tested the skin sensitiveness to pain by pinching up folds of skin or by stroking the skin with the point of a sharp pin. I often employ the vibrations of a tuning-fork for demon- strating the zones and the vibration -sensation may either be increased (hyperalgesia) or diminished (hypalgesia). The method of Elsberg and Neuhof 45 is as follows: A sharp pin is held between the thumb and index finger of the the right hand, the nail of the index finger resting on the patient's skin. The pin is then made to traverse slowly the surface of the skin, care being taken that the nail of the index finger presses equally along the area examined. The patient must say "now" the moment the stroke of the pin becomes painful. 60 Dermatomes I-'IGS. 23 and 24. Sensory areas of the skin according to Head. Anterior and posterior views. C, cervical; D, dorsal; L, lumbar segments of the cord. Further description of these and subsequent figures on page 62. * 61 S p o n d y I o t h e r a p y SEGMENTAL DISTRIBUTION OF REFERRED PAIN AND TENDER- NESS IN VISCERAL DISEASE. SEE FIGS. 23, 24, 25 AND 26. Heart. Third cervical and first, second and third dorsal segments. Lungs. Third and fourth cervical and first to ninth (sometimes tenth) dorsal segments, especially the third, fourth and fifth. Breast. Fourth and fifth dorsal segments. Esophagus. Fifth, sixth and eighth dorsal segments. Stomach. Third and fourth cervical and sixth, seventh, eighth and ninth dorsal segments. Cardiac end from the sixth and seventh and the pyloric end from the ninth. Intestines. Down to the upper part of the rectum: Ninth, tenth, eleventh and twelfth dorsal segments. Rectum: Second, third and fourth sacral segments. Liver and Gall-bladder. Seventh, eighth, ninth and tenth dorsal segments and perhaps the sixth. Kidney and Ureter. Tenth, eleventh and twelfth dorsal segments. The nearer the lesion lies to the kidney the more is the pain and tenderness associated with the tenth dorsal segment. The lower the lesion in the ureter the more does the first 'umbar segment tend to appear. Biadaet. Mucous membrane and neck of the bladder: First, second, third and fourth sacral segments. Over-distention and ineffectual contraction: Eleventh and twelfth dorsal and first 'umbar segments. Prostate. Tenth, eleventh anc 1 twelfth dorsal, first, second and third sacral and third lumbar segments Epidiaymis. Eleventh ana twelfth dorse ? nd first lumbar segments. Testis Tenth dorsal segment. Ovary. Tenth dorsal segment. Uterine Appendages. Eleventh and twelfth dorsal and first mmbar segments. Uterus. In contraction: Tenth, eleventh and twelfth dorsa! and first iumbar segments. Os uteri: First, second, third and fourth sacral segments, and very rarely, the fifth lumbar 62 Dermatomes Flos 25 and 26- Sensory areas of the skin according to Head. Spondyloth e r a p y ASSOCIATED PAINFUL AREAS ABOUT THE HEAD RELATED TO VISCERAL DISEASE. SEE FIG. 27. AREA ON BODY. ASSOCIATED AREA ON HEAD. ORGANS IN PARTICULAR RELATION WITH THESE AREAS. Cervical 3 and 4 Fronto-nasal Apices of lungs, stomach, liver, aortic orifice (?). Dorsal 2 and 3 Mid-orbital Lung, heart, arch of the aorta. Dorsal 4 Doubtful Lung. Dorsal 5 Fronto-temporal Lung and occasionally the heart. Dorsal 6 Fronto-temporal Lower lobe of lung and heart. Dorsal 7 Temporal Bases of lungs, heart and stomach. Dorsal 8 Vertical Stomach, liver and upper part of the small intestine. Dorsal 9 Parietal Stomach and upper part of the small intestine. Dorsal 10 Occipital Liver, intestine, ovary and testicle. AREAS OF REFERRED PAIN AND TENDERNESS IN AFFECTIONS OF THE HEAD AND NECK. SEE FIG. 27. ORGAN INVOLVED. MAXIMUM POINT OF REFERRED PAIN AND TENDERNESS. ORGAN INVOLVED. MAXIMUM POINT OF REFERRED PAIN AND TENDERNESS. Ciliary muscle Mid-orbital Upper teeth Frontonasal, nasolabial, (Disorders of temporal, maxillary, accommodation) or mandibular. Cornea Frontonasal Lower teeth Mental, hyoid, superior laryngeal and in the ear. Iris Fronto - temporal, Tongue, anterior Mental. temporal, and part maxillary Vitreous body Temporal Tongue, lateral Hyoid, superior laryn- (Glaucoma) part geal and in the ear. Retina Vertical Tongue, posterior Superior laryngeal, hy- part oid, occipital. Tympanic mem- Hyoid Tonsil Hyoid and in the ear. brane Middle ear Vertical and be- Nose, olfactory Frontonasal and mid- hind the ear portion orbital. Nose, respiratory Nasolabial (occasion- portion and pos- ally). terior nares Larynx Superior and inferior laryngeal (in destruc- tive lesions). 64 a n f u I A a 65 S p o n d y I o the r a p y Not infrequently, if the hyperalgesia is pronounced, the patient will scream as soon as the border of the zone is reached. Young children cannot give correct answers, hence with them this method is useless. The zones of hyperalgesia extend from the median line in front to the spines behind. In Figs. 28 and 29 (Elsberg and Neuhof ), the maximum areas of sensitiveness within the boundaries of a zone are deeply shaded. VERTEBRAL PAIN. This symptom may be determined in a variety of ways : 1. By pressure of the vertebral spines with the fingers or by percussion of the spines by means of the plexor and pleximeter (Fig. 2). The latter method is preferable. Very frequently no pain is elicited when a vertebral spine is pressed downward, yet, when the spine is pushed to one side or lifted, sensitiveness can be demonstrated. 2. By pressure alongside of the spine at points corre- sponding to the exit of the spinal nerves. 3. By pressure vertically down through the spine made on the head and again on the shoulders. 4. By firm pressure on the transverse processes so as to rotate the individual vertebrae and thus determine implication of the joints. 5. By aid of the hot-sponge test , which consists of passing down the spine a sponge wrung out in warm water. The latter must only be sufficiently warm so as not to be unpleas- ant to the healthy skin. In definite affections, notably my- elitis, pain is experienced by the patient when the sponge passes over the site of the disease. 6. By testing pain-susceptibility (pallesthesia). In the norm, if a C (130 vibrations) or an A (440 vibrations) 66 a I a n tuning-fork is placed on any of the vertebral spines, a trem- bling or whizzing sensation is perceived. The skin, as well as the bone, participates in the perception of the vibrations. Sensation is diminished or lost (bone -anesthesia) in the ataxic stage of tabes. Bone-sensibility may be increased in FlG. 28. General location and outline of hyperalgesic zones for some of the abdominal organs. Anterior view. The maxima are deeply shaded. incipient tabes and the vibrations of the fork produce a burning as well as the whizzing sensation. Bone-sensibility is also altered in other nervous affections, thus in hysteria, the application of the fork is followed by the sudden disappearance of sensibility of the bone and skin. If the vertebrae or corresponding spinal nerve-roots are 67 Spondyloth r a p y sensitive, the vibrations of the tuning-fork are more keenly appreciated by the patient. 7. By finding painful centers. 40 For this purpose the patient's back is bared and a high tension Faradic coil is brought into use. Before applying this current the coil FlG. 29. Posterior view of the zones in Fig. 28. should be tested with a four-to-six inch Geissler tube. If the coil is capable of illuminating the tube, then it possesses the proper amount of penetrative power. For this diagnostic work the Kidder Manufacturing Company of New York make a special coil. One pole of the battery (it does not make any difference which) is attached to the 6x6 inch moist electrode and placed in front over the epigastric plexus. The other electrode (2x2 inches), well moistened, is passed 68 Vertebral Pain lightly over the spinal column with a current-strength sufficient to be agreeably susceptible. This current is passed up and down the entire length of the spinal column with ordinary pressure eight or ten times and the electrodes re- moved when one will note vivid red spots on a white back- ground. The latter become more prominent several min- utes after the current is removed. Digital pressure upon these spots will elicit sensitiveness, whereas no pain will be complained of in the intermediate region. These spots are pathognomonic of certain ailments and the clinician can almost make a diagnosis from the reflex centers involved. 8. Very frequently, if one pole of a Galvanic current (with the other electrode at an indifferent point) is passed along the spine, no appreciable sensation is felt until a sen- sitive area is attained. 9. It is known that many patients suffer from pains in the head and chest when exposed to draughts. The latter may be substituted by a current of cold air from an air- pump, which, when directed at the vertebral exits of the affected nerves, will reproduce the pains from which the patient suffers. Very often the pain is also reproduced when the air is directed on the site of the reflected pains. Other methods for the elicitation of vertebral tenderness are described on page 72. Having located by any of the foregoing methods the area of tenderness, it is well to employ some mark for future refer- ence in treatment. For this purpose a stick of nitrate of silver, slightly moistened, may be used as a pencil, thus leaving a line which cannot be effaced. If one desires to remove the stain of the latter, apply a drop of tincture of iodine and then ammonia, or use potassium iodid solution. 69 S p o n d y I o therapy DEDUCTIONS RESPECTING VERTEBRAL PAIN. For the objective elicitation of pain, one must exclude cutaneous hyperesthesia, which is a dominant factor in the so- called hysterical spine and which is present in many neuroses. Here, when the skin is lightly touched or pinched without any pressure on the bone, pain is experienced. If the patient's attention is diverted the identical spot may be touched without eliciting any pain. Friction of the tender area with a rough fabric of cotton to induce irritation of the skin is often followed by disappearance of the painful areas. Tenderness of the vertebrae, rather than pain, is rarely absent in neurasthenia and sensitive areas may be demon- strated in the latter affection as well as in hysteria. These TOPOALGIAS may not disappear until treatment is directed to the general condition. Topoalgia limited to the vertebral column is known as rachialgia. In the hysterical spine there is usually a history of traumatism and it must be recalled that hysteria long latent and unrecognized may be awakened into obvious activity by a blow or accident. To determine whether a given sensitive area is real or simulated, the following signs may be employed : 1. Mannkopff's sign. Take the pulse-rate before, dur- ing, and after pressure is made on the sensitive area. If the pulse becomes increased in frequency it is a proof that the pain is genuine. 2. Sign of Lcewi. Dilatation of the pupil is in direct proportion to the intensity of the pain. Thus, if in a healthy man one exercises energetic pressure on the testicle, the pupil dilates, whereas in the tabetic in whom the testicle is in- sensitive, no pupillary dilatation is observable. 70 Vertebral Tenderness 3. In neuroses the spine is not rigid at the points of sensitiveness. In diagnosis one must look for other symptoms suggestive of a neurosis. In children radiating pains dependent on vertebral disease are frequently misinterpreted, as headache, cough or stom- achache. In Pott's disease reflex muscular spasm is associated with pain. In disease of the cervical region the head is held stiffly or is supported with the hands. In disease of the dorsal region the pain may radiate to the chest, respiration may be groaning and night cries occur. In lumbar disease the pain is referred to the legs or lower abdominal region. In Pott's disease there may be absolutely no local pain on pressure, but spasm of the spinal muscles, especially on an attempted movement, is practically always present and is an early sign. Angular deformity of the spine is a late manifestation of the disease. Pains due to other causes are discussed later. VERTEBRAL TENDERNESS. The elicitation of the dermatomes of Head is a tedious method of examination and not always accompanied by satisfactory results for the reason that a great amount of experience is necessary. Alsberg 18 in the examination of 200 women (with gynecological affections) found cutaneous areas of hyperalgesia in only seventeen, ten of whom were hysterical. Therefore, he could attribute no diagnostic im- port to the zones in question beyond commenting on the fact that hysterical stigmata must be excluded before the zones of hyperalgesia could be regarded as trustworthy. There is no longer any doubt concerning the fact that 71 S p o n d y I o t h e r a p y spinal tenderness corresponding to different segments of the spinal cord is associated with visceral disease. To attain definitiveness of localization, however, it is necessary to care- fully examine the vertebrae by percussion (page 66), or by palpation ; place the patient in the recumbent position, first on the right and then on the left side, to secure muscular relaxation, for it is quite evident that a contracted muscle over a given area of sensitivenes's will thwart the elicitation of pain. If the patient is seated the muscles may be relaxed by having the patient lean backward. Pressure with the finger (care must be taken that the pressure is equal) is next made over each intervertebral foramen and, if contracted muscular bundles or pain can be demonstrated by the palpating finger, vertebral tenderness is present. The writer has frequently found that, firm pressure on the sensitive vertebras may evoke pain in lieu of tenderness and what is of greater diagnostic import is the fact that, some of the sensations from which a patient suffers may be reproduced. Many recent writers, notably Arnold 17 and Ludlum 18 , found that the areas of vertebral tenderness correspond to the vaso-motor centers in the spinal cord and that there exists a compensatory relationship between the blood-vessels of the cord and those structures supplied by the posterior primary divisions of the spinal nerves. The vaso-motor nerves are evidently not wholly concerned in vertebral tenderness. Physiology teaches that our con- scious sensations do not originate in the viscera to which the afferent nerves are distributed and where they are stimu- lated. On the contrary, the nerves merely transmit the stimuli to the gray matter of the spinal cord (section of which 72 Vertebral Tend e r n e s s abolishes sensations of pain without affecting the tactile sensations), whereby through summation they produce changes in the cells of the gray matter. Such changes are identified with hyperesthesia and hence the vertebral tenderness. It is known that frequently repeated painless tactile stimuli may eventually arouse the sensation of pain. Again, a neuritis at first limited to a visceral nerve may pass upwards (ascending neuritis) and involve larger nerve- trunks or even the spinal cord. It is in this way only that one can explain the vertebral tenderness which persists after apparent recovery from a visceral disease. In addition to the vaso-motor and sensory reflex phenom- ena in visceral disease there are also motor symptoms. The latter may be experienced by either an irritation or paresis. Thus, in angina pectoris, the constriction around the chest is dependent upon a contraction of the intercostal muscles. Paretic symptoms may attend a paroxysm and enfeebled power of the muscles of the left arm is present. In the inter- paroxysmal 'periods of angina, as well as in other cardiac lesions, sensory, motor and vaso-motor symptoms may be demonstrated in several segments of the spinal cord, and Mackenzie's conception of them is as follows: In cardiac disease (as a paradigm) a persistent irritation of the sym- pathetic nerve conduces to the irritation of the spinal seg- ment at a site where the fibers of the heart connect with the spinal cord. Irritation of the sensory part of the spine con- duces to the sensation which is projected into the periphery innervated by the nerves of the spinal segment (law of Muller). After this manner the motor and vaso-motor symptoms are of like segmental character. The following table fairly represents the areas of vertebral tenderness in visceral disease and corresponds to the distribution of the spinal segments. S p o n d I t h r a p y VERTEBRAL TENDERNESS IN VISCERAL DISEASE. VISCERAL DISEASE.* GASTRIC ULCER. CHOLELITHIASIS (Gall-stones). CARDIAC DISEASES. PULMONARY DISEASES. GASTRIC DISEASES. PELVIC DISEASES. VERTEBRAL TENDERNESS. At the level of and to the left of the loth to the i2th dorsal vertebra. Somewhat to the right of the i2th dorsal vertebra. Painful area may persist for weeks after an attack. Usually to the left of the first four dorsal vertebrae. From the 3d to the 6th dorsal vertebra. From the 4th to the xoth dorsal vertebra. At the 4th and 5th lumbar verte- bras. The foregoing table is based on the observations of different writers on the subject and the author presents the following table of vertebral tenderness in visceral disease, which he has elaborated after palpation of the palpable organs and by aid of his visceral reflexes (Fig. 30). Thus, in myocarditis, the symptoms of this affection may be elicited by concussion of the four lower dorsal vertebrae (Fig. 5), which manceuver provokes dilatation of the heart. If the counter-reflex of cardiac contraction is provoked by concus- sion of the yth cervical vertebra, the area of vertebral tender- ness disappears at once. One may also note that the vertebral tenderness after palpation of an organ is of a few minutes duration only, and *Vide also the observations of the Griffin brothers (page 2). 74 V e r t e b r a I T e n d e r n e s s if present before manipulation of the diseased viscus it is accentuated after such manipulation. The point of tender- ness is located either at the side of the vertebrae or at a point 4 cm. from the median line of the spinous processes or in both situations. It is better to determine vertebral tender- ness before palpating the organs, for otherwise one is unable LffT St*0 Sfpf FIG. 30. Vertebral areas of tenderness after palpation of the viscera. The localization is only approximate. to say whether the tenderness in question was not already present. A practical point in relation to these areas of vertebral tenderness after palpating a sensitive organ, joint or tissue is the following fact : If the area of vertebral tenderness is thoroughly frozen, the organ, joint or tissue may be manipu- lated for a time with either diminished or no pain. Even the subjective pain may disappear for hours after the freezing. 75 Spondylotherapy If the sensibility of the skin over the painful organ, tissue or joint is tested with a pin before and after freezing, it will be noted after the latter manoeuver that the skin is anesthetic. This anesthesia is likewise of variable duration. The cita- tion of two observations will make my meaning more lucid. I. The subject has gout located in the left metatarso- phalangeal articulation of the big toe. The latter is ex- quisitively tender on manipulation. There are no vertebral points of tenderness. The toe is now manipulated and when- ever it is moved a localized muscular spasm may be palpated at the side of the spine of the nth dorsal vertebra. Within a minute two points of vertebral tenderness may be located corresponding to the left side of the nth dorsal vertebra and another about 4 cm. to the left of the spinous process of the latter vertebra. The vertebral areas of tenderness are now thoroughly frozen and within two minutes the big toe may be manipu- lated without pain. The skin over the toe in question is anesthetic. The anesthesia lasts only three minutes, but the patient is without pain in the joint until the following day. Again the vertebral area (which has been marked with a stick of silver nitrate to avoid a repetition of localization) is frozen and the patient is without pain for two days. Two more freezings sufficed to control the pain completely. II. The subject has an ulcer of the stomach. A sensi- tive vertebral point is already present, but when the tender point over the stomach is subjected to pressure, the vertebral area becomes decidedly more sensitive. The latter area is now frozen, after which procedure the sensitive point over the stomach may be manipulated with scarcely any pain at -all. The subjective pains of the patient disappeared for only six hours. Freezing was again executed and the pains evanesced for twelve hours. 76 Vertebral Tenderness Now to the average physician it would be ridiculous to assume that freezing over the area of vertebral tenderness was anything more than a palliative measure, yet sober thought endows analgesia with curative action. The use of anesthetics to wounds will hasten their healing and by so doing we are executing what the author is pleased to call a "peripheral rest-cure." Rest of any kind in the treatment of painful organs or tissues is curative. The author has seen abraded surfaces on the lips and mucous membranes, which having resisted treatment for months were regarded as clinically malignant. These abraded surfaces were constantly irritated by cauterization and the use of antiseptic lotions, yet in a few days a pro- tective coating of collodion over the abraded surfaces sufficed to cure them. One must also remember that the nerves which convey sensory impressions also carry trophic fibers. Take again coughs. When the sinusoidal current is used with one electrode over the sacrum and the other applied alternately over the spinous processes, it will be found that a reflex cough can be excited in many instances over the spinous processes of the 6th, yth, 8th and gth dorsal vertebrae. Patients with persistent coughs will often show areas of vertebral tenderness corresponding to the vertebrae in question. If now, the tender areas are thoroughly frozen, it is an excellent means of inhibiting a cough. Inhibition of a cough is, in many instances, a curative measure and when we employ narcotics with discretion to subdue a persistent cough in bronchitis and other pulmonary affections recovery is hastened. Concerning the action of freezing for the relief of pain, vide page 172. The author has also noted that areas of vertebral tenderness may be elicited when definite areas of the skin are irritated 77 S p ondylotherapy by pinching or by means of a point of a pin. Such areas of tenderness are likewise of short duration and appear on the same side of the vertebral column (or 4 cm. from the spinous processes) corresponding to the side of cutaneous irritation. The areas of tenderness may not appear for fully a minute after scratching or pinching a definite cutaneous area. GO' Ga FIG. 31. Approximate areas of vertebral tenderness elicited after irritation of cutaneous areas in different regions. Localized spasm of the spinal musculature is associated with the tenderness, i. e., each time the skin is irritated the finger detects a muscular contraction corresponding to the area where tenderness will subsequently appear. By this means one is now in the possession of an objective method for determining pain-reaction to cutaneous stimulation. The intensity of pain is an individual question and depends as much on the sensitiveness of the registering apparatus as it does on the degree of stimulation. 78 Vertebral Percussion The localization of vertebral tenderness in the writer's experience cannot be governed by any fixed rules, the individ- ual case only must serve as a criterion. The various therapeutic methods discussed in a sub- sequent chapter (chapter V), when applied to the areas of tenderness are endowed with considerable value in influencing the visceral condition. This statement applies with special cogency to the vaso-motor and viscero-motor fibers from a given segment. INTERCOSTAL NEURALGIA is a frequent condition respon- sible for vertebral tenderness and is discussed at length on page 1 86. VERTEBRAL PERCUSSION. The tracheo -bronchial glands are enlarged in pertussis and in other infectious diseases, notably in children. In every one of 127 cases of tuberculosis, Northrup found the glands enlarged. BRONCHIAL PHTHISIS has been fully described in the literature but the scope of such description has been limited in regarding it as an affection peculiar to children with symp- toms suggestive of increased intrathoracic pressure. The author has portrayed 19 a picture of bronchial phthisis occurring in adults which in all essentials tallies with the tableau of symptoms common to pulmonary tuberculosis with which it is frequently confounded. In an analysis by the author of 100 cases of bronchial phthisis the following diagnostic conclusions were formulated : 1. There is a history of cough which is spasmodic in character and almost suggests the brazen, metallic cough of aortic aneurism. 2. Tubercle bacilli may be found in the sputum after repeated examinations, and then only when the bronchial glands have suppurated and perforated the bronchus, or when tuberculosis is present elsewhere in the lungs. Spondylotherapy 3. Dyspnea is out of all proportion to the signs obtained by physical examination of the lungs. 4. Dullness of the lungs anteriorly and posteriorly, corresponding to the bifurcation of the trachea (at about the level of the intervertebral disc between the 4th and 5th dorsal vertebrae). 5. The Smith and Hare sign, viz., when the patient throws the head well back a "purring" sound is heard when the stethoscope is placed below the suprasternal notch. 6. The Roentgen ray evidence (enlarged glands), viz., when the target of the tube is so placed that when the rays are traversing the chest, they will fall at a point corresponding to either the right or the left side of the vertebral column posteriorly corresponding to a point just below the bifurcation of the trachea. Among the signs cited dullness over the manubrium sterni anteriorly and posteriorly corresponding to the 4th, 5th and 6th dorsal vertebrae is common. It must be recalled, however, that the region correspond- ing to the 5th dorsal vertebra is normally dull, the dullness extending for a short distance on either side of the vertebral column but more to the right than to the left side. The shape and size of this square patch of dullness, if much modified, may indicate enlargement of the bronchial glands. The enlarged bronchial glands often escape detection by percussion, owing to vibration of the sternum and spinal column. Insomuch as the method of vibrosuppression 20 is of great value in topographic percussion of the chest, brief reference will be made to it at this time. If one percusses the normal chest, say beneath the clavicle, a sound is produced which is the product of the vibration of the lung tissue and the thoracic walls. It is 80 V i b r o s u p p re s s i o n f / i fl rn f , / ;! i S \1 ' (il i FIG. 32. The vibrosuppressor and its application to the chest Spondyloth e r a p y the summation of this vibration which interferes with the elicitation of the dullness of the airless organs in juxtaposition to the lungs. If the vibration in question can be eliminated, the definition of the viscera will prove easy of attainment. Briefly, lung resonance is made up of two chief factors, viz., vibration of the air in the lungs and vibration of the sternum. The latter is essentially a sounding-board. Thoracic vibra- tion can be eliminated as far as possible by percussion of the organs at the end of a forced expiration, when there is comparatively little air in the lungs to vibrate, and by sup- pressing the vibrations of the sternum by means of the vibrosuppressor (Fig. 32). The apparatus is modeled after a tourniquet, consisting of a pelote, screw, band (6 cm. wide) and clamp for fixing the latter. It is so applied that the pelote rests on the xiphoid cartilage of the sternum. The pelote is made to compress the cartilage by aid of the screw with all the pressure the patient can tolerate. Percussion is then executed during the time the apparatus is employed and preferably during suspended respiration after forced expiration. In the absence of the apparatus, firm pressure made on ike lower end of the sternum by the hand of an assistant will aid topo- graphic percussion during the time the patient has suspended respiration after forced expiration. More recently, the author has noted that suppression of the vibrations of the spinal column by aid of compression of the latter by the hand of an assistant is of material aid in percussing enlarged bronchial glands and defining the lower border of the liver, spleen and stomach. In many instances it is better to com- press the sternum and spine simultaneously. Among other signs of enlarged glands are those of Grancher (unilateral restriction of breathing) and Petruschky (area of tenderness between the shoulder blades). ^ 82 Backache CHAPTER IV. SUMMARY OF SPINAL DISEASES AND SYMPTOMS. BACKACHE CHEST DEFORMITIES COCCYGODYNIA FAULTY ATTITUDES LITIGATION BACKS LUMBAGO NEUROTIC SPINE OSTEO-ARTH- RITIS POTT'S DISEASE OF THE SPINE SACRO-ILIAC DISEASE SACRO-ILIAC RELAXATION SPINAL CURVATURES SCOLIOSIS KYPHOSIS AND LORDOSIS ANGULAR CURVATURE SPONDYLITIS SPONDYLOLISTHESIS TRAUMATISM OF THE SPINE TUMORS OF THE SPINE TYPHOID SPINE VERTEBRAL INSUFFICIENCY DIAG- NOSIS OF SPINAL DISEASES PAINS DEFORMITY COMPRESSION OF THE SPINAL CORD PARAPLEGIA TUBERCULOSIS SYPHILIS GONORRHOEA RHEUMATISM RICKETS SPINAL MENINGITIS. BACKACHE. / T > HE popular conception of the etiology of backache in * men is the kidney, and in women pelvic disease. As a matter of fact the kidney and pelvis are infrequently concerned in the etiology of this common affection. It is practically axiomatic that organic heart-lesions as a rule are dissociated with pain and the same may be said of the average renal disease. I adopt the following simple manceuver for excluding the kidneys as factors in the causation of backache : Place the pleximeter first over one and then over the other kidney in the lumbar region and practice forcible concussion. The hands (Fig. 3) may be employed for a similar purpose. By aid of this transmitted palpation of the kidneys no pain can be elicited in the norm, but if the pain from which the patient suffers is of renal origin the exact nature of it may be reproduced by this manceuver. This method of trans- mitted palpation is equally efficient in determining the sen- sitiveness of the liver. 83 S p ondylotherapy The lumbar muscles (lumbago) are commonly concerned in the etiology of backache and they must be excluded in diagnosis (page 99). When the muscles in question are involved, bending far forward suddenly will stretch the muscles and elicit pain. Backache dependent on pelvic or renal disease would be uninfluenced by such a movement. It must be remarked, however, that the latter movement and pain in LUMBAGO are influenced by the muscles involved. Thus, involvment of the erectors permits bending forward, but elicits pain when the vertebral column is straightened; when the flexors (quadratus and psoas) are involved, bending forward is painful and rotation of the thigh (psoas) causes distress ; when the serratus posticus is involved, deep breath- ing and not spinal movements causes pain. Backache may be located in the lumbar, lumbo-thoracic, sacral or coccygeal regions. In women, the neurotic spine, sacro-iliac disease, con- stipation, hemorrhoids and pelvic disease are frequent causes of backache. If CONSTIPATION is present in either sex the pain is located in the regions of the ascending and descending colon and is associated with tympanites. The expulsion of gas brings temporary relief and the same may be said of carminatives, purgatives, enemata and a diet (non- amylaceous) which inhibits the formation of gastro-intestinal gases. In GASTRIC TYMPANITES, backache may be felt in the left interscapular region. The writer has shown 23 how easily the heart may be dislocated by distension of the stom- ach. It is unnecessary to descant on the practical value of this observation. Heart-dislocation from stomach-dilatation is associated with a circumscribed area of dullness in the left interscapular region. Over this area, bronchial respira- 84 B a a tion is heard. When the patient leans far forward, dullness and bronchial breathing disappear to reappear when the erect attitude is resumed (Fig. 34). The foregoing syndrome may be reproduced synthetically by artificial distension of the stomach. An enormously dis- tended heart may produce identical signs. Artificial insufflation of the colon is incapable of producing the same degree of cardiac luxation. In gas tro -intestinal affections, notably ulcerative in character, pain in the back FIG. 33. Radioscopic appearance of the heart before and after the admin- istration of a Seidlitz powder. The silhouette of the heart is represented by the dark area. often ensues within a few minutes after the ingestion of fluids and food. I have employed the phrase RESPIRATORY ATAXIA, to designate many respiratory neuroses which, in my experience, are associated with a defective type of breathing and with inco-ordination of the muscles of respiration. In males, the type is costal instead of abdominal, and in women, abdominal instead of costal. These patients have one symptom in common: A paroxysmal tendency to "catch the breath." There are, however, other symptoms, notably backache, syncope, dyspnea, cardiac palpitation and insomnia. 85 Spondyloth e r a p y Mere inspection makes the diagnosis, viz., the recognition of the reversed type of breathing. Auscultation elicits no respiratory murmur in the lower lobes of the lungs in males and the upper lobes in females. Encircling the chest with a rubber bandage to exclude costal breathing and the abdo- men in females to exclude abdominal respiration brings immediate relief, whereas re-education of the type of respira- tion results in cure. FIG. 34. Patch of dullness and area of bronchial respiration in dislocation of the heart upward after artificial distension of the stomach. The adjoining illustration shows an increase in the area of dullness when the same patient is leaning backward. A nasal anomaly may be the exciting factor and this may be demonstrated by the immediate relief of the symptoms following cocainization of the nasal mucosa. HEMORRHOIDS may induce reflex pains running to the back but more often down the left leg, thus simulating sciatica. As a rule such hemorrhoids have abraded surfaces and for this reason, an ointment containing a large percentage of orthoform is effective as a local anesthetic and, in this action a diagnosis may be made. If, for instance, the pains in the back are ameliorated 86 B a a after the application of the salve to the hemorrhoid, we know that the latter is concerned in the etiology of the pains. More radical measures addressed to the cure of the hemorr- hoids are equally efficient and the author can highly recom- mend the daily application of Monsel's solution to the hem- orrhoids by means of a brush once or twice daily. Other rectal affections, notably fissures, may be excluded by the local application of a 5 or 10 per cent solution of cocain. One must also think of the POST -OPERATIVE -BACKACHE provoked by the straight dorsal position of the patient during a protracted operation. This may be prevented by flexing the limbs and body and using cushions under the shoulders, knees and small of the back during an operation. Rose 21 directs attention to a chronic PERIOSTITIS of one of the spinal processes (lumbar and sacral usually) as an important cause of backache. The latter may be detected by the pain produced by pressure with the finger on the implicated spine. Immediate relief is secured by one appli- cation of leeches to the spinal process and cure, by the daily application of iodine-tincture and potassium-iodid internally. When over-distended SEMINAL VESICLES cause backache, immediate relief is often achieved by stripping the vesicles. PROSTATIC DISEASE may cause backache which is often misinterpreted as sciatica or lumbago. This is due to the intimate association existing between the pudic nerve from which the prostate receives its spinal fibers and the roots of the lumbar and sacral plexuses. A PENDULOUS ABDOMEN may cause backache and this may be demonstrated by the relief secured by raising the abdominal walls with both hands. If the latter manceuver is effective, a proper abdominal support must be worn. Here the pain is probably caused by traction of the mesentery 87 S p o n d y I o t h e r a p y on the spine. The drag of the abdomen in obese subjects will cause lordosis and strain on the sacro-iliac articulations. In chronic APPENDICITIS backache may be present and is increased in severity after fatigue. Byron Robinson has shown that the appendix is frequently in contact with the psoas muscle and may, therefore, be bruised by the action of this muscle. With the patient in the recumbent posture sudden extension and flexion of the thigh on the trunk will often elicit severe pain. On the other hand, the pain is relieved when 'both thighs and knees are partly flexed in recumbency. ANEURISM of the thoracic aorta is characterised by sharp paroxysmal and lancinating pains. Anginal attacks are not infrequent when the aneurism is located at the root of the aorta. The pains often radiate down the left arm, up the neck or along the upper intercostal nerves. In aneurism involving the descending aorta, one of the most frequent symptoms is pain and Huchard, referring to this form of aneurismal neuralgia, says that when one is dealing with persistent pain of long duration which cannot be explained, which resists ordinary medication and which is either in- creased or diminished in severity in certain attitudes of the patient, one should always consider aneurism as a probable diagnosis and, if no tumor can be demonstrated, one must have recourse to the x-rays for additional evidence in diagnosis. If backache is caused by PELVIC DISEASE, palpation of the ovaries and movements of the uterus should reproduce the pains from which the patient suffers. The pain from uterine affections is often located in the upper sacrum and is described generally as a dragging sensation. In such instances retro -flexion is the most common cause. Referring to the pains of pelvic inflammations, Kelly 88 Backache makes the following pertinent observation: Inflammatory pain has a definite habitat. . . . The pain of inflamma- tion is a fixed point ; it is never in one place to-day and then at some remote part of the body to-morrow, one day in the shoulder and the next in the foot or calf of the opposite leg. . . . . It is a safe working hypothesis to conclude that a patient who complains of a definite pain and who from day to day and week to week is definite in her complaint as to the character and seat of the pain, has some gross lesion. Garrigues 22 divides pelvic backaches into two varieties : 1. When pain and tenderness are located at the 4th and 5th lumbar vertebrae (spinal-center for the internal pelvic organs) ; 2. When a tender spot can be located on either side of the 2nd sacral vertebra. The latter variety is caused by a cellulitis of the utero- sacral ligaments. Garrigues contends that in the norm the utero -sacral ligaments are so elastic that the uterus can be brought for- ward bimanually until arrested by the pubic bones. When the ligaments are inflamed, any movement of the uterus forward causes acute pain in the baek. Many persistent backaches in women owe their origin to improper methods of DRESS. Here an^ important element is the pressure of corsets. In the developmental period of some of the ACUTE INFECTIONS, notably small-pox, dengue and influenza, back- ache is a frequent concomitant, the pathology of which is obscure. Associated with what is known as INDURATIVE HEAD- ACHE (which, according to Edinger, is regarded as the most frequent form of headache) there are also pains in the neck 89 S p o n d y I o the r a p y and back caused by indurations within the bodies of the muscles due to a chronic myositis. The indurations are painful on palpation and may feel like grains of shot. They are most frequently located in the muscles of the head and neck, although other sites are not exempt (Fig. 35). FIG. 35. The most common sites of indurations (modified from Edinger by Yawger). Several months may be necessary to effect a cure and this may be attained l)y removal of the indurations by means of vibration and Gal vano -therapy but most effectually by massage. This subject is more exhaustively discussed elsewhere. 38 One must remark, however, that fibrous indurations are 90 B a c k a c h e not essentially rheumatic insomuch as they may also follow infections and local injuries or strain of the muscles. In my experience, the indurations are best detected by relaxing the affected muscle and then rubbing the skin with vaselin when firm pressure with the finger will demonstrate the nodules. After a few seances of massage the indurations will become more defined. Depage, of Brussels, directs attention to the infrequency of backache (in 10 to 15 per cent of the cases) in floating kidney (nephroptosis) and observes that, notwithstanding nephrorrhaphy, the pains in the back continue. Here, as in backache referred to other causes, the following condition has been overlooked by clinicians, viz., owing to deformity of the ribs, the loth or nth rib comes in contact with the crest of the ilium either on one side or the other and the rubbing thus provoked gives rise to a dull, intermittent pain which is accentuated by movements. The false position of the ribs may occur as a result of scoliosis. The loth and nth ribs are painful on palpation and there is little or no space between the lower ribs and the crista ilei. Resection of the anterior ends of the ribs in question resulted in cure when mechanotherapeutic methods failed. 55 SYNOPTIC TABLE OF BACKACHES.* DISEASES OF THE SPINAL CORD. LOCATION OF PAIN. CONCOMITANT SYMPTOMS. In distal parts of the body de- No spinal rigidity nor vertebral ten- pendent on the pain-fibers that derness. Dependent on the seg- are irritated. ment of the cord involved, motor and sensory disturbances are present with loss of reflexes. *The essential facts of this table have been gleaned from a paper by Dr. C. M. Cooper of San Francisco, which was kindly placed at the disposal of the author prior to its publication. 91 Spondyloth r a p y DISEASES OF THE SPINAL-ROOTS AND MEMBRANES. May occur either in juxtaposition to the lesion or in distal parts and is intense and shooting in character. Pains occur in definite anatomic zones and are inclined to encircle half the trunk or shoot into the extremities. Spinal rigidity and tenderness are usually absent, thus excluding vertebral disease. If a single nerve-root is involved it may be the precursory symp- tom of herpes, DISEASES OF THE VERTEBRAL COLUMN. Pains are root-like in character with or without vertebral ten- derness. Deformity may or may not be present. Usually spinal rigidity and impaired mobility corre- sponding to the vertebrae impli- cated. The nature of the spon- dylitis (q. v.) must be determined. EXTRA- VERTEBRAL ARTICULAR DISEASES. Pains may be confined to the Backache is worse in the recumbent region of the ribs, scapulae or posture and referred pains in- ilia. In abnormal sacro-iliac nervated by the lumbo-sacral mobility (vide sacro-iliac dis- cord are frequent, ease), pain is referred to the sacro-iliac joints or sacrum. DISEASES OF THE MUSCLES AND LIGAMENTS OF THE BACK. Usually described under the gen- Rigidity of the back-muscles may eric term lumbago. Pains are increased by movements which contract the muscles. Muscles tender when compressed by the fingers. The Faradic cur- rent is useful in diagnosis (page 99). BACKACHES FROM STATIC ERRORS. In taking the strain off of distal The diagnosis is established when anomalies, the muscular fa- the flat-foot or knock-knee is tigue graduates into pains. remedied by some orthopedic Rotary or lateral curvature manceuver. may be present. be present but no pain can be elicited by percussion of the vertebrae and there are no nerve- root pains. B a a BACKACHES FROM VISCERAL DISEASE. The visceral stimuli may be: 1. Spasm in a hollow muscular organ (ureteral colic); 2. Distension of a capsule (en- larged spleen, liver or kid- ney) 3. Inflamed serous coverings (adherent appendix) ; 4. Insufficient blood supply (ab- dominal arteriosclerosis) ; 5. Excessive functioning (exces- sive venery) ; 6. Pressure (tumors and aneur- isms) ; Visceral pains are dissociated with excessive vertebral tenderness or stiffness or by movements which call the fasciae and ligaments into play as in lumbago. Usually referred pains, which are sharp, aching or stabbing. Hyperesthesia over zones cor- responding to the areas inner- vated by the disturbed spinal- segments (Figs. 23, 24, 25 and 26) and tenderness and rigidity of the muscles innervated by the same segment. Location of pain suggests organ involved: i, between the shoulders, gastric pains; 2, right shoulder blade or tip, hepatic disease; 3, left shoulder blade, over- loaded heart; 4, dorso-lumbar region, varicocele, loaded colon, ovarian or testicular disease; 5, angle between lowest rib and erector spinae muscle, kidney- stone; 6, loin, kidney disease; 7, base of sacrum, prostatic or uterine disease; 8, sacro-iliac synchondrosis, distended sem- inal vesicles, inflamed utero- sacral ligament, pelvic and rectal diseases. SPECIAL BACKACHES. 1. POST -OPERATIVE BACKACHE. After operations in the supine posture due to improper support of lumbar arch with muscular relaxation during anesthesia. The backache in women occurring at night is due to improper support of the lumbar arch and may be prevented by a pillow under the loins during sleep. 2. PROFESSIONAL BACKACHE. Observed in dentists and surgeons who assume a constrained posture and the 93 S p ondyloth e r a p y remedy consists in raising the right leg and placing the right foot on a stool ; thus the lumbar spine is partly unarched and strain is removed from the stretched ligaments. 3. HYSTERICAL BACKACHE. vide hysterical spine. 4. COCCYGODYNIA (page 95). CHEST-DEFORMITIES. The configuration of the thorax is frequently modified as a sequence of curvature of the spine and the deformities are as follows : kyphotic, scoliotic and scolio-kyphotic. Such deformities are readily recognized by the short thorax^ low stature and the exaggerated breadth of the shoulders. The RACHITIC chest is especially characterized by the keel -shaped prominence of the sternum (pigeon-breast) and may be associated with deformities of the spine, notably scoliosis and kyphosis. The BOAT-SHAPED chest (thorax en batteau) has only been observed in syringomyelia and consists of a depression in the median line of the upper portion of the anterior chest -wall. In the ALAR or PTERYGOID chest there are prominent scapulae. Projection of one scapula indicates the presence of a lateral curvature. In 1743, Hunauld described the condition known as CERVICAL RIB. The anterior limb of the transverse process of the yth cervical vertebra has an independent center of ossification and may develop into a separate bone (known as a cervical rib), which may not extend beyond the trans- verse process or may form a complete rib attached ante- riorly to the sternum. A cervical rib may be present either on one or both sides. Since the employment of x-rays in diagnosis, the cervical rib is more frequently recognized and is not an uncommon condition in explaining many vascular 94 Coccygodyn a and nervous symptoms referable to the upper extremity and neck. A supposititious osseous growth of the neck may be a cervical rib or exostosis emanating from it. A cervical rib may exist with or without symptoms. In the former event, the symptoms are associated with pressure on the subclavian artery (aneurism, gangrene of the hand and minor vascular affections) and on the brachial plexus (neuritis). The symptoms may develop suddenly in chil- dren and adults. COCCYGODYNIA. This is a neuralgia of the coccygeal plexus and is also known as coccydynia. The chief sign of this affection is pain in and around the coccyx which is accentuated in the sitting posture (sitting -pain), by rising, walking, urination, defecation, coitus and during pregnancy. Pressure on the coccyx is painful. The pain may be intermittent or con- tinuous and dull or neuralgic. With the patient in the dorsal or the left lateral position by grasping the coccyx between the index finger (in the rectum) and thumb and moving the coccyx, the pain from which the patient suffers may be re- produced and in this sense such an examination is diagnostic. The affection is chiefly confined to women and is occa- sionally observed in children. In quack literature the affection is often described as the "elongated spinal column." Occurring rarely in males, it owes its origin to some sexual anomaly. The etiology is obscure, the predominant factors being traumatism (horse -back riding), pregnancy, labor, rheu- matism and pelvic diseases. Many writers regard the affection as a neurosis or neuralgia and the success attending Graefe's method of treatment would suggest the latter hypothesis as correct in the majority of cases. Graefe cured all his cases within 95 Spondyloth e r a p y twelve seances by applying one pole of the Faradic current to the sacrum and the other pole to the coccyx and surround- ing tissues. FAULTY ATTITUDES. Above the age of twelve years the normal attitude may be roughly estimated by aid of the plumb-line held against the back of the sacrum; this line approximates the con- vexity of the dorsal spine. The FLAT BACK is observed in children with a tendency to scoliosis and the HOLLOW BACK (lordosis), unless due to disease, is usually an anomaly of conformation. ROUND SHOULDERS are associated with the following attitude : head is flexed and carried forward, the shoulders are drooping, the chest is narrow and flat, the scapulae are prominent and the physiologic curve in the dorsal region is accentuated. The age of puberty is the usual time for the occurrence of round shoulders. The etiology is identified with general muscular weakness (especially of the posterior shoulder- muscles), defective hygiene, supporting the clothing from the shoulders in lieu of the waist, and protracted spinal flexion from incorrect school furniture which lends no sup- port to the back. In PARALYSIS AGITANS the attitude is characteristic: head and body are bent forward with trunk flexed on thighs and fore-arms on the arms. The other essential points in diagnosis are : tremor at rest ceasing upon voluntary move- ments, mask -like face, monotonous voice and rigidity of the back. In CERVICAL CARTES the head is held to one side, supported by one or both hands in a fixed position. In PSEUDO- HYPERTROPHIC MUSCULAR PARALYSIS, the enlarged though feeble muscles, and the attitude (legs far apart, shoulders 96 Litigation Backs thrown back, abdominal protrusion and lordosis) are characteristic. In SHOULDER MALPOSITIONS, with drooping of the shoulder forward, rotation of the scapula lowers the glenoid cavity, thus causing the humerus to rest against the ribs and by so doing, the axillary structures are compressed, resulting in circulatory disturbances in the hand and pains in the distribution of the brachial plexus. LITIGATION BACKS. As a result of accident, many individuals suffer from symptoms referred to the back which in reality do not exist and which often evanesce after a favorable verdict by a jury. It is easier for a patient to simulate a disease which gives little objective evidence, hence the nervous system is a prolific field for^he malingerer. Simulation of organic nervous disease is extremely diffi- cult, and for this reason, the symptomatic picture is essentially neurasthenic. Simulation can only be excluded by the physician after a thorough objective examination of the nervous system. The behavior of the patient, when his attention is diverted from his symptoms, must be carefully noted. Disease of the cord and membranes may be excluded if the reflexes are intact and if there is no distal spasm, paralysis or anomaly of sensation. Vertebral implication is excluded if there is no vertebral tenderness, deformity or limitation of spinal movement. If unilateral spasm is present it cannot be feigned. In real PARALYSIS, any change in the condition of the muscles cannot be feigned. In simulated paralysis, move- ment of the involved limb may show some muscular stiffness if it is suddenly raised or dropped, or, if motion is secured by 97 S p o n d y I o t h e r a p y painful stimuli such as the prick of a pin or a powerful Faradic current. Under anesthesia the patient may execute movements of a simulated paralyzed extremity and in one case of malinger- ing, the author induced the malingerer to move his limb during hypnosis. ANESTHESIA is easier of simulation than the preceding symptom, for the reason that sensibility varies even in the norm. Thus women are more tolerant to pain than men and even in healthy criminals analgesia is frequently ob- served. Polish Jews are said to show anomalies in the per- ception of pain. Bailey 25 asserts, that there are many in- dividuals who can suppress any evidence of pain as long as their attention is fixed upon this object. The "human pin cushions" in museums really suffer pain, but in consideration of the salary they receive, willingly submit to the thrusts of the pin. In making a sensory examination, the eyes must be blind- folded and the tests must be executed without any fixep system. Thus, when one leg is being examined, prick the anesthetic leg quickly or employ a Faradic current and suddenly use the full force of the battery. Again, mark with a pencil on the skin the areas of anesthesia and examine later to observe if the areas correspond. Feigned anesthesia is not limited to the exact distribution of the peripheral nerves, nor to the sensory distribution of the spinal -segments. To determine objectively the existence of PAIN, the signs noted on page 70 may be employed. The REFLEXES are not under control of the will, hence, if modified or lost, feigning may be excluded. It is true, however, that the knee-jerk may be inhibited if the patient firmly contracts the knee -muscles. 98 L u m b a g LUMBAGO. A muscular rheumatism (myalgia) limited to the muscles of the loins and their tendinous attachments is known as lumbago. An attack of lumbago may occur suddenly after stooping, or a sudden twist, hence" the phrase, "kink in the back" or "Hexenschuss" (witches' shot), as the Germans call it. The differentiation of pain located in the muscles or vertebral ligaments is often difficult of attainment, yet, one may say, that if the pain is worse in straightening up, the erector spinae muscles are involved, whereas implication of the ligaments is probably present when the greatest pain is experienced when the patient bends far forward. Schreiber notes than an intense dull pain extending from the sacrum to the 3rd dorsal vertebra dissociated with any limitations in the movements of the spine, indicates the involvement of the fascia lumbo-dorsalis. Difficult bending forward suggests implication of the flexor muscles (psoas and quadratus). Involvement of the psoas is indicated by the pain evoked in rolling the thigh outward. Pain in the region of the 4th and yth ribs uninfluenced by bending the spine but accentuated by breathing, suggests involvement of the serratus posticus. In general, muscular pain is diagnosed when the muscles are tender on pressure and passive stretching or active con- traction accentuates the pain. When the muscles cannot be grasped between the fingers, muscular contraction may be provoked by the Faradic current and after this manner, the areas of sensitiveness may be elicited. This current is therefore equally efficient in differentiating myalgia from pains of other origin. Myalgia, in contradistinction to neuralgia, shows no 99 S p ondyloth e r a p y periods of exacerbation, but becomes accentuated from pressure and active and passive movements and the muscles may show changes in volume and consistency. From vertebral disease, the diagnosis is usually not difficult (vide backache). It must be emphasized, however, that per- sistent lumbago mav be a symptom of masked Pott's disease. Lumbago caused by fatigue is ameliorated by massage, which removes the fatigue-toxins. Myalgia may also be provoked by an intramuscular neuritis or by pressure on the intramuscular nerves by the indurated connective tissue of the muscles (page 89). Myalgia of rheumatic origin yields to the salicylates and when associated with a toxemia dependent upon some digestive anomaly, small doses of calomel followed by a saline is an effective measure. Strapping would be equally efficient in pain of muscular or vertebral origin, whereas acupuncture (page 146), if efficient, is practically diagnostic of a myalgia. By means of strips of adhesive plaster (preferably zinc oxid) properly applied to the lumbar muscles without in- cluding the spine, immediate relief is often obtained in myogenic pain. Almost miraculous in action is freezing (page 172) of the skin overlying the affected muscles. Unless relief is immediate after the use of freezing no results can be expected from its repetition. Myalgia of gouty origin demands the employment of remedies addressed to the gouty state. In URIC ACID LUMBAGO dependent on a supposed pre- cipitation of uric acid in the muscles of the back the local application of OIL OF WINTERGREEN (by massage) is, accord- to Haig, both diagnostic and curative. For purposes of massage I employ an electric massage-apparatus, which is illustrated in Fig. 36. 100 u m a The author does not seriously consider the so-called uric-acid theory of disease, yet he feels that in a book of this character, he dare not obtrude his personal opinion nor FIG. 36. Electric massage-apparatus for inunction. demolish a theory which has won favor. Therefore, a few words are pertinent respecting this theory. Many causes have been assigned for the uric -acid diathesis, but in reality 101 Spondyloth r a p y the essential cause may be thus summarized: excessive eating and drinking with deficient muscular exercise. There is practically no known remedy for eliminating uric -acid from the blood and one is constrained to have recourse to a diet with the object of diminishing the ingestion of foods containing uric acid. Adams suggests the following diet-lists in cases of uric-acid intoxication. MAY BE EATEN. White Meat of Chicken, Sparingly. Fat Bacon or Fat Pork or Ham. Macaroni, Spaghetti, Vermicelli. Barley, and all .Cereals and "Flaked" Breakfast Foods. Potatoes in all forms but Fried. Sweet Potatoes. Kale and Spinach, Sparingly. Flounders, Fresh Cod, Hake or Haddock. Fresh Fish, Soup or Chowder. Vegetable Soups, with Barley. Game, once a week, Sparingly. Cheeses of all kinds. Very useful. Stale Bread, Crackers, etc. Rusks, Cake without Eggs. Raw Cabbage, "Slaw." Corn on the Cob or from the Tins. Cucumbers, Lettuce, Parsley. Dandelion, Beet and other "Greens." Beets, Turnips, Squash, Pump- kins. Puddings of Crackers, Bread, etc., without eggs. Rice, Sago, Tapioca. Milk, Buttermilk, "Cereal Coffees." Chestnuts, Almonds, Walnuts, Pecans, Grapes, Raisins, Figs, Apple Sauce, Pears, Lemons. Grape Fruit, Oranges. Dried Fruits in Sauces, Sweetened only when cold and ready to eat. TO BE AVOIDED Eggs, and foods containing them. Pickled, Salted or Preserved Fish. Beef. Veal. Pork. Mutton. Lamb. Beef Tea. All Soups made with Meats. Salmon, Bluefish, Mackerel or any Oily Fish. Mushrooms. Celery, Kale. Tomatoes, Rhubarb. New Bread or Biscuit. Made Dishes, as Puddings with 102 Neurotic Spine Potted or Preserved Meats. Eggs. Lobsters, Crabs, Clams, Oysters. Hot Griddles, Waffles, etc. Dark Meat of Chicken or Fowl. Beer, Wine, Whiskey and all Liver, Sweetbreads, Kidneys, etc. Alcoholics. Beans, Peas or Lentils, Dried, in Tea, Coffee, Cocoa andChocolate. Soups or Baked. Peanuts. Bananas, Gooseberries. TRAUMATIC LUMBAGO often follows injuries of the verte- bral column and is dependent on strain or laceration of the tissues which protect the spinal cord. Injury of the spinal cord is excluded by the absence of paralysis, anesthesia and loss of sphincter -power. In this form of lumbago there is pain in the back, aggravated by motion. Painful areas may be detected over the vertebral spines and muscles, and the latter are usually in a condition of spasm. Vide osteo -arthritis (page 105) which is often falsely designated as lumbago. NEUROTIC SPINE. In hysteria and neurasthenia, spinal symptoms may pre- dominate conducing to a condition known as spinal irritation or spinal neurasthenia. Among the symptoms are : weak- ness and pain in the back and intercostal -like neuralgic pains, which shoot down the legs. The rachialgia may only appear after exhaustion or movements of the spine or it may occur spontaneously. In practically all cases areas of tenderness may be elicited on the spine. The diagnosis of the neurotic spine is based on the diagnosis of neurasthenia and hysteria. In neurasthenia, the chief symptom is tire, without which sign the disease cannot be said to exist. Amyosthenic symptoms are present (page 52), and it is 103 S p ondylotherapy evident, that if the back -muscles (which are the only agents in maintaining the spine erect) are involved in the hypo- tonicity, backaches must be of frequent occurrence. Respecting the diagnosis of hysteria, one searches for the stigmata (anesthesia, hyperesthesia, etc.). According to the modern conception of hysteria, the so- called stigmata are of artificial production, evoked by the suggestion of the physician during his examination; hence the stigmata are characterized by mobility, variability and incertitude.* If anesthesia is present it may be revealed by certain manceuvers. In the method known as TRANSFERENCE, if a coin or any metal is placed on an anesthetic area, the latter will show a return of sensibility, whereas another area with normal sensibility may become anesthetic. The manceuver may be reversed by placing the coin over an area of normal sensibility; this in turn becomes anesthetic and sensibility is restored in another anesthetic area. Janet suggests an ingenious manceuver. The patient, let us assume, has an anesthetic area on the back. He is told to say "yes" each time he feels the prick of the pin and "no" when it is not felt. The examination must be con- ducted rhythmically so as to give the patient no previous warning. If the patient says "no" when the anesthetic area is touched, the nature of the anesthesia is revealed insomuch as the patient could not say "no" if tactile sensation were not present. In hysteria, the psychic origin of the disturbed sensations is further revealed by the fact that they bear no relation to the distribution of the sensory nerves nor to the segments of the spinal cord. The neurotic spine is frequently associated with diseases *This conception merits modification in traumatic neuroses (page 377). 104 s t e o -Arthritis of the pelvis insomuch as areas of hyperesthesia are fre- quently located over the ovaries (ovarian tenderness). In the majority of instances the ovaries are not implicated and, if bimanual examination of the pelvis is made and the finger in the vagina is made to approximate the finger on the area of tenderness, it can easily be demonstrated that the pain is located in the abdominal walls and not in the pelvic organs. OSTEO -ARTHRITIS . Synonyms. Rheumatoid Arthritis ; Arthritis Deformans ; Chronic Rheumatic Arthritis ; Rheumatic Gout. In this affection pronounced structural changes in the joints and cartilages are present. When the spine is in- volved, there is hypertrophy and overgrowth of bone. The x-rays have been a valuable aid in the recognition of these changes which, when present, exclude rheumatism, insomuch as the latter affection is unattended by pathologic alterations in the cartilage and bone. The affection usually occurs between the ages of thirty and fifty years and women (notably those who have pelvic disease or are sterile) are as frequently affected as males. The affection is neither related to rheumatism nor gout. It was formerly held, that the disease was dependent on lesions of the spinal cord owing to the occurrence of muscular atrophy, pain, neuritis, increase of reflexes, etc., but the modern theory is in favor of a chronic infection resulting from gonorrhea, influenza and other infectious diseases. In children, Still has described a form characterized by en- largement of the joints and swelling of the lymph -glands and spleen. The onset usually occurs before the second dentition and girls are more frequently affected than boys. The children are puny and show arrest of development. 105 S p ondylotherapy Nathan 48 describes a metabolic form of osteo-arthritis which is characterized by a symmetrical involvement of many joints with swelling and increasing deformity. Radiograms show a peculiar punched -out rarefaction in the early stages, and absorption and distortion in the late stages without the presence of proliferative processes or bony ankylosis. It is interesting to observe that in such cases the employment, of the thymus shows a remarkable effect. One begins with two five-grain tablets thrice daily. In a couple of weeks the dose is increased to three tablets and after a month three tablets four times a day are given. A toxemic factor has been recognized in the etiology of arthritis deformans and treatment directed toward a pyorrhea alveolaris or albuminous putrefaction of the intestines has been followed by satisfactory results. In the latter condition, indicanuria is present. Intestinal putrefaction is combated by interdicting meat in the diet, the use of intestinal anti- septics, the employment of laxatives to produce daily move- ments of the bowels and the use of soured milk (one or two pints daily). The latter may be substituted by tablets containing lactic acid bacilli, but care must be taken that the products are reliable.* It is the VERTEBRAL form of this "affection which is of particular interest to us. Here there is a progressive ankylosis of the vertebrae conducing to spinal rigidity (poker- back). This condition has been described as SPONDYLITIS DEFORMANS, of which there are two varieties; that of Von Bechterew, which is either hereditary or secondary to a trauma in which nerve-root symptoms (anesthesia, pain and muscular atrophy) predominate and the spine alone is involved. In the Strumpell-Marie type, also known as *This subject is more fully discussed on page 344. 106 s t e o -Arthritis SPONDYLOSE RHizoMELiQUE, the spinal signs are less char- acteristic and the shoulder-joints may be involved as well as the hip. When the spine in the lumbar region is involved, the pains may simulate sciatica or lumbago; in the cervical region the pains are referred to the neck and arms and in the dorsal region along the intercostal nerves. My friend, Dr. S. J. Hunkin, who has had an extensive experience, contends that probably most lumbagos and sciaticas are of osteo-arthritic origin. Spondylitis deformans is about three times as frequent in men as in women and the ages of predilection are from twenty-five to forty-five years. The LABORER'S SPINE (duplicature champetre of Marie), occurring in laborers who must adopt the stooping posture, must not be confused with this affection. In the laborer's spine, the entire spine is never "welded together" and there is no exostosis nor decided ankylosis of the joints of the extremities. In the diagnosis of osteo-arthritis, mention has been made of the x-ray plate for revealing the osseous overgrowth. The latter may also be revealed by palpation, which shows thickenings or nodes. If the affection implicates the spine, the range of motion is limited and the lordotic curve instead of ending at the loth or nth dorsal vertebra, runs up to the yth or 8th dorsal vertebra or perhaps higher (Hunkin). Involvement of the vertebrae is further noted by limitation of the hip -movements and stiffness of the back. The normal curves are accentu- ated, notably the lumbar and dorsal ones, and the patient is bent in walking. If there is any ankylosis between the ribs and the spine the breathing is abdominal, owing to deficient expansion of the chest. Diminution or absent chest-expan- sion shows implication of the articulation of the ribs. 107 Spondyloth e r a p y If there is any motion in the spine it is painful and may be associated with crepitus. It is necessary to distinguish loss of motion due to muscular spasm and locking of the joints by the osteophytes. Little nodules (Heberden's nodosities) may be felt upon the sides of the distal phalanges. Although this disease is regarded as incurable, thiosinamin may be tried or anesthesia employed. Fibrolysin is preferable to thiosinamin and is used hypodermatically. The drugs in question soften scar tissue. Anesthesia is effective for a dual reason ; if the ankylosis is fibrous it may be forcibly overcome. Again, Marshall 26 has recently shown the following re- action after ether-anesthesia in the usual manner from a cone for fifteen minutes in osteo-arthritis without apparent in- fection ; complete subsidence of pain, restored motion in the involved joints and partial disappearance of periarticular swellings. Amelioration may not occur for twenty-four hours and the relief between anesthesia and the return of pain is from two days to two weeks. Acute, show more decided changes than chronic cases. If the patient is made worse by the anesthesia the arthritis is probably of infectious origin. The therapeutic value of repeated anesthesias was not determined, owing to the insufficient number of cases. Relief of pain in the early stages of the disease is secured by fixation of the spine, but later, such immobilization is not indicated owing to ankylosis, which must be prevented by active and passive movements. POTT'S DISEASE OF THE SPINE. This refers to a progressive tuberculosis of the vertebral bodies or discs, eventuating, as a rule, in ankylosis and kyph- osis. The disease is localized in order of frequency as follows : 108 D i s e a i. Dorsal; 2. Lumbar; 3. Cervical portion of the vertebral column. The great majority of cases occur before the age of four- teen years and one or several vertebrae may be simultaneously involved. The disease is equally common in the male and female. Heredity, traumatism and the diseases of children which enervate the vitality, are frequent etiologic factors. The tuberculous lesion in this disease is usually located in the body of the vertebra leading to disintegration of the osseous structure which may terminate in caries or suppura- tion. In consequence of softening and absorption of the vertebrae they cannot sustain the superimposed weight, hence deformity (kyphosis) results. When the disease involves the last vertebra, the deformity resulting causes the lower lumbar vertebrae to project over the brim of the pelvis like a roof (vide spondylolisthesis). MUSCULAR SPASM is an early and characteristic symptom manifested by anomalous attitudes, lateral deviations of the column and reduced flexibility of the spine. Muscular rigidity is so important an early sign that the following rules of Lloyd 27 are apropos: 1. If stiffness is present when the patient is told to nod the head affirmatively, there is occipitoatloid disease. 2. If stiffness is noted when the patient is directed to look far to the right or to the left, there is atlo- axoid disease. 3. When the shoulders are firmly fixed to the back of the chair and the eyes are carried back along the ceiling, any stiffness suggests disease below the second cervical vertebra. 4. Place the patient prone on the lap and indicate the tip of each spinous process with a pencil, after 109 Spondyloth e r a p y which direct the child to stand straight and note if any of the pencil-marks approximate; if two or more marks do not approach each other ap- proximation is prevented by rigidity and the disease is in the dorsal region. 5. To detect lumbar rigidity, place the nude patient upon a couch and grasp the ankles and raise the pelvis. If the lumbar spine is flexible the pelvis is lifted without raising the chest from the couch and the movement deepens the hollow of the loin. If the lumbar spine, however, is stiff, the trunk is raised and there is no alteration of the outline of the lumbar spines. In Pott's disease, when the child is directed to pick up an object from the floor, the knees (not the back) are bent. PAIN, usually dull, may be located at the site of the disease or referred to the peripheral distribution of the irritated nerves, and it is for the latter reason, that the child may be treated for some visceral affection. Bilateral pains (sciatica and intercostal neuralgia) are suggestive of vertebral disease and chronic bilateral belly- aches in children are diagnostic according to Lloyd. Pain and tenderness in the back suggest abscess -formation. Very often the pain of dorsal disease may be assuaged by raising the shoulders and in cervical disease by lifting the head. DEFORMITY, especially when angular and in the median line, is pathognomonic of this disease. Angular deformity is noted more often in regions where the normal curves are posterior than when they are anterior. A skiagram is invaluable in the early diagnosis of Pott's disease. When the disease has subsided, there is no longer any tenderness of the spine to vertical pressure, and jarring of the column in various ways causes no inconvenience. Rigidity 110 Sacro-Iliac Disease may continue as a result of the welding together of the affected vertebrae. In adults and less often in children, Pott's disease may occur without deformity and the only symptoms may be the signs of a spinal abscess and implication of the cord and spinal roots. SACRO-ILIAC DISEASE. Synonyms. Sacro-coxitis ; Sacro-coxalgia. This is either an acute or chronic tuberculous disease of the sacro-iliac articulations,* commencing either in the synovial membrane or bone, and is practically identical with Pott's disease of the spine. It occurs most frequently in early adult life and the predisposing cause is identified with occupations (equestrians) exposing the joints to traumatism. The pain in this disease may be confined to the affected joint or may be referred to the distribution of the dorsal or sciatic nerves. It usually begins on getting up after a night's rest and is accentuated by all movements which jar the joint. Examination per rectum will reveal tenderness over the joint. The pathognomonic sign is the following : pain in the joint when the sides of the pelvis are pressed together. In walking, the steps are cautiously made to avoid all jars to the joint and the patient walks chiefly upon the ball of the foot and the body is inclined toward the sound side with tilted pelvis. Examination of the joint shows swelling and elevation of local temperature. SACRO-ILIAC RELAXATION. The sacro-iliac joint is a true joint and may be the site of the same diseases as other joints. *The two superior posterior spinous processes of the ilium are on a line with the third sacral spine, below which are the sacro-iliac joints. Ill Spondyloth e r a p y Goldthwait, 28 refers many backaches in women to luxation of the sacro-iliac joints. Even in the norm, the latter show definite motion which, during pregnancy and menstruation, is augmented. These joints are also relaxed in consequence of traumatism and general weakness. The so-called "stitch" in the back, from strain or overwork, represents a strain of the joint in question. The backache occurring in the morning after sleep and after operations is referable to the general relaxation following the dorsal posture which strains the lumbar spine and draws the sacrum backward. It is suggested that the backache thus produced is com- monly relieved by stretching upon first waking, which draws the lumbar spine forward. Drag of the abdomen in obese individuals is often a source of sacro-iliac weakness in consequence of the lordosis and pelvic-joint strain. The most frequent symptom in sacro-iliac relaxation is backache referred either to the sacro-iliac articulations or the sacrum. The backache may develop during sleep, owing to the recumbent posture. The lumbo -sacral cord passes directly over the upper part of the sacro-iliac articulation and the pressure thus induced accounts for the referred pains in the lower extremities. Objectively, one may note when the patient stands, an obliteration of the lumbar curve of the spine. The diagnosis of sacro-iliac relaxation is often made by the therapeutic results. Thus relief at night is attained by lying on a firm bed with a firm hair-pillow under the hollow of the back. If the joints are strained or only relaxed, some support to the pelvic bones, like adhesive straps or a wide webbing belt fixed to the base of the corsets and kept up by the insertion of light steels, may be employed. If 112 Spinal Curvatures luxation of the upper part of the sacrum is present, it may be corrected by extending the spine; legs on one table and head and shoulders on another table with the face downward and the unsupported body hanging between. After this manner, the sacrum is replaced and a plaster- jacket is applied. Sacro-iliac relaxation is frequently confounded with sciatica and lumbago. It is differentiated from the former, by the absence of pain on pressure along the sciatic nerve and from the latter, by the absence of pain on pressure over the lumbar muscles and free motion of these muscles. In the diagnosis of relaxation of the sacro-iliac joint, one must not forget that a rectal examination will often reveal a tender point on either or both sacro-iliac joints. If certain move- ments cause pain and the cause is sacro-iliac relaxation, the same movements may be made without pain during the time the sides of the pelvis are compressed by the hands of the physician. SPINAL CURVATURES. The curves of the normal spine have already been dis- cussed (page 39). The chief varieties of curvature are: 1. Scoliosis or lateral curvature. 2. Posterior curvature, also known as kyphosis, gib- bosity or excurvation. 3. Lordosis or anterior curvature. 4. Angular curvature from caries of the spine. SCOLIOSIS. This refers to a lateral deviation of the spinal column with or without rotation of the vertebrae on their vertical axes. Scoliosis is the most frequent of all orthopedic affections 113 Spondyloth e r a p y and is more common in girls than in boys (four to seven girls to one boy). The largest percentage of cases occurs before the age of fourteen years and very few cases occur thereafter. The most frequent curve is toward the right in the dorsal region, owing to the fact that the right is used more often than the left arm. Scoliosis is usually acquired and the most frequent causes are general muscular debility and rickets. Scoliosis may result from an empyema with adhesions and the concavity of the curvature is toward the affected side. Caries and spinal tumors may eventuate in scoliosis. In SCIATICA, scoliosis is frequent, the body being in- clined toward the healthy side (convexity of the spinal column toward this side) or, more rarely, the trunk is inclined toward the affected side, or even more rarely the trunk may alternate in being inclined toward one side and again toward the other side (alternating sciatic scoliosis). The probable cause of scoliosis in sciatica is unilateral reflex contractures of the muscles of the back. Other varieties of scoliosis are : 1. HABIT SCOLIOSIS, due to habitual faulty positions, and in this category may be included vocational scoliosis resulting from faulty postures during occupation and observed in dentists, barbers, dressmakers and others. 2. STATIC SCOLIOSIS, due to inequality as a result of alterations in the extremity. Thus, in shortening of one leg an obliquity of the pelvis results in the opposite direction with a primary deviation of the lumbar vertebrae. It is not difficult to recognize scoliosis when all the clothing is removed and the child stands. Scoliosis is made 114 Spinal C u r v a t u res evident by marking the spinous processes with an anilin pencil. Numerous scoliosometers are used for measuring and recording the degree of the deformity. It may happen that in neurasthenics, the spines of the vertebrae are tender on pressure and here mistakes arise in the incorrect diagnosis of spinal caries. In the latter affection, spinal rigidity is the essential factor in diagnosis due in the early stages to involuntary muscular spasm and in the latter stages to ankylosis. When the spine is flexible and curvature can be combated by manipulation, the case is one of scoliosis. Scoliotic curves however, may be rigid, but only after having been present for many years. There are cases of functional lateral deviation of the spine which are easily corrected and must not be confused with true scoliosis. In the latter, flexion of the spine in- creases the deformity and in the former it is obliterated. Functional deviation, if neglected, may be converted into a true scoliosis. Respecting prognosis in scoliosis one may say, that when there is no deformity of the bones, i. e., when the physician can by traction and manipulation, correct the deformity, and when the spinal muscles are intact, a cure can be pre- dicted. There is no antagonism between scoliosis and tuber- culosis as was at one time supposed. If scoliosis is caused by a shortened extremity, a thick- soled shoe is indicated. Muscular nutrition is effected by correct exercises, massage, electricity and central sinusoidali- zation (page 158). KYPHOSIS AND LORDOSIS. When the normal dorsal curve is increased it is known as kyphosis or posterior curvature, and increase of the 115 S p ondylotherapy lumbar curvature is called lordosis, anterior concavity or saddle-back (Fig. 37). Compare the latter with Fig. 16 showing the divisions and contour of the normal spine. Kyphosis and lordosis may co -exist. Lordosis is fre- quently an act of compensation to counteract the center of gravity going too far forward. This compensatory lordosis is noted in pregnancy, in obese individuals, from abdominal enlargement, in rickets, etc. A paralytic variety of lordosis is observed in muscular atrophy and pseudohypertrophic paralysis. FIG. 37. A, increase of the dorsal curve or kyphosis; B, increase of the lumbar curve or lordosis. Adolescent kyphosis is frequently noted in young women who have been overworked in the workshop or field. As a rule, the deformity cannot be overcome by voluntary effort, and, in consequence of compensatory changes in the bones, it becomes permanent. MUSCULAR KYPHOSIS may result from muscular weakness due to faulty attitudes and is observed in tailors, carpenters, shoemakers and others. SENILE KYPHOSIS is caused by absorption occurring in the intervertebral discs. RACHITIC KYPHOSIS is most pronounced in the lumbar region and disappears in the recumbent posture and in suspension. 116 Spondylitis In all recent cases of kyphosis, the deformity disappears when the patient lies upon the stomach. Kyphosis is differentiated from the angular curvature of spinal-caries by the absence of rigidity of the spinal-muscles and pains when the vertebral column is percussed. LUMBAR BULGING must not be confounded with kyphosis. It is usually a swelling on either side of the spine and is commonly associated with some renal affection (tumors, pyonephrosis, etc.). ANGULAR CURVATURE. This may result from any disease of the vertebral bodies, notably, tuberculosis, osteomyelitis, syphilis, secondary carcinoma of the vertebra, etc. Insomuch as this condition usually results from tuberculous caries of the vertebral bodies, the reader is referred to the description of Pott's disease (page 108). SPONDYLITIS. Spondylitis deformans has already been described (page 1 06). The vertebrae are implicated in various diseases usually of infectious origin. The following forms of spondylitis may be differentiated. i. TRAUMATIC SPONDYLITIS. This affection follows an injury and bears a close" resemblance to Pott's disease. The vertebrae between the 3rd and yth dorsal are most frequently implicated. The pain which is present may be located in the injured area or may be referred, and is accentuated by pressure and movements. Kyphosis may also be present. The injury may be associated with fracture and the spinal cord may be ultimately involved in this affection. Whereas traumatic spondylitis is non -tuberculous, it must not be 117 S p o n d y I o t h e r a p y forgotten that Pott's disease may follow traumatism. In tuberculous disease of bone,' here as elsewhere, the injury creates an area of least resistance in which the bacilli are deposited or a latent area of tuberculosis may be aroused into activity. 2. INFECTIOUS SPONDYLITIS. This is observed in actino- mycosis, syphilis, gonorrhea, osteomyelitis and typhoid fever (page 121 ). SPONDYLOLISTHESIS. This refers to a deformity of the spinal column produced by the gliding forward of the lumbar vertebrae in such a way that they overhang the brim of the pelvis and obstruct the inlet of the latter (spondylolisthetic pelvis). It is an uncommon affection and results from malforma- tion, strain or violence. The diagnosis is established by: 1. A history of injury during the developmental period with pain in the lower part of the back. 2. Shortening of the body in the lumbar region. 3. Lordosis with separation of the ilia. A like deformity of the pelvis known as SPONDYLIZEMA is produced by caries of the last lumbar vertebra and the top of the sacrum. TRAUMATISM OF THE SPINE.* It is an undeniable fact, that spinal injuries may prove an exciting factor in the development of many chronic diseases, notably, general paralysis of the insane, locomotor ataxia, etc. Whether traumatism can be regarded as a cause of the latter affections is still a debatable question insomuch as *Vide litigation backs (page 97) and neurotic spine (page 103). 118 S p n a I T r a u m a t s m they may have existed unrecognized prior to the injury. Schlesinger, shows that the symptoms ascribed to a traumatic neurosis may be due in many cases to some pre-existing affection. He examined one hundred victims of various accidents within ten days of the accident and was amazed FlG. 38. Relation of the spinal cord to the surrounding structures. V, body of vertebra; V 1 , spinous process; i, ligament; 2, vessels; 3, dura mater with the arachnoid lying directly beneath it; 4, anterior root; 5, posterior root; 6, spinal ganglion; 7, ligament (Dana). at the large proportion of pathologic conditions found. Only twenty-two of the one -hundred persons were found normal. It is likewise difficult to dissociate true from fictitious nervous symptoms following a simple strain which is often associated with the term traumatic lumbago (page 103). A spinal sprain may result from direct or indirect in- juries and the lumbar region is usually involve'd. According to the nature of the injury SPINAL SPRAINS may be differen- tiated as follows : 119 S p o n d y I o t h e r a p y 1. Simple sprain. 2. Sprain with nervous symptoms. 3. Sprain with spinal cord symptoms. The relation of the spinal cord to the surrounding structures may be noted in Fig. 38. A simple sprain is pathologically associated with some injury to the spinal-muscles and ligaments or both. The dominant symptom is pain moderated by rest and accen- tuated by motion. The spinal-muscles are in a condition of compensatory spasm to immobilize the vertebral column. Areas of tenderness may be present and simulation of pain may be excluded by the signs of Mannkopff and Loewi (page 70), NERVOUS SYMPTOMS, usually neurasthenic or hysterical in character, may co-exist with the symptoms of a simple sprain and when .cord-symptoms (paralysis, anesthesia, changes in the reflexes, girdle pain and sphincter-changes) follow the sprain, one must suspect concussion of the cord (when the symptoms abate within a week), hemorrhage within the cord (hematomyelia) or the development of a meningitis. Simulation is a constant factor in spinal injuries and in diagnosis one must not forget Charcot's conception of a trauma in etiology. The latter taught that functional symptoms following an injury, were related to like symptoms which could be made to appear and disappear by hypnosis. The shock of an injury is tantamount to an hypnotizing agent (suggestion) which directs the attention of the patient to the injured part and suggests the symptoms (traumatic suggestion}. There are many neurologists who assume that the symp- toms of a traumatic neurosis can be produced by one idea and removed by another idea, in other words, all is referred 120 T y p h o id Spine to suggestion and that there can be no purely functional troubles in the absence of anatomic lesions. OSTEOPATHIC TRAUMATISM. In the author's experience, the mechanic manipulations of many osteopaths often conduce to severe spinal sprains for, if the osteopath regards a dislocated vertebra as the cause of disease or supposes that a vertebra is compressing a vessel or nerve, he is in- clined to conciliate his conviction with more force than discretion. TUMORS OF THE SPINE. Tumors of the spine are usually carcinomatous and less frequently sarcomatous. Carcinomata are rarely primary. They are secondary in nature and due most frequently to metastases from carcinomata of the breast and occur there- fore with greater relative frequency in women. Secondary deposits in the lumbar spine are relatively frequent in individuals with cancer of the breast and a group of symptoms designated by the term paraplegia dolorosa accompany the deposits, viz., lancinating pains, hyperes- thesia and occasionally paralysis of the bladder and rectum. In malignant ^disease of the spine the following are characteristic signs : rapid course, cachexia, local tenderness and severe pain, deformity, rapid emaciation and anemia, absence of fever, paraplegic symptoms, antecedent history of a malignant growth and localization in the lumbar region. The iso-hemolytic power of the serum may yet serve of diagnostic value as a characteristic reaction of cancer. TYPHOID SPINE. Bone-lesions (periostitis, caries and necrosis) are occa- sional sequelae of typhoid fever. In 1889, Gibney described a condition of the spine 121 Spondylotherapy occurring during the course of the disease in protracted cases and more often during convalescence, in which pain is felt either in the lumbar or sacral regions, especially after a slight injury or shock. Usually the condition is a neurosis with a good prognosis, but in rarer instances, the pathologic process may be a periostitis with or without a subperiosteal abscess or spondylitis. Among the symptoms are stiffness, localized pain and weakness of the back. The total number of cases thus far reported is about seventy-four. VERTEBRAL INSUFFICIENCY. This condition has been described by Schanz in individ- uals between the ages of 20 and 40 years who complained of severe pains in the back. The spinous processes of the vertebrae are painful on percussion and the bodies of the lumbar vertebras are equally sensitive. The latter is demonstrated by deep abdominal palpation when the fingers attain a point where the pulsations of the abdominal aorta are perceptible. Another sign is the difficulty experienced in changing the dorsal for the ventral posture. Vertebral insufficiency is frequentl/ regarded as an expression of neurasthenia and often it has been misin- terpreted as a tuberculous spondylitis, but the immediate results of the treatment exclude neurasthenia and spondy- litis. Some of the patients date the symptoms from the moment corsets have been discarded. The treatment con- sists of rest, massage and particularly the use of an orthopedic corset. ORTHOSTATIC ALBUMINURIA. In this affection, which occurs most frequently in children, albuminuria is present when the patient is up and about but disappears after rest in bed. The condition is not associated with nephritis. 122 M al-Alignment Jehle 39 regards lordosis as an invariable concomitant of this condition and he has induced albuminuria in healthy children by provoking a curvature of the spine. It is sup- posed that the incurved vertebrae protrude into the space between the kidneys, thus twisting them around on a vertical axis and causing circulatory disturbances. It is further assumed that when the children are up, the weakness of the spinal muscles causes a lordosis. The albuminuria may be corrected by a supporting corset or by strengthening the muscles of the back and by making the sole of the shoe a little thicker. MAL -ALIGNMENT OF THE CERVICAL VERTEBRAE. 51 As observed on page 42, our conception of the movements of the spine is too limited and if the current opinion is enter- tained, that the vertebras are firmly bound together to form an elastic whole or entity, it is impossible to credit such a condition as mal-alignment of the cervical vertebrae without the presence of a traumatic dislocation. Bates 51 observes, "the muscles are designed and attached to each vertebra so -as to enable it to contribute its propor- tionate share to any of the movements of the neck as a whole, and this arrangement guarantees it a certain amount of individual mobility; which is needed for the execution of the more complicated motions of the head and neck." Reference has been made on page 47 to the author's observations on spasm of the spinal musculature provoked by peripheral sources of irritation. The muscles, in a condition of spasm by exercising traction on the cervical vertebrae, may force them out of the normal alignment. Now the osteopath contends that, in consequence of the spasm of the muscles and mal-alignment of the vertebrae, 123 Spondyloth e r a p y compression of the vessels and nerves ensues which conduces to definite systemic anomalies. The recognition of cervical spasm and mal-alignment is not difficult The former may be recognized by palpation ; the muscles are painful and in a condition of contraction. Mal-alignment is noted by deviations from the normal articular line of the head and vertebral column. Dr. Geo. Gould comments on the frequency of mal- position of the head, torticollis and spinal curvature due to eye-strain. The author has noted even in the norm that, when the physician directs a patient to make strained movements of the eyes (without moving the head), and at the same time palpates the muscles of the neck on either side of the spine, the muscles in question contract spasmodically. It is not difficult to conceive then that, if the peripheral irritation is persistent, the muscles can pass into a state of tonic con- traction.* Now a bit of conservatism is necessary in estimating the results attained in the treatment of these cases. It is difficult to conceive, at least, theoretically, how any manipulation of the muscles will bring benefit until the source of peripheral irritation is eliminated. However, one must regard with tolerance the observations of those who contend that relaxation of the contracted muscles and re- leasing "locked out vertebrae" suffice to cure. For the sake of completeness, the author desires to describe the methods employed by osteopaths for the "adjustment of muscular lesions" and the "adjustment of cervical vertebrae. 2 ' *Dr. Louis C. Deane, recently referred a patient to me for diagnosis, who in con- sequence of a severe injury to the head, suffered from diplopia and vertigo. The condition was one of muscular asthenopia. In this patient the muscles of the neck were in a state of tonic contraction and the head almost approxi- mated the shoulder. Suggestion made during hypnosis sufficed to remove the diplopia after a single seance and when corrected the head was again held in a normal position. Vertebral Adjustment ADJUSTMENT OF MUSCLES. 1. Pressure with quiet and slight rotation usually in a direction at right angles to that of the muscular fibers. 2. Relaxation is attained by stretching the muscle with the object of separating the origin and insertion of the muscle. 3. By approximating the origin and insertion of the muscle. The foregoing methods are infrequently employed alone, but are usually used in combination. ADJUSTMENT OF CERVICAL VERTEBRAE. 1. With the patient in the recumbent posture, the physician at the head of the table grasps with the fingers of each hand the tissues along the region of the arches of the vertebrae with the thumbs on the transverse processes; the lesion is exaggerated by pushing with the left hand directly to the right the tissues overlying the lateral arches; simul- taneously the patient's head is forced against the abdomen of the physician to steady the movement. Next, reverse pressure is applied over the right lateral arch and rotation is achieved by movement of the hands and body of the physician. 2. With the patient in the same position as in the fore- going method, pressure is effected after the same manner but the fingers on one side and the thumb on the opposite side grasp the postero -lateral arches and with the hand upon the crown of the head, manipulation is made for purposes of rotation. Pressure is made downward upon the head in the direction of the axis of the vertebral column so as to fully relax the muscles and other tissues. 125 S p o n d y I o the r a p y CONGESTION OF THE SPINAL CORD. According to some authorities, areas of vertebral tenderness are associated with congestion of the spinal vaso-motor centers. The pathologist, however, is unable to confirm this clinical observation. On the contrary, anemia does cause changes in the cell-bodies of the cord with degeneration. It is an undeniable fact that, any interference with the motions of the spine resulting from weakness of the spinal musculature is associated with venous stasis which must necessarily interfere with the nutrition of the cord. The spinal muscles in the lumbar region are supplied by the lumbar arteries and in the dorsal region by the intercostal arteries. Branches from these vessels enter directly into the spinal canal on a level with each vertebra. The SPINAL VEINS have no valves. The venous plexuses upon and within the spine are as follows : i . Those placeo on the exterior of the column (dorsal spinal veins;; 2. Those located in the spinal canal between the vertebrae and the membranes (meningo-rachidian veins); 3. The veins of the vertebral bodies; 4. The veins of the spinal cord (Fig. 39). DIAGNOSIS OF SPINAL DISEASES. In the differential diagnosis of spinal diseases the genesis of PAIN* and DEFORMITY must be determined. Inen ov>.- must decide if the membranes and spinal cord are implicated and also the character of the lesion. The following tables will aid in the differentiation of pain and deformity. *Vide backaches and lumbago (pages 83 and 99). Spinal Veins FIG. 39. The upper figure represents the transverse section of a dorsal vertebra showing the spinal veins. The lower figure is a vertical section of two dorsal vertebrae showing the spinal veins. 127- S p o n d loth r a p y PAINS. DISEASE. ANEURISM (thoracic). COMPRESSION MYELITIS. HEP-JOINT DISEASE. CONCOMITANT SYMPTOMS. Sharp paroxysmal lancinating pains when the aneurism erodes the vertebrae. Pain radiates down the left arm, to neck and up- per intercostal nerves. Also anginoid pains. Signs of intra- thoracic pressure. In spinal curvature, dislocation of the heart may cause displacement of the aorta, causing the latter to pulsate to the right of the sternum. Nerve-root symptoms. Radiating pains, anesthetic areas, trophic disturbances and atrophy of the muscles. Cord symptoms. Cervical reigon Retropharyngeal abscess, spasm of the cervical muscles, dilatation of the pupil and unilateral flush- ing or sweating. Thoracic region. Paraplegia of the spastic type (exaggerated reflexes) and when the com- pression is complete (rare), re- flexes are abolished. Lumbar region. Paraplegia with implication of the sphincters. Often confounded with lesions of the lumbar region. Pain in hip, front of thigh, or at inside of knee. Limitation of motion of the hip-joint, unilateral atrophy of the muscles (especially the adductors) , lameness, swelling 128 Spin a a n DISEASE. INTRASPINAL TUMORS. LATERAL CURVATURE. LEUKEMIA. LUMBAGO CONCOMITANT SYMPTOMS. confined to the front and back of hip-joint and attitude of limb (abducted and everted). Symptoms vary with the segment involved. Radiating pains from the level of the lesion. Usually paralysis of the leg on one side and sensory disturbances on the opposite side and jerking move- ments of the lower extremities. A radiogram may show infiltra- tion of the vertebrae by the growth. At the level of the growth, pressure at the side of the spinous processes may elicit the pains felt by the patient. Severe cases in the lumbar region may simulate malignant disease of the spine. The latter is ex- cluded by the long duration of the disease absence of cachexia, presence of compensatory curves and the unilateral deformity. The sternum and spinal column are exquisitely tender on pres- sure. Usually occurs after a sudden muscular effort in a gouty or rheumatic subject or after ex- posure to cold or wet. Patient usually in excellent health and pains yield as a rule to treat- ment. Lumbago resisting treat- ment may be symptomatic of an organic lesion of the spine (Pott's disease, tumors). 129 Spondylotfi r a p y DISEASE. LOCOMOTOR ATAXIA. NEUROMIMESIS (Hysteria). OSTEOARTHRITIS. OSTEOMYELITIS. PLEURODYNIA (Muscular rheu- matism of the intercostal mus- cles, pectorals and serratus magnus; . SCIATICA. CONCOMITANT SYMPTOMS. Lightning pains usually of a few seconds duration are most com- mon in the legs and about the trunk. History of syphilis, ataxia, absence of knee-jerk, Argyll-Robertson pupil and sen- sory disturbances in the legs. The spinal symptoms (spinal irri- tation) of hysteria and neuras- thenia may simulate locomotor ataxia. The spinal tenderness is general, the pains are fugitive and evanescent and are not limited to definite anatomic ter- ritories. The patients are usually women and the history is corrob- orative. Vide spondylitis deformans (page 1 06). Local symptoms of swelling and rigidity of the spine, constitu- tional symptoms of sepsis, sudden in onset and suppuration always occurs. Usually second- ary to some distant suppurative focus. Pain usually on left side and accen- tuated by breathing and cough- ing. Affected muscles painful on pressure. Often mistaken for pleurisy and intercostal neural- gia (page 1 86). A bilateral sciatica is always sug- gestive of a cord-lesion, notably pressure on the nerve-trunks of the cauda equina. Sciatica is 130 S p in a I D eformity DISEASE. SPINAL MENINGITIS. DISEASE. ACROMEGALY. ANEURISM. r^QNDRODYSTROPHIA rickets). CONCOMITANT SYMPTOMS. often secondary to a chronic arthritis of the spinal column and may be unilateral in the lumbo- sacral roots in Pott's disease. The root-pains are often con- founded with Pott's disease. In the latter disease, the root-pains are relieved by rest and accen- tuated by movement and the erect posture. In meningitis, there is a lymphocytosis of the cerebro-spinal fluid, whereas in Pott's disease (tuberculosis out- side of the membranes) the fluid is normal. DEFORMITY. CONCOMITANT SYMPTOMS, This dystrophy manifested by hypertrophy of the bones of the face and extremities is charac- terized by kyphosis. Deformity due to eroding into the bodies of the vertebrae occurs late in life and other symptoms of aneurism co-exist. (Fetal MALIGNANT SPINE. DISEASE OF THE OSTEOMYELITIS (.vertebral). Rigid kyphosis without spasmodic muscular contraction. Deform- ity of the chest and premature ossification of the epiphyses of extremities. Deformity absent or rounded with- out bursa. No suppuration, rapid course, cachexia, severe localized pain and paraplegia. Acute onset, rapid suppuration, constitutional signs of sepsis and rigors. S p o n d y I o the r a p y DISEASE. FACET'S DISEASE (Osteitis defor- mans) . POTT'S DISEASE (caries). CONCOMITANT SYMPTOMS. The dorso- cervical kyphosis is associated with forward projec- jection of the hea,d, prominent clavicles, triangular-shaped face and shortening of the stature. Kyphosis is sharp and angular and usually gradual in development with muscular rigidity of the spine. Kyphosis as a rule, when not due to caries, shows soft erector spinae muscles and the absence of pain on concussion trans- mitted to the back. PULMONARY OSTEOARTHROPATHY Kyphosis may be present. En- (Hypertrophic). largement of the articular ends of the bones, enlarged terminal phalanges and incurvation of the nails. Usually associated with i : pulmonary diseases. RICKETS. SCURVY (Barlow's disease). SENILITY. Kyphosis most pronounced in lumbar region and disappears in recumbency and suspension. Other signs: open fontanels, en- larged abdomen, rachitic rosary, enlarged epiphyses and deform- ity of the long bones, Kyphosis is not frequent in infan- tile scurvy and is associated with other joint-lesions, swollen gums, ecchymoses, swelling of the epi- physeal junctions and pain on moving legs and thighs. Kyphosis occurs in elderly persons from flattening out of the verte- bral discs from pressure 132 Compression Myelitis DISEASE. CONCOMITANT SYMPTOMS. SPONDYLITIS DEFORMANS (Rheu- Occurs late in life with stiffness matoid arthritis). and arching of the spine without kyphosis, muscular spasm and suppuration. SYPHILIS. Congenital and acquired syphilis by causing kyphosis may lead to the erroneous diagnosis of Pott's disease, but syphilitic and not tuberculous symptoms are present. COMPRESSION OF THE SPINAL CORD. (COMPRESSION MYELITIS). Spinal diseases may, or may not, be associated with interruption of the functions of the cord by slow compression. Among the causes of compression are the following : 1. Caries (Pott's disease). 2. Malignant growths (vertebral and retroperitoneal). 3. Aneurisms. 4. Syphilis. 5. Trauma. 6. Parasites in the spinal canal (echinococcus and the cysticercus). The symptoms of compression are : i. VERTEBRAL. Spinous processes tender on pressure, muscular rigidity of the spine and pain. The latter is accentuated when the spine is concussed or twisted. Kyphosis associated with vertebral disease is rarely the cause of compression, for the reason that the latter is more often the result of inflammation of the spinal meninges and the presence of inflammatory products between the involved vertebrae and meninges. The relation of the spinal cord to the surrounding structures is shown in Fig. 38. 133 S p o n d y I o t h e r a p y 2. NERVE -ROOT SYMPTOMS. Caused by compression of the nerve -roots as they emerge between the vertebrae and consist of pains in the region innervated by the nerves whose roots are compressed. Additional symptoms are : Sensory and trophic disturb- ances, herpes; and when the ventral roots are compressed, there is wasting of the muscles supplied by the affected nerves. 3. CORD -SYMPTOMS.* They are dependent on the region involved. i. CERVICAL REGION. Retropharyngeal abscess, spasm of the cervical muscles, dilatation of the pupils, unilateral sweating and flushing of the face and paralysis of all four extremities. ii. THORACIC REGION. Disturbances of sensation in the lower extremities, girdle sensations and pains in the course of the intercostal nerves and paraplegia (usually spastic) with exaggerated reflexes. iii. LUMBAR REGION. Paraplegia without exaggerated reflexes and involvement of the bladder and rectum. PARAPLEGIA. This is a symptom of many special diseases and may require a careful differentiation. Following a TRAUMA, it occurs almost instantly or it may be partial and in the course of a brief period it may be complete as a result of a de- structive hemorrhage or from additional laceration of the cord from a fractured vertebra. The paraplegia associated with the following affections demands differentiation : *The site of the lesion is easily determined (page 30). 134 Pa raplegia 1. Rickets. 2. Barlow's disease. 3. Syphilis. 4. Hysteria. i. RICKETS. The pseudo-paresis of this disease results from muscular weakness plus the pain caused by movements of the extremities. The muscles may atrophy from disuse, but there is no reaction of degeneration. The latter is also absent 'in cerebral paralyses but the reflexes are exaggerated and there are brain-signs and spasticity of the extremities. ii. BARLOW'S DISEASE (infantile scurvy). The pseudo- paralysis of this affection is likewise caused by muscular weakness and pain as well as by the subperiosteal extravasa- tion of blood which causes tenderness in the shafts of the bones. Scurvy and rickets may co-exist. In both affections the electric reactions are unaltered. In scurvy, antiscorbutic treatment (fresh cow's milk, meat -juice and orange-juice or lemon -juice) yields prompt results and, in this sense, it is equally diagnostic and curative. iii. SYPHILIS. In children there is a syphilitic pseudo- paralysis known as Parrot's disease, in which sudden loss of motion may occur in either the lower or upper extremities or both and is caused by a separation of the cartilage at the end of the bone. Crepitation and pain follow movement of the affected extremity. iv. HYSTERIA. The disturbances of motility are essen- tially paralyses of function or will-power. In one class of cases, movements like standing and walking are impossible, whereas all other functions may be executed by the same muscles. The reflexes are intact or exaggerated, the electric reactions are normal and there is no muscular atrophy. Symptoms of the bladder common in organic paraplegia are usually absent in the hysterical form. 135 S p o n d y I o the r a p y If the affected muscles offer any resistance to passive movements, it is suggestive of hysteria. HOOVER'S SIGN for the detection of malingering and functional paralysis of the lower extremities is as follows: In the norm, when a person lying on a couch on his back is requested to raise the right foot off the couch with the leg extended, the left heel digs into the couch as the right leg and thigh are elevated ; in other words, the left heel is used to fix a point of opposition. If a normal person is requested to press the right leg against the couch there will be a counter -lifting force shown in the left leg. This complemental opposition is present in the norm and in genuine paresis or paralysis (even though feebly expressed) but its absence in the malingerer and in hysteria signifies the existence of cerebral inhibition. The sign of Beevor 30 is based on the fact that, in func- tional paralysis the patient is unable to inhibit the antago- nistic muscles. This condition is often noted in the knee and for this purpose the patient lies with the face downward and the leg is put up at right angles to the thigh and the patient is directed to extend the knee against resistance. In the norm the hamstrings should be relaxed at once, but in functional paralysis these muscles can be seen and felt to contract along with the extensors. The limb must be fixed and prevented from moving, otherwise as the joint is extended or flexed, the antagonists may be passively drawn on and give the impression that their muscles are actively con- tracting. Anesthesia from the waist downward without involvement of the genitalia is usual. The latter condition may be reversed ; anesthesia of the genitalia, whereas the other parts may retain their sensibility. According to Kahane, neuroses are favorably influenced 136 Nature of Lesion by the high-frequency current, whereas hysterical subjects react unfavorably and new symptoms are added to the old ones even after a single application. In fact, latent hysteria has been detected after this manner. NATURE OF THE LESION. TUBERCULOSIS. Respecting the relative frequency of tuberculous joint - disease, the following statistics of Young 31 are apposite : Vertebrae 46.7 per cent. Hip 34.4 " Knee 12.2 " Ankle 5.1 Elbow 0.8 Shoulder 0.5 " Wrist c. 3 In etiology, a history of heredity is important. Acquired predisposition is developed in consequence of conditions which diminish resistance and predisposition to tuberculosis. Environment is a cogent predisposing factor. The absence of sunlight and fresh air predispose to infection. During the first decade of life, the bones, meninges and lymph-glands are more frequently involved. A surgical operation may convert a localized into a generalized tuber- culous process, notably, acute miliary tuberculosis. As a rule, practically all tuberculous joint-lesions are referred to some injury and all authors agree that only mild injuries result in tuberculosis. In severe traumatism, the process of repair is so active that the tubercle bacilli are destroyed. Experiments by inoculation confirm the latter clinical observation. Thus Krause, after inoculating animals with tuberculous material and then contusing the joints, obtained typical joint-lesions. 137 Spondylotherapy If, however, the traumatism were severe there was no second- ary involvement of the joint. Tuberculous involvement of the vertebrae usually occurs during childhood (before the age of 14 years). Several joints may be simultaneously involved in tuber- culosis, notably, the hip and spine and the knee and spine. Asthenia, fever, night-sweats and emaciation are the characteristic symptoms of tuberculous infection. The x- rays may prove of some value in early diagnosis, but as a rule, the skiagram only demonstrates lesions which have at- tained some magnitude. Respecting the diagnosis of tuberculous lesions by aid of TUBERCULIN, the latter can only prove of value as a negative test (showing the absence of tuberculous foci in the body) and rarely as a positive test, owing to the fact, that vertebral involvement is usually secondary to a tuberculous lesion elsewhere in the body. The reaction with tuberculin is based on the fact, that in tuberculosis the tissue-cells develop a hypersensitiveness to the poisons of the tubercle bacillus (oiler gistic reaction}. In cachectic individuals, in acute tuberculosis, and in all those far advanced in the disease, tuberculin tests are usually negative owing to the fact, that the organism is so over- whelmed by the poisons that it is unable to react. The tuberculin test may at first be negative, but when repeated it is positive. In such instances it is assumed, that there are latent tuberculous foci which have not been in contact for a long time with the poisons of the tubercle bacillus and that the first test stimulates immunization which favors a reaction when the subsequent test is applied. A positive reaction with the subcutaneous method is obtained in from 50 to 80 per cent of clinically healthy individuals. In the presence of fever, the cutaneous or conjunctival 138 S y p h i I i s method is preferable to the original hypodermic method. In the latter the puncture -reaction (red area of infiltration, edema and pain at point of puncture) is even more diagnositc that the febrile reaction. The MORO TEST is harmless and consists of rubbing into the unbroken skin of the abdomen a mixture of equal parts of tuberculin, (old) and anhydrous lanolin. The rubbing should continue for about two or three minutes. The reaction, if positive, is manifested in from 1 2 to 48 hours after the inunction by small papules and redness of the anointed area. The latter reaction is fairly reliable. The presence of tubercle bacilli in the circulating blood in tuberculosis, demonstrable after the simple method of Rosenberger, 33 may prove of greater value in diagnosis than the tests with tuberculin. Many authorities, however, have been unable to confirm the observations of Rosenberger. Snow, finds that the employment of the static current gives prompt relief in non-infected joint-conditions, but produces negative results or aggravates the condition in tuberculous infections. SCROFULA is an attenuated tuberculosis of the lymph - glands and practically in all cases of acute tuberculosis the source of infection is from unhealed foci in lymph -glands (tuberculous adenitis). SYPHILIS. Tardy hereditary syphilis of the bones may occur in adults, but is most frequent between the ages of 6 and 10 years. The pains of this affection may be regarded as rheumatic and the associated syphilitic fever may suggest typhoid fever. The bones of the extremities are notably involved, usually at the shafts or in juxtaposition to the articulations, and swelling and deformity ensue. The tibia is most frequently 139 S p o n d y I o therapy implicated, resulting in a forward projection of the bone (saber-bladed deformity). The surface of the bone may show irregularity due to the presence of nodes. Syphilis of the spine resembles Pott's disease. The following signs of congenital syphilis suggest the diagnosis : 1. Nasal catarrh (snuffles). 2. Depression at root of the nose. 3. Cutaneous lesions. 4. Fissures at the angles of mouth (rhagades). 5. Alopecia (hair of head and eyebrows). 6. Tardy development (infantilism). 7. Deformed teeth. 8. Interstitial keratitis. 9. Ear-affections. The therapeutic test is fairly conclusive if employed with circumspection. Here nutrition must be maintained to get the best results. Syphilis with lesions of the bones responds favorably to Gibbert's syrup : Biniodid of mercury i grain. Potassium iodid \ ounce. Water 2 ounces. Dose. Five to ten drops three times a day gradually increased and continued for months. The Wassermann reaction is extremely valuable in the diagnosis of syphilis, but the reaction is too complicated for the practitioner and in consequence has been supplanted by the simplified method of Noguchi 37 : To o.i c. c. of spinal fluid in a tube of not over i cm. diameter, add 0.5 c. c. of 10 per cent butyric acid ; heat till bubbling and while hot add i c. c. of 4 per cent sodium hydrate solution. The fluid be- comes flocculent in a few moments, whereas normal fluids are only opalescent or cloudy. 140 Rheumatism GONORRHEA. Many obscure bone -lesions incorrectly diagnosed as rheumatism owe their origin to the gonococcus, the result of systemic gonorrheal infection. Gonorrheal arthritis is characterized by involving joints which are not usually implicated in acute rheumatism, viz., sacro-iliac, intervertebral, temporo -maxillary and sterno- clavicular articulations. A history of gonorrhea suggests the character of the lesion. The employment of a gonococcic vaccine 34 promises to prove of diagnostic value in gonococcic infections. The gonococcus reaction usually appears in from 8 to 12 hours after the injection and lasts about 24 hours. The most con- stant feature of the reaction consists of an increase of pain and tenderness in the affected joints and a slight pyrexia following the injection. It is well to recall the remarkable cures of gonorrheal arthritis reported by Fuller, who insists that the infectious material is derived from a gonorrheal vesiculitis and by opening and draining immediate relief of the arthritis occurs. RHEUMATISM. An acute arthritis deformans may be mistaken for acute rheumatism and the diagnosis is often established when the affection has lasted for weeks and with subsidence of the fever, periarticular indurations and deformities persist. Implication of the smaller joints and the early deformities exclude acute rheumatism. An acute osteo -myelitis may also be confounded with rheumatism, but the following signs are characteristic of osteo-myelitis : 141 Spondyloth e r a p y 1. It is most common in infants or children, i. e., during the period of active growth of bone. 2. Severe constitutional symptoms of septic absorption. 3. Involvement of the epiphyses rather than the joints. 4. The condition is sudden in onset and pus forms rapidly. 5. In osteo-myelitis of the vertebrae angular deformity is rare (differentiation from Pott's disease). The use of salicylates is a valuable aid in diagnostic pharmacotherapy. Failure in the treatment of rheumatism with the salicylates frequently results from their faulty administration. The usual doses are absolutely inadequate. If sodium salicylate is given at regular intervals until its physiologic action is manifested (tinnitus or deafness), then stopping its use and resuming it when the latter have abated, usually on the second day there is a decided fall of temper- ature and relief from pain in acute rheumatism. The joint- swelling usually disappears by the fourth day. McCrae and Clarke have directed attention to the diag- nosis of various forms of arthritis by the use of salicylates. The true rheumatic can tolerate from 150 to 300 grains of sodium salicylate before toxic symptoms occur, whereas in other forms of arthritis such symptoms develop after smaller doses. Thus in gonococcic arthritis, the average amount to produce toxic symptoms was 131 grains. In true rheumatism, the fever, pain and swelling disappear in two or three days, whereas in other forms of arthritis, while the temperature may fall to normal, there is no change in the swollen joints. Doctor Lees, in a paper contributed to the Proceedings of the Royal Medical Society, also believes, that in most instances where the salicylates fail to relieve arthritis, the condition is not one of acute articular rheuma- tism but of some other form of infection. 142 Rheumatism in children is unattended by typical joint - symptoms and a heart -lesion may be the only manifestation of the disease. The following signs may also suggest the disease in children: tonsillitis (initial symptom), growing pains, chorea, myalgia, pleurisy, frequent attacks of bron- chitis and anaemia. In children the salicylates must likewise be given in large doses: For a child of from 7 to 12 years, from 10 to 100 grains daily, and for a child under 7 years, from 5 to 50 grains daily, with twice the amount of sodium bicarbonate in each case. The latter drug is employed to counteract the toxic symptoms of the salicylates. In all cases when the salicylates are given in large doses one must care- fully watch for the development of drowsiness, acetone odor of the breath and disturbances of tke respiration. RICKETS. The associate symptoms of this affection are diagnostic ; 1. During incubation, local sweatings (head and neck) and nocturnal fever preceding the period of bone-change. 2. Deformation of the bones is marked by hyperesthesia or tenderness of the latter and pain on voluntary movement. 3. Deformity of the thorax; changes in the epiphyseal junction of the ribs (rachitic rosary, characterized by a series of bead -like enlargements) ; pigeon-breast or chicken -breast. 4. Deformity of the spine, exaggeration of the normal curves, scoliosis and lordosis, which are accentuated by the large size of the abdomen. 5. Deformity of the head: oblong or square head, anterior fontanel open (closed in the norm about the i8th month); softened spots in the occiput (cranio-tabes), early decay of the teeth and retarded cerebral development. 6. Deformity of the extremities : an increase in the size of the epiphyses (wrist, elbow, ankle, knee) which suggests 143 S p o n d y I o the r a p y a joint (hence the popular expression "double-jointed") and bending of the long bones. Recovery may occur within a few months, the bones remaining thick and hard with firm and short muscles and partial disappearance of the deformities. SPINAL MENINGITIS. A chronic meningitis may be confounded with a tumor of the spinal cord or disease of the vertebral column and Horsley 35 has seen a number of such cases which he has treated by laminectomy, opening the theca and washing it out with a mercurial solution. The cases occur most often in adults with syphilis or gonorrhea as possibly efiologic factors. In differential diagnosis the following points are of value : A tumor of the cord exhibits pain usually localized to one nerve-root, but in meningitis, the pains spread gradually to the front and back of the thigh and cause painful cramping and twitching of the muscles of the right leg. Other signs are tightness and numbness of the thigh and a progres- sive loss of power in the legs eventuating in a progressive paraplegia. 144 Abdominal Supporters CHAPTER V. GENERAL SPONDYLOTHERAPY. ABDOMINAL SUPPORTERS ACUPUNCTURE COUNTERIRRITATION ELECTROTHERAPY EXERCISES RE-EDUCATION OF CO-ORDINATED MOVEMENTS SPINAL HYDRO-THERAPY LUMBAR PUNCTURE MASSAGE PStfCHROTHERAPY THERMOTHERAPY VIBRATORY MASSAGE. ABDOMINAL SUPPORTERS. Reduced intra-abdommal tension conduces to a condition described by the author as intra-abdominal insufficiency, and the latter contributes to a group of symptoms made up of backache and neurasthenia. Minor grades of insufficiency may be detected by the following signs, which the writer has described more fully elsewhere: 38 first, auscultate the heart -tones, palpate the pulse, determine blood -pressure and define by percussion the borders of the heart and the upper border of the liver while the patient is standing. Next, direct an assistant standing behind the patient to firmly and forcibly lift the abdomen, exerting the pressure in a direction upward and inward. While the latter pressure is maintained, the foregoing methods of examination are again executed and if abdominal tension is reduced the following are noted : the heart-tones become stronger, the pulse fuller, the blood -pressure augmented from 5 to 30 mm. and the percussion areas of the heart and liver become higher and more pronounced. The heart is prolapsed (cardioptosis) as well as the liver in diminished abdominal tension. The author has frequently noted a systolic aortic murmur when the abdomen was pendulous which disappeared during 145 S p o n d y I o the r a p y the time the abdomen was raised by an assistant and re- appeared when the abdominal wall was dropped. This murmur is probably caused by traction on the aorta by a prolapsed heart, the result of an intra-abdominal insufficiency. Many of the local symptoms of reduced abdominal tension are at once relieved by raising the abdomen in the manner suggested and if an abdominal support is employed, its value may be tested by noting the effects on the pulse, blood - pressure and position of the heart before and after its application. Those who object to mechanic supports will find in the method of Kellogg, an excellent means of strengthening the abdominal muscles and thus securing a natural increase of intra-abdominal tension; the electrodes of a sinusoidal cur- rent are placed on either side of the spine about four inches apart and just below the inferior angles of the scapulae. When the current is sufficiently strong, all the abdominal muscles will be thrown into vigorous contraction. ACUPUNCTURE. The author has already portrayed his conception of many diseases as expressed in the antagonism of muscles (page n). This theory is in accord with our percutaneous methods of treatment and refers with special cogency to spondylotherapy. In the foregoing pages the following fact has been elaborated, viz., that throughout the spinal region one may arouse definite reflexes and that every reflex has its counter-reflex. Thus our therapy by peripheral methods resolves itself into the following: either an abnormal reflex is inhibited or it may be antagonized by a counter- reflex. In a word, peripheral stimulation signifies irritation of centrifugal or centripetal nerves. In arousing the former 146 Acupuncture to activity we stimulate motor, secretory, trophic, inhibitory and thermic nerves, whereas stimulation of the centripetal nerves predicates an. action on the reflex -motor, reflex- secretory and reflex -inhibitory nerves.* Lumbago (myalgia lumbalis), may be confounded with many reflex troubles and affections of the vertebral column. If the lumbar pains originate in the muscles alone, acupunc- ture, by its almost miraculous curative action, is diagnostic of lumbago. The method may be made painless by local anesthesia before ordinary sterilized bonnet -needles are forced into the painful points of the lumbar muscles and allowed to remain for about ten minutes. It may be necessary to repeat the manceuver. A number of smaller needles may be passed through the skin into the muscular tissue. The method is equally efficacious in the treatment of myalgias elsewhere and appears to be more successful in those who have bilateral pain. Sir James Grant supposes that the needles set free an excessive storage of electricity which has accumulated in the muscles. An intramuscular injection of morphine (1-6 grain) and- atropin (1-60 grain), or a few minims of chloroform, may also give immediate relief, but here it is difficult to differentiate the action of the medicament and the acupuncture. *The excitability of certain nerve-centers is diminished by calling other centers into action. Franck, in the "Dictionnaire Encyclopedique des Sciences Medicales" observes, that when one considers the normal functions of the nervous system, one finds that there exists a necessary equilibrium between the different parts of this system. This equilibrium may be destroyed by the abnormal pre- dominance of certain centers which seem to divert to their own advantage too great a proportion of the nervous activity; thus, the functions of the other centers appear to be disturbed. The ankle-clonus depends on an exaggerated excitability of the calf muscles. If now, I excite with the sinusoidal current the spinal segment (page 30) presiding over the muscles which antagonize the calf muscles, for a time, at least, the ankle-clonus can no longer be elicited. This method has been employed successfully by the author in overcoming spasms of definite groups of muscles. 147 S p o n d t h r a p y COUNTERIRRITATION. Counterirritants are valuable agents for the relief of pain if applied in correct situations. As we will notice in the subsequent chapter on PSEUDOVISCERAL DISEASES, the pains usually experienced in the thoracic and abdominal walls are Phthisis. Pericarditis or pleurisy. Flying blister or sina- pism, in pleurisy or pneumonia. Vomiting. Chronic thickening after perityphlitis. Acute rheumatism^ Laryngitis, hysteric aphonia. Pericarditis. Ovarian irritation. Gout. FlG. 40. Diagram of the body showing some of the areas where counterirritants are usually applied. Front view. pains referred to the periphery, whereas the actual site of the lesion is alongside of the spine at the vertebral exits of the affected nerves. It is evident then, that if the counter- irritant is applied at the point where the pain is felt rather than at the site of the lesion, no result is achieved. It was the custom of Trousseau to trace a neuralgia along the course 148 Co u n t'-tr irritation of a nerve to the spine from which it made its exit, at which site the painful point was blistered. In diseases of the hip, pain is felt in the knee, yet the Epistaxis, cerebral con- gestion, 'delirium, and tendency to coma, or constant . wakefulness, in fever, headache, gid- diness, tinnitus au- rium. Hemoptysis. Intercostal neuralgia. Rheumatic gou Headache, giddiness, tin- nitus aurium, ophthal- mia. Flying blister or sina- pism, in pleurisy or pneumonia. Dysmenorrhea, spinal ir- ritation, leucorrhea. Sciatica. Sciatica. FIG. 41. Diagram of the body showing some of the areas where counter- irritants are usually applied. Back view. counterirri tantj to be effective, must be applied to the hip. Insomuch as counterirritants achieve their analgesic effects by influencing the distribution of blood in a part either reflexly through changes in the caliber of the vessels or by anemizing the morbid structures, leeching and cupping may, in many instances, achieve like effects. It may be necessary in some instances to accentuate counterirritation and for this purpose an escharotic or :he actual cautery is used. 149 S p o n d y I o t h e r a p y The observation of Head (page 58) shows that the vis- cera and definite areas on the surface of the body receive their nerve -supply from the same segment of the spinal cord and that irritation of the one reacts favorably upon the other. It will be noted in the accompanying figures (40 and 41 ) from Brunton, that the areas established empirically for applying counterirritants to influence the viscera nearly correspond to the dermatomes of Head. Nothing in my experience equals freezing (vide psychro- therapy) for the purpose of counterirritation in spondylo- therapy and for this reason, I employ freezing to the exclusion of all other methods. Cantharides is the usual vesicant employed, although many preparations on the market are useless. Before apply- ing cantharidal collodin or a plaster, wash with soap and water and then dry the skin thoroughly with alcohol and if a plaster is used, moisten it with a few drops of acetic acid. Vesication occurs in about eight hours. At the end of that time, carefully remove the plaster to avoid rupturing the bleb and puncture the latter at its most dependent part with an antiseptic needle and dress with dry absorbent cotton. After the latter fashion the skin rapidly forms under the blister. If the latter is broken, sprinkle the surface with orihoform, which renders the healing painless. Cantharides is readily absorbed from the skin and toxic symptoms (strangury, priapism and nephritis) may follow, hence blistering must be achieved with other drugs. Methyl iodid has no unpleasant action on the urinary organs. About 15 to 30 drops of the liquid is poured on a piece of blotting paper which has been cut to the desired size and then fastened to the cleansed skin by adhesive plaster. Blisters appear in from 3 to 18 hours. A blister may be produced in several minutes by saturat- 150 Electro t h e r a p y ing a piece of lint with chloroform and after its application covering it with oiled-silk or a watch-glass. Equal parts of lard and ammonia will blister in about five minutes. ELECTROTHERAPY.* It is yet customary to regard the results obtained from electric treatment as dependent on suggestion. Mcebius tells us that four-fifths of all electric cures are dependent on mental influence. Even Beard, who, in his time, was one of the leaders in electrotherapeutics, is quoted by Kellogg as saying : "If you expect to get definite results from electrical applications, you must be sure that your patient has faith, otherwise the application will do him no good." Electrotherapy is now founded on a scientific and, what is more important, a utilitarian basis. All currents do not show the same physiologic and therapeutic effects any more than do the various alkaloids derived from opium, although the same plant is the common source of all. The discovery of the SINUSOIDAL CURRENT is accredited to D'Arsonval, although Kellogg's description of the current in 1888, pre- ceded the publication of the former. The sinusoidal current does not produce the unpleasant and painful effects of the Faradic current and is decidedly more effective for the average therapeutic purpose than is the Galvanic current. The Faradic current is alternating in character in which the break in the direction of the current occurs at the maximum point of intensity. The Galvanic current is continuous and any change in the direction or in the interruption of the current is a sudden break associated with a painful shock. *Only the sinusoidal current will be described, as it is used by the author almost exclusively in the diagnosis and treatment of spinal diseases. 151 S p ondyloth e r a p y The preceding conditions with the sinusoidal current do not exist. It is probable that the rapidity of alternations is so great that the sensory nerves fail to appreciate the im- pressions of such high frequency. The current gradually rises from the base line, zero, to the maximum, then equally gradually returns to zero, then likewise rises to the maximum in the opposite direction, and returning to zero repeats the rhythm at the rate of many thousand alternations per minute (Fig. 42). FIG. 42. A true sine curve from which the sinusoidal current obtains its name. The length of the sine being from points i to 2, which is one complete cycle and two complete alternations. In what is called the 60 cycle current, which goes through this change sixty times per second, this distance from i to 2 repre- sents one-sixtieth of a second and in the 125 cycle variety, 1-125 f a second. These currents are sometimes spoken of as having 7,200 and 15,000 respectively* alternations per minute, since there are, of course, two alternations (one each way) in each cycle and 60 seconds in a minute. The distance of this curve above or below the horizontal neutral line represents at each instant the potential or degree of polarity at that point, the points above the line being positive and those below negative, and this degree of polarity determines the strength of the current at that instant and the direction of its flow. Many of the sinusoidal apparatuses on the market are such in name only and do not achieve the results cited in this work. With the original Kenelly machine, one could obtain a frequency up to 150,000 alternations per minute. The latter machine is, however, too expensive for general use and with less costly apparatus equally efficient results can be attained. The author's (Fig. 43 ) apparatus is simple in construction 152 E I troth r a p y and has, therefore, few of the faults of more complicated machines. By screwing the plug attached to the cord into a lamp- socket, it is ready for use. The number of alternations is FIG. 43. The author's sinusoidal apparatus. determined by a rheostat and varies from 2,000 to 20,000 per minute. It is especially constructed for the direct street - current, although it can be made available for the alternating current. With an alternating current -supply only, the value 153 Spondyloth a p y of the current obtained is very much restricted. The Galvanic current may also be obtained from the same apparatus. Doctor J. H. Kellogg's sinusoidal apparatus* (Fig. 44) embodies Kellogg's discoveries and is a very efficient appara- tus for obtaining sinusoidal effects. It is provided with a finely graduated rheostat, by means of which the powerful FIG. 44. Sinusoidal apparatus of Dr. J. H. Kellogg. currents generated may be reduced to the smallest require- ment. It consists essentially of a specially constructed magneto -generator operated with an electric motor. A slowly alternating current designated as SS (slow sinusoidal), is usually employed for muscular effects, and the rapidly alternated current RS (rapid sinusoidal), is used to induce powerful tonic contractions and to secure analgesic action or other nerve-effects. Another efficient apparatus (Fig. 45) for sinusoidal purposes is the outfit made by the Victor Electric Company of Chicago. In the multiplex outfit of the latter company one can adequately control the length of the sine wave and the voltage as well. The apparatus can be attached to any *Made by the Modern Medicine Company, Battle Creek, Michigan. 154 E I r o a p y electric -light socket and it is calculated for the direct current. It is also supplied for connection to the alternating current, but when employed in this way its value is very much restricted. When the Victor apparatus is employed for eliciting the vertebral reflexes, the author suggests only the employment of the rapid sinusoidal current. FIG. 45. Sinusoidal apparatus made by the Victor Electric Company. DIAGNOSTIC AND THERAPEUTIC APPLICATION OF THE SINUSOIDAL CURRENT. This subject will be discussed in detail in special chapters devoted to visceral diseases. One of the most important properties possessed by this current by its cutaneous appli- cation alone, is the powerful and demonstrable action on the internal organs. Thus, with one electrode at an indifferent point (the author prefers the sacral region), and the other over the regions of the various organs, visceral reflexes may 1S5 Spondyloth r a p y be elicited. If both electrodes are applied to the abdomen it reduces intra -abdominal congestion. By aid of this current, as will be demonstrated later, toxic intestinal and hepatic products are brought to resorption and excreted in the urine. The various vertebral reflexes (page 7) can be elicited by this current, but for therapeutic purposes, concussion (page 175) often exceeds it in value. The current has a specific action in hyperesthetic con- ditions whether superficial or deep-seated, and is of all FlG. 46. Interrupting electrodes. currents the most available for inducing analgesic effects. It is very often the most efficient current for developing weakened muscles and not infrequently it will provoke muscular contractions in degenerative lesions when Faradism produces no response. In applying this current for diagnostic and even for therapeutic purposes the moistened indifferent pad (usually large) is placed over the sacrum, whereas the interrupting electrode (Fig. 46), which permits one to close and open the circuit, is placed over specific regions. To induce muscular contractions it is not necessary, as in the use of other currents, to find the motor points (points of greatest excitability). To obtain the maximum contraction of the muscles of the back, the latter must be relaxed. 156 E I t h a p y To excite the muscles of the back for diagnostic or develop- mental purposes strong currents must be used. Referring to Fig. 47, the effects of a strong sinusoidal current are noted FIG. 47. Muscles of the back showing Triangle of Petit (shaded triangular area). The trapezius retracts the scapula and braces back the shoulder; when the head is fixed, the upper part of the muscle will elevate the point of the shoulder (electromotor point, E.M.P., A), whereas the lower fibres depress the scapula (E.M.P., B) ; with fixed shoulders, action of one trapezius will draw the head to the corresponding side (E.M.P., C). The latissimus dor si when the arms are fixed raise the lower ribs and assist in forcible inspiration (E.M.P., D). Application of the electrode at any of the points marked E, E, E, will accentuate the lordosis in the lumbar region and, at F, on the right side, scoliosis is produced to the left side, and, at a corresponding point on the left side, scoliosis to the right side. By marking the tips of the spinous processes or by noting the spinal furrow, the scoliotic changes are best observed. G, electromotor point which causes an approximation of the scapula to the spine. when one pole is applied over the sacrum and the interrupting electrode is placed at various points indicated by circles. The effects of this current can be more easily demonstrated 157 S p o ndylotherapy if the spinous processes are marked with a pencil, thus indi- cating any deviation of the vertebral column. Changes in the curvature of the spine are naturally less evident in adults than in children. This current is specially indicated when the development and strengthening of the spinal muscles are the objects in view. Here the electrodes must be placed at corresponding points on either side of the spine so that the muscles on one side should not exceed in development or strength the muscles on the other side. By inducing the central reflexes (page n), a symmetrical development is easily achieved. A backache is very frequently a weak back ; the muscular tire graduating into pain and here the remedy is muscular development. It is difficult to devise any exercises which will bring into action the thirty-one muscles of the back which are sub- divided into five layers. Not infrequently, the so-called uric-acid diathesis is a localized intoxication ; the unused muscles favoring the pre- cipitation of uric -acid or other products of defective meta- bolism and creating what is popularly called "stiff-back." To destroy such products, it is necessary to bring a greater supply of blood to the parts, for more circulating blood means more oxygen and more oxygen means better nutrition. Sinusoidalization of the muscles of the back is more efficient than any exercises. The author has investigated the output of urea before and after sinusoidalization of the muscles of the back in many cases of backache and noted the pertinent fact that, as a rule, there was an augmented excretion of urea after sinusoidalization. Voit has shown that work does not increase the elimination of nitrogen by the urine, hence the increased output in my cases was due to the removal of urea stored up in the muscles. 158 Exercises It is evident to the reader that in the event muscular rigidity is present, muscular contraction is less readily elicited by the current than when the muscles are relaxed, hence in this respect, the current subserves a diagnostic use. EXERCISES. About one -half of the body -weight is dependent on the muscular system which, even in a state of rest, holds about one-quarter of the total quantity of blood When the muscles are in activity the amount of blood which they hold is very much augmented. Muscular exercises subserve the following objects : 1. They increase the frequency and amplitude of the respiratory movements. 2. By increasing pulmonary capacity they aid the work of the right heart. 3. By determining an increased quantity of blood to the muscles* certain congested areas are depleted.f 4. Waste-products are increased in the blood and there is augmented excretory activity of the kidneys, skin and lungs. In prescribing exercises, one must never forget their bane- ful effects on the nervous system when carried to excess. When a muscle is fatigued by voluntary contraction, it involves not only the muscle but the nervous system, and the latter to a larger degree than the former. It is erroneous to suppose that a healthy nervous system can be acquired by vigorous muscular exercises. The latter always means an expenditure of nerve -force which may, or may not, be beyond *Oliver has shown that the relative quantity of the corpuscles is increased in the blood of an exercised limb. tThe same author has demonstrated that while, after a period of rest, a relatively large amount of blood can be expressed from the abdomen into the systemic vessels, no such result can be attained by abdominal compression after exercises. 159 S p ondylotherapy the capacity of the individual. Many nervous wrecks are recruited from this fallacious argument. Spinal exercises achieve the following objects : 1. Increased flexibility of the spine. 2. Strengthening the muscles which hold the trunk erect. 3. Combating a faulty attitude. Supports and plaster-jackets in the treatment of curva- tures are only indicated in acute inflammatory affections of the bone. Otherwise they conduce to ankylosis in a deformed position with muscular atrophy from disuse. Impaired mobility of the spine is frequently the cause of distressing backaches, sciaticas and other affections. Here passive movements of the spine are often curative. The patient sits on the bed and the physician can repeatedly force the body forward or he can execute any degree of traction on the arms. Exercises for the muscles of the back are most often prescribed in the treatment of round shoulders and lateral curvature. ROUND SHOULDERS.* This condition is more frequently encountered in girls than in boys, owing to the fact that in the adjustment of clothes there is a drag upon the shoulders equal to several pounds on either side. Here, as Goldthwait suggests, the weight must be removed from the outer part to the inner or rigid part of the shoulder at the base of the neck. The patient should be taught to assume a correct position, chest- deformities must be corrected by breathing, gymnastics, and the following exercises recommended by Lovett are indicated : *Vide page 96. 160 E X 1. The patient hangs from a bar by the arms. 2. In the recumbent position, with a hard roll under the scapulae, the arms are extended and stretched and pulled above the head upwards and back- wards by an assistant. 3. The patient sits on a stool with the hands behind the head and the elbows squared; during the time the elbows are pulled backwards, the knee of the manipulator presses forward against the spine on a level with the shoulders. LATERAL CURVATURE. Here muscular exercises constitute the essential part of the treatment. At least one hour daily must be devoted to their execution, and as Robert Jones suggests, the arms should always be moved by direct muscular effort and not allowed to swing. Ridlon 49 employs the following exercises: 1. The patient lies upon her back upon a table of con- venient height, width and length. The Swedish table known as the plinth is perhaps the most con- venient. With her arms at the sides of her body, and the palms upwards, she breathes slowly and deeply ten times. In patients who present a pro- jection of the ribs below the breast, it is of advan- tage for the surgeon to make pressure downwards with his hands upon these projecting ribs as the patient takes a full breath. 2. The patient grasps a bar of steel shafting 3-4 ft. in length and 10-20 Ibs. in weight. With the elbows straight, she swings this from the thighs forwards and upwards above the head until the bar reaches the level of the table. From here she swings it downwards again to the thighs, and this is repeat- ed ten times. 161 S p ondylotherapy 3. The arms are then stretched directly outwards from the sides of the body, and in this position, as in (i), she breathes deeply ten times while the projecting ribs are held down by the surgeon. 4. Again, the iron bar is swung from the thighs to the table above the head and back ten times. 5. Then the arms are stretched upwards by the side of the head to the fullest reach, care being taken that the lower shoulder is raised as far as the other. The arms are held in this position, and the patient breathes deeply ten times, the ribs again being held down. 6. Then an iron bar of the same length, but double the weight of the former, is placed in the patient's hands as she lies upon her back, and she raises it directly upwards from the chest, fully straighten- ing the arms, and repeats the exercise ten times. 7. Still lying on the back, with the knee held straight and rigid and the foot extended, the patient circles the limb from the hip-joint, making as large a circle as possible with the foot ten times. Then the other limb is circled in the opposite direction ten times. 8. Still lying on her back with hands grasping the top of the table, both limbs are lifted, while the knees are held straight and the feet extended upwards to the fullest point, if possible to the vertical position, and repeated five times. 9. The patient then turns on her face, is pushed out so that the body extends beyond the end of the table by the surgeon, and she, holding the head and shoulders as high as possible, makes with her arms the motion of swimming, the forward stroke of which should be particularly vigorous. In this position ten strokes are taken. 162 E x 10. The patient is then pulled back upon the table, and lying face downward with the knee straight and the foot extended, she circles first one leg and then the other, making the largest possible circle with the foot, ten times. 11. The patient is again pushed out with the body beyond the end of the table, and with the arms in the key-note position, she bends the body down- wards and raises it upwards as far as possible. This is repeated five times. The key-note position consists of such a position of the arms as places the back in the straightest line. For an ordinary dorsal curvature with a convexity to the right, the key-note position consists of pushing the left arm as far as possible up beside the head and holding it there close to the ear, while the right arm is stretched directly outwards with the palm turned upwards; but the key-note position must be determined for each particular case. 12. With the patient again pulled back and lying com- fortably upon the table, she takes a 5-lb. dumb- bell in each hand, and swings them outwards and upwards, that is, backwards, as far as possible, ten times. 13. The patient, still lying on her face on the table, places her arm in the key-note position; then as she counts aloud one, two, the legs are held down, she raises the head and shoulders upwards and backwards as far as possible; then, counting three, four, she bends the head and shoulders as far as possible towards the convexity of the curva- ture; then counting five, six, she twists the head and shoulders around towards the side of the convexity, as if in an effort to look over the shoulder; then, counting seven, eight, she swings and turns back into the straight position from which she started, and this exercise is repeated five times. 163 S p o n d y I o t h e r a p y 14. The patient then sits astride the narrow end of the table, while the surgeon sits astride the table behind her, steadying her hips with his knees. Then, with arms in the key-note position and the spine as straight as possible, she bends forward from the hips freely, and then backwards against the resistance exerted by the hands of the surgeon. This is repeated five times. 15. Then, with the arms stretched out from the side, she twists the body freely towards the side of the concavity; then she twists backwards towards the side of the convexity against the resistance afforded by the hands of the surgeon, one hand resting against the ribs forming the convexity of the cur- vature at the back and the other against the ribs that are prominent below the breast in front. This exercise is repeated five times. 1 6. The patient is then bent backwards and to the side of the convexity of the curvature over the knee of the surgeon, so that her waist rests through the bulging ribs across his knee, while the shoulder on that side is twisted still further backward. In other words, the position assumed is the one, both as to flexion and rotation, which most nearly corrects or over-corrects the spinal deformity. Lying lax in this position, the patient breathes deeply ten times. In the early months of treatment greater improvement will be gained if the patient exercises in the prone position. Patients with lateral curvature are able to lie with the spine straighter than when they sit or stand, and the success of the treatment depends greatly upon making muscular effort while the spine is at its best. Klapp's "Creeping Exercises" are not only useful in scoliosis but are equally efficient in expanding the chest by mobilizing the thoracic vertebrae. 164 Re-Education of M ovements The patient kneels, the thighs perpendicular, the elbows bent so that the arms imitate the bow-leg position of the dachshund while the head is bent far back. The pelvis is thus above the shoulders and the thoracic portion of the spine is in lordosis; this position must be maintained during the creeping. The arm is advanced and stretched before the hand touches the floor. This hand then turns and the elbow is bent as the trunk is advanced until the upper arm forms a right angle with the trunk. The arm thus forms the axis over which the thoracic vertebrae are levered by the drawing forward of the other arm, the scapula of the supporting arm forming the fulcrum of the lever. This exercise loosens up the thoracic vertebrae and spreads the ribs apart, and corrects torsion of the spine if present. The thorax expands more, the more correctly the lordosis of the thoracic vertebrae is localized during the sideward bend. RE-EDUCATION OF CO-ORDINATED MOVEMENTS. In locomotor ataxia, co-ordination exercises are of great value in regaining control of the voluntary movements which have been lost. The exercises in question exert no effect on the lesions and the best results are attained when the motor tract is intact. It is not necessary to employ the apparatus 6f Fraenkel to achieve results; in fact, good results are equally achieved without apparatus. 41 In executing the exercises the following rules must be observed : 1. One must begin with simple exercises; first with the eyes open and later with the eyes closed. Each movement must be executed with precision. 2. Fatigue must be avoided, hence the exercises should be taken in the recumbent and later in the sitting and erect postures. Fatigue may be avoided by 165 Spondylotherapy counting the pulse which, when increased in fre- quency beyond the norm, indicates that the exercises must be temporarily suspended. At first the seances should not last longer than about ten minutes and later the entire exercises, includ- ing resting periods (to enable the pulse to become normal) should not exceed thirty minutes. 3. A trained assistant for supervising the exercises is equally as important as the patient's persever- ance. Respecting the nature of the exercises, each physician will suggest his own methods. After the patient succeeds in exe- cuting simple movements with his ataxic extremities, then walking exercises like the following are indicated : 1. Line- walking in a straight line. 2. Walking at a mark which is placed on a wall at a limited distance. 3. Obstacle-walking. By placing books on their long edges about 20 inches apart and then directing the patient to walk over them. 4. Stair-walking. Ascending and descending steps. SPINAL -HYDROTHERAPY. The spinal-coil has replaced the Chapman bags. The former consists of thin rubber tubes through which a con- tinuous current of water of any desired temperature is per- mitted to flow and is applied to the spine (never directly upon the skin) upon a thin moist compress. The bags of Chapman consist of the usual rubber bags (long and narrow) which can be filled with ice or water of any desired tempera- ture and are placed upon the vertebral column. Cold applied to the cervical spinal-region (used in asthma and cardiac irritability) has a primary stimulating action suc- ceeded by sedation. Cold applied to the lumbar spine, 166 Lumbar Puncture determines an increased flow of blood toward the lower extremities and the pelvic organs. Heat applied to the lumbar spine is said to diminish the flow of blood to the pelvic organs hence it is indicated in excessive menstruation. Cold applied to the entire spinal column reduces general reflex irritability and is employed in spinal neurasthenia. In the rational employment of hydrotherapy, heat or cold water must be applied by means of a douche to definite vertebrae to elicit specific reflexes. The author, however, regards electricity and vibra-massage as more convenient methods insomuch as the object to be attained irrespective of the method employed is to evoke definite reflexes. Win- ternitz suggests the use of cold water poured over the back of the neck for relieving nasal congestion. He ascribes the result to action on the vaso -motor center. Elsewhere (page 284), the author directs attention to a more certain and permanent method for achieving the same object. LUMBAR PUNCTURE. Lumbar puncture is usually made just below the tip of the fourth lumbar spine (fourth interlaminal space) with a sterilized needle about three inches in length attached to a syringe or with a small trocar and canula. If a horizontal line is drawn across the back on a level with the highest points of the iliac crests it will cross the spine at the level of the tip of the 4th lumbar spine. The patient should lie on the left side with knees drawn up and the trunk bent forward. The skin at the site of the puncture may be frozen. The physician places his finger on the tip of the 4th lumbar spine and introduces the needle half an inch below and to the right of the 4th lumbar spine, and directs it horizontally forwards and a little inwards until the arachnoidal space is reached. When the syringe is 167 Spondyloth e r a p y detached, the fluid escapes in drops and the amount per- mitted to escape at a single seance should not, as a rule, exceed 5 cc. Lumbar puncture is indicated for the relief of headaches of various origin due to augmented intracranial pressure. Thus, the pains secondary to herpes zoster have been relieved by the withdrawal of 20 cc. of fluid and it was therefore assumed that hypertension of the fluid existed. Vertigo and tinnitus dependent on increased pressure of fluid in the internal ear are likewise relieved. MASSAGE. The pressure exerted by massage influences all the tissues within its reach. It increases the power of endurance and abolishes fatigue. Experiments on frogs show that, after the muscles have been exhausted, their loss of vigor is soon restored by massage, whereas rest without massage has no effect. Massage increases the flow of blood and lymph. Brunton has shown that the blood passes three times more rapidly through a part while it is being masseed than when it is not. In many cases there is an increase in the number of red corpuscles and in the hemoglobin. Upon the nervous system, massage, if properly done, has a sedative effect. Therapeutically, massage accomplishes the following: 1. It assists the peripheral circulation and lessens the work of the heart. 2. In tissues accessible to manipulation if hastens the resorption of exudations and separates adhesions in joints and tendon-sheaths. 3. It augments the oxidizing powers of the blood, thus modifying disturbances in its composition. 168 Massage 4. By stimulating the sympathetic nervous system it promotes secretions and various reflexes, and thus gives relief in functional derangements. 5. By augmenting the flow of blood in the muscles it diminishes congestion of the viscera. 6. Wright has demonstrated that the effect of massage on an infected joint, by discharging a number of bacteria into the circulating blood, is to raise the opsonic index, after temporarily lowering it in in the first place. In the manipulation of joints any elevation of temperature signifies extreme caution in manipulation, in fact, any in- creased temperature is a centra-indication for the employ- ment of massage in affections of the joint. When it is a question between a functional and an organic joint -lesion the experience of the author shows that if fever follows passive movements of the joint it suggests an infectious lesion and the leucocyte count, as a rule, is increased. Dowse observes that ten minutes massage of the spine will increase the volume of the pulse and the temperature gen- erally more than one hour's work at the body as a whole, the spine being omitted. Fig. 48 demonstrates a series of visceral reflexes excited by deep pressure at the vertebral exits of the various spinal nerves. The foregoing figure has been elaborated after a series of very careful clinical observations by the author. Firm pressure is usually made with the thumb of one hand and it is indeed remarkable how, in many instances, the symptoms may be relieved and even cured by such deep and firm pressure over definite regions. It is evident to the reader that if such pressure is executed promiscuously, counter-reflexes are evoked which nullify the reflexes sought. In fact, the symptoms by such promiscuous manipulation may 169 S p o n d y I o t h e r a p y be accentuated. One may observe quite frequently that when pain due to a spinal neuralgia is associated with a point of vertebral tenderness, temporary inhibition of the pain may be achieved by deep pressure on the sensitive vertebral area and, in this respect, pressure may accomplish in an emergency almost as much as psychrotherapy. If the pains are of visceral origin and are associated with a point of vertebral tenderness, pressure upon the latter point is decidedly less BIGHT LEFT corvtractio right lim Cardiac inhibition enlargement of liver. - Contraction of. intes- tine and ine liver. Contraction left lung. "Contraction of heart ana aorta. .Cardiac inhibition. Dilatation left . lung. ilatation of _ntestine and .stomach. Contract ior\ of stem* ach, intestine, and spleen. FIG. 48. Visceral reflexes elicited by firm pressure at definite vertebral areas. effective in relieving the pains. When it is necessary to make more forcible compression at the vertebral exits of the sen- sitive nerves the author employs his vibro -suppressor (Fig. 32) with a smaller pelote or he makes pressure with one end of the rubber of a pleximeter. The latter is shown in Fig. 2. Assuming that a patient has a neuralgia of the cervico- occipital nerves, one seeks for a sensitive point at the verte- bral exits of the cervical nerves usually on one side of the spine. As a rule, muscular spasm of the cervical muscles 170 Points of Election is associated with such a vertebral area of tenderness. Hence, before pressure is exerted by the thumb over the area of sensitiveness, the head is thrown backwards so as to relax the muscles. As a rule, pressure is primarily painful, but it soon yields to continued pressure and the neuralgic pains cease at once. A repetition of such manipulation may be necessary on successive days before the pain is permanently relieved. The author has observed that pressure exerted after the foregoing method at the vertebral exit of a spinal nerve has usually only a slight effect on the cutaneous sensitiveness in the normal subject. If, however, the nerve is the site of a neuralgia, a decided effect can be observed on a given area of skin -tenderness. Many osteopaths exercise great discretion in their man- ipulations insomuch as they do not massage the parts affected, but exert pressure upon the exits of the spinal nerves which are correlated to the parts involved. Thus the parts impli- cated are merely placed at rest and not manipulated until the acute symptoms have subsided. The POINT OF ELECTION for pressure at the vertebral exits of the spinal nerves may be determined (if spasm or tender- ness is absent) by noting the site of spasm of the spinal musculature (page 47), when an organ or tissue peripheral to the region of the spine is manipulated or by the develop- ment of an area of vertebral tenderness* (page 71) after such manipulation. The conductivity of a nerve may be temporarily diminished *The area of vertebral tenderness is often more conspicuous on the side of the spinal column opposite to the source of cutaneous irritation and this fact must be taken into consideration in employing our therapeutic manceuvers. The foregoing observation aids in solving the dubitable question concerning the propagation through the spinal cord of sensory impressions received by the skin; in all probability, the impressions after entering by the posterior horn ascend on the same side, whereas other impressions cross to the opposite side. 171 Spondylotherapy or abolished by external pressure (familiar example of the limbs "going to sleep") without annihilating its physical integrity. As remarked on a previous page (page 72), some writers associate the areas of paravertebral tenderness with the vaso-motor subcenters in the cord and claim that when the areas have become chronic, the paravertebral tissues are infiltrated and thickened. Here deep massage of the affected areas is indicated. PSYCHROTHERAPY. In the treatment of localized areas of vertebral tenderness, nothing in the experience of the author exceeds cold as a remedial measure. To attain any result, however, the skin overlying the area of tenderness must be distinctly whitened and frozen and this condition must be maintained for one or two minutes. Very often a single application suffices for the cure of a neuralgic affection but, in other instances, the process must be repeated on several successive days. The author has never noted any bad effects from such radical freezing as a remedial measure. The hyperemia resulting may be assuaged by a simple dressing of zinc oint- ment on lint fixed to the part with adhesive plaster. Among the agents used for freezing are rhigolene and ether which are used in an atomizer and directed on the part to be frozen. Recently the author has been unable to obtain rhigolene, hence ether was employed in its place. Other freezing agents are ethyl chlorid Bengue and Kelene, which are sold in glass tubes and by holding one of the latter in the hand a fine jet is projected on the area to be frozen. The nozzle is held from 6 to 8 inches from the skin. The latter first becomes pink, then a deep red and finally white, like parchment. The latter degree must be reached and maintained for several minutes. 172 Psych r o t h e r a p y The author has also used for freezing a preparation of benzine (Distilled between 35 and 45 degrees C.), which is a cheap and efficient fluid for freezing. The odor of the latter, like ether, may be objectionable, but this may be corrected by the addition of some essential oil to either preparation. Many preparations of ether on the market are quite in- efficient, but if ethyl chlorid is first used until the skin is whitened, almost any preparation of ether will maintain the freezing ad libitum. Ethyl chlorid or Kelene is too expen- sive if used extensively, hence, in the absence of a reliable ether preparation for freezing, first freeze with ethyl chlorid or Kelene and then maintain freezing with practically any preparation of ether. The foregoing liquids are inflammable and should not be used near a light. In an emergency, a piece of ice sprinkled with fine salt and held against the skin by means of a towel will freeze the part. The author has had no personal experience with either liquid air or carbonic acid snow for freezing purposes and for information on this subject the reader is referred elsewhere. 43 In intractable pains due to lesions at the vertebral exits of the nerves, the author has had recourse to what he calls reinforced freezing. It consists of injecting sterilized water beneath the skin over the part to be frozen or directly into the tissue until an appreciable bulging is produced. If the freezing solution is now directed on the protuberant part, a lump of ice is formed under the skin or in the tissues. Respecting the rationale of congelation the author directs the reader elsewhere 42 to his investigations on the subject. Vide page 187, concerning the use of freezing in spinal neuralgias.* *Vide page 367, concerning the employment of concussion for the relief of pain. 173 S p on d y I o t h e r a p y THERMOTHERAPY. This refers to heat as a therapeutic agent. Media having a temperature above that of the body are referred to as hot FIG. 49. Cutaneous areas for influencing the viscera. and as very hot, when the temperature exceeds 104 degrees F. (40 degrees C.). 174 Vibratory Massage Respecting the physiologic effects of heat, it suffices to say, that a prolonged application of a high temperature is primarily an excitant, and secondarily, a depressant ; a brief application, however, is strongly excitant and the depressing effects, if any, are imperceptible. The viscera are influenced reflexly through cutaneous areas (Fig. 49) which have been definitely established and are of great clinical importance. As a rule, the cutaneous reflex areas overlie the individual viscera, but in the author's experience, the most pronounced effects are achieved by the application of heat (very hot water in small rubber bags) over the different vertebral regions; a brief application to secure stimulating effects and a prolonged application to achieve sedative action. Von Bernd, by means of an apparatus which consists of a transformer, a high frequency current is obtained from the usual electric supply and which, when passed through the tissues, subjects the latter to any degree of heat which can be modified at will. With this apparatus the gonococci in an infected joint have been killed within one-half hour. ELECTRO -THERMAL PADS of any size, attachable to an electric light socket, are now purchasable and supply a uniform source of heat. They are also made to contain material used for cataplasms, thus obviating the necessity of changing the latter to secure a constant supply of warmth.* VIBRATORY MASSAGE (SISMOTHERAPY). Vibra-massage or mechanic vibration has achieved some distinction as a remedial measure, but owing to its indis- criminate application without regard to physiologic principles, most of the results attained by its use must be attributed to *Made by the F. R. Whittlesey Co., 591 66th Street, Oakland, Cal. 175 S p o n d y I o the r a p y suggestion. The author only seeks to discuss vibra -massage with reference to its spinal application, and it will be evident to the reader if he has given careful consideration to the vertebral reflexes (page 7), that the manipulation of definite vertebrae corresponds with the elicitation of definite reflexes but, if the vertebrae are promiscuously handled, counter -reflexes are evoked, which may often accentuate the reflexes in action and thus intensify the co-existing symptoms. The foregoing sentence has been quoted several times throughout this book, but it is deserving of repetition. In the therapeutic elicitation of the vertebral reflexes, the only kind of vibratory apparatus which is effective is one giving the PERCUSSION STROKE. All other motions, such as oscillations, shaking and friction, interfere with the results. In other words, it is concussion and not vibration which is effective. Vibration is milder and of higher frequency than per- cussion. The author has tested very many devices for vibra- massage and has been disappointed with the results. Thus there are many instruments which concuss, but in so doing, they also produce considerable friction, which is undesirable in prolonged seances with the apparatus. When the author first employed vibra-massage with in- adequate apparatus, the friction provoked in association with concussion, resulted in severe wounds over the spinous processes. Such accidents no longer occur in the author's experience, although the spinous processes may become tender owing to a mechanic periostitis which is of little or no consequence. With an apparatus which does not cause friction, the concussors (Fig. 50) may be applied directly to the spinous process or processes and the application can be prolonged 176 Vibratory Massage for several minutes at a time. In the event friction attends the use of the apparatus, one must interpose some medium between the concussor and the spinous process. Here a strip of linoleum is efficient and the treatment must be inter- rupted at once if the patient complains of a burning sen- sation.* The author's apparatus (Fig. 50) is essentially a FIG. 50. The author's pneumatic hammer with concussors. pneumatic hammer giving a stroke of i \ inches and operated by compressed air. The force of the concussion -blow may be regulated by a stop -cock or by the pressure of the con-, cussor on the spinous process. To start the action of the hammer it is often necessary to place the finger on the suction opening and then suddenly release it or strike the concussor forcibly with the hand. The absence of latch pins, springs or plugs avoids any waste of air and insures a steady working *If a layer of rubber (i cm. in thickness) covers the surface of the concussor, no heat is generated and there is no necessity for interposing a medium between the skin and the concussor. 177 S p o n d y I o t h e r a p y hammer. No vibration is transmitted to the operator's hand. Although quite heavy, it is easily manipulated, being sus- pended from the ceiling by means of a counter-weight. The concussors are of different sizes to include one, two, three or more spinous processes. The apparatus in question is only available when compressed air of considerable pressure can be obtained, but this is rarely objectionable insomuch as all modern office buildings are equipped with air compressors. Smaller pneumatic hammers are procurable, but they can only be regarded as mere toys for the elicitation of the verte- bral reflexes. An efficient percussion -stroke may be obtained from an electric apparatus (Fig. 51). It strikes from 3,500 to 5,000 blows per minute, and the force of the blow varies according to the pressure on the spine by the concussor in the vibrator from an imperceptible to the maximum blow. It is run with a J H. P. and may be arranged for any kind of an electric current. The only objectionable feature is its price (about $160). If the physician cannot obtain an efficient apparatus, then a hammer and pleximeter (Fig. 2 ) may be used with fairly good results. In the excellent book 44 of Doctor M. L. H. Arnold Snow, the author specially cautions the reader to avoid the spinous processes in the application of vibration. In my opinion, this caution is absolutely unnecessary. Many times a day, for years, the author has concussed the spinous processes most unmercifully, yet he has never noted any un- toward results. His experience in this regard, prompts him to side with those who hold that spinal concussion and cerebral commotion cannot give rise to the symptoms of a traumatic neurosis, for otherwise, many of his patients would have been the victims of "railway spine," insomuch as they have been subjected to as much concussion as they would 178 FIG. 51. Electric concussion- hammer. Spondyljtherapy have experienced in several railroad accidents without suffer- ing from any untoward results.* It will be noted in the special chapters that vibra-massage is, in some instances, more efficient than the sinusoidal current for the elicitation of the vertebral reflexes. It may also be noted, that if treatment with either method is too prolonged, the spinal visceral reflexes become exhausted and a condition other than that sought for will result. Experience only will determine the time necessary for each treatment, although the relief of symptoms is a fair gauge for the dura- tion of a seance. Reference has been made on page 169 to the increase of temperature following massage of the spine, but in the opinion of the author, concussion with the pneumatic hammer is decidedly more efficient. Concussion of any of the spinous processes will elevate the temperature, but the best results are achieved when the spinous process of the yth cervical vertebra is concussed. The two following cases of myocarditis are cited to show the effects of concussion on the spinous process of the yth cervical vertebra: CASE i. Temperature before concussion 97-2 F. " after " for 4 minutes ..98 F. u " " " 8 " ..98.8F. CASE II. Temperature before concussion 96. 4 F. " after " for 4 minutes... 98 F. No such effects could be produced with the sinusoidal current. *The fear of employing forcible concussion on the spinous processes and the use of inefficient apparatus are responsible for the inefficient results achieved by vibra-massage. 180 Vibratory Massage The author does not believe that elevation of temperature following concussion of the yth cervical vertebra is dependent on stimulation of a problematic thermogenic center, but to a stimulation of the heart (heart reflex). In fever, the author has never succeeded in reducing the temperature by aid of concussion of any of the spinous processes, although his efforts have been many. The employment of concussion to induce analgesia is discussed on page 367. S p o n d y I o the r a p y CHAPTER VI. PSEUDO -VISCERAL DISEASES. NEURALGIA INTERCOSTAL NEURALGIA DIFFERENTIAL DIAGNOSIS PSEUDO- APPENDICITIS PSEUDO-CEREBRAL DISEASE PSEUDO- AN- GINA PECTORIS PSEUDO-ARRHYTHMIA PSEUDO-ESOPHAGISMUS PSEUDO-NEPHROLITHIASIS PSEUDO-DYSPEPSIA PSEUDO- CHOLELITHIASIS PSEUDO-MAMMARY NEOPLASMS. T^VERY physician owes a modicum of his success to the *-' recognition and successful treatment of some special disease. In this respect, the author's talismanic affection is neuralgia of the spinal nerves with their bizarre and protean manifestations. The author may be pardoned for his apparent presumption when he asseverates that he feels justified in having written this book, if for no other reason than to direct the attention of the profession to recognize the greatest simulator of visceral diseases, viz., NEURALGIA OF THE SPINAL NERVES. It very frequently happens that neuralgia of the spinal nerves may be accompanied by visceral symptoms of such prominence that the neuralgia is overlooked and unsuccessful treatment is directed toward the supposititious visceral disease. Such cases, while presenting varied clinical pictures, are frequently analogous, if only atypically so, to gastric, cardiac, renal, vesical and intestinal affections. The neuralgic paroxysms occurring in spinal diseases like tabes are manifested by symptoms occurring in organs like the stomach, intestine, bladder, etc. Here, like in neuralgias of the spinal nerves, we are dealing with lesions represented by nerve-root symptoms. Many pseudo-visceral diseases may be partially explained by the anastomosis existing between 182 Pseudo -Viscera I D i s eases the spinal and sympathetic nerves (vide sympathetic sensa- tions, page 57). Neuralgia of the intercostal nerves most frequently simulates visceral disease. The upper group of the thoracic nerves is distributed entirely to the thoracic wall and the lower group (yth to i ith) is distributed partly to the thoracic and partly to the abdom- inal wall. It is the latter fact which often makes the recog- INTERNAL BRANCH Longissimus dorsi Bemispinalis dorsi Multifldus spinae Superior eosto-transversa ligament DORSAL ROO VENTRAL ROOT- RECURRENT BRANCH SYMPA THETIC GANGLION MEDIAL BRANCH BRANCH TO AORTA (Esophagus Internal mammary artery Transverse thoracic muscle STERNUM Ilio-eostalis dcrsi EXTERNAL BRANCH J>nKTF.KTnK PRIMARY DIVISION ANTERIOR PRIMARY DIVISION Internal intercostal muscle External intercostal LATERAL CUTANEOUS BRANCH ANTERIOR BRANCH Anterior Intercostal membrane FIG. 52. Diagram of the distribution of a typical thoracic nerve (Morris). nition of intercostal neuralgia difficult, insomuch as the word intercostal (between the ribs), connotes an erroneous topog- raphy in the localization of pain. It is evident that in dis- eases affectingthe nerve-trunks at or near their origin, the pain is referred to their peripheral terminations. Thus, in Pott's disease of the spine, the pain is referred to the belly, owing to the irritation of the nerve-trunks at their origin. In 183 S p o n d y I o the r a p y pneumonia or in pleural affections, the pain may be referred to the abdomen or the right iliac fossa and may suggest appendicitis. Here the lower thoraco -abdominal nerves are irritated owing to their juxtaposition to the pleura. pectoral is major. Supracl av i cul ar Branch of cervical Plexus Pectoral is minor Iiio- Irfguinal FIG. 53. Cutaneous nerves of the thorax and abdomen viewed from the side (Morris, after Henle). A typical thoracic nerve is shown in Fig. 52. In the posterior parts of the intercostal spaces, muscular branches are distributed to the levatores costarum and the nerves pass forward between the external and internal intercostals and di- vide into: i. Lateral branches, which after penetrating the external intercostals near the mid-axilliary line, divide into anterior and posterior branches. 2. Anterior branches, which at a short distance from the sternum give off terminal 134 Neuralgia branches. Fig. 53 shows the cutaneous nerves of the thorax and abdomen. To properly appreciate this subject it will be necessary first to describe neuralgias in general and later intercostal neuralgia in particular. NEURALGIA. Neuralgia is usually a unilateral affection associated with paroxysmal pains and painful areas (points douloureux} on pressure, at certain points in the course of the nerve where the latter passes through bones, muscles, or lies superficially. The painful areas are also present in the interparoxysmal periods. Associated symptoms of neuralgia are : disturbances of sensation (hyperesthesia or anesthesia), vaso-motor symp- toms, anemia or hyperemia of the skin and increase of the secretions, trophic disturbances and localized clonic spasm of the muscles. The pains in neuralgia are usually localized to a single nerve, but at the height of the paroxysm the pains may radiate to other nerves. MUSCULAR PAINS show diffused areas of tenderness in the muscles, are dependent on movement and are not paroxysmal. Malaria has often been accused as an etiological factor in neuralgia because the pains are paroxysmal, but this is an erroneous supposition insomuch as the pains of neuralgia, irrespective of cause, are paroxysmal. Again, syphilis is accepted as a cause because the parox- ysmal onset occurs at night. But this feature is common to many neuralgias. On the other hand, the absence of noc- turnal exacerbations speaks against syphilis. Among the more frequent etiologic factors of neuralgia are : 185 Spondyloth e r a p y 1. Mechanic (pressure on nerve from growths, exuda- tions, etc). 2. Thermic (chilling draughts, etc). 3. Toxic (drugs, infectious diseases and nutritive disturbances). One must not forget that, whereas in the majority of instances intercostal neuralgia is primarily due to cold (with the lesion at the vertebral exit of the nerve), it may be second- ary to vertebral disease, spinal meningitis and pressure from an aneurysm, tumor, etc.* INTERCOSTAL NEURALGIA. As before remarked, the diagnosis of this affection is not difficult when the middle intercostal nerves are involved; the difficulty arises when the lower group is involved, owing to the distribution of the nerves to the skin of the lateral and anterior abdominal wall. In intercostal neuralgia three painful points are invariably found on pressure, viz., at the vertebral exit of the nerve, in the mid -axillary line and in the median line of the thoracic and abdominal walls. The point at the vertebral exit is most constant and the method for the elicitation of the pain or tenderness has already been described on page 66. Here a word of caution is necessary. Unless the muscles are relaxed the contracted muscular fibers over the areas of tenderness will prevent elicitation of pain upon pressure. Presuming the patient suffers from pain dependent on a lesion of the spinal nerve, our primary endeavor is to locate the vertebral point of tenderness. Insomuch as several points of tenderness may be elicited, we proceed to locate *In neuralgia and neuritis of the intercostal nerves, pain is frequently accentuated when the patients lean far forward. The stooping attitude in corpulent persons may cause intercostal pains (pressure of the ribs on the nerves or traction), and in such instances cure may be achieved by instructing the patients to assume the erect posture. 186 Intercostal Neuralgia the point first from above and, when the sensitive area is reached, it is marked with a dermograph (skin-pencil). Next we locate the sensitive area from below and, when the latter is reached, it is also marked. It is wise to compare the sensitiveness on both sides of the spine although, as a rule, the neuralgia is unilateral. The author makes exclusive use of freezing (page 172) for diagnostic and therapeutic purposes. The area to be frozen in neuralgia of a spinal nerve or nerves is that included between the two pencil marks just referred to. It will be noted that if the mid-axilliary and sternal points of tenderness are marked with a pencil and freezing is executed at the vertebral point, the other points of tender- ness disappear, or will be, at least, less sensitive after a single freezing. This latter test is diagnostic of neuralgia of any of the spinal nerves. Several freezings, however, may be necessary before the neuralgia is cured. In practically every case the author ever saw, when a diagnosis of neuralgia of a spinal nerve was made, the attend- ing physician had applied his counterirritant at the site of the pain, i. e., at the peripheral distribution of the nerve and not as he should have done near the site of the lesion, viz., the vertebral exit of the affected nerve. If the negative pole of a Galvanic current is fixed at an indifferent spot, and the positive pole is placed successively over the other sensitive points, neuralgic pain is likewise in- hibited, but this method cannot compare in accuracy nor in rapidity with the freezing method. The author has often utilized the following method in the absence of a freezing apparatus; firm pressure is made with the thumb and maintained for several minutes at the vertebral area of tenderness. At first, the pains are accen- 187 S p o n d y I o t h e r a p y tuated, but later they are mitigated or disappear. The method cited is used in an emergency and is decidedly less radical than freezing. Reference has- been made to it on page 171. It may happen, and indeed it often does, insomuch as cold is the common etiologic factor of neuralgia and muscular rheumatism, that both affections coexist. Here Faradism temporarily inhibits the pain of rheumatism, leaving the pain from other causes uninfluenced. Again, Faradism will accentuate the painful areas of muscular rheumatism. Congelation (freezing) may be employed as a means of diagnosis for the following purposes : A. To diagnose neuralgia of central from one of peripheral origin. B. To differentiate neuralgia from neuritis. C. To localize the lesion in neuralgia. A. If a nerve the seat of neuralgia is frozen nearest its point of origin, the pain will disappear if the neuralgia is of peripheral origin and it will persist if of central origin. In the absence of spontaneous pain the painful points in the course of the nerve-distribution may serve as guides. B. Freezing is a specific for all forms of uncomplicated neuralgia, provided it can be executed near the point of origin of the involved nerve, i. e., close to the site of the lesion. If, however, the pain is central in origin or due to a neuritis, the pain, as a rule, will not be inhibited. Many years ago I suggested freezing for the pains associated with herpes zoster. In some instances it was marvelously efficient, but in the majority of cases, no relief followed. Here the pain was of central origin, due presumably to disease of the intervertebral ganglion. C. The following cases illustrate the employment of freezing for localizing pain: 188 Intercostal Neuralgia Case I. Male. In a row received many cuts on the scalp. Various cicatrices resulted. He suffered from ill-defined neuralgia located in the scalp. All cicatrices were equally sensitive to pressure. Freezing was conducted at the exit of the occipital nerves in the neck without effect. Then the indi- vidual scars were successively frozen during a paroxysm. Pain continued until one cicatrix in the occipital region was frozen, when the pain ceased at once. Excision of the latter cicatrix resulted in cure. Case II. Case of occipital neuralgia. Usual painful points. Freezing conducted during a painful paroxysm. When freezing was made over a particu- lar sensitive point the pain ceased. Palpation at this point demonstrated the presence of a little growth. Cure after removal of a small neuroma. Case III. Neuralgia of the trigeminus (prosopalgia) . Freezing during a painful paroxysm at the supra- orbital foramen, infra-orbital foramen and mental foramen respectively. Relief from the pain when congelation was conducted at the latter point. Examination of the teeth of the lower jaw showed the presence of a carious tooth, which, when ex- tracted, was followed by a cure. DIFFERENTIAL DIAGNOSIS. Visceral diseases are frequently confounded with inter- costal neuralgia. Here, as a rule, we find only a vertebral area of tenderness, whereas the mid-axillary and sternal points of tenderness are absent. Again, freezing at the vertebral area of tenderness is not followed by any relief of the pain. In visceral disease simulating intercostal neuralgia, one may demonstrate dermatomes (page 58) which, like the vertebral tenderness, become accentuated after palpation of special organs. Supposing, for example, one finds a 189 S p o n d y I o t h e r a p y sensitive area over the stomach. If pressure sufficiently great is made at this point to induce pain, the area of verte- bral tenderness in my experience, becomes accentuated and the dermatomes are more easily demonstrated. In localizing the latter, however, one must not forget that hyperesthetic zones may also be demonstrated in neuralgia. As a rule, in visceral disease, vertebral tenderness may be demonstrated on both sides of the spinal column, whereas, in intercostal neuralgia, the sensitiveness is unilateral. Bilateral sensitiveness in the latter affection suggests an intravertebral lesion. Whereas, in intercostal neuralgia, pressure on the area of vertebral tenderness may reproduce the pains from which the patient suffers, in vertebral tenderness of visceral origin, like pressure may reproduce other symptoms. Thus arrhythmia may be reproduced or accentuated when the area of vertebral tenderness is firmly compressed. Similarly, in gastric disease, pressure on the sensitive vertebral area may cause eructations of gas and other symptoms suggestive of a gastric anomaly. The aphonia and dysphonia of LARYNGITIS (acute) may be differentiated from like symptoms due to other laryngeal affections by the following simple method : First, mark with a pencil on either side of the neck the approximate point in the thyro-hyoid membrane where the internal laryngeal branch of the superior laryngeal, the nerve of sensation to the larynx, passes into the latter organ. Next, thoroughly freeze the points marked with the pencil. Relief is, as a rule, almost instantaneous and is of signal advantage to many professionals. In some instances, the restoration of the voice is of only short duration and freezing may have to be repeated several times. The author desires to illustrate by the citation of a few 190 P s e u d o - A p p e n die it is cases what he intends to convey by the phrase, pseudovisceral disease. In this respect he will be brief, for in this epoch of therapeutic skepticism, one dare not report phenomenal cures without being accused of extravagant representation, misinterpretation or, if the calumniator is charitable, of auto-suggestion. PSEUDO -APPENDICITIS . LUMBO -ABDOMINAL NEURALGIA which involves the SIX branches of the lumbar plexus is frequently mistaken for appendicitis. The author has observed many patients who had even contemplated an operation for the relief of their pain, but who were cured after one or several freezings at the vertebral exits of the sensitive nerves. One patient in particular is recalled who was seen in consultation, and who, despite the protests of the author, had his appendix removed. After the operation the persistent pains of a lumbo-abdom- inal neuralgia were cured by several freezings. These cases are not difficult to diagnose. Painful areas are located near the lumbar portion of the vertebral column, in the center of the iliac crests, over the symphysis in the hypogastric region, at the scrotum in the male and at the labium majus in the female. Pain in these patients is also felt on the anterior surface of the thigh corresponding to the area of distribution of the lumbo-inguinal nerve. Difficulty in diagnosis in these cases is often hampered by the fact that there is a circumscribed tonic spasm of the abdominal muscles in the ileocecal region which may be mistaken for a deep-seated intumescence. We have long recognized the almost intelligent function of muscles whether displayed in fixing a diseased joint or spine, or in protecting an inflamed serous membrane. The fact is, that in spinal neuralgias, spasm of the muscles can almost 191 S p o n d y I o t h e r a p y invariably be demonstrated and it is a nerve-root symptom. When the lesion, as in neuritis, is destructive rather than irritative, muscular atrophy and not spasm is the con- comitant sign. One would naturally conclude that a skilled diagnostician could not possibly err in mistaking a lumbo -abdominal neuralgia for appendicitis. In Paris, the author recently saw an American lady who was suffering from atrocious pains in the ileocecal region. She consulted some of the leading surgical and medical clinicians of Europe. All were unanimous in their conviction that she had appendicitis, and that an immediate operation was imperative and the only means of arresting the pains. An examination demonstrated the spasm of the abdominal muscles in the neighborhood of the appendix, which, at one point, was so circumscribed as to awaken the suspicion of a tumor. A point over the appendix was exquisitely tender. There were the usual tender points elsewhere in the gluteal region, on the outside of the thigh, symphysis pubis and at the vertebral exits of the involved nerves. A single freezing gave immediate relief, although about ten freezings were necessary to effect a permanent cure. These patients often suffer a relapse, especially in inclement weather, but a single freezing suffices to cure. My only excuse for citing the latter case is to illustrate the frequency of pseudovisceral affections which are often erroneously interpreted by some of the best men in the profession. Verily, if the surgeon were a better diagnostician there would be less surgery. PSEUDO -CEREBRAL DISEASE. When a neuralgia implicates respectively the four superior cervical nerves, it is referred to as cervico-occipital neuralgia and the four inferior cervical nerves, as a cervico-brachial 192 P s e u do - Mastoiditis neuralgia. In the former neuralgia, the major occipital nerve is most frequently involved and the pain is located in the neck and radiates along the occipital region as far for- ward as the eyes. There is practically always a spasm of the cervical muscles which interferes with the elicitation of pain upon deep pressure at the vertebral exits of the implicated nerve or nerves. Not infrequently, branches of the brachial plexus are similarly involved and the pains radiate down the arms. In cervico -occipital neuralgia, localized areas of sensitiveness may be detected notably at the external occipital protuberance and at the tip of the mastoid process. The latter point of sensitiveness has, in my experience, often been mistaken for a mastoiditis by enthusiastic aurists, yet a single freezing at the verterbal exits of the involved nerves will determine the nature of such forms of PSEUDO -MAS- TOIDITIS. Pseudo-mastoiditis is frequently mistaken for the true form of the disease if a discharge from the ear (otorrhea) is present. When the pathologist makes an autopsy he records the many pathological conditions as anatomic diagnoses. The clinician should be similarly guided, but, unfortunately, he too often errs in tracing a connection between varying symptoms in his effort to include them all in a single diag- nosis. Co-existing symptoms may be the expression of not only one but of several distinct diseases. The following case will amply illustrate the author's meaning: A gentleman having fallen from a ladder sustained an injury of the spinal column which resulted in a kyphotic deformity. Several weeks later he developed atrocious pains in his right leg which several orthopedists attributed to the original injury. Examination of the patient in question demonstrated a sciatica which had absolutely no connection with the primary traumatism and after several freezings over the region of 193 S p o n d y I o t h e r a p y the nerve, the pains subsided completely and have ceased to reappear after several years, notwithstanding the per- sistence of the spinal deformity. About four years ago one of my tabetics returned from Europe suffering from severe pains in the head which several specialists had told him were dependent on a cerebral lesion. The pains resisted conventional treatment. Examination of the patient, who returned to San Francisco in despair and without relief, demonstrated the presence of a cervico- occipital neuralgia. The localized areas of sensitiveness on his scalp disappeared after a single freezing at the vertebral exits of the involved cervical nerves and cure resulted after a thorough repetition of the procedure. A lady with pains in the left half of the abdomen con- sulted several gynecologists, all of whom discovered a pro- lapsed ovary and suggested its removal. The pains due to a lumbo -abdominal neuralgia continued after the operation and were cured after several freezings at the exits of the involved nerves. PSEUDO -ANGINA PECTORIS An intercostal neuralgia is frequently misinterpreted for angina pectoris. In the latter affection pains' radiate to the neck and arm. The investigations of Head and Mackenzie show the following : 1. In cardiac and aortic disease, the pain is referred along the ist, 2nd and 3rd dorsal nerves. 2. In angina pectoris, the pain in addition may be referred from the 5th to the pth dorsal nerves. The forms of anginal pains referred to in this connection are not concerned with functional angina pectoris observed in neuroses, but are distinctly traceable to a neuralgia of the intercostal nerves. 194 Pseudo-Arrhythmia About fifteen years ago an elderly individual was referred to me by an Eastern physician with a diagnosis of angina pectoris. Several prominent clinicians had made a similar diagnosis. Like in true angina, the common exciting factor in provoking a paroxysm of pain in this patient was exposure to cold. Despite the concomitant symptoms which suggested the correctness of the diagnosis, the patient was examined for the signs of intercostal neuralgia which could easily be demonstrated. A few freezings at the vertebral exits of the involved nerves sufficed to rid the patient of his pains which, up to the time of writing, have not recurred. PSEUDO -ARRHYTHMIA. An irregular heart may be clinically manifested as an intermission when one or more beats of the heart are dropped r or, as an irregularity, when the beats show inequality in volume and force. The causal classification of Baumgarten is as follows: 1. Organic cerebral affections. 2. Reflex from visceral diseases. 3. Toxic, from tobacco, coffee, tea and from drugs like digitalis, belladonna and aconite. 4. Changes in the heart. Arrhythmia may exist for a long period without symptoms. It is usually in connection with other cardiac signs that its presence is noted. Associated with myocardial or valvular lesions it is ominous, but as a permanent con- dition, secondary to mental influences, it is usually without significance. Irregularity of the heart-rhythm may give no expression in the pulse. The purely neurogenic type of irregularity observed in healthy children and young adults is due to overaction of the vagus. When the latter is para- lyzed by atropin (grain 1-120 to 1-60), the pulse becomes 195 Spondyloth e r a p y regular. Heart intermittency is differentiated from simple irregularity, by the fact, that, in resumption of the cardiac contractions they are regular from the beginning. The author has demonstrated that, in the norm during the time the pulse is palpated, firm pressure made at the exit of the spinal nerves (preferably at the sides of the upper dorsal vertebrae), will result in decided alteration in the character of the pulse which often amounts to inhibition of the latter. In a few instances a decided arrhythmia may be observed. The observations of the author have taught him that a neuralgia of the upper intercostal nerves is not an infrequent etiologic factor in arrhythmia notwithstanding the fact that, this cause is unrecognized in the text-books. In intercostal neuralgia associated with arrhythmia, pressure on the sensitive areas corresponding to the exits of the involved nerves will accentuate the condition, and, if absent, will provoke it. In such instances of arrhythmia, a single freezing at the vertebral exits of the involved nerves will often arrest the trouble at once. Arrhythmia may also exist as a result of a nerve-root lesion of the upper group of dorsal nerves without any symptoms of intercostal pains. PSEUDO -ESOPHAGISMUS . The following case, selected from many cases of a similar nature, is interesting as a paradigm of this condition. The patient, a female, has suffered for months in consequence of painful deglutition and is very much emaciated in conse- quence of her difficulty in swallowing not only solid foods, but liquids. An examination was negative beyond pain on pressure in the cervical region with sensitive cervical vertebras on percussion. There were no symptoms of hysteria. The 196 Pseudo-Visceral Diseases dysphagia disappeared completely after three applications of the freezing-spray to the region of the sensitive cervical nerves. PSEUDO -NEPHROLITHIASIS . The patient, a physician, had suffered for many years from pains in the lumbar region on the right side occurring in paroxysms and simulating the pain of renal colic. An exploratory incision down to the kidney was made by an eminent surgeon of Philadelphia, and nothing was found. When the patient came to me his pain still persisted. The first and second lumbar vertebrae were sensitive to percussion and areas of vertebral sensitiveness were located to the right of the spinal column. Successive freezings of the para- vertebral area of sensitiveness checked the painful parox- ysms completely. PSEUDO -DYSPEPSIA. There are many cases which I have denominated fictitious dyspepsia, which are comparatively frequent and are asso- ciated with involvement of the spinal nerves. The patients may exhibit all the symptoms of dyspepsia, yet the presence of the painful areas of sensitiveness of an intercostal neuralgia are demonstrable. These cases, like the others, yield to freezing. PSEUDO -CHOLELITHIASIS . About several months ago several surgeons had made the diagnosis of gall-stones in an adult male, who for several years had suffered from paroxysmal pains in the region of the gall-bladder. Before submitting to an operation he decided to consult three medical clinicians. We also con- curred in the diagnosis. The author was reluctant to question the diagnosis for the reason that the severe paroxysms of pain necessitated the use of morphine. When pain is severe 197 S p o n d y I o t h e r a p y enough to necessitate an analgesic so powerful as morphine (in the author's experience) intercostal neuralgia can be excluded. On the following day, the patient in question was re-examined and the areas of sensitiveness peculiar to intercostal neuralgia could be demonstrated. About ten freezings over the vertebral exits of the implicated nerves sufficed to completely rid the patient of his paroxysms of pain. In fact, after the first freezing, the painful area located near the gall-bladder was no longer sensitive to pressure. The author has seen a number of such cases and one case in particular is recalled, where jaundice accompanied the painful paroxysms. The jaundice in the latter case could be explained by the fact that respirations on the affected side were limited. It is well-known that the bile is secreted under very low pressure and that the diaphragm in contract- ing, subjects the liver to pressure which is an active factor in forcing the bile from the smaller to the larger biliary ducts. Interference with the movements of the diaphragm is likely to cause icterus of resorption. PSEUDO -MAMMARY NEOPLASMS. As before remarked, neuralgia of the intercostal nerves is associated with a circumscribed tonic spasm of muscle and, if the neuralgia involves the nerves in juxtaposition to the mamma, the pain and intumescence suggest a neoplasm. In such instances, an error is unavoidable, unless the phys- ician recalls the fact, that mastodynia may be a variety of intercostal neuralgia. 198 The Heart Reflex CHAPTER VII. THE CIRCULATORY SYSTEM. THE HEART REFLEX CARDIAC SUFFICIENCY DIFFERENTIAL TABLE OF ASTHMA TESTS FOR HEART-SUFFICIENCY ANGINA PECTORIS THE HEART REFLEX OF DILATATION DIFFERENTIAL TABLE OF TRUE AND FALSE ANGINA FUNCTIONAL AFFECTIONS OF THE HEART INHIBITION OF THE HEART PHYSIOLOGY AND PATH- OLOGY OF THE BLOOD-VESSELS BLOOD-PRESSURE VASO-MOTOR FACTOR IN BLOOD-PRESSURE SPHYGMOMANOMETRY HYPERTEN- SION AND HYPOTENSION THE AORTIC REFLEXES ANEURYSM OF THE THORACIC AORTA THE VASO-MOTOR APPARATUS VASO-MOTOR NEUROSES. THE HEART REFLEX. A TTENTION was first directed in 1898 to the phenom- * enon 52 now known as the heart reflex of Abrams. The reflex in question is a contraction of the myocardium of varying duration, which results when the skin of the pre- cordial region is irritated. The cutaneous irritant may be a spray of ether directed over the region of the heart, or the skin may be rubbed with a blunt instrument, or by means of an ordinary pencil eraser, or by a series of percussion blows. The nearer the irritant is applied to the precordial region and the more vigorous the cutaneous friction, other things being equal, the more pronounced is the heart reflex. The reflex is best observed with the Roentgen rays with the fluorescent screen approximating the anterior chest-wall. The reflex is, as a rule, more manifest in the left than in the right ventricle, and the contraction of the myocardium is not always sudden and of momentary duration; on the contrary* its duration in children, on whom most of the original observations were made, is not less, as a rule, than 199 S p o n d y I o t h r a p y two minutes,- and, furthermore, the myocardial recession continues even after the source of cutaneous irritation is removed. The degree of myocardial recession (heart reflex) varies greatly. In some persons it is scarcely percep- tible, while in other individuals the heart may recede more than 2 cm. on either side upon the first application of the cutaneous irritant (Fig. 54). * FIG. 54. Heart reflex in a boy, aged eight years. Duration of reflex two and a half minutes. The normal outline of the heart drawn on the fluoroscope is represented by A, whereas B represents the outline of the heart after cutaneous irritation and shows the degree of myocardial recession of the heart reflex. In other instances, although the reflex is practically never absent in the norm, it is strictly confined to the left ventricle, as shown in Fig. 55. In individuals with dilated hearts the reflex is very evident and is of much longer duration than in healthy hearts. This latter observation, as we shall learn presently, has been confirmed by the careful observations of Merklen and Heitz. In the original communications concerning the heart 200 T h H art Reflex reflex, the latter was only observed in the transverse cardiac diameter, but with the x-rays it can also be seen in the sagittal diameter. Subsequent observations demonstrated that the heart reflex could be elicited by irritation of more remote regions, viz. : 1. Irritation of the nasal mucosa. 2. Irritation of the gastric mucous membrane. 3. Irritation of the rectal mucosa. 4. By irritation of the esophageal mucosa in the act of swallowing. 5. By percussion of the muscles. 6. By psychic influences. 7. By vertebral concussion. FIG. 55. Heart reflex in a boy, aged fourteen years. Duration of reflex, fifteen seconds. A represents the cardiac outline before, and B after, cutaneous irritation, while C represents the upper border of the liver. IRRITATION OF MUCOUS MEMBRANES. Here investiga- tions were conducted during the time the x-rays were tra- versing the chest, and by means of the fluoroscope the heart was directly observed. It was noted that, when irri- tating vapors were inhaled there was a decided recession of the cardiac ventricles (heart reflex), especially the left, and that this heart reflex was more pronounced than when 201 S p o n d y I o therapy excited through the skin of the precordium. Ether and chloroform inhalations also excite the reflex and in a few instances, these vapors produced a veritable cardiac in- hibition. It was noted that, the reflex in question was excited by irritation in succession of the nasal, pharyngeal and laryngeal mucous membranes, and when the latter were made anesthetic by cocain, no heart reflex could be elicited. The accompanying sphygmogram (Fig. 56) shows a decided difference in the output into the general circulation before and after the inhalation of ammonia. The heart reflex may also be elicited by irritation of the gastric mucosa when the sponge of the gyromele is made to FIG. 56. Sphygmogram of the radial artery ; A before, and B after, the in- halation of ammonia. revolve against the membrane in question. One may also excite the reflex by irritation of the rectal mucosa by means of the finger in the rectum. PERCUSSION OF THE MUSCLES. If one percusses the muscles (tapotement} of the extremities, one can elicit the cardiac reflex. The latter is essentially a reflex of muscular origin exclusively, as such a reaction does not follow irritation of the skin of the extremities or percussion of the bones. Percussion of the muscles of one arm usually suffices to elicit this reflex. Another curious feature of this myopathic heart reflex is, that it causes contraction of the right ventricle of the heart only, the left being uninfluenced. Placing the subject before the x-rays, this reflex is at once evident. After the borders of the heart are defined, request an assistant 202 The Heart Reflex to percuss the muscles of one arm by means of a percussion - hammer. Following the manosuver the right ventricle shows considerable retraction. The effect on the systemic blood- pressure by percussion of the muscles is very slight, and this is obvious, considering that the left heart -ventricle is uninfluenced by the manoeuver. PSYCHIC INFLUENCES. We have always recognized the influence of emotions on the heart, but no tangible evidence of such effects has been demonstrated. The epigram of Peter is worth repetition : "The physical heart is the counter- part of a moral heart." The conventional expression of the frightened individual, "My heart was in my mouth," finds justification by an x-ray study of the organ. Inform the patient standing before the x-rays, that you are going to burn him with a hot iron or frighten him in some other way, and the effect on the heart is at once manifested. It is a veritable psychic heart reflex implicating the entire organ. The heart becomes very much reduced in size, and appears as if it were retreating towards the neck. I know of no irritation, cutaneous or otherwise, that is so pronounced as this psychic factor of fright in inducing the heart reflex. The foregoing fact is of the utmost importance in eliminating emotional influences in the treatment of cardiac diseases. Even in an ordinary x-ray examination of the heart, one may observe in nervous patients a reduction of the heart- mass. Mr. Bezley Thorne 53 observed that the heart shrank after exposure to the Roentgen rays. It is evident that the shrinkage thus observed, was naught else but a cardiac re- action (heart reflex) to emotional influences, for an x-ray examination to the average patient is a momentous procedure. The author has frequently witnessed the pulmonary reaction of fright ; the lungs became hyperresonant on per- cussion and the superficial areas of cardiac, hepatic and 203 S p o n d y I o therapy splenic dullness became diminished, a condition which the author has called the psychic lung reflex of dilatation. The latter psychic reflex may be easily demonstrated, if the areas of the organs in question are first outlined, and later, if the patient is frightened, percussion will demonstrate that the areas of the organ are reduced in proportion to the psychic reaction which provokes a dilatation of the lungs. VERTEBRAL CONCUSSION. Perhaps the most effective method of provoking the heart reflex is by means of con- cussion of the spinous process of the yth cervical vertebra. It will be noted that this refers to the heart reflex of con- traction, for there is still another heart reflex which is to be described presently, known as the heart reflex of dilatation. PRACTICAL VALUE OF THE HEART REFLEX. Percussion of heart, or, for that matter, any other organ adjacent to the lung, is associated with many errors unless one takes into consideration the lung reflex. Percussion of the heart, as executed ordinarily, yields an absolute or superficial, and a deep or relative dullness. Practically little or no value can be attached to the superficial dullness in estimating the size of the heart, as it varies with the position of the overlapping lung-borders. Even the lightest percussion blow will provoke sufficient cutaneous irritation to induce the lung reflex of dilatation, i.e., an acute dilatation of the lungs which may diminish the area of superficial cardiac dullness, even to obliteration. Cabot, 54 in his classical book, makes the following observation : "Any- one who has demonstrated an area of percussion dullness to many students in succession must have noticed occasionally that the more we percuss the dull area the more resonant it becomes, so that those who last listen to the demonstration, the difference which we wish to bring out is much less obvious than to those who heard the earliest percussion 204 The Heart Reflex strokes. Abrams has referred to this fact under the name of the 'lung reflex.' ' Sahli, in his "Diagnostic Methods," refers to the same fact. The mere influence of room tem- perature materially changes the results of percussion. Let any one, after percussing the areas of superficial dullness, direct a current of cold air, e.g., from an atomizer, over the regions percussed, and the result will be diminution or obliteration of the areas in question. It is evident from what has preceded that, while the heart reflex can always be determined by the x-rays, after cutaneous irritation of the precordium, mere percussion of the superficial area of cardiac dullness cannot determine its existence because the irritation necessary to evoke the heart reflex will also induce the lung reflex, which must necessarily mask the heart reflex. Thus the observations of Schott and others, who seek to demonstrate the effects of carbonated baths on the heart by percussion of the latter organ are evidently erroneous unless such percussion takes into consideration only the deep or relative cardiac dullness. Heitler 56 perpetrates the same error by failing to take into consideration the coincident lung reflex when making cutaneous irritation. Heitler seeks to determine the sufficiency of the heart muscle by a series of percussion blows over the 'heart region. If, thereafter, the cardiac dullness is much diminished, it is an evidence, he argues, that the cardiac musculature is sufficient, for the tendency of the normal muscle tonus of the heart is to maintain a limited patch of dullness. As before remarked, the heart reflex can be observed directly with the rays, but if strong percussion is employed so that reliance is alone placed on the deep or relative cardiac dullness, the reflex in question may be determined by percussion. Heitz, 57 in discussing "Le Reflexe Cardiaque d'Abrams," observes that, while in the normal subject the heart reflex is of short dura- 205 S p n d y I o t h r a p y tion, in cardiectasis it may persist for several hours. In the third edition of their valuable book ("Examen et Semeiotique du Cceur"), Merklen and Heitz show graphically the effects V FIG. 57. Cardiac reflex in a neurasthenic with functional troubles of the heart; reduction of the absolute and relative dullness. (After Merklen and Heitz). of friction of the skin in the region of the heart of a cardiac neurasthenic (Fig. 57), and in a cardiopath with hyposystolie (Fig. 58). FIG. 58. Hyposystolie in an arteriosclerotic; reduction of the absolute and relative cardiac dullness and ascension of the inferior border of the liver under the influence of precardial massage. (After Merklen and Heitz). In Fig. 58 the reduction of the hepatic dullness is shown following the friction of the skin ; the continuous lines show the superficial and the deep dullness of the heart before, and the interrupted lines the reduction of the areas after friction of the skin. 206 The Heart Reflex All physicians do not possess equal skill in determining the relative cardiac dullness, and I have devised a simple apparatus called the "Vibrosuppressor," which serves to simplify topographical percussion (page 80). The Heart Reflex of Nasal Genesis. Reference has al- ready been made to the fact that the heart reflex can be provoked by irritation of the nasal, pharyngeal, and laryngeal mucous membranes, and that if the irritation is sufficiently prolonged and violent the movements of the heart may be inhibited. If the membranes in question have been previously cocainized the heart reflex cannot be elicited. It is evident, then, that previous cocainization of the nasal and pharyngeal mucous membranes should precede the employment of an anesthetic. On theoretical grounds, the laryngeal mucosa should not be cocainized, as it is necessary to preserve the laryngeal reflex to prevent the entrance of foreign substances into the larynx. The Heart Reflex of Gastric Genesis. Knowing that irritation of the gastric mucosa will provoke the heart reflex, it is not improbable that sudden death of gastric origin may be caused by refljex inhibition of the heart. In instances of this kind the fact of a dilated stomach directly compressing the heart cannot be ignored. I have studied, by aid of the x-rays and the fluoroscope, the action of a dilated stomach on the heart by artificial distension of the stomach. The healthy heart can tolerate considerable compression and dis- location without modifying the intensity of the heart tones, but when the organ is diseased, the slightest compression and dislocation is followed by evil consequences. Artificial insufflation of the colon will also compress and dislocate the heart, but never in the same degree as will insufflation of the stomach (Fig. 33). The Heart Reflex of Rectal Origin. Irritation of the 207 Spondyloth e r a p y rectal mucosa will also induce the heart reflex. Straining at stool in elderly people by increasing intraabdominal pressure, and thus putting a strain on the cerebral vessels, predisposes to rupture of the latter. Straining, however, is not wholly a question of pressure. Some patients, particularly those with weak hearts, suffer from collapse symptoms while straining at stool. In investigating the cause of such symptoms, I found that contraction of the abdominal musculature will cause even in the norm a veritable weak heart reflex with diminished output of blood from the left ventricle. For the latter reason the amount of blood is decreased in the arterial system and FIG. 59. Sphygmogram (A) before and (B) while straining at stool. increased in the veins. The accompanying sphygmogram (Fig. 59) illustrates the effects of contraction of the abdom- inal musculature on the heart. It is evident that if the heart is enfeebled the effects of such cardiac inhibition may be attended with serious results. It is well known that different nerves from the abdomen and intestine are in close communication with the cardioin- hibitory center in the medulla and that reflex inhibition of the heart can be easily produced in the frog by tapping a loop of the intestine with the handle of a scalpel. Severe abdom- minal affections, like peritonitis and appendicitis, are frequently attended with symptoms of heart collapse, owing, no doubt, to reflex inhibition of the heart. Anyone can appreciate the inhibitory influence on the 208 Heart R e f I x heart if the radial pulse is palpated during contraction of the abdominal muscles while straining at stool. Relative Valvular Insufficiency. The normal heart can easily adapt itself to the average grades of dilatation such as occur during exertion ; in fact, the size of the cavities of the heart varies even in health, and a dilatation is physiologic as long as the heart cavity is capable of emptying its contents during systole. What is called "getting wind" in climbing a mountain or in athletic training is practically a moderate dilatation of the cavities of the right heart. In relative valvular insufficiency the valves are normal, but they are no longer capable of completely closing the orifices of the heart. This condition is frequent after heart strain and involves particularly the tricuspid valves. A murmur which is heard in such instances may be made to disappear temporarily by inducing the heart reflex, which, by causing myocardial con- traction, reduces the size of the cardiac orifices, thus enabling the valves to close the openings. Here the excitant of the heart reflex must be vigorous and for this purpose the sinu- soidal current, with both electrodes to the precordial region, is most efficacious. Percussion of the precordial region with a percussion hammer will often suffice. Pericardial Effusion. The differential diagnosis between a dilated heart and a pericardial effusion is often conceded to be a difficult clinical problem. From what has preceded the heart reflex can be employed in diagnosis. The reflex in question is absent in pericardial effusions and present in cardiectasis. In other words, after the heart reflex is pro- voked the area of deep cardiac dullness will be uninfluenced in effusions but modified in cardiectasis. It may be difficult to say whether a pulsating intra- thoracic mass examined with the x-rays is the heart or an aneurysm. A retraction of the mass after provoking the 209 S p ondyloth e r a p y heart reflex would indicate that it is the heart and not an aneurysm. Cooper utilized the foregoing fact in differential diagnosis. I will not now attempt to discuss the therapeutic value of the heart reflex, but it is my personal opinion that the carbonated baths in the Schott treatment possess no special effect beyond their action in provoking the heart reflex by cutaneous irritation and that cutaneous friction by any other method is equally efficacious. The foregoing con- clusion is formulated only as a result of many years of obser- vation. Massage of the precordial region or the employment of the sinusoidal current, especially in cardiopaths, will reduce the area of the heart and the pulse -rate and augment blood -pressure. The now prevailing fetish in cardiothera- peutics is Nauheim. I subscribe equally to the efficiency and deficiency of this famous resort, but it is puerile to endow its waters with marvelous attributes. CARDIAC INSUFFICIENCY. - One frequently observes in a large number of individuals at about the period of middle-age, definite signs of cardio- vascular disturbances even though no valvular lesions are present. Here the condition is due to some change in the heart -muscle which has not been definitely established even by the microscopist. This condition has been popularly designated as heart-failure or heart-weakness, and others speak of the condition as chronic .cardiac insufficiency or incompetency. The signs of incompensation vary according to whether they are caused by a lesion of the valves or occur independently of the latter and are dependent on changes in the myocardium. All diseases of the heart, whether of the valves or myocardium, lead eventually to disturbances of circulation. The phe- nomena associated with the latter are easier of interpretation if we study the effects of valvular lesions. 210 Cardiac Insufficiency The compensatory mechanism of the heart illustrates why cardio- vascular disease is not at once followed by dis- turbances in the circulation. The normal heart can easily adapt itself to the average grades of dilatation such as occur during exercise. In fact, the size of the cavities of the heart varies even in health, and a dilatation is physiologic as long as the heart-chamber is capable of emptying its contents during systole. Any increased work on the part of the heart, if continued, leads to an increase in the size and number of the muscle -fibers, a condition known as hypertrophy, .which enables the organ to contend with ad- ditional burdens. Although a valve-lesion may be of some significance in prognosis, yet the essential factor always is the question of compensation. Valvular lesions are of two kinds, narrowing of the valve- openings (stenosis), and incomplete closure of the orifices (incompetency or regurgitation) due to retraction of the valves. In either condition dilatation of one of the chambers of the heart occurs because it is always distended with blood, and incompletely discharges its contents at systole. When the heart hypertrophies, to overcome the latter defect, and thus prevents stasis in any part of the blood-current, the lesion is compensated. Thus compensation is practically dependent on the condition of the heart-muscle. If the heart fails to hypertrophy, or if the latter has occurred and it is subjected to burdens beyond its capacity, or in consequence of degen- erative changes, the heart fails as a motor and it becomes insufficient, or, as is often said, compensation is broken or ruptured. In consequence of incompetence, a diminished quantity of blood is pumped into the arterial system, hence the arterial pressure is decreased, venous pressure is increased and the current of the blood in the capillaries is retarded. 211 S p o n d y I o t h e r a p y The cavities of the ventricles dilate because they cannot discharge their contents (increased area of cardiac dullness). Overloading of the veins conduces to the collection of fluid in the tissues which begins primarily in the feet and gradually invades the other parts of the body. Cyanosis of the skin is an early symptom and appears as soon as there is a disturbance in the pulmonic circulation. In children, a lesion of a valve retards development and nutrition and produces a condition known as cardiac cachexia. The pulse is often characterized by intermittency and is caused by feeble contractions of the heart which are not strong enough to drive the blood to the radial artery. In such instances, if the heart is auscultated synchronously with palpation of the pulse, there are more heart -tones than pulse-beats. DYSPNEA in disease of the heart is out of all proportion to the physical changes in the lungs and is caused by pressure of the enlarged heart on the lungs, disturbed pulmonic cir- culation, hydrothorax, ascites, or bronchial catarrh. CARDIAC ASTHMA may be confounded with asthma of bronchial origin and the following table will assist in differ- ential diagnosis : DIFFERENTIAL TABLE OF ASTHMA. CARDIAC ASTHMA. BRONCHIAL ASTHMA. Signs of cardiac disease. Usually absent. Dyspnea is equally inspiratory and Dyspnea is expiratory. expiratory. Pulse in the early stage of parox- Pulse-tension usually increased ysm may be strong, but it soon throughout the paroxysm. becomes soft and small. Percussion shows an extension of Extension of lung-borders more the borders of the lungs and pronounced. obliteration of the area of super- / ficial cardiac dullness. 212 c a r d i a c I n s u f f i c i e n c y CARDIAC ASTHMA. Auscultation shows an absence of rales unless complicated by lung- edema. Tracheal traction-test is positive.* Cardiac stimulation will inhibit attacks and cardiotonic medica- tion will prevent them. Tests show cardiac insufficiency (page 215). Concussion of the ;th cervical ver- tebra may arrest an attack at once by provoking the heart re- flex (page 199). BRONCHIAL ASTHMA. Sonorous and sibilant rales are always heard and are loudest during expiration. Tracheal traction-test, negative. No special results from cardiac stimulation. No cardiac insufficiency unless heart-weakness exists as a com- plication, and then the right heart is usually compromised. Very frequently the attack can be subdued by concussion of the 4th and 5th cervical vertebrae (page 313). Cardiac insufficiency due to myocardial disease may be divided into three main groups, which are as follows : 1. An arrhythmic form, in which the pulse is irregular and intermittent and lacks force and volume. 2. A group characterized by acceleration of the pulse (tachycardia) and paroxysms of palpitation. 3. An asthmatic group, which is characterized by attacks of acute pulmonary edema and cardiac asthma. Usually the patients are middle-aged men of strong physique who have eaten to excess and have taken very little exercise. The frontier symptoms of cardiac incompetency in such *The author has described this test as an aid in the diagnosis of idiopathic asthma. ?0 When the head of a patient is thrown forcibly backward, the normal resonance obtained by percussion over the manubrium sterni and lungs contiguous thereto becomes converted into a dull or flat sound. This manceuver is the tracheal traction-test. It is positive in health and in all cardiopulmonary affections, excepting in idiopathic asthma. In other words, in the latter affection, the pulmonary resonance over the manubrium is unchanged when the head is thrown backward. The explanation of this phenomenon is dis- cussed on page 311. 213 S p o n d y I o t h e r a p y individuals are slight difficulty in breathing on exertion in ascending stairs and in walking up a slight hill. The in- dividual may observe that, after a hearty meal there is a feeling of uneasiness or a dull pain in the region of the heart. These symptoms continue to become more pronounced and are not infrequently associated with attacks of fluttering or palpitation of the heart. One may also observe in these cases signs of arter- iosclerosis. Percussion shows as a rule an increase in the area of cardiac dullness which may involve either ventricle or both. Respecting the prognosis in cases of cardiac insufficiency, it is usual to regard the cases as hopeless and that little can be done to patch up the crippled heart. The author, however, finds that provided a good heart reflex can be obtained, the prognosis is, as a rule, favorable. In this regard one may cite the observations of Heitz who shows that, the heart reflex of Abrams is a good guide by which to determine the probable effect of contemplated balneologic treatment. If the size of the heart does not change under the excitation of the reflex, by sharp blows over the precordial region, the treatment will be ineffectual or may even be contra-indicated on account of the probable development of cyanosis. In very large dilatations and in advanced myocardial degeneration, the heart does not respond to precordial excitation and is not favorably in- fluenced by baths. If the reaction is feeble, good results may be achieved, but the treatments must be used cautiously. Since the author has employed concussion of the spine of the yth cervical vertebra for provoking the heart reflex, decidedly better results can be achieved from treatment than by mere precordial excitation which has heretofore been practiced. 214 He a rt-Suffic i e n c y It may be remarked, that while the x-rays furnish the best proof of the amplitude of the heart reflex, yet results may be achieved by percussion, if the vibrosuppressor is employed as an aid (page 80). Here one percusses the heart to obtain the deep or relative cardiac dullness and the limitations of the organ are carefully marked with a pencil. Next, one rubs vigorously the skin over the region of the heart, or, better still, one strikes a series of concussion -blows upon the spinous process of the yth cervical vertebra and percussion of the heart is again executed ; any diminution in the area of cardiac dullness indicates the amplitude of the heart reflex. TESTS FOR HEART-SUFFICIENCY. In disease of an organ, the severity of a lesion is generally gauged by the incapacity of the organ to execute its functions. Thus it is, that in affections of the kidney, the percentage of albumin in the urine is of minor prognostic importance, provided the nitrogenous excretion is relatively normal. Similarly, in affections of the heart, a murmur is of no value in determining the prognosis of any given case, inso- much as some of the most serious affections of the heart are unaccompanied by murmurs. In the presence of a cardiac disease, whether of the valves or of the muscle of the heart (myocardium), it should be the primary endeavor of the physician to determine the functional capacity of the organ. Many functional diseases of the heart, described as cardiac neuroses are mere instances of heart-fatigue, for the heart like the skeletal muscles will tire when an additional burden is cast upon it; in fact, the heart may be the most vulnerable muscle in exhaustion. We have already noted (page 203) the effects of emotions on the heart and among neurasthenics, emotional influences 215 S p o n d y I o t h e r a p y must be regarded as additional etiologic factors in super- inducing heart -fatigue. There are many individuals, notably women, labeled as neurasthenics, who are really sufferers from cardiac incom- pensation. To determine the vigor of the myocardium, the conven- tional physical methods of examination furnish little practical aid, hence recourse is had to any of the following manceuvers : 1. THE PULSE METHOD. The pulse of the cardiopath is altered in character after body-movements and physical exertion in a more pronounced manner than in health, and such alteration is in proportion to the insufficiency of the heart -muscle. When the heart is healthy and one counts the pulse first in the erect and again in the recumbent posture, a retardation of the pulse in the latter position from 10 to 12 beats per minute is observed. In disease of the heart-muscle, however, retardation of the pulse in the recumbent posture becomes less and less conspicuous, the greater the degree of cardiac insufficiency, until in pro- nounced grades of the latter, the frequency of the pulse may even be greater in the recumbent than in the erect posture. 2. BLOOD-PRESSURE METHOD. This method (like the two following methods) requires the use of a blood -pressure instrument (sphygmomanometer, page 244). It is known that muscular work is associated with alterations in the arterial blood -pressure. In health muscular exertion in- creases the blood -pressure, but, if the heart is insufficient, this rule is reversed, viz., muscular exertion will reduce the blood -pressure. The less evident the rise in pressure after exercising the muscles, and the deeper the remissions of the blood -pressure curve and the less muscular exercise it takes to produce such remissions of pressure, and the longer it 216 He a rt-Suffic i e n c y takes for the blood -pressure curve to attain the normal, the greater is the functional incapacity of the heart. 3. METHOD OF KATZENSTEIN. After determining the blood -pressure and the pulse on the reclining patient, both of the femoral arteries are compressed with the middle finger of each hand at Poupart's ligament, the other fingers testing whether the compression is absolute. With normal heart -energy the blood -pressure then rises by from 5 to 15 mm. mercury, while the pulse remains unaffected or drops. When the compression is relinquished, the blood- pressure gradually returns to normal. A slightly enfeebled heart is not able to raise the blood -pressure when the ob- struction to the circulation is interposed, and with a much enfeebled heart the blood -pressure actually sinks under the compression, while in both events the pulse becomes more or less accelerated. The respiration is kept superficial during compression. 4. HEART REFLEX METHOD. After taking the blood- pressure, fix over the heart-region a pleximeter and strike the latter a series of vigorous blows with a hammer (Fig. 2), after which immediately take the pressure again. If the myocardium is sufficient, the blood -pressure remains the same or rises ; otherwise, it falls, and the rise and fall are in proportion respectively to the vigor and insufficiency of the heart-muscle, e.g.: BLOOD -PRESSURE BEFORE AND AFTER EXCITATION OF THE HEART-REGION. BEFORE. AFTER. CONCLUSION. 120 mm 140 mm Myocardium very strong. 135 mm 138 mm Myocardial sufficiency. 190 mm 155 mm Myocardial insufficiency. Concussion of the heart region elicits a maximum heart reflex with a temporary augmentation of vigor if the myocar- 217 S p ondylotherapy dium is normal, otherwise, the stimulation is in the nature of a shock. TREATMENT OF CARDIAC INSUFFICIENCY. One must concede the phenomenal results achieved in cardiotherapeutics since the inauguration of the Schott methods by saline baths and resisted movements in failing heart -power. If the Schott methods of treatment are effective, their efficiency is recognized by the following results : 1. A sensation of warmth. 2. Augmented pulse- volume with diminished frequency. 3. Stronger cardiac systole. 4. Diminished area of cardiac dullness. 5. Ameli oration of precordial distress. 6. A feeling of well-being. There are many theories concerning- the action of the saline baths and resisted movements, but in the opinion of the author, the theory that best responds to reason is that which supposes their action to be due to the elicitation of the heart reflex. From what has been said concerning the latter reflex (page 199), it is known that cutaneous stimulation of any kind will result in a vigorous contraction of the heart -muscle. Hence, mere friction of the skin with a coarse towel is equally as efficient as the waters of Bad Nauheim, in Germany, which owe their action to various chlorid salts and to the presence of carbonic acid.* In studying the amplitude of the heart reflex (Fig. 54), when elicited from various regions of the organism, the *"Dr. Bloch, of Franzensbad, uses carbonic acid douches for producing contraction of the heart, based on the fact discovered by Dr. Abrams, of San Francisco, that friction of the precordial region will produce contraction of the heart (Satterthwaite)." 218 Cardiac I n s u f f i c i e n c y author is justified in concluding that the most effective site is the spinous process of the *jth cervical vertebra, and that the most satisfactory method for its elicitation, is by means of the pneumatic hammer (Fig. 50) or any similar apparatus giving a percussion stroke. In the absence of an apparatus, mere concussion by means of a pleximeter and hammer (page 8) may be employed. The duration of each seance is governed by the results and one must not forget that a reflex may be exhausted as well as excited. My usual custom is to limit each seance to about five minutes with frequent periods of rest during the application of the percussion stroke. In the opinion of the author, the results achieved are more satisfactory and more rapid than by any other method of treatment. Very frequently he has observed cardiopaths with severe dyspnea and other signs of heart failure, who obtained immediate relief after a single seance of concussion -treat- ment. It is evident, however, that many seances are necessary before one may expect permanent results. It is equally evident that concussion must not be em- ployed to the exclusion of other methods of treatment in failing compensation, although the author has employed concussion exclusively in his cases to enable him to formulate conclusions respecting the efficacy of the method. Reference to Figs. 60 and 61 shows the effects of con- cussion of the yth cervical spinous process in two patients with dilated hearts superinduced by myocarditis. The relief following concussion is dependent on the duration of the heart reflex which, in turn, is dependent on the condition of the heart-muscle. In several instances of myocarditis no results were achieved by concussion, but in these cases the myocardium was past restitution. 219 S p o n d y I t h r a p y When attacks of cardiac asthma (page 212) or other paroxysmal symptoms of heart-failure occur at the home of the patient, some competent member of the family is instruct- ed to concuss the spinous process of the yth cervical vertebra by means of the pleximeter and hammer. FIG. 60. The effects of concussion of the spine of the yth cervical vertebra on the area of the heart in a patient with myocarditis. The continuous line represents the area of the heart before, and the broken line after, concussion. FIG. 61. The effects of concussion of the spine of the yth cervical vertebra on the area of the heart and liver in a patient with advanced myocarditis. The continuous line represents the area of the heart and liver before, and the broken line after, concussion. As a rule, the latter manceuver is followed by immediate relief of the symptoms. As observed on a previous page (215), some patients owe their infirmity to heart-failure and many anemic women who respond unceasingly to the demands of an active social life, who say they are "worn out," often suffer from an over- strained heart. The subjective symptoms are lassitude, slight dyspnea on exertion and digestive disturbances. 220 Angina Pectoris Objectively, one may recognize dilatation of the ventricles by percussion, feeble heart-tones, and a pulse which is rapid and feeble and may be irregular or intermittent. These cases, as well as those hearts which fail to respond to the tests of cardiac sufficiency (page 215) are benefited by concussion-treatment. ANGINA PECTORIS. THE HEART REFLEX OF DILATATION. Heretofore only one heart reflex was recognized, viz., the heart reflex of contraction (page 199), but when the spinal processes of the 9th, loth, nth and i2th dorsal vertebrae are rapidly concussed in succession there is a decided increase in the area of cardiac dullness as obtained by percussion. This increase in the area of cardiac dullness is not associated, as the x-rays show, with any increase in the diameters of the heart. The latter fact corresponds with the investigations of Kornfeld, who demonstrated that the heart -muscle possesses the property of increasing the size of its cavities without any corresponding augmentation of tension of its walls, a condition which he calls Ausweitungs- f'dhigkeit. Among the theories of ANGINA PECTORIS, that of Allan Burns appeals most cogently to reason. The latter assumes that, in consequence of a transient ischemia of the heart -muscle caused by disease or spasm of the coronary arteries, a condition analogous to intermittent claudication ensues. It is known that the coronary arteries are practically always diseased in fatal cases of angina, but if we accept the observation of Schafer that the coronary vessels are unprovided with vasomotor nerves, the theory of intermittent claudication of the coronaries must necessarily suffer a serious setback unless supported by other evidence. 221 S p o n d y I o t h e r a p y The coronary arteries supply the heart with blood only during diastole, for during systole the ventricular wall is so strongly contracted that the muscular tension becomes greater than the coronary pressure and so the coronary artery and branches are compressed and the blood is driven back into the aorta. It is our contention that the theory of Burns is correct, but that the ischemia is quite independent of the coronary arteries, which are merely passive structures. We assume that any factor operating to augment the tonicity of the cardiac musculature compresses the arteries in question and thus induces ischemia. The heart reflex is essentially a myocardial contraction and when the reflex is in evidence the coronary arteries are subjected to varying degrees of pressure. If in an attack of angina, the pulse shows augmented tension and is small and perhaps diminished in rate, or if syncope is observed, such symptoms are explainable by the heart reflex. We know that when the reflex is in evidence, the heart is practically inhibited; there is a diminished output of blood into the general circulation and, if the pulse shows increased tension, it is only an expression of vaso-motor activity which assumes the burden of maintaining the circulation. If one studies the etiology of angina, one notes that the factors which precipitate a paroxysm are also equally operative in inducing the heart reflex. Muscular effort is a potent factor which also provokes the myopathic heart reflex. Emotion is another prominent factor and led John Hunter to observe that "his life was in the hands of any rascal who chose to annoy and tease him." Emotion as a cause corre- sponds with the psychic heart reflex. A gust of wind striking the chest is equally involved in inducing either an attack of angina or the heart reflex. Oliver demonstrated that patients who have suffered from 222 Angina Pectoris precordial pain obtain permanent relief on the supervention of cardiac dilatation and failure, and Broadbent has shown that the supervention of mitral insufficiency may diminish the tendency to anginoid attacks. Now, in cardiectasis, while the heart reflex can be provoked, the cardiac musculature is enfeebled and the resulting pressure on the coronary arteries is correspondingly diminished. Reference has been made to the heart reflex of dilatation and in several instances, during my office hours, I have inhibited anginoid pains by concussion of the vertebrae which induces cardiac dilatation, and I have employed the same method with fairly good results in the treatment of angina pectoris. In other instances, I have unintentionally provoked attacks of angina in studying the heart reflex and the methods for its elicitation. Here concussion of the spinous process of the yth cervical vertebra is often effective in developing some of the symptoms of angina pectoris when absent and the same may be said of concussion of the precordial region. Thus, concussion from either region is a diagnostic sign of some importance and serves as corroborative evidence of the author's heart reflex theory of angina pectoris. Not infrequently eructa- tions of gas attend the concussion and here it is assumed, that concussion not only provokes the heart reflex by reflex stimulation of the vagus, but also the stomach reflex of contraction (page 316). By means of the heart reflex, one can easily comprehend the attacks of false angina. In functional angina, the heart reflex is always accentuated, as I have assured myself by repeated x-ray examinations. In cardiodynia (Herzangst) observed in neurotics, one is dealing essentially with a psychic heart reflex. The following table will aid in the differentiation of true and false angina pectoris : S p o n t h r a p y DIFFERENTIAL TABLE OF TRUE TRUE ANGINA. Most frequent between the ages of 40 and 50 years. More frequent in males and the paroxysms are evoked by exer- tion. The attacks are rarely periodic and nocturnal. No other symptoms. Pain is agonizing with the sensa- tion of compression by a vice. The pain is of short duration and the patient is silent and immo- bile. The lesion is a sclerosis of the coronary artery. Prognosis grave.' Arterial medication is effective. Antipyrin (large dose) may ac- centuate the pain, at any rate it gives no relief. AND FALSE ANGINA PECTORIS. FALSE ANGINA.* (Neurotic Form.) May occur at any age and even in children. More frequent in women and the attacks are spontaneous, peri- odic and nocturnal. Associated with nervous symp- toms. Pain is less severe and the sensa- tion is one of distention. Pain may continue for one or two hours and the patient is restless and talkative. Neuralgia of nerves and cardio- plexus. Never fatal. Antineuralgic medication. Anti- pyrin (large dose) is effective in subduing the pain (Huchard). There are etiological factors concerned in angina which on first view could find no explanation by my heart reflex ischemic theory, yet, on reflection, the theory is applicable. Thus, one of my friends, a physician in Paris, suffers like several other members of his family from pronounced attacks of angina pectoris several hours after the use of coffee, tea or tobacco. One knows, for instance, that the effect of caffeine in small doses on the cardiac muscle is to increase its activity ; in larger doses, it produces phenomena analogous to fatigue, and in very large doses, the muscle is thrown into *Reference on page 194 has already been made to false angina caused by intercostal neuralgia. 224 g n a c t o r rigor. In the latter instance, the strong contraction of the myocardium (which is essentially a heart reflex) mechanically compresses the coronary vessels. The toxic factor here involved in eliciting the heart reflex is necessarily delayed and cannot be immediate like the other factors concerned in the elicitation of the reflex in question. Digitalis and other circulatory stimulants may provoke an attack of angina for the reason that they augment the tonicity FIG. 62. The heart reflex; A before, and B, after, the use of digitalis. of the cardiac musculature. Digitalis increases the ampli- tude of the heart reflex as shown in Fig. 62. Recently I have observed the following singular phenom- enon : After placing the ankle of one lower extremity on the knee of the other extremity, the pulse of the anterior tibial artery is easily palpated (Fig. 63). Next, direct the patient forcibly to extend and flex his foot (the leg occupying the same position) a number of 225 Spondylotherapy times in succession. If the tibial pulse is again sought, it will be either very feeble or absent. In the norm fully thirty seconds may elapse before the pulse has attained its former volume. The blood -pressure also falls. In a patient with claudication, five minutes elapsed before the tibial pulse resumed its former volume. This test may prove of value in the diagnosis of the latter affection. I assume that the tibial artery, immersed as it is in a muscular atmosphere, responds reflexly to the muscular contractions, and in arte- FlG. 63. Position of the leg to facilitate palpation of the anterior tibial artery. riosclerosis the longer duration of the arterial contraction accounts for the phenomena of claudication. Here, as in my heart reflex theory of angina, the ischemia is dissociated with vaso-motor action, insomuch as when amyl nitrite is inhaled, obliteration of the tibial artery is effected by the muscular manceuver suggested. The treatment of angina pectoris includes the elimination of all factors concerned in the elicitation of the heart reflex. The value of amyl nitrite inhalation in the treatment of a. 226 Angina Pectoris paroxysm is universally conceded. When the latter drug fails, and it often does, the failure may be attributed to irritation of the nasal mucosa which induces the heart reflex, which would still further accentuate the paroxysm. In such instances and, in fact, in nearly all instances, the action of the drug in question is aided by previous cocainization of the nasal mucosa, which eliminates the irritant factor in amyl nitrite inhalations. Concussion of the lower dorsal FIG. 64. Demonstrating the amplitude of the heart reflex: C, left border of the deep cardiac dullness; A, recession of the same border when the heart reflex is elicited after excitation of the precordial region; B, still further recession of the same border when the heart reflex is elicited after concussion of the spinous proc- ess of the 7th cervical vertebra. Note in this figure that after concussion of the four lower dorsal vertebrae to excite the heart reflex of dilatation, the amplitude of the heart reflex of contraction after concussing the spinous process of the 7th cervical vertebra is from C to A only. vertebrae (daily treatment) should be given a trial in the treatment of angina pectoris to induce the counter-reflex of dilatation. It will be noted in Fig. 64, that after the heart reflex of dilatation is elicited, the amplitude of the heart reflex of contraction is diminished. In some instances, the treat- ment suggested for angina pectoris (true and false) and 227 Spondyloth r a p y cardiodynia is very effective, whereas in other instances, no results are achieved. FUNCTIONAL AFFECTIONS OF THE HEART. INHIBITION OF THE HEART. The rapidity and force of cardiac action are regulated by the pneumogastric or vagus nerve, which inhibits it, and the FIG. 65. Position of head to inhibit the heart. This position is the one adopted for obtaining the vago-visceral reflexes (q. v.). sympathetic, which accelerates it. Many persons can volun- tarily stop the action of the heart, and among Indian sorcerers, the phenomenon is regarded as a marvelous feat. The explanation, however, is very simple: by voluntary contraction of the muscles of the neck innervated by the 228 Heart - Inhibition nervus accessorius, the branches of the latter running in the path of the vagus nerve are irritated, resulting in temporary stoppage of the heart action. Czermak was able to press his vagus nerve against a little bony tumor in the neck, and by thus subjecting the nerve to mechanic stimulation was able to slow or even stop the beating of his own heart. If, in almost any healthy person, the carotid artery, or a point immediately adjacent to it in the neck, is compressed, slowing or complete inhibition of the heart and pulse ensues. This phenomenon is explained by compression of the vagus lying alongside the carotid artery. The author has shown, that forcible compression of the abdominal muscles (Fig. 59), inhalation of irritating vapors, firm pressure in any of the intercostal spaces and pressure at the vertebral exits of the spinal nerves (preferably at the side of the upper dorsal vertebrae, Fig. 48), will result in a reflex inhibition of the heart. A method which the author employs for this purpose is to have the patient firmly contract the muscles of the neck as shown in Fig. 65. There are many functional NEUROSES OF THE HEART, such as palpitation, arrhythmia and tachycardia, which owe their origin to insufficiency of the vagus nerve, and in con- sequence of such incompetency, the mastery of the organ is assumed by the sympathetic. Now we know that the action of the vagus can be reflexly controlled by the manceuvers already cited, and in this action, acceleration and irregularity of the heart can be mastered. By executing such a manceuver, we are merely subduing one reflex by its counter-reflex. In a case of tachycardia (heart -hurry) reported by Nothnagel, the attacks were jugulated by deep inspirations, and Rosenfeld's patient controlled her attack by going to bed, raising her head with her feet planted firmly against 229 Spondyloth e r a p y the foot of the couch, and then taking a forced inspiration she pressed down with all her might, with the object of closing her glottis. A patient of mine, a neurasthenic, controlled his attacks of palpitation by firm compression of an intercostal space with his finger. An analysis of the foregoing manceuvers, acquired instinctively, shows that what the patients did was to call into action the functions of the vagus nerve. The spinal region in juxtaposition to the vertebral exits of the upper spinal nerves (at about the spinous process of the 4th dorsal vertebra), is the most favorable site for calling into activity the functions of the inhibitory nerve of the heart. Here the most suitable method is to make firm compression (and maintain the compression for several minutes) with the thumbs on either side of the spine. The application of an ice-bag in the region shown in Fig. 48 (corresponding to yth cervical spine) is often of service and the same may be said of the sinusoidal current; one electrode in the sacral region and the other electrode in the region indicated in Fig. 48. In arrhythmia, the action of this current is often surprisingly efficient. The latter manceuver is equally available in diagnosis. Thus, in irregular action of the heart or in delirium cordis, the inhibition manoeuver, by temporarily inhibiting the rapidity of the heart, enables us to determine the time of a murmur; the manoeuver thus simulating the physiologic action of digitalis.* *Concerning the further employment of this manoeuver in diagnosis, vide "Diseases of the Heart," by the author, page 59. 230 The Blood-Vessels THE BLOOD-VESSELS. PHYSIOLOGY. The blood -pressure is most evident in the arteries and least pronounced in the veins, whereas in the capillaries, it is intermediate between the arteries and veins. Thus the blood circulates continuously in the direction of the lowest pressure (arteries to veins). Arterial pressure or tension is made up of four factors : 1. Ventricular pressure. 2. Peripheral resistance. 3. Elasticity of the arterial walls. 4. The volume of the circulating blood. INNERVATION of the blood-vessels is effected through the vaso -motor nervous system, which consists of the center in the bulb, subsidiary centers in the spinal cord and vaso-motor nerves. The latter are of two kinds : Vasoconstrictor nerves, which when stimulated cause contraction of the vessels, and vaso- dilator nerves, which dilate the vessels. The latter supply the musculature of the vessels and regulate their caliber, and their most pronounced action is on the arterioles, which contain relatively the largest amount of muscular tissue. In the norm, the arterioles are in a state of tonic contraction, and this is what constitutes the peripheral resistance which helps to maintain the blood -pressure and thus promotes the circulation of the blood. By means of the vaso-motor apparatus the amount of blood supplied to an organ is regu- lated. Thus, during digestion more blood must be supplied to the digestive organs, hence the arterioles of the splanchnic area are relaxed and there is a constriction of the vessels in other areas, as, for example, the skin; the chilly sensations after a meal are attributable to the latter fact. In certain 231 Spondyloth e r a p y organs, like the lung and brain, there are no vaso-motor nerves, because there are no variations in the blood -supply. There are afferent impulses which may reflexly excite the vaso-motor center in the medulla, and such impulses are divided into pressor and depressor. Most sensory nerves contain pressor fibers which, when stimulated, cause a rise of blood -pressure, whereas the depressor fibers also present in many sensory nerves will, when stimulated, cause a fall of blood -pressure. A distinct nerve known as the depressor nerve exists in animals in the trunk of the vagus, or as a separate branch running from the heart or the commence- ment of the aorta, and reaches the vaso-motor center by joining the vagus. PATHOLOGIC PHYSIOLOGY. The primary factor in blood -pressure is the force of ventricular systole, and any increase in the volume-output causes a rise, and conversely a fall, in pressure, provided the peripheral resistance is the same. In animals the pulse- rate is slowed when the arterial pressure is raised and accelerated when lowered. A continued high blood -pressure entails increased work on the part of the heart, but the abnormal tension of the ventricular wall stimulates the fila- ments of the depressor nerve and thus automatically causes a fall of pressure. Another protective mechanism exists to prevent excessive blood -pressure, and that is, when the peripheral resistance is very much augmented, the volume - output of the ventricle diminishes. Peripheral resistance, as has been noted, is made up of the tonus of the arterioles, but there are minor factors also concerned, notably, friction due to the viscosity of the blood and the subdivisions of the arterial tree. It has been show r n that the veins also possess tonus. Thus, stimulation of a splanchnic nerve will produce a contraction of the portal vein. The vasodilator have not 232 Blood r e s s u the same physiologic value as the constrictor nerves, for their division causes no narrowing of the vessel, hence they possess no tonus. It has been shown that stimulation of the muscles and the mucosa of the rectum and vagina will cause a fall of blood -pressure, and this fact is more evident during anesthesia. In the latter instance depressor in lieu of pressor reflexes occur. The abdominal vessels supplied by the splanchnic nerves have the most pronounced influence on the general blood -pressure, for the evident reason that they are sufficiently capacious to hold practically all the blood -volume of the body. Arterial elasticity diminishes the work of the heart. Hasebroek contends that there is a pro- pulsive energy at the periphery independent of that in the heart, and that the periphery represents another second independent pumping apparatus, coupled with that of the heart. The periphery has not only its elastic contraction and expansion, but also its active diastole and systole in the arteries. This diastolic -systolic activity is manifested in the capillaries as a sucking-in, an inspiration, as it were, while in the arteries it is more of a propulsive energy. Both these forces combine to create an independent and forcible stream into the veins, which are passive, and merely serve as a passive reservoir for the blood -stream. The blood-volume has only a subordinate influence on blood -pressure, as many experiments show. When the blood-volume is diminished, pressure is maintained by peripheral contraction of the arterioles, and when the volume is increased, certain compensatory mechanisms come into play, viz., dilatation of the vessels, transudation into serous cavities and lymph-spaces, and increased activity of the secreting organs. Another important factor in compensation is dilatation of the arterioles of the abdominal viscera caused by stimulation of the depressor nerve. 233 Spondyloth e r a p y NORMAL BLOOD-PRESSURE. Pressure, like temperature and the rate of respiration, is subject to fluctuations. Most of the recorded results have been obtained with the Riva- Rocci apparatus and the figures quoted represent the systolic pressure. Cook and Briggs present the following as repre- senting the average pressure: Children up to two years 75 to 90 mm. Children after two years 90 to 1 10 mm. Young adult males, about 130 mm. Women icto 15 mm. lower. A pressure below 70 mm. signifies very low, and above 200 mm. very high tension. Janeway has never seen a pressure above 180 mm. in a normal person, and seldom one above 160 mm. There are postural variations of pressure, hence all pressure estimations should be taken in the same position. Sleep lowers the pressure. Tobacco either increases or diminishes the pres- sure according to whether the subject experiences a stimu- lating or sedative effect ; this, at least, has been my observa- tion. Emotional influences and intellectual application in- crease the pressure. Muscular exertion increases the pressure, owing to augmented ventricular force; if, however, exertion is carried to exhaustion, the pressure falls. BLOOD -PRESSURE IN DISEASE. Among the dominant factors inducing high pressure (hypertension} are pains of all kinds which reflexly cause a stimulation of vaso -motor tone. Drugs like strychnin, digitalis, adrenalin, and other cardiotonics act by increasing either the peripheral resistance (vasoconstriction) or cardiac energy or both. Vasoconstriction is evoked by many toxic conditions (plumbism, nicotinism, gout, uremia). No doubt a toxic 234 Blood Pressure factor is also present in many psychoses. During labor pains two factors are present, the pain and the increased volume of blood sent to the heart by compression of the abdominal vessels. In renal affections the cause of high pressure is due to a number of conditions, notably, cardiac hypertrophy and increased peripheral resistance due to a vaso-motor spasm provoked by the irritating action of waste- products in the blood or degeneration of the peripheral vessels or both. Hypertension necessarily increases the work of the heart 'unless a compensatory factor is brought into play, and the primary effect is to cause cardiac hypertrophy. A hypertrophic heart is by no means as good as a normal one, as the old dictum runs, for, sooner or later, that heart will become insufficient. Hypertension diminishes the elastic distensibility of the arterial wall, and this in turn conduces to dilatation (aneurism) and rupture (cerebral hemorrhage) of the vessels. Diminished pressure (hypotension) is usually regarded as such when the systolic pressure in an adult is below 100 mm. Any or all of the factors concerned in blood -pressure may be involved ; wasting diseases reduce pressure by compromising all these factors. The vasodi- lators reduce pressure by diminishing the peripheral resist- ance and chloroform acts by directly paralyzing the vaso- motor center or heart. In acute infectious diseases the fall in pressure is due in part to vaso-motor paralysis and in part to weakness of the heart -muscle. Hypotension causes blood to accumulate in the veins (notably the abdominal) and diminishes the rapidity of the circulation. The vigor of the heart becomes compromised because it receives less blood. In affections of the nervous system Pal found that in tabes, during the occurrence of lightning pains, the pressure fell, and that during gastric and abdominal crises there was an enormous augmentation of pressure, hence he concludes 235 S p o n d y I o t h e r a p y that the latter are caused by a spasm of the splanchnic vessels. Cerebral hemorrhage, like all other conditions in- creasing intracranial tension, will cause an increase of pressure in proportion to the degree of such tension. A high and rising pressure points to more bleeding and a progressive failure of the circulation in the medulla. The observations of Bruce show that in insomnia there are cases with high and low pressure, and that the administration of erythrol tetranitrate to the former acted as a hypnotic (if it reduced tension). In arteriosclerosis (which will be discussed later at great length), the pressure is usually high. The arteries may be thickened and yet no rise of pressure exists ; in fact, if the heart-muscle is weak, the pressure may even be lower than normal. Janeway concludes that high pressure in this disease indicates involvement of the small arteries, especially in the splanchnic circulation. Among the symptoms of arteriosclerosis are headache, vertigo, apoplectiform attacks, and irritability. Such symptoms are accentuated when the pressure is high, and are aggravated by raising the latter with subcutaneous injections of adrenalin and ameliorated by the use of vasodilators. Amyl nitrite inhalation may be tried to rapidly secure the latter action. Sphygmomanometry has been utilized in tracing the etiology of insomnia. Thus, it is claimed that when the latter is caused by auto-intoxication, the blood -pressure is augmented, whereas it is very low in the insomnia of neu- rasthenia. Marfan contends that arterial hypotension is the rule in chronic pulmonary tuberculosis, and that a normal or increased pressure indicates a favorable prognosis. When the tension at the commencement of the treatment is low, and is subse- 236 Blood Pressure quently raised, the prognosis is equally favorable. Inversely, a constant low pressure portends an unfavorable course. In the differential diagnosis between gouty and tuber- culous affections of the skin or elsewhere, a high pressure argues in favor of the former and a low pressure in favor of the latter affection. Albuminuria is probably of renal origin if the pressure is high. In neurasthenia due to intestinal auto-intoxication the pressure is usually high, and treatment addressed to the condition will lower the pressure, whereas in neurasthenia due to actual exhaustion, the pres- sure is low. In high blood -pressure due to augmented tonus of the vaso-motor center (usually present in neurasthenic conditions) the bromids carried to their physiologic effects will cause such pressure to fall. When dependent on the absorption of enterotoxins, the abdominal application of the sinusoidal current for a week (daily seances of fifteen minutes) will cause a marked reduction in blood -pressure, otherwise the influence of the current is without pronounced effect. Amyl nitrite inhalations and nitrogylcerin are transitory in their action in reducing pressure. Cook found that sodium nitrite is less transitory in its action, and that one or two grains averages a fall of from 25 to 50 mm. Hg, coming on rapidly in from five to ten minutes on an empty stomach, and its effects may last as long as four hours. Veratrum viride is more permanent in its effects for vasodilation than the other remedies mentioned. The testimony of clinicians concerning pressure -figures in diseases of the heart are very conflicting, and I must there- fore still adhere to my observations concerning this subject, and referred to elsewhere (page 239). Janeway regards pressure as a means of differentiation between true and false angina, and observes that in the pres- 237 S p o n d y I o the r a p y ence of a pressure above 180 mm. anginoid pain is dependent on organic disease. In chronic interstitial nephritis high pressure is an early and important symptom. In other renal affections the question of pressure is less important. Uremic symptoms cause a rise in pressure, and that improvement spontaneous or as a result of treatment will cause the pressure to fall. In fact, many writers claim that uremic symptoms (headache, vertigo, etc.) are the result of high pressure. In typhoid, fever observations to be of any value must be made daily with the sphygmomanometer, just as one makes the record of the pulse and temperature. In this disease the pressure begins to fall with the development of toxemic symptoms, and one notes that this fall is progressive. The following figures of Crile are interesting: The highest pressure in 115 cases was 138 mm. ; the lowest, 74 mm. ; and the average, 104 mm. The average pressure in the first week of the disease was 115 mm. ; second, io6mm. ; third, 102 mm. ; fourth, 96 mm. ; and in the fifth week, 98 mm. A rapid fall in pressure indicates hemorrhage, whereas a progressive fall suggests enfeeblement of the vaso-motor centers. If per- foration occurs, there is usually a sudden rise of pressure. The fall of pressure in this disease suggests the value of cardiotonic medication, which in most instances is of more value than the measures employed for reducing the temperature. In surgery blood -pressure estimations are of unquestion- able value. The use of ether as an anesthetic either causes the pressure to rise, to be unaffected, or in a very small proportion of the cases to fall. Chloroform, as a rule, dimin- ishes the pressure. Peripheral operations involving irritation of nerve-endings and nerve-trunks cause a rise in pressure, and it has been suggested that sudden death following trivial operations may be caused by rupture of 238 Blood- P u diseased cerebral arteries, the result of a sudden increase of pressure. Hemorrhage in an anesthetized patient causes a sudden fall of pressure followed by a rise, provided the bleeding is not severe or complicated by shock. In collapse and shock a fall of blood -pressure is one of the most positive signs, and the fall is always in proportion to their severity. According to Crile, collapse is a sudden shock, a progressive fall of pressure, and in which the vaso-motor center does not respond to stimuli. In these cases the danger exists in loss of the vaso-motor and not of the cardiac function. The use of chloroform is interdicted when shock is feared and pe- ripheral stimuli are inhibited by "blocking" large nerves by means of cocain before their division. Bishop has directed attention to a constitutional condition of low arterial tension in children in whom no heart lesion exists. Such children suffer discomfort for lack of circulation (cold feet, depression and fainting attacks). The functional heart-tests show that the heart is not compromised. Otis, of Boston, suggests that blood -pressure should be taken as a routine measure. The average blood -pressure in tuberculous persons is about 126, and a fall in tension is suggestive of impending hem- orrhage. This latter may be warded off by ergot. In hemorrhage when the blood -pressure for the individual is high, inhalations of amyl nitrite or nitroglycerin may be used internally ; if low, ergotin is injected subcutaneously. THE VASO-MOTOR FACTOR IN BLOOD -PRESSURE. Among the factors which contribute to blood -pressure, the resistance offered by the blood-vessels is paramount. If the vessels are dilated, the pressure falls ; if contracted, it will rise. The nervous mechanism which presides over the tonus of the blood-vessels is the vaso-motor apparatus, and while the latter, I concede, may be reflexly influenced 239 Spondylotherapy by irritation from the blood-vessels themselves or from the end -organs of sensory nerves in general, we are inclined to forget that the vaso-motor apparatus may operate independ- ently of such influences. Emotions, and the state of mind in general, greatly influence the caliber of the blood-vessels through the vaso-motor system of nerves. Take neuras- thenics for a paradigm, and I have examined a large number of .them at different periods under emotional influences, intense mental application, and when their brains were at rest, and in each instance my results varied. Emotional influences and intellectual application increased blood - pressure, while mental rest reduced it. Blood -pressure is also influenced by physical activity, ingestion of food, mens- truation, etc. In other words, blood -pressure, to me, signifies nothing unless one takes into consideration the vaso-motor factor. Concerning the vaso-motor factor, the following con- clusions may be formulated : (i ) Blood -pressure is an expres- sion of action of two chief factors ventricular force and vasoconstriction. (2 ) The inhalation of amyl nitrite dissipates the vasoconstrictor factor and brings into play the ventric- ular force, which is the real factor to be encouraged in a failing heart. (3) The vasoconstrictor factor may and does compensate ventricular inadequacy, for it is essential in most cardioarterial diseases for the blood -pressure to be main- tained to afford better nutrition for the heart and to promote arterial elasticity as a means of establishing the circulation of the blood. (4) The recognition of the ventricular and vaso-motor factors in blood -pressure serves as a clue in the correct administration of cardiotonics. VASO-MOTOR SUFFICIENCY is tested as follows : Take the blood -pressure of the individual first in the recumbent and then in the erect posture. Normally there is a postural 240 Blood Pressure variation. In the erect posture blood -pressure rises, owing to compensatory arteriole contraction, and this difference between recumbency and standing varies, according to my measurements with the Riva-Rocci instrument, between 15 and 30 mm. In vaso-motor insufficiency the postural variations are reversed, and this is especially true in neuras- thenia, notably, the angiopathic form, and in the form described by the author as "splanchnic neurasthenia," where the blood shows an abnormal tendency to accumulate in the splanchnic area. I regard a continuously maintained high blood -pressure as the most constant factor in the etiology of arteriosclerosis, and, further, consider that the poisons absorbed from the intestinal canal are largely responsible for such high tension. The latter factor is easy of deter- mination. VASO-MOTOR METHOD OF TESTING CARDIAC SUFFICIENCY. As remarked before, blood -pressure is the resultant of two chief factors, viz., force of the cardiac ventricle and vaso- constriction. Remove the latter, and the ventricular force will come into play. Blood -pressure as taken ordinarily means nothing, for it is difficult to gauge how much of it is due to the action of the vaso-motor nerves and how much to the condition of the heart-muscle. The heart may be very weak, and yet show high blood -pressure, because vasocon- striction compensates a failing heart. The method is, briefly, to take blood -pressure in the usual way ; next have the patient inhale amyl nitrite from a bottle until the physiologic action (flushing) of the drug is secured, at which time again take the blood -pressure. In the norm the average increase of the pressure after the inhalation is from 6 to 10 mm. In cardiac enfeeblement there is a fall instead of a rise of pressure, and the degree of fall is proportional to the degree of myocardial insufficiency. All my investigations were 241 S p o n d y I o t h e r a p y made with the Riva-Rocci instrument. Clinicians have un- reservedly accepted the dictum of the physiologist that the nitrites lower the blood -pressure. The latter may be true with toxic doses, but my clinical investigations show that amyl nitrite inhalations will, in the norm, cause the pressure primarily to fall, but the systolic pressure immediately rises. It has been shown experimentally that if a nitrite is intro- duced into the cerebral circulation and prevented from attaining the general circulation, there is no fall in the blood- pressure. ARTERIOSCLEROTICS, according to my clinical observa- tions, may be classified as follows: (i) Those with high blood -pressure and strong cardiac tones who show, after amyl nitrite inhalations, a stabile or a slight rise of blood -pressure. Here the cardiac musculature is not yet compromised. (2) Those with high blood -pressure and enfeebled cardiac tones, who show after the inhalation a decided decrease of blood -pressure. In this, as well as the succeeding class, the reduction in blood-tension is influenced by the elimination of the tonus of the arteries, which was maintained by the vaso-motor system of nerves, thus allowing the true endo- cardial pressure, which is enfeebled, to be brought into action. (3) Those with relatively low blood -pressure and enfeebled heart tones who demonstrate a still further reduction of pressure after the inhalation. In a prognostic sense the latter class of arteriosclerotics belong to the hopeless category, insomuch as the vaso-motor system of nerves is either exhausted or unable to properly usurp the functions of a failing heart. TEST FOR ADMINISTERING HEART TONICS. All cardiac tonics may be divided into direct or indirect; the former acting by direct stimulation of the heart; the latter, by improving the nutrition of the organ or by relieving vessel- 242 Blood u tension and hastening the output of blood from the heart. I select a reliable infusion of digitalis for diagnostic purposes. In the therapeutic stadium i. e., after its administration for about three days it has a dual action, slowing the pulse and augmenting blood -pressure. The latter is the product of two forces increased heart-work and augmentation of the vessel-tone. Now, it is evident that digitalis may do as much harm as it does good. Supposing, before giving digitalis, we noted that the blood -pressure was 218 mm., and that after the inhalation of amyl nitrite it was reduced to 190 mm. ; that after the use of digitalis it was 215 mm., but the amyl nitrite inhalation reduced it to 1 50 mm. Now, the theory of action of the drug on the patient was practically as follows: The blood -pressure was essentially the same after as before the use of digitalis, but while amyl nitrite before the use of digitalis reduced the blood -pressure only 28 mm., after its use the pressure was reduced 65 mm. This would indicate that the digitalis was unfavorable in its action, for, after the tonus of the blood-vessels was removed by amyl nitrite, the greater reduction in blood -pressure demonstrated that the cardiac force was further reduced after than before the use of digitalis. In other words, digitalis was goading a jaded heart, and the high blood -pressure was illusory. This action is not uncommon in the administration of digitalis, owing to its vasoconstrictor influence, and when the latter implicates the coronary blood-vessels, the nutrition of the heart must suffer. In the case just mentioned digitalis showed an unfavorable action, but when it was given in combination with diuretin, which antagonizes the vaso- constrictor components of digitalis, the action of the latter drug was more favorable, the blood -pressure falling only 15 in lieu of 65 mm. Any of the nitrites may be combined with digitalis or strychnin when the vasoconstrictor effects of 243 Spondyloth e r a p y the latter are undesired. Strychnin, like many other drugs, has been discredited as a heart tonic because clinical meas- urements of the blood -pressure show no rise. The fact is that the vaso-motor mechanism which supplements the cardiac vigor increases the blood tension when the latter is enfeebled, and diminishes it when the cardiac strength is not involved. After adequate doses of strychnin hypoder- matically, the vaso-motor method of estimating pressure shows the cardiotonic properties of strychnin. In all instances cardiac auscultation and sphygmomanometry are necessary for estimating the action of cardiotonics. The sphygmomanometer only gauges the force of the left ventricle, and to determine the sufficiency of the right ventricle, auscultation of the cardiac tones is alone adequate. The cardiac chambers, even in health, are not constant as far as their diameters are concerned ; on the contrary, they contract and dilate; in other words, their capacity tends to diminish with increasing cardiac vigor; hence percus- sion shows an increase or diminution in the area of cardiac dullness according to whether the heart is insufficient or sufficient. SPHYGMOMANOMETRY. The instrument employed for estimating blood -pressure is called a sphygmomanometer and it is as essential to the physician as is his clinical thermometer. All sphygmomanom- eters are based on the principal of circular compression of the arm by an arm -piece, B (Fig. 66), connected with a manometer (^4) and an inflating apparatus (C). When the arm-piece is sufficiently tight to obliterate the pulse at the wrist, the height of the mercury in the manometer indicates the maximum systolic pressure. With the in- struments of Janeway and Stanton, the diastolic pressure 244 S p h y g m omanometry can also be obtained. The highest pressure in the pulse - wave is the systolic; the lowest, the diastolic; and mean pressure signifies the average of systolic and diastolic pressures. For all practical purposes it is sufficient to esti- mate the systolic pressure, for it is more often modified by pathologic conditions than the diastolic pressure. The diastolic pressure in a normal pulse is 25 to 40 mm. below FlG. 66. Sphygmomanometer of Riva-Rocci (Cook's modification): A, manometer; B, arm-piece; C, inflating apparatus. the systolic pressure, and in high tension it may be as low as 50 to 80 mm. Many circumstances modify our clinical results, and certain precautions must "be taken with the use of all sphygmomanometers. All observations must be made with the patient in the same position ; the arm-piece should be applied at the heart-level and should fit accurately. A wide arm -piece (12 cm.) must be employed. The con- nections must consist of non-distensible tubing. It is, of 245 S p o n d y I o t h e r a p y course, better to employ an instrument which measures systolic and diastolic pressures. The author has frequently noted in his observations the possibility of mistaking his own pulsations for those of the patient. To obviate this error in estimating blood -pressure, he places a rubber ring at the base of his index -finger to exclude the blood, and consequently the pulse from the latter (Fig. 67). TREATMENT OF HYPERTENSION. The drugs employed for reducing a high blood -pressure are known as vasodilators. They produce paralysis of the vasoconstrictor mechanism, which is first manifested in the FlG. 67. Rubber- ring for excluding auto-pulsations. face by dilatation of the cutaneous blood-vessels (blushing). The redness is not confined to the face, but may extend over the entire trunk. With the flushing there is also a sense of heat, throbbing of the blood-vessels, headache, quickening of the pulse and respiration, and ringing of the ears. The veins are likewise dilated. The dilatation of the arterioles and veins of the splanchnic area leads to a decline in the general arterial pressure. In the administration of the drugs of this class one must push them sufficiently to secure their physiologic effects, and then reduce the dose or stop the drug when the patient complains of throbbing or a feeling of fullness in the head. Some patients show a 246 High Blood -Pressure remarkable idiosyncrasy to drugs of this class, reacting to insignificant doses, whereas others are resistant to very large doses. It is evident, then, that one must begin with small doses to test individual susceptibility. Among the drugs used for lowering blood -pressure are the following: 1. Amyl nitrite, which is employed by inhalation. Its action is manifested within fifteen seconds and the symptoms disappear within three minutes. 2. Erythrol tetranitrate (tetranitrol). Its effects appear only after an hour and they last about five hours. Dose, one-half to two grains, usually in tablets. 3 N itroglycerin (trinitr^n). This drug acts in about two or three minutes, but its effects only last from one-half to three hours. It is official as a one per cent alcoholic solution; Spiritus glycerylis nitratis, dose, one to three minims. 4. Sodium nitrite, given in doses of from two to three grains. It corresponds in rapidity and duration of action to trinitrin. 5. Potassium iodid, although not an active vasodilator, clinical observations show that by its prolonged use, a lowering of blood-pressure may be achieved, probably in consequence of its vasodilator action. 6. High blood-pressure is often maintained as a result of augmented tonus of the vaso-motor center, and is quite independent of vascular disease. It is essentially a nervous phenomenon. Give such subjects sufficiently large doses of bromids for several days, and it will be noted that there is a considerable fall in the blood-pressure. In the opinion of the author, pharmacotherapy is not always satisfactory in the treatment of hypertension for the reason that toleration for the vasodilators is rapidly acquired and for the additional reason that their action is evanescent. 247 Spondylotherapy From what has preceded, one is justified in concluding that, hypertension is often a condition which is desirable and not to be opposed, insomuch as the vasoconstriction may compensate a failing heart. In such instances, vaso- constrictors are injurious and the correct course to pursue is to strengthen the heart and the blood -pressure will fall of its own accord. The latter effect may be rapidly attained by concussion of the spinous process of the jth cervical vertebra or more slowly by the administration of digitalis. The following case is cited as a paradigm of many like cases illustrating the preceding fact. A patient has a blood -pressure of 240 mm. Auscultation and percussion of the heart demonstrate cardiac enfeeble- ment. Concussion of the spinous process of the yth cervical vertebra is executed (duration of seance, 5 minutes). The blood -pressure is again taken and found to have fallen 30 mm. Each day thereafter, concussion is executed and, at the end of about ten days, the blood -pressure has fallen to 165 mm., the area of cardiac dullness is diminished and there is a decided strengthening of the heart-tones. Later, in consequence of over-exertion, an examination of the heart shows cardiac enfeeblement and the blood -pressure has risen to 200 mm., but with repetition of the concussion - treatment, the pressure falls to 165 mm. Now, in a case like the preceding, an examination of the heart would not have been necessary to justify the conclusion, that the high blood -pressure was only an expression of cardiac enfeeblement; estimating the blood -pressure before and after the concussion -treatment would have sufficed to warrant the deduction. Many erroneous conclusions are formulated concerning the vigor of the heart by aid of auscultation. Here, it is 248 Hyp ertension and H y potension assumed, that accentuation of the second aortic tone suggests vigor of the left ventricle of the heart, yet one may hear very loud heart-tones in anemic and emaciated persons. The fact is, that two factors contribute to the genesis of the tones of the heart, viz., muscle and valves, and it is often difficult to distinguish the prolonged and dull sound of the former from the short and sharp sound of the latter. CONCUSSION IN HYPERTENSION AND HYPOTENSION. The writer has established empirically that, one may rapidly reduce the blood -pressure by applying the concussor (large enough to include two spinous processes, Fig. 50) of a vibratory apparatus yielding a forcible percussion stroke to the spines of the 2nd and yd dorsal vertebra and maintaining the seance for about five minutes. Hundreds of investigations thus made convince the author that, by this method, one is in possession of a means for reducing pressure heretofore unattainable by pharmacotherapy, insomuch as the results are more rapid and lasting. The following are the records of two arteriosclerotics : 1. Mrs. W. Blood-Pressure before vibration of the 2nd and 3rd dorsal spines 225 mm. One minute after vibration 218 mm. Two minutes after vibration 185 mm. Three minutes after vibration 178 mm. Fifteen minutes after vibration 180 mm. Thirty-five minutes after vibration 178 mm. Two hours after vibration 172 mm. The following day 168 mm. 2. Mr. S. Blood-Pressure before vibration 228 mm. Two minutes after vibration 232 mm. Five minutes after vibration 210 mm. Eighteen minutes after vibration 200 mm. 249 S p o n d y I o t h e r a p y Not infrequently, the primary result of concussion is manifested by a temporary rise of pressure followed by a decided fall which attains its maximum in about two hours time. One must not assume, however, that the results in hypertension are always uniform. In some instances no effect is achieved, and the author is constrained to believe that, in such cases, the hypertension is due to cardiac enfeeblement, and it is only after toning the heart that a fall of blood -pressure occurs. When the blood -pressure is diminished in arteriosclerotics by aid of concussion, it is usual to find a heart showing little or no enfeeblement. If there is no fall of pressure following concussion of the 2nd and 3rd dorsal spines and and a fall is only observed after concussion of the 'jth cervical spine, the high pressure is caused by cardiac weakness and concussion of the spine in question is indicated to reduce pressure which it does by toning the heart. If a patient has certain symptoms which one assumes are caused by the arterial hypertension, a reduction of the latter by the foregoing method (concussion of the 2nd and 3rd dorsal spines or yth cervical spine) suggests the correct- ness of the diagnosis and the treatment conducted along the same lines will prove in a relative sense, curable. Thus in cerebral arteriosclerosis, the patient may have headache, vertigo, transient pareses or aphasia. If, following concussion, there is diminished arterial-tension and an abatement of symptoms, the diagnosis is suggested. LOW BLOOD -PRESSURE. (Hypotension.) A systolic pressure below loomm., suggests hypotension and is observed in wasting diseases, infections, hemorrhages, collapse and shock and after the use of vasodilators. 250 Low Blood- Pressure SUPRARENAL INSUFFICIENCY. The "tache cerebrate" is a red line with white borders produced by drawing the nail over the skin. It is a vaso-motor phenomenon present in typhoid fever and meningitis, and is without diagnostic significance. Sergent directed attention to a "white line," which is the converse of the tache cerebrate. Like the latter, it is evoked by drawing the finger-nail across the abdominal skin. Within thirty to sixty seconds a white line appears, which persists from two to five minutes. Sergent found the line in Addison's disease and in a number of specific fevers, all of which were characterized by low arterial-tension. In these cases he found that the administration of suprarenal extract caused the white line and the low tension to dis- appear. He therefore regards this line as useful in the diagnosis of suprarenal insufficiency and in affections of the capsules. Other French writers have confirmed this observation. The white line is caused by a reflex spasm of the capillaries, and can be provoked in vasodilatation and in conditions of low vascular tension. There is much reason to question the constancy of the white line as a diagnostic symptom. Thus, de Massary failed to observe the sign in six cases of Addison's disease, even though the arterial tension was very low. Grimbaum finds that the oral ad- ministration of suprarenal extract to normal individuals does not cause a rise of blood -pressure, and that when a rise follows exhibition of the drug by the mouth, it indicates suprarenal inadequacy. In doubtful cases the blood -pressure is accurately determined, and then 3-grain doses of the extract are administered thrice daily for three days. The pressure is again estimated, and a distinct increase is very suggestive of Addison's disease, provided there is no valvular lesion of the heart. Suprarenal insufficiency should be tested whenever asthenia and pigmentation are present. 251 S p o n d y I o t h e r a p y The latter are the chief symptoms of Addison's disease, but are likewise present in many other diseases. If there is no bronzing in Addison's disease the application of a mustard plaster will draw the pigment to the surface of the skin. NEURASTHENIA is often associated with hypotension, in fact, it is the only demonstrable sign in these cases. Such patients usually complain of obscure abdominal symptoms (SPLANCHNIC NEURASTHENIA) and this is not surprising considering the fact that the loss of vaso -mo tor tone conduces to a large accumulation of blood in the abdominal veins. TREATMENT OF HYPOTENSION. It is exceedingly injudicious practice as a routine method, to have recourse to symptomatic treatment, but insomuch as physicians are human and not divine, such treatment is often imperative and indeed efficacious, when the causal factor is not demonstrable. Thus, in hypotension, many drugs are efficient for influencing collapse and the drugs used for this purpose are the following: Strychnin, camphor, caffein, strychnin and ether. The foregoing cardio-vascular stimulants, however, are only temporary in their action. Much was expected of adrenalin in the treatment of hypotension, but, unfortunately, disappointment has attended its employment. This agent causes a decided rise of blood-pressure, due to its vasoconstrictor action on the blood-vessels and by its direct action on the heart. It causes retardation and strengthening of the heart-beat. The vascular constriction is most pronounced in the splanchnic and muscular vessels, and feeble or absent in the cerebral and pulmonary vessels. 252 Low Blood -Pressure The renal vessels are first constricted, with diminished flow of urine, but dilate with larger doses and increased flow of urine. The augmented blood -pressure almost immediately succeeds the use of the drug, but it is of short duration. It has been found that vasoconstriction is of greater duration than the rise of blood -pressure, and this is explained by the fact that the stimulating effect on the heart is of less duration than the stimulating action of the arterial musculature. The bath -treatment of typhoid -fever has demonstrated that, the water has a decided hypertensive action on the vaso -motor system and that it produces a rise of the blood - pressure. The latter result demonstrates the very pertinent fact that cold water acting as a peripheral cutaneous stimulant provokes the heart reflex and, insomuch as the force of the ventricular systole is the primary factor in blood -pressure, the latter rises. Now, the author has repeatedly demonstrated that there are many individuals showing cardiac enfeeblement in whom there is no response on the part of the vaso -mo tor mechanism to compensate the failing heart. Here, strengthening of the enfeebled heart by means of digitalis or by concussion of the spine of the yth cervical vertebra results in a rise of blood - pressure. The author has established empirically that concussion of the spines of the 6th and jth dorsal vertebra will raise the blood -pressure. The results, however, are not as uniform as is the method for reducing blood -pressure, and not infrequently, the effects are only noted after a lapse of about two hours. If the latter method is effective, the results are relatively permanent and many neurasthenics with hypotension can bear testimony to the foregoing statement. 253 S p o n d y I o t h e r a p y The duration of the seances is about the same as when concussion is employed in hypertension. ANEURYSM OF THE THORACIC AORTA. THE AORTIC REFLEXES. The course of the upper surface of the normal aorta in the adult of middle life may be projected on the thorax by * kc. FIG. 68. Relation of heart and aorta to the chest wall: i-io, ribs; Ao, aorta; RS and RC, right subclavian and carotid; LS and LC, left subclavian and carotid. drawing a curved line, beginning at a point corresponding to the right sternal line in the middle of the first intercostal space and ending at the point of insertion of the first left rib to the sternum (Fig. 68). The highest point of the aortic arch is distant about 5 cm., and the beginning 2 cm., from the anterior thoracic wall, hence a forcible percussion blow (which is propagated to a depth of 5 cm.) cannot fail to elicit the dullness of the aortic arch if dilated. 254 A o r R e f I e In the norm, the transverse dullness of the aorta at the level of the manubrium extends 2 or 3 cm. to the right of the median line of the sternum and 1.5 to 2.5 cm. to the left of the medial line. If the transverse dullness at this point exceeds 5 cm., the aorta is either dilated or the site of an aneurysm. The aorta is nearest the anterior chest-wall at FIG. 69. Aortic reflex of contraction FIG. 70. Aortic reflex of contraction, and dilatation. Front. and dilatation. Back. the junction of the 2nd right interspace with the sternum. From this point as it arches over to the left, it sinks deeper into the cavity of the thorax so that it eludes percussion. Concussion of the four last dorsal vertebras (gih to the 1 2th dorsal vertebra) in succession, by a series of sharp, vigorous blows will, in the norm, dilate the thoracic aorta which can be demonstrated by the x-rays and by percussion. Percussion must be executed at once after concussion of the vertebral spines in question, insomuch as the duration of 255 Spondyloth e r a p y the reflex of aortic dilatation is limited (from one -half to one minute). Vibrosuppression (page 80) will aid in defining the course of the aorta. Concussion of the spine of the *]th cervical vertebra causes a contraction of the thoracic aorta (aortic reflex of con- traction}. Thus it is, that when one provokes the dilatation reflex, the counter reflex of contraction will, at once, dissipate the former reflex. Percussion of the vertebral spines is executed by means of the hammer and pleximeter or the hands (Fig. 3). THE AORTIC REFLEXES IN DIAGNOSIS. As before remarked, one is able to define by percussion the normal area of the arch of the aorta after concussion of the four lower dorsal vertebrae. Thus it is, that if the diminished resonance or dullness exceeds the norm, either the vessel is dilated or it is the site of an aneurysm. One may remark that if an aortitis is present, the reflex of dilata- tion will reproduce the symptoms peculiar to this affection, viz., pains in the upper sternal region extending through the mediastinum and to the shoulder and arm. A dull area in the upper thoracic region or in the back (corresponding to the site of the aorta), if caused by a thoracic aneurysm, will show a diminished area of dullness when the spine of the yth cervical vertebra is concussed (aortic reflex of contraction), and an increased area of dull- ness, when the spines of the four lower dorsal vertebrae are successively concussed (aortic reflex of dilatation). Up to the present time of writing, the author has examined 45 cases of aneurysm of the thoracic aorta and has noted an absence of the reflex in only two patients in whom the aneurysms had attained enormous dimensions. All these cases were controlled by skiascopic examinations. With 256 Aortic Reflex of Contraction the latter, one may note a contraction and dilatation of the aneurysmal sac when the spines of the special vertebrae are concussed. One may generally observe an almost immediate evanescence of pressure -symptoms (dyspnea, cough and pains) when the sac is brought to contraction after a single seance of vibration -treatment applied to the spine of the yth cervical vertebra. THE AORTIC REFLEX OF CONTRACTION IN TREATMENT. It occurred to the writer when he first employed the aortic reflexes in diagnosis, that if concussion of the yth cervical vertebra would cause contraction of an aneurysmal sac, this fact would prove advantageous in the treatment of a thoracic aneurysm. The results achieved have exceeded the author's expectations. Only fourteen patients with thoracic aneurysm have thus far been treated by the author according to his method, but they were all advanced cases. Absolutely no results were achieved in one case (the aneurysm had attained an immense size and the sac ruptured). This much may be said for this treatment that the results usually follow after several seances of the concussion -treatment. The first case of aneurysm of the thoracic aorta thus treated was seen in consultation with Dr. A. J. Sanderson, of Berkeley. The following record is presented : Treatment was commenced July y, 1905, on which date the patient complained of violent pains in the chest and dyspnea on the slightest exertion. On August 2, 1905, the x-ray shadow of the aneurysm was denser, and the aortic reflexes could not be elicited. The latter I attribute to clot- formation in the aneurysmal sac, which inhibited whatever elasticity remained in the aortic walls. At this date aneurys- mal pulsations could no longer be detected by the rays. Dullness, formerly present over the sac on the anterior chest-wall could no longer be elicited. Tracheal tugging 257 S p o n d y I o t h e r a p y was barely perceptible. The thoracic pains had disappeared, and there was no longer any dyspnea on exertion. On the first of September, Dr. Sanderson stated that the only symptom which remained at the time the patient left his home was slight tracheal tugging. In all my cases the latter symptom persisted despite the disappearance of subjective symptoms. Dr. Hubert N. Rowell, of Oakland, directed a patient (male, age 56 years) to me, who noted about four years before coming, the following symptoms : Cough, pressure in the chest, dyspnea and a sensation of suffocation when he assumed the recumbent posture. An examination demon- strated a large aneurysm of the arch of the aorta. Just before treatment was commenced, the patient could not get more than three hours sleep at night owing to paroxysmal attacks of coughing and choking. After the first treatment he could sleep the entire night, and after two weeks' treatment consisting of daily seances (five minutes duration) by means of vibration applied to the spine of the yth cervical vertebra, the patient was practically well and there was nothing to indicate the persistence of his original trouble beyond a slight tracheal tugging. During this brief period he gained ten pounds in weight.* Dr. William Clark, of Alameda, made the following notes concerning a patient whom he sent to me for treatment on February 26, 1909 : Miss G. Age 30 years; native of California. Complains of croup at night whenever she catches cold. HISTORY: Measles, whooping-cough and diphtheria; typhoid fever thirteen years ago. Is not sure about scarlet fever. Menstrual history normal. About *This patient, re-examined after a year, is absolutely well and shows an increase in weight of twenty pounds. 258 Aortic Reflex of Contraction eight years ago noticed a choking sensation. This becoming worse, was the reason for consultation. She cannot lie on left side at night; also is quite short of breath upon exertion. EXAMINATION: Fairly developed; eyes protruding; no trouble since using glasses; no headaches; has no pain. Notices that voice is more husky since I last saw her. Is slightly dyspneic at this time. Veins on the anterior part of the chest quite dilated. No pulsation over upper part of chest noticed. Exam- ination of lungs negative. Spleen not palpable. An area of slight dullness over upper part of sternum and to the right. Loud bruit over the arch of the aorta, heard loudest at junction of the clavicle with the sternum on the left side; bruit transmitted to the subclavian and carotids, more so to the left; is also transmitted along the course of the aorta, and is heard over the abdominal aorta; also heard posteriorly over the entire course of the aorta. Radial arteries apparently not atheromatous. With laryngoscope, right vocal cord apparently not as active as the left. This, however, may be erroneous, as there is considerable difficulty in obtaining a clear view, owing to position and contour of epig- lottis. No tracheal tugging detected. Left radial- pulse possibly more forcible than right. With x- ray, pronounced pulsation of the arch of the aorta noticed, and arch also noticeably elongated in a vertical line. Heart apparently not much enlarged. DIAGNOSIS: Aneurysm or dilatation of the aortic arch. This patient was examined by the author in association with Dr. Clark and the percussional results elicited by inducing the aortic reflexes of contraction and dilatation are noted in Fig. 71. It was noted that, when the aortic reflex of dilatation was provoked, there was a temporary aggravation of the dyspnea 259 Spondylotherapy and spasmodic cough, but they were at once subdued when the aorta reflex of contraction was elicited. Within several days after treatment was commenced, all the subjective symptoms disappeared and after five weeks' treatment by percussion-massage of the spine of the yth cervical vertebra the patient was practically discharged. The patient's FIG. 71. Aortic reflexes of contraction and dilatation represented by the clotted lines within and without the continuous line (which represented the area of aneurysmal dullness before elicitation of the aortic reflexes). exophthalmos disappeared after a few treatments and further reference to this subject is made on page 280. It is unnecessary to detail the histories of the other cases of thoracic aneurysm beyond saying that the results achieved corresponded in the main to the cases cited.* *Since the above was written, a gentleman of approximately 53 years of age had developed an attack of whooping-cough which was epidemic. Cough and laryngitis persisted for over four months. Examination demonstrated the presence of an aneurysm of the thoracic aorta. The question naturally arose, Was the cough due to the whooping-cough or aneurysm ? Concussion of the 7th cervical vertebra was executed and it was not until the sixth seance that the cough and laryngitis abated, showing that the aneurysm alone was responsible for his cough. Unlike my other cases of aneurysm, the cough did not yield to the first concussion-treatment. Again, the aneurysm as a sequela of whoop- ing-cough is interesting. I had examined the patient while under the care of Dr. Grant Selfridge in the commencement of his attack of pertussis and found absolutely no signs of an aneurysm. The patient in question had absolutely no more attacks of coughing after the twelfth treatment and the area of aneurysmal dilatation was no longer evident by percussion. 260 Aortic Reflex of Contraction Now, a few words are necessary respecting the method of treatment. In the therapeutic elicitation of the vertebral reflexes, notably, the aortic reflexes, the vibratory apparatus which the physician must employ is one giving the percussion stroke. All other motions, such as oscillations, shaking, and friction interfere with results; in other words, one must select an apparatus which percusses. First, dust some talcum powder over the site of the spine of the yth cervical vertebra to avoid irritation from any friction of the pad connected with the apparatus; next, cover the spine of the vertebra with several layers of lint which are attached to the skin by adhesive plaster. After this, the percussion stroke may be communicated directly to the spine of the yth cervical vertebra, or indirectly, if the skin is sensitive by interposing a strip of linoleum. The daily seances according to results, may last from five to fifteen minutes, but during the seance the treatment must be interrupted from time to time to avoid irritation of the skin. The latter may be avoided if the operator directs the patient to inform nim the moment a burning sensation is experienced. The author only employs the pneumatic hammer (Fig. 50) for concussion and, insomuch as there is no friction, the preceding precautions are unnecessary to avoid irritation of the skin. In the absence of a suitable apparatus one may employ a pleximeter (a strip of linoleum) applied to the yth cervical spine which is struck a series of rapid and moderate blows by means of a hammer to the end of which is fixed a large piece of hard rubber. It is wise in this method, to protect the spinous process with a thick layer of lint. The author has not the hardihood to regard his method of treatment of aneurysm of the thoracic aorta as curative, for time alone is the decisive factor; yet a conservative 261 S p o n d y I o t h e r a p y estimate of the results thus far achieved prompts him to say that as a palliative method, it surpasses any which has yet been recommended to the profession. The diagnosis of aneurysm of the thoracic aorta, despite our physical methods of examination, is often fraught with difficulty, but the latter is minimized if the physician will remember the following facts: Symptoms suggestive of an aneurysm of the thoracic or abdominal aorta are accentuated after concussion of the spines of the four lower dorsal vertebrae and they are mitigated after concussion of the spine of the yth cervical vertebra, although several seances may be necessary to note the latter result. Further, an area of percussional dullness which enlarges when the four lower dorsal vertebrae are concussed and diminishes when the spine of the yth cervical vertebra is concussed, suggests an aneurysm. It is reasonable to assume that an aneurysm of the abdominal aorta would be similarly influenced by the maneuvers suggested, but the author is in the possession of no evidence to permit him to cite a supposition as a fact. * ANEURYSM OF THE ABDOMINAL AORTA. Since the foregoing was written, a patient was referred to me by Dr. E. N. Torello. The patient in question (male, age 65 ) had excruciating pains referred to the abdomen and thorax for nearly a year, which resisted all methods of treatment and necessitated the constant use of analgesics. An examination revealed signs of arteriosclerosis and a dullness in the left lumbar region ; the area of dullness in- creased when the four lower dorsal spines were concussed and diminished when the jth cervical spine was concussed (Fig. 72). Beyond the latter, nothing was demonstrated, although 262 Abdominal A o r t a FIG. 72. Area of dullness in aneurysm of the abdominal aorta. The con- tinuous line represents the area of dullness before concussion, whereas the dotted line within the latter, is the aortic reflex of contraction (concussion of the 7th cervical spine), and the dotted line without, the aortic reflex of dilatation (concussion of the spines of the four lower dorsal vertebrae). It is interesting to observe that the percussion- sign in question was the only evidence suggesting an aneurysm and the diagnosis was established later by other signs. 263 Spondylotherapy the latter sign suggested an aneurysm of the abdominal aorta. Some weeks later the author again examined the patient with Dr. H. Sawyer, and a definite tumor could be felt with an expansile pulsation and a slight thrill. The diagnosis having been definitely established, treatment consisting of concussion of the spine of the yth cervical vertebra was commenced ; the daily seances lasting about ten minutes. After the fourth treatment the pains continued with the same intensity (night and day) as before, but the pains were strictly localized on the left side of the abdomen. Until about the tenth seance, the patient asserted that the pains were not mitigated. The latter statement was dis- couraging considering the fact that in the author's experience, the symptoms of thoracic aneurysm had usually yielded to a few .treatments. After the tenth seance, however, the pains gradually became less intense and analgesics were no longer required. There was later, however, a decided interruption in the improvement of the patient owing to the fact that one morning, after considerable straining at stool, the pains recurred with almost the same violence as before, but a continuation of the treatment by concussion caused the pains to disappear gradually, and at the time of writing, the patient is practically well. It may also be noted, that coincident with the recurrence of pain after straining at stool, the dullness in the left lumbar region was demonstrable. Straining at stool increases intra-abdominal pressure and rupture of an aneurysm is very likely to occur. The author wishes to emphasize that in all his aneurysmal patients, concussion was the only method of treatment em- ployed. Considering the results attained in aneurysms of the aorta, it is not beyond the domain of reason to hope for like results in aneurysms of other vessels. 264 Reflex of Abdominal Aorta REFLEX OF THE ABDOMINAL AORTA. The 1 2th dorsal spine corresponds to the aortic orifice in the diaphragm and also to the celiac axis. It is known that the most frequent site of an aneurysm of the abdominal FlG. 73. Area of dullness corresponding to the iath dorsal vertebra and representing the reflex of the abdominal aorta after concussion the four lower dorsal spines with the hammer and pleximeter (Fig. 2). The increased area of the dullness represented by the dotted lines on both sides suggests a dilatation of the aorta, whereas the irregular dotted line on one side suggests an aneurysm. aorta is just below the diaphragm in the neighborhood of the celiac axis. In the norm, the area over the i2th dorsal vertebra and to either side yields a resonance on percussion. If one strikes in succession the four lower dorsal spines, the normal resonance over the i2th dorsal vertebra and to either side yields a dullness which in the average subject measures about 5 cm. (Fig. 73). If the lumbar vertebrae show resonance on percussion 265 Spondyloth e r a p y prior to the elicitation of the aortic reflex of dilatation, a dullness is likewise noted over the four first vertebrae in question. The dullness over and to the right and left of the i2th dorsal vertebra is caused by distension of the aorta. It persists for several minutes or may be dissipated at once by evoking the counter aortic reflex of contraction (concussion of the yth cervical spine). Vibrosuppression (q. v.) will accentuate the dullness. If the dullness at the i2th dorsal vertebra exceeds 6 cm. in diameter, one may conclude the existence of a dilated aorta and, if the dullness is irregular, an aneurysm of this vessel may be suspected. Since the author has elaborated the reflex of the abdom- inal aorta, he has recognized several cases of abdominal arteriosclerosis (by the augmented area of dullness) and by concussion of the 7th cervical spine, he has successfully treated the cases in question.* In this connection the author wishes to refer to the valuable observation of Buch. According to the latter, arterio-sclerotic abdominal colic is specially amenable to theobromin (1.5 to 2 gm. a day), diuretin (3 to 4 gm. a day) or tinct. strophanthi (5 to 8 drops three times a day). No other form of abdominal colic is thus relieved. PHYSIOLOGY OF THE AORTIC REFLEXES. Claude Bernard's interesting observations advanced the clinical study of vaso-motor phenomena. He found that when the sympathetics in the neck of a rabbit were cut, *Thus in one patient, the disease presented the picture of a mucous colitis. The abdominal aorta (elicted by the reflex) measured 8i cm. at the I2th dorsal vertebra. The attacks had resisted treatment for a year, yet three seances of concussion of the yth cervical vertebral spine, sufficed to ameliorate the attacks and they were later inhibited by further treatment. Concussion in augmenting the contractility of the dilated aorta merely contributed to the value of this vessel as a peripheral pump, thus yielding a better supply of blood. 266 Clinical Observations the blood-vessels in the ear on the corresponding side became dilated and that if the peripheral ends were stimulated, the ear became blanched. Those who are adepts in manual therapy find that manual pressure along the vertebral column will evoke either vasoconstriction or vasodilation; the former by brief and the latter by continuous pressure. It is evident that in explaining the genesis of the aortic reflex of contraction, one is concerned with stimulation of the vasoconstrictor nerves, the centers of which are chiefly in the medulla, where they pass into the cord and emerge with the anterior roots as preganglionic sympathetic fibers. These fibers are not only capable of altering the caliber of the vessel, but by means of continuous stimuli passing over them, they maintain the tone of the vessels. The aortic reflex of dilatation is associated with stimula- tion of the vasodilator nerves, the reflex centers of which are located in the medulla and throughout the spinal cord. From the latter situation, they emerge with the posterior spinal nerves. The author seeks to explain the aortic reflexes by either stimulation of definite vasoconstrictor and vasodilator nerves or their centers in the cord, and he has established empirically that concussion of the yth cervical vertebra stimulates the aortic constrictor nerves, whereas the dilator nerves are excited by concussion of the spines of the four lower dorsal vertebrae. THE PSYCHOLOGY OF CLINICAL OBSERVATIONS. When the author published his original communication 58 on the subject of the aortic reflexes, he was the recipient of many letters, the burden of which represented the inability of the correspondents to confirm the observations of the author. It was impossible to answer all the communications at that time and, as this is an opportune moment, I will 267 Spondylotherapy now endeavor to answer some of them. One of the most eminent physiologists in this country protested that con- sidering the pathologic condition of the walls of the aorta in aneurysm of that vessel, it could not in consequence be excited reflexly to alternate contraction and dilatation. Again, such clinical observations could not be accepted unless corroborated by physiologic investigations. No one can gainsay the fact that pulsation is an important sign of an aneurysm, and insomuch as this phenomenon is dependent on the elastic recoil of the walls, it follows, that elasticity of the vessel is not annihilated in aneurysm of the vessel. It is true, as the author has frequently observed, that the walls of the aneurysm do not contract nor dilate equally in eliciting the aortic reflexes; in fact, there may be no perceptible change under the influence of the reflexes at one point, but a decided change at another point, although in every instance some perceptible change was observed. Theoretically, at least, the aortic reflex will persist as long as the aneurysm pulsates. It is now many years since Langenbeck employed ergot hypodermatically in the treatment of aortic aneurysms. He argued, that this drug by stimulating muscular tissue produced vasoconstriction and in this action the cure of an aneurysm could be effected. A storm of protest was en- gendered by this suggestion, his opponents declaring that the middle coat of the aorta did not contain sufficient muscular tissue to enable it to contract. Theoretically, one would suppose that because the aorta is almost entirely composed of fibrous tissue, it is not likely to possess any contractile power, but it has such a power, nevertheless. In the case of a criminal executed at Wiirz- burg, it was found to contract by aid of electricity imme- diately after death. 59 268 Clinical Observations Even though the physiologist denies that the aorta pos- sesses contractility he must be equally consistent and deny the evidence of the x-rays, which prove that the pathologic as well as the physiologic aorta shows contractility. Until the advent of the x-rays we accepted the statement of the physiologist that the diaphragm flattened with each in- spiration, but the rays demonstrated that its curve is always maintained unaltered, and in its excursions it plunges piston-wise up and down. Physiologists have always taught that the central tendon of the diaphragm is capable of only limited movement in respiration, hence the respiratory mobility of the heart is likewise restricted. The rays, how- ever, disproved the fallacy of this contention as well as many others which space will not permit us to cite. The clinician no longer regards the pronunciamento of the physiologist as apodictic. We have learned to discredit many statements emanating from the laboratory-investigator, not so much because the observations of the latter are faulty, but because there is a considerable difference between a laboratory and the bedside and a guinea-pig and patient. Many of the facts derived from the laboratory suggest the comment of the mathematician who, having demonstrated a new mathematical theory, thanked God that it could not be of the slightest utility to any living soul. Neither the pathologist nor the physiologist should forget that, "Path- ology is the physiology of the sick." The presence of broncho- dilator as well as bronchoconstrictor fibers in the vagus was conclusively established by the physiologic investigations of Dixon and Brodie in 1903, yet the author demonstrated seven years before by a simple clinical observation that the vagus must contain bronchodilator as well as broncho- constrictor fibers. 80 The final court of decree of the clinician is neither the 269 S p ondyloth e r a p y physiologic nor pathologic laboratory. To test a given function one must compare it with a like function in indi- viduals of the same species. Thus, if the same quantity of uric acid were excreted in a mammal as is excreted in a normal bird, it would have to be regarded as pathologic. If disease were wholly a question of demonstrable lesions then the pathologist would be compelled to deny the existence of the so-called functional diseases. In consequence of this conflict between the laboratory and clinical investigator, a hiatus has arisen which is now occupied by clinical pathology, a branch which endeavors to conciliate scientific and em- pirical medicine. Several years ago, the writer observed that one could make the record of the pulsations of the head and, furthermore, that the cephalograms thus obtained in certain subjects were pathognomonic of cerebral arterio- sclerosis. Investigating this subject further in the physio- logical laboratory of the University Hospital, London, and in Paris, the writer did not obtain the slightest clue to the cephalic pulsations and he questions, whether he is justified in rejecting a clinical observation which does not permit of physiologic demonstration in animals. One vituperator condemned my method of treating aneurysms as absurd, because it was not responsive to reason. My vituperator recalled the erudite German professor of economics who received a bed as a present. Until the small hours of the morning he busied himself with abstruse calculations to determine whether he was large enough for the bed or if the latter were large enough for him. Finally, he was struck with the happy idea of getting into the bed, and to his intense delight discovered that it was admirably suited to his pro- portions. If my detractor were endowed with the true scien- tific spirit, he would not have condemned a new method of treatment without a trial, considering the kaleidoscopic 270 Clinical Observations changes constantly arising in all branches of science The scientist rejoices one day at the birth of a new theory and of- ficiates at its burial on the morrow. In 1903, in several issues of ^The London Lancet" a discursive polemic was agitated on the subject of my "lung reflex." It was quite evident that one of the disputants did not rigorously execute the method for eliciting the reflex in question but failed to cite this reason for condemning it, although others employed the reflex as a clinical sign of value. Many new methods for a like reason have been relegated to oblivion. Some time ago, while in Paris, the writer found several clinicians who elicited the heart reflex as a routine method of exam- ination and appeared quite content with the sign. The writer demonstrated that the sign as elicited was of no value, insomuch as when the precordial region was stimu- lated, it likewise evoked the lung reflex which also dimin- ished the area of cardiac dullness, and that, in consequence, one could only rely on the deep area of cardiac dullness as an index of myocardial retraction. A prominent Eastern clinician spent several days at the author's office inves- tigating visceral reflexes. One of the patients submitted had an aneurysm of the thoracic aorta. Here the aortic reflexes were the object of study. It was impossible to convince the clinician that there was any modification of the area of dullness after the elicitation of the reflexes, until the writer compelled him to close his eyes while per- cussing, when the results of percussion tallied. The author regrets the necessity of obtruding his per- sonality in the discussion of this subject, but considering the theoretic objections to his method of treatment, he feels that any merit attached to it may be obscured by its simplicity. 271 S p o n d y I o t h e r a p y THE VASO -MOTOR APPARATUS, f The muscular walls of the blood-vessels (arteries, veins* and capillaries) are under the control of the vaso- constrictor and vasodilator nerves. The latter act chiefly on the walls of the small arteries (arterioles). If the vaso- constrictor nerves are stimulated, the arterioles contract and, in consequence, the resistance to the flow of blood is augmented, the pressure in the arteries rises and the cap- illary and venous pressures fall. A contrary effect is produced on stimulation of the vasodilator nerves. The nervous mechanism presiding over vascular tone concerns itself with the following: 1. Ganglia of the blood-vessels; example: pallor from cold and hyperemia from heat. 2. Anomalies of the sympathetic ganglia; example: facial hyperemia in lesions of the cervical ganglia. 3. Reflex action through the spinal cord; example: pallor from pain. 4. Reflex action through the medulla oblongata; ex- ample: glycosuria subsequent to sciatica. 5. Impulses from the cortex of the brain; example: blushing. The splanchnic area 1 is most abundantly supplied with vaso-motor nerves and it is this region which is specially concerned in the distribution of blood and the general blood -pressure. *Mall has shown that stimulation of the splanchnics will cause contraction of the portal system and thus send twenty-seven per cent of the total quantity of blood in an animal into the right heart. fThis subject is further discussed on page 278. tThe splanchnic area includes the vessels supplied to the intestinal tract, liver, kidneys and spleen. 272 Vaso-Motor Apparatus In the norm, by aid of the regulatory mechanism of the vaso-motor nerves, each part of the body receives an amount of blood necessary for its activity and the greater the latter, the more blood it will receive in consequence of vasodilation. Simultaneously, the vessels in other parts of the body are contracted, and it is by this vascular reciprocity between FIG. 74. Illustrating the path of a vasoconstrictor nerve; A, anterior root, showing the course of the preganglionic fiber as a dotted line; D.V., dorsal and ventral branches of the spinal nerve; R, ramus communicans; G, sympathetic ganglion. The postganglionic fibers in each ramus come from the sympathetic ganglion with which it is connected. The preganglionic fibers entering at any ganglion may pass up or down to end in the cells of some other ganglion (Howell). the different regions, that the normal blood -pressure is maintained. Vasoconstrictor or dilator effects may be produced at the periphery by means of vaso-motor reflexes. Thus, if the right hand is immersed in cold water, the temperature falls in the left hand, and one also observes the red cheek on the implicated side in pneumonia. The vaso-motor reflex consists of sensory impulses which enter the spinal cord with the posterior nerve -roots and by irritating the centers in the cord excite constrictor or dilator effects. The cells of the vesicular columns of Clarke are supposed to be the seat of the reflexes in question. 273 S p o n d y I o t h e r a p y THE VASOCONSTRICTOR NERVES. The vasoconstrictor nerves which supply the skin, trunk and extremities, emerge from the ganglion (Fig. 74) to the corresponding spinal nerve by way of the gray ramus, and, after attaining the spinal nerve, they accompany it to its corresponding region. The chief center for the vasoconstrictor nerves is in the medulla, but throughout the entire length of the spinal cord (excepting the cervical region and lowest part of the lumbar region), there are subsidiary centers. The majority of the vasoconstrictor nerves emerge from the central nervous system in the anterior nerve-roots. The following table shows the location of the vasocon- strictor neural cells in the segments of the cord : DISTRIBUTION. ORIGIN. Brain, face, scalp, mucosa of the 2nd, 3rd and 4th dorsal segments. nose, mouth, salivary glands, ear and eye. Esophagus and stomach. 4th to the Qth dorsal segments. Small intestines. 6th dorsal to the 2nd lumbar. Liver. 6th dorsal to the ist lumbar (chiefly in the xoth, nth and 1 2th dorsal). Pancreas, spleen and suprarenals. 8th to the i2th dorsal. Large intestines. nth dorsal to the 2nd lumbar. Bladder, uterus, external organs nth dorsal to the 2nd lumbar of generation, ovaries, testicles segments. and prostate gland. THE VASODILATOR NERVES. These nerves are characterized as follows: i. The latent period for their stimulation is longer than that of the constrictors. 274 Vaso-Motor Neuroses 2. It takes a longer time to attain the maximum effects on the dilators than it does on the constrictors. 3. The after-effect is longer. 4. The vasodilators, unlike the vasoconstrictors, are not in tonic activity and they appear in activity only during the functional activity of an organ as in the case of the erectile tissue of the penis. The vasodilator neural cells supplying the blood-vessels of the head, scalp, face, eye and mouth are chiefly located in the nuclei of the cranial nerves. The vasodilator cells for the abdominal organs are found in the nucleus of the loth cranial nerve and for the pelvic organs and the testicles in the 3rd, 4th and 5th sacral segments of the cord. Vaso- constrictor and vasodilator cells for the nutrient blood- vessels of the lungs and bronchial tubes (bronchial arteries), have been located with a degree of certainty in the 3rd to the yth dorsal segments of the cord. PATHOLOGY OF THE VASO-MOTOR NERVES. (VASO-MOTOR NEUROSES.) A vasomotor neurosis is expressed either as a spasm of the vessels (angiospasm) or less often as a paralysis (angio- paralysis). ANGIOSPASM is characterized by pallor, coldness and trophic disturbances. If the spasm affects the superficial vessels, the following symptoms occur : sensory disturbances (tingling, anesthesia and analgesia) and cutis anserina (goose-skin). When the spasm involves larger vessels, one observes the condition known as intermittent daudicatiou, in which the patient in walking suddenly loses the power in his legs. Cases of temporary aphasia, numbness and paralyses are provoked by a like angiospasm of the cerebral vessels. 275 S p o n d y I o t h e r a p y The veins may likewise be implicated in a spasm and the blood, not being able to escape from the capillaries, the parts become blue and edematous, nutrition is impaired and gangrene may ensue. ANGIOPARALYSIS may be caused either by diminished function of the vasoconstrictor nerves or by excessive action of the vasodilators. The symptoms are similar to those observed in spasm of the veins (vide supra). In the con- dition known as causalgia, the blue, cold and edematous part is associated with severe pains of a burning character. In the condition known as erythromelalgia, pain, tender- ness and congestion of the soles of the feet are associated with a burning pain not unlike that produced by a blister. The vaso-motor phenomena occur paroxysmally and are resistant to treatment. Another vaso-motor neurosis is the so-called angioneurotic edema, in which there is a sudden swelling of some part (face, neck, larynx or an extremity). Loss of vascular tone is observed in neurasthenia, hysteria and at the menopause; there are sudden flushes or pallor. Individuals with a "poor circulation" have cold hands or feet or the face is constantly congested. We have also the less understood visceral angioneuroses characterized by hyperemia, transudations and ecchymoses. There is an old Latin aphorism, "Naturam morborum curationes ostendunt" (cure shows the nature of diseases). In this sense, the pathology of many diseases is revealed by the results of treatment. In accordance with the preceding aphorism, the author contends that, there are many diseases regarded as distinct affections which are merely symptomatic of a fundamental condition, viz., instability of the nervous mechanism which controls local vascular tone. This faulty mechanism, which the author is pleased to call angio-ataxia, 276 A n g i o p a r a lysis has already been referred to on page 275. It is reasonable to assume that the chief dereliction of action of this mech- anism is resident in the vaso-motor centers of the spinal cord. The author submits the following classification of angioneuroses based on the results of treatment : ANGIOSPASM. Symptoms: no vaso-motor reflex on irritation, skin shrunken or thrown into folds, arrested metabolism and function due to insufficient blood-supply and sensory dis- turbances (numbness, tingling, anesthesia and analgesia). ANGIOSPASTIC AFFECTIONS, i, intermittent claudication ; 2, temporary paroxysms of paralysis, aphasia or hemianopsia due to spasm of the cerebral vessels ; 3, reflex spasm of the vessels of the leg in sciatica, Nothnagel has reported five cases of the latter affection which eventuated in partial paralysis, sensory disturbances and atrophy; 4, Raynaud's disease; 5, migraine; 6, akroparesthesia. ANGIOPARALYSIS. Symptoms : red or mottled appearance of the skin, sub- jective sensation of heat, sensory disturbances (hyperesthesia and hyperalgesia), notably, a burning sensation (causalgia). The primary symptoms of redness and heat are usually succeeded by blueness, cold and impaired nutrition. The laches cerebrates of Trousseau, formerly regarded as path- ognomonic of meningitis, is essentially an angioparalysis in- dicating enfeebled vasoconstrictor action. The sign is elicited by slight irritation of the skin with the finger-tip or a pencil ; a white line appears followed by a bright red dis- coloration which persists for several minutes. Dermato- graphism is closely related to the foregoing sign : wheals in lieu of a white spot or line appear after cutaneous irritation. 277 Spondyloth e r a p y ANGIOPARALYTIC AFFECTIONS: i, erythromelalgia ; 2, acrodynia; 3, aneurysm; 4, exophthalmic goitre; 5, diabetes; 6, coryza; 7, cold extremities; 8, angioparalytic symptoms of the neuroses; 9, certain toxic conditions. Some of the foregoing conditions will be described more fully under treatment of the vaso-motor neuroses. TREATMENT OF THE VASO-MOTOR NEUROSES. The author presents the following table of the vaso-motor nerves in relation to the spinous processes, the object being to stimulate clinical observations in the treatment of the vaso-motor neuroses which is conceded to be a difficult matter : ORIGIN OF THE VASOCONSTRICTOR NERVES. AREA SUPPLIED. DERIVATION. RELATION TO SPINOUS PROCESSES. Head. First three dorsal nerves. 6th and 7th cervical spines. Arm. Seven upper dorsal nerves. 6th cervical spine to the 4th dorsal spine. Leg. Five lower dorsal and first 5th to the yth dorsal spine. lumbar nerves. Abdominal Viscera. Splanchnic nerves which are and to the 8th dorsal spine. made up of fibers from the 5th to the i2th dorsal nerves inclusive. ORIGIN OF THE VASODILATOR NERVES. AREA SUPPLIED. DERIVATION. RELATION TO SPINOUS PROCESSES. Buccofacial region. 2nd to 5th dorsal nerves. 6th cervical to the 2nd dorsal spine. Eye, head and ear. 8th cervical and ist dorsal 6th cervical spine. nerves. Arm. Five upper dorsal and last 5th cervical to and dorsal cervical nerves. spine. Leg. 6th to the lath dorsal 3rd to the 8th dorsal spine, nerves, inclusive. In the experience of the author the foregoing table is of slight value in treatment with relation to the vasoconstrictors of the head, arm and abdominal viscera (page 349), but it 278 Vaso-Motor Neuroses serves of no value in influencing the vasodilators in treat- ment. In eliciting the aortic reflexes (page 254), vasoconstriction of the aorta is best attained by concussion of the *jth cervical spine and vasodilation, by concussion of the spines of the four lower dorsal 'vertebra. The author has found that the same rule holds good for practically all the vessels of the body, and this fact simplifies the treatment of thevaso-motor neuroses. Of all the methods investigated by the author for influencing the vaso-motor centers in the spinal cord, no method is comparable to that of concussion; in fact, it is the only method. Even in the norm, if concussion is executed over the yth cervical spine, usually within a minute, vasoconstriction as evidenced by some pallor is noted in the hands, face and feet, whereas concussion of the four lower dorsal spines overcomes the constriction and redness and even congestion substitutes the pallor. These effects are more conspicuous when there is a diminished function of either the constrictors or dilators. Naturally, the conspicuity of pallor or redness is merely relative, and one must look sharply for the change. The author has treated a very large number of patients with vaso-motor instability (angio-ataxia) and, when the affection was characterized by angiospasm, the four lower dorsal spines were concussed, whereas in angioparalyses, concussion of the yth cervical spine was executed. Results were achieved in practically all instances after repeated treatment, provided a reaction could be elicited, i.e., when concussion of the yth cervical spine would replace hyperemia by anemia, and when concussion of the spines of the four lower dorsal vertebrae would substitute hyperemia for anemia. Very often the reaction could not be noted until after several treatments. Spondylotherapy MIGRAINE (hemicrania ; sick headache). The pathology of this disease is obscure and the innumerable affections to which its origin has been attributed probably act as exciting factors of a basic condition, viz., angio-ataxia. Many writers regard migraine as a vaso-motor neurosis; in fact, a former classification of two varieties of the affection is no longer viewed with tolerance by clinicians: i, an angio- spastic form characterized by pallor of one side of the face ; 2, an angioparalytic form, manifested by redness of one side of the face. Those who support the vaso-motor theory of migraine contend that the early symptoms are caused by vasoconstrictor and the later symptoms by vasodilator influences. The author has treated about eight cases of migraine by concussion of the yth cervical spine based on the theory of instability of the vaso-motor center in the spinal cord. The attacks were subdued in four cases, relieved in two patients and the attacks in two other patients were un- influenced. The treatment must be executed in the inter- paroxysmal periods. EXOPHTHALMIC GOITRE (Grave's, Basedow's or Parry's disease). This disease is characterized by protrusion of the eyes (exophthalmos), enlargement of the thyroid gland, tremor and rapid heart-action (tachycardia). The theory which has gained most favor in explaining the symptoms of the disease is, that it is caused by a hypersecretion (hyper- thyroidism) of the thyroid gland conducing to a kind of chronic intoxication. There is, however, a gap in the theory which evades the question, What causes the hyperthyroidism ? Based on the results of his treatment, the author is con- strained to believe that the disease is essentially an angio- paralytic affection and that stimulation of the vaso-motor center in the cord by concussion of the yth cervical spinous process suffices to relieve and even cure the affection in 280 Vaso-Motor Neuroses question. Every successful method of treatment in this disease, medical or surgical, has been directed toward a reduction in the size of the thyroid gland, and it is reasonable to assume that one can stimulate or diminish the activity of this gland by increasing or diminishing its circulation. Among the symptoms which yield most rapidly to treat- ment by concussion are tachycardia, flushing and tremor. Among six cases of the disease treated by the author the latter signs, plus the enlarged thyroid, were improved after a few treatments by concussion, but the exophthalmos in all but two cases persisted (although less pronounced). In all the cases, a decided retraction of the protruded eyes was noted after each treatment. The following notes concerning one patient suffice to illustrate in the main the results of treatment : The patient presented all the cardinal symptoms of the disease. The pulse-rate was 160; tremor involved practically every muscle of the body; the slightest exer- tion was associated with perspiration; the thyroid was enlarged. After the third treatment by concussion, the pulse was 130, and after the eighth treatment, it was reduced to 88, and so remained after the patient was discharged. After the fifth treatment, the tremor was perceptibly diminished and perspiration following exertion no longer occurred. As shown in illustrations (Figs. 7 5, 7 6), although the exophthalmos persisted, it was less conspicuous, whereas the thyroid gland is practically normal in size. ' DIABETES MELLITUS. The pathology of this disease is obscure. In the celebrated piquire experiment of Claude Bernard, diabetes in an animal can be produced by irritating the floor of the 4th ventricle. Since then it has been shown that irritation of other parts of the nervous system will 281 produce diabetes. In consequence of the preceding, there has arisen a neurotic theory of diabetes which supposes it FIG. 75. Photograph of a patient with exophthalmic goitre. to be caused by a vaso-motor paralysis, resulting in a greater quantity of blood flowing through the liver. The author, giving credence to the latter theory, has 282 Vaso-Motor Neuroses treated ten diabetics by concussion of the spine of the yth cervical vertebra* and the results were as follows : FIG. 76. Same patient after three weeks treatment (concussion of the spine of the yth cervical vertebra). 1. No results in three cases. 2. The percentage of sugar very much reduced in four cases. *The author wishes to emphasize the following: In testing the methods of treat- ment employed throughout this book, recourse was had to no other therapeutic procedure. Not even rest, so essential in the treatment of aneurysm, was enjoined. 283 Spondylotherapy 3. Slight reduction in the percentage of sugar in one case. 4. Disappearance of glycosuria in two cases. The duration of treatment in the latter cases extended over a period of one and two months respectively. CORYZA (Cold in the Head). The prevention and treatment of this condition is a constant rebuke to progressive medicine, insomuch as we have added nothing to that con- tributed by our medical ancestors. The sequelse of a cold in the, head include affections ranging from sinusitis to cerebral abscess. The prevailing theory regards coryza as a nasal infection varying in virulency according to the microbal cause. If, however, it were wholly an infection, then in a region so accessible to the employment of bactericides, the latter must be discredited. The infectious factor must be regarded in the same light as any other peripheral irritant which, acting reflexly upon the vaso-motor center, causes all the symptoms of an angioparalysis. This angioparalysis need not necessarily be excited from the nasal mucosa but from other vulnerable areas. The vaso-motor theory of coryza is partially sustained by the author's method of treatment, viz., concussion of the jth cervical spine. When the latter is executed in the incipiency of the affection, it may be aborted. Later, it modifies the condition either by diminishing its severity or by altering the character of the discharge. When the nose is obstructed in consequence of congestion of the nasal mucosa, a few concussion-blows on the spine of the yth cervical vertebra will often overcome the obstruction as effectually as cocain, and the relief thus obtained may last from minutes to hours. Very often the author instructs a friend of the patient to strike the spinous process (after the manner shown in Fig 284 Vaso-Motor Neuroses 3), whenever the nose is obstructed or, to execute it as a method of treatment, several times a day. Naturally, the spinous process will become sensitive when concussed repeatedly and, in this event, it may be struck at different angles directly or on one side or the other. In asthma, reflexly provoked by congestion of the nasal mucosa, concussion as cited by giving immediate relief to the nasal congestion will inhibit the asthmatic paroxysm. The nasal mucous membrane is continuous with the lining membrane of the pharynx, Eustachian tubes, larynx, trachea and bronchial tubes and concussion is equally influential for weal in acute congestion of the same membrane irrespective of location. Thus many acute congestions of the bronchial mucosa may be aborted by concussion of the yth cervical spinous process. COLD EXTREMITIES. This frequent condition has never, to my knowledge, been dignified by a technical name, and the author proposes the term acropsychrosthesia, signifying a feeling of cold in the extremities. The effects of cold upon the skin (dermatitis congelationis} as in that common condition known as chilblain or pernio are really caused by insufficiency of the vaso-motor apparatus and the writer has successfully treated this obstinate con- dition by repeated seances of concussion of the spinous process of the yth cervical spine. During treatment, if the parts are hyperemic, one may note definite areas of anemia in the hands, feet or face. Many circulatory disturbances in the face, notably acne rosacea, are likewise vaso-motor neuroses and they also yield to the foregoing method of treatment. ANGIOPARALYTIC NEUROSES. In neurasthenia, hysteria and other neuroses, the vaso-motor symptoms seem to 285 S p o n d y I o t h e r a p y dominate the clinical picture. Here the patient complains of pulsations throughout the body, notably the head, and the face is observed to be in a condition of hyperemia. Neu- rasthenics have a symptom in common : a feeling of heavy weight or constriction about the head. Charcot graphically described the head -sensation as the "casque neurasthenique" a feeling as though the patient were wearing a tight -fitting helmet. The author has never encountered in the literature any explanation of this phenomenon, and he is constrained to conclude that it is a vaso-motor symptom considering the beneficial results of treatment consecutive to the employ- ment of concussion of the spinous process of the yth cervical vertebra. Toxic CONDITIONS. During the change of life or MENOPAUSE, the vaso-motor disturbances are almost as common as the arrest or irregularity of the menses. Flushing, heat and perspiration alternate with pallor and chills, and these symptoms often persist despite treatment to the end of life. DIGESTION-AUTOINTOXICATION. The author employs this term to signify a train of vaso-motor symptoms peculiar to some individuals who, after the ingestion of a meal, suffer from fullness and pulsations of the head, followed by throb- bing in the arteries throughout the body. In association with these signs, the patients are depressed or despondent and are disinclined to execute their routine work. These symptoms are regarded as neurasthenic, but they are really due to autointoxication. Our conception of the latter affection is faulty, insomuch as we regard its causation to be associated with putrefaction of albuminoid food in the intestines. We forget that there are also poisonous album- oses, i.e., intermediate products manufactured in the digestion of albuminous foodstuffs, and investigations show 286 Vaso-Motor Neuroses that an aqueous extract of the contents of the small intestine is infinitely more toxic than an extract made from the contents of the large intestine. Patients suffering from digestion -autointoxication ex- perience relief as a rule, several hours after a repast. In the treatment of these patients, the exclusion of albuminoid food is beneficial, but the best results are achieved if the vaso -motor center, which bears the brunt of the dis- turbance, is made resistant to the action of the poisons. Here, treatment by concussion of the yth cervical spine has given me excellent results. 287 S p o n d y I o the r a p y CHAPTER VIII. THE RESPIRATORY APPARATUS. PHYSIOLOGY HISTOLOGY POSTURAL LUNG-DULLNESS LUNG REFLEX OF DILATATION LUNG REFLEX OF CONTRACTION PULMONARY ATELECTASIS BRONCHIAL ASTHMA SPASMODIC BRONCHOSTEN- OSIS TUBERCULOSIS HEMOPTYSIS. PHYSIOLOGY. '"T^HE object of respiration is to exchange gases between *- the tissues and the external air. The blood circulating through the lungs absorbs oxygen from the alveolar air and yields its gaseous products of decomposition, notably carbon dioxid. There are two phases of respiration: 1. Inspiration, which is effected by elevation of the ribs and by contraction of the diaphragm. 2. Expiration, which is a passive act and requires no muscular effort. In man, the diaphragm predominates over the rib-lifting muscles, and the reverse is the case in women; hence, the normal type of respiration in man is abdominal, and in women, costal. When this type of respiration is reversed (page 85), it becomes the fundamental condition of many respiratory neuroses and accentuates the symptoms of organic affections of the lungs. In Fig. 77, two extreme types of respiration are indicated : A, the diaphragmatic, and B, the thoracic type. In A, there is no thoracic movement, but the anterior abdominal wall during inspiration projects to i. In B, on the contrary, 288 Respiratory Mechanism the thoracic wall moves forward and upward, whereas the abdominal wall instead of projecting is really drawn in. The RESPIRATORY MECHANISM (Fig. 78) is regulated by the respiratory center in the medulla oblongata, the so- called rioeud vital of physiologists, which corresponds in position with the vagus-nuclei. The muscles which enlarge and diminish the size of the thoracic cavity are innervated FIG. 77. Diaphragmatic breathing in a male and the thoracic type of breathing in a female. by nerves derived from the spinal cord; the diaphragm is supplied by the 3rd and 4th cervical roots and the phrenic nerve. The motor nerves for the muscles of the larynx and bronchi run in the trunk of the vagus. HISTOLOGY. It is now known that longitudinal as well as circular muscular fibers exist in the finer bronchial tubes of rabbits, and Aufrecht has shown that a powerful layer of circular and a weaker layer of longitudinal fibers exist in man- 289 S p o n d loth r a p y These bronchial muscles are under the influence of the vagi and can be made to contract and relax as the result of stimulation of the vagi. Thus we have bronchoconstrictor and bronchodilator fibers in the vagus. The chief bronchoconstrictor reflexes are elicited from the mucous membrane of the nose and larynx. Respiratory Centre in Medulla FIG. 78. Diagram of the respiratory center (Butler). The bronchial musculature is further discussed on page 308. Recently, the presence of vaso-motor nerves in the lungs has been absolutely denied. The author has referred 61 to a condition known as POSTURAL LUNG-DULLNESS. Any one, however, reasonably skilled in percussion will, when attention is called to the fact, recognize a decided difference in the percussion note of the lungs if percussion 290 Postural Lung - Dullness is made first in the erect and then again in the recumbent posture. One will also note a difference if the patient is percussed first leaning far forward and then backward (sup- ported by an assistant). In other words (the author is assuming an average typical normal subject), the percussion changes correspond in a minor degree to the alterations in the percussion note when fluid is present in a pleural space. The changes noted would be as follows : Leaning far forward: Anterior chest region diffused dullness, especially marked in a definite area. Posterior chest region hyperresonant. Leaning far backward: Posterior chest region shows diffused dullness, notably in a definite area. Anterior chest wall elicits a hyperresonant percussiqn note. Leaning to one side: Side of chest wall toward which patient inclines shows dullness, whereas the other side is hyperresonant. Lying on one side: Side of chest on which the patient lies demonstrates dullness of the lung, including the apex, whereas the other side is hyperresonant. Recumbent posture: The anterior thoracic wall is decid- edly more resonant than in any other posture. Prone posture: The posterior thoracic region is more resonant than in any other posture. Exaggerated Trendelenburg: Slight dullness of the pulmonary apices ; lower chest region hyperresonant. Differential Diagnosis: Postural dullness as a patho- logical phenomenon is frequently encountered and may be confounded with the dullness of atelectasis. Dullness dependent on atelectasis is usually circumscribed and may be dispelled by a series of forced inspirations, rubbing the skin over the area of dullness to provoke the lung reflex of dilatation and by the cocain test (page 297). 291 S p o n d y I o the r a p y Postural dullness is usually diffused, involving one or more lobes, and cannot be dispelled by forced inspirations, the cocain test, or by exciting the lung reflex. The dullness in question, however, disappears at once by a complete change in the posture of the patient. Assuming, for example, that the dullness is somewhere over the posterior surface of the chest, its dissipation cannot be effected until the patient assumes the prone posture. Etiology of Postural Dullness. After a careful consid- eration of this subject the author is constrained to conclude for the following reasons that the dullness provoked by posture is dependent on the blood normally present in the blood-vessels of the lungs, which is influenced by gravity, like any other fluid : i. The blood in the lungs, unlike in other viscera, is not restricted in amount, owing to the absence of vaso-motor nerves. 2. The area of most pronounced dullness (as influenced by posture) corresponds to the situation of the largest pulmonary vessels, and is least manifested in areas where the vessels are less abundant. 3. In passive conges- tion of the lungs observed in cardiopaths, the dullness elicited by postural changes is most pronounced. 4. The postural dullness is uninfluenced by all the manceuvers which act upon either the bronchoconstrictor or bronchodilator nerves of the vagus. Postural Lung Dullness in Disease. As already observed, postural lung dullness is observed as a normal condition, or perhaps, to speak more definitely, in the norm, lung resonance is modified by posture. In passive congestion of the lungs it is most pronounced. In pulmonary tuberculosis I have noted only slight impairment of lung resonance as determined by posture, and this observation applies with equal cogency to the pretuberculous lung. For this reason 292 Postural Lung - Dullness I seek to augment the quantity of blood in the apices of the lungs by having my tuberculous patients raise the foot of the bed so that the blood will gravitate toward the apices. After this manner I endeavor to induce a passive hyperemia of the regions in question. I cannot speak of results, inas- much as this innovation has not been subjected to the test of time. Sir James Barr, in his erudite Bradshawe lecture before the Royal College of Physicians, London, refers to the frequency of atelectasis in exhausting diseases, which may be mistaken for a pleural effusion. He furthermore says : "Atelectasis is often mistaken for hypostatic congestion of the lung, and forcible rubbing of the affected side, acting through the lung reflex of Albert Abrams, causes some expansion of the lung and clears up the percussion note." My observations do not tally with the latter. On the con- trary, ever since I recognized the method of differentiating lung atelectasis and lung hyperemia, I am convinced that what is frequently regarded as atelectasis is in reality a passive congestion. Postural Dullness in Treatment. The empirical treat- ment of pulmonary affections by external applications to the thoracic wall is fully justified, since the lung reflex of dilatation has been recognized. The postural treatment of diseases of the lungs is equally justified by the foregoing observations of the author. One fact, however, must be emphasized, and that is, the posture assumed by the patient must be an extreme one. Thus, to contend against hypo- static congestion the patient must assume the prone posture at least for a time several times a day. In hemoptysis, the correct posture can be determined when the area involved in the bleeding yields a resonant percussion note and in- dicates the exsanguination of the area in question. 293 Spondyloth e r a p y THE LUNG REFLEX OF DILATATION. This reflex demonstrates the important fact that the respiratory area may be influenced indirectly by stimuli acting on the vagi. In a contribution by Moscucci, 62 the suggestion was made that when ether was sprayed over the left half of the abdomen, marked reduction in volume of the spleen was observed in twelve cases. In repeating the experiments, I likewise noticed a decided reduction in the area of splenic dullness in all individuals on whom this method was tried, irrespective of the fact whether enlarge- ment of the spleen existed or not. Investigations convinced me that this diminution in the area of splenic dullness was not real, but only apparent. When the ether spray was directed over the region of the heart, the percussional area of that organ was reduced at once; in fact, the superficial area of cardiac dullness could be obliterated by the man- oeuver. Similarly, when the spray was directed over the hepatic region the superficial area of dullness of that organ could be reduced at once. When the spray was directed over the border of the lungs posteriorly, the lung borders could be made to descend from two to four inches, dependent on certain conditions. It was further ascertained that dis- location of the lung-borders by forced inspiration never approached the dilatation of the lungs produced by the cutaneous application of the ether spray. Further experi- ments demonstrated in brief the fact that the application of any cutaneous irritant, whether the latter be mechanic, chemic or electric, would always induce acute dilation of the lungs. Even in emphysematous individuals the application of a cutaneous irritant still further augmented the existing lung-dilation. The question naturally arose, by what means could we establish the fact that the application of any 294 L, u n % Re f I ex of Dilatation cutaneous irritant would cause acute dilation of the lungs, a condition which, it may be mentioned parenthetically, is only of a few minutes duration. Such a hypothesis was made tenable by the aid of conventional physical signs and the use of the fluoroscope. These aids show that when the skin is irritated by means of cold, by friction, or by a strong Faradic current, lung dilation will ensue. The degree of lung dilation is dependent upon the character of the irritant and the severity of its application. The response of the lung to dilation is always greatest in that part of the lung con- tiguous to the source of cutaneous irritation. Lung dilation may be recognized by the following physical signs: i. Diminished respiratory excursions of the lung borders. 2. Extension of the pulmonary percussion note and oblit- eration of the cardiac and splenic areas of dullness. 3. Hyperresonance of the lungs. 4. Obliteration of the apex beat. Auscultation is of no value as a physical sign, inas- much as the artificial dilation does not last longer than three minutes after the source of cutaneous irritation has been removed. Lung dilation spreads from the source of cutaneous irritation involving primarily circumscribed parts. In lungs showing resonance, the latter could always be in- creased by cutaneous irritation over the part percussed. The x-rays show how the brightness of the lungs is increased by cutaneous irritation. By gradually applying the irritant to different parts of the skin of the thorax, one may note that eventually the entire lung may be made to yield a more intense luminosity. This increased luminosity, however, does not last longer than three minutes in the average person, after which time the lungs resume their normal appear- ance. In a number of measurements made during the study of the lung reflex after cutaneous irritation, I found 295 S p ondylotherapy the average dislocation of the lower border of the lung, as follows : Right sternal line 3^ cm. Right parasternal line 3^ cm. Right mammillary line 4 cm. Right axillary line 6 cm. In another communication, I demonstrated that acute dilation of the lungs can be evoked in healthy persons by irritation of the nasal mucosa and conversely, that this con- dition can be dissipated after the removal of the source of irritation. The pulmonary neurosis of dilation can be obtained by firmly compressing cotton in both nasal cavities. The degree of lung dilation with its concomitant phenomena will naturally vary according to circumstances which modify other reflex acts. After the introduction of the cotton, a few moments elapse before percussional results are noted. One will then observe superresonance and immobilization of the lung-borders and diminution of the areas of hepatic and cardiac dullness, in the latter instance, even to obliter- ation. Irritation of one nasal cavity with cotton does not yield manifest results. If the mucosa of both nasal cavities has been thoroughly cocainized before the introduction of the cotton, no lung dilation ensues. I have frequently en- countered in my clientele, individuals presenting the sympto- matic picture of pulmonary vesicular emphysema in whom wa^ associated, some abnormity of the nose. The anomaly was a simple coryza, spurs, deflection of the septum, hyper- trophic rhinitis or polypi. At any rate, after eradication of the nasal anomaly, the symptoms of pulmonary dilation disappeared. The form of emphysema here cited is in reality an acute lung dilation, an eradicable condition dis- sociated with the anatomico -pathologic conditions conven- tionally allied with emphysema. The typic clinical picture 296 Lung Reflex of Dilatation of acute lung dilation could nearly always be made to dis- appear by the aid of the cocain test, which constitutes in this form of pulmonary neurosis a diagnostic aid of unques- tioned value. After application of a solution of cocain to the nasal mucosa, the lung-borders will recede and the lung resonance and normal vesicular respiration are restored. In patients suffering from asthma of presumable nasal origin, impaction of cotton in one or both nasal cavities may induce a typic asthmatic paroxysm. This fact is of undoubted diagnostic value. I maintain that the phenomena of lung dilation can be provoked at any point in the extensive course of distribution of the pneumogastric nerves, and that the stimuli may act indirectly on the vagi through the terminal fibers of the trigeminus or, by irritation of the cutaneous sensory nerves contiguous to the lungs. It is necessary to hypothesize the existence of two distinct functions of the vagus nerve, or, at any rate, different fibers, with two distinct functions fibers which can dilate (bronchodilator nerves) and fibers which contract (broncho - constrictor nerves) the lungs upon application of the appro- priate stimuli. In the action of these two sets of nerve fibers, the vasoconstrictor and vasodilator nerves of the vaso-motor system may be cited as analogous. It may be interesting to observe that the author's hypo- thesis concerning the existence of bronchodilator and bronchoconstrictor fibers in the vagus was confirmed seven years later by the well-known physiologic investigations of Dixon and Brodie. Respecting the diagnostic value of the lung reflex, atten- tion has already been directed to its importance in percussion (page 204). In England, Auld and Sir James Barr, and in Italy, Plessi, direct reference to the reflex in the differentiation of 297 Spondylotherapy atelectasis and consolidation of the lung; in atelectasis, irritation of the skin contiguous to the affected area will convert the dullness into resonance, whereas if the dullness is due to a consolidation, the lung reflex will not influence the dullness. In x-ray examinations of the lungs, an area of opacity due to atelectasis may be mistaken for consolidation; the lung reflex would immediately clear the opacity in atelectasis but would not influence the shadow caused by a consolidation. Cesare Minerbi, of Ferrara, Italy, regards the absence of the lung reflex posteriorly as one of the earliest and most trustworthy signs of pulmonary tuberculosis. This con- clusion was based on a study of 300 cases and 14 autopsies. THE LUNG REFLEX OF CONTRACTION. Cherchevsky directed attention to a sign of early arteri- osclerosis. He found that in the norm, the diameter of the aorta varies at different times. It became dilated if the region of the chest over the arch of the aorta is struck with the percussion hammer, while it shrinks in size if the blows are struck in the epigastrium. In arteriosclerosis it is impossible to produce these variations in diameter. Cherchevsky has misinterpreted the phenomenon ob- tained by his manceuver. What he really elicits is a cir- cumscribed lung-contraction adjacent to the part struck on the chest by the hammer and the blow on the epigastrium merely causes the collapsed lung-area to dilate (lung reflex of dilatation), thus supplanting dullness by resonance. Dullness may be elicited in practically any chest-region by using a plexor and plexi meter. The circumscribed dullness thus induced lasts but a few seconds, but may be made to disappear at once by striking the epigastrium. Observed with the x-rays, the lung reflex of contraction 298 Pulmonary Atelectasis is an interesting study. After the blow is struck, the adjacent lung-area becomes gradually dark, showing that the air has been expelled from the lungs, whereas in a few seconds the lung-area becomes bright again. This lung reflex of con- traction cannot be obtained if the nasal mucosa has been previously cocainized. This reflex may be elicited from the nasal mucosa or the vertebral region so that both lungs are brought simultan- eously into a condition of contraction and when the reflex is thus obtained, it proves of great therapeutic value in the treatment of asthma (page 312). PULMONARY ATELECTASIS. The proponent of any new method of treatment, may, in his enthusiasm, permit the imagination to run riot, thus presenting assumptions which can neither be demonstrated nor corroborated by experience. The author has endeavored to avoid the Scylla and Char- ybdis of medical theorists and, for this reason, will only discuss certain diseases of the respiratory apparatus which experience has taught him can be successfully combated by methods advocated in this book. It is the accumulation of our experiences, observes Mundy, that makes our empirical knowledge, at last, scien- tific fact. Pulmonary atelectasis or lung-collapse, refers to a con- dition in which the vesicles of an entire lung or only lung- areas are collapsed and contain little or no air. We may here disregard the many causes of atelectasis and confine ourselves to the discussion of two frequent causes : T. Obstruction somewhere in the air-passages (atelectasis of obstruction) ; 2. Defective expansion of the chest. ACUTE BRONCHITIS is a common and very rarely a serious 299 S p o n d I t h r a p y disease in healthy adults. In young and old subjects, how- ever, there is always danger of an extension of the catarrhal process downwards to the finer tubes, thus conducing to an atelectasis of obstruction. Such atelectatic areas are fre- quently the site of broncho-pneumonic patches or, as it is also called, capillary bronchitis. The author has frequently observed that in children suffering from broncho-pneumonia, the areas of dullness are not wholly due to the broncho - pneumonic condition, but to adjacent areas of atelectasis which may be readily be dissipated by elicitation of the lung reflex (page 294). FIGS. 79 AND 80. Atelectatic zones on the anterior and posterior surfaces of the thorax. DEFECTIVE EXPANSION OF THE CHEST. Any loss of inspiratory power may induce lung-collapse independent of any other factor. Weak and rickety children with their feeble muscular development lack this inspiratory power and one observes this enfeebled power in old age, long con- tinued fevers and in individuals who are bedridden. Even in the norm, certain portions of the lungs are collapsed and deprived of sufficient air to yield a dullness and, in some instances, flatness on percussion. Not infre- quently, the apex of the lung in its entirety may be atelectatic and for this reason alone, some individuals have been pro- 300 Pulmonary Anemia nounced phthisical by physicians who fail to recognize atelectasis of the lung. These areas of lung-collapse or atelectatic zones, as the author has called them, usually dis- appear after a series of deep inspirations or upon application of the lung reflex test (page 298), i.e., by vigorous rubbing of the skin over the site of atelectatic dullness. Not infrequently, reflex irritation of the bronchocon- strictor fibers in the vagus by some anomaly of the nasal mucosa may maintain a condition of atelectasis. In the latter instance, cocainization of the nasal mucosa by inhibit- ing the action of the constrictor fibers will translate the dullness of an atelectatic patch into resonance. In the accompanying illustrations (Figs. 79 and 80), a composite picture is projected defining the usual situation of atelectatic zones based on an examination of over one hundred apparently healthy individuals (children as well as adults). These zones are frequently mistaken for areas of lung- consolidation, either when detected by percussion or seen at an x-ray examination. The zones bear a definite relation to the points of election and paths of distribution of the lesions in chronic pulmonary tuberculosis and they are frequently present in what the author has called "PULMONARY ANEMIA." The latter condition is more frequent in children than in adults and fails to yield to ferruginous preparations. The syndrome of anemia, however, disappears after a course of methodic respiratory exercises. Should the anemia reappear, its recrudescence is almost invariably associated with a reappearance of the zones of atelectasis.* *For a more extended discussion of the subject of pulmonary anemia, the reader is referred to the author's books, Diseases of the Heart, page 46, and Diseases of the Lungs, page 20. 301 Spondyloth e r a p y TREATMENT OF PULMONARY ATELECTASIS. Among the various methods for expanding the lungs and thus opposing the condition of atelectasis, the following manoeuvers are suggested: 1. By action on the cutaneous sensory nerves. 2. By forced voluntary breathing. 3. By developing the muscles of respiration. 4. By aid of posture. 5. By vertebral concussion. The two latter methods are advocated in cases of emer- gency. I. We have already shown that the lung reflex of dilatation and the heart reflex of contraction may be evoked by cutaneous stimulation. The stimulation of the respiratory center is greater through the cutaneous nerves than through the branches of the vagus to the respiratory organs. In animals which have been made apneic, cutaneous stimulation induced strong respiratory movements. We must therefore regard cutaneous stimulation as a simple and powerful stimulant of the centers of circulation and respiration. The empirical treatment of pulmonary affections by external applications (poultices, friction with liniments and hot and warm compresses) to the thoracic wall is fully justified, since the lung reflex of dilatation has been recog- nized. In acute pulmonary affections, and in infectious diseases like typhoid, the author employs carbonated baths and the cutaneous irritation thus induced powerfully influences cardiac and pulmonic vigor. In these affections we must be prepared to dismiss antipyresis as the great desideratum in the acute infectious diseases. II. Forced voluntary breathing may be achieved by 302 B-ronchial Asthma respiratory exercises and for rapid lung-development, the aid of the pneumatic cabinet is unquestionably the best method. III. Feebly developed muscles of the thorax may be strengthened by stimulation of the respiratory muscles peripherally or, better still, centrally (to secure symmetrical development, page n), by aid of the sinusoidal current. IV. Reference has been made to postural lung-dullness on page 290. Here it is important to recall the necessity of frequent and complete changes in posture to obviate the tendency to atelectasis and passive congestion of the lungs. V. Concussion of the spines of the third to the eighth dorsal vertebrae will provoke a rapid dilatation of both lungs, thus inducing the lung reflex of dilatation which, however, is of short duration only; hence the necessity of a frequent repetition of the manceuver. Other rapid methods of eliciting the latter reflex are: 1 . Stimulation of the nasal mucosa by irritating vapors ; strong vapors like those of ammonia must be avoided owing to their inhibiting action on the heart (Fig. 56). 2. By tapping the epigastrium lightly. Here, forcible percussion like the "Klopf-Versuch" of Goltz, will inhibit the heart's action. 3. By placing the patient in a warm bath and directing cold water from a pitcher to strike the nape of the neck and flow down the back. BRONCHIAL ASTHMA. If we regard this affection as a distinct neurosis of the respiratory apparatus, it may be defined as a series of paroxysmal dyspneic attacks in which no organic disease can be recognized in its causation. Whatever the etiologic factor, three conditions are essential : 303 S p o n d y I o t h e r a p. y 1. Diminished resistance of the center of respiration. 2. Asthmogenic points somewhere. 3. Irritation of the asthmogenic points. The asthmogenic point may exist anywhere in the course of the distribution of the vagus nerve, or the bronchocon- strictor fibers of this nerve may be irritated reflexly. The usual sources of irritation are: 1. The nose. Here a probe may detect some sensitive spot (asthmogenic point) and irritation of this spot may induce a typic asthmatic paroxysm or symptoms approaching it like dyspnea or a feeling of constriction about the chest. In these cases of asthma of nasal genesis, if the nose is firmly packed with cotton (considering the fact that no asthmogenic point can be detected), an asthmatic attack may be elicited. A spray of cocain introduced into the nose may inhibit a paroxysm of asthma if it is of nasal origin. It is better in such cases to cocainize first one, and then the other nostril to determine which side of the nose is respon- sible for the irritation. By so doing, the side on which the nasal anomaly is present may be corrected and thus cure of the asthma may be effected. 2. The asthmogenic point may be located in the larynx (pharyngo-laryngeal asthma). Here, likewise, the probe may be used for diagnostic purposes. 3. The point of irritation may be intrabronchial de- pendent on bronchial catarrh and one observes in the inter- paroxysmal period all the symptoms of bronchitis. It is difficult, however, to determine during an asthmatic par- oxysm which of the rdles heard during auscultation are due to bronchitis and which to bronchial spasm. This question is determined by the author by having the patient inhale nitrite of amyl and carrying it to its full physiologic effects ; 304 Bronchial A s t h m a the rales due to spasm will disappear temporarily, whereas the rdles of bronchitis will persist. 4. The source of irritation may be the stomach (dys- peptic asthma) caused by indigestion. Here an emetic or vomiting may inhibit an attack.* Intestinal worms rriay also cause asthma (asthma verminosum). Among other causes of asthma may be briefly mentioned the sexual apparatus in men and women, the kidneys (renal asthma), the heart (page 212), malaria, hysteria, neuras- thenia, etc. Suggestion, as a factor, often casts discredit on the etiology of asthma just the same as it does on any other neurosis. The operations of' the gynecologist and rhinolo- gist, and the treatment of the neurologist act in many instances by the mere suggestion which is thrown out by the therapeutic manceuvers. If asthma can be produced by suggestion, the same factor can cure it. Thus odors, particularly of flowers, may bring on an asthmatic paroxysm, and one physician induced an attack by allowing the patient to smell an artificial rose. Of late, exposure of the chest to the action of the x-rays in asthma has been followed by cure, and here again, sug- gestion cannot be excluded. Thus I recall a patient who was brought to my office for an examination of the chest. She had asthma and the x-rays were used for a diagnostic object, yet her physician whom I saw several months later assured me that the patient was cured. She was under the impression that the rays were used for a therapeutic object and a single exposure sufficed to cure her. There are numerous conditions, the number of which is rapidly multiplying, which are operative in etiology, and *Vide page 320, concerning the etiology of asthma from odors. 305 Spondyloth e r a p y which, when corrected, lead to the cure of asthma. To relegate asthma to the category of the neuroses is a simple task, but to do so will deprive many sufferers from ultimate recovery. The trend of modern medicine is to deny the existence of functional diseases as mere entities, but to endow them with distinguishing attributes. THEORIES OF CAUSE. 1. Spasm of the bronchial muscles. 2. Paralysis of the bronchial muscles leading to loss of expiratory power (Walshe). 3. A bulbar neurosis consisting of an excessive reflex irritability of the center of respiration (See). 4. A spasm of the diaphragm (Wintrich). 5. A spasm of the inspiratory muscles (Budd). 6. A microbic inflammation of the bronchial tree (Berkart). 7. Hyperemia of the bronchial mucosa analogous to urticaria (Clark). 8. The asthma -crystals found in the sputum of asth- matics irritate the peripheral ends of the fibers of the vagus and induce reflex spasm of the bronchial musculature (Leyden). 9. Swelling of the bronchial mucosa as demonstrated by tracheoscopic examination (Stoerk). 10. An exudative bronchiolitis which induces expiratory dyspnea (Curschmann). 11. Epilepsy of the lungs (Trousseau). Among the more recent theorists, Kingscote contends that a dilated ventricle (right) of the heart predisposes to and maintains a condition of chronic asthma. He assumes that a paroxysm occurring at night is associated with the recumbent posture; the dilated heart striking the vagi 306 Bronchial A s t h m a which lie immediately behind the heart on the. bony spine. The theory of Haig assumes that the uric acid in the blood irritates the vagi. The x-rays, in the opinion of the author, who has exam- ined many asthmatics during a paroxysm, show the in- correctness of several theories. Thus, while the diaphragm is retarded in its excursions, it is not sufficiently immobile to warrant the theory of diaphragmatic spasm. Again, the heart does not approximate the spine in the recumbent posture to the extent of obliterating the triangular space between the heart and the spine; hence the author cannot accept the theory of Kingscote. A study of the pathologic anatomy of bronchial asthma reveals the pertinent fact that nothing is suggested con- cerning the etiology of the disease and even the pathologist in consequence, contends that it is a reflex neurosis. We are thus constrained to determine the pathology of the disease by clinical observations.* Based on clinical observations, the author assumes the following theory concerning asthma : A spasm of the circular muscular fibers of the bronchi with inability on the part of the weaker (paralytic} longitudinal fibers to expel the residual air imprisoned by the spasm of the circular fibers. The foregoing mechanism has its analogue in the bladder musculature, when, in consequence of a spasm of the sphincter vesicae, the weak detrusor vesic cannot expel the urine and ischuria spastica results. The spastic retention *A. G. Auld (The Lancet, Oct. 17, 1903), in commenting on "THE LUNG RE- FLEX OF ABRAMS," observes, "It was not, however, until recent years that anything like a satisfactory demonstration of the presence of broncho- dilator, as well as bronchoconstrictor fibers in the vagus was made by Roy and Brown, and during the present year this seems to have been conclusively established by the work of Dixon and Brodie. But it undoubtedly stands to the credit of Abrams to have proved, at least, seven years since, by a simple clinical observation that the vagus must contain bronchodilator as well as bronchoconstrictor fibers." 307 S p o n d y I o t h a p y of air in the lungs during an asthmatic paroxysm is schemati- cally represented in Fig. 81. In support of the author's spasmo- paralytic hypothesis of asthma, the following evidence is presented : 1. Histologic and physiologic facts. 2. Clinical facts: A. The picture of the asthmatic paroxysm; B. Results achieved by treatment. FIG. 81. A, the normal appearance of the terminal branch of a bronchial tube; B, in consequence of a spasm of the circular fibers the bronchial tube is partially occluded and, insomuch as this occlusion cannot be combated by the enfeebled longitudinal fibers (which can, in the norm, open the bronchial tubes when the latter are contracted) the retention of air causes a dilatation of the lung- structures peripheral to the site of occlusion. Aufrecht 63 has shown that the musculature of the finer bronchi consists of a stout layer of circular and a weaker layer of longitudinal fibers. The clinical observations of the author, which were subsequently confirmed by the physiologic investigations of Dixon and Brodie, demonstrate that the vagus contains fibers which can either dilate or constrict the bronchi. The lung reflex of dilatation (page 294) demonstrates the predominant action of the circular fibers of the bronchial musculature, whereas the counter- 308 Bronchial A s t h m a reflex of lung-contraction (page 298), shows the predominant action of the longitudinal fibers. In asthmatics, the lung reflex of contraction is obtained with difficulty owing to enfeeblement of the longitudinal fibers, hence any therapeutic manoeuver which will accen- tuate this reflex will arrest asthmatic paroxysms and will prevent their recurrence. This is the basis of the author's method of treatment in bronchial asthma. In the norm, the lung reflex of contraction may be elicited in the following ways : 1. By forcible concussion over any area of the lungs by means of a plexor and pleximeter. This manoeuver will only elicit a circumscribed lung reflex of contraction (page 298). 2. By inhalation of amyl nitrite after previous cocainiza- tion of the nose. Here the lung reflex of contraction, as evidenced by dullness of the lungs on percussion, is most conspicuous in the infraclavicular regions. It will be noted that amyl nitrite inhalations are currently employed to arrest an asthmatic paroxysm, but its effects are usually transitory. The reason for this is evident. Any irritant to the nasal mucosa will provoke the lung reflex of dilatation, but if the nasal mucosa is previously cocainized, amyl nitrite, like many other drugs, will reflexly stimulate the broncho- constrictor nerves and by inducing the lung reflex of con- traction will arrest an asthmatic paroxysm. 3. There are several preparations used in a nasal atomizer which are efficacious in arresting an asthmatic paroxysm but which are not curative. One is a secret preparation known as the Nathan Tucker remedy. Coincident with the relief attending its use, the hyper- resonant lungs become dull on percussion and the dullness is always in proportion to the relief obtained. In other 309 S p o n d y I o t h e r a p y words, this preparation by provoking reflexly from the nose the lung reflex of contraction brings relief to the asthmatic. From various analyses made of the Tucker remedy, some claim that no cocain is present, but according to the obser- vations of the author, it is impossible to obtain any decided effects without its presence. The author suggests the fol- lowing as a cheaper substitute for the Tucker remedy: Cocain 3 per cent. Atropin sulphate gr. ii. Natrii nitrosi gr. ix. Glycerin gr. xxx. Aquae destil oz. ss. M.S. Atomize for two minutes in each nostril and inspire deeply. It may be necessary to reduce the percentage of atropin insomuch as in several instances mild atropin intoxication has followed the use of the spray. 4. By concussion of the spines of the 4th and 5th cer- vical vertebrae and by sinusoidalization of the same spines. This will be discussed under the treatment of asthma. On page 297 reference was made to the cotton test in asthma. Here reference will be made to another test in support of the spasmo -paralytic theory of asthma. By con- cussing the spines of the dorsal vertebras (3rd to the 8th), one may provoke a decided lung reflex of dilatation and in one predisposed to asthma, an attack or symptoms of an attack (dyspnea, constriction about the chest) may be provoked. If now, the spines of the 4th and 5th cervical vertebrae are concussed, the attack, or the symptoms, may be temporarily inhibited. In the first manceuver the lung reflex of dilatation brought the circular muscular fibers into action and in the second manceuver the action of the circular 310 Bronchial A s t h m a fibers was inhibited by contraction of the longitudinal fibers. 5. By the tracheal traction test, 65 During the time the head is thrown forcibly backward, the normal resonance obtained by percussion over the manubrium, the anterior chest and the lower lobes of the lungs posteriorly, becomes translated into a dull or flat sound. This manceuver is called the tracheal traction test by the author and is similar to another vago -visceral reflex described elsewhere (page 321). This test is positive in health and in all cardio- pulmonary affections, but it is negative in all cases of idio- pathic asthma. This test is present in the interparoxysmal asthmatic periods of asthma, and is thus of value in the differential diagnosis of other spasmodic affections which suggest an asthmatic genesis. Tracheal traction evokes contraction of the bronchial muscle by stimulation of the bronchoconstrictor nerves in the vagus. In asthma the tone of the bronchial muscle is so reduced that it no longer responds to vagus stimulation when the neck is forcibly extended on the sternum; hence the test is negative in asthma. The dull sound supplanting the resonance in the normal subject by tracheal traction is due to contraction of the bronchial muscle, which puts the air in the trachea and bronchi under considerable tension. There is another affection closely related to asthma which the author has called SPASMODIC BRONCHOSTENOSIS, and in which, like asthma, the tracheal traction test is nega- tive. Patients with bronchospasm suffer from a persistent spasmodic cough, with or without expectoration, in other words, spasmodic bronchostenosis is asthma without par- oxysms. Many physicians have encountered persistent spasmodic coughs in subjects with bronchitis and have no doubt com- 311 S p ondyloth e r a p y mented on the intractability of the cases. In such instances, a bronchospasm complicates the disease. Here climate yields immediate results. The patients often lose their spasmodic cough at once if sent to another climate. Here the spray described on page 310 is very efficient in con- trolling the spasmodic cough, and the same may be said of the smoke from various antispasmodic agents. The following formula, which owes its efficacy to pyridin, may be used : Powdered stramonium Powdered belladonna Powdered hyoscyamus Powdered potassium nitrate aa i oz. M.S. Burn one-half teaspoonful or more and inhale fumes. 6. The picture of an asthmatic paroxysm suggests the spasmo-paralytic theory. The lungs are in an acute em- physematous condition, and the dyspnea is expiratory in character. The moment the spasm is relaxed by appropriate treatment, the lung reflex of contraction is provoked. The table on page 212 gives the differential diagnosis of cardiac and bronchial asthma. TREATMENT OF BRONCHIAL ASTHMA. An attack of asthma may be jugulated by any manoeuver which will promote the expiratory phase of respiration or which will induce the lung reflex of contraction. The author recalls a patient seen in consultation, whose asthmatic paroxysm was of two days' duration despite complete anesthetization with chloroform and recourse to the con- ventional methods yet, a few minutes rhythmical compression of the chest during expiration sufficed to control the attack. This simple method has been used with success in other cases. As before remarked, the lung reflex of contraction can 312 Bronchial Asthma be provoked by concussion of the spines of the 4th and 5th cervical vertebrae and, in the absence of a hammer and pleximeter, the hands may be used (Fig. 3). The latter ma- nceuver often succeeds in arresting a paroxysm, but it may be necessary to repeat it several times. In the treatment of asthma, one frequently observes astonishing cures reported by the rhinologist and other specialists. Here the source of irritation (asthmogenic point) is removed, but the en- feebled condition of the bronchial musculature is unconnected and any other irritant may be operative in provoking an attack. In the following method of treatment suggested by the author, an attempt is made to increase the vigor of the longi- tudinal fibers of the bronchial musculature with the object of inducing the lung reflex of contraction. This is best effected by a strong sinusoidal current one electrode over the spines of the 4th and 5th cervical vertebrae and the other electrode over the sacrum. The treatment must be executed daily and each seance may last from fifteen minutes to one hour. Very often an interrupting electrode at the cervical region may be advantageously employed with the object of exciting more vigorously the bronchoconstrictor fibers of the vagus. All sinusoidal machines are not equally efficient, and to test the latter one electrode is placed over the spines of the 4th and 5th cervical vertebrae in a normal subject and the other electrode over the sacrum. If the former lung-resonance is converted into dullness, after a few minutes action of the current, the latter is efficient, and its efficiency is always in proportion to the degree of lung-contraction which it provokes. This method of treatment will often yield phenomenal results even in cases of asthma of many years' duration. Until the bronchial musculature is strengthened, the 313 S p o n d y I t h r a p y attacks of asthma will continue (with less violence) and to combat the attacks, the nasal spray (page 310) may be used. Adrenalin chlorid is one of the most efficient agents in inhibiting an attack of asthma, and the author employs it in doses of from eight to fifteen minims hypodermatically. The action of this drug is to provoke the lung reflex of contraction and, when effective in asthma, the previously FIG. 82. Arrangement of bottles for promoting lung-contraction. resonant percussion tone of the lungs is converted into a dull or flat sound. Like action on the percussion sound is observed in the normal subject. In addition to sinusoidalization as suggested, the patient should be instructed to execute respiratory exercises at least twice daily with the object of increasing the expiratory force. The latter is best attained by extinguishing with the breath the flame of a candle; the distance of the latter from the patient is gradually increased. At first, the effort of blowing may provoke asthmatic symptoms, but gradually the latter yield. The latter method may even be employed in arresting an asthmatic paroxysm. 314 He m op t y s i s Another efficient method of promoting the muscles of expiration is to instruct the patient to practice daily for a definite time, to blow water by air-pressure from one bottle to another. Each bottle should hold, at least, a gallon, and by the arrangement of tubes, as in the Wolff bottle, the force of expiration will transfer the water from one bottle to another (Fig. 82). Osier and others claim that the method just cited will expand the lungs, but the author has shown that the effect is to contract the lungs. EMPHYSEMA is an affection associated with enfeeblement of the longitudinal fibers of the bronchial musculature. Here sinusoidalization as suggested in the treatment of asthma (page 313) is often very efficient in the treatment of emphysema provided, one can elicit the lung reflex of con- traction (dullness of the lungs on percussion) even in a moderate degree. TUBERCULOSIS is associated with a too voluminous lung and the lungs are practically in an emphysematous condition. The lungs always show deficient expiratory force. Here the bronchial musculature may be brought to contraction by sinusoidalization as in the treatment of asthma (page 313). HEMOPTYSIS may yield to posture (page 293) and the inhalation of amyl nitrite carried to its physiologic effects after cocainization of the nose. This is the most efficient drug we possess in arresting hemorrhage of the lungs. Unless it is efficient after the first inhalation, it is usually without any action. The blood-vessels of the lungs have no vaso -motor nerves and any constriction of the blood- vessels must be effected by provoking the lung reflex of contraction. Cocainizing the nose increases the efficacy of the inhalations. Whereas, amyl nitrite may effect its object without the previous use of cocain, the latter drug increases its efficacy for the reason cited on page 309. 315 S p o n d y I o i h e r a p y CHAPTER IX. THE DIGESTIVE SYSTEM. THE STOMACH THE STOMACH REFLEXES PERCUSSION OF THE STOMACH TREATMENT OF DISEASES OF THE STOMACH THE INTESTINES THE INTESTINAL REFLEXES DISEASES OF THE INTESTINES TREATMENT OF CONSTIPATION THE INTESTINAL NEUROSES. THE STOMACH. By means of the movements of the stomach the food is mixed with the gastric juice. The motor nerves of the stomach are derived from the vagus and sympathetic nerves. Fig. 83, after Openchowski, shows the nerves of the mus- culature of the stomach. THE STOMACH REFLEX OF CONTRACTION." This consists of a contraction of the walls of the stomach elicited by the following manceuvers: 1. Concussion of the Traube. area. 2. Concussion or sinusoidalization of the spines of the three first lumbar vertebrae. 3. By eli citation of the vago- visceral reflex. 4. By pressure in definite paravertebral areas. I. The Traube area or space (Fig. 84) is that half- moon-shaped space which normally yields on percussion a tympanitic sound, owing to the presence of the cardiac end of the stomach. It is bounded above and laterally by the contiguous borders of the liver, lung and spleen. Fixing our pleximeter firmly in the center of the Traube area of tympanicity, we strike the pleximeter with a hammer a series of vigorous blows, and then proceed to percuss the 316 Stomach Reflex of Contraction area of Traube. One observes at once that this region which formerly yielded a tympanitic sound now presents on FlG. 83. Nerves of the stomach musculature. C, the cerebrum; V, stomach; MO, medulla; MS, spinal cord; 5-10, thoracic roots; VRS, right vagus; VS, left vagus; ND, dilators of the cardia; NC, constrictors of the cardia; A, Auerbach's plexus; S, S, fibers from the sympathetic plexus; i, sulcus cruri atus; 2, corpus striatum; 3, corpus quadrigemina; 4, centers in the spinal cord. The dilator center for the cardia inhibits the movements of the pylorus. percussion a dull or even flat sound. The phenomenon thus elicited is the stomach reflex of contraction. II. Concussion of the spines of the ist, 2nd and 3rd lumbar vertebrae will also produce the stomach reflex of contraction. III. Vide percussion of the stomach, page 321. 317 S p o n t h r a p y IV. Firm and deep pressure with the thumb alongside of the spines of the first three lumbar vertebrae on the left side will also elicit the reflex in question. THE STOMACH REFLEX OF DILATATION. This reflex, consists of a dilatation of the stomach pro- voked by irritation of the skin over the area of Traube, FIG. 84. Normal percussion-boundaries of the lungs, liver and spleen, and Traube's space anterior view (Sahli). after tapping the epigastrium, by deep and firm pressure to the left of the spine of the nth dorsal vertebra and by concussion or sinusoidalization of the latter spinous process (Fig 85). Both stomach reflexes may be confirmed by the vago- visceral reflex which is described under percussion of the stomach. 318 Stomach Reflex of Dilatation FlG. 85 Effects of the inhalation of ether on the stomach : continuous line (A), the lower border of the stomach before and (C), after the inhalation of ether. Also illustrating area of gastric tenderness. If a point of tenderness exists at xi, it is shifted to X2, after eliciting the stomach reflex of contraction, which causes the lower border of the organ to recede from A to B.* *Dilation of the fundus is not shown, although it occurs. This illustration is further described on page 323. 319 S p o n d y I o t h e r a p y There is, perhaps, no greater excitant of the stomach reflex of dilatation than irritation of the nasal mucosa by irritating vapors. The effects of inhaling ether are shown in Fig. 85. The reflex in question thus excited is of longer duration than any other visceral reflex. In one patient the stomach remained dilated for fully eight hours. Chloroform vapor is less active than ether in provoking the reflex. In this reflex the fundus of the stomach likewise dilates and the author believes that the asthma from odors is due to pressure of an acutely dilated stomach on the heart. Thus, one patient who suffered an asthmatic paroxysm from the odor of hay, demonstrated an enormously dilated stomach. When the latter was reduced by concussion of the spines of the first three lumbar vertebrae, the paroxysm ceased. When the nose was previously cocainized, no asthma could be provoked from the odor of hay. The effect of insufflation of the stomach on the heart is shown in Fig. 33. In the literature, a number of cases of acute dilatation of the stomach have been reported following operations which are characterized by sudden onset, symptoms of collapse and vomiting of large quantities of fluid. The cause is obscure, but the author's investigations seem to show that the dilatation is associated with the irritating action of the vapors employed as anesthetics. Here the condition is a reflex due to irritation of probable gastro -dilator fibers in the vagus. As the author has shown (page 202) irritating vapors will inhibit the heart, but if the nose has been pre- viously cocainized such action does not ensue. He therefore suggests the use of cocain in the nose as a routine method before employing anesthetics to inhibit the action of the vapors on the heart and on the stomach. Fig. 85 shows the effects of inhalation of ether (duration of inhalation, one minute) on the stomach. 320 Percussion o f t h e Stomach It may be noted that concussion of the spines of the first three lumbar vertebrae will at once reduce the lower border of the stomach to the norm; otherwise the dilatation con- tinues for some time. Such concussion may be of service in acute dilatation of the stomach following operations. PERCUSSION OF THE STOMACH. No gastrologist can lay any claim to distinction in his chosen speciality until he has devised some original method for percussing the stomach, and the result has been a number of complicated and, in some instances, faulty methods of examination. The author contends that any physician who is able to appreciate percussion -sounds can accurately percuss not only the lower border of the stomach, but the upper border of the organ as well (Fig. 86) by the following simple method which elicits the vago-visceral reflex of stomach-contraction. By directing the patient to draw the head slowly back- ward, though forcibly, thus inducing hypertension of the cervical muscles, the pneumogastric nerves are stimulated and this stimulation is manifested clinically: 1. By inhibition of the heart (page 228). 2. By the tracheal traction test (page 311). 3. By the stomach reflex of contraction. To obtain the latter reflex, the borders of the stomach are percussed during the time the patient forcibly extends his head as far back as possible. When he is unable to do this satisfactorily, an assistant may do it for him. During the time tension of the muscles of the neck is maintained, the stomach yields a dullness on light percussion with the patient standing.* *The dullness is accentuated if an assistant compresses the spinal column during percussion (page 80). 321 Spondyloth r a p y To explain the altered percussion sound in the stomach reflex of contraction, one must have recourse to the Skodaic interpretation of the condition which exists when dullness supplants tympanicity. In the stomach reflex of contraction, the gastric walls become tense, thus putting the air or gas within them under increased tension, and, for this reason, we have the physical elements necessary for the transition of a tympanitic to a dull sound. FlG. 86. Percussion of the stomach by aid of the vago-visceral reflex (the head to be fixed as shown in Fig. 65). The illustration with the dotted line indicates an increased area of the organ after irritation of the skin of Traube's area. The other illustration demonstrates the outline of the stomach in a case of gastroptosis. Reference to Fig. 5 shows that concussion of the spines of the first three lumbar vertebrae is not available for per- cussion. While the latter manoeuver is advantageous in treatment, it also provokes the intestinal reflex of contraction and as the latter yields a dullness on percussion, the dullness of this reflex cannot be differentiated from the dullness of the stomach reflex of contraction. THE STOMACH REFLEX OF CONTRACTION IN DIAGNOSIS. Reference has already been made to the value of this reflex in percussion of the stomach. 322 S t o m a c h - D i s location It remains to consider its value in determining the motor power of the organ and the localization of pain. Having determined the lower border of the organ by aid of the vago -visceral reflex, we concuss rather forcibly tjie area of Traube and note the difference of the lower border before and after such concussion. Naturally, the head must be maintained properly during the time percussion of the stomach is executed. It will be noted in Fig. 85, that the lower border of the stomach shifts from A to B, which represents the degree of the stomach contraction which is in direct ratio to the motor power of the organ. In the norm the degree of recession of the lower border of the stomach varies from 2 to 4 cm. Let one assume that the patient has a fixed point of sensitiveness in the epigastrium and it is a question whether this area of tenderness is or is not associated with the stomach. In the former event, concussion of the area of Traube by causing contraction of the stomach, will shift the area of tenderness from Xi to X2 (Fig. 85). Within a minute, however (the duration of the reflex), the area of tenderness will again be located at Xi*. The presence of a growth and its association with the stomach may be shown to exist by aid of the stomach reflex, for elicitation of the latter will cause a dislocation of the growth upward and to the left. Eliciting the stomach reflex of dilatation (concussion of the spine of the nth dorsal vertebra) will cause an area of tenderness or a growth to be dislocated downward. *The author suggests this manceuver in the differential diagnosis of a gastric and duodenal ulcer. The employment of this manceuver will not cause a dis- location of the area of tenderness on palpation if the ulcer is duodenal. 323 S p ondylotherapy TREATMENT. MOTOR-INSUFFICIENCY, or lack of power of the muscular wall of the stomach to discharge its contents, results from many causes, notably the burden thrown upon it by in- discreet eating. This insufficiency of the organ, which practically always eventuates in dilatation of the stomach (gastrectasis), is usually regarded as a dyspepsia, insomuch as the symptoms are dyspeptic in character. Many so-called neuroses of the stomach are dependent on the same cause. The author realizes that he gives expression to heterodoxic views when he attempts a classification of all diseases of the stomach into two main classes : organic and functional. To the former belong chiefly ulcers and tumors, whereas, the latter are not diseases but merely symptoms. In his early professional career, the author religiously executed the conventional gastric analyses, and while he was able to determine anomalies in the gastric secretion, he rarely succeeded in curing his patients; he was successful as a diagnostician and a failure as a therapeutist. The moment he departed from traditional lines and sought a constitutional cause for the symptomatic affections of the stomach, he began to achieve a modicum of success in the treatment of his cases. There is an element of nervousness in all dyspepsias, and this nervousness is maintained by an enervated nervous system. In all instances of functional diseases of the stomach, treatment must be addressed to an enfeebled nervous system ; this is essentially the basis of gastrotherapy. In the experience of the author, the most constant con- dition identified with functional diseases of the stomach is an insufficiency of the muscular walls with a moderate dilatation of the organ and the relief of this condition, which 324 The Intestine is possible after the manner to be cited, is of greater value than any other symptomatic method of treatment. To contract the stomach and to augment the tone of its musculature two methods are available: i. By aid of the sinusoidal current; one electrode over the space of Traube and the other over the spines of the first three lumbar vertebrae. 2. By concussion of the spines of the first three lumbar vertebrae. Treatment by either method must be executed daily and each seance should, at least, last fifteen minutes. In gastric or intestinal TYMPANITES, concussion of the spines of the first three lumbar vertebrae to elicit the stomach and intestinal reflexes is a very effective method. THE INTESTINE. The movements of the intestine are controlled by the central nervous system and the small intestine receives its efferent nerves through the vagus and the splanchnic. Respecting the action of these nerves there is no unanimity of opinion. It may be remarked, however, that vagus- stimulation by contraction of the muscles of thi neck (page 228) while it influences the heart, bronchi and stomach, is absolutely without any influence on the percussion sound of the intestine. THE INTESTINAL REFLEX OF CONTRACTION. This reflex consists of a contraction of the intestine and is evidenced by dullness on percussion supplanting the tympanitic tone prior to the eli citation of the manceuver. Of all the visceral reflexes described by the author, this particular reflex is of longest duration. In some individuals it may persist for five or more minutes, and it is more evident and longer in duration in children than in adults. It is 325 Spondylotherapy best elicited by concussion or sinusoidalization of the spines of the first three lumbar vertebrae. Firm and deep pressure alongside of the spines of the first three lumbar vertebrae (Fig. 48) will also evoke this reflex; pressure on the right side of the spines in question will contract the intestine only on the right side, whereas pressure on the left side will only influence the intestine on that side. Concussion of the spines in question, however, evokes contraction of the intestine on both sides. THE INTESTINAL REFLEX OF DILATATION. This reflex consists of a dilatation of the intestine and may be elicited in one of the following ways : 1. By irritation of the skin of the abdomen. Here the intestinal dilatation is very circumscribed and practically limited to the area of cutaneous irritation. 2. By firm and deep pressure at the side of the spine of the nth dorsal vertebra. Here the intestinal dilatation is limited to either the entire right or left side of the abdomen dependent on the side subjected to pressure. 3. By concussion or sinusoidalization of the spine of the nth dorsal vertebra. Concussion is more potent than sinusoidalization in discharging this reflex. Here the intes- tinal dilatation involves all of the intestine. The reflex of dilatation is less pronounced and of shorter duration than its counter-reflex of contraction. DISEASES OF THE INTESTINES. It is generally conceded by the gastro-enterologist that in intestinal and gastric diseases, the chemical or digestive functions are subservient to the more important motor functions. In the functional intestinal diseases, one again notes muscles in antagonism (page n), and the anomaly 326 Constipation in function is expressed by the predominant action of either the longitudinal or circular muscular fibers. The movements of the intestines as revealed to us by the physiologist are of little or no clinical value. The chief form of intestinal movement is known as peristalsis. The peristaltic move- ment is essentially a constriction of the intestinal wall, com- mencing at a definite point and passes downward from segment to segment, whereas the parts behind the advancing zone of constriction relax slowly. The physiologist does not account for the action of the longitudinal fibers in peristalsis, but assumes that, insomuch as constriction is the attribute of the circular layer of muscles, the latter layer is the chief factor in peristalsis. CONSTIPATION. In one class of patients, constipation may exist without any symptoms, whereas others complain of headache, anorexia, lassitude, mental depression, etc. The latter symptoms have been dignified by the term copremia, which is supposed to indicate fecal poisoning. The fetich of many neurasthenics is the water-closet, and the elysium of others is a purgative. It is easier to take a simple pill than to pursue a prolix dietetic regime, hence the prestige of the purgative habit. What constitutes constipation? We do not, as a rule, seek to analyze this question, and content ourselves with the bare statement of the patient. Grant suggests the following test for constipation : The patient is given a tablespoonful of animal charcoal. Normally it appears in the stools in twenty-four hours. By this means, even though the patient affirms that he is or is not constipated, the charcoal test will decide the question. Dr. C. M. Cooper of San Francisco, resorts to the following test to determine the origin of 327 S p o n d y I o the r a p y constipation. The test is based on the fact that, in the norm, the passage of charcoal or bismuth (which blacken the feces) from the stomach to the rectum is attained in from twelve to forty-eight hours. If more than seventy-two hours elapse before colored feces are detected in the rectum, constipation is present. Hertz, of London, has shown that, if after the lapse of forty-eight hours the rectum is empty, or, as Cooper shows, if the sigmoidoscope demonstrates the presence of blackened feces lodged in the sigmoid, there is some retarda- tion from the middle of the transverse colon. If the feces lodge in the rectum longer than twenty -four hours, then the constipation is rectal in origin, dependent on one of the following causes: Loss of the reflex of defecation from anesthesia or neglect (indolence, false pride, pain of fissures or hemorrhoids), atony or paresis of the rectum and weak- ness of the voluntary muscles of defecation. One must differentiate two forms of constipation : atonic and spastic. In some instances the latter are combined, ATONIC CONSTIPATION is recognized by the dilated intestines which cause a protuberance of the abdomen and percussion of the latter yields a tympanitic sound. Here, concussion of the spines of the first three lumbar vertebrae, fails to yield as in the norm a decided intestinal reflex of contraction as revealed by the dull percussion note. Not only are we thus able objectively to determine this form of constipation, but can also say what part of the bowel is implicated. Very often the dullness is obtained only over the ascending or descending colon, showing that wherever dullness is obtained, that portion of the intestinal canal is not involved in atonic constipation. SPASTIC CONSTIPATION is less frequent than the atonic form. The former is caused by a tonic contraction of in- testinal segments which hold back fecal masses, whereas 328 Treatment of Constipation the latter is dependent on an inherent enfeeblement of the intestinal musculature. There is always a feeling in the spastic form as if the evacuation were unsatisfactory. The patients press a great deal at stool and evacuate long, thin and flattened fecal masses. On palpation of the abdomen one may detect localized contractions, especially of the transverse colon (corde colique). The implicated intestinal segment may be rolled under the finger like a cord. Percussion over the spastic intestinal areas yields a dull in lieu of a tympanitic sound. Normally, when one scratches the abdominal skin over a dull intestinal area, or by a few blows directed against the epigastrium, the dullness becomes tympanitic, owing to temporary dilatation of the intestine (intestinal reflex of dilatation). The per- cussion sound of the spastic intestine does not change. As a rule, the spastic form does not lead to meteorism, yet in rare instances, there may be symptoms corresponding to ileus and even celiotomy has been performed by mistake. In the spastic form not only are cathartics useless, but they accentuate the symptoms. When olive oil is effective in constipation in tablespoonful doses one-half hour before each meal, it is almost diagnostic of the spastic form of constipation. TREATMENT OF CONSTIPATION. Whatever treatment is employed in this condition, one must always conciliate a psychic factor. The psychic factor takes into consideration the fact that the desire to go to stool is a habit. Habit in itself is a great economizer of nerve-force, for it is automatic in action and reduces cerebral participation to a minimum. Thought directed toward a part will increase its functional activity. The mental state influences the intestinal canal 329 Spondylotherapy and one may recall the frequency of nervous diarrhoea. The diarrhoea of students before an examination, of nervous women and men during transient periods of excitement, etc., is of this nature. Canstatt tells of a surgeon who had an attack of diarrhoea before every important operation. From what has preceded, the treatment of atonic con- stipation consists in methods which have for their object the elicitation of the intestinal reflex of contraction. In the experience of the author, the latter is best elicited by sinu- soidalization or concussion of the spines of the first three lumbar vertebrae. Concussion appears to be more effective in the treatment of atonic constipation. If the sinusoidal current is employed, one electrode is fixed over the sacrum and the other over the spines of the first three lumbar vertebras. Strong currents must be used and the daily seances should last fully fifteen minutes. Within a week, usually, the treatment is effective, but must be continued thereafter less often. Spastic constipation is remedied by the method for eliciting the intestinal reflex of dilatation, viz., sinusoidaliza- tion or concussion of the spine of the nth dorsal vertebra. When neither form of constipation predominates, sinu- soidalization or concussion at the same seance may alternate between the spine of the nth dorsal vertebra to stimulate the longitudinal muscular fibers and the spines of the first three lumbar vertebras to excite contraction of the circular fibers of the intestines. INTESTINAL NEUROSES. Among the motor neuroses favorably influenced by the methods suggested in this work are the following : i. NERVOUS DIARRHOEA. This condition presumes an absence of all anatomic changes in the intestinal wall. The 330 L i v e r-Reflexes subjects are usually neuropaths. The treatment consists of alternate toning of the circular (concussion or sinusoidaliza- tion of the spines of the first three lumbar vertebrae) and longitudinal muscular fibers of the intestines (spine of the nth dorsal vertebra). 2. PERISTALTIC UNREST. In this condition (tormina intestinorum) patients suffer from loud noises, which may often be heard by others. The peristaltic movements may be so loud as to interfere with sleep. The movements are often visible and may be palpated. The same treatment may be used as indicated in nervous diarrhoea. 3. ENTEROSPASM. In this condition the intestinal spasticity may be limited or diffused, and in the latter instance the abdomen is retracted. Enteralgia is quite independent of the colicky pains observed in enterospasm and is caused by a tetanic contrac- tion of the enteric musculature. The treatment in both affections consists of relaxing the spasm by concussion or sinusoidalization of the spine of the nth dorsal vertebra. 4. NERVOUS CONSTIPATION. This is frequently asso- ciated with atony of the intestines and the subjects are usually hysterical and suffer paroxysmally from meteorism. There is always a tendency to meteorism whenever there is any weakness of the intestinal musculature. The treatment of this condition is similar to that described under nervous diarrhoea. THE LIVER. There are two LIVER REFLEXES : that of contraction and that of dilatation. The liver re/lex of contraction may be elicited in three ways: 1. By irritation of the skin over the liver. 2. By fixing a pleximeter anywhere in the hepatic region 331 S p n d y I o t h r a p y and striking the pleximeter a series of vigorous blows with a hammer. 3. By concussion or sinusoidalization of the spines of the first three lumbar vertebrae. The latter manoeuver is the most effective. By any of the foregoing methods, percussion demonstrates (Fig. 87) a contraction of the liver. In percussing the lower border FIG. 87. Demonstrating the liver reflex of contraction. The continuous lines represent the borders of the organ before and the interrupted lines the borders after eliciting the liver reflex of contraction. The latter reflex in this patient was elicited by concussion of the spines of the first three lumbar vertebrae. The liver in the mammary line measured 12 cm. and was reduced to 7 cm. of the liver, the dullness of the lower border of the organ is facilitated by inclining the body backwards or by having an assistant fix the hand upon the spinal column to prevent vibrations of the latter (Page 80). The liver re/lex of dilatation is evidenced by an enlarge- ment of the organ subsequent to the execution of the following manceuvers : 332 Pathologic Physiology of Liver 1. By deep and firm pressure with the finger to the right of the spinous process of the nth dorsal vertebra (Fig. 48). 2. By sinusoidalization or concussion of the spine of the nth dorsal vertebra. This is the more effective of the two methods. FIG. 88. Illustrating enlargement of the liver by concussion of the spine of the nth dorsal vertebra. The continuous lines represent the area of dullness before, and the interrupted lines the area after eliciting the liver reflex of dilatation. The liver in the mammary line measured 12 cm. and was increased to 16 cm. PATHOLOGIC PHYSIOLOGY. Circulatory Disturbances. During digestion there is a physiologic congestion of the liver, but in persons who eat and drink to excess, this congestion may become pathologic and may even conduce to organic change. The fullness or distress in the right hypochondrium, to which reference is frequently made by dyspeptics, may be caused as Osier suggests, by hyperemia of the liver. The amount of blood contained in the liver is equivalent to one -fourth the amount 333 Spondyloth e r a p y of blood contained in the body. During digestion this amount is very much increased, hence the drowsiness after eating, especially in dyspeptics, the result of brain-anemia from portal congestion and the cold extremities and chilly sensations. Hyperemia of the organs has been noted in suppression of the menses. Passive congestion is frequent in all conditions leading to venous stasis in the right ventricle of the heart, and is associated with swelling of the organ. HEPATIC TOXEMIA. Any hepatic disease may be associ- ated with a variety of toxic symptoms connected with the nervous system. In the norm, the poisonous substances in the intestinal canal are either not absorbed or, if they are, they are made innocuous and rapidly excreted. Auto-protection of the organism against self -poisoning is achieved by organs which either arrest or transform the poisons or eliminate them. The organs of defense practically represent the bodily resistance. This, equationally expressed for germ-infection, is applicable to auto-poisoning, viz.: PTA T-V R D, the disease, equals P, the poison, multiplied by T, its toxicity, multiplied by A, its amount, the product being R, the resistance of the individual attacked. The liver is unquestionably the chief organ of defense. It converts the poisons into non-toxic and assimilable sub- stances, niters them, and excretes them in the bile. When the liver-function becomes insufficient, the poisons des- tined for destruction enter the blood, and the clinical picture of hepatic toxemia results. If the liver is ex- cluded from the general circulation by connecting the portal vein with the inferior vena cava, nervous manifes- tations and even death may follow the ingestion of meat. The condition known as autointoxication is, practically speaking, an hepatic toxemia. 334 In t e s t i n a I Autointoxication Intestinal autointoxication, as we now comprehend it, may be briefly summarized as follows: During digestion, a number of poisons or enterotoxins are manufactured as a result of putrefaction of albuminoid food in the intestines. These enterotoxins attain the liver by way of the entero- hepatic circulation where they are made innocuous. From the liver they pass into the general circulation and are excreted in the urine. If albuminoid putrefaction is excessive, or if the liver and kidneys (notably the former), prove inadequate in either neutralizing or excreting the poisons, autointoxication ensues. Intoxication is expressed by a motley group of symptoms, which often parade under the equivocal designa- tion, neurasthenia. Now, this conception of intestinal autointoxication is only partially correct. While the usual enterotoxins are bacterial products, there are also poisonous albumoses, i. e., intermediate products manufactured in the digestion of albuminous foodstuffs. It is well known that when peptones and albumoses (normal products of digestion) are injected directly into the blood, they are poisonous and even fatal in their effects. Falloise has recently had an excellent opportunity of studying this subject in a patient with a fistula of the small intestine. He concludes that albuminoid-putrefaction is not the only process concerned in autointoxication, and that an aqueous extract of the con- tents of the small intestine is infinitely more toxic than an extract made from the contents of the large intestine. Hence, if we accept the prevailing opinion that putrefaction of the albuminous molecule is limited in the norm to the large intestine, factors other than putrefaction of the albu- minous molecule must be concerned in intestinal autointoxi- cation. Contrary to current belief, I have found that, in those suffering from self-poisoning, diarrhoea, or at any rate, 335 Spondylotherapy looseness of the bowels prevails rather than constipation, and it appears as if this were a compensatory attempt on the part of the organism to rid itself of noxious products. Strassburger has shown that retarded bowel-action rather indicates diminished products of decomposition which norm- ally stimulate the action of the intestines. If one were guided in the diagnosis of autointoxication by the statements of the patient, the condition would rarely be recognized. The fact is, the patients infrequently complain of symptoms of indigestion. It is only in aggravated cases that one encounters the conventional symptoms of dyspepsia. In most instances, nervous symptoms precede the local signs of indigestion. Another supposed classical symptom of the affection is indicanuria; yet my experience shows that it is comparatively infrequent. If one electrode of a sinusoidal current is placed over the sacrum and the other over the spines of the first three lumbar vertebrae, or, if the spines in question are concussed, one evokes the liver reflex of contraction. Either manceuver will promote the excretion of indican in the urine and its presence in the urine may be demonstrated after a single seance lasting fifteen minutes, even though previously absent. Naturally the urine must be voided before and after the application of the current and the specimens compared after examination is made for indican. For the examination of the latter I prefer the simple test recommended by Porter: Add in a test-tube equal quantities of urine and chemically pure hydrochloric acid. To this mixture add three drops of a one-half per cent solution of potassium permanganate. If indican is present in the urine there will be formed a purplish cloud in the fluid in the test- tube. Then add a few drops of chloroform then one drop 336 In t e s t i n a I Autointoxication more of the potash solution and a few drops more of chloroform and shake vigorously. The deep-blue color resulting is due to precipitation of indican by chloroform and the amount and intensity of the precipitated indican determine the extent of the putrefactive changes going on in the alimentary tract. SPLANCHNIC NEURASTHENIA. In his book on this subject, the author has described a condition dependent on intraabdominal venous congestion superinduced by in- sufficiency of the splanchnic vaso-motor mechanism, and that the neurasthenic symptoms resulting therefrom may be corrected by relief of the congestion and by manoeuvers which will increase the efficiency of the liver as an organ of defense. The fact is, splanchnic neurasthenia is intimately associated with autointoxication. When this venous con- gestion exists it interferes with a proper supply of arterial blood, and in consequence, the tissues and organs are bathed in pools of stagnant blood they are practically asphyxiated. Again, the impeded circulation cannot remove the toxic products of digestion, and instead of the latter being at once conveyed to organs of elimination like the kidneys, they are arrested or transformed by organs like the liver, which soon prove inadequate to discharge their anti -toxic function; then we have the creation of symptoms which belong to the category of self -poisoning. TREATMENT. CIRCULATORY DISTURBANCES. Every condition conduc- ing to a stagnation of blood in the right "heart is eventually followed by passive congestion of the liver. Merklen and Heitz have shown that coincident with the elicitation of the heart reflex, there is a reduction in the size of the liver (Fig. 58). Here, the heart momentarily awakens from its lethargy and by pumping an augmented quantity of blood 337 Spondylotherapy into the circulation temporarily reduces the congestion of the liver. Many Anglo-Indian physicians directly aspirate eighteen or more ounces of blood directly from the liver and it is claimed that excellent results ensue from this hepato-phle- botomy. This method was suggested by observing the reduction in the volume of the liver after bleeding from piles. Now, in many instances, one may regard congestion of the liver as a process of compensation, the liver acting as a reservoir for the redundant blood which correspondingly reduces the work of the heart. By enlarging the volume of the liver by concussion of the spine of the nth dorsal vertebra, the patient may be bled into his own vessels for, even in the norm, this organ contains approximately one-fourth of the amount of blood in the body. In other instances, the organ may be depleted by exciting the liver reflex of contraction by sinusoidalization or con- cussion of the spinous processes of the first three lumbar vertebrae. INTESTINAL AUTOINTOXICATION. Food as a factor in the treatment of autointoxication is a much-abused com- modity. Someone has observed that the ultimate trend of the physician was to prove that even food was poisonous and what has been suggested as a facetious prognostication, appears to have been endowed with reality, when one seriously contemplates the endeavors of dietetic revolution- ists. Many dietetic vagaries are as consistent as the per- fervid plea of the poet Shelley, who wanted us to become vegetarians and marry our sisters. By opposing alimentary insufficiency we possess a formidable weapon in immunizing the tissues against interminable dietetic insults. One must not forget that there is such a condition as "indigestion toxemia," due either to an excessive production of poisons 338 Intestinal Autointoxication or to enfeeblement of the defenses. Thus there is an hepatic as well as a gastric and intestinal dyspepsia and the liver dare not be ignored even in the treatment of an ailment so plebeian as dyspepsia. Intestinal asepsis is, in my experience, a purely theoretic conception which is rarely realized in practice. Intestinal antisepsis is difficult, if not impossible, for the following reasons: i. An antiseptic strong enough to destroy germs is equally destructive to the intestinal mucosa. 2. Germicides will destroy the innocent germs which are concerned in digestion. 3. Germicides are rapidly absorbed or are made chemically inert. Recourse is also had to purgatives, but they often accentuate the symptoms of autointoxication because they concentrate the poisons already absorbed and remove the intestinal epithelium and mucus which practically act as barriers against the absorption of enterotoxins. We have discarded the swab in infectious diseases of the throat, for the reason that it mechanically injures the membrane of the throat and thus opens up new portals of infection. In this sense, the purgative is essentially an intestinal swab. Intestinal autointoxication is a misnomer; the term of qualification refers only to the site where the poisons are manufactured. The offending viscus in autointoxication is usually the liver and, if this organ is made equal to the task of destroying the poisons, the subject of self -poisoning would be simplified. In autointoxication the liver is congested, enlarged and extremely sensitive to pressure ; in fact, when the latter signs are present in the absence of organic disease, we are in the possession of the most positive evidence of hepatic inade- quacy. Reference has already been made to the increased excretion of indican following the elicitation of the liver reflex of contraction (page 336) and the manceuver for 339 S p o n d y I o t h e r a p y exciting the latter is the method employed by the author in correcting hepatic inadequacy in autointoxication. To best elicit the reflex in question sinusoidalization or concus- sion of the spines of the first three lumbar vertebrae is executed daily. The results even after a single treatment is evident ; the liver is reduced in volume and palpation shows diminished tenderness. It would be manifestly inconsistent were the author to contend that the method suggested is curative to the exclusion of other methods of treatment. On the contrary, he is more disposed to say that concussion or sinusoidalization of the lumbar spines is more effectual as an individual method of treatment. Excessive albuminous food, that is to say, a diet con- taining a large quantity of meats and eggs, augments intestinal putrefaction, and even though the organs of defense are relatively normal, they are incapable of perform- ing their functions when an increased burden is thrust upon them. It will be necessary for us to briefly consider other methods of treatment in autointoxication. Some contend that if indican can be detected in the urine, even by a feeble reaction, it is an indication that it is excreted in excessive quantity. Indican in the urine (indicanuria) suggests bac- terial putrefaction of the proteid substances in the intes- tines, for in perfect digestion of the proteids, it cannot be detected in the urine. Intestinal putrefaction as already suggested results from the action of proteolytic bacilli on albuminous food and the primary indication in treatment is to modify the culture medium of the intestine so as to render it inimical to the germs in question. 340 Intestinal Autointoxication The best and most certain method of treatment is by means of an antiputrid regime. It has been suggested that a sterile regime will destroy the virulence of the bacterial flora of the intestine, but observations show that sterile food will diminish but does not completely inhibit intestinal putrefaction. An aseptic regime is best attained by the avoidance of crude vegetables and fruits, for no matter how thoroughly they are washed they still remain contaminated. The cooking of foods will diminish the danger of infection by destroying bacterial growths and larger parasites (tapeworms and trichinae). The cooking of vegetable foods breaks up the starch grains, bursting the cellulose and thus permitting the digestive fluids to come into immediate contact with the granulose. ANTIPUTRID REGIME. As before remarked, this is the most satisfactory means of antagonizing intestinal putrefaction. The putrescent aliments are the proteids and if the latter could be completely eliminated, there would be no putrefaction, and consequently, no intestinal autointoxication. All investigations show that intestinal putrefaction augments parallel with the quantity of albuminous foodstuffs. We know, however, that the proteids or albuminous foodstuffs are true tissue-builders and repairers and consequently cannot be eliminated without compromising nutrition. We know, furthermore, that the proteid requirements of the individual have been exaggerated and that the experiments of Professor Chittenden show that men can maintain health and muscular efficiency for long periods on about half the amount of proteid which is usually consumed. It would be difficult now to maintain, as did Herbert Spencer, that the consumers of meat showed superior physical strength to the consumers of rice, which would be equivalent to saying the Russians demonstrated more physical endurance than the Japanese. One may conclude conservatively that we ordinarily consume more proteid food than is necessary and that ingested in excess, it is either conserved for future uses of the economy, or remaining undigested, it must be reduced by bacterial digestion. Instead of the individual requiring one hundred and twenty grams daily of proteid according to the diet table of Moleschott, or one hundred grams according to the diet table of Ranke, 341 Spondylotherapy the amount of proteid may be reduced considerably without prejudice to the individual. If an individual were desirous of taking his daily supply (100 grams) of proteid in the form of meat, it would be necessary for him to consume a little more than one pound (500 grams) of meat. It was at one time supposed that fats exercised no influence on intestinal putrefaction, but more recent experiments have demonstrated that this observation is faulty and that fats do increase intestinal putre- faction. The lacto-farinaceous diet of Combe is the antiputrid regime par excellence in the treatment of autointestinal intoxication; it acts not by any destructive influence on the intestinal flora, but seeks only to modify the soil in which the microbes live. MILK. Of all aliments, milk is probably the most resistant to putrefaction, and it has been found by Winternitz that if a certain quantity of milk is given with a meat diet, it will diminish the pro- duction of enterotoxins. Milk owes its antiputrid properties to the lactose which it contains and which, under the influence of the aerobic bacilli of the small intestine (coil and lactis aerogenes) is decomposed into succinic and lactic acids. These acids inhibit the action of the proteolytic bacilli in the large intestine from acting on the albuminous foodstuffs. Cow's milk contains about 3.5 per cent of proteids (chiefly caseinogen) against 12.2 per cent in the white of eggs and about 20 per cent in meats. I find that some individuals cannot tolerate even small quantities of milk (raw or boiled) without causing diarrhoea. In such instances, I employ lactose (milk sugar). Cow's milk contains 5 per cent of lactose; hence if the individual will take about 400 grains of lactose at each meal, he will have consumed an amount equal to about three pints of milk daily. Very often raw milk is tolerated when boiled milk is not. It has also been proposed to substitute milk by a number of aliments which already contain lactic and succinic acids and many of them are more digestible than the ordinary cow's milk. They are as follows: 1. Curdled milk. 2. Whey. 3. Buttermilk. 342 In t e s t i n a I Autointoxication 4. Koumiss. 5. Kefir. ' .6, Fresh cheese (frontage a la creme). Buttermilk, owing to its small amount of fat and casein (chief proteid of milk), is a very desirable product in autointoxication, inso- much as one knows that these substances favor putrefaction. Again, the presence of lactic acid and lactose enables the latter to produce lactic acid in statu nascenti. Condensed buttermilk may be obtained in flasks containing 330 grams, and to prepare the buttermilk one mixes the contents of one flask with 660 grams of a decoction of cereals, thus obtaining one liter of porridge (potage au babeurre). The composition of Koumiss varies with its age, containing on the first day about .96 per cent of lactic acid and about one per cent on the twenty-first day after its preparation. It contains nearly the same percentage of alcohol as beer. Koumiss is an agreeable and easily digestible preparation. Fresh soft cheese contains considerable assimilable casein and therefore subserves a useful purpose in proteid nutrition and it has all the advantages and none of the disadvantages of milk. Thus the soft cheese known as petit suisse contains the following: Albumin 4 per cent ; casein, 24 per cent; lactose, 2 per cent ; and lactic acid, .60 per cent. FARINACEOUS ALIMENTS. Combe* formulates the following conclusions: 1. The carbohydrates, or sugary foods, prevent proteid putre- faction in the intestine. 2. That in natural digestion, the farinaceous foods (rice, farina of cereals and their derivatives) surpass all other carbohydrates because they are less easily absorbed and they penetrate more pro- foundly into the intestine and only gradually furnish lactic and succinic acids. 3. That the maximum quantity of farinaceous food must be given with each repast and, if possible, to carry out this cramming process, this food must be given five or six times a day. *L' Auto-Intoxication Intestinale, Paris, 1907. There is an English translation of this book published by the Rebman Company. 343 S p on d y I o t h e r a p y 4. Interdict as far as possible, all albuminous foodstuffs but choose among them the least putrescent (like eggs) and when they are used, combat their action by an excess of farinaceous food. 5. In the ordinary forms of autointoxication, milk mixed with farinaceous food is better supported than milk alone. 6. Avoid fats, which augment putrefaction, and choose butter in preference. If one is desirous of carrying out, if only for test purposes, an antiputrid regime, one may select the following: 1 . Milk, or lactose as a substitute. 2. Cooked vegetables, preferably as purges. 3. Preserved or cooked fruits. 4. Weak coffee, tea or cocoa. 5. Toast with little butter. 6. Farinaceous foods prepared as puddings, or otherwise. These must be consumed in abundance. 7. Buttermilk or Koumiss. 8. Fresh cream cheese. Later, if the condition of the patient is ameliorated, easily digestible albuminous foodstuffs like eggs, ham and cold meat, together with fresh fruits (preferably bananas), may be permitted. ANTAGONISTIC MICROBES. Ever since Metchnikoff directed atten- tion to the fact that sour milk microbes are antagonistic to the microbes of putrefaction, it is quite the custom in France to employ the former in the treatment of autointoxication. The chief characteristic of the intestinal flora of the autointoxicated, is the marked diminution of the saccharolytic aerobic bacilli and the preponderance of the pro- teolytic anaerobic varieties. To modify the foregoing condition a vegetarian or lacto-vegetarian or lacto-farinaceous diet is indicated on account of the small quantity of proteid matter which it contains and the lactic acid which it produces. Another method is to feed the subject with lactic acid ferments or microbes which are innocuous but exert an inhibitory influence on the microbes of putrefaction. There are now several lactic acid culture mediums on the market, but many of them seem to lose their therapeutic action when prepared in the form of tablets or globules. 344 Splanchnic Neurasthenia Unquestionably, the liquid lactobacilline, as it is called, is the most efficient. It may be taken in milk or water directly from the small bottles in which it is sold, and one bottle (containing about half a tea- spoonful) a day is the average dose. During the first few days, digestive disorders may follow its use but soon constipation ceases, the stools lose their putrid odor, the breath sweetens and the tongue becomes cleaner. The signs of autointoxication disappear slowly but surely. To make these good results permanent, the treatment is continued on an average for two and a half months. The ferment is ordinarily employed in association with the diet, although some writers claim that nearly all the effects can be secured from the ferment alone. According to Cohendy, it takes about six days before the lactic acid microbes change the intestinal flora. If diarrhoea is caused by intestinal putrefaction, it is said to be arrested by this bacterio-thera- peutic method. If lactic acid culture mediums cannot be obtained, then buttermilk or koumiss may be used. Holt suggests the following formula for the domestic manufacture of koumiss: one quart of fresh milk, one- half ounce of sugar, two ounces of water and a fresh piece of yeast cake (one-half inch square) , are put in wired bottles and kept at a temperature between 60 and 70 degrees F. for one week. The bottles are shaken five or six times a day. They are then put on ice and kept ready for use. This bacterio-therapeutic method may have to be employed to the exclusion of the laco-farinaceous diet for there are some individuals who suffer from dyspeptic symptoms if the latter is pursued too vigorously. SPLANCHNIC NEURASTHENIA. The chief abdominal symptoms of this affection are : abdominal sensitiveness, ten- derness and enlargement of the liver, and gaseous accumula- tions in the bowels. The dominant symptoms of the affection are resident in the nervous system. Depression, or as it is popularly called, an attack of "the blues," is scientifically speaking, an exacerbation of splanchnic neurasthenia and coincident with the depression, there is hepatic enlargement and tenderness. Eliciting the liver reflex of contraction will 345 S p o n d y I t h r a p y at once dissipate partially or completely the liver tenderness and enlargement, and will ameliorate the condition of the patient. Splanchnic neurasthenics find that their symptoms are accentuated after meals and this may be accounted for by the augmented amount of blood in the liver at this par- ticular time. The factors which contribute to the development of splanchnic neurasthenia are essentially nerve -force lacking FIG. 89. Illustrating the cardio-splanchnic phenomenon. The shaded area indicates the dullness obtained after vigorous compression of the abdomen. The contiguous area is the superficial area of cardiac dullness. in the muscles of the abdomen and in the nervous mechanism which regulates the supply of blood in the abdominal vessels. The former factor indicates reduced intraabdominal tension, for the greater the latter, the less blood will be contained in the abdominal vessels. It is for this reason, that one finds in splanchnic neurasthenia the objective signs of reduced intraabdominal tension (page 145). There is 346 Splanchnic Neurasthenia another sign which the author has called the cardio -splanchnic phenomenon 67 (Fig. 89). There is a tendency of the blood to accumulate in the splanchnic area, with consequent syncope. Like the generality of veins, the great splanchnic veins are very susceptible to pressure, and the amount of blood within them is greatly influenced by the pressure of the abdominal walls. Mere pressure of the latter suffices to squeeze out of them a large quantity of blood. More blood accumulates in the splanchnic veins in the erect than in the recumbent posture, and it is not an uncommon observation for syncope to occur in bedridden patients who are suddenly constrained to get out of bed. The removal of stays in women often induces a feeling of faintness, and the same symptom may occur when a large quantity of ascitic fluid is removed and, in susceptible subjects, when the bladder is emptied or feces discharged. Hill has shown that in consequence of some failure, the blood gravitates into the splanchnic veins from the right heart, and that pressure upon the abdomen will send back the blood from these veins to the right heart, and thus re- establish the circulation. If the lower sternal region, i. \-- N. peron, tufir, \V N. suralis, N. peron. prof. FIG. 94. Peripheral distribution of sensory nerves. 372 s n y N V rf. lig. sacrq-tub, N. eut.fott. R. cut. fat, N. pcron, N. .//. N. suralis. . N. plant, tat. N. ;// /<<, FIG. 95. Peripheral distribution of sensory nerves. 373 Spondylotherapy the skin of the face, the mucosa of the mouth and nasal cavities and the cornea. The author has endeavored to influence the sensory functions of the trigeminus by concussion, sinusoidalization and freezing over the site corresponding to the location of the Gasserian ganglion (Fig. 96), from the sensory cells of which the sensory root of the trigeminus arises. The results have not been as good as when the spinal nerves are similarly influenced. Here freezing (at the site of the Gasserian gan- FIG. 96. The trigeminus or 5th cranial nerve with its three chief branches arising from the Gasserian ganglion. glion) and sinusoidalization are more effective than con- cussion.* SINUSOIDAL -ANALGESIA. The sinusoidal current is less effective than concussion in producing segmental-analgesia. Only the slow sinusoidal current is effective for this purpose and it is obtained from the Victor multiplex sinusoidal outfit. The current bombards the segment with a series of painless concussion-blows. A *The author has not had a sufficient number of cases of neuralgia of the trigeminus nerve to test the value of freezing and the slow sinusoidal current (one electrode to the back of the neck and a smaller electrode over the Gasserian ganglion). The suggestion having been given, however, dentists may elaborate on the method and test its efficiency. 374 S e g m e n t a I- -'Freezing strong current must be used and the duration of the seance must not be less than five minutes. Small electrodes are placed on either side of the spinous process (corresponding to the segment), or, if more spinous processes represent the segmental area of pain, the electrodes are placed along the line of the spine so as to cover the entire segmental area. SEGMENTAL -PS YCHROTHERAPY. Reference has already been made on page 172 to the subject of psychrotherapy. Freezing acts more rapidly than the slow sinusoidal current and concussion in producing segmental analgesia. It is used exclusively by the author in influencing visceral sensation. The effects, however, in comparison with the other methods are not as permanent, and one is handicapped in its repetition by the soreness of the skin which it produces. It may be repeated, however, several days in succession when ether is employed for congelation. To inhibit peripheral and visceral pain either the spinous process over the segmental area is frozen or what is equally efficient, freezing is executed over the areas of vertebral tenderness corresponding to the point of exit of the spinal nerves from a given segment. A patient has a painful shoulder-joint in association with a neuritis. Manipulation of the joint develops areas of vertebral tenderness (previously absent) at the points of exit of the 2nd, 3rd and 4th spinal nerves. These areas are marked with a pencil. Pressure over the sensitive nerve develops an area of vertebral tender- ness at the 7th cervical nerve corresponding to a point between the spines of the 6th and 7th cervical spines. The latter area is also marked with a pencil. Thorough freezing over the 2nd, 3rd and 4th spinal nerves inhibits the pains in the shoulder-joint and freezing over the 2nd, 375 S p o n d y I o t h e r a p y 3rd and 4th spinal nerves arrests the pains of the neuritis. The treatment to be effective must be repeated daily. In some instances it is advisable to freeze not only the points of exit of the spinal nerves, but likewise the seg- ments corresponding to these nerves. In intractable cases, the author has recourse to re-enforced freezing (page 173) or he connects a large hypodermic needle with his atomizer by means of rubber tubing and freezes (with ether) the subcutaneous tissues by aid of the needle. SEGMENTAL- AN ALGESIA OF THE VISCERA. The reader is referred to page 58, where consideration was given to the dermatomes of Head. It may be observed that the latter noted that the distribution of the lesions in patients with herpes zoster corresponded with the areas of cutaneous pain and tenderness occurring in certain visceral affections and by comparing the areas implicated in cases of herpes zoster with disturbances of sensation in a number of cases of nervous diseases (with lesions of the spinal cord), he was able to map out the dermatomes. The latter correspond to the segments of the cord and not to the peripheral distribution of the posterior roots. In the following table the author has located the segments of the cord related to the viscera after the following manner ; repeated manipulation of a sensitive viscus will develop an area of vertebral tenderness corresponding to the roots of the spinal nerves. Having located the sensitive nerves, it was not difficult to trace their relation to definite spinal- segments. 376 S e g m e n t a I -Analgesia SPINAL-SEGMENTS ASSOCIATED WITH ViSCERAL SENSATION.* ORGAN. SEGMENT OF CORD. RELATION TO SPINOUS PROCESS. Heart. Lungs. Breast. Esophagus. Stomach. Stomach (Cardiac end). Stomach (Pyloric end). Intestines. Appendix. Rectum. Spleen. Liver and Gall- bladder. Kidney. Ureter. Bladder. Prostate. Epididymis. Testicle and Ovary. Uterus and appendages. III C and I, II, III D. IV C and I, II, III, IV, V, VI, VII, VIII, IX D. IV and V D. V, VI, VIII D. Ill and IV C and VI, VII, VIII, IX D. VI and VII D. IX D. IX, X, XI and XII D. X and XI D. II, III, IV S. XI D. VII, VIII, IX, X D. X, XI, XII D. XII D and I L. XI, XII D, I L and I, II, III S. X, XI, XII D, III L and I, II, III S. XI, XII D and I L. X D. X, XI, XII D, I Land I, II, III, V S. and, 6th and yth C. 2nd, 6th, 7th C and ist, 2nd, 3rd, 4th and 5th D. ist and 2nd D. 2nd, 3rd, 4th and 5th D. ist and 2nd C and 3rd, 4th and 5th D. 3rd and 4th D. 5th D. 5th, 6th, yth, 8th D. 7th D. i2th D. 7th D. 4th, 5th and 6th D. 6th, 7th, 8th D. 8th, Qth D. 7th, 8th, gth, 1 2th D. 6th, 7th, 8th, loth, i2th D. 7th, 8th, 9th D. 6th D. 6th, 7th, 8th, gth, i2th D. SEGMENTAL- ANALGESIA IN DIAGNOSIS. "The Paris Neurological Society" concluded that all the symptoms legitimately included under hysteria are imposed by suggestion, and this conclusion refers with all cogency to the traumatic neuroses. The latter, it is argued (spinal commotion), cannot give rise to symptoms of the character *C, cervical; D, dorsal; L, lumbar; S, sacral. 377 S p o n d y I o t h e r a p y and duration complained of by the victims of "railway spine." The foregoing contention cannot be correct inso- much as the author has endeavored to show that concus- sion of definite spinal- segments in even normal subjects will produce analgesia and anesthesia in definite regions of the body. Suggested, auto-suggested and hysteric pains are amenable to diagnosis by segmental-analgesia. Let one assume that the patient has a joint-pain. If the skin over the segment corresponding to the joint in question is frozen, or the spine is concussed, temporary evanescence of the pain should ensue. The foregoing observation is equally applicable in the hyperalgesia of neurasthenic patients. NEURALGIC PAINS may be peripheral, i. e., they are local- ized in areas corresponding exactly to the peripheral dis- tribution of the nerve-trunk or nerve involved (Fig. 94). Here, thorough freezing over the entire area of sensitive- ness will inhibit the pains. The pains may be due to irritation of the sensory roots. Here, freezing at the vertebral exit of the affected nerves will assuage the pains. The pains may be intravertebral in origin (spinal-tumors, tabes, myelitis, syringomyelia, etc.) Here, freezing of the spinal segments is alone effective in inhibiting the pains. In pains of visceral origin, the author employs freezing to the exclusion of other expedients in diagnosis. Let us assume that the differential diagnosis rests between an appendicitis and a liver or gall-bladder disease. Referring to the table on page 377, it will be noted that the loth and nth dorsal segments are related to the appendix. If now, one freezes thoroughly the region corresponding to this segment (7th dorsal spine), the pains, if caused by appen- dicitis, will be inhibited. 378 Physiology of Methods Again, after such freezing, the previously sensitive appendix may be palpated without pain. . Thus it is, one may exclude definite viscera as implicated in disease. Assuming one has palpated a sensitive organ supposed to be the kidney. In the table already referred to, the 6th, yth and 8th dorsal spines are related -to the segments associated with the kidney. If the spines in question are concussed or the skin over them is frozen, manipulation of the organ (if it is the kidney) should be painless. The dermatomes of Head should no longer be in evidence if definite spinal -segments related to the different viscera are frozen or concussed. Associated painful areas related to visceral disease (Fig. 27) should disappear when the segments corresponding to the viscera are concussed, sinusoidalized or frozen. In visceral disease, the irritation develops an area of vertebral tenderness which is accentuated by palpation of a sensitive organ (page 369). Here, freezing of the area of tenderness will not only inhibit the pain, but will permit of painless palpation of the organ. The vertebral tenderness from cutaneous or visceral irritation is usually temporary in duration, and when the tenderness persists, it is probably due to changes in the roots of the spinal nerves (ascending neuritis). It is in this way only that one is able to account for the pains which outlast the cure of a visceral disease (excluding, of course, conditions in juxtaposition to the organ). The author has never been able to influence the sensibility of the rectum. PHYSIOLOGY OF SPONDYLOTHERAPEUTIC METHODS. Physiologists are not in accord whether the spinal cord, 379 Spondyloth e r a p y like the peripheral nerves, reacts directly to electric and mechanic stimuli. Those who oppose the excitability of the cord claim that any reaction is dependent on stimulation of the roots of the spinal nerves which give rise to move- ments or sensation. The clinician, however, has evidence to show that the spinal cord is excitable to direct stimulation. Experiments show that most motor nerve-cells discharge their motor impulses at a rate of about ten per second, and if these cells are stimulated artificially, the motor discharge is about the same rate as the normal. This reaction of the nerve-cells of the cerebrum and cord is endowed with a definite rhythm which has been com- pared with the rhythmical beat of the heart. After the discharge of an impulse the cells fall into a refractory phase for a period of time lasting about o.i second. When a nerve-cell has discharged a strong impulse as a consequence of summation of its stimuli, it is exhausted, and requires a certain time to be recharged. CONCUSSION is a mechanic stimulus and is equivalent to a blow, pressure, pinching or section. Mechanic stimuli are only effective when they are applied with sufficient rapidity to produce a change in the form of the nerve-particles. When a motor nerve is stimulated, the resultant is motion and pain if a sensory nerve is stimulated. If the continuity of the nerve is interrupted or the molec- ular arrangement is disturbed by a mechanic stimulus, conduction of an impulse is interrupted and the excitability of a nerve is either diminished or extinguished. In con- clusion one may say that concussion of short duration augments the excitability of the nerves, but when prolonged, the excitability is diminished or abolished. PRESSURE if continued upon a mixed nerve, paralyzes 380 Physiology of Methods the motor earlier than the sensory fibers. If the pressure is applied gradually, the nerve may be rendered inexcitable without demonstrating any evidence of its being stimulated. Pressure on a mixed nerve extinguishes reflex conduction sooner than motor conduction. SINUSOIDALIZATION is the equivalent of an electric stimulus. An electric current shows its most powerful action upon the nerves at the moment it is applied, and at the moment when it ceases, and any increase or decrease in the strength of a current acts as a stimulus. When the current is flowing through a nervous structure, a condition known as electrotonus occurs, whereby the physiologic properties of the structure are greatly modified. The rapid sinusoidal current is stimulating, whereas the slow sinusoidal current yields a series of electric shocks. In the application of the latter current to the spine no motor effects are observed, the action being limited to subduing the sensory component of a spinal-segment. FREEZING. The author has endeavored, by a series of histologic examinations, to explain the rationale of freezing as a remedial agent, but the microscope affords no clue. It certainly does not act by counterirritation, insomuch as the latter shows none of the immediate analgesic effects of congelation. The local application of cold probably acts as a shock, thereby diminishing the conductivity of the nerves and annulling the functions of the centers in the cord. The initial contraction of the vessels and tissues is followed by a greater dilatation andturgescence. The sensory nerves are paralyzed with loss of sensibility. In fact, when the temperature is sufficiently low, the excitability of all the nerves is diminished. 381 S p o n d y I o t h e r a p y SPINAL NERVE -TRUNK ANALGESIA. It is known that if cocain is injected into the tissues about a nerve- trunk, anesthesia follows in the area supplied by the nerve. Anesthesia ensues in about five minutes and lasts about fifteen minutes. It is evident that if the injection is effective, there is an absolute block to the transmission of afferent and efferent impulses. The foregoing fact is of great importance in spondylodiagnosis and spondylotherapy. For local anesthesia, cocain is usually employed, but owing to the occasional toxic symptoms arising from its use, it has been substituted by eucain hydrochlorate, stovain and other local anesthetics. The danger from cocain is minimized if the following precautions are taken: i, Never inject more than one- third of a grain hypodermatically; 2, Never inject the drug into a vein; 3, Never use it if the kidneys are inefficient; 4, The patient should be in the recumbent posture; 5. Use the infil- tration-anesthesia of Schleich. Schleich's formula may now be obtained in tablets and one tablet is dissolved in 100 minims of sterilized water. This formula is absolutely innocuous: the formula No. 3 containing only i-ioo grain of cocain. The infiltration can be made painless by touching the point where the needle is inserted with pure carbolic acid or by freezing the spot. It is well to remember that if one- quarter of a pound of ice (broken into fine bits) is mixed with one-eighth of a pound of salt and placed in a gauze- bag, the application of the latter to a part causes analgesia in about fifteen minutes. A hot solution of the Schleich formula is more efficient than a cold solution. A moderately long needle attached to the barrel of the 382 Cortical Sinusoidalixation syringe is used and made to penetrate the tissues of the back approximating the exit of the spinal nerves as shown in Fig. 10. Assuming that one wishes to make the ulnar nerve analgesic. Reference to Fig. 10 shows that the nerve from which it arises makes its exit between the yth and ist dorsal vertebrae and between the ist and 2nd dorsal vertebrae, hence the infiltration-anesthesia must include the para- vertebral area in question. One may also recall the fact, if cocain, or its substitutes, are interdicted, that infiltration of the tissues with warm or cold sterile water is often very efficient in causing anesthesia. CORTICAL SINUSOID ALIZATION.* In 1870, Herbert Spencer declared that different parts of the cerebrum must subserve different kinds of mental action. Hughlings Jackson affirmed that the gray matter of the convolutions was really excitable, but physiologists regarded his observations as ingenious speculations insomuch as there was no evidence that the cerebral cortex responded to any of the ordinary stimuli of nerves. In 1870, Fritsch and Hitzig, established a new era in cerebral physiology, viz., that the application of the galvanic current to the surface of ike cerebral hemisphere in dogs, gave rise to movements on the opposite side of the body. The latter are movement complexes bringing into play several muscles concerned in various movements or acts and not individual muscles. Thus, the effect of injury to a definite area of the cerebral cortex is the inability to execute particular movements or acts. *The author's reference to this subject is in the nature of a preliminary report. Its intimate relation to the vertebral reflexes (page 7) justifies its consideration. It has only been investigated physiologically, but its possibilities in clinical pathology are far-reaching. 383 S p o n d y I o the r a p y Our knowledge concerning the psychomotor area in the cerebral cortex emanates from the following sources: i, Experiments upon the cerebral cortex of monkeys; 2, Electric stimulation of the cortex in human subjects during the progress of a cerebral operation for the object of localizing a diseased area; 3, Clinical observations confirmed by autopsy in cases of cerebral tumors and Jacksonian epilepsy. FIG. 97. Localization of the motor area. This may be determined approxi- mately by drawing two perpendicular lines, one from the depression in front of the external meatus, and the other from the posterior border of the mastoid process at its root; f, most prominent part of parietal eminence. It has already been shown that spinal muscular reflexes could be elicited by sinusoidalization of definite spinal segments (page n), and it occurred to the author that the motor area of the cerebral cortex could be similarly in- fluenced. That this is true is evidenced by execution of the following method: Having cocainized the skin of a bald-headed individual, corresponding to the motor area 384 Cortical Sinusoidalixation (Fig. 97), a powerful sinusoidal current (rapid sinusoidal from the Victor or the Kellogg apparatus) was conveyed to the motor area either by an interrupting bipolar electrode or with one interrupting electrode over the motor area and the other over the sternum. By opening and suddenly closing the circuit, muscular contractions were observed in the muscles of the face, arm and leg on both sides of the body. Later, it was found that local anesthesia was un- necessary to obtain contractions of the muscles of the face and arm. It is better to employ a bipolar interrupting electrode over the motor area to exclude from participation in the muscular contractions the motor areas of the cord. One must not conclude that because the co-ordinated movements do not occur exclusively on the opposite side of the body, the clinical observations of the author do not correspond with the physiologic evidence. On the contrary, stimulation of an area on one side in animal experimentation results in bilateral movements in the case of corresponding muscles on opposite sides of the body that usually act together. Thus, Exner contends that such muscles appear to have a center not only in the opposite but also in the hemisphere of the same side. All observers have noted that stimulation of the facial center results in identical movements on both sides of the face. It has always been a question with physiologists whether similar areas exist in man. If the evidence adduced by the author is sufficient, the question may be answered in the affirmative. By placing one electrode of a slow sinusoidal current (Victor apparatus) over the sensory area (Fig. 97) and the other at an indifferent point and using a strong current for about ten minutes, a moderate grade of hemianesthesia may be produced on the opposite side of the body. Both 385 S p ondylotherapy sides of the body may be similarly anesthetized by fixing the electrodes on either side of the cranium corresponding to the psychosensory centers of the cortex. 386 R e f I e x CHAPTER XII. THE REFLEXES* AND THE PERIPHERAL SYMPTOMATOLOGY OF VISCERAL DISEASE. PURPORT or SPONDYLOTHERAPY GENERAL FEATURES OF REFLEXES THERAPEUTICS OF REFLEXES THERAPEUTICS OF CONCUSSION COMPARISON OF METHODS TROPHIC FUNCTIONS OF CORD TROPHIC DISEASES PERIPHERAL REFLEX PHENOMENA INSUF- FICIENCY OF THE FOOT TEST FOR THE SPLANCHNIC CIRCULATION REFLEXES OF THE CRANIAL NERVES. THE PURPORT OF SPONDYLOTHERAPY. TT 7"HEN the author first suggested the neologism, SPON- DYLOTHERAPY, he anticipated no misconception con- cerning its object, yet "THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION" conceived the following analysis of the work in question : " One wonders whether this is an attempt to explain osteopathy and chiropractic to the understanding of the regular practioner, or to exploit the very ingenious percussion devices of the author, or whether it is really true that medical men really know practically nothing about the cure of disease through treatment of the spine. Let us hope that it is the latter, and that a careful study of this unique volume may open new avenues of therapy heretofore undreamed of." Now, osteopathy is a system which concerns itself with anatomic abnormalities and their correction. "Its nosology is a lesion, its symptomatology a subluxation." *The reader should consult the index to find the fundamental facts concerning the visceral reflexes. 387 S p o n d y I o t h e r a p y Chiropractic presumes disease to .emanate from displaced vertebrae. The Spinal centers are referred to in osteopathic and chiropractic textbooks, "with a dogmatism and certainty begotten of beneficial results." SPONDYLOTHERAPY concerns itself only with the excita- tion of the functional centers of the spinal cord by different methods which may be executed and demonstrated with the same certainty in the living human subject as is done by the vivisectional experimentalist. (This phase of medicine is referred to by the author as "Clinical Physiology"} In brief, Spondylotherapy is based on the clinical physiology of the human, in contradistinction to the study of physiology by the laboratory vivisectionist. Thus human, and not animal physiology, is made the basis of clinical pathology. In this way one has disproved by clinical observation many apodictic data created in the laboratory. Whereas spondylophysiology concerns itself with a study of the spinal reflexes, the therapeutics of the latter is embraced by the designation, spondylotherapy. SPONDYLOPATHOLOGY. Life is expressed by a rhythmic flow of automatic functions known as reflexes. Each reflex has its antagonistic reflex and, when both are co-ordinated, the result is a physiologic condition. When they are in a state of inco-ordination, the result is a pathologic-physiologic condition. According to this con- ception of spondylology, pathology is founded on physiology, and pathology is nought else but the physiology of the sick. Thus, a pathologic-physiologic condition creates its own patho- logic anatomy. That is, instead of regarding the morbid tissue-change as a primary requisite of disease, it is in reality secondary to physiology in a state of disequilibration. The real object of the practice of medicine is to cure disease and 388 The R e f I e x e s it is only the doctrinaire whose fealty invokes the Skodaic pessimism: "We can diagnose disease, describe it, and get a grasp of it, but we dare not by any means expect to cure it." Thus the soulless philosophy which is too generally accepted as scientific medicine permits the scientist to diagnose diseases while the charlatan cures them." Conservative medicine is too often a practice of trusting to nature and confirming the diagnosis at the autopsy. We are inclined to forget the Hippocratic allusion to medical art; that it consists of three things the patient, his malady and the physician. This is the era of therapeutic medicine, and he who prates about the bankruptcy of therapeutics, substitutes the guinea- pig for a human and the laboratory for the bedside. Therapeutic nihilism owed its conception to the path- ologist, who sought to identify every disease with definite anatomic changes, and his coadjutor, the clinician, studied disease only in relation to these anatomic conditions. Thus, the clinician perpetrated the egregious mistake of associating the autopsic findings with the previous disease, whereas, as a matter of fact, the anatomic changes were sequential to the disease and not the disease itself. In other words, a perturbed physiology created its own pathologic anatomy. One of the most epoch-making developments of modern medicine is "Physiologic Therapeutics," which regards disease as an expression of morbid physiology and all that affects health, affects disease and that, to promote recovery, one must influence the general health. That disease is nought else but physiology gone mad is illustrated in bacteriotherapy and in our modern conception of semeiology. Thus, the inutility of bactericides in the treatment of infectious diseases led to an investigation of the 389 Spondyloth e r a p y latter from a new view-point, viz. : How does the organism deal with infections? It was soon demonstrated that the organism possessed chemical defenses and, as a consequence, modern bacter- iotherapy developed the therapeutics of immunity by utilizing as antitoxins the same products which the animal organism developed to combat infection or, by attempting to stimulate the organism to an augmented production of such defensive agents. Again, we have misinterpreted defensive reflex phenomena as symptoms of disease. Thus, hyperemia, long regarded as a symptom, is now utilized as a valuable physio-therapeutic method. Muscular spasm, by immobilizing a diseased joint or spine, or by protecting a sensitive viscus, is an expression of defense. Fever is probably a salutary process, for by this means the infected body is "cleansed by fire." Pathogenic bacteria thrive best at the normal temperature of the body and they either die or lose their toxic properties with the commence- ment of fever. The micro-organisms of malignant pustule cannot survive a temperature above 104 F., and thus can- not infect birds, whose normal temperature exceeds this limit. This immunity however, is destroyed if the temperature of the bird is reduced artificially. Our present conception of fever is in accord with the teaching of Hippocrates, that fever is a remedy. That it is "a reaction of the organism striving for a useful end, but that this end may not be reached or that it may be overstepped." GENERAL FEATURES OF REFLEXES. Reflexes function- ate with machine-like regulation (regulative reflexes}, and are usually automatic, i. e., independent of our own wills. If one stimulates the nerve of taste, there is a reflex secretion 390 The Reflexes of saliva and gastric juice. However, one dare not exclude a psychic factor in the mechanism of reflexes. Thus, the mere sight of food causes a secretion of gastric juice; the heart is influenced by emotions, and definite psychic condi- tions influence the flow of urine. One of the most important objects of the reflexes is to protect the body from external injuries. The protective movements of pithed or decapitated frogs are so purposive in character and so co-ordinated that Pflliger regarded them as directed by and due to "conscious- ness of the spinal cord." Just as will may excite a reflex, it may also prevent it (inhibition of reflexes). Thus, at well-regulated sanatoria for consumptives, one rarely hears a cough. There patients are disciplined to inhibit a cough and are informed that to cough in public is as much a breach of etiquette as to scratch one's head when it itches. It is still dubitable whether there are definite inhibitory centers or whether there are special afferent inhibitory nerves. As a rule, a reflex is more easily discharged by stimulation of the peripheral end-organ than by stimulation of the cor- responding afferent nerve-trunk. Even though recent phy- siologic investigations show that some of the secretions are not reflexes in the sense that they are mediated by the afferent nerves, yet in a general way they are still reflexes. It has been shown that the ductless glands elaborate specific chemical products known as hormones, which are manufac- tured in one organ of the body and are conveyed by the blood to another organ or organs where they stimulate physiologic activity by their presence. Generally the reflexes are local, i. e., they are discharged in the region of the body irritated. If the reflex irritability is in- creased or if the stimulation is severe, the reflexes may be diff- used to regions remote from the area irritated (reflex dispersion). 391 S p o n d y I o t h e r a p y ORIGIN OF THE REFLEXES. The former view that the spinal cord was the center of all reflexes is doubtful and the following classification of reflexes by Jendrassik is worthy of consideration : 1. Spinal Reflexes, include tendon, periosteal and joint- reflexes. They are usually discharged from areas with diminished sensation; are dissociated with any special feeling; mechanic irritation (like a blow) suffices for their discharge ; the intensity of the reflex is based on the degree of irritation and not upon its duration; making other muscles tense augments the reflex (Jendrassik's method of reinforcement); the reflexes are augmented when attention is distracted. 2. Cerebral Reflexes include the cutaneous reflexes, and they are discharged from sensitive areas. Unlike the spinal reflexes, they are increased or diminished by psychic in- fluences and distraction of the attention impairs them. 3. Complex Reflexes include such which are made up of a series of movements like coughing, sneezing, vomiting, defecating, etc. They are discharged by protracted stimu- lation (summation of stimuli); the reflex involves different groups of muscles and even antagonistic reflexes and psychic influences are of greater moment than with the cerebral reflexes. THERAPEUTICS OF THE REFLEXES.* When the oculist contracts or dilates the pupil, he employs reflexes in treat- ment. Contraction of the pupil is controlled by the oculo- motor nerve, which supplies the sphincter pupillae (and ciliary muscle), and dilatation of the pupil is governed by the sympathetic. Thus eserin, which stimulates the oculo-motor nerve contracts the pupil, whereas atropin, which paralyzes the same fibres, dilates the pupil. Thus, in iritis the most *The pharmacology of the reflexes is discussed in Chapter XIII. 392 The Reflexes important remedy is atropin, because among other effects, the eye is put at rest, owing to paralysis of the sphincter. The day is fast approaching when improved methods of spinal nerve-trunk analgesia (page 382) will enable us to inhibit or excite reflexes to cure disease. Surgery has already invaded this field in the treatment of spasticity, by resection of the posterior spinal-roots (rhizotomy). Here, the object is to inhibit afferent impulses from the muscles which excite the cells of the anterior horns of the cord to send out excessive motor reflexes to the muscles. In the therapeutic elicitation of the spinal reflexes one must take cognizance of the physiologic data which are applicable clinically: 1. A stronger stimulus is necessary to excite a reflex movement than for the direct stimulation of motor nerves. 2. A reflex movement is of shorter duration than the same movement executed voluntarily and there is a decided delay after the moment of stimulation. The reflex time diminishes as the strength of the stimulus increases. 3. Stimuli must be regarded as various forms of energy and over stimulation conduces to exhaustion, when even a powerful stimulus fails to elicit a response. In other words, weak irritation augments the irritability of the spinal centers; medium irritation benefits them; strong decreases; and very strong abolishes the irritability. Some of the failures in my early practice in the appli- cation of spondylotherapy were due to overstimulation of the spinal-centers. Now, I make short and interrupted seances, a fundamental principle in treatment. Several treatments may be given daily but they must be of short duration. The physiologist employs electric in preference to mechanic stimuli for the reason that they are easily applied and their intensity controlled. He has committed himself to 393 S p o n d y I o t h e r a p y the Galvanic or Faradic current for electric stimulation and the sinusoidal current receives no consideration in the text- books on physiology. In my animal experiments I found the sinusoidal current used percutaneously, the only effective one for elicitation of the visceral reflexes. With the use of strong currents over definite vertebral regions, practically every viscus could be made to contract or dilate at will. In association with contraction, the organ became anemic and conversely, hyperemic when the organ was dilated. These circulatory modifications were due no doubt to the visceral musculature and were quite independent of any action on vasomotor centers. With repetition of sinusoidalization, however, the visceral reflexes became exhausted and even the strongest stimulation was without effect. After a period of rest one could again elicit the reflexes in question. THERAPEUTICS OF CONCUSSION. My observations on concussion, as presented on pages 175 and 380, have been further exploited. No reliance can be placed on the average concussion apparatus; it is what it is intended to be, a mere vibrator. The apparatus which the author employs (Fig. 50), operates with an average pressure of 40 pounds and yields a blow equivalent to 12 pounds. Unfortunately, this appar- atus is noisy and compressed air is not always obtainable. To obviate these difficulties the author has devised an effi- cient electro-concussor. Methods are frequently discredited for the reason that they are faultily executed. A physician employed the author's method for several months in a case of aneurysm of the thoracic aorta without results. The patient got progressively worse and the con- dition was apparently hopeless. My colleague had employed 394 The Reflexes a mere vibratory toy for treatment. Within a few seances, after vigorous concussion of the seventh cervical spine, the patient began to progress rapidly toward recovery. The author has repeatedly demonstrated that vibration will not elicit a visceral reflex, hence it is of no avail in treatment. In the absence of a trustworthy apparatus, the method shown in Fig. 2 should be used. Several physicians have successfully employed the latter method exclusively in the treatment of aneurysms. Some physiologists deny the excitability of the spinal cord and attribute any reaction to stimulation of the roots of the spinal nerves. On page 170 (Fig. 48), reference is made to the elicitation of visceral reflexes by paravertebral pressure* Now, if one compares the results of pressure with a special instrument (Fig. 112), at definite paravertebral areas, with concussion executed in the usual way (concussors applied directly to the spinous processes), the following results were obtained in the same subject, with the stomach reflex of contraction : After five minutes concussion of the first lumbar spine the amplitude of the reflex was 2 cm., and its dur- ation, one-half minute. After pressure on both sides of the first lumbar spine for one-half minute, the amplitude of the reflex was 3 cm., and its duration, 15 minutes. Here, the results were clearly shown to be due to nerve- trunk stimulation and not to segmental excitation. Later, the author evolved a special kind of metallic concussor, as shown in Fig. 98, which concusses both sides of the spinous process, instead of direct concussion of the latter. This concussor fitted into the pneumatic hammer, or the apparatus of the author, elicits visceral reflexes of greater *Vide Chapter XIII for a more extended discussion of this subject. 39* S p o n d y I o t h e r a p y amplitude and of longer duration than when the spines are directly concussed. SLOW AND RAPID CONCUSSION. The physiologist attains different results from stimulation according to whether the stimulus is applied rhythmically at a slow or rapid rate. Fig. 98. Concussor which delivers blows to both sides of a spinous process. It is of metal and covered with layers of felt and rubber to eliminate any possible traumatism resulting from concussion. My clinical results are in accord with the foregoing obser- vation. Thus, a liver by percussion measures 12 cm.; after rapid and continuous concussion, it measures 8 cm., and after slow and interrupted concussion-blows, it is still further reduced to 6 cm. After concussion of the first three lumbar spines to elicit the stomach reflex of con- traction, rapid blows caused a recession of 1.7 cm. of the lower border of the stomach, whereas slow and inter- rupted blows resulted in a recession measuring 3.5 cm. In this, as in all other recorded observations, the same blow and pressure were used and the duration of treatment was the same. For the purpose of contracting the viscera, slow and interrupted concussion-blows are more efficient than rapid and continuous blows. 396 The Reflexes To secure dilatation of blood-vessels,' the slow and interrupted concussion-blows are equally more efficient. Thus, in an aneurysm which has a transverse diameter of 6 cm., rapid and continuous blows to elicit the aortic reflex of dilatation increase the diameter to 8.3 cm., where- as slow and interrupted blows increase the diameter to 9.5 cm. To contract blood-vessels (and aneurysms), rapid and continuous blows are more efficient. Thus, an aneurysm with a diameter of 7 cm., is, after slow and interrupted blows to elicit the aortic reflex of contraction, reduced to a transverse measurement of 5.8 cm., whereas, after rapid and continuous blows, the transverse diameter is reduced to i cm. COMPARISON or METHODS. It is only possible in a general way to say what is the most efficient method for elicit- ing the visceral reflexes. Like all cells, the neurones do not react to the same stimulus. Electricity with weak currents increases, and strong currents decrease the activity of the cells. Unfortunately few physicians are sufficiently skilled in percussion to determine for themselves the best method to employ. Very often the rapid sinusoidal current is more efficient than concussion. Thus, in a patient with an aortic aneurysm, the following comparative results were obtained in eliciting the aortic reflex of contraction: METHOD. DURATION OF TREATMENT. DURATION OF REFLEX. Concussion. i min. to yth cervical 12 minutes. spine. Rapid sinusoidal current. i min. to both sides of 36 minutes. same spine. STOMACH REFLEX OF CONTRACTION. METHOD. DURATION OF TREATMENT. DURATION OF REFLEX. Slow blows directly to One-half minute. 3 minutes and 3 5 seconds. spinous process. Slow blows to both sides One-half minute. 16 minutes. of spinous process. Slow sinusoidal current to One-half minute. 8 minutes. to both sides of spine. 397 Spondyloth e r a p y VASODILATOR LUNG REFLEX.* (Application to the loth dorsal spine.) METHOD. Concussion. Rapid sinusoidal current. Slow sinusoidal current. High-frequency current. Paravertebral pressure. DURATION OF TREATMENT. i minute, i minute, i minute, i minute, i minute. DURATION OF REFLEX. 45 seconds. 6 minutes. No result. 4 min., 10 sec. 10 minutes. VVhen pressure exceeded one minute, the dullness was of short duration. The reflexes are more easily exhausted by pressure than by any other method. For discharging visceral reflexes, the rapid sinusoidal current is always more efficient than the slow current. With different sinusoidal machines one secures discordant results. Fig. 99. The Mclntosh polysine generator. *This reflex is fully discussed in Chapter XVI, page 606, and is associated with dullne?* of the lung. Here, duration of reflex refers to the duration of dullness. 398 The Reflexes In my investigations, the Polysine Generator (Fig. 99), made by the Mclntosh Battery and Optical Co., of Chicago, was employed. The dial selector attached to this apparatus obviates the necessity of learning by rote the operation of the many switches in order to obtain the required combi- nations. The high-frequency current, applied by means of a double vacuum electrode (Fig. 100), to either side of definite spines, Fig. 100. Double Vacuum Electrode. will elicit visceral reflexes of great amplitude and long dur- ation. For this purpose, in some instances it is more effective than the other physio-therapeutic methods.* The visceral musculature is of the non-striped variety, which is more easily fatigued than striped muscles. Exces- sive stimulation of muscle results in degeneration of the latter. If a muscle is stimulated by maximum induction- shocks until it ceases to contract, its excitability may be restored by massage, the constant current, veratrin, per- manganate of potash, or rest. *The author has investigated the Leduc (direct interrupted current of low tension) and thermo penetrating currents, and finds them of no value in the elicita- tion of visceral reflexes by vertebral excitation. 399 Spondyloth e r a p y The foregoing facts may be illustrated clinically in the use of physio-therapeutic methods. Thus, if the visceral reflexes can no longer be elicited after the prolonged use of one method of excitation, another method may evoke a response. In a patient with a large aortic aneurysm every symptom had practically yielded in about two weeks to treatment by concussion, excepting a slight cough. Recourse was then had to the rapid sinusoidal current on either side of the seventh cervical spine and within a few days this vestigial symptom of the disease disappeared. An elderly gentleman was practically moribund on two occasions and was restored to comparative comfort by concussional treatment. A slight dyspnea on exertion with a rapid pulse persisted despite treatment. Within a few days after daily hypodermic use of strophanthin, dyspnea and tachycardia disappeared. This same drug prior to concussional treatment was ineffective. Thus, drugs must be employed as succedanea for physio- therapy and the latter for drugs. TROPHIC FUNCTIONS OF THE SPINAL CORD. Aside from the function of the cord as a conductor of impulses, one' must not disregard its puissant function of presiding over muscular, cutaneous, osseous and arthritic nutrition. The trophic control is probably resident in the gray matter. Lesions of the lower motor neurone cause atrophy or dystrophy of the muscles. To question the existence of trophic nerves is a mere matter of logomachy. Suffice it to say that the nerve- cells of the cord maintain the normal state of nutrition of the organs and tissues and implication of the cells predicates definite trophic disturbances. CELL-STIMULATION. The essential principle of living substance is its property of altering its metabolism and transforming its energy. This principle is known as irrita- bility, and the agents which can excite it (heat, light, electri- 400 The Reflexes city and chemic and mechanic agents), are known as stimuli. The metabolic change resulting from stimulation may develop kinetic energy and the cellular condition is known as excitation, or potential energy is developed and the cellular condition is known as its trophic effect. Stimuli which may evoke the former propitious effect may also check metabolism (cellular paralysis). The follow- ing observations on cell-stimulation are axiomatic: 1. The development of energy is greater than the energy of the stimulus used. 2. Cells summate the effects of stimuli. With a rapid succession of stimuli, contractions may be evoked which are stronger than that obtained by a single stimulus. 3. Cells always react in a specific way, irrespective of the nature of the stimulus; a muscle-cell responds with contraction; the cell of a salivary gland will secrete saliva. 4. Stimuli are transient in their action and overstimu- lation always conduces to exhaustion. I have italic- cized the latter fact to emphasize its importance. It applies with equal cogency to pharmaco-, or physio-therapy. TROPHIC DISEASES. There are a number of diseases characterized by nutritional disorders in which the lesion is probably resident in the gray matter of the cord or in the peripheral nerves (which comprise the lower motor neurons presiding over nutrition). The trophic impulses usually traverse the motor nerves. It is only necessary to mention several trophic diseases in which I have employed concussion as a mechanic aid to cell-stimulation. ARTHRITIS DEFORMANS.* This disease is recognized by the following: *This affection is likewise discussed on page 105. 401 Spondyloth e r a p y 1. Muscular atrophy precedes the involvement of the smaller and unusual joints (maxillary articulation, fingers, toes). 2. Presence of trophic or pigmentary lesions in juxta- position to the implicated joints and stiffness or soreness antedating the actual inflammatory changes. 3. Persistence of the condition when a joint is once attacked. 4. The negative action of the salicylates (page 142), and the infrequency of endo or pericarditis excludes rheumatism. 5. Gout is excluded by the absence of movable deposits of sodium urate in the soft parts beneath the skin. In the monarticular form of arthritis deformans, large joints (shoulder, hip, knee), may be involved. When the hip is involved, it corresponds to the condition known as morbus coxae senilis. It is usual to regard arthritis deformans as a chronic infection, an hypothesis which has supplanted the view once held that it was associated with lesions of the spinal cord. In accordance with this theory, I have employed concussion of definite vertebrae. While my results have not been phenomenal and I have not restored the shape of crippled joints, pains were subdued, a modicum of function was restored to the joints and I believe the progress of the disease was arrested. In 1831, Prof. K. Mitchell, associated this affection with lesions of the ganglion-cells of the anterior horns (congestion) and he successfully treated this and chronic forms of rheu- matism by cupping and blistering. From 8 to 16 ounces of blood were abstracted from the regions corresponding to the cervical (upper extremities affected,) or lumbar enlarge- ments (lower extremities affected). When cupping was unsuccessful, blistering was employed in the same regions. 402 The Reflexes Latham 80 , and others, have recently reported brilliant results in hopeless cases following thorough and repeated blistering. Freezing, in my experience, is more efficient and less troublesome than blistering. Unless the results are immed- iate (less pain and stiffness), nothing can be expected from repetition of the treatment. When the upper extremities are involved, one should freeze in the region of the cervical enlargement of the cord (3d cervical to 2d dorsal vertebra), and to influence the lower extremities, the entire region cor- responding to the lumbar enlargement (gth dorsal to ist lumbar vertebra) should be frozen. The employment of dry hot air in this disease has been highly commended by a number of observers. However, to be efficient, the air must attain a temperature of from 350 to 400 F. A lower temperature gives indifferent results. Thermotherapy is often discredited for the reason that the amount of heat applied to a part is insufficient. The fact of the matter is that as long as the peripheral circulation is maintained, neither extreme heat nor cold shows pene- trating power of sufficient practical value. The latter objec- tion I have often obviated by making an extremity anemic by aid of a rubber bandage. When a multiplicity of remedies are recommended for an individual disease, it is less a reproach to physiologic pharmacology than it is to pathology. The latter, for many diseases, is not definitely established and it varies according to the stage of the disease and the reaction of the individual. Among the physio-therapeutic methods which have recently enjoyed therapeutic renomee in the treatment of arthritis deformans and other affections, is thermopenetra- tion. Insomuch as the latter has given excellent results accord- 403 Spondyloth e r a p y ing to a method original with myself, I shall give it special consideration. DIATHERMIC SPONDYLOTHERAPY. The local application of heat has always been recognized as a valuable empiric method of treatment. The physiologic action of heat is produced by irritation of the cutaneous nerve-endings manifested by dilation of the blood-vessels, augmented functionation of the sweat- glands with increased local elimination, improved nutrition of the tissues and changes in the cellular metabolism resulting from the increased temperature of the part. Perhaps the most important physiologic action of heat is to produce hyperemia. The latter is nature's own remedy and occurs with the regularity of a natural law. Among the effects of hyperemia are: Relief of pain, bactericidal action, resorption property of dissolving blood- coagula, exudates in joints and tendons, etc. Heretofore, the different methods employed for raising the temperature of the subcutaneous tissues suffered the drawback of injuring the skin. The latter is a very poor conductor of heat and investigations show that it is practically impossible to raise the temperatures of the subcutaneous structures by the conventional methods of using heat to the skin. It has been found that a high potential oscillating current passing into the body over a small cross-section generates heat in the tissues in inverse proportion to the conductivity of the structures. It has been demonstrated that when the electrodes from an efficient high-frequency current are placed upon the flanks of a guinea-pig, whose temperature was 100.6 F., in about three minutes the temperature in the rectum was raised to 108 F. The method for raising the temperature 404 The Reflexes of the subcutaneous structures is known as diathermy, trans- thermy and thermo-penetration. In the conventional use of diathermy, notably in affections of the joints, the electrodes are applied opposite each other and the current is used to the point of toleration as long as possible. The high-fre- quency current for diathermic purposes is devoid of chemic action provided sparking is prevented. In my experience, the heat generated by the current is so great that patients can only tolerate it for a very limited period of time. To obviate the latter objection, the sponge contacts are immersed previous to application in a saturated solution of ammonium nitrate. Applied directly to the affected joints in arthritis de- formans, there is a local reaction manifested by swelling, pain and stiffness of the joint. This reaction is less accentu- ated with repetition of the treatment, which, if successful, yields results after a few seances. Better results in my experience, however, follow the use of diathermy to definite vertebral areas. As a rule, one finds sensitive vertebral areas on pressure corresponding to the joints involved and the electrodes are then applied on both sides of the spine. LOCOMOTOR ATAXIA. The exact seat of the initial lesion in tabes is dubitable but there is every reason to believe that it is primarily an inflammation of the posterior nerve-roots or the ganglion-cells in the posterior ganglia are first implicated. In my experience, diathermy is practically a specific for the characteristic pains of this disease which follow dorsal root- areas. Figs. 92 and 93 show the vertebral sites for the application of the diathermic current. Thus, if the pains are located below the knees, the electrodes are placed on either side of the spinal column corresponding to the nth and i2th dorsal 405 Spondyloth e r a p y spines. The same method is applicable in pains of spinal origin which prove refractor}' to conventional treatment. Here, the morbid anatomy is practically identical with early tabes, viz., a radicular meningitis. THE FUNCTIONAL SPINE. 81 In this condition, diathermy is also very effective. In the functional spine, pain is felt in the region of the lower dorsal and upper lumbar spine. It is in the nature of an ache and stiffness on attempting to straighten up from a stooping posture or in getting up in the morning. Limitation of motion is caused by muscular spasm. DISEASES OF THE MOTOR TRACT. Atrophic change in the motor neurons is the basic anatomic lesion in these diseases and concussional treatment should be given a trial. In one case of Polio-Myelitis, in which both legs were affected and the paralysis had failed to yield to conventional treatment, an almost complete cure was effected by vertebral concussion. The affected muscles began to react to the in- duced current after twelve seances* If the lower extremities are implicated, concussion is executed in the region corresponding to the lumbar enlarge- ment (gth dorsal to ist lumbar vertebra). BERI-BERI. This disease, which is very prevalent in tropical countries, is characterized by motor and sensory paralysis and atrophy of the muscles. Among the clinical forms of the disease, there is the acute cardiac form asso- ciated with symptoms of cardiac failure. Dr. George Day- wait has forwarded me the following report concerning the treatment of beri-beri by aid of vertebral concussion. *In the examination of a child with a disabled limb in this disease, it is well to remember that when the child is suspended in a warm bath, better movements can be made; hence, this method gives a clearer picture of the degree of impairment, and facilitates treatment by enabling the child to exercise the limb which would otherwise be impossible. 406 The R e f I e x e U. S. A. T. "Seward," MANILA, P. I., May 7, 1910. "In answer to your letter of inquiry concerning my experience in the treatment of chronic beri-beri, it gives me pleasure to inform you that remarkable results have been obtained by means of a series of concussions, made by the strokes of a rubber-tipped hammer, weighing about one ounce, on both sides of the spinal column, over the exit of the nerves supplying the parts of the body diseased.* The exact technique used is that des- cribed in your monograph, "The Treatment of Aneurysm by Spinal Concussion." For a weak heart, concuss the nerve at its exit from the third dorsal; to affect the muscles above the knee, and calf of legs, concuss the nerves at their exit from the third and fourth dorsal, those of the plantar muscles, the nerves from the fourth sacral. As the hammer falls gently over the nerves near their exit from the spinal column, a play of the muscles may be seen successively, as each group is concussed. The patient arises from the seance with a sense of re- newed strength in the use of the muscles, which here- tofore had failed him in walking. There is improvement from the first treatment. Each treatment lasts about five minutes, and is given daily for five to twenty days. There is often some trouble in locating the nerve. Make exploratory taps and, when the expected reflex action shown by the contracting muscle is seen, it is well to mark the spot by a point of indelible ink.f Locate all the nerves it is desired to concuss; this having been done, dismiss the patient to return the next day. At the second and subsequent sittings, let the hammer play over each nerve guided by the ink-spots; on first one and then the opposite side of the column, going up and down the column much as the fingers of the *Vide Fig. 2. fCarbol fuchsin is better for dermography 407 Spondyloth e r a p y piano player following the scale on the white and black key-boards. Tap with the hammer gently, with just sufficient force to cause the muscles to respond. My experience has been limited to six cases. The first, a man 37 years, had beri-beri five years previously. Ever since his recovery from the acute symptoms he had not been capable of continued exertions for more than a few minutes without feeling a fainting sensation. The only organic trouble discernible was a distinct hemic murmur of the heart. He had taken the usual tonics with but little effect. I proceeded to concuss the nerves on both sides of the spinal column only opposite the third dorsal vertebra. The effect was beneficial. After the seventh sitting he declared himself well. His hemoglobin count had risen from 60 to 80. I saw him a month later, the picture of health and no murmur noticeable. The third case was a soldier, 22 years old, who had beri-beri eighteen months previously, was returned to duty after a month in the hospital but was unable ever to do full duty. When I saw him his captain had just forwarded a request for his discharge. He could not make more than two or three hundred yards without "falling out," because of weakness of his knees, legs and feet. Treatment was begun at once with the result that within two months he was doing full duty, even to scaling a 1 2 -foot wall. In not one of the six cases was any medicine used. Good hygiene and proper food were the only synergists used. In one only, the heart symptoms predominated. The other five had the lower extremities affected, and of these five, three were cured, the other two markedly improved. Wishing you every success in your pioneer work to make scientific the treatment of chronic and heretofore incurable affections resulting from apathetic conditions of the nervous system, I remain very sincerely, G. W. DAYWALT, ist Lt. Med. Res. Corps, U. S. A. 408 The Reflexes Beri-beri is essentially a multiple neuritis and concussion is indicated in the latter disease after the acute symptoms have subsided. THERAPEUTIC-PHYSIOLOGY or CONCUSSION.* Numer- ous correspondents have solicited further information con- cerning this subject. What is said of concussion refers with equal cogency to other methods for eliciting the visceral reflexes and, if aneurysm is selected as a paradigm, it is because it has been made the subject of the most frequent interrogation. The balneologic treatment of heart-disease by Nauheim baths has shown itself to be of great value and is based on sound physiologic principles. Schott, who inaugurated this treatment suggested among other things, that the good results were due to a reflex stimulation of the heart which evokes slower and more powerful contractions of the organ. In other words, one elicits by this method the heart reflex as suggested on page 218. MUSCLE TONUS refers to a continuous (however slight) contraction of muscle under normal conditions and which is maintained by subminimal nerve-impulses constantly dis- charged from nerve-centers into the muscles. In this way, the neuro-muscular apparatus is in a condition of tonic activity. Thus, the sphincters in the norm are in a state of tonic contraction. Tonus is of the greatest importance in clinical medicine as we shall learn in chapter XIII. It is most probably maintained by the direct stimulating effect of the internal secretions upon the peripheral organs or upon the central or peripheral nerve-cells. That tonus may be augmented from the periphery is illustrated when the skin becomes chilled. Here, the sensory stimulation thus evoked, reacts upon the nerve-centers and *Reference has already been made to this subject on page 267. 409 S p o n d y I o t h e r a p y the discharge along the motor paths to the muscles causes the discernible movements of shivering. It is in this way that one may explain the elicitation of visceral reflexes either by peripheral or central stimulation (vertebral reflexes). We shall als.o learn in chapter XIII that tonus may be influenced by psychic factors. Let us in our polemic concede that the foregoing holds as far as musculature is concerned. In the aorta, however, the tunica media (middle-coat), in comparison with the coat of other arteries, is thicker and contains relatively more elastic and less muscular tissue. In the root of the aorta, this coat consists chiefly of striated muscle (like that of the pulmonary artery), and resembles that of the myocardium with which it is continuous. The contractility of the aorta, however, is a question of physiology and not histology. The majority of writers contend that mesarteritis result- ing in degeneration of the elastic tissue of the aorta is the predisposing cause of aneurysms.* Experimental aneurysms result when the wall of an artery is cauterized; the resulting inflammation causing the formation of fibrous tissue without elasticity and the latter being less resistant than an elastic tube, dilatation of the vessel ensues. In small sacculated aneurysms, a spontaneous cure has been known to occur by thrombosis. In our many successful symptomatic cures of aneurysms, we have not had an oppor- tunity of determining the role played by thrombosis, hence the doctrinaire must await the verdict of the necropsy. We believe that our results are achieved by increasing the tonicity of the vagus (vide chapter XIII), which in reacting on the fibro-muscular coat of the aorta diminishes the *As will be shown on page 552, the author is not in accord with this view-point. 410 The Reflexes caliber of the vessel and by augmenting its elasticity makes it more resistant (Fig. 119). The results attained are not unlike the effects on the heart by the methods of Schott. The physiologic excitation of the aortic and other visceral reflexes increases the contractility and tonicity of the aorta and viscera but when the stimulation is excessive, the opposite effect is produced, viz. : dilatation and diminished contractility and tonicity. PERIPHERAL REFLEX PHENOMENA OF VISCERAL DISEASE. i. Pain; 2. Hyperalgesia; 3. Muscular Spasm; 4. Secretory reflexes; 5. Vasomotor reflexes ; 6. Pilo-motor reflexes; 7. Paravertebral tenderness; 8. Elevation of temperature. Before consideration is given to the foregoing symp- toms attention must be directed to the cerebro-spinal and to the autonomic-nervous system* (page 24). The former system including the brain, spinal cord and the peri- pheral nerves mediates sensation and muscular contrac- tion. The autonomic system innervates the viscera. Both systems are intimately associated and afferent impulses passing from the viscera stimulate the nerves of the cerebro-spinal system so as to eventuate in peri- pheral pain, hyperalgesia and muscular spasm. The autonomic system, according to Langley, is shown in Fig. 101. *Further discussed in Chapter XIII. m S p o n d y I o t h a p y Sphincter of iris. ( Ciliary muscle. I * * Dilator of iris. Orbital muscle. Heart. Blood-vessels of mucous membrane of "head. Walls of gut from mouth to de- scending colon. Outgrowths from this region of the gut (muscle of trachea and lungs ; gastric glands, liver, pancreas). The skin (arteries, muscles, glands). Blood-vessels of gut between mouth and rectum, of lungs and of abdominal viscera. Arteries of skeletal muscle. Muscle of spleen, ureter, and of internal generative organs. Walls of stomach, intestine, gall bladder and ducts, urinary bladder. Arteries of rectum, anus and external generative organs. Walls of descending colon to end of gut. Walls of bladder and urethra. Muscle of external generative organs. Mid-brain autonomic. Bulbar autonomic. Sympathetic. (I. Th. to II. or III. L. in man.) Sacral autonomic. (II. to IV. S. about in man.) Fig. 101. Illustrating the origin and distribution of efferent autonomic fibers. "Muscle," refers to unstriated muscle only and the "walls" of a structure signify the unstriated muscle in them. The innervation of the gastric glands, pancreas and liver and the arterioles of the skeletal muscles and the central nervous system is still dubitable. 412 The Reflexes i. PAIN. When the cerebro-spinal nerves are stimu- lated, the pain is referred to the peripheral distribution of the nerve. In many instances, however, the pain is not strictly localized in the irritated nerve itself but it radiates to different areas. Mackenzie 68 quotes Sherrington, who states that, after applying a mustard leaf over the front of the upper part of the sternum, an unpleasant tingling sensation was exper- ienced above the inner condyle over each upper arm. In explanation of this phenomenon, one knows that the second thoracic nerve supplies equally the upper chest and the inner side of the upper arm and that, when the stimulus from the chest (after application of the mustard plaster) reaches the spinal cord, it affects the adjacent cells. Hence, although the peripheral parts are widely apart, they have a common center in the cord. This overflow of the reflexes, or what is currently known as radiation of pain, is illustrated in daily practice and is often a source of error in diagnosis. Thus, one may cite abdominal pain. Palpate the abdomen almost anywhere and the pain is often as keenly felt in one as in another situation. In such instances, the pain without conspicuous associate symptoms may mean an appendicitis, and for that matter, it may just as well be the pain of biliary or renal colic, or if a woman be the subject, pelvic disease. Here the inhalation of chloroform, not to the point of anesthesia, but just enough of it to quiet the patient without affecting con- sciousness, causes the disappearance of radiating pains, *vhile the original pain remains fixed in the region of the right hypochondrium in gall-stone colic, or over McBur- ney's point, in appendicitis. Morphin, hypodermatically, accomplishes the same object. In this connection, I wish to refer to another diagnostic 413 Spondyloth e r a p y point. If one is in doubt concerning the organ as the source of pain, palpation or pressure on the implicated organ will reproduce the exact pain about which the patient complains. A fixed pain practically always denotes an organic and not a functional lesion. In trigeminal neuralgia, I have frequently encountered sensitive areas at the side of the ist and 2nd cervical spines, and freezing of the latter was followed by relief for a vari- able period of time. This also applies to odontalgia. A spinal tract of the trigeminus can be traced as far down as the second cervical segment of the cord. It is also easy to understand vagal-reflexes in consequence of trigeminal irri- tation; at its cranial end, the vagus is in direct relation with the trigeminus through the intervention of the tubercle of Rolando. Even under anesthesia, the trigeminus maintains its sensibility and though sensation is abolished elsewhere^ punctures in the temples and frontal region are still per- ceived. Dr. Geo. Baert, of Michigan, having availed himself of the foot-note suggestion on page 374, employed the treat- ment successfully in several cases of trigeminal neuralgia, notwithstanding futile results with injections of alcohol. An overflow of the reflexes is frequently noted in func- tional disturbances. Thus in hysterical anesthesia, there is a temporary restoration of cutaneous sensibility after the use of morphin hypodermatically. In hysteria, one also observes during the stage of chloroform excitation, the dis- appearance of contractures and other stigmata of the disease. One must not forget that spinal nerves are composite structures and spasm and pain are associated with their irritation. Thus, in laryngeal stenosis of children, the use of an opiate excludes the spasmodic element and often makes 414 Visceral Pa n a tracheotomy unnecessary. This same practice applies to the introduction of an instrument into the bladder when there is spasm of the vesical sphincter. VISCERAL PAIN.* Mackenzie contends that the viscera are insensitive to ordinary stimulation and what is regarded as visceral sensitiveness by the examining physician is merely cutaneous and muscular hyperalgesia. In other words, visceral pains are not felt in the organ, "but are referred to the peripheral distribution of cerebro-spinal nerves in the external body-wall." In support of his hypothesis, Mac- kenzie cites the following: 1. Pressure exerted over a supposed gastric ulcer, an enlarged liver, or an inflamed pleura, causes pain; but this method of investigation ignores the augmented sensibility (hyperalgesia) of the tissues (skin and muscles) covering the external body- wall. . 2. Pain is felt in the position where the organ is situated. If this were true, then the pain would shift in accordance with the location of the organ. Thus, in gastric ulcer even though the stomach is dislocated by deep respiratory move- ments, the pain remains stationary. . I contend that there is visceral pain sui generis but that, it may be associated with pain referred to the coverings of the body-wall connected with the same segments of the spine. The investigations of Mackenzie demonstrate that the viscera are only insensitive to such stimuli as pressing, drying, application of silver-nitrate, burning, cutting, etc., and that, were a definite stimulus employed, visceral sensi- tiveness could be shown. It is known that a nerve-ending may respond to one form of stimulation and yet prove insensitive to others. Every nerve when stimulated responds *Reference is made to this subject on pages 58 and 413. 415 Spondylotherapy in a manner peculiar to its function. Stimulation of the optic nerve creates the sensation of light and excitation of the auditory nerve responds with the sensation of sound. The recent investigations of Hertz 69 show that tension is the only cause of true visceral pain and that pain originating in the peritoneum* is not uncommon in the absence of visceral pain. In a patient where the diagnosis of gastric ulcer was definitely established, the skin and muscle in the region of a sensitive point were anesthetized yet, by deep pressure, I succeeded in eliciting the same degree of tenderness as before local anesthesia. By my method of transmitted palpation (page 83), vis- ceral sensitiveness is easily demonstrated. By aid of the vertebral reflexes (page 7), visceral pain may be accentuated or inhibited and the same holds good for segmental analgesia of the viscera (page 376). The local area of tenderness of visceral origin does shift when the vertebral reflexes are employed (Fig. 85). 2. HYPERALGESIA. Cutaneous hyperalgesia consecu- tive to visceral disease has already been discussed (page 58). Hyperalgesia of other structures, notably the muscles, is equally common. Pressure, to elicit muscular hyperalgesia is faulty, for the reason that one cannot exclude cutaneous hyperalgesia. Here, one may make passive movements, or the muscular tenderness may be evoked by active move- ments of the muscles by the patient. When the muscular hyperalgesia is associated with spasm, mistakes in diagnosis are. not infrequent (page 191). *Lennander, contended that the parietal peritoneum is intensely sensitive to pain, but not to pressure, heat, or cold and that painful abdominal sensations are transmitted by the phrenic, lower six intercostals, lumbar and sacral nerves (which innervate the parietal peritoneum). The visceral peritoneum and abdominal organs (innervated by vagus or sympathetic), are not sensitive to pain. 416 M u s c u I a r Spasms 3. MUSCULAR SPASMS.* The term, viscera-motor reflex has been applied to the spasm of a muscle in consequence of visceral disease. This reflex is commonly observed in affec- tions of the abdominal viscera (hardness of the abdominal muscles and tenderness which are accentuated by palpation). Muscular spasm as a peripheral symptom of visceral disease, may be manifested by clonic or tonic contraction and involve- ment of a part or the whole of a muscle. When the part of a muscle is involved, it may be mistaken for a tumor (page 191). In some instances, the viscero-motor reflex in question is only recognized by increased resistance on palpation. Muscular spasms may persist during deep narcosis and as a rule, they yield last of all the muscles during anesthesia. Dr. C. A. Reed 7 , based on the observations of Nothnagel and Lennander, who insist that visceral pain is only a phenomenon of muscular hyperalgesia, seeks by subduing the latter to relieve visceral pain. Many post-operative pains following operations on the uterus and adnexa have been subdued (even though morphin failed), by deep muscular injections of the following solution into the hyperalgetic areas: 1$ gm. or c.c. Morphin hydrochloric! o|oi Novocain o 1 04 or Scopolamin 0(0015 Normal salt solution 1 1 "This represents a single dose which, before adminis- tration, is further diluted with physiologic salt solution to permit of its distribution by numerous deep punctures with an ordinary hypodermatic needle into the hyperal- getic areas. 2. For analgesia, after thoroughly cleansing the integument, all of the mixture is injected into the muscular *Vide page 46, et seq. 417 S p o n d y I o t h e r a p y layer, several punctures being employed and care being taken to make them at points that approximately define the circumference of the hyperalgetic area. The anal- getic effects will be realized within from five to ten minutes, and in consequence of the presence of the scopolamin, will be continued often from six to eight hours, while in some instances they will be permanent. 3. For local anesthesia, the same solution is used in the same way, with the exception that it is discharged into the subcutaneous connective tissue at points that approxi- mately define the circumference of the area that it is desired to anesthetize. The sensibility will disappear in from five to eight minutes and will remain absent for a period varying from an hour to three hours." Reed argues that, if an algetic impulse can be telegraphed from viscus to muscle, an analgetic impulse can be trans- mitted from muscle to viscus and thus pain may be con- trolled. It is true that we know little of autonomic phenom- ena and are not sure of that but it is reasonable to assume that the analgesic formula before mentioned owes its efficacy to its action on the sensory nerves of the muscle. It is known that an inflamed joint may be absolutely fixed in consequence of powerful contractions of the sur- rounding musculature. This condition may suggest a false ankylosis and insomuch as the muscular spasm may persist even during narcosis, I would suggest the use of Reed's formula for releasing the spasm and thus aiding diagnosis. The author recalls circumscribed spasms of the sterno- mastoid muscle, which were mistaken for tumors and which were dispersed by a few applications of the Faradic current. Mitchell reported a phantom tumor in the left pectoral region. Despite the irrelevancy of the interpolation, I wish to direct attention to circumscribed tonic spasms of the visceral 418 Muscular Spasms musculature. It is known that phantom tumors of the abdomen may be caused either by a contraction of the abdominal muscles or meteorism, and when such tumors occupy the lower abdomen, they simulate pregnancy (pseu- docyesis). Anesthesia may be necessary to cause their disappearance. To my knowledge, no reference has been made to circumscribed tumors of the uterus mistaken for fibroids and often due, as I believe, to subinvolution of the uterus. These pseudo-fibromata may be dispersed by elici- tation of the uterus reflex, (page 358). Dr. M. Turnbull reports the following case: "Patient suffers from menorrhagia and profuse metrorr- hagia. She is very pale, emaciated and growing pro- gressively weaker. Examination of the blood shows a profound anemia. Has been advised by several promi- nent gynecologists to have a myomectomy or a hysterec- tomy performed. All concurred in the diagnosis of an. interstitial fibroid. Uterus is enlarged and a. fibroma? is distinctly palpable. Treatment consisted of eliciting the uterus reflex by application of the interrupted sinusoidal current to either side of the second lumbar spine every day for a period of three minutes. At the first treatment, one could observe contractions of the uterus through the speculum and the expulsion of clots of blood from the uterus. After about three weeks treatment, patient was practically cured and has continued so up to the present time of writing. Examination shows a normal uterus and the supposititious fibroid can no longer be palpated. The patient has been cured of a chronic constipation." (Comment by the author. The patient suffered from atonic constipation (page 328), and the treatment directed toward elicitation of the uterus reflex was equally appli- cable in this form of constipation. Electricity (Galvan- ism) has been credited with a selective effect (electro- chemic) on fibroids. It is probable that the action is due 419 Spondyloth e r a p y to dispersion of irregular contractions of the uterine musculature) . ABNORMAL POSITIONS OF THE UTERUS, caused by relaxed ligaments, may be improved and cured by eliciting the uterus reflex. Some of the ligaments contain non-striped muscular fibers, whereas the round ligaments consist essen- tially of muscular tissue, prolonged from the uterus. SEGMENTAL PSYCHROTHERAPY (page 375) is likewise of diagnostic value assuming that one is unable to palpate the abdominal viscera owing to rigidity of the muscles. Reference to the table on page 33, shows the segmental origin of innervation and Fig. 10, the spines corresponding to these segments. If the spines are thoroughly frozen, palpa- tion is facilitated. I recall a case where taxis was employed without result to reduce an inguinal hernia but when freezing was used in the manner indicated, reduction was effected. In another patient, reduction was effected by refrigerating the hernia. MUSCULAR RIGIDITY IN THORACIC DISEASE. In thor- acic affections, notably, pleurisy, pericarditis and pneumonia, the pain may be reflected from the chest to the abdomen. The abdominal symptoms are often so fulminant in char- acter as to suggest appendicitis, peritonitis or perforation, and thoracic symptoms are absent or may be overlooked. The abdominal signs consist of tenderness and rigidity of the muscles, abdominal pains and symptoms of collapse. Diagnosis can usually but not always be established by the absence of tenderness over the subjectively painful abdo- minal region and by a careful exploration of the chest. In differentiation, the use of chloroform as suggested on page 413, may be used. Ppttenger 71 and Wolff-Eisner 72 direct attention to muscular rigidity in thoracic disease. The latter regards light touch- 420 Rigidity of the Spinal Muscles palpation as valuable in the recognition of pulmonary affections. Pottenger, however, is entitled to the greater credit for having elucidated this sign. He describes two signs : 1 . Muscle rigidity, which may be defined as a feeling of resistance noted on palpating the muscles which overlie inflammatory conditions affecting the pulmonary parenchyma or pleura due to acute muscle spasm when the inflammation is acute and pathological change in the muscles when the inflammation is chronic. 2. A feeling of different degrees of resistence noted over organs or parts of organs of different density on "light touch palpation." The two signs are clearly distinct. Muscle rigidity is confined to the muscles alone, while the difference in resistance found on light touch palpation applies to the density of tissues as found not only in the muscles, but the deeper organs as well, and may be used in outlining either normal organs or areas of disease where such disease pro- duces change in density of any of the tissues which we are able to palpate. SPASM OF THE ESOPHAGUS, notably its lower end, asso- ciated with cardiospasm, is not infrequently of reflex origin and due to hypertonicity of the vagus (page 452). RIGIDITY OF THE SPINAL MUSCLES. This subject has already been discussed on page 46 et seq. There are, however, conditions remote from the site of the spasm which are related to the latter and interpreted by the patient as back- ache. Such conditions embrace many affections of the lower extremities, specified as rheumatic or neuralgic and which owe their origin to disabilities of the feet. The latter, as offending factors are frequently ignored because the reflex backache is so far removed from the foot. Pains, specified as sciatica are likewise caused by some pedal infirmity. The most frequent condition represented by the latter is the 421 S p o n d y I o t h e r a p y weak-foot. The chief function of the foot is the support of body-weight, and the most characteristic sign of a weak-foot is the sensation of weakness, which soon graduates into pains extending to the knees, hips and regions of the back. The fact that the pains are intensified when the foot is in use and in damp weather, and that temporary rest causes a remittance of symptoms, often accounts for the erroneous diagnosis of rheumatism. One must also remember that the weak, is the initial stage of the flat-foot. A chronic backache associated with pains in the legs, suggesting sciatica, when no adequate cause is apparent, may be caused by back-strain incurred by an undue effort to maintain the balance of the body. 77 The erect position is maintained by tonicity of the posterior musculature and forward displacement of the body makes an increased demand on this musculature to maintain the erect position. Static backache may also be due to varicose veins and to intra-pelvic disease. In the latter, there is an instinctive tendency to lessen intra-pelvic pressure by change of attitude. CHRONIC FIBROSITIS. This subject has been partially described on page 90, Fig. 35. Further reference to it is dictated by the fact that the muscular infiltrations may be confounded with circumscribed tonic contraction of the muscles. The infiltrations or myistides, may involve any voluntary muscle of the body and their presence in the abdominal muscles may suggest disease of the abdominal viscera. Many so-called cases of chronic articular rheumatism are nought else but an hyperplasia of the periarticular white fibrous tissue. The myistides are more painful in inclement weather and they may be so large as to suggest a gumma, notably when they extend to the peri- osteum or fascia. The infiltration may consist of a deposit of uric aoid salts or allied substances plus the connective tissue insomuch as Yawger has noted after vigorous massage of the indurations an attack of acute muscular rheumatism. I have frequently observed that 422 Secretory Reflexes vigorous rubbing of the infiltrations causes them to swell with accentua- tion of the pains. In addition to the treatment suggested on page 90, fibrolysin (page 1 08), may be used by injection into the gluteal muscles. If the treat- ment is effective, the infiltrations and pain begin to disappear after two or three injections. The local application of salicylates is often of service. An ointment composed of two drachms of oil of wintergreen in an ounce of lanolin may be used, or more costly preparations, known as mesotan and anesthol. In intractable cases of fibrositis, inject into each infiltration a few drops of alcohol (85 per cent). Repetition of the injection may be indicated. Disinfection prior to injection may be achieved by painting the skin with iodin-tincture. Quinin and urea hydrochlorid (soluble i in about i of water), may be used as an injection (i per cent, solution). It acts as a local anes- thetic (also hemostatic), and the effects last from four to seven hours. In the author's experience, the most effective means of dispersing the indurations is by diathermy (page 404). The electrodes are applied directly over the infiltrations. I have frequently found very circumscribed muscular contractions (suggesting myistides), associated with neuralgia of the spinal nerves. Freezing at the vertebral exits of the affected nerves causes an immediate disappearance of the muscular contractions. 4. SECRETORY REFLEXES. The reflex center for the salivary secretion is located in the medulla oblongata in juxtaposition to the origin of the gth and loth cranial nerves. The latter may be stimulated reflexly in visceral diseases, notably in angina pectoris. The same reflex effects are noted with the secretion of urine. Thus, one notes the fre- quent micturition in appendicitis and the excretion of large quantities of urine after attacks of visceral pain. In a num- ber of instances, the secretory reflexes are mediated through the afferent fibers of the vagus. 5. VASOMOTOR REFLEXES.* These reflexes are noted *Vide page 272. 423 Spondyloth e r a p y in individuals in whom there is a maladjustment of the cir- culatory relations; "a tempermental condition of aberrant motility of the vasomotor system," which is comprehen- sively designated by Cohen 78 as, vasomotor ataxia. The symptoms of the latter may be : i. Constrictive ; blanching or cyanosis of the skin according to whether the venous or arterial system is predominantly affected. 2. Dilative or hyperemic; edema, flushing or cyanosis of the skin. 3. Mixed ; the most common form, in which dilatation and con- striction alternate, and there is cutaneous cyanosis, mottling, blanching and edema. The foregoing phenomena are not confined essentially to the skin but have also been observed in the eye-grounds and throat. For a description of the visceral angioneuroses, the reader is referred to the original communication of Solomon Solis Cohen 78 . The vasomotor temperament, if one may be permitted to so call it, may be recognized by the following signs: SKIN. Marbled or mottled skin, intensified by cold and diminished by heat. The cutaneous signs may be limited to a definite region of the body. The hands may assume almost any color but usually the latter runs out upon raising the limb and upon resumption of the natural position, it becomes pink and then passes into purple and blue tints. Spastic blanching is seen in the so-called dead finger. Alter- nations of blanching and congestion yield the "tattooed" appearance and blue, red and white stripes. Pigmentation of the skin, maculated or diffused, and transient or permanent, is observed in one-third of the cases. Leucoderma is also observed. Perspiration may either be excessive, scanty or absent. Skin-lesions like urticaria, erythema and eczema, are transient and recurrent. When the hands or feet are immersed in hot or cold water, the responses correspond to the norm, although exaggerated. NAILS. In nearly every case there is a deep red terminal line a loop of dilated capillaries. EYES. Widening of the commissure, tremulousness of the lids 424 l&, a $ o m o t o r Reactions upon light closure, dilated pupils, pain in the eyes, drooping of the lids, distention or contraction (less common) of the retinal vessels. Among other symptoms are: Enlargement of the thyroid gland, irregularity of the heart and tremor of the muscles in some part of the body. VASOMOTOR REACTIONS. Insufficiency of the vasomotor apparatus may be present in one region of the body and absent in another. I have essayed to elaborate a few prac- tical reactions which are of great value in diagnosis and treatment. They refer specially to the head, respiratory apparatus and the splanchnic circulation. Only the latter will receive present consideration, reference to the former is made on page 614. COURSE or THE VASOMOTOR NERVES. The relation of the vasomotor nerves to the spinous processes is discussed on page 278, but Fig. 102, from Howell, will give one a more comprehensive idea respecting the course of the autonomic (sympathetic) fibers. From the vasomotor center, some of the fibers pass directly through some of the cranial nerves to their area of distribution, whereas the others, descend in the spinal cord where they enter into connection with the subordinate vaso- motor centers in the cord and then leave the latter, through the anterior roots of the spinal nerves or pass into the sym- pathetic through the rami communicantes, from which point they attain the blood-vessels to which they are distributed. The following table, by Langley, illustrates the probable relations of the spinal roots to the ganglia of the sympathetic system in man, according to which the chief outflow of sympathetic fibers occurs between the first thoracic and second lumbar roots. 425 S p o n d y I o t h e r a p y Fig. 102. Schematic representation of the course of the autonomic (sympa- thetic) fibers arising from the thoracico-lumbar and sacral regions of the cord. The arrows indicate the normal direction of the nerve-impulses or nerve-conduction. Sc., superior cervical ganglion; Ic., inferior cervical ganglion; T., first thoracic ganglion; Sp., splanchnic nerve; C., semilunar or celiac ganglion; m, inferior mesenteric ganglion; h, hypogastric nerves; N. E., nervus erigens. The numerals indicate the corresponding spinal nerves. Vide Fig. 74. 426 Ganglia of the Sympathetic System GANGLIA OF THE SYMPATHETIC SYSTEM. SPINAL-ROOT. CERVICAL. THORACIC. LUMBAR. SACRAL. I Sup. cerv. II Sup. cerv. III Sup. cerv. IV Sup. and inf. cerv V Sup. and inf. cerv I, 2 VI Sup. (?) and inf. cerv. . . I, 2, 3, 4, S ThoracicVII Inf. cerv i, 2, 3, 4, 5, 6, 7, 8, 9 VIII ? S, 6. 7. 8, Q. IO. II, 12 IX ? 8, 9, 10, ii, 12 I, 2 X II, 12 I. 2. \ XI 12 I 2. 1 d. XII I, 2. 3, 4, 5 I I ? 2, 3, A, ? I, 2. 3 Lumbar II ? ?, 4, ^ I. 2, 7, 4, C The ganglia of the sympathetic nervous system are as follows: Cervical portion, 3, Dorsal, 12, Lumbar, 4, and Sacral, 4 or 5 pairs of ganglia. The cervical sympathetic, which supplies the majority of the blood-vessels of the head, obtains its fibers from the first to the seventh thoracic roots, all of which terminate in the superior cervical ganglion which is located opposite the second and third cervical vertebrae. The upper extremities, are supplied by vasomotor nerves which terminate in the first thoracic ganglion. The vasomotor nerves of the lower extremities pass through the nerves of the lumbar and sacral plexuses into the sympathetic. TEST FOR THE SPLANCHNIC CIRCULATION. Recapitulat- ing certain facts concerning splanchnic neurasthenia (pages 252, 345) we note that it is a condition dependent on intra- abdominal venous congestion superinduced by insufficiency of the splanchnic vasomotor mechanism, and that the neur- 427 Spondyloth e r a p y asthenic symptoms resulting therefrom may be corrected by by relief of the congestion, and by maneuvers which will increase the efficiency of the liver as an organ of defense. Toning the splanchnic vasomotor mechanism is the most potential of all methods in the treatment of splanchnic neurasthenia. It has already been observed on page 346, that when one presses the abdomen, or when the sinusoidal current is applied to the abdomen, the blood is driven from the intra- abdominal veins back into the heart. The latter action is chiefly due to the elicitation of the liver reflex (page 331), which results in a decided reduction in the volume of the liver. Insomuch as it has been estimated that the latter organ contains blood equivalent to one-fourth the amount of blood contained in the body, it is not difficult to conceive that, by contraction of the liver alone, considerable blood may be expressed from the splanchnic circulation. However, the author finds that it is now possible to in- fluence the latter circulation by direct stimulation of the splanchnic nerves which control the blood-vessels of the abdominal organs. True, digitalin or strophanthin, alone or in combination, quickly relieve abdominal congestion. They are endowed with the property of constricting the splanchnic vessels alone, whereas digitoxin constricts all the blood-vessels. However, with pharmaco-therapy only temporary results are achieved, and the latter should be superseded whenever possible by physio-therapy. Before describing the physio-therapeutic method of the author, it is necessary to advert succinctly to the splanchnic circulation. The latter properly comprises the arterial and venous 428 Splanchnic Circulation supply to the abdominal organs and is known as the splanch- nic area. The largest vascular areas in the body are : 1. The splanchnic area; 2. The brain; 3. The muscles; 4. The skin. The splanchnic area is large enough to contain almost the entire volume of blood of the body. If the portal vein is tied, practically the entire blood- volume of the body will accumulate in the intestinal and hepatic blood-vessels and, in this way, an animal may be bled into its own veins. There is an incongruity in an animal like man built on the longitudinal plan. The erect posture of man causes the blood to gravitate into the intra-abdominal veins. The effect of gravity on the circulation is important, The chief effect of gravity is that the veins become filled with blood in the dependent parts. If an animal is held with its legs hanging down, the amount of blood going to the heart is reduced and the blood-pressure in the arteries is consequently diminished. This hydrostatic effect of gravity, however, is overcome in the norm by constriction of the ves- sels of the splanchnic area and by augmented vigor of the respiratory apparatus. If a "hutch" rabbit is suspended by the ears with its legs hanging down, it soon passes into unconsciousness and will, if left in that position, die in about half an hour. What occurs? The blood leaving the brain accumulates in the abdomen of the animal but the deficient tone of its splanchnic vasomotor mechanism is unable to overcome the evil effects of gravity. If the animal, however, is placed in a horizontal posture 429 Spondyloth e r a p y or, if while still suspended, the abdomen is squeezed or bandaged, consciousness is soon restored. A wild rabbit, owing to its efficient splanchnic vasomotor mechanism, suffers no inconvenience when held in a vertical position. The SPLANCHNIC NERVES, are the vasomotor nerves of the abdominal blood-vessels and control the largest vascular area in the body. If the splanchnic nerves are stimulated, the blood-vessels contract, but when the nerves are cut, the vessels dilate. In the latter case, a large amount of blood accumulates in the abdominal vessels resulting in an anemia of the other parts of the body which may be so great (brain-anemia) as to cause death. We shall presently learn that the physician can by simple methods either increase or diminish the tone of the splanch- nic nerves and, in this respect, he can achieve results tanta- mount to the vivisectional experimentalist. The splanchnic nerves are composed of fibers issuing from the spinal cord in the 5th to the i2th dorsal nerves inclusive. The dorsal nerves in question correspond to the spines of the 2nd to the 8th dorsal vertebrae, inclusive. If the spines in question are sinusoidalized, or better still, struck in succession by means of a plexor and plexi- meter, the cardio-splanchnic phenomenon (page 346) is at once brought into evidence. In other words, the blood is expressed from the abdominal vessels to the right heart. The phenomenon in question is of short duration, hence one must not delay the percussion. If, in the norm, an individual assumes the recumbent posture for several minutes and is then requested to stand erect, and the physician at once proceeds to percuss the 430 The Splanchnic Nerves lower part of the abdomen, he will elicit two areas of dull- ness as shown in Fig. 103. The latter areas are usually of short duration and may be dissipated at once by a series of deep breaths or by striking the 2d to the 8th dorsal vertebral spines. What reasons have we for assuming that the dull areas in question are caused by the accumulation of blood in the abdominal blood-vessels ? 1. The areas of dullness correspond to the largest abdominal vessels. 2. They are at once dissipated by deep breathing which facilitates the return of blood from the abdominal vessels to the heart and by striking or sinusoidalizing the spines of the sd to the 8th dorsal vertebrae. The latter methods stimu- late the splanchnic nerves and by thus constricting the vessels of the abdomen send the blood to the heart. Thus it is, that by the execution of the methods in question, the cardio-splanchnic phenomenon is brought into evidence. 3. If a large vacuum cup is applied to the abdomen at a point just above the navel, and the cup is exhausted, two areas of dullness corresponding to Fig. 103, appear. 4. If, in a given individual, the dull areas corresponding to Fig. 103, are elicited by a change from the recumbent to the vertical position, such areas can no longer be demonstrated by change of position if the vertebral spines corresponding to the origin of the splanchnic nerves are previously sinu- soidalized or concussed. By the latter method, we have at least temporarily, augmented the tone of the splanchnic vasomotor mechanism, thus inhibiting the gravitation of blood to the abdominal vessels in sufficient amount to elicit dullness. 5. The dull areas may be evoked (although absent) in the erect posture, by sinusoidalization or concussion of the 431 Spondylotherapy four lower dorsal spines (gth, loth, nth and i2th dorsal vertebrae). The author has determined empirically that the spines in question correspond to segments in the spinal cord which, when stimulated, will diminish the tone of the splanchnic nerves, thus permiting a large quantity of blood to gravitate into the patulous abdominal vessels. 6. In splanchnic neurasthenics, the patches of dullness are not isolated as in the norm but the dullness is diffused and occupies the entire lower abdomen (Fig. 104). With the betterment of the splanchnic neurasthenic there is a corres- ponding diminution of the dullness on percussion. The dullness in such patients is always more diffused and pro- nounced when the symptoms of the patient are accentuated, and it is even possible to elicit many of their sensations (vertigo, sinking sensations, lack of energy, etc.) or aggra- vate them, by concussion or sinusoidalization of the four lower dorsal spines which, as we have shown, practically paralyze the splanchnic nerves, thus causing an increased quantity of blood to accumulate in the abdominal vessels.* The author, based on an examination of hundreds of cases with reference to the vigor of the splanchnic vaso- motor mechanism submits the following classification: 1 . Patients in whom no dullness in the lower abdomen can be elicited when a change is made from the recumbent to the erect posture; a condition which demonstrates an ideal vaso-motor mechanism. 2. Patients in whom a dullness of short duration (last- ing about one minute), is elicited (Fig. 103) on change of position; a condition representing an average vaso-motor mechanism. *The author suggests to the investigator that the dullness of intra-abdominal con- gestion be utilized as a gauge in determining the action of drugs on the splanchnic circulation. 432 The Splanchnic Nerves 3. Patients in whom the dullness is diffused (Fig. 104) and persistent (longer than three minutes), after change from the recumbent to the erect position; a condition repre- senting an enervated mechanism. Fig. 103. Fig. 103. Patches of dullness in the norm, when the erect is substituted for the recumbent posture; percussional evidence of the gravitation of blood into the splanchnic vessels by the attitudinal change in question. Fig. 104. Fig. 104. Diffused area of dullness in insufficiency of the splanchnic vaso- motor mechanism. Compare with the normal areas of dullness in Fig. 103. 4. Patients in whom the dullness is diffused and per- sistent in the erect posture without having previously adopted the recumbent attitude. Here, we are confronted with the most accentuated types of splanchnic neurasthenia. From what has preceded it will be evident that one must not base inferences on false premises. One must assure himself that dullness of the lower abdomen is really depend- ent on intra-abdominal congestion by execution of the tests already cited. Thus, there will be an augmentation of the dullness if the four lower dorsal spines are concussed or, conversely, the dullness will be dissipated by deep breathing 433 Spondyloth e r a p y (in non-aggravated types of congestion) or by concussion of the upper dorsal spines (2d to the 8th). In the TREATMENT of splanchnic neurasthenia, two methods are available, viz.: 1. Concussion. 2. Sinusoidalization. Concussion is more efficient than sinusoidalization. Con- cussion is a mechanic stimulus and, when it is of short dura- tion, it augments the excitability of the nerves, but when prolonged, the excitability is diminished or abolished. It is evident then that, in the application of a seance of con- cussion, the treatment must be intemiDted from time to time. Mechanic stimuli are only effective when they are applied with sufficient rapidity to produce a change in the form of the nerve-particles. In the therapeutic elicitation of the splanchnic reflex of vaso-constriction, the only kind of vibratory apparatus which is effective is one giving a PERCUSSION STROKE. The con- cussion is applied directly to the spinous processes in suc- cession. The duration of each daily seance should not be less than 15 minutes, but treatment must be interrupted. Sinusoidalization may likewise be used for exciting the splanchnic reflex of vaso-constriction. The rapid sin- usoidal current is employed for this object. A large electrode is placed over the sacrum, whereas a small interrupting electrode (which permits one to close and open the circuit) is placed in succession over the indicated spinous processes. The daily seances must be at least of 15 minutes duration, but interrupted. 434 The Splanchnic Nerves In concluding this subject, the author wishes to direct attention to the vertebral reflexes in diminishing the volume of the liver which, in splanchnic neurasthenia is invariably enlarged. Our conventional conception of the liver is that of an organ which is hard and unyielding. In reality, however, the organ in question is like a sponge ; it swells with augmenting, and diminishes in volume with decreasing pressure. Concussion of specific vertebral spinous processes con- tracts the liver for the following reasons : 1. Concussion of the yth cervical spine acts on the general vaso-motor apparatus. 2. Concussion of the first three lumbar spines acts by eliciting the liver reflex (page 331) of contraction. 3. Concussion of the 2d to the 8th dorsal spines, in- clusive, acts by constriction of the splanchnic blood-vessels. In a number of measurements of the liver made in the parasternal line, the author obtained the following results: 1 . Size of liver by percussion before concussion, 12.5 cm. 2. Size of liver after concussion of yth cervical spine, ii cm. 3. Size of liver after concussion of ist 3 lumbar spines, 8 cm. 4. Size of liver after concussion of 2d to 8th dorsal spines, 6 cm. It is evident, according to the foregoing measurements, that, after elicitation of the splanchnic reflex of vaso-con- striction (4), the greatest reduction in the volume of the liver is obtained.* *The essential facts of this subject have been excerpted from the 4th edition of the author's work, Splanchnic Neurasthenia, E. B. Treat & Co., New York. 435 Spondyloth a p y 6. PiLO-MoTOR REFLEXES. Stimulation of the pilo- motor nerves, causes contraction of the erectores pilorum, and the reflex causes the appearance of "goose-skin" (cutis anserina). When the muscles (erectores pilorum) attached to the hair-roots contract, in addition to the goose-skin, one experiences a chilly sensation which is probably due to vaso- constriction. Mackenzie 68 observes that, if the skin under the nipple is rubbed with flannel, goose-skin appears over the part Fig. 105. Composite dikgram of pilo-motor reflexes. rubbed and extends to the clavicle and to the inner side of the upper arm and forearm. At the same time the pupil dilates. This phenomenon is explained by noting that the dilator pupillae nerve leaves the spinal cord (at a point where the part has been rubbed), by the upper thoracic nerves. In Fig. 105, 1 have projected a composite picture of pilo- motor reflexes, as shown by goose-skin over different verte- bral areas, after irritation of different peripheral regions with some sharp object. The numbers refer to the vertebral region where the goose-skin is seen or felt by the patient. Thus, the region over the anterior surface of the thigh is designated ist and 5th lumbar, indicating that the goose- 436 Paravertebral Tenderness skin is observed over these vertebrae. The results are only approximate. Subdued light must be used. Limited areas of anemia with elevation of hairs are associated with the goose-skin. In other instances, a faint tremor of the muscles may be noted. The pilo-motor reflexes are rapidly exhausted. 7. PARAVERTEBRAL TENDERNESS. This subject has already been discussed on page 71, et sequentia, and I have not modified my views respecting the reason for the tender- ness. Certainly it is not a question of congestion, insomuch as cupping to one side of the tender areas only accentuates the vertebral and peripheral areas of tenderness. We asso- ciate tenderness with congestion despite the fact that pain is often the piteous appeal of a hungry nerve for blood. In several instances, when freezing, 'which is the sovereign remedy for dissipating tenderness, was ineffective, notably in intercostal pains, suspension of the patient (Fig. 1 16), caused the disappearance of the vertebral and peripheral points of tenderness. Here one assumed, and the results demon- strated the verity of the assumption, that the pains were caused by a faulty posture (Vide foot-note, page 186). 8. ELEVATION OF TEMPERATURE. Rise of temperature consecutive to concussion has already been noted on page 1 80. Recently, the author has observed the curious fact that pressure exerted and maintained for about two minutes with an instrument (Fig. 112) at the vertebral exits of any of the spinal nerves, will also elevate the temperature from .6 to 1.6 F. The mechanic irritation thus evoked, is equivalent to a pathologic irritation caused by visceral disease and manifested by areas of vertebral tenderness. The fact just cited may explain the elevation of temperature in some conditions. The even temperature of the body is maintained by a thermotactic condition which adjusts the rate of heat-production (thermogenic factor) and heat-radiation (thermolytic factor). 437 Spondyloth e r a p y Fig. 106. Representing the mechanism of visceral pain, cutaneous and muscular hyperalgesia (viscero-sensory reflex), the viscero-motor reflex and the organic reflex. A stimulus from the organ, V, by the sympathetic nerve (Sy. N.), to its center in the spinal cord extends to the adjacent cells of nerves, and excites them to activity, when the function peculiar to each nerve is exhibited. Thus the stimulus affecting the cells of a pain- nerve (SN), eventuates in the perception of pain which is referred by the brain to the peripheral distribution of the nerve in the external body-wall (Sk. M); affecting the cell of a motor nerve (MX), causes a con- traction of the muscle (M), supplied by the motor nerve; affecting the cells innervat- ing other viscera (as V), stimulates them to their peculiar function (contraction of a hollow muscular viscus, increased secretion of a secretory organ) . If the stimulus is of sufficient strength, it may leave an irritable focus in the spinal cord (shaded area), as shown by a persistent hyperalgesia of skin and muscle (Sk. M), and by a persistent contraction of the muscle (M). 438 Irritable S p i n al Segments The relation of the latter factors to thermo taxis may be repre- sented as follows: Thermogenesis. Temperature^ Thermolysis. The impulses of temperature and pain which are intimately associated, enter the spinal cord at the same point and pass into the gray matter. MECHANISM OF PERIPHERAL REFLEXES IN VISCERAL DISEASE. Fig. 22 (page 58), illustrates cutaneous tender- ness and radiation of pain in visceral disease and Fig. 106, from Mackenzie shows the viscero-motor and sensory reflexes. IRRITABLE SPINAL SEGMENTS. Irritable foci in the cord may survive the apparent cure of a visceral disease. This is shown by the persistent areas of vertebral tenderness, the accentuation of physiologic reflexes, persistent dermatomes, reflex muscular contractions corresponding to the irritable spinal segment, and subjective sensations corresponding to the hypersensitive spinal segments. It is not unusual for patients to complain of pains or sensations in definite regions of the body (previously implicated in visceral disease) under emotional influences. PSEUDO- VISCERAL DISEASES. It is impossible to exaggerate the importance of this subject which has already been discussed in Chapter VI. Neuralgia of the spinal nerves is the greatest simulator of visceral diseases. A spinal segment is a unit possessed of motor, sensory, vaso-motor, trophic and reflex functions, with regard to the peripheral distribution of the roots of the nerves which emerge from and enter it. The following case of pseudo phthisis is cited to illustrate the im- portance of this subject: A young man was sent to California by his physicians in consequence of a painful and incessant cough. Paroxys- mal pains located in the right upper chest were severe. The patient had lost about 20 pounds in weight. The auscultatory evidence on 439 Spondylotherapy examination of the upper lobe of the right lung approximating the painful chest-region, suggested an apical catarrh. The clinical picture was that of pulmonary tuberculosis minus the presence of tubercle bacilli in the sputa. The diagnosis of an intercostal neuralgia having been established, three successive freezings of the implicated nerves at their vertebral exits resulted in an immediate disappearance of all the symptoms and the patient was rapidly restored to health. Here was a man, stigmatized as a poitrinaire, by at least seven capable diagnosticians to whom an atypic neuralgia of a spinal nerve was a terra incognita. Fig. 107, illustrates schematically, the visceral phenomena which may ensue incident to the creation of an irritable spinal segment by a neuralgia of a spinal nerve. Fig. 107. Diagram ot a spinal nerve (Ross). C, spinal cord; pr, ar, posterior and anterior roots; SPD, IPD, superior and inferior primary divisions; d v, dorsal and ventral branches; sr, sympathetic root. A spinal nerve with a lesion at, or approximating its vertebral exit, conduces to augmented irritability of a definite segment of the cord with a perturbation of func- tion of that particular segment as is shown in Fig. 106. REFLEXES OF THE CRANIAL NERVES.* Excessive, or anomalous stimulation of the cranial nerves may react on the spinal centers, thus provoking remote reflexes which are *To grasp this subject more fully one should first read Chapter XIII. 440 Reflexes of the Cranial Nerves commonly misinterpreted. It is now possible to demon- strate objectively this overflow of cranial-nerve irritation, and thus eliminate many inchoate data founded on sub- jective symptomatology. THE EYE. Hansell correctly observes: "We have not yet advanced to that stage when we study diseases of the body in relation to ocular defects, and fail to consider diseases of the eye in relation to general diseases," and Helmholtz contended that nature seems to have packed the eye with mistakes, as if with the avowed purpose of destroy- ing any possible foundation for the theory that organs are adapted to their environment. An ocular defect is one of the most common peripheral irritants in the creation of reflexes, and well-fitting glasses, have frequently achieved the marvelous task of translating a pessimist into an optimist, so essential is correct vision for our condition of well-being. The following nerves enter into the innervation of the eye and its appendages: i. Optic nerve; 2. Motor oculi; 3. Trochlear (pathetic); 4. Trigeminus (trifacial); 5. Abducens; 6. Facial; 7. Branches from the carotid and cavernous plexuses of the sympathetic system. The nerves just cited anastomose with the vagus (pneumo-gastric) and the upper cervical nerves. Fig. 108 (from O'Malley 79 ), represents a diagram of the ocular nervous system. The motor oculi or third cranial nerve has three sets of fibers, i . One set supplies all the external ocular muscles (excepting the external rectus and superior oblique) and the levator of the upper lid. 2. A set to the pupillary sphincters. 3. A set to the ciliary muscle (muscle of accommodation). It is impossible even in the norm to conceive the eye as an organ functionating independently of the other organs. 441 S p o n d y I o t h e r a p y Reflex disturbances are frequently initiated by refrac- tive errors. The refractive apparatus is composed of the cornea, iris, lens (adjusted by the ciliary muscle), and the retina. When objects are viewed at a distance of fifteen feet (or more), y Fig. 108. The ocular nervous system. there is a relaxation of the refractive apparatus and it is passive (except the retina) in visualization. In normal accommodation, which is associated with neither fatigue nor irritation, objects near the eye are focused clearly upon the retina by involuntary action of the ciliary muscle which curves the anterior surface of the lens. 442 Reflexes of the Cranial Nerves In errors of refraction, the brunt of the burden is borne by the ciliary muscle and nerves, thus conducing to their exhaustion and irritation. Among the reflex symptoms of refractive disturbances are headaches and functional derangements of the heart and stomach. Zimmerman, in a study of 2,000 eye-cases, cal- culated that over 71 per cent suffered from headache and de Schweinitz, contends that, 60 per cent of all ocular headaches are caused by astigmatism. I proceeded to study reflex symptoms from ocular anom- alies by straining the accommodation of normal subjects and by wearing glasses which caused asthenopia (eye-strain due to fatigue of the ciliary or extraocular muscles). After this manner, one could note the development of objective symp- toms. Even in the norm, if one eye of the patient is covered, and the other eye is forced to view an object under strain for a number of seconds, the primary manifestation is tremor or spasm of the cervical muscles on one or the other side (Vide, page 124). Later, one or several points of vertebral tender- ness develop and areas of sensitiveness may be elicited in the course of the cervico-occipital nerves (midway between the mastoid process and the spine, the sternomastoid and the trapezius, and above the parietal eminence). While the eye is still under strain, the tonus of the vagus is augmented; the pulse is partially or completely inhibited (best seen in sphygmograms), there is a descent of the lower lung-border, recession of the heart (heart reflex) and the stomach can be percussed. If the eye-strain is continued, the stomach alters its position as in the act of vomiting. In other words, the chief reflex visceral phenomena are mediated by the vagus. Mere pressure on the eye-ball suffices to pro- 443 Spondyloth e r a p y voke the vagal reflexes but not the reflex sensory disturbances of the cervico-occipital nerves. In diagnosis, each eye may be tested separately. The signs observed in the norm when accommodation is strained are accentuated and persistent in asthenopia. By this method of testing, the symptoms from which the patient suffers may be reproduced and, by inhibiting the ocular reflexes (page 443), the diagnosis may be clinched. Reflex disturbances from the ear and nose are described in the following chapter. T o n u s o f t h e Vagus CHAPTER XIII. TONTJS OF THE VAGUS AND PHARMACOLOGY OF THE REFLEXES.* TONUS OF THE VAGUS ANATOMY OF THE VAGUS PHYSIOLOGY AND CLINICAL PATHOLOGY OF THE VAGUS DIAGNOSIS OF VAGUS- TONUS VAGUS-TONE AND THE SENSE ORGANS PSYCHOVAGUS- TONE METHODS FOR INCREASING AND DECREASING VAGUS- TONE THERAPEUTIC RESULTS DISEASES CAUSED BY VAGUS HYPERTONIA AND VAGUS HYPOTONIA PHYLOGENETIC DISEASES VAGAL HYPERESTHESIA CLINICAL PHARMACOLOGY. TN this chapter the author will endeavor to show, how by mere pressure of certain vertebral areas, one may tem- porarily or permanently inhibit the phenomena of a number of diseases in consequence of the elicitation of definite vertebral reflexes. The citation of simple maneuvers to attain puissant results does not impugn scientific medicine, on the contrary, it demonstrates the paths of least resistance in combating reflex phenomena. J. Madison Taylor 88 , in commenting on the hand as a therapeutic agent, shows that, "often by clumsy, empirical methods great things are, and greater things can be, thereby done." He proceeds to say, "The body is like a piano or harp, to be played upon at will." He relates how by *This is regarded by the author as one of the most important chapters in the book, but demands careful study. It shows that there are many diseases regarded as distinct affections which are merely. symptomatic of a fundamental condition, viz. : hypotonicity or hypertonicity of the vagus. Thus it is that several diseases grow from a common pathogenic trunk. Spondyloth e r a p y manual treatment his daughter was promptly cured of a lameness which had resisted the efforts of the best surgeons. Much in physiotherapy has justly been discredited, owing to exaggerated statements emanating from incompe- tent sources. Cures mean nothing to the scientist. The author, in the application of his methods, has never been influenced by empiricism alone, and the elicitation of his reflexes to combat disease may easily be demonstrated by anybody reasonably skilled in physical diagnosis. The subject of tonus of the vagus has engaged the atten- tion of the author for years and it is only recently that any- thing approaching the confirmation of his investigations has appeared. In a monograph*, which is largely hypothetic, emanating from the von Noorden clinic, an endeavor has been made to demonstrate the relation of the tone of the vagus to other diseases. Insomuch as there is no evidence in this mono- graph to recognize the tone of the vagus by its effects on the visceral reflexes, the discussion is necessarily theoretic. Before studying this subject, it is necessary to recapitulate certain facts concerning the vagus. ANATOMY OF THE VAGUS. The tenth or pneumo- gastric nerve (nervus vagus), is the longest and most extensively distributed cranial nerve and contains motor and sensory fibers. The branches of the nerve are shown in Fig. 109. The vagus communicates with the gth, nth and i2th nerves, with the sympathetic, and with the loop between the ist and 2nd cervical nerves. The following are the terminal branches: Meningeal, auricular, pharyngeal, superior and inferior laryngeal, cardiac, pericardial, bronchial, esophageal and abdominal branches. *DiE VAGOTONIE; Eine Klinische Studie, von Dr. H. Eppinger und Dr. L. Hess. Herausgegeben von Prof. Dr. Carl von Noorden. Berlin, 1910. 446 A n a t o m y of the Vagus GLASSO-PHAR YNGEAL HER VE Internal carotid artery SYMPATHETIC SUPERIOR CERVICAL GANGLION External carotid artery RIGHT VAGUS "" RECURRENT PER VE THORACIC CARDIAC BRANCH ' (RIGHT VAGUS) A URICVLAR BRANCH MENINOEAL BRANCH GANGLION OF ROOT SPIRAL ACCESSORY NERVE HYPOGLOSSAL SERVE LOOP BETWEEN FIRST TWO CZ VIC A L NER VES GANGLION OF TRUNK SUPERIOR LABYSGEAL NERVE LEFT VAGUS SUPERIOR CERVICAL CARDIAC BRANCH INFERIOR CERVICAL CARDIAC BRANCIf CARDIAC BRANCH FROM RECURRENT NER VE ANTERIOR PULMONARY PLEXUS POSTERIOR PULMONARY PLEXUS SPLENIC PLEXV* Fig. 109. Diagram of the branches of the vagus nerves (Morris). 447 Spondylotherapy PHYSIOLOGY AND CLINICAL PATHOLOGY OF THE VAGUS. The nerve is motor, for the soft palate, pharynx, larynx, bronchial muscle, heart and abdominal organs. The nerve is sensory for the pharynx, larynx, trachea, esophagus and probably the heart. When the nerve is diminished in tonus (which will be described later), it produces symptoms varying in the motor sphere from hypotonia (page 52), to paralysis and, in the sensory sphere, from hyperesthesia (diminished sensibility), to anesthesia. Increased tonus of the vagus in the motor sphere is asso- ciated with spasms and in the sensory sphere with hyper- esthesia. The following anomalies are associated with individual branches of the vagus: 1. PHARYNGEAL BRANCHES. The muscles, and mucosa of the pharynx are implicated and deglutition is impaired. Spasm of the pharynx is manifested by the "globus hystericus," in hysterical subjects and dysphagia, in nervous individuals. 2. LARYNGEAL BRANCHES. Paralysis and spasm of the laryngeal muscles. Spasm is not uncommon in children (laryngismus stridulus). Hyperesthesia and anesthesia of the laryngeal mucosa. 3. CARDIAC BRANCHES. The motor fibers inhibit and control the action of the heart. In hypertonicity, the heart's action is retarded, whereas, in hypotonicity, owing to the uninfluenced accelerator action, all grades of heart-hurry (tachycardia) may be present. The sen- sory symptoms in lesions of these branches include ir- regularities, palpitation, and other subjective symptoms of cardiac neuroses. In lesions of the vagus, fatty de- generation of the myocardium has been observed, hence the nerve has a trophic function. The inhibitory action of the vagus on the heart is manifested in controlling the rhythmicity (chronotropic 448 Physiology of the Vagus action), irritability (bathmotropic), conductivity (dromo- tropic), contractility (inotropic), and tonicity. Blood-pressure is indirectly under vagus-control. 4. PULMONARY BRANCHES. The motor fibers in a hypertonic state produce spasmodic bronchostenosis (page 311), and asthma, whereas, in a hypotonic con- dition, they conduce to dilatation of the lungs and em- physema. One knows that the vagus contains fibers which can constrict or dilate the bronchi (page 308). In hypertonia of the nerve, the sensitized mucosa of the air-passages accentuates the cough-reflex. 5. ESOPHAGEAL BRANCHES. Spasm of the esoph- agus (esophagismus), cardiospasm and paralysis. Dys- phagia is the essential symptom in these conditions. 6. GASTRIC BRANCHES. Insomuch as the vagus is the motor nerve of the stomach, it is identified with the motor neuroses of the organ. The vagus also contains secretory nerves for the gastric mucosa, and is therefore associated with the secretory and most probably with the sensory neuroses of the stomach. Among other functions attributed to the vagus are: Vasoconstrictor fibers for the heart, stomach, intestine, kidneys, spleen, and possibly the lungs; vasodilator fibers for the coronary vessels and the lungs, inhibitory fibers for the cardiac sphincter of the stomach, longi- tudinal muscles of the small intestine and bronchial muscles, and secretory nerves of the pancreas. Another important function of this nerve is to main- tain the tonus of the thoracic and abdominal viscera. There are many problems in the physiology of this nerve which have not been solved by the physiologist, hence the aid of the clinician must not be ignored, inso- much as the nature of many diseases is revealed by the remedies employed. NERVOUS SYSTEM. This is divided into cerebro-spinal and sympathetic. The cerebro-spinal system consists of the brain, spinal 449 Spondyloth e r a p y cord, cranial and spinal nerves. It supplies the special senses and the voluntary muscles. The sympathetic nervous system (Fig. 101), presides over the visceral movements, controls the phenomena of secretion and influences the caliber of the blood-vessels. Anatomically, these two nervous systems are with diffi- culty differentiated, but this difficulty is surmounted by the use of nicotin. The function of the sympathetic fibers is inhibited by painting them with nicotin, whereas the same agent is without effect on fibers of the cerebro-spinal system. The sympathetic system is composed of fibers which according to their origin may be divided into cranial, bulbar and sacral (Fig. 101). 1. CRANIAL DIVISION. This is composed essentially of fibers which pass to the eye through the oculo-motor nerve. 2. BULBAR DIVISION. The fibers of this division pass through the facial and glosso-pharyngeal nerves and innervate the glands and blood-vessels of the head. The chief nerve of this division is the vagus, which is the chief nerve of the viscera. 3. SACRAL DIVISION. This innervates the struc- tures shown in Fig. 101. FURTHER DIFFERENTIATION OF THE SYMPATHETIC. All the nerve-fibers of this system which run into the gangliated cords of the sympathetic (Fig. 102), are known as sympathetic fibers, whereas the others are called autonomic (page 411), which represent essentially the extended vagus. These two sets of fibers are physiologically in antagonism; the irritation of one set inhibiting the functions of the other set. Each set shows a definite pharmacologic reaction equivalent to their electric stimulation. ADRENALIN acts exclusively on the sympathetic, whereas the autonomic fibers are stimulated by PILOCARPIN. 450 T o ,n u s of the Vagus The behavior of atropin is peculiar. It may inhibit the action of other drugs on the autonomic fibers and while its action is most powerful on the cranial division, it is practically without effect on the sacral division. THE CHROMAFFIN SYSTEM. This refers to an organ or group of organs made up of certain cells which show a specific staining reaction with the salts of chromium. These cells have the same embryonic origin as the sympathetic nerves and are found with the latter in groups from the base of the skull to the bottom of the pelvis. The medullary portion of the adrenal glands contains the largest group of these cells from which epinephrin is derived. There is an intimate relation existing between the thyroid and pancreas and the chromaffin system. TONUS OF THE VAGUS. What has been said on page 409, respecting the tone of muscles applies with equal cogency to the viscera. In health, the viscera are in a state of tonicity, i. e., their musculature is in a more or less permanent although variable condition of contraction. Physiologists give us little information concerning the factors controlling visceral tonicity, although they admit that the function is most important in regulating the cavities of the heart and other organs. The sympathetic fibers are stimulated experimentally by adrenalin (sympathicotropic action), and the tonus of these fibers in the organism is maintained by the constant secretion of adrenalin and other products (epinephrin, suprarenalin), from the adrenal bodies. A similar internal secretion has not yet been demonstrated for maintaining the tonus of the autonomic fibers, although we know that such physiologic action can be exhibited by pilocarpin (vagotropic action). It has been shown that the pancreas has an inhibitory 451 S p o n d y I o t h e r a p y influence on the secretion of adrenalin and that after extir- pation of the pancreas, adrenalin is increased. When the adrenalin secretion is augmented, the reflexes of the sym- pathetic fibers are increased, and conversely, diminished when the secretion is reduced. The pharmacologic excitation cited, is analogous to what occurs when the sympathetic fibers supplying the iris are cut, viz., pupillary contraction and dilatation of the pupil, when the autonomic fibers are divided. In the norm, when an adrenalin solution is dropped into the eye, no dilatation of the pupil ensues, but in diabetes, with pancreatic involvement, such instillation causes mydri- asis. In diseases of the pancreas, the inhibitory influence of the pancreas on adrenalin secretion is checked. When the sympathetic and autonomic fibers are equally stimulated, we have what is known as tonic innervation. In my experimental and clinical work, I have concerned myself chiefly with the tonus of the vagus and clinical pictures have been evolved which are identified either with a diminution of vagus- tone (vagus-hypotonia), or an aug- mentation of tone (vagus-hypertonia). Variations in vagus- tone may involve the entire nerve, or it may be confined to one or more of its individual branches (Local vagus-hypotonia or hypertonia). Humans, like animals, show variations in vagus-tone. Thus in some animals, section of the vagus (vagotomy), will produce tachycardia, whereas in other animals no such action is observed. The vagus is more active in middle life than in old age, and least active in infancy. In some humans, infinitesimal doses of atropin (which inhibit vagus-impulses), will produce tachycardia, mydriasis, glycosuria, etc., whereas in others large doses of the same drug produce scarcely any effects. 452 Diagnosis of Vagus-tonus DIAGNOSIS OF VAGUS-TONUS. i. Pharmacologic meth- ods. 2. Paravertebral pressure. 3. Therapeutic results. i. PHARMACOLOGIC METHODS. Insomuch as adrenalin acts exclusively on the sympathetic, and pilocarpin on the autonomic fibers, adrenalin will ameliorate symptoms caused by augmented vagus-tonus, whereas pilocarpin will increase them. If one concusses the first three lumbar spines to produce the stomach re/lex of contraction (page 316), one finds that, after an hypodermatic injection of 8 minims of a solution of adrenalin chlorid, i :iooo, the stomach instead of contracting as in the norm, dilates (stomach reflex of dilatation). Thus, before concussion of the spines in question, the stomach retracted 2j cm., whereas after the injection, it dilated 2 cm. After an injection of pilocarpin, the stomach reflexes are accentuated. .Thus, Stomach reflex of contraction before injection, 3 cm. " " " " after " 5 cm. " " dilation before " 2 cm. " " " after " 3.8 cm. Atropin paralyzes the motor endings of the vagus. An injection of o.ooi gm. (gr. 1-60), of the latter drug will manifest its action within thirty minutes and disappears in from one to three hours. During the full physiologic action of the drug, the stomach reflexes are abolished. Atropin may thus be utilized in excluding any aug- mented irritability (hyperkinesis) of the vagus-endings in the stomach. Thus the motor neuroses of the organ (super- motility, peristaltic unrest, gastric crises, spasm of the cardia, and pylorus, etc.), must yield to an adequate dose of atropin. An injection of pilocarpin will, on the contrary, accentuate the motor neuroses. 453 Spondyloth e r a p y A gastric ulcer will simulate many gastric diseases. In suspected ulcer, a drachm of salt in a glass of water, ingested on an empty stomach will excite an attack of pain. Hydrogen peroxid, used for the same object, causes a burning sensation. Orthoform (8 grains), in one ounce of hot water will only arrest the pains of an abraded surface (ulcer). If the gastric pain is caused by hyperesthesia due to hydrochloric acid, 10 drops of the dilute acid ingested while fasting causes epigastralgia, which is relieved by sodium bicarbonate. Rinsing out the stomach with a i per cent, solution of glacial acetic acid closes the pylorus, and if there is a positive reaction of blood in the syphoned fluid, it speaks for a gastric in lieu of a duodenal ulcer. 97 The heart reflex (page 199), is abolished by atropin and accentuated by pilocarpin. Thirty minutes after an injec- jection of pilocarpin (gr. i-io), the heart reflex measured 4 cm., after irritating the precordial skin, whereas before the injection, like irritation elicited a reflex measuring 2 cm. In several instances when it was impossible to elicit the heart reflex, the latter could be demonstrated after an in- jection of pilocarpin. The majority of cases of heart-block (Adams-Stokes syndrome), are caused by lesions of the auriculo- ven- tricular bundle, but there are also neurogenic forms due to vagus-hypertonia. Atropin, which paralyzes the vagi, removes the block in the neurogenic, (pulse-rate becomes rapid), but not in the myogenic forms. Atropin increases the pulse-rate in bradycardia due to direct or reflex excitation of the vagus. Aconite tincture slows the heart by vagus-stimulation and if it slows the pulse in tachy- cardia, vagus-hypotonia is present. Vagus-stimulation not only slows the heart-rate, but creates irregularities in rhythm. If this vagus influence 454 Pharmacologic Methods is eliminated by atropin and arrhythmia, disappears, the neurogenic nature of the irregularity is demonstrated. One may physiologically block a host of reflex cardiac anomalies by an adequate dose of atropin. Thus, a case of angina pectoris vasomotoria may be cited with the following signs: heart symptoms, chest-pressure and fear ensuing from exposure to cold. Here, the peripheral vasoconstriction due to cold by increasing blood pressure stimulates the depressor nerve, which in turn by acting on the vagus causes cardiac signs. By paralyzing this physiologic chain with atropin, the hands may be dipped into ice-water without subsequent symptoms, but the latter reappear after the effects of atropin have evan- esced. 88 The lung reflexes* (page 294 et seq.*), are mediated by vagal action. Thirty minutes after an injection of atropin (gr. 1-60), both lung reflexes are absolutely abolished. It is well known that small doses of pilocarpin are almost exactly antagonistic in their action to atropin, and this applies in all cogency to their action on the vagus. After an hypodermatic injection of pilocarpin (gr. i -i o), one may note an exaggeration of both lung reflexes. Thus, before the injection of pilocarpin, the lower lung-border posteriorly could be made to descend (lung reflex of dilatation), 4 cm. after cutaneous irritation, whereas, after the injection, the border in question descended 7 cm. *In a recent work by Leonard Hill (Further advances in Physiology), the following obscure observation is made: "Even now most medical writers ascribe the reflex contraction of the lung (Abrams' reflex), which follows any stimulation of the chest-wall to the action of the bronchial musculature. It is more prob- able that the retraction of the lung is due to a reflex contraction of the .muscu- lature of the body- wall." Misconception concerning the lung reflex is due to the failure to recognize two distinct lung reflexes and to properly interpret their rationale. 455 Spondyloth e r a p y The lung reflex of contraction before the injection lasted 20 seconds, whereas, after the injection, it lasted fully one minute. After an hypodermatic injection of 8 minims of a i : 1000 adrenalin chlorid solution, the following phe- nomenon was observed: After cutaneous irritation, the lower lung border instead of descending as in the norm (lung reflex of dilatation), receded from 2 to 4 cm. In other words, cutaneous irritation elicited the lung reflex of contraction in lieu of the counter reflex of dilatation. If one accepts the prevailing opinion that, asthma consists essentially of a spasmodic constriction of the bronchioles, then an appropriate dose of atropin which paralyzes the bronchial musculature through its action on the motor endings of the vagus, must invariably inhibit an asthmatic paroxysm. Here, the action of atropin, as some assume, is not caused by a dilatation of the bronchi, because the action of the drug is to paralyze the dilator as well as the con- strictor fibers of the bronchial musculature. Atropin in sufficiently large doses is one of the most satisfactory drugs in asthma, and aside from its action in inhibiting bronchospasm, it diminishes secretion, reduces the sensitiveness of the mucous membranes to reflexes, and stimulates the respiratory center. Now, as a matter of fact, all asthmatic paroxysms do not yield to atropin, hence one is constrained to conclude that bronchospasm is not the invariable concomitant of asthma. There may be a hyperemia of the bronchial mucosa analogous to urticaria, a swelling of the same mucosa, or, even an exudative bronchiolitis. Determining the tonus of the lung reflex of contraction is an important test in differential diagnosis. In asthma due to a defective bronchial musculature, the lung reflex of contraction cannot be elicited. A supposed spasmodic factor in the pathology of pulmonary diseases must yield to atropin, and in this sense atropin is of diagnostic-therapeutic value. 456 Pharmacologic Methods Adrenalin chlorid (in doses from 8 to 15 minims hypodermatically of the 1:1000 solution), is one of the most efficient agents in inhibiting an attack of asthma. The action of this drug was discovered by Kaplan and Bullowa, and it may truly be regarded as a specific in arresting many paroxysms of asthma. As noted by the investigations of the writer, adrenalin chlorid evokes the lung reflex of contraction which per- mits the longitudinal fibers of the bronchial musculature to expel the residual air imprisoned by the spasm of the circular fibers.* It is furthermore evident that, in our employment of drugs in the treatment of asthma, it is irrational to com- bine atropin and adrenalin in the same prescription. The aortic reflex of contraction is controlled by vagus- tone. The aorta contracts in proportion as the tone of the vagus is increased. Reference to Fig. no, shows the effects of pilocarpin (which increases vagus- tone), on an aortic abdominal aneu- rysm, and although I have never found it necessary to employ this drug in the treatment of aneurysms, it will aid the physio-therapeutic methods as a synergist, should one encounter cases resistant to treatment. Atropin will inhibit the aortic reflexes. The effects of adrenalin on an aneurysm of the abdomi- nal aorta are shown in Fig. in. This drug dilates an aneu- rysm of the aorta. While it is true that the majority of vessels are con- stricted by adrenalin, the effect is not uniform. Even in the norm, dilator effects have been noted. The physiologic tonus of the vagus is dependent on the thyroid secretion. When the latter is diminished (hypo- thyroidism), symptoms of cardiac weakness may be present, *Vide, the spasmo-paralytic hypothesis of asthma (page 308). 457 Spondyloth e r a p y but it is usually an increased secretion (hyperthyroidism), which diminishes vagus-tone. As a rule, in hypothyroidism, Fig. no. Illustrating the effects of an hypodermic injection of pilocarpin (gr. i-io) on an aneurysm of the abdominal aorta. A, outline of aneurysm by percussion before injection; B and C, aortic reflexes of contraction and dilatation before injection; D, contraction of aneurysm by the action of pilocarpin unaided by the elicitation of the aortic reflex. The degree of contraction extends from A to D. E, the degree of contraction of the aneurysm after the use of pilocarpin aided by the aortic reflex of contraction (extent of reflex from D to E). the use of thyroid extract by ameliorating certain symptoms, is diagnostic. In hyperthyroidism, antithyroidin or the antiserum of Beebe, may improve the condition. It is well to know that the cardiac signs of Basedow's disease are accentuated by ten 5-grain doses of a reliable thyroid pre- paration, lodothyrin or iodin will act in the same way and intolerance to iodin is an early sign of hyperthyroidism. 458 Pharmacologic M e t h o d s My investigations show that, even in the norm, reduction in the vagus-tone may be demonstrated after a few doses of thyroid extract by methods described on page 469.* Fig. in. Illustrating the effects of an hypodermic injection of 8 minims of adrenalin chlorid (1:1000) on an aneurysm of the abdominal aorta, i, area of aneurysm by percussion before the injection; 2, aortic reflex of dilatation before the injection; 3, area of aneurysm by percussion after the injection which persisted for an hour; 4, aortic reflex of dilatation after the injection. *In phthisis, the author has found the vagus to be in a condition of hypertonicity as far as the pulmonary branches are concerned and he has used thyroid ex- tract (with poor results) in reducing such tonicity. Thus, in one patient, be- fore giving the extract in five grain doses thrice daily, the lower lung-border descended 5 cm. (after pressure on either side of the yth cervical spine). After the first day, it descended only 2 cm., on the second day, i cm., and on the third day, .6 cm. 459 Spondyloth e r a p y Inaccuracy of thyroid medication is due to variations in the iodin-content of the different preparations on the market and to the fact that the weight of the tablets is based on different standards. If the preparation is reliable, it will be shown by the progressive immobility of the lower lung-border after vagus-stimulation (page 459). The latter test is so simple and reliable that the author suggests as a field for pharmaco-clinical research, the action of different drugs on vagus-tone. Bromids reduce the excitability of the motor area in the cerebral cortex and they also act on the motor and sensory columns of the cord by reducing their motor and sensory conductivity. They reduce all vagal reflexes and are val- uable in diagnosis. To get the effect of bromids, or for that matter, any other drugs, we must push them to saturation, until the border-line of toxicity and physiologic action is reached. In the use of bromids we have attained our object for diagnostic or therapeutic purposes when the palate reflex is lost. The pharyngeal reflex may even be abolished in the norm, hence this reflex is only of value if tested prior to the administration of the bromids. When the period of intoxication with bromids is reached, there is myd- riasis and loss of pupillary reflex to light and accom- modation. Nervous dyspeptics show improved digestion after bromids have been used in large doses for several days. This therapeutic test enables us to differentiate gastric symptoms dependent on lesions of the viscus from those caused by an exhausted nervous system. High blood-pressure is often maintained as a result of augmented tonus of the vasomotor center and is quite independent of vascular disease. It is essentially a ner- vous phenomenon and usually due to psychic stimulation (psychogenic hypertension). Such cases do not respond to the author's method of concussion (page 249), but yield to bromids, as indicated on page 247. 460 Hypertension Respecting hypertension, the author finds that better results are achieved by concussing the region between the third and fourth dorsal spines, in lieu of the second and third dorsal spines as described on page 247, when the high blood-pressure is not associated with cardiac insufficiency. Hypertension is mediated by the vagus and pressure at the point indicated diminishes vagus- tone and augments the quantity of blood in the splanch- nic vessels. The latter may be demonstrated by the areas of dulness on the abdomen (vide Fig. 103), sequen- tial to pressure. Concussion of the four lower dorsal spines will likewise cause the areas of abdominal dulness (Fig. 103), but if pressure is executed synchronously at the yth cervical spine (which increases vagus-tone), no areas of dulness can be elicited. This shows that the centers of the cord corresponding to the four lower dorsal vertebrae are subsidiary to the dominant influence of the vagus. Dr. H. C. Sawyer contributes the following report concerning a case of hypertension: "Woman, 60 years of age, blood-pressure 210 mm., reduced to 160 mm., after several months treatment at a sanatorium. When treatment by concussion was commenced pressure was 1 80 mm. Treatment by concussion thrice weekly reduced pressure to 138 mm., and below, and has con- tinued so over a period of several months. The author again emphasizes the fact referred to on page 248, viz., that in hypertension caused by a failing heart, reduction in pressure can only be achieved by concussion of the 7th cervical spine. All emotions directly influence the heart and the caprices of the organ with its protean symptoms may be subdued by bromids. Any neurosis embraces the entire field of pathology and this applies in all cogency to the heart. Rest and a few doses of morphin are capable of completely altering the picture of a cardiac disease. 461 Spondyloth e r a p y VAGUS-TONE AND THE SENSE ORGANS. If both nostrils are firmly packed with cotton one may excite the vagus reflex- ly through the trigeminus. Reference to this fact has already been made on page 297. Even though a paroxysm is not excited, one may auscultate after the cotton-test, the rales peculiar to asthma. It is only recently, however, that the writer has noted that the hypertonicity of the vagus thus elicited includes practically all the branches of the vagus. Like results follow firm pressure on the posterior part of the external auditory meatus (supplied by the auricular branch of the vagus). If one cocainizes both nostrils (5$ solution suffices in the norm), one observes the following: 1 . Inhibition of the visceral tone (page 45 1), of the liver, spleen and heart. 2. Inhibition of the stomach reflex and the lung reflex of dilatation. The lung reflex of contraction and the heart reflex persist. With these facts at our command, one need no longer equivocate with specious hypotheses in explanation of the reflexes of the cranial nerves (page 440). The nose is a very important reflex center and must be examined as a routine measure in determining the etiology of many diseases of vagal origin. All kinds of reflex disturbances including headaches, neuralgias, chorea and even epilepsy, may be due to a nasal anomaly and by treatment of a naso-pharyngitis, deflection of the septum, enlarged turbinates, etc., it is possible to cure many disturbances. Reference has already been made to the diagnosis of emphysema by aid of cocain (page 297). Asthma is often of nasal origin and paroxysms may be inhibited by saturating pledgets of cotton with a 10 per cent, solution of cocain and then introducing one into 462 Vagus Tone and the Sense Organs each nostril. If relief is obtained, one should determine from which side of the nose the paroxysm is excited. If, for instance, after cocainization of the right nostril, the paroxysm persists, and desists only after its application to the left nostril, one is occasionally justified in con- cluding that the attack is provoked by some abnormity of the nostril on the left side. One must not forget, however, that mild attacks of asthma may be annihilated by cocain to the nostrils despite the fact that there is no asthmogenic nasal area. Here we recall the fact that cocain anesthesia of the nose inhibits the lung reflex of dilatation without influencing the counter-reflex of con- traction. It is the exaggeration of the latter reflex which determines the jugulation of a paroxysm. When adrenalin arrests a paroxysm it does so by stimulation of the bronchoconstrictor fibers (page 457), and cocain (which is less efficient), acts by inhibiting the tonus of the bronchodilator fibers, thus enabling the antagonistic fibers to have unopposed sway. One may provoke sneezing, cough, dyspnea or an asthmatic paroxysm, by touching different parts of the nasal mucosa with a probe. Such areas cauterized with chromic, trichlor- acetic or glacial acetic acid may prove curative. The following are susceptible areas of the nasal mucosa: i. The anterior portion of the septum; 2. The anterior end of the inferior turbinate. 3. Lat- eral wall of the nose slightly above the region of the anterior end r of the middle turbinate; and 4. Upper part of septum about the tubercle. Irritation of the mucosa of the nasal septum opposite the middle turbinate bone will evoke an arrhythmia, of vagal genesis. Here the irritation is conveyed, in- directly, to the vagus by the trigeminus. If the nasal mucosa has been cocainized its irritation by a probe will not evoke arrhythmia. According to the theory of Fliess, dysmenorrhea is often associated with nasal affections. He determines such asso- 463 Spondyloth e r a p y ciation by noting whether the pains are influenced by cocainization (10 to 20 per cent.), of the nasal mucosa. Fliess further observes that when the hyperesthetic areas in the nose are irritated with a probe, the pains of dysmen- orrhea can be provoked. The latter observation was made by Fliess to contravene the assumption of others, that his results were due to suggestion in hysterical subjects, and that equally good results could be obtained if the cocain were applied to the cervix, rectum, or some other mucous surface. My observations show that the proponent and his op- ponents are equally right and wrong. If one first elicits the reflex of the uterus (page 358), in a normal subject and then cocainizes the nostrils with a 5 per cent, solution of cocain, the uterus reflex cannot be provoked during the action of the cocain. Furthermore, cocain-anesthesia of any other mucosa is equally effective in abolishing the uterus reflex. In other words, anesthesia of a peripheral area diminishes vagus-tonus. When Fliess excites dysmenorrheal pains by probing the nose, he merely augments vagus-tone. When cocain solution (5%) is instilled into the eyes all the vagal reflexes are temporarily abolished. We can now understand why Koblauck finds that nasal cocainization will temporarily inhibit labor pains, and that applications of adrenalin will exgite them. Siegmund finds that gastric pains are inhibited by the nasal application of a 20 per cent, solution of cocain, which he considers diagnostic and he likewise establishes by the same diagnostic-therapeutic method, the relation between the nose and the genito-urinary apparatus (enuresis and masturbation). It will be evident to the reader, from what has pre- ceded, that the method of nasal cocainization proves nothing. It is only one of the many methods for dimin- ishing vagus-tone. By cocainizing the urethra, I find that one can inhibit the various visceral reflexes. 464 Vagus Tone and the Sense Organs As we shall learn later, diminished vagus-tone may be effected by paravertebral pressure (page 467), and, after this manner, it is my routine practice to inhibit the motor and sensory reflexes of the vagus. The foregoing observations of the author lead one to a consideration of the interesting physiologic problem, viz., whether the doctrine of specific nerve energies applies to the muco-cutaneous nerves, i. e., whether there are specific nerve fibers giving only their own quality of sensation. This view is supported by Donaldson, who found that when cocain is applied to the nose or throat, the senses of pain and pressure are destroyed, leaving those of heat and cold. My observations show a very important clinical fact, viz., that there are specific muco-cutaneous nerves which preserve the tone of the viscera and that others exist which, when irri- tated, diminish visceral tone (page 544). The facts thus elicited by clinical physiology must sub- stitute the observations of the physiologist. Visceral tone is therefore the resultant of not one, but of a summation of peripheral sensory stimuli, and that the continuity of tone may be blocked by annihilation of a single stimulus. It is for the foregoing reason that one is able to confirm the observations of Kast and Meltzer (Foot-note, page 58). There is yet another observation to which attention should be directed, viz., that after nasal cocainization, in lieu of a uterus reflex, one elicits a powerful reflex contraction of the vaginal walls (vaginal reflex). This latter observation may be utilized in toning relaxed vaginae. Here the sinusoidal current is used at the same site for elicitation of the uterus reflex. In concluding this interesting subject of nasal re- flexes, let us recall the practical fact that, impaction of the nares with cotton will accentuate or provoke symp- 465 Spondyloth e r a p y toms of problematic nasal genesis, whereas nasal cocain- ization will inhibit them. The pharmacology of the ocular reflexes is dis- cussed elsewhere, (page 498). PSYCHOVAGUS-TONE. Psychic influences on the heart and lungs have been discussed on page 203, and it is import- ant to demonstrate such influences objectively. Reduction of vagus- tone may be of psychic origin. Physiologic ex- periments show that in fatigue of the nervous system, the nerve-cells, which in health are plump, large, and with easily demonstrated nuclei, become small and shrunken and the nuclei indistinct. In consequence of this enervation of the nervous system, reflexes are with difficulty elicited and cure protracted. The author recalls a patient with a thoracic aneurysm referred to him by Dr. A. J. Minaker. Within a few treatments such cases show amelioration, but in this case the final beneficial results were delayed by grief following the death of a member of the family. Here, it was noted that during the period of grief, there was a considerable reduction of vagus-tone. Another factor is involved in psychic influences. Splanchnic stimulation increases the content of epine- phrin in the blood and adrenal secretion is under the control of the sympathetic system. There is reason to believe from the investigations of Cannon and De La Paz 84 that emotional excitement stimulates adrenal secre- tion. It is evident that when the sympathetic is stimu- lated, the tonicity of the vagus is reduced. Emotional disturbances conduce to symptoms suggestive of vagus- depression and sympathetic irritation; aortic-dilatation, inhibition of the gastro-intestinal apparatus, rapid heart, etc. I have often been impressed with the inconsistency of our conception of hysteria as a disease in which the will controls the body and produces morbid changes in 466 Paravertebral Pressure its functions. The fact is, the symptoms of the disease are caused by stimulation of the sympathetic system and the latter is not under the influence of the will. It is equally inconsistent to ask such patients to control their symptoms by exercise of the will. 2. PARA VERTEBRAL PRESSURE. We have shown under the preceding caption that pilocarpin, increases vagus-tone and that atropin annihilates it. That adrenalin, by stimu- lating the sympathetic fibers, puts the latter in a state of increased tonus, thereby resulting in a relative reduction of vagus-tonus. We shall now endeavor to show that augmentation and reduction of vagus-tonus may be obtained in a simplified and more expeditious manner by paravertebral pressure. The excitation of visceral reflexes by spinal pressure has already been noted on page 169. The points of exit of the spinal nerves are relatively superficial. Thus in a number of measurements, I found the exit at a point corresponding to the yth cervical vertebra to be at a depth of 2.6 cm. (approximate only), almost in a direct line with the corresponding spinous process and the distance between the two exits corresponded to an average width of 2 cm. At the first lumbar vertebra, 4.5 cm. represented the depth and 5 cm., the width of the exits on either side. For making pressure I employ the simple apparatus shown in Fig. 112. The prongs of the instrument are separ- ated by a distance of 5 cm. If one makes pressure (the prongs approximating the intervertebral foramina on both sides), at a point corresponding to the seventh cervical spine, vagus- tone is increased and decreased or abolished when pressure is applied at a point between the third and fourth dorsal spines. Pressure is maintained for about one minute. 467 Spondyloth e r a p y The author assumes that at the former point, the pressor, and at the latter situation, the depressor fibers of the vagus are stimulated (page 232.) Fig. 112. The instrument with two prongs (Radicular pressor} is employed in diagnosis and treatment for making bilateral pressure on the roots of the spinal nerves at their exit from the intervertebral foramina. The instrument with a single prong is used for demonstrating areas of paravertebral tenderness (vide, page 66). The depressor nerve is the most important centripetal nerve of the heart, and while existing as a separate anatomic structure in warm-blooded animals, its homologue has been 468 Paravertebral Pressure traced in the human with central connections in the vagus and endings in the walls of the ventricle. Fig. 113 shows the origin of the depressor nerve in the rabbit. Fig. 113. Scheme of the cardiac nerves in the rabbit (Landois and Stirling). P, pons; M, medulla oblongata; VAG, vagus; SL, superior, IL, inferior laryngeal; sc, superior cardiac or depressor; ic, inferior cardiac or cardio-inhibitory; H, heart. METHODS OF INCREASING VAGUS-TONE. Elsewhere (page 228), reference has been made to maneuvers for exciting the tone of the vagus and the practical ones may be recapitu- lated as follows: i. Pressure at the yth cervical spine by aid of the instrument shown in Fig. 112. 2. Position of the head, as shown in Fig. 65, and so maintained while observing the vagal phenomena. 3. Pressure in an intercostal space. Preference is accorded to the first method when an assistant is present, although when one is dealing with an 469 a p y intelligent patient, the second method suffices. Even with- out an assistant, one can demonstrate the exalted vagal reflexes, if pressure is made at the yth cervical spine with the instrument, or in an intercostal space (firm pressure), with the finger, and one proceeds at once with percussion (some visceral reflexes do not exceed the duration of a minute). However, one may note in the following table the duration of the lung reflex of dilatation when pressure is made for one-half minute. Insomuch as the degree and duration of descent of the, lower lung-border \s> most conveniently utilized in testing vagus-tone, a comparison of methods is cited in the normal subject: COMPARISON OF METHODS. METHOD TIME IN APPLICATION OF METHOD DEGREE OF DESCENT OF THE RIGHT LOWER LUNG-BORDER POSTERIORLY DURATION OF DESCENT Pressure corresponding to both sides of the yth cervical spine . . One-half minute. 5 cm. 9 minutes Forcible extension of the neck. (Fig. 65). One-half minute. 4 cm. 3i minutes Pressure in an intercostal space. One-half minute 3 cm. i minute Direct concussion of the yth cervi- cal spine. One-half minute. 4 cm. 2} minutes Sinusoidal current (rapid) with poles on either side of the yth cervical spine. One-half minute. 5. 5 cm. 2^ minutes High-frequency current on either side of yth cervical spine with a double vacuum electrode (Fig. 100). One-half minute. 5- 5 cm. 2\ minutes VAGAL-PHENOMENA. During the time pressure is made at the yth cervical spine with the instrument shown in Fig. 112, one notes the following: 470 V a g a I Phenomena 1. Augmented tone of the heart, aorta, lungs, stomach, liver, spleen and intestines, manifested by increased dulness of the organs in question and better definition of their borders.* Reference has already been made to visceral-tone (page 451), but to further appreciate the importance of this subject, let us refer to the heart. During diastole, the walls of the heart are relaxed but this diastolic relaxation varies with the tonicity of the heart-muscle. Fibers exist in the vagus of the frog, which, when stimulated, increase the tone of the myocardium. When one makes pressure as above, the cardiac muscle normally relaxed becomes rigid (diastolic rigidity). I employ this method for facilitating the percussion of the heart and in testing its tone. If the myocardium is normal, the precordial dul- ness is accentuated after the above maneuver, whereas, if diseased (diminished tone), the degree of dulness is unchanged. Forcible extension of the neck may likewise be utilized in testing the tone of the organs specified and determining their borders by regional percussion 2. Contraction of the pupils (this is not constant). 3. Closure of the cricp- thyroid space. The latter phenomenon is best elicited when the finger-tip is placed at the side of the crico-thyroid mem- brane. Pressure brings out the phenomenon best. If not detected easily have the assistant make intermittent pressure at the yth cervical spine. The crico-thyroid muscle is supplied by the superior laryngeal (branch of the vagus) nerve, and it produces tension and elongation of the vocal cords. An hysterical paralysis of the vocal *In association with the augmented visceral tone, there is visceral contraction, and this contraction is greater, e. g., of the stomach at the yth cervical spine than at the upper lumbar spines (page 316). Thus, the degree of stomach-contrac- tion when the first three lumbar spines are concussed is only 2 cm., but 4 cm. after concussion of the 7th cervical spine. The same observation applies to the spleen. 471 Spondyloth e r a p y cords may be diagnosed objectively by closure of the crico-thyroid space by the suggested maneuver. 4. Eosinophilia. 5. Hyperesthesia of the fauces. 6. Descent of the lower border of the lung (lung reflex of dilatation). 7. Diminution in volume of pulse and slowing to extinc- tion. It is more convenient to select the lower border of the lung posteriorly on either side. The lower border is first determined by percussion, after which pressure is made for one-half minute and the border again determined. In the norm the descent is about 4 cm. In vagus-hyper- tonia, it may descend 6 cm., and in hypotonia, it may descend only 2 cm., or not at all. Pressure between the spines of the third and fourth vertebrae causes the lower lung-border to recede. Increased vagus-tonus is gener- ally associated with a low lung-border and its converse condition with a high border. METHODS FOR DECREASING VAGUS-TONUS. i. Pressure with the instrument (Fig. 112), at a point between the third and fourth dorsal spines. 2. Pressure behind both ears. During the time such pressure is made one notes the following: 1. Diminished tone of the heart, aorta, lungs, stomach, liver, spleen and intestines. 2. Annihilation of the reflexes of the lungs, stomach, heart, aorta, spleen and intestines. 2. Pupillary dilatation. 3. Widening of the crico-thyroid space. 4. Anesthesia of the fauces. 472 Pressure Behind Both Ears 5. Ascent of the lower lung- border (lung reflex of con- traction. 6. Pulse diminished in volume and rapidity increased. In this connection, it is necessary to note the approx- imation of the sites for increasing vagus- tone (yth cervical spine) and for diminishing it (between the 3d and 4th dorsal spines). A physician whose results were futile in the treatment of an aneurysm by concussion made the egregious error of employing a large concussor which embraced simultaneously the 'areas for increasing and diminishing vagus-tone. 2. PRESSURE BEHIND BOTH EARS. The observations of Milligan and Home have been confirmed by others : pressure applied to the mastoid processes generally relieves pain (due to faucial inflammation), in swallowing. Hald explains the effect as due to counter-irritation of the skin at a point where the sensory nerves are closely connected (centrally), with the sensory nerve-supply of the tonsils In investigating this subject, the author finds that pressure between the 3d and 4th dorsal spine is the more efficient of the two methods. In both methods, dysphagia (whether due to faucitis or esophagismus), is combated by inhibition of the sensory functions of the vagus. Even in the norm, one may anesthetize the throat for practical purposes (laryngoscopic examination or intro- duction of a stomach-tube), by firm bilateral pressure for one or two minutes at the site noted (between the 3d and 4th dorsal spines). The anesthesia however, is limited in duration but it may be prolonged by resumption of pressure. In pressure behind both mastoids the same vagal phenomena ensue as were cited when pressure is made between the third and fourth dorsal spines. By bilateral mastoid-pressure one probably compresses the 473 Spondylotherapy auricular branch of the vagus which appears cutaneously behind the ear. One must note another fact when vagus-tone is diminished by pressure between the 3d and 4th dorsal spines, viz.: dilatation of certain viscera. Thus, an aneurysm which shows a diameter of 4 cm., by percussion is reduced to i cm. when vagus-tone is increased by pres- sure at the yth cervical spine and increased to 7 cm., when vagus-tone is decreased. Pressure or concussion of the region for reducing vagus-tone, produces greater dilatation of the aorta than the conventional site for eliciting the aortic reflex of dilatation (page 256). Thus, an aneurysm measures 4.8 cm. in the transverse diam- eter; concussion of the 9th-i2th dorsal spines gives a measurement of 8 cm., and 10 cm., after concussion be- tween the 3d and 4th dorsal spines. THERAPEUTIC RESULTS. Cures show the nature of diseases. Draper made the sapient observation that: "Mastery of all the sciences upon which medicine is founded does not make the physician . . . until he learns how to construct out of them the special art which enables him to cure disease." Broussais observed that the real physician is one who cures. A story is related of an American phy- sician who was shown through a large pathologic laboratory in Paris, and was wearied looking at shelf after shelf loaded with pickled specimens of organs and tissues from people long since dead. At last he turned to the great pathologist and said: "Great God! where are the people you have cured?" It is difficult to charm ache with air, and agony with words, and unless we call a halt on scientific medicine ( ?) we shall soon regard it as a misdemeanor should the patient be so presumptuous as to demand a cure. A short time back, the author sent to a leading German 474 Therapeutic Results medical journal, a report of 40 cases of aortic aneurysm, symptomatically cured. Most men will agree that the cure of aneurysms should be considered one of the greatest con- tributions ever made to scientific medicine. The report, however, was refused publication, based on the assumption that, insomuch as aortic aneurysms were incurable, any reports to the contrary were in violation of our accepted theories concerning the pathology of the disease. The physio-therapeutic methods suggested in this book for inhibiting or exciting visceral reflexes are equally available in diminishing or increasing vagus-tone. In the application of our method, whether it be concussion, pressure or electric- ity, we must always remember that to increase vagus-tone, we confine ourselves to the bilateral paravertebral area corresponding to the yth cervical spine, and when vagus-tone is to be diminished, the site of election is, between the 3d and 4th do?sal spines. Symptoms, in some affections, abate rapidly, whereas in others the results are more tardy. We may gauge our results by noting the degree of descent and position of the lower lung-border. If the symptoms do not abate despite the augmentation or decrease of vagus-tone, then vagus-tone is in no wise related to the symptoms (page 451). In the choice of the method to be employed, the physician can determine for himself the one most effective for causing either a descent (increased vagus- tone), or ascent (dimin- ished vagus- tone), of the lower lung-border. When ability is lacking in this regard, then concussion should be given the preference, insomuch as it is easy of application and generally reliable. Over-treatment must be avoided to prevent exhaustion of the reflexes. The following table represents the degree of ascent of the lower lung-border after different methods to the 475 Spondyloth e r a p y region between the third and fourth dorsal spines for decreasing vagus-tone: CONCUSSION 2.3 cm. RAPID SINUSOIDAL CURRENT i.6 cm. SLOW SINUSOIDAL CURRENT 1.6 Cm. PRESSURE 1.6 cm. HIGH-FREQUENCY CURRENT No ascent. Fig. 114. Base-knob for executing para vertebral pressure or eliciting para- vertebral tenderness The duration of retraction was greatest with the slow sinusoidal current; one pole applied on each side of the spine between the third and fourth dorsal vertebrae. In many instances the patient is provided with two ordinary base-knobs (Fig. 114), and he is instructed to have some member of the family make firm pressure four times daily on either side of the spine (corresponding to the area to be influenced) for a period of time not ex- ceeding one minute. To protect the skin and to locate the site of pressure the physician should apply a narrow strip of adhesive plaster. One of my patients suggested screwing the base-knobs on the back of a chair or into a wall at a convenient 476 Therapeutic Results height and by bracing the feet, the patient can exert pressure himself. In locating paravertebral tenderness, the physician will find the base-knob very convenient. Another and most effective method which can be em- ployed by the patient at home for increasing vagus-tone, is that of extending the muscles of the neck, as shown in Fig. 65. Fig. 115. Heart reflex elicited by the method of extending the muscles of the neck (vide, Fig. 65). The amplitude of the reflex is indicated by the reduced area of cardiac dullness extending from without to within the nipple. This may be executed twice or thrice daily, and about twenty forcible extensions can be made at a seance. In affections of the heart and other diseases caused by diminished tone of the vagus, my patients are instructed to execute these exercises in addition to treatment at my office. The effect of such exercise on a dilated heart is noted in Fig- 115- Fig. 116 represents an apparatus for applying bilateral paravertebral pressure. Suspended from the middle bar is a suspension apparatus which is quite independent of the other. 477 Spondyloth e r a p y Suspension Treatment, when first advocated for loco- motor ataxia, was employed indiscriminately and soon passed into desuetude. With this treatment the patient Fig. 116. Apparatus for applying bilateral para vertebral pressure. Adjusted to the bars are two pieces which can be raised or lowered. The front piece is pro- vided with a cushion which is 6xed to the chest with a screw and is used for counter- pressure. The back piece is provided with two small knobs (barely visible in the illustration), which are fixed over a definite vertebral area and by means of a screw any degree of pressure can be made. Suspended from above is a suspension ap- paratus which is independent of the other. is suspended in a Sayre apparatus. This treatment is still used by the author as an invaluable method in some cases for the relief of pain, bladder-disturbances and impotency. The method is curative when pains simu- lating lumbago are really due to adhesions in the verte- 478 Diseases Caused by Vagus-Hypertonia bral articulations. Suspension was used in 1829 by J. K. Mitchell, of Philadelphia, for affections of the cord secondary to vertebral disease. The investigations of Motschutkowski, show that during suspension, the nerve- roots pass from a horizontal to an almost perpendicular position and the cadaver was increased in length. I have found that, during suspension, the tone of the viscera is augmented. It is for the latter reason, if for no other, that suspen- sion may be regarded as a valuable method of treatment. Effects, almost equal to suspension may be achieved by having the patient sit on the floor or a table and then forcibly flexing the head and trunk upon the thighs, while the lower extremities are kept straight. DISEASES CAUSED BY VAGUS-HYPERTONIA AND VAGUS- HYPOTONIA DIABETES MELLITUS. The great majority of cases of this affection observed by the author have been associated with vagus-hypotonia, and he has treated his cases by the method suggested on page 281. Since the results were pub- lished on page 283 he has encountered a group of cases yielding better results and even though no symptomatic cure was effected in several cases, the tolerance for carbohydrates was augmented. In two cases with a pronounced history of heredity (several members being similarly afflicted with diabetes), no results were achieved. The only restriction respecting diet was the avoidance of any excess of carbo- hydrates. In several individuals with alimentary glycosuria, the assimilation limit for carbohydrates was increased by aug- mentation of vagus-tone by concussion. The test employed was that of Naunyn: two hours after a breakfast consisting of a roll and butter, with coffee, 100 grams of glucose, given 479 Spondyloth e r a p y in solution, ought not to cause a glycosuria. If glycosuria ensues, the individual shows a diminished capacity for ware- housing carbohydrates and true diabetes may eventually follow. The liver is the probable source of sugar production and is in turn controlled by the pancreas and suprarenals (the pancreas playing the role of inhibition, and the supra- renals that of stimulation in sugar production). The secre- tion of the thyroid inhibits the function of the pancreas as is demonstrated in the tendency to glycosuria in hyperthy- roidism. After thyroidectomy, the inhibitory influence of the pancreas on the liver is so powerful that it is almost impossible to produce glycosuria. Modern writers regard the glycosuria ensuing from puncture of the medulla to be due to suprarenal stimulation, which excites the liver to an increased output of sugar. The puncture of the medulla stimulates the left sympathetic nerve and this stimulation is transmitted first to the left and then to the right suprarenal. If the left suprarenal is separated from the left sympathetic nerve, glycosuria does not follow puncture of the medulla. If the vagus-tone is normal, adrenalin (given hypoder- matically), will not cause glycosuria, nor will the ingestion of glucose up to 300 grams. Atropin diminishes or abolishes vagus-tone and in individuals with reduced vagus-tonus, even small doses may cause glycosuria. One also knows that pilocarpin, which augments vagus- tone, will suppress glycosuria from adrenalin. In several instances I have found glycosuria in sus- ceptible individuals to follow paravertebral pressure between the 3d and 4th dorsal spines. This maneuver abolishes or diminishes vagus-tone (page 472). In practically all of my diabetic patients I have found enlargement of the liver and the signs of diminished tone of the splanchnic circulation. 4SO Diabetes M e I I i t u s Dr. H. C. Sawyer reports 85 the following case of diabetes treated according to the method of the author: "Female, fifty-two years of age, and weighing about 180 pounds presented herself April 9, 1910, with a history of incessant thirst and frequent urination owing to the ex- cretion of enormous quantities of urine. The latter at this time had a specific gravity of 1,040 and contained eight per cent, of sugar; the reaction for diacetic acid was positive. The following represented the average daily menu prior to the commencement of treatment which consisted of daily concussion of the seventh cervical spine of an average duration of about ten minutes: Breakfast. Coffee, toast, and scrambled eggs. Luncheon. Cold chicken, chop, asparagus, potatoes, and several slices of bread. Dinner. Soap, egg salad, chicken, several slices of bread, asparagus, ice cream, and coffee. The foregoing diet was permitted during the treatment. Within one week, polydipsia and polyuria had com- pletely evanesced, but sugar continued in the urine vary- ing in percentage from 5 to 0.77 per cent, on May 7, 1910. After the latter date and up to the present time of writing (July 30, 1911.) there was absolutely no trace of sugar in the urine with the exception of one day when it reappeared temporarily after the patient partook, at a picnic, of a bottle of root-beer and ingested many other elements containing an excess of sugar. Comments. The reappearance of sugar on a single day was of no moment and indicated a physiological glycosuria which occurs in certain persons of apparently good health after the rapid ingestion of an excessive quantity of carbohydrates. From the evidence pre- sented, the case in question can only be regarded as one of true diabetes mellitus. The rationale of the method con- sists of diminishing the quantity of blood flowing through the liver by augmenting the tone of the splanchnic blood- 481 Spondyloth e r a p y vessels and thus improving the nutrition of the hepatic cells concerned in the warehousing of carbohydrates. By the method of percussing the liver as suggested by Abrams, enlargement of the organ may be demon- strated in diabetes and a diminution of its volume may be noted after a single concussion seance. The latter fact is probably due to a diminished volume of blood in the liver and is not a true liver reflex such as is elicited by con- cussion of the spinous processes of the first three lumbar vertebrae. Twenty seances of the concussion treatment in the foregoing case were necessary before the sugar disap- peared from the urine." It is the practice of the author, before commencing treatment to get the urine sugar-free and then to add, gradually, small quantities of carbohydrates to the die- tary. DISEASES OF THE THYROID GLAND. Organotherapy has demonstrated the causal relation between this gland and a host of diseases. It has already been shown that the physiologic tonus of the vagus is probably dependent on the thyroid secretion. In diseases due to diminished thyroid secretion (hypothyroidism), vagus-tonus is increased and conversely diminished when the secretion is excessive (hyper thyroidism) . HYPOTHYROIDISM. Insufficiency of the thyroid gland may be recognized by the tests on page 488, et seq. The diagnostic-therapeutic test by the administration of thyroid is equally valuable. Diseases caused by hypersecretion are aggravated, and those due to hyposecretion, are ameliorated or cured by thyroid. One must give thyroid to obtain physiologic and not toxic effects (thyroidism). The symptoms of thyroidism indicate that the thyroid dosage must be reduced or inter- dicted. The signs of thyroidism are: anorexia, emaciation,. 482 Diseases of the Thyroid Gland perspiration, insomnia, headache, nervous excitement, heart palpitation, tachycardia, tremors, prostration, etc. Inso- much as thyroid diminishes vagus-tone (page 459), it is not surprising to note that glycosuria may attend its adminis- tration. Thyroid function is identified with the metabolism of carbohydrates, insomuch as it has been shown that the administration of thyroid interferes with the retention or assimilation of carbohydrates. Thyroid should never be given in the presence of symptoms suggesting exophthalmic goitre. The dessicated thyroid is a yellow powder made from the thyroid glands of sheep, and the dose varies from \ grain to 1 5 grains. It is more convenient to give it in tablet form, and reliable tablets are made by Merck, Parke, Davis and Co., and Burroughs Wellcome & Co. It is also given as the raw, fresh gland of a sheep, on bread, beginning with the eighth part of a gland and gradually increasing the amount. The latter mode of administration is indicated when the dried preparations cause thyroidism. Thyroid has been given for every imaginable disease, but there are certain affections which empiricism has taught are identified with subsecretion of the gland. In children hyposecretion and athyrea (absence of secre- tion), are associated with slow and stunted growth, retarded pulse, phlegmatic temperament, juvenile obesity, delayed puberty and cretinism. In girls, delayed menstruation, amenorrhea, chlorosis, hysteria and epilepsy contribute to the symptomatology. In the adult one finds myxedema and an abnormal tendency to obesity. Many symptoms of senility have been attributed to hyposecretion, notably lesions of the skin (nutritive distur- bances and eczema). 483 Spondyloth e r a p y In certain forms of melancholia or hysteria, associated with depression and tardy cerebration, thyroid has been phenomenally efficient. Peabody, 86 avers that 75 per cent, of patients who die from mental disease show anomalous thyroid glands. Vomiting of pregnancy is often arrested by thyroid ad- ministration, and many competent observers regard thyroid as an excellent treatment for eclampsia. Epileptic attacks associated with the menstrual period have been cured by thyroid. Enlargement of the thyroid gland may be associated either with a diminished or excessive thyroid secretion. The enlargement may be structural (hyperplastic), or vascular. Vascular enlargement (peculiar to exophthalmic goitre), may be distinguished from hyper- plasia (goitre), by the fact that a murmur or thrill is elicited when the gland is pressed upon. HYPERTHYROIDISM. In hyperthyrea, vagus-tone is diminished and this hypotonia is recognized by the tests on page 471, et seq. Little can be expected of the diagnostic-therapeutic test for the reason that the various antithyroid preparations are inconstant in action and they are equally lauded by some and condemned by others. Symptoms of hyperthyrea are accentuated by certain preparations described on page 453. A seance of concussion or sinusoidalization of the 7th cervical spine lasting five minutes will reduce the rapid pulse of a thyroid heart from 10 to 30 beats and ameliorate many other symptoms. This test is generally reliable. Conversely, if one concusses the 3d and 4th dorsal spines, the symptoms of hyperthyroidism are accentuated. The typical disease which represents an excessive secre- tion of the thyroid gland is exophthalmic goitre (page 280). 484 Hype r t h y r o i d i s m This disease occurs more frequently in women than in men. Transitory hyperemia of the gland occurs in females at puberty, menstruation and pregnancy. It is not unlikely that many symptoms at these periods are caused by hyperthy- roidism. The vascularity of the thyroid gland is enormous. Every minute, the quantity of blood passing through the gland is equivalent to six times its weight and it is said that it is twenty-eight times as vascular as the head, and five and one-half times as vascular as the kidney. The symptomatology of exophthalmic goitre is made up of the classic tetrad: struma, tachycardia, tremor and exoph- thalmos. The recognizability of such symptoms is facile. It is the recognition of minimal hyperthyroidism, which demands diagnostic acumen. Let us, however, first interpolate cer- tain facts concerning the thyroid heart. Cardiac disturbances may be associated with all forms of goitre and conduce to the condition known as thyroid heart (Kropfherz). Goitre, however, may be secondary to cardiac disease (cardiac goitre). The cardiac disturbances of a goitre may be due to essentially mechanic causes (pres- sure on the trachea, veins and sympathetic ganglia). When pressure is exerted on the sympathetic, tachycardia and exophthalmos (usually unilateral) ensue, leading to a clinical picture known as pseudo-exophthalmic goitre. Cardiac disturbances may also be caused either by a deficient or excessive secretion of the thyroid gland. In the former (cardiopathia thyreoprivea), the dominant symptom is cardiac weakness, insomuch as vagus- tone is largely dependent on the secretion of the gland which is deficient. Early arteriosclerosis is another condition associated with hypothyroidism. 485 Spondyloth e r a p y Insanity may be associated with a disfunctionating thyroid and psychoses concurrent with exophthalmic goitre are not infrequent. The psychotic symptoms represent one of two groups: maniacal agitation or a depressive type. Some authorities claim that chronic paranoia, dementia precox and even general paresis may be associated with exophthalmic goitre. The fact must be emphasized that hyperthyroidism may be present without visible or palpable enlargement of the thyroid gland. The active principle of the gland is iodothyreo globulin. Thyreoglobulin is manufactured within the cells and acquires its iodin from the blood. In hyperthyroidism, when an excess of iodothyreoglobulin is thrown into the blood, metabolism is augmented (loss of weight), and there is a stimulation of the peripheral nerves. The early recognition of atypic forms of hyperthyroidism (formes frustes) is of great importance in determining the etiology of many obscure affections which masquerade under a medley of names. The symptoms peculiar to hyperthy- roidism are accentuated by factors which augment the vas- cularity of the gland or decrease vagus-tone. Such factors are: menstruation, pregnancy, emotional disturbances (which diminish vagus-tone, page 466), sexual excitement, genital disturbances (chiefly uterine), infectious diseases (notably, influenza), coffee, tea, alcohol and certain drugs (iodids and especially, thyroid extract). The fact that the thyroid gland is more active in women accounts for the predominance of their nervous and hysteri- cal symptoms and the fact that exophthalmic goitre occurs more frequently in women than in men. MENORRHAGIA in young girls and women is often a 486 Hyp e r t h y r o i d i s m symptom of hyperthyroidism, whereas hypothyroidism is associated with amenorrhea and chlorosis. Menorrhagia due to hyperthyroidism may be con- trolled by tablets of mammary extract in doses of about 4 grains taken thrice daily. The tablets must be crushed by the teeth before swallowing. MENOPAUSE SYMPTOMS are unquestionably associated with hyperthyroidism. Among other early symptoms are, 1. Cardiac signs; palpitation and irregularity, increased pulse-rate, attacks of tachycardia and throbbing of the arteries. Digitalis has little or no action on the cardiac signs. 2. Psychic signs: mental excitement, restlessness and insomnia. The exalted states ensuing from wine or coffee are probably caused by a transient hyperthyroidism. 3. Ocular signs: widening of the palpebral slit, staring without winking for a considerable time and inability of the lids to follow the eyeballs when vision is directed at the descending finger of the physician. In the author's exper- ience when the lid does follow the ringer, it drops in 'oto and not gradually. The author has noted an accentuation of the latter symp- tom (v. Graefe's sign) when the ringer of the physician is directed downward in an oblique direction. He has further noted a slight spasmodic retraction of the lids when vision is directed downward in an oblique direction. When the patient first looks at an object, there is usually a spasmodic contraction of the upper-lid (Kocher-Boston sign). 4. Nutritional sign: Loss in weight despite good appe- tite and digestion. Among other early signs are : Feeling of heat, elevation of temperature, flushes, perspiration and a fine tremor. The tremor is best observed when the patient is directed to spread the fingers. In hyperthyroidism, not- 487 Spondyloth a p y ably in exophthalmic goitre, I have noted a tendency of the fingers to become adducted when separated and this tendency especially implicates the middle and fourth finger. There is another symptom which I have observed and that is dyspnea on exertion. This symptom may be caused by a dilated aorta, a condition which is frequently associated with exophthalmic goitre and which is easily recognized by careful percussion (page 558). Kocher directs attention to tenderness of the thyroid, a systolic blowing over the thyroid arteries, and a characteristic blood picture: leucocytes half as numerous as usual, neutrophiles reduced and lymphocytes twice the normal figure. In the absence of this constant blood-picture, he will not operate. The symptoms of hypersecretion and hyposecretion of the thyroid may be recapitulated as follows: SYMPTOMS OF HYPERTHYROIDISM AND HvpoxHYROiDiSM 87 . HYPERTHYROIDISM. History of fatigue and slow onset. More common in adoles- cence than in middle life and in women. Cutaneous flushing; tachy- cardia; manifest overac- tion of heart; pulsation of cervical vessels; all in- creased by exertion; blood pressure 120-130. Mental instability and ex- citability rather than men- tal alertness; tremor; rest- lessness; quick, jerky movements of extremi- ties; insomnia. HYPOTHYROIDISM. 1. The same. 2. More common during and after middle life and in women. 3. Flushed skin over malar prominences only, marked pallor elsewhere ; slow pulse; blood-pressure us- ually below 1 20. 4. Mentality sluggish, rather than dull; headache; in- somnia with changes to somnolence only in ter- minal stages; slow move- ments. 488 Hyperthyroidism and Hypo thy roidism 6. 10. ii. 12. Muscular weakness and in- ability to withstand ordi- nary fatigue. Exophthalmos generally present in some degree, and the more marked it is the worse is the prog- nosis. It is often absent in the early stages. Goiter of variable size and consistency. Its vascu- larity and density give some indication of the relative importance of the thyroid in the general disturbance; goiter is often imperceptible in the early stages. Appetite abnormally good and out of proportion to the evident poor nutrition; movements regular or diarrheic. Thirst con- stant. Skin moist with a subjective feeling of heat. Temperature 99 to 101. Blood shows relative lym- phocytosis, anemia slight or absent. Menstruation irregular or absent. Urine in nitrogen partition shows excess of creatin and diminished creatinin. 5. The same. 6. No exophthalmos except in those who have passed through a preceding Graves' disease. In place of it there is a charac- teristic puffiness and edema around the eyelids and in the supraclavicular regions and on the back of neck and below the knees. 7. Goiter is common, but by its consistency and absence of vascularity suggests a functionless organ. Appetite poor; apparently good nutrition. Consti- pation. No thirst. 9. Skin dry and scaly; subjec- tive feeling of cold. 10. Temperature subnormal. ,11. Negative, anemia regularly. 12. Regular but scanty, occas- sionally excessive. 13. Negative; albumin some- times present. 489 Spondyloth e r a p y The TREATMENT of exophthalmic goitre is equally appli- cable for the minor and atypic manifestations of hyperthy- roidism. In the conventional medical treatment, which ranges from Galvanization of the cervical sympathetic and exposure to the X-rays to the use of specific sera, the results are uncer- tain and recurrence is the rule. Respecting operative treatment (thyroidectomy), the re- sults achieved by Kocher (who has had the largest experience in such cases), are as follows: absolute and permanent cure in 83 per cent., and 3.5 per cent, of deaths. C. H. Mayo had 9 deaths in 176 cases. Removal of the sympathetic ganglia (sympathectomy), on both sides is a procedure unattended by good results. The author's method of treatment (page 280) is practi- cally a specific in hyperthyroidism and the results are immed- iate and usually permanent. Recurrence of symptoms is transient and associated with factors which augment the vascularity of the thyroid gland. The first symptoms to yield are tachycardia and cardiac irregularities, nervousness and perspiration. Exophthalmos is the most resistant sign and may yield synchronously with the other signs, it may improve after treatment is suspended or it may be permanent. Operations yield no better results, for in cases of long standing the exophthalmos is permanent owing to the deposit of orbital fat which causes the eye to protrude even though the muscle of Miiller is no longer contracted. The exophthalmos and separation of the lids in Exo- phthalmic goitre is caused by contraction of Miiller's muscle which is innervated by the cervical sympathetic. This muscle is attached to the bony wall of the orbit and is inserted into the sclerotic coat of the eyeball and the upper or lower lids. 490 Exophthalmic Goitre Reports received from many physicians, respecting the author's treatment of exophthalmic goitre are very encouraging. In several instances, only the methods of concussion shown in Figs. 2 and 3 were used. One physician writes, "in one week tachycardia reduced from 160 to no, enlargement of thyroid gland decreased about one-half, although exophthalmos is the same." Another reports, "I have never witnessed such rapid and marvelous results in the treatment of a disease." Another says, "Within three weeks practically every symptom disappeared but at the next menstrual period some symptoms recurred but have not reappeared up to the present time of writing." A physician, whose enthusiasm regarding the author's method was dictated by results, observes as follows: "It is only a question of time when physicians will and must recognize your specific treatment and when it will be regarded as criminal negligence for the physician to invoke surgery before giving your method a trial." A physician reported, "The symptoms were aggra- vated." On inquiry, I found that he was concussing not only the ;th cervical spine, but likewise the upper dorsal spines (which decreased vagus-tone). I have never heard further concerning his results. Any of the methods for increasing vagus-tone as suggested on page 469, are available in treatment. Dr. M. Turnbull cites one case with a history of exophthalmic goitre for 1 5 years. Despite an operation (ligation of thyroid arteries), the enlarged gland and car- diac signs persisted. Within 2 weeks, no gland could be seen nor palpated and the cardiac signs, tremor, etc, disappeared. At one menstrual period, the gland en- larged for 2 days. In this patient, a woman of 28, the hair had become thin and absolutely white. Soon after the commencement of treatment, the hair grew more luxuriantly and is being restored to its natural color (brown). 491 Spondyloth e r a p y In another patient, all the symptoms subsided in three weeks excepting the exophthalmos which was ameliorated about 50 per cent. The patient gained one- half pound a day for about three weeks. In both cases, the treatment was concussion of the 7th cervical spine. In some of the author's cases, patients who were apparently obese lost considerably in weight. This was probably due to edema and myxedema complicating exophthalmic goitre and coincident with improvement of the latter, myxedema and edema disappeared. Among letters received from physicians, one question is paramount: "Will concussion cure simple forms of goitre?" The reply to this question may be as follows: The greater the vascularity of the gland (soft and tender, systolic blowing), the greater is the chance for its reduction. When much fibrous tissue has developed no results can be expected. Treatment by concussion is so simple that it should at least be given a trial. Very often a goitre is a true hypertrophy occurring in response for an augmented supply of secretion. Here, the use of thyroid extract will cause a reduction in the size of the gland. EMACIATION. In some individuals despite careful exam- ination, one cannot account for their poor nutrition. Weir Mitchell, and later, Playfair, demonstrated the great value of forced alimentation in many neuroses. This mastcure or methodical overfeeding was used in combination with an absolute rest cure. As I take a retrospect of the cases thus treated and of my success and failures, I now believe that I was unconsciously treating thyroid glands in a condition of hypersecretion. In a rest cure one executes all the methods necessary to depress the functions of the gland, viz.: rest, seclusion, quiet, an absence of genital irritation and sexual 492 Exophthalmic Goitre Fig. 117. Case of Exophthalmic goitre made up of the following tetrad: tachycardia, exophthalmos, tremor and pulsating thyroid gland. i. : Sphygmo- gram of pulsating struma before commencing treatment (the record shows tachy- cardia and irregularity of pulsations) ; 2. Tracing of gland after 5 minutes appli- cation of the rapid sinusoidal current in the region of the yth cervical spine. 3. Tracing of tremor before treatment; 4. Tracing of tremor after sinusoidalizalion in the region of the yth cervical spine; 5 and 6. Cardiogram and pneumogram before, and 7 and 8, the same after concussion of the yth cervical spine. Respiratory ataxia (page 85) is a not infrequent sign (according to the observations of the author) in this disease. This patient's heart became absolutely normal in rhythm after 3 treatments of concussion to the seventh cervical spine although this irre- gularity had existed since the inception of her disease 15 years before. 493 S p o n d y I o t h e r a p y excitement and a diet of milk and farinaceous foods with a minimum of meat. Many of my cases in women suffered from relapses and not infrequently three rest cures were given in a single year. Some of these cases showing reduced vagus-tonus, have since then been treated successfully by concussion of the yth cervical spine or by para vertebral pressure. Improvement is associated with an increase in weight without any change in the diet. Treatment at my office was supplemented by contraction of the cervical muscles (page 2 2 8) or by para ver- tebral pressure corresponding to the yth cervical spine (page 467), three or four times a day for one minute each time. BRONCHIAL ASTHMA. Reference has already been made to this subject on page 303, with supplementary observations on page 456. This disease is practically always associated with vagus-hypertonia. Even in the norm, if an assistant maintains firm pressure at the yth cervical spine with the instrument shown in Fig. 112, within thirty seconds to two minutes, one can auscultate rdles peculiar to asthma In asthmatics or in cases of vagus-hypertonia, less pressure or a shorter interval of time is necessary to create rales. Asthmatic paroxysms may be arrested by firm pressure with the thumbs in the absence of an instrument on both sides of the column between the third and fourth dorsal spines. The foregoing facts are of great importance in pulmonary auscultation. Many adventitious sounds are due either to increased or diminished vagus-tonus and by availing our- selves of the maneuvers suggested, one may avoid errors in diagnosis. Boeri 88 , found that when no abnormal breath-sounds were heard over the apex in incipient phthisis, they became audible after a few minutes deep massage over the apex of 494 Bronchial A s t h m a the lung. The phenomenon in question is probably due to an augmentation of tone of the vagus ensuing from massage. Stretching the neck (Fig. 65) several times in succession accomplishes the same object. Phthisis is a disease usually due to hypertonia, and one frequently finds it associated with bronchospasm, a condition not unlike asthma. If one makes pressure for about one minute between the third and fourth dorsal spines, the rdles peculiar to asthma or bronchospasm disappear. Respecting the treatment of asthma, my experience con- cerns itself chiefly with the method described on page 312. My more recent experience justifies me in saying that I be- lieve more expeditious results may be achieved by depressing vagus-tone and to attain this object it is suggested to employ sinusoidalization or concussion of the region for depressing the vagus and to supplement it by treatment at home, viz. : pressure three or four times a day for one minute at a point on either side of the column between the third and fourth dorsal spines. In my experience, paroxysmal dilatation of the thoracic aorta may simulate asthma. Here one finds by careful percussion an increase in the area of aortic dulness. Vagus- tone is diminished and not increased as in asthma. In such instances of pseudo-asthma, the treatment indicated is that for aneurysms. EMPHYSEMA. Increased vagus-tonus is associated with this condition in a number of instances, notably in young persons. We have already noted (page 296) how one may transitorily dissipate the disease by nasal cocainization. The methods employed for reducing vagus-tone should be given a trial. One must, however, carefully supervise the treatment to avoid the development of symptoms dependent on reduced vagus-tonus. 495 Spondyloth e r a p y In some instances, diminished vagus-tone being present, the antithetic method of treatment is indicated. CARDIAC NEUROSES. The pharmacologic diagnosis of these affections has been discussed on page 454. They may be associated with increased or diminished vagus-tonus. GASTRIC NEUROSES. The vagus controls the tone, peristalsis and secretion of the stomach. When the tone of the nerve is pathologically increased the motor, sensory and secretory phenomena of the organ are accentuated and give expression to clinical pictures identified with the gastric neuroses. Esophagismus, may be attributed to the same cause and one may note its temporary evanescence by methods which reduce vagus- tone, viz. : paravertebral pressure or an hypo- dermatic injection of atropin. INTESTINAL NEUROSES. In the diagnosis of these affec- tions one must remember that atropin inhibits and that pilocarpin, intensifies intestinal peristalsis. The many affections identified with increased or diminished vagus-tone include diarrhea, constipation and membranous enteritis. The latter is probably a motor-secretory neurosis and is favorably influenced by atropin. In individuals with this disease, the use of pilocarpin may precipitate a paroxysm. DISTURBANCES OF VISION.* Vagus-tone is identified with hysterical and neurasthenic forms of amblyopia and asthenopia. The former refers to reduced visual acuity, contraction of the field of vision and the field for colors. The diagnosis of hysterical amblyopia is established by the absence of demonstrable ocular changes, exhaustion of the visual field during examination and by the fact that the *A preliminary reading of the subject-matter on page 441, will aid in the better understanding of this caption. 496 As then op i a contraction of the field for colors is reversed (limits for red wider than those for blue.) The oculist observes that the acuity of vision and the extent of the visual field varies with the amelioration or aggravation of the health of the patient. That this form of amblyopia is a matter of vagus-tone I have demonstrated as follows: In a normal subject, determine with a perimeter the extent of the normal field of vision and the field for colors. Then, during the time the vagus-tone is depressed by an assistant (pressure between the third and fourth dorsal spines), again determine the fields. One notes that the visual field is contracted and the field for colors reversed. Pressure at the yth cervical spine will in- crease the extent of both fields. In asthenopia, despite good visual power, the eye becomes incapacitated for continuous exertion and the patient com- plains of pains in or above the eyes, frontal or occipital headaches, neuralgia, lacrymation and burning sensation in the lids, blurring of near vision and a host of other symptoms. The foregoing signs are always accentuated with arti- ficial illumination, after reading, writing, sewing and other forms of near application and in disturbances of the general health. Even in the norm, one may provoke asthenopic symptoms by reducing vagus-tone (pressure between the third and fourth dorsal spines), during the time patient is requested to read. Each eye may be separately tested. Pressure at the seventh cervical spine will improve acuity of vision and in asthenopia, vision previously blurred, becomes sharp and defined. The maneuvers suggested do not modify the vision of an astigmatic, myopic or hypermetropic eye. We have already demonstrated (page 443), that eye-strain is equivalent to vagus-stimulation and will evoke the vagal- 497 Spondylotherapy reflexes. If, however, one cocainizes the eyes with a 5 per cent, solution in a normal subject, the vagal reflexes cannot be obtained. Paradoxical as it may appear, the reflexes continue despite the use of homatropin or atropin. The foregoing facts are in defiance of current opinion insomuch as atropin as a cycloplegic, by paralyzing accom- modation, is supposed to annihilate the majority of ocular reflexes. I have, however, made repeated tests in this respect and the results have been practically uniform. The preceding facts furnish an important guide in treat- ment. Many patients with amblyopia and asthenopia suffer for years and are incapacitated for serious occupation. Glasses often give no relief and stimulation by strychnin and electricity are the usual remedies. Concussion or sinusoidalization of the seventh cervical spine to increase vagus-tone, and supplementing this method by home-treatment (paravertebral pressure or extension of the muscles of the neck), may rescue some patients from hopeless invalidism. In rarer instances, spasm of accommodation (asthenopic symptoms and diminished acuteness of vision), may necessi- tate depression of vagus-tone (pressure between the third and fourth dorsal vertebrae or concussion of the latter). Dr. B. L. Baker, of Seattle, referring to a patient with intractable symptoms in whom sinusoidalization (elec- trodes on either side of the yth cervical spine) was em- ployed, observes as follows: "Abnormal sensations of long standing were removed and she was able to be fitted with glasses in a very satisfactory way. Perfectly so in her left eye which we were never able to do. The eyes when turned in any direction caused intense pain and nausea but the latter symptoms have disappeared." DISTURBANCES or HEARING. I believe that the sense of 498 Auditory N e r v e audition is under the control of the autonomic nervous system. The following simple experiment will show how audition may be improved or diminished; determine with a normal subject the distance at which the tick of a watch is heard in the ear under examination. If an assistant now presses the seventh cervical spine with an instrument (Fig. 112) to in- crease vagus- tone, the patient perceives the tick at a greater distance. If pressure is now made between the third and fourth dorsal spines, to diminish vagus-tone, the tick is heard with less intensity and at a diminished distance. Hearing in the norm may be made more acute after concussion of the seventh cervical spine or after exercises which embrace extension of the head (page 228). More accurate quantitative tests may be made with Politzer's acoumeter. The auditory nerve consists of the cochlear and vesti- bular roots. The former is concerned in hearing and the latter in the maintenance of equilibrium. Hyperesthesia and irritation of the nerve may be manifested by hyper- acusis (sounds heard with disagreeable intensity), dysacusis (sounds cause unpleasant sensations), or as tinnitus aurium (subjective sounds). Another symptom of irritation may be dizziness somewhat like Meniere's disease. Diminished function or nervous deafness is not infrequent in hysteria and bone c-onduction is impaired or lost. Neurasthenia and hysteria are the most frequent functional nervous affections which exert the most pro- nounced effect upon the organ of hearing. With the tests cited, one may facilitate diagnosis. The specialist does not hope to modify these functional symptoms without treating the conditions which cause them. However, one must not forget that they may be signs of a local vagus-hypotonia or hypertonia, (page 452), and may be modified or cured by treating the irritative (reducing 499 Spondyloth e r a p y vagus-tone) or paralytic symptoms (increasing vagus- tone) . The sense of smell may also be modified according to the methods cited for increasing or decreasing the sense of hearing. One may continue to dangerous extremes in the dis- cussion of this subject. The author has limited himself to a consideration of questions which he has amply veri- fied by clinical results and he has attempted to show the necessity for testing vagus-tone as a routine measure in clinical practice with the hope that it may lead to a bet- terment of our nosology. In diagnosis, diminished or in- creased vagus-tone may modify symptoms, and I shall show how one may create at will certain cardiac mur- murs and how they may be made to disappear (page 525). The creation of adventitious respiratory sounds has been already discussed (page 494). PHYLOGENETIC DISEASES. The term phylogenesis, refers to the evolution of a group or species of animals or plants from the simplest form. For a like reason, I employ this designation in accordance with my concept that many diseases and symptoms owe their origin to a primal basic anomaly. The preceding contra- venes the ontogenic conception of disease. Among the diseases in which I have established reduced vagus-tone are the following: 1. AORTIC DILATATION. 2. ANEURYSM. 3. DIABETES. 4. HYPERTHYROIDISM. 5. PERTUSSIS. A dilated aorta is probably one of the causes of dyspnea in exophthalmic goitre (page 488). In four of my cases, 500 Phylogenetic Diseases classic symptoms of aneurysm (thoracic) were associated with Basedow's disease. Glycosuria was found in several patients with aneurysm. A patient with an aneurysm of the thoracic aorta, referred to me by Dr. Hubert N. Rowell, of Berkeley and who was discharged as symptomatically cured after treatment lasting four weeks, returned after three years absolutely well respecting the aneurysm but with sym- toms of diabetes (3 per cent, of sugar despite the most rigid diet). Vagus-tone absent. Within three weeks after treatment (concussion of seventh cervical spine), the lower lung-border which did not descend at all when pressure was made at the 7th cervical spine-region, de- scended 3 cm., and sugar disappeared from the urine, notwithstanding the ingestion of the average carbo- hydrate consumption. At the time of writing, the patient is well. Before coming to my office the second time, the attention of the patient was called to his condition by polyuria and an intractable neuritis. The latter disap- peared with disappearance of sugar in the urine. It is easy to explain many anomalies of function by correctly assuming modifications in glandular activity. Thus, the amount of epinephrin produced and entering the circulation varies. This substance stimulates plain muscle and glandular cells which are functionally related to the sympathetic nerve-fibers. Its subcutaneous ad- ministration causes the appearance of dextrose in the urine and a condition of hyperglycemia. Exophthalmic goitre is coordinated with emaciation and occasionally, with polyuria, glycosuria and true diabetes. Pertussis is associated with aortic dilatation (Chapter XVII) and in both affections the vagus- tonus is reduced. Some infectious diseases reduce vagus-tone and they may be recog- nized as etiologic factors in Basedow's disease and aneurysm (syphilis). 501 S p o n d y I o t h e r a p y A neurotic temperament (reduced vagus-tone) is a domi- nant etiologic factor in diabetes. One notes the occurrence of the same or like diseases in one family or between man and wife, maladies which I have called diseases of prop- inquity. Contagious influences like tuberculosis are not in- cluded in this category. Thus, Schmidt observed among 2320 diabetics, twenty-six cases in which the disease occurred concurrently in man and wife. It is questionable concerning the role played by food in the etiology of reduced vagus-tone, although my limited observations show that an exclusive diet of proteid food has a marked influence in reducing vagus-tone. I recently saw two sisters in consultation with Dr. L. Boyd, of Long Beach, one of whom had diabetes, and the other an aneurysm of the thoracic aorta. Among the diseases in which there is increased vagus- tone are: 1 . BRONCHIAL ASTHMA. 2. EMPHYSEMA. 3. TUBERCULOSIS. 4. GASTRIC and INTESTINAL NEUROSES. Emphysema is almost invariably associated with phthisis and asthma. In my clientele, I have frequently noted pul- monary tuberculosis following asthma and observed that the cough and. paroxysmal dyspnea of the latter affection were often caused by bronchos pasm. Asthma often runs in families with irritable nervous systems and the reflex causes which provoke attacks also augment vagus-tonus. Many gastric and intestinal neuroses are associated with symptoms of cardiac disease suggestive of vagus-hypertonia. Enuresis, was frequently observed by the author in asthmatic children and reduction in the tone of the vagus 502 Reflex Symptoms was productive of good results. The mother was in- instructed to make pressure several times a day on either side of the spine between the 3d and 4th dorsal vertebrae to reduce vagus-tone. Dr. L. Boyd reports the case of a young man of 20 years, with enuresis since birth. Treatment had been tried without results. Concussion of the fifth lumbar vertebra to provoke the bladder reflex (page 358) yielded excellent results. A placebo was given to the patient. The author finds it absolutely necessary with some patients to employ an indifferent drug in association with treatment. Some patients are obsessed with the conviction that drugs are the /ons et origo of medical practice and they will con- tinue no treatment in which drugs are excluded. "It is quite as important to know what kind of a patient the disease has got, as to know what kind of a disease the patient has got." "The patient wishes not only to be cured, but to be treated; his luxury is the importance of the physician and his remedies." Reflex symptoms may so mask the primary disease that the latter is disregarded. Reduced tone of the vagus is associated with dilatation of the heart and the symptoms may be essentially abdominal owing to the rapid distension of the liver and the paralytic inflation of the stomach and intestines. The attacks in some forms of angina pectoris and certain neuroses terminate with eructations of gas and the discharge of a large quantity of clear urine. What probably occurs is as follows: The increased vagus-tonus closes the cardiac or pyloric orifice of the stomach and when the tone of the vagus is reduced, the orificial spasm of the stomach yields, permiting eructa- tion of the incarcerated gas. I have seen two cases of aneurysm of the abdominal aorta in which there were only thoracic symptoms. 503 Spondyloth e r a p y The crises of tabes are caused by autonomic irritation as evidenced by pupillary contraction, increased secre- tion and peristalsis of the stomach and intestines. In the later stages of the disease, the hypertonic are suc- ceeded by hypotonic signs. One knows that in tabes, anatomic lesions of the vagus may be demonstrated. VAGAL HYPERESTHESIA. In diseases caused by vagus- hypertonia, the vagus in the neck is extremely sensative to pressure, whereas in diseases caused* by vagus-hypotonia, paravertebral areas of tenderness may be detected between the third and fourth dorsal spines. The sensitiveness in question disappears pari passu with the disappearance of the disease. The dorsal areas become less sensitive at once by concussion of the yth cervical spine (which increases vagus-tone) and the vagus in the neck, by concussion of the third and fourth dorsal spines (which de- creases vagus- tone). CLINICAL PHARMACOLOGY. The scientific study of pharmacology should not be limited to laboratory-animals, on the contrary, the human offers a fruitful field for investigation (vide, page 270). The author has investigated many drugs and concludes that a large number owe their physiologic and toxic action to their influence on vagus-tone. Only a few drugs will be cited, insomuch as the scope of this work precludes any extended reference to this subject. The author suggests, however, that it may serve as an index for research work along new and original lines. Many drugs, according to their action, may be divided into two classes: 1. Drugs which increase vagus-tone; 2. Drugs which diminish vagus-tone. 504 Clinical Pharmacology Their action may be manifested directly or indirectly. Thus adrenalin acting exclusively on the sympathetic-fibers by stimulation, depresses the vagus-fibers and therefore indi- rectly diminishes vagus-tone (page 453). METHOD OF INVESTIGATION. As we have already shown (page 469), para vertebral pressure at the yth cervical spine increases vagus-tone and among other effects it causes the lower-lung border to descend. The degree and duration of descent are accepted as criteria of vagus- tone. The lower lung-border posteriorly is first determined, after which pressure is made opposite the yth cervical spine for 30 seconds and the lower border is again ascertained. Not only must we determine the degree of descent but its duration. Drugs which act by increasing vagus-tone cause a descent of from 4 to 6 cm., and this descent is maintained from one to ten or more minutes. Drugs which diminish vagus-tone cause little or no descent of the lung and if the latter does descend, its descent is brief. Many drugs show a primary stimulation of vagus-tone followed by depression of the latter. Powerful vago-tonic drugs cause a descent of the lung-border without previous pressure at the yth cervical spine. Reference -has been made to some drugs investigated by the author. Among other drugs may be mentioned: QUININ. This drug has a powerful action in increasing the tone of the vagus. It is now possible to comprehend many therapeutic facts heretofore inexplicable. Exophthalmic goitre is due to diminished vagus-tone (page 484). Now, among the most satisfactory drugs for influencing the latter disease is quinin hydrobromid in capsules containing 5 grains each, to the limit of the patient's tolerance. Toxicity is shown by the appearance of tinnitus, when the use of the drug must be suspended 505 S p o n d y I o t h e r a p y temporarily. The drug must be taken for months or . years. In a study of 56 cases thus treated by Jackson 88 , 76 per cent, had no signs or symptoms for two years, while 13 per cent, had been benefited, and only 6 cases (n per cent.) could be considered failures. Within two weeks after taking this drug, improvement was noted by diminution of the palpitation, sweating, tremor and other nervous symptoms. In many cases the thyroid diminished in size, but the exophthalmos was the last sign to disappear (2 or 3 years) or it persisted with the tremor. MALARIA. A typic paroxysm of this disease may be pre- cipitated by eliciting the splenic reflex of contraction (page 355). I saw a case of latent malaria with Dr. R. Bine, in which a typic paroxysm was precipitated on the day following the elicitation of the reflex. We speak of quinin as the most effective parasiticide in this disease and there is ample reason to justify such a conclusion but in this action, we dare not ignore the bactericidal power of the blood owing to the protective substances or by anaphylaxis. Italian observers claim that the present drug-treatment of malaria is unable to free the system completely of the malarial parasites. As long as the spleen is enlarged the disease cannot be regarded as cured. A single hypodermatic injection of 15 grains of quinin and urea hydrochlorid will, in ma- laria, cause a "freedom period" lasting either 6J or 13 days (S. Solis Cohen). A small dose (0.3 to i gram, at intervals of -3 days to one week about half a dozen injections), will often enable one to demonstrate plas- modia in the peripheral blood although previously absent (Billings). . Now, the action of quinin is to increase vagus-tone and, by so doing, to contract the spleen. Strychnin, is likewise a vagus-tonic and within one hour after an hypo- dermatic injection of a therapeutic dose, the plasmodia of malaria may be demonstrated in the peripheral blood although previously absent. 506 C I i n i c a I P h armacology Quinin is effective in enlargement of the spleen from any cause simply because it contracts the organ by stimulation of the vagus. Perhaps the time will yet arrive when we shall gauge the value of drugs in malaria according to their action on the vagus and that pilocarpin or other efficient vagal excitant may be used to the exclusion of quinin. In a case of splenic leucocythemia, I could always produce an enormous increase of leucocytes in the blood immediately after the elicitation of the splenic reflex of contraction. Leucocytosis, following the hypodermic injection of pilocarpin, is essentially mechanic and due as Kenwood, of Toronto, suggests to contraction of the muscle-element in the spleen and lymph-glands. DIABETES. Magyary-Kossa 90 extols the inhalation of carbon dioxid to reduce glycosuria. In diabetes, dimin- ished vagus-tone can be demonstrated (page 479), and carbon dioxid is a vagal-excitant. Suspension of respiration for 30 seconds or longer increases vagus-tone. Our present conception of shock is not attributed to vasomotor failure, but to acapnia (diminished carbon dioxid in the blood). Stimulation of the respiratory center depends upon carbon dioxid alone, oxygen play- ing a passive part. No one drug in diabetes seems to have a curative influence. Arsenic may act by increasing vagus-tone, and opium, bromids and antipyrin probably achieve their action by subduing the neurotic element in this disease. Antipyrin primarily excites the vagus for about 5 minutes and is then followed by powerful depression of the nerve. The iodids, chloroform and ether, diminish vagus- tone. The latter act as evanescent vagal-irritants, but there is a marked secondary depression of tone. Potassium iodid often acts as a specific in asthma 507 Spondylotherapy and this is probably attained by diminishing vagus-tone, which in asthma is increased. Fowler's solution often prevents iodism, iodin diminishes and arsenic increases vagus-tone. Potassium iodid is used empirically in aneurysms. The effects are probably attained by diminishing blood- pressure, for by diminishing vagus-tone, the aneurysm dilates. It may be that the latter is less than the re- duction in pressure, otherwise the drug would do more harm than good. Nasal cocainization elicits an immediate depression of vagus-tone, whereas the inhalation of ammonia, increases the tone. Amyl nitrite inhalation increases vagus-tone. This drug, in my experience, is only efficient in the cardiec- tatic forms of angina pectoris due to diminished vagus- tone (page 543). Sodium cacodylate and mercury are powerful tonics of the vagus. The latter observations invite theorization, which will however be curtailed. The present treatment of syphilis with salvarsan is chemo-therapeutic, and by the method of "therapia sterilisans magna," the action of the drug is parasitotropic. In syphilis, I have found diminished tone of the vagus and it is not improbable that remedies in this disease (excepting the iodid), by increasing the tone of the vagus accomplish another object as yet not definitely known. Reliable preparations of digitalis and strophanthin given hypodermatically increase the tone of the vagus. Within 15 minutes, the lung-border may be made to descend double the distance that it did prior to the in- jection. After this manner, the author tests the relia- bility of these drugs which are notoriously unreliable. A normal subject is used for experimental purposes. In the same way, one can predict the action of the drugs on patients. 508 Recapitulation RECAPITULATION. The vagal and sympathetic fibers in the norm are in physiologic antagonism. The ideal vagal-stimulant is pilo- carpin, and the ideal sympathetic-stimulant is adrenalin. Atropin diminishes vagus-tone by paralyzing the motor end- ings of the vagus. Thyroid diminishes vagus-tone. Symptoms or diseases (asthma, angina pectoris), due to increased vagus-tone are acentuated by pilocarpin and ameliorated by adrenalin and atropin. The toxic action of some drugs may be inhibited by com- bining them with their physiologic antagonists. Thus quinin may be used with thyroid or pilocarpin with the iodids. However, this method is not scientific, for we are adminis- tering synchronously a drug with its antidote, an undesirable procedure when one desires to test adequately the physiologic action of a medicament. Therapeutically, we employ drugs which increase vagus- tone (pilocarpin) in diseases which demand them and con- versely, drugs which decrease vagus-tone (thyroid, iodids, adrenalin) are indicated. S09 Spondylvth e r a p y CHAPTER XIV. FURTHER ADVANCES IN THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE CIRCULATORY SYSTEM. TESTS FOR HEART SUFFICIENCY KUATSU HEART-FAILURE FUNC- TIONAL CARDIAC MURMURS REFLEX OF THE PULMONARY ARTERY INHIBITION OF THE HEART CARDIOPTOSIS SUBCLAVIAN MUR- MURS ANGINA PECTORIS ANGINOID PAINS PHRENIC NERVE DIAPHRAGM REFLEX ANEURYSM FLUOROSCOPY OF THE AORTA. TESTS FOR HEART-SUFFICIENCY.* In making a comparative estimate of different functional tests of cardiac efficiency, the author is constrained to con- clude that the test to be specified presently is the most re- liable. Numerous writers confirm the observation of de la Camp, viz., when the cardiac muscle is normal, exercise even carried to'exhaustion and fainting does not produce dilatation of the ventricles. On the contrary, the heart diminishes in volume. In myocardial disease, even moderate exercise provokes ventricular dilatation. In other words, the diameters of the heart are maintained by visceral-tone (page 451). One first determines the borders of the heart by percussion. The latter is facilitated by forcible extension of the neck during the time percussion is executed (page 228). Next the patient is directed to raise and lower the body a number of times (until slight dyspnea is produced), by flexing the knees. *Vide tests on page 215 et seq. 510 Tests f o r H e a r t - S uffi c i en c y If percussion (with neck extended), shows a diminished area of cardiac dulness, the myocardial tone is normal and the muscle is efficient, otherwise the tone is deficient and the muscle is inefficient. In percussion, reliance is only to be placed on the elicitation of the deep or relative dulness (forcible percussion). A method original with the author for testing cardiac tone is described on page 471. FIG. 118. Illustrating the author's method of threshold percussion. The modified threshold percussion of the author is available for defining the borders of the viscera. Per- cussion is executed in the mid-respiratory position. The tip of the index finger of one hand is firmly fixed in an intercostal space at an angle with the chest-wall, but parallel with the boundary that is to be percussed. As the finger gradually approaches the boundary, it is struck with the middle finger of the other hand at its base and side, as indicated by the black spot in fig. 118. Continental writers, notably Zulawski 91 , and Merklen and Heitz 92 , find that when the heart reflex (page 199), can be elicited in myocardial weakness, it indicates a favorable 511 Spondylotherapy prognosis. The former finds that the reflex (by irritating the skin of the precordial region), in the norm reduces the dulness of the heart from i to \\ cm., and the latter show that, in cardiectasis, the reflex may persist for several hours.* My results are not in accord with the latter observa- tions; it is the duration and not the presence of the reflex which counts. In the norm, the reflex lasts from one-half to three minutes; in myocardial disease, it may persist for hours. In the latter instance, this heart reflex of degen- eration corresponds with the reaction of degeneration, viz., a muscular contraction which is tardy and persistent. Myocardial disease may be suspected even in the ab- sence of cardiac signs, when symptoms not unlike those which accompany the broken compensation of valvular diseases present themselves. A reliable preparation of digitalis may solve the difficulty; if, after five days, the symptoms are not relieved and there is no rise of the peripheral arterial tension nor increased strength of the pulse, the drug can do no good and may even be danger- ous. Many preparations of digitalis are practically inert, and this fact may be demonstrated by its physiologic action. Within thirty-six hours after the use of a reliable preparation given in adequate doses, one finds that the pulse becomes stronger, more regular and slightly de- creased in frequency (provided the pulse was accelerated before the use of digitalis) and diuresis is augmented. By estimating the quantity of urine excreted one is af- forded a guide" in a dual direction: the reliability of the drug and the efficiency of the cardiac muscle. In cardiac muscular insufficiency, the quantity of urine may be di- minished by one-half or more. Owing to the delayed action of digitalis, an increase in the quantity of urine does not occur until the second day of its use; then it continues to increase day after day until the normal is *The comparative results obtained from different methods for evoking the heart reflex are shown on page 636. 512 Tests for Heart -Sufficiency attained (1500 c.c. in twenty-four hours in a healthy adult) ; at this time, and when the pulse frequency has been reduced and the tension is increased, one should withdraw the drug, reduce the dose, or give it less fre- quently. In using digitalis for diagnostic or therapeutic pur- poses, the writer first unloads the bowels and diminishes hepatic congestion with a few small doses of calomel. He gives a reliable fresh infusion of digitalis in doses of 4 fluid drachms combined with diuretin (sodio-theo- bromin salicylate). Diuretin is administered in doses of 15 grains; it is a powerful diuretic and antagonizes the vasoconstrictor components of digitalis. The more recent researches of Lowy seem to show that digitalis dilates the coronary and renal vessels. The latter pharmacologic observation, however, is not wholly in accord with the clinical results. It is often impossible to differentiate between a prim- ary myocarditis and a primary nephritis. If digitalis causes diuresis, one may conclude that the previous oliguria was caused by a failure in the circula- tory apparatus, because its effects are secured by its stim- ulating action on the heart and blood vessels. If drugs like theocin, diuretin and calomel are effective, we con- clude that the effects are attained by direct action on the renal epithelium. In the differential diagnosis of primary myocarditis and primary nephritis, Winternitz has suggested the catalase test. In chronic nephritis, the catalase of the blood is destroyed, hence, when the latter is brought into contact with hydrogen peroxide, there is absolutely no liberation of oxygen whereas the blood of patients with heart enfeeblement splits peroxide. Others concede the importance of this test only in advanced cases of nephritis either in the uremic or preuremic states. The symptoms of broken compensation from myocar- dial disease may be quickly differentiated from a host of other maladies by stimulation of the myocardium by con- 513 S p o n d y I o t h e r a p y cussion of the sevent \ cervical spine. Even within a few min- utes after concussion is executed, cyanosis, dyspnea and other signs of an insufficient myocardium become less evi- dent or disappear for several hours and for a longer inter- val with repetition of the concussion. To the uninitiated, it is impossible to conceive the great possibilities of this very simple mechanical method of cardiac stimulation. The writer has seen several practically moribund patients with pneumonia in whom the conventional cardiac stim- lants were employed without avail, yet these very pa- tients were not only revived but were revived quickly by the method in question. In myocardial disease, when it is a question of fortifying the jaded cardiac musculature, the writer no longer employs drugs but relies solely on concussion of the seventh cervical spine. When the latter fails, the cardiac musculature is no longer capable of res- titution. The real danger with concussion to elicit the heart reflex is its overuse conducing to exhaustion of the myocardium. Concussion should only be used once a day until there is a moderate restoration of the myocardium and then twice or thrice weekly. This over-stimulation compromises the duration rather than the amplitude of the heart reflex. Thus, concussion of the yth cervical spine for one minute gives a reflex with an amplitude of 1.6 cm., and a duration of 3 inin. and 40 sec., whereas, concussion for 5 minutes yields a reflex with an amplitude of 2 cm., but lasting only two minutes. Recently, the writer saw a patient with apex pneu- monia in consultation with Dr. V. G. Vecki, of San Fran- cisco, the eminent genitourinary specialist. The patient was practically moribund. During the course of her disease, the conventional cardiac stimulants were em- ployed. Suddenly during the night, however, she be- came extremely cyanotic and pulseless and it was deter- 514 Tests for Heart -Sufficiency mined to concuss the seventh cervical spine to awaken, as it were, the enervated heart. No percussion appara- tus was at command and, in lieu of the latter, the palmar surfaces of the fingers were applied to the seventh cervi- cal spine, and, with the clenched fist, the dorsal surfaces of the fingers were struck a series of short and vigorous blows (Fig. 2). The latter method of concussion was continued for about ten minutes with intervals of rest. Soon after concussion was commenced, the cyanosis be- came less evident and the pulse was again perceptible. Every two hours during the night this method was con- tinued and thereafter at less frequent intervals until con- valescence was established. It was evident to the nurses and others that after each seance of the concussion treat- ment there was an immediate evanescence of the cyano- i sis and the pulse always became stronger and less fre- quent. It is conceded that pneumonia is the most fatal of all acute diseases, tha* there exists no specific medication, and that the most important indication is to maintain the cir- culation. I am firmly convinced that the systematic exe- cution of the method cited will prove of material aid in hastening recovery from this dread disease, which other- wise may prove fatal. An efficient percussion apparatus should be at the physician's command in all acute diseases and, as Dr. Vecki 93 suggests, after operations when there is any dan- ger of cardiac implication. I must emphasize, however, the necessity of a suitable apparatus. The latter must give a percussion stroke. All other motions, such as os- cillations, shaking, and friction, yield absolutely no re- sults. In a recent contribution 94 , the author has described Kuatsu or the Japanese method of restoring life. Kuatsu, or the restoration of life, is an integral part of jiu jitsu. The latter is usually regarded wholly as a means of physical training and as a method of combat, but when the victim is "knocked out," recourse is had 515 S p o n d y I o t h e r a p y by adepts to definite methods of resuscitation known as kuatsu.- Many centuries ago, when jiu jitsu was primarily con- ceived in Japan, kuatsu was used for reviving individuals who were rendered unconscious by the various systems of jiu jitsu, but later it was shown that kuatsu was equally effective in instances of sunstroke, drowning, and injuries from other causes. It is stated that the adept in jiu jitsu inflicts no injury that cannot be promptly remedied by the aid of kuatsu, whereas our pugilists may inflict blows which may render their opponents unconscious and yet are unable to do any- thing to revive them. The captious critics of kuatsu seek to dispose of the supposed exaggerated claims of the latter by the derisive observation that the jiu jitsu man is able to restore those whom he kills. The line of demarcation between life and death is difficult of determination and an individual should, para- doxical as it may appear, only be regarded as dead when it is demonstrated that he is not alive. The extraordinary tenacity of life shown by the exsected heart is really mar- velous. By artificial perfusion Kuliabko elicited well marked contractions of the entire heart of the rabbit five days after the death of the animal, and the same author- ity completely revived the heart of a four year old boy who had died of pneumonia twenty-four hours after death. A study of the charts in any representative work* on jiu jitsu shows a number of points on the body surface which, when struck, will cause either insensibility or death. The writer has exerted firm pressure over the various points in question and noted that in the majority of instances there was a reflex inhibition of the heart dur- ing the period of pressure. The latter effects were more evident when the sphygmograph was employed. The *A representative work of this character is that of Hancock, The Complete Kano Jiu- Jitsu. There are many systems of jiu-jitsu in Japan, but the Kano system has been adopted by the government. 516 Tests for Heart -Sufficiency writer has demonstrated elsewhere, however, that the heart may be inhibited reflexly practically anywhere on the body surface, but that the definite points of election are the intercostal spaces, the abdomen, the muscles of the neck, and the region on either side of the spine corres- sponding to the upper dorsal vertebrae. Irritation of the mucosa of the stomach, nose, and rectum is equally ef- fective in inhibiting the heart, but, if the mucous mem- branes in question have been previously cocainized, such inhibition does not ensue. Inhibition of the organ in the foregoing instances, is effected by reflex sensory impulses acting on the vagus, the inhibitory nerve of the heart. The action of atropin and pilocarpin on the heart reflex has been considered on page 454. In kuatsu, the subject is placed in the prone posture with arms extended sideways and the operator with his wrist lands severely upon the seventh cervical vertebra with the regularity of a carpenter strik- ing with a hammer. As soon as the patient recovers con- sciousness, he is placed in a sitting posture, his arms are rotated, and he is aided in walking. The latter injunc- tion is regarded as mandatory in the application of kuatsu, the object being to completely restore the func- tions of the circulation and respiration, otherwise, it is said the patient relapses into unconsciousness.* The resistance of the myocardium in stretching during diastole represents the tonicity of the cardiac muscle. In the normal state stretching of the cardiac parietes is effected by the pressure of the blood which enters the heart from the large veins and is essentially a venous pressure. It follows that in high venous pressure, pro- vided the cardiac tonicity is compromised, a cardiac dilatation must ensue. In the latter condition the amount of residual blood in the heart usually exceeds the systolic output of the organ. *The minute details of the method are not recounted although regarded as im- portant by authors on the subject. In the opinion of the writer, the essential feature of the method is concussion of the seventh cervical spine. 517 V Spondyloth e r a p y In the vagus of the frog there is one set of fibres which only influences the heart rate (chronotropic effects), whereas another set increases the force of the contraction and cardiac tonicity without affecting the rate. The latter tonic fibres in the vagus are stimulated by the usual cardiotonics, but the action of the latter is inhibited if the vagi have been cut or paralyzed by atropin. The action of the cardiac nerves has always been a subject of contention. The vagus slows the action of the heart (inhibitory ac- tion), whereas the accelerator nerves quicken the action of the heart. Both nerves in the norm are in tonic activ- ity. i Reference to Fig. 119, shows the origin and course of the cardiac nerves. It will be noted that the spinous process of the yth cervical vertebra corresponds to the 3d dorsal seg- ment of the cord, which in turn corresponds to the root- origin of the third thoracic nerve. Concussion is often a more powerful nerve stimulant than electricity and a blow on the head results in photopsia due to stimulation of the optic nerve by the propagated blow. In concussion of the yth cervical spine, the blow is trans- mitted through the spinal nerves to the sympathetic ganglia which form in connection with branches of the vagus, the superficial and deep cardiac plexus, and it is essentially by this indirect stimulation of the vagus that the effects are attained by concussion of the yth cervical spine. Aortic contraction in aneurysms is effected through the same neuro-medullary pathway. The writer has shown empirically that the best site for stimulating the vagus and thus increasing the force of cardiac contraction and cardiac tonicity is the spinous process of the seventh cervical spine. The most effective excitant of the heart reflex is concussion, which is a me- 518 Heart Re fl ex of Dilatation chanical stimulus and that the reflex in question may be elicited with the same certainty and precision as are the reflexes by the vivisectionist in his laboratory. A just appreciation of the latter facts by the clinician will prove of great value to him in the treatment of myo- cardial insufficiency and as an aid in resuscitation. They also explain the kuatsu method of reanimation. In conclusion, I may say for academic purposes only that the heart reflex cited is the heart reflex of contraction. The counter reflex of dilation, has been described on page 221. S@ '?& ' n V 55 -"*^ ^ ^ .- ^-*_ ' t j .Ir * ~ \ ^- v : 'J $ // ^ kM^ FIG. 119. Origin and course of the cardiac nerves. Mot, Sens, nuclei of the efferent (motor) and afferent (sensory) fibers of the vagus. C, i, 2, 3, 4, 5, 6, 7, 8, and T, i to 8, cervical and thoracic (dorsal) spinal nerves. SCO, MCG, ICG, superior, middle and inferior cervical ganglia. REC LAR, recurrent laryngeal nerve; CPL, cardiac plexus. T, 3 (inclosed in a circle), corresponds to the spinous process of the seventh cervical vertebra (from Powell and Gibson, slightly modified). THE HEART REFLEX OF DILATATION, elicited by con- cussion the last four dorsal vertebrae (concussion of the loth dorsal spine suffices), is a dilatation of accommoda- 519 Spondyloth e r a p y tion, owing to an increased volume of blood provoked by such concussion (page 617). Concussion of the third and fourth dorsal spines, or pressure between the latter, re- duces vagus-tone (page 472), and eventuates in an active dilatation. The heart reflex of dilatation is of little value in practice excepting when the heart is undersized -(hypo- plasia) in phthisis, advanced valvular disease (specially the left ventricle in mitral stenosis) and in old age (senile heart). Concussion of the zoth dorsal spine should be executed to achieve our object. When rapidity of action from drugs is desirable in diag- nostic-therapeutics, much may be expected from the in- travenous employment* of strophanthin. Thus adminis- tered, its action it fully manifested within sixty minutes. Administered by the mouth, its action is not evident for at least seventeen hours. When it is remembered that the physiologic action of digitalis is not manifested for at least thirty-six hours, it is not difficult to note the many advantages accruing from the intravenous employment of strophanthin. A single injection of the latter drug is capable of fully restoring a patient with cardiac incom- petency. The dose of strophanthin (a reliable prepara- tion is that of Thomas) is from i to ^ mg. (gr. 1-240 to 1-120). It is also procurable in sterile, vials. In suspected myocardial disease due to lues, a positive Wassermann reaction may prove as valuable as the same reaction in the diagnosis of luetic aortic insufficiency and the subsequent therapeutic results with mercury and potassium iodide will clinch the diagnosis. To appreciate the diagnostic-therapeutic value of digi- talis, one must recognize its action which may be divided into two periods: (i) therapeutic stadium, in which the cardiac force is increased; (2) toxic stadium, when such *To make an intravenous injection, dilate veins of arm with a rubber band above the elbow. Partially fill syringe (free of air-bubbles) with the solution and then insert needle into the median vein. Before injecting, some blood is drawn into the syringe to be sure that the needle is in the vein. Then, the rubber band is removed and the contents of the syringe emptied. 520 The Heart and Its Innervation force is diminished. In the first stadium, slowing of the pulse is slight, whereas in the second stadium, it is very much diminished in frequency, and may even become arrhythmic. This excessive slowing of the pulse may be accepted as the primary signal of the toxic action of digi- talis. The chief effects of digitalis are exerted on the heart muscle, and the greater the integrity of this muscle, the better the action of this drug on the heart; hence such reaction may be accepted as a diagnostic indication of the condition of the cardiac muscle. Thus, the more in- tense the myocardial degeneration, the more susceptible is the reaction to small quantities of digitalis. If, instead of securing the physiologic action of digitalis, toxic effects are observed, one would conclude that the myocardial changes were pronounced. In such instances, the use of digitalis is positively dangerous. The author desires to emphasize the fact that there are neither exclusive nor specific methods in therapeutics but that the synergistic action of different remedies must be conciliated. In awakening the tonicity of an enervated heart, the use of digitalis with diuretin (page 513), may be indicated in association with concussion of the yth cervical spine when the heart fails to respond to the latter method alone. Con- cussion is essentially a stimulant to the vagus-fibers which increase the contractility (inotropic) of the myocardium and may be without action on the rhythmicity (chronotropic influence), hence the value of digitalis, which brings about slowing of the heart. Having achieved our object with the combined digitalis- diuretin prescription, one may dispense with the latter and employ concussion exclusively. THE HEART AND ITS INNERVATION. A thorough understanding of this subject has an important influence on our therapeutic efforts. In addition to the vagus nerve, the action of which has already been studied, there 521 Spondylotherapy are motor fibers from the sympathetic system, known as the accelerator nerve of the heart (Fig. 113). Stimulation of the latter, causes an increase in the rate of beat of the heart, but not infrequently Deforce or energy of the beat may be increased and the rate may remain unaffected. In consequence of the latter effects, physiologists assume that, the accelerator nerve contains fibers which acceler- ate the rate, and others (augmentors) , which cause a more forcible beat. Hering has shown that stimulation of the accelerators may revive a heart that has ceased to beat. The vagi and accelerators are normally in tonic activity. Now, cardiac vigor is not only a muscular but a neuro-muscular question. While muscular tone, as a rule, is secured by vagus-stimulation (the after-effects on this inhibitory nerve being to increase the force of the beat) , we have in our discussion ignored the influence of the accelerator nerve. Both nerves are in physiologic antagonism. In a given case of cardiac-insufficiency, it is wise to test the tone of the sympathetic and vagus-fibers according to the methods described on pages 469 and 472, to determine whether our therapy should be sympathico- tropic or vagotfopic (page 451). In addition to these tests, one may employ the method of demonstrating abnormal irritability of the sympathetic system. In the norm, instillation of a drop of a one per thousand solu- tion of adrenalin into the eye has no effect on the dilator pupillas (page 452), but if the sympathetic system is ex- citable, pronounced mydriasis follows the instillation (The nerve-fibers for the dilator muscle of the pupil run in the cervical sympathetic and terminate in the superior cervical ganglion) . To further demonstrate the value of the author's tests, the following may be cited: A patient fond of coffee, invariably suffers after its use from tachy- cardia and arrhythmia. Prior to its use, the tone of the vagus was found normal (page 469). Within one-half hour after consuming coffee, the vagus-tone was absent, the heart was arrhythmic and the pulse 1 20. Within one hour after the use of pilocarpin (gr. i-io) per os the vagus- 522 Forms of Heart -Failure tone was restored to normal, arrhythmia inhibited and the pulse reduced to 80. The hypodermatic use of pilo- carpin (page 454), is followed by more rapid results. FORMS OF HEART-FAILURE. Heart-failure is chiefly a muscular question, although a neuro-muscular factor must not be ignored. In cardiac insufficiency (decompensation), it is the cardiac muscle (myocardium), which fails to do the work of the heart. 1. HEART-FAILURE OF INFLAMMATORY ORIGIN. This form includes inflammation of the myocardium, endocar- dium and pericardium. One of the most common etiologic factors in the inflam- matory involvement of these structures is rheumatism. The pyogenic cocci, pneumococcus and gonococcus also play a very important role in etiology. In fact, metastatic infection is exceedingly common. Tonsilitis, heretofore regarded as a trivial affection is now viewed as a grave one, insomuch as it is often the only recognizable cause of endocarditis, poly- arthritis and other diseases. If polyarthritis is caused by suppurating tonsillar crypts, incision or removal of the latter may cause an immediate disappearance of pain and fever. A bacteriologic study of the tonsillar crypts will reveal all kinds of micro-organisms, and the wonder is that the tonsils are not more often accused as factors in the etiology of disease. 2. HEART-FAILURE OF ARTERIOSCLEROTIC ORIGIN. The circulatory apparatus must be regarded as a unit. In the embryo, the heart is only a blood-vessel and its elaboration into a special organ is only the result of muscular overgrowth which in one situation make a heart and in another, the wall of a blood-vessel. In arteriosclerosis, the hypertrophy of the heart ensues 523 S p o n d y I o t h e r a p y from an increase in the peripheral resistance of the blood- vessels. Soon, however, dilatation of the organ ensues, with signs of decompensation (dyspnea on exertion, attacks of cardiac asthma, scanty urine, etc.). It is usual to specify a renal form of heart-failure, but such a form is identified with arteriosclerosis in such a way that it is difficult to say which is primary and which is secondary. 3. HEART-FAILURE FROM OBESITY. Oertel first ex- plained the effects of obesity on the heart and blood-vessels. Indeed, heart failure is more frequently encountered in fat than in lean individuals. A fatal error is often made in the treatment of these cases when an attempt is made to execute a reduction-cure with- out first strengthening the myocardium. Naturally, one must eventually reduce the weight, but care must always be exercised to reduce gradually and to avoid subalimentation. It is better to provide the patient with about i ,600 calories a day to attain our goal more slowly. Thyroid intoxication, the cardiac neuroses, in fact any cause operating to increase unduly the work of the heart eventuates in failure of the organ. Heart-failure from syphilis (congenital or acquired), is not infrequent. Some forms of myocarditis are always syphilitic. In the presence of symptoms of cardiac insuffi- ciency in a subject with a history of syphilis, the latter as an etiologic factor is not only possible, but probable. Here the use of mercurial inunctions is indicated : In Pulmonary Edema, the tonicity of the right ventri- cle is implicated and its dilatation is manifested by cyan- osis, dyspnea and pulmonary edema. Referring to page 202, one finds that the myopathic heart reflex only influences the right ventricle of the heart. Percussion of the muscles is a puissant method of tieatment in pulmonary edema. 524 Cardiac Murmurs of Functional Origin CARDIAC MURMURS OF FUNCTIONAL ORIGIN. Perhaps no fallacy in medicine has been more sacredly perpetuated than the belief that a cardiac murmur is always indicative of a disease of the heart. Some of the most serious heart-affections are unaccompanied by murmurs. "The idea that a murmur in itself and by itself is a serious thing dies hard." (Shattuck). Sir Andrew Clark gave utterance to the truism that ''a murmur in itself is of little or no moment in determining the prognosis of any given case." Osier voices the opinion of the skilled cardiac diagnostician as follows: "Practitioners who are not adepts in auscultation and feel unable to estimate the value of the various heart-murmurs should remember that the best judgment of the conditions may be gathered from inspection and palpation. With an apex-beat in the normal situation and regular in rhythm, the auscultatory phenomena may be practically disregarded." Fowler is responsible for the epigram: "The position of the heart- apex is the key to the diagnosis of nearly all affections of the chest and heart." FUNCTIONAL AORTARCTIA AND AORTECTASIS. These terms refer respectively to contraction and to dilatation of the aorta. It is known that, when the lumen of an elastic- walled tube through which liquid flows is narrowed, eddies are created which cause the walls of the tube to vibrate and eventuate in a palpable thrill and a blowing sound called a murmur. The latter is loudest below the narrowing and is transmitted in the direction of the flow. By means of the aortic reflexes (page 254), one may con- tract or dilate the aorta. If, after auscultating the aortic sounds, one executes concussion of the spine of the yth cervical vertebra (reflex of 525 S p o n d y I o t h e r a p y contraction), and again auscultates, a systolic aortic murmur is usually heard, varying in duration from one-half to three minutes. The murmur replacing the systolic tone is of longer duration than the latter. It is observed in the norm in children as well as in adults and is equally pronounced in arteriosclerosis of the aorta. My primary endeavor to utilize this auscultatory sign as an evidence of loss of elasticity of the aorta was therefore futile. The murmur in question is the result of temporary aortarctia (aortic contraction), super- induced by elicitation of the aortic reflex of contraction, and it may be dissipated at once by provoking the counter aortic reflex which dilates the aorta. In several instances only, was the author able to create a diastolic aortic murmur by elicitation of the aortic reflex of dilatation. REFLEX or THE PULMONARY ARTERY. As a rule, simul- taneously with the creation of a systolic aortic murmur, a systolic murmur was also audible over the pulmonary artery. Indeed, it was often heard in the latter situation, although inaudible over the aorta. It was specially loud in children. Like the aortic systolic murmur, it was at once dissipated by elicitation of the aortic reflex of dilatation (concussion of the 4 lower dorsal spines). Although the pulmonary artery eludes percussion, the auscultatory evidence just cited would seem to show that there are likewise two reflexes of the pul- monary artery, viz. contraction and dilatation. DEDUCTIONS. Aside from the inestimable value of the aortic reflex of contraction in the treatment of aneurysms, the reflexes of the pulmonary artery and aorta subserve a useful object in diagnosis. Thus dilatation of these vessels may exist, for the calibre of the large arteries is never con- stant. If, then, at an inauspicious moment, one were to auscul- 526 D e d u c t / o n tate either artery and a diastolic murmur were heard, a faulty diagnosis would be made. Such diagnostic errors are frequent. However, having recognized the physiologic rhythmicity of the large vessels (page 620), one would at once execute the method for provoking contraction of these vessels by concussion of the yth cervical spine and the dias- tolic murmur would be dissipated if it were wholly caused by dilatation of the large vessels. Similarly, a systolic murmur caused by narrowing of the aorta and pulmonary artery would evanesce after concussion of the spines of the four lower dorsal vertebrae. The auscultatory phenomenon with reference to the reflex of contraction of the pulmonary artery directs our attention to the incorrect apodictic pronunciamento of some physiol- ogists who aver that the pulmonary blood-vessels are unprovided with vasomotor nerves. From what has pre- ceded, the pulmonary artery must be under vasomotor control. Dr. H. C. Sawyer, of San Francisco, directed my attention to the fact that in the treatment of aneurysms of the thoracic aorta by the author's method of concussion of the yth cervical spine, aneurysmal murmurs would disappear for a variable period of time after treatment. Even the patient who was conscious of the murmur noted its disappearance for about four hours after treatment. Since my attention was directed to this sign by Dr. Sawyer, I have also observed the tempor- ary disappearance of the thrill. In a number of instances, however, the aneurysmal murmur did not completely dis- appear, but only became less loud. Murmurs are so commonly encountered without valvular lesions that Laennec was constrained to conclude that they were of no diagnostic importance, whatever. Laennec's observation is worthy of citation, despite its falsity, in direct- 527 S p o n d y I o t h e r a p y ing attention to the frequency of functional or accidental murmurs. Potain found accidental murmurs in one-eighth of all the patients seen in his hospital service. Many theories have been suggested in explanation of the accidental murmurs, but the author believes, based on the maneuvers suggested for their creation and disappearance, that they are caused by a functional stenosis or dilatation of the aorta and pulmonary artery. Later (page 604), we shall learn the relation of functional pulmonary stenosis to tuber- culosis. Careful percussion of the thoracic aorta by the author, together with measurements of the vessel by the ortho- diagraph several times a day on the same patient, show the variations in the calibre of the aorta in accordance with the law that, each part of the body receives an amount of blood necessary for its activity. The diag- nosis of murmurs of relative valvular insufficiency has been noted on page 209. INHIBITION OF THE HEART (page 228) This phenome- non may be utilized in diagnosis. It may be elicited by exten- sion of the muscles of the neck (Fig. 65), or by contraction of the abdominal musculature (page 208). The employment of the phenomenon is based on the fact that the loudness of a murmur is largely dependent on the activity of the heart. Thus, in weakness of the heart in febrile diseases and the dying state, murmurs become less loud or disappear. Dur- ing the time inhibition is properly executed, cardiac tones and murmurs diminish in intensity. A few seconds usually elapse before the effect on the heart becomes manifest, then, while the subject is still inhibiting the organ, the heart tones become less and less evident, assuming an embryocardial character, until finally they are no longer audible. 528 Intra-Abdominal Insufficiency My investigations with this method may be summarized as follows: 1. Organic murmurs become faint and almost inaudi- ble. 2. Transmitted murmurs are more amenable to inhibi- tion and when they are inhibited, the tones which they mask can be auscultated. 3. The fainter the murmur, the more easily it is inhib- ited. 4. Heart-tones are less amenable to inhibition than murmurs. 5. Functional, are more easily inhibited than organic murmurs and when tones replace the murmurs, the functional nature of the latter is determined. 6. Incorrect execution of inhibition will intensify rather than diminish murmurs and repetition of the maneuver eventuates in futile results owing to exhaustion of the vagi. INTRA-ABDOMINAL INSUFFICIENCY. The frequency im- portance and neglect to recognize this condition prompts the author to make supplementary observations in addition to those cited on page 145. The condition in question is practically identical with Glenard's disease (page 349), but if the physician is guided in the diagnosis of this affection by the palpation of prolapsed abdominal viscera, intra-abdomi- nal insufficiency will often escape recognition. In asso- ciation with the signs noted on page 145, one seeks for the symptoms identified with intra-abdominal venous congestion (page 427). Cardioptosis or ptosis of the heart is a participating phenomenon of intra-abdominal insufficiency. The position of the diaphragm and with it the heart, is influenced by intra- abdominal tension. The latter is maintained by pressure of the atmosphere on the yielding abdominal parietes and 529 S p o n d y I o t h e r a p y contraction of the abdominal muscles. Artificial reduction of intra-abdominal pressure by means of a large vacuum cup applied to the abdominal wall will often, as long as suction is maintained, cause the appearance of systolic pulmonary and aortic murmurs. The former, however, less frequent than the latter. The systolic aortic murmur of cardioptosis is associated with signs peculiar to the latter, viz., cyanosis, dyspnea on exertion or in certain attitudes, and weight or oppression in the lower sternal region or epigastrium. The disappearance of the cardiac murmur and the temporary relief afforded by lifting the abdomen and the almost immediate and per- manent relief following the wearing of a proper abdominal support, with the chief pressure at the umbilical region, are diagnostic-therapeutic signs. It is surprising to note the large number of individuals with neurasthenic and digestive symptoms caused by intra-abdominal insufficiency. These patients are treated futilely for every conceivable condition but the right one. In advanced grades of the condition, the "habitus enter- optoticus seu paralyticus" may be recognized. Stiller insists that a fluctuating or floating tenth rib (costa decima fluctuans) is pathognomonic of this condition. In Stiller's book, "The Asthenic Diathesis," he shows that the patients digest quite well until fatigued. Mucous colitis is often associated with the condition. Mere in- spection may enable one to make a diagnosis when the patient is standing, viz., long and flat thorax with narrow epigastric angle, retracted and flat abdomen in epi- gastrium and protuberant lower abdomen. Prolapsed organs may be palpated in the recumbent posture. These patients are best treated by hyperalimentation and an abdominal support. We must not forget however, that the victims of intra-abdominal insufficiency may be obese as well as emaciated. 530 Intra - Abdominal Insufficiency Before a permanent abdominal support is obtained, one may temporize with Rose's method of strapping the abdomen for determining whether gastric, cardiac, neu- rasthenic and other symptoms are dependent on intra- abdominal insufficiency. The plaster may be worn for a week or longer. Z. O. adhesive plaster on moleskin ' (Johnson and Johnson) is used, seven inches wide and as long as the circumference of the waist measure of the FIG. 120. Illustrating the method of Rose in the application of the plaster bandage. The figure above shows the method of cutting the plaster and the other figures show respectively, the method of applying the strip A, and the strips B, B, which complete the bandage. patient. This plaster is cut into three pieces according to figure. The abdomen is shaved and washed with ether. The large piece is first applied, the point being placed over the symphysis, the ends meeting and over- lapping in the back. The plaster should be applied above the crest of the ilium. Then the side-pieces, which run from the hypogastrium over the iliac and inguinal regions and unite at the spine, are applied with consid- erable force. 531 Spondyloth e r a p y I usually apply the plaster in the Trendelenburg posi- tion although the dorsal posture may be used, the ab- dominal viscera being raised by an assistant during the time the plaster is tightly approximated to the back. The removal of the plaster is facilitated by benzine or oil of wintergreen. Another method 100 , more satisfactory than the latter for supporting the abdomen is the following which is illustrated in Fig. 121. FIG. 121. Illustrating a method for supporting the abdomen. A indicates double-padded bandage and B, zinc oxid strip. "A strip of zinc oxid adhesive plaster 2 or z\ inches wide and about 5 or 6 inches long, the length varying with the size of the patient, is placed transversely across the extreme lower abdomen as nearly as possible to the pubes, the hair having been shaved clean for this purpose. To each end of this strip of adhesive plaster is attached a bandage of about the same width, long enough to reach around the body above the iliac crest, and be tied or otherwise fastened behind, or better, one end long enough to reach around and fasten at opposite end of plaster. If the ends of the plaster have a tendency to become loosened and pull up by traction of the bandage, this can be prevented by a narrow verticle strip across each end of the adhesive strap and applied to the skin above and below. The bandage itself is well padded with cot- ton, either folded within it or applied to the body imme- 532 Subclavian Murmurs diately beneath it. This prevents any irritation of the skin from the bandage and permits of its being drawn as tightly as necessary in order to furnish the necessary support from below." The point of pressure in the lower abdominal area gives the greatest amount of support. Where the plaster approximates the skin, a thin layer of collodion to the latter may precede the application of the bandage. Any abdominal condition causing the diaphragm to be forced upward may cause functional murmurs and the hori- zontal position of the heart with an apparent increase in the transverse diameter may still further complicate the situation. SUBCLAVIAN MURMURS. Subclavian murmurs are frequently misinterpreted as evidence of an aneurysm or cardiac disease. The literature on the subject is meager and indefinite and for that reason I may be pardoned for interpolating my investigations. From the literature the following facts were gleaned: Subclavian murmurs are sounds heard over the sub- clavian artery which are dependent on the phases of respiration. They are usually best heard at the height of inspiration, less often at the end of expiration. When very intense, they may be recognized by the finger as fremissement. They are heard more often on the left than on the right side, rarely on both sides, and least often on the right side. English practitioners of medicine have been especially prominent in the study of the phenome- non, and have regarded it as a clinical sign of pulmonary tuberculosis when it is only manifest on one side. This opinion was combated by Fuller and Palmer. The former found the subclavian murmur twelve times among one hundred healthy persons, whereas Palmer found it to exist thirty-seven times among one hundred and twenty-nine healthy laborers. 533 SpGndylotherapy MECHANISM OF THE SUBCLAVIAN MURMUR. The mechanism of its origin has not been made definite, al- though it has been variously attributed to compression of the subclavian artery by the elevation of the first rib in inspiration or to the action of the subclavius and scaleni muscles. Friedreich, observed the subclavian murmur most frequently among phthisical individuals, and suggested as a cause, the occurrence of adhesions be- tween the vessel wall and the lung pleura, which led to a narrowing of the artery in one or both phases of respira- tion. He contended that, insomuch as pleural adhesions were not infrequent, even among healthy persons, he was constrained to conclude that such adhesions sufficed to explain all subclavian murmurs, the extent and direction of the synechiae determining the occurrence of the mur- mur during inspiration or expiration. From an exam- ination of more than three hundred persons, I am able to formulate the following conclusions: i The subclavian arterial murmur is an independent (autochthon) and rarely a transmitted murmur. 2. Its point of maximum intensity is the fossa of Mohrenheim, with feeble tendency to propagation. The fossa of Mohrenheim is that depression under the clavicle in the outer part of the infraclavicular region be- tween the pectoralis major and deltoid muscles. 3. It is heard most often on the left side, less fre- quently on both sides, and least frequently on the right side. In order of frequency it is heard at the height of inspiration, at the end of expiration, and after momen- tary suspension of respiration. 4. It is usually a succession of murmurs uniform in character and intensified by certain maneuvers, notably deep inspiration, forced expiration, suspension of respir- ation, and voluntary stretching of the neck. 5. One of the chief characteristics is its momentary duration, disappearing usually after a few deep inspira- tions. 534 Anatomic Conditions 6. Its dependence on the phases of respiration dis- tinguishes it from all transmitted murmurs. 7. It may be present at one and absent at a subse- quent examination, and neither its character nor dura- tion is ever uniform from one examination to another. 8. The position of the patient may influence its gen- esis, but this is never sufficiently uniform to be of prac- tical value. 9. A phthisical lung is not specially propitious to its occurrence, as it is found nearly as often in healthy as in phthisical persons. 10 It was present in 36 per cent, of all healthy per- sons examined, advantage being taken in this enumera- tion of re-examinations and those propitious factors which determine its occurrence, viz., respiration and decubitus. 1 1 . The venous subclavian murmur was only heard in six individuals with a preponderance of its occurrence on the right side. 12. The arterial subclavian murmur could be artifi- cially induced on the left side in nearly 80 per cent, of all individuals examined, and on the right side in about 65 per cent, of the cases by a simple maneuver, viz., raising the arm gradually until it assumes a vertical position, while auscultating the Mohrenheim fossa during the time that the arm is brought to the latter position, the murmur suddenly appearing at some time during the execution of the movement. 13. By the foregoing maneuver the subclavian venous murmur could be induced on the right side in 43 per cent, of all persons examined. ANATOMIC CONDITIONS. To explain the origin of the subclavian, arterial, and venous murmurs, a short ex- cursion into the realms of anatomy is necessary. The right subclavian artery arises from the arteria innominata whereas the same vessel on the left side arises from the end of the transverse portion of the arch of the aorta. The left subclavian artery is longer than the right and 535 S p o n d y I o t h e r a p y directed almost vertically upward, instead of arching outward, like the vessel of the opposite side. The inner aspects of the upper lobes of both lungs are occupied by grooves, one on each side, for the subclavian vessels, where they are invested by the pleura. The third por- tion of each subclavian artery on the outer surface of the first rib, and at the lower border of this bone becomes the axillary artery. The points in connection with the first rib that suggest attention are the tubercle and ridge, which serve for the attachment of the scalenus anticuc muscle, the groove in front of it transmitting the subclav- ian vein, that behind it the subclavian artery. Both subclavian veins, which are the continuation of the axil- lary veins, unite with the internal jugulars to form the right and left vena innominata. If we auscultate the subclavian artery, we hear, in the majority of cases, just as we do in listening over the carotid, two clear tones, one corresponding with the filling of the vessel, the dias- tolic, and the other with the emptying of the vessel, the systolic tone. Less often only one tone is heard, which is usually coincident with the systole of the blood-vessel. The tones thus heard are the transmitted first and second aortic tones. If we press moderately with the stetho- scope, let us say, the carotid artery, we hear a pressure- murmur corresponding to the arterial pulse; by stronger pressure, which almost, but not quite, closes the artery, this murmur is changed into a tone, the so-called pres- sure-tone. With these preliminary facts at our disposal, we can make explicable the subclavian murmur as heard in health. The following facts demand solution: 1. Why is the subclavian murmur heard loudest dur- ing forced inspiration and expiration? 2. Why is the murmur of short duration, disappear- ing after a few deep inspirations? 3. Why is the murmur heard more often on the left than on the right side? FACTORS NECESSARY FOR ITS PRODUCTION. The es- sential factor necessary in the production of the subclav- 536 Anatomic Conditions ian murmur is a moderate narrowing of the lumen of the blood-vessel. The recorded frequency of the subclavian murmur in phthisis, and its explanation that pleural adhesions are responsible for its occurrence, is in a meas- ure untenable, for such a condition presumes a narrow- ing of the blood-vessel that would be persistent at some phase of the respiratory act. My observations show that the murmur occurring in phthisis is just as transitory as it is in health. Moderate narrowing of the subclavian artery occurs during forced inspiration. This is a fact which is easily demonstrable in almost any individual by palpation of the radial pulse. In not a few instances deep inspiration will cause the radial pulse, especially the left, to disappear. The paradoxic pulse has lost much of its clinical significance as a diagnostic aid in med- iastino-pericarditis, since observations have shown that in health distinct respiratory changes in the pulse are demonstrable by means of the sphygmograph. The sphygmogram shows a fall in the pulse-curve during in- spiration and a rise during expiration. Deep, prolonged inspiration, by elevating the first rib, effects compression of the subclavian artery, which accounts for the murmur, which is really a pressure-murmur. Violent contraction of the muscles of inspiration or forced contraction of the muscles which draw the shoulder forward while the arm is at the side will change the murmur into a tone the pressure-tone. The occurrence of the murmur only dur- ing expiration may be explained in part by the fact that after the artery is excessively compressed by the act of in- spiration, this pressure is in part removed during the be- ginning of expiration, which act converts a pressure-tone into a pressure-murmur. Then again the blood-pressure must be taken into account during the expiratory act. Stretching of the neck, which will sometimes elicit the murmur, is explained by the action of the scalenus med- ius elevating the fifth rib. The short duration of the murmur finds explanation in the artificial production of the pressure-murmur in the normal artery. Here, as in 537 Spondylotherapy the normal artery, the ever-increasing narrowing of the lumen of the subclavian artery will convert a murmur into a tone. This is practically what occurs during forced inspiration, for a murmur heard during the beginning of the inspiratory act may no longer be audible at the end of that act. Then again attention must be directed to a condition (page 299), which Kernig and myself have described, viz., a complete dulness of the lung-apices without any structural change in the lung. In many healthy persons this condition is manifest. It is not difficult to conceive that the subclavian artery would be . more effectually compressed by an atelectatic upper lung-lobe than by an aerated lobe. After a few deep inspirations th^ subclavian murmur is no longer evident, owing, perhaps, to the fact that the apices becoming more aerated offer less resistance to the superimposed arteries. The more frequent occurrence of the murmur on the left side finds facile explanation in the anatomic differences between the two arteries; the left reacting more easily than the right subclavian artery to the in- fluence of those factors which conduce to compression of the blood-vessels. MEANS BY WHICH THE MURMUR MAY BE ELICITED. The method I have advocated for eliciting the subclavian murmur is simple. Placing the pectoral end of our stethoscope in the fossa of Mohrenheim, we listen for the subclavian murmur. If the latter is not heard, we slowly raise the arm of the patient corresponding to the side auscultated until it is audible. The murmur may not be demonstrable until the arm is elevated to a level with the shoulder or until it assumes a vertical position. This maneuver evokes the subclavian phenomenon by narrow- ing the lumen of the subclavian artery, for coincident with the elevation of the arm the radial pulse becomes less and less evident, until, when the arm has attained the vertical position, the pulse is no longer palpable. This diminu- tion in the pulse-volume is more manifest on the left than on the right side. In a certain percentage of persons ex- 538 Angina Pectoris amined, the maneuver of raising the arm gave rise to a subclavian venous instead of an arterial murmur, while in other persons both murmurs were distinctly audible. The soft, musical, continuous hum of the venous mur- mur cannot be confounded with the arterial murmur. Like the artificial venous murmurs produced by pressure of one of the large veins by means of our stethoscope, so may the subclavian venous murmur be explained, viz., that by raising the arm we elevate the first rib, which in turn narrows the subclavian vein. The more frequent occurrence of the subclavian venous murmur on the right side is explained in the same way as we explain the increased irequency of the jugular venous murmur on the same sfde. ANGINA PECTORIS.* Anginoid pains are symptomatic of a variety of cardiac affections and are equally independent of the latter. We shall first differentiate the so-called varieties of angina pectoris (stenocardia). 1. ANGINA ABDOMINIS. Here, the spasm is confined to the vessels innervated by the splanchnic nerve, causing an enormous increase of blood-pressure. Even in true angina there are attacks of abdominal pain suggesting gall-stone colic. 2. ANGINA PECTORIS VASOMOTORIA. Here, there is no primary cardiac lesion, but a wide-spread arterial spasm with secondary anginoid pains. The peripheral angiospasm causes paresthesias in the hands and feet, and if the pale and cold (often cyanotic) extremities are warmed, or if the patient walks, anginoid pains are inhibited. 3. ANGINA PECTORIS FROM CORONARY SCLEROSIS. In this true form of the disease the lesion in the majority of *Vide, page 221, et seq. 539 S p o n d y I o t h e r a p y instances is an arteriosclerosis of the coronary arteries. The pains are probably caused by an ischemia of the myocar- dium (page 222), which fact is supported by the observation that the pains diminish in frequency as age advances, owing either to muscular insufficiency or because the too-rigid vessels do not permit of vasoconstriction. ETIOLOGY OF ANGINOID PAINS. Practically any painful abdominal affection, notably gastric ulcer, may simulate the pains of angina pectoris. In endocarditis and perhaps in obesity (if coronary arteriosclerosis is not present), narrowing of the coronary vessels may conduce to attacks of angina. Pericardial adhesions may also narrow the lumina of the vessels. Syphilis of the heart is not an infrequent factor. Probably the lesion is more often aortic (implication of the region corresponding to the origin of the coronary arteries). Here, antisyphilitic treatment may establish the diagnosis. Tabes dorsalis (cardiac crises), gout, diabetes, lead poisoning, hyperthyroidism, autointoxication and nervous affections may cause anginoid pains. Tobacco is no doubt a frequent etiologic factor in angina. When tobacco or alcohol is the problematic cause, the pres- ence of scotomata (blind spots in the visual-field), will clinch the diagnosis. Test for scotomata. Let patient with one eye closed look steadily at tip of physician's nose at a distance of about two feet; then take any green or red colored object (wool or card board) , about 2 to 5 mm. in diameter, and move it from the periphery to the point of fixation; when the object arrives at the scotoma (seat of defect in the visual-field), it will appear dull or colorless. Green is usually less readily perceived than red. Osler, 9S presages an increasing number of cases of angina pectoris (cardiac neuralgia), corresponding with the rapid 540 Angina c t o r / s increase of cigarette smoking among women. He observes that very heavy smokers may die from vagus-inhibition. In investigating the influence of tobacco on the heart, I noted that in some, individuals the blood-pressure was re- duced and in other instances, it was raised. The effects thus produced corresponded to its sedative or stimulating action. The chief effect, however, was on the cardiac musculature, tobacco eliciting a veritable heart reflex lasting from one minute to several hours. This effect was accent- uated when the tobacco was inhaled and partially inhibited when the smoke was filtered through cotton. The effects varied with the kind of tobacco smoked. Thus, in some individuals, Havana tobacco produced a marked retraction of the left ventricle, whereas, Turkish tobacco was without any effect. In my investigations, the effects of tobacco were not only tested with reference to the heart reflex but by other methods for testing vagus-one (page 469). Insomuch as tobacco is a vagus-tonic, I do not pro- hibit its use among my patients who suffer from aneur- ysmsormyocardial affections (excluding angina pectoris). To illustrate my investigations, the following two cases are cited: CASE I AMPLITUDE OF a. Havana cigar partially smoked b. Same cigar smoked through cotton in a holder c. Manila cigar without cotton d. Manila cigar with cotton RETRACTION OF LEFT VENTRICLE o. 3.5 cm. DURATION OF HEART REFLEX a. 2 min. b. c. d. No retraction. 4 cm. 2 cm. 4 mm. 3 min. CASE II Same condition as a Same condition as b Same condition as c Same condition as d 2.5 cm. No retraction. 4 cm. No retraction. 2 mm. 7 min. 541 S p ondyloth e r a p y It is quite probable that anginal pains from tobacco are caused by ischemia of the myocardium superinduced by the heart reflex. Anginoid pains are not infrequent in aneurysms and Osier refers to angina pectoris as an early symptom of the disease, due probably to overstretching of the aorta. Here, concussion of the seventh cervical spine (which contracts the aorta), will cause an immediate evanescence of the pain, whereas, the maneuver, which likewise contracts the heart will increase the pains in true angina (page 223). With increasing experience in the treatment of angina pectoris, the author is constrained to make a dogmatic differentiation of the disease into two forms : Angina, with- out and with an increase in the diameters of the heart. ANGINA WITHOUT DILATATION. It is not only necessary to demonstrate that the heart is not dilated, but also to establish the fact by the method cited on page 510, that the myocardium is efficient. When the myocardium is efficient and the heart is not dilated, the angina is probably caused by coronary arteriosclerosis. If examination shows a dilatation of the organ and an inefficient myocardium, the pains are caused by an acute or chronic dilatation of the heart. I shall differentiate these two forms as cardio-tonic (no increase in cardiac diameters), and cardiectatic angina pectoris. The tone of the myocardium, as has already been shown (page 471), is maintained by vagus-tone, and any increase in the latter will precipitate a cardio-tonic paroxysm of angina. It is in this way only that one may explain attacks caused by the action of digitalis, pilocarpin and concussion of the yth cervical spine, which increase vagus-tone. Atropin inhibits the pains of the cardio-tonic variety and accentuates the pains of the cardiectatic forms. 542 Cardiectatic Angina Pectoris Concussion of the yth cervical spine will cure the car- diectatic forms. By inhibiting vagus-tone (concussion or sinusoidalization of the region corresponding to the third and fourth dorsal spines), the author has achieved promising results in the treatment of cardio- tonic angina pectoris. This corresponds to the method on page 221, for eliciting the heart reflex of dilatation; the dilatation by this method being to evoke an active dilatation of the organ (page 520). CARDIECTATIC ANGINA PECTORIS. Investigations by Hyde, in Porter's laboratory, show that dilatation of the heart alone will diminish the flow of blood through the coronary arteries. It is for the latter reason that the pains associated with dilatation may be subdued by withdrawing some blood. Among the soldiers of the Civil war, da Costa noted precordial pains of anginoid intensity, due to overstrain and dilatation of the heart. Acute cardiac dilatation, such as is observed after physical exertion (climbing, dancing, rowing, running, etc.), causes anginoid pains. Within a few days, treatment by concussion causes the disappearance of symptoms peculiar to dilatation of the heart. The following case of a San Francisco physician is cited to illustrate the importance of recognizing the cardiectatic variety of angina pectoris. My stenog- rapher's verbatim report from the physician is as follows: "My age is 52 and weight, 172 pounds. Several promi- nent physicians (names suppressed) diagnosed my case as one of true angina pectoris and I was doomed to live a life of hopeless invalidism. My father suffered from similar attacks of anginal pains which began at my age. He was like myself inclined to obesity. I am forced to give up my outside practice, because the least exertion in walking and particularly when the cold air strikes my 543 Spondyloth e r a p y chest brings on severe and radiating pains with a feeling of fear and oppression." In this patient, the cardiectatic variety of angina was demonstrated. Within three weeks, the patient was able to resume his practice and up to the time of writing could make any physical exertion without any recurrence of symptoms. Concussion of the seventh cervical spine (daily seances, ten minutes) was the only treatment em- ployed. Provision later, however, was made for a grad- ual reduction in weight for it is impossible to fully re- construct cardiac musculature immersed in an at- mosphere of fat. The fact that the patient's father had similar attacks at his age only emphasized heredity in relation to the tendency to corpulency which impaired the integrity of the cardiac musculature. The fact in the previous history, that "cold air striking the chest" precipitated an attack, led me to investigate this phenomenon which is by no means uncommon in angina pectoris. Some patients also suffer from attacks when cold air is inspired. I found that when a current of cold air is directed over the precordial region, the heart dilates. In the norm this dilatation is slight, but it is exaggerated in cardiac insufficiency. Inhalation of cold air produces a like, though less pronounced effect. This heart reflex of dilatation (pages 221 and 520), like its counter reflex of contraction, is mediated by the vagus, for, when the latter is inhibited (pressure between the 3d and 4th dorsal spines), no reflex can be elicited A current of warm air over the heart is neutral in action. The foregoing observation is of great physiologic and therapeutic value. As a rule, cold air impinging on a visceral area is in the nature of a cutaneous irritant and one would premise that the result would be a contraction of an organ, like the heart reflex of contraction and other visceral reflexes. It was found that cold air similarly used, dilated the stomach, spleen and liver. The physiologist 544 Differential Diagnosis of Chest-Pain has extended the scope of the cutaneous sensory nerves by not only endowing them with the sensation of touch, but of pressure, warmth, cold and pain. He must now recognize the puissance of specific cutaneous nerves (page 465), which influence visceral-tone; nerves, which in response to a special irritant, will either contract or dilate an organ. A better understanding is also had of percutaneous medication. Thus, Short and Salisbury 96 , endeavor to show by scientific investigations that applica- tions to the skin (ointments, lotions, plasters), are abso- lutely without value as determined by methods of testing the cutaneous sensations. In fact, many recognized local anesthestics applied to the unbroken skin rarely produced an anesthesia. In view of the author's ob- servations, such investigations which do not take the visceral reflexes into consideration are futile. It is known that, stimulation of the respiratory center is greater through the cutaneous nerves than through the branches of the vagus to the respiratory organs. DIFFERENTIAL DIAGNOSIS OF CHEST-PAIN. It is by no means always easy to differentiate the pains of angina pectoris from other chest-pains, insomuch as there are many grades of true angina. Two factors make up a typic anginal paroxysm: pain (dolor pectoris), located in the sternum and radiating to the arm (usually the left), and a feeling of anguish and sense of imminent dissolution (angor animi). Among other typic signs are: increased blood- pressure, sensory areas of the skin (Figs. 23 and 24), and the relief of the paroxysms by amyl nitrite (page 226), or other vasodilators. Chest-pain may be caused by diseases of the heart, pericardium and vessels, pleura, lungs and bronchi, media- stinum, esophagus, intrathoracic nerves and nerves of the chest- wall, bones, joints and periosteum, mammary glands, 545 Spondylotherapy skin and muscles. Space will not permit me to discuss all these varieties of pain. INTERCOSTAL NEURALGIA. Fully 95 per cent, (analysis by author of 1,000 cases), of all cases of chest-pain are caused by intercostal neuralgia (Chapter VI), and the immediate relief by paravertebral freezing constitutes one of the most brilliant triumphs of therapeutic medicine.* This form of neuralgia is observed more often on the left than on the right side, owing, as Henle supposed, to the fact that the veins on the right side pour their blood into the great veins by a less circuitous route. Occasionally one finds intercostal pains secondary to intrathoracic tumors, aneurysms, diseases of the spinal cord and its membranes and skeletal mal-alignment (foot-note, page 1 86 and page 123). Pains simulating intercostal neuralgia may be one of the frontier symptoms of gastric cancer and are caused by infil- tration of the paravertebral tissues. In the foregoing instances, freezing is negatively diag- nostic, insomuch as it affords no relief. According to Wolfs Law, which is generally accepted, every change in the form and function of the bones, or of their function alone, eventuates in definite changes in their internal and external configuration in conformity with the laws of mathematics. The shape of a bone is caused by the function it performs. In this sense, skeletal mal-alignment may be produced by improper static conditions. Intercostal and other neuralgias (notably, sciatica) may be caused by changes in verte- *For the relief of pain in the intervals of freezing, the author employs the following efficient analgesic formula for a single dose, which may be repeated if necessary: Caffein, grains, 2; pyramidon, grains, 5; phenacetin, grains, 5; sodium bicar- bonate, grains, 10; sodium bromid, grains, 20. Owing to their deliquescence the powders are dispensed in homeopathic vials. 546 Intercostal Neuralgia bral alignment alone. As a rule, in such instances, sciatica is secondary to lesions of the sacro-iliac joints (page in), for, when there is any restriction in the movements of the vertebral column, there is either an increase in motion in the sacro-iliac joints or there is a change in the inclination of the pelvis. Mai-alignment of the vertebrae of static or muscular origin (page 123) will exert pressure on the spinal nerves at their exit from the intervertebral foramina. This can be easily demonstrated on a cadaver or by the insertion of cylinders of wax in the foramina. Such pressure is equivalent to stimulation, notably if there is any anomaly of the spinal nerves. Weir-Mitchell has demonstrated that a nerve subjected to a thermic insult becomes swollen, congested and hemorrhages occur in the nerve. On page 123, reference is made to albuminuria caused by lordosis. My investigations show that, albuminuria is really caused by traction or pressure on the lumbar nerves. If one makes continuous pressure on either side of the second lumbar spine for about three minutes, one may even in the norm detect the presence of traces of albumin in the urine by aid of Tanret's reagent. About fifteen minutes Faradization of this region will as a rule, effect the same object and when the urine al- ready shows albumin as in nephritis, its quantity is very much increased. When the pains implicate an extremity, it is important to differentiate radicular pains from pains of a nerve trunk. Here, the essential point in differential diagnosis^is in the distribution of the hypoesthesia or anesthesia as de- termined by the objective examination. A nerve-trunk represents a combination of an anterior motor and a posterior sensory root, and the latter in their intraspinal course are in relation with the dura mater and the verte- brae. If a lesion involves the sensory root within the 547 Spondyloth e r a p y column, the sensory disturbance ensuing will have a radicular distribution. In affections of a peripheral nerve-trunk, the sensory disturbance is distributed irregularly in a longitudinal or oblique direction whereas when the root of the nerve is involved, the hypoesthesia or anesthesia represents a regular longitudinal distribution parallel with the axis of the limb. Freezing aids in differentiating pains of peripheral and central origin (page 188) or the peripheral nerve-trunk may be blocked. Thus in sciatica, a perineural injection into the nerve may be made with 50 cc. of normal salt solution containing one grain of beta-eucain. The in- jection is made at the gluteal fold, midway between the tuberosity of the ischium and the great trochanter. The needle should be about 3 inches in length and should be directed upward and slightly inward. When the nerve is reached by the needle, there is a slight twitching of the leg. This injection is curative as well as diagnostic. The following case of a physician is cited to illustrate a sensory phenomenon, which I have frequently noted, when there are several sources in the excitation of pain. For about five years, the patient suffered from agoniz- ing paroxysmal pains radiating from the precordium to the neck and left arm. The attacks were associated with a sense of suffocation, pressure in the chest and perspira- tion. Several physicians had concurred in the diagnosis of true angina pectoris. Examination demonstrated a cervico-brachial neuralgia (pseudo-angina, page 194). Freezing of the sensitive paravertebral areas brought immediate relief and cure after six seances. At each successive seance, new points of paravertebral tenderness developed and new areas in the distribution of pain (the former paravertebral areas of tenderness and areas of pain having disappeared). The areas were no doubt present at the primary ex- amination but they were overwhelmed by the more in- tense areas elsewhere. This is in accordance with the 548 Phrenic Nerve Law of Weber: Sensations increase as the logarithm of the stimuli. Thus, a candle light will increase the illum- ination in a dimly-lighted cellar, but the light would not be in evidence in the bright sunshine. This phenomenon from another view-point is in accordance with the physi- ologic dictum that "any center mediating a definite reflex suffers a loss in excitability whenever it is acted upon at the same time by any other pathway not concerned in that particular reflex." PHRENIC NERVE. Among the intrathoracic nerves this nerve may be implicated in a veritable neuralgia. The phrenic nerve is distributed to the pleura, pericardium and diaphragm, and after piercing the latter it supplies the capsule of the liver, spleen and gall-ducts. This nerve springs chiefly from the fourth cervical nerve, although it usually receives a twig from the third and fifth cervical nerves. Referring to Fig. 10, it will be noted that its chief source of origin corresponds to the fourth cervical segment. We note further, that its exit corresponds to the second and third cervical spines. In pleurisy and pericarditis I have almost invariably found points of tenderness corresponding to the latter spines, and by freezing the areas of tenderness, I have not only inhibited, but arrested the pains of these affections. In a diagnostic sense the maneuver is equally valuable, although one must reckon on possible implication of the capsule of the liver, spleen and gall-ducts, likewise innervated by this nerve. In pleural pains, I have noted dermatomes connected with the fourth cervical segment (Figs. 23 and 24). It is known that, when pain is associated with pul- monary disease, it is usually caused by pleural involve- ment. In pneumonia and pleurisy, the chief pain is located in the abdomen. Here, the reflex pain is probably med- 549 Spondyloth e r a p y iated by the phrenic nerve, which supplies the parietal peritoneum (page 416). In involvement of the struc- tures innervated by the phrenic, shoulder-pain is not infrequent. The skin of the shoulder is supplied by the fourth and fifth cervical nerves, hence, the reflex dis- tribution of pain (Fig. 22). DIAPHRAGM REFLEX. When intermittent pressure is made between the second and third cervical spines, a slight protuberance is noted on one or both sides in the epigastrium under the costal borders, with a wave running between the two protuberances. The maneuver is executed with the patient in th'e recumbent posture, knees flexed, head toward the window and at the end of expiration. The phenomenon is specified by the author as the diaphragm reflex. It is more constant than the phrenic shadow of Litten. It is absent in diseases of the phrenic nerves leading to spasm or paralysis of the diaphragm. ANEURYSM OF THE AORTA. DEFINITION. An aneurysm signifies, literally, a dila- tation, but there are nomenclators who insist in differen- tiating a dilatation from an aneurysm of the aorta. This, like many classifications of aneurysm, is essentially an anatomic and not a clinical question. Clinically, aortic dilatations may be divided into two groups, dilatations with- out (latent cases), and with symptoms.* Prior to my recognition of the aortic reflexes, several of us saw a patient with pains radiating to the left arm and chest in whom the X-rays revealed simple aortic *Even though an aortic dilatation is demonstrable, it is difficult to say what bearing it may have on the symptoms. The diagnostic-therapeutic test by daily con- cussion of the 7th cervical spine may be necessary for a decision. Within ten days, if aortectasis is related to the symptoms, the latter must show ameliora- tion. 550 Aneurysm of the Aorta dilatation. The pains were sufficiently severe to demand analgesics, and yielded after three weeks rest in bed. After three years, the pains recurred and the X-ray picture was identical with that of the first examination, yet several treatments of concussion to elicit the aortic reflex of contraction sufficed to subdue the symptoms. Peripheral pains in the thorax and arms simulating neuritis without the symptoms of the latter (tenderness of the nerves in the implicated region, motor and sensory disturbances), suggest an aneurysm. The latter fact is illustrated in the case cited on page 575. To escape the confusion created by a hybrid anatomico- clinical terminology, a compromise may be effected by em- ploying the term dortectasis, to designate aneurysm or dila- tation of the aorta. Aneurysm of the aorta is by no means as infrequent as is currently supposed; on the contrary, the percentage of deaths varies from 0.6 per cent, of total mor- tality (Emmerich) to 1.49 per cent. (Miiller). Death occurs suddenly, as a rule, owing to rupture of the sac, and many cases of sudden death referred to other conditions, owing to the absence of an autopsy, are often caused by an aneurysm. Practically three-fourths of all aneurysms are aortic and nineteen-twentieths of these are located in the thoracic aorta. Of the latter, about 90 per cent, are saccular;from 80 to 90 per cent, occur in the male, and about 50 per cent, occur between the ages of 35 and 50. Respecting the etiology of aneurysms, it has been said that the victim is usually one who has worshiped at the shrine of Venus, Bacchus or Vulcan. In etiology most writers ascribe the preponderating role to syphilis. The latter, as an etiologic factor varies in percentage from 25 (Klemperer) to 92 per cent. (Rasch). Indeed, Osier affirms that an aneurysm in a person of either sex, under the age of 551 Spondyloth e r a p y thirty, is presumptive evidence of syphilis. Among my own patients (60), a syphilitic history was positively established in only 20 per cent, of the cases. In several instances, where a history of syphilis was positive, no Wassermann reaction was obtainable. Statistics show that in some of the late lesions of syphilis, a reaction may be elicited in only 50 per cent, of the cases. The reaction is usually positive in the secondary stage of untreated syphilis. Whether the reaction is positive or negative, mercurial inunctions are nevertheless indicated, although I have never observed any benefit from them in my aneurysmal cases. MESAORTITIS. This is a peculiar type of arterio- sclerosis associated with aortic insufficiency and aneurysm, and is comparatively frequent in syphilitics, notably in young subjects. A similar lesion is found in congenital syphilis. Spi- rochetes are demonstrable in the lesions. Evidence is accumulating to show that aortic insuf- ficiency is one of the most frequent causes of syphilis, and a positive Wassermann reaction may be elicited in a number of patients thus afflicted. The Babinski syndrome (inequality of pupils and Ar- gyll-Robertson phenomena with aneurysm), suggests syphilitic infection and so does the prompt relief afforded by potassium iodid, as suggested by Osier. Among other factors contributory to the etiology are, overwork, traumatism, abuse of alcohol and the infectious diseases. In the opinion of the writer, the foregoing factors may operate by diminishing vagus-tone. In accordance with this view-point, the anatomic changes in the aortic-wall may be secondary to the primary aortectasis. In young persons the most important etiologic factors are trauma and endo- 552 Symptomato logy carditis, causing the so-called embolomycotic aneurysms. In the latter, bacteria are found in the aneurysm'al wall similar to those found in endocardial vegetations. SYMPTOMATOLOGY. Since the advent of the X-rays and exact methods of percussion, the non-recognition of an aneurysm is an unpardonable error in diagnosis. The sub- jective symptoms are essentially pressure-symptoms and vary with the degree and location of the dilatation. Among the symptoms may be mentioned: 1. Pain in the sternum, ribs or the spine from direct pressure; surrounding the upper-chest, from pressure on the intercostal nerves; radiating down the side of the chest and the inner surface of the arm, from pressure on fibers dis- tributed by the intercosto-humeral nerve. 2. Dyspnea. Caused by irritation of the recurrent nerve (aphonia, hoarseness and a metallic cough), tracheal, bronchial or pulmonary pressure. Dyspnea may be parox- ysmal and suggests asthma. 3. Cough. A frequent early sign, of a peculiar wheezy, brazen or metallic character ("goose-cough"). Cough is caused by pressure on the vagus, recurrent laryngeal nerve, compression of the trachea or a main bronchus. Pressure on either of the two latter structures is associated with stridor and expectoration. Cough and dyspnea are out of proportion to the physical signs. The symptoms may sug- gest phthisis (aneurysmal phthisis}. 4. Dysphagia. Caused by spasm or stenosis of the esophagus. 5. Hemorrhage. Caused by tracheal granulations at the point of compression, rupture into the bronchial tree or from erosion or perforation of the lung. Bleeding may be sudden, profuse and fatal, or recurrent for months. 6. Emaciation. From pressure on the thoracic duct. 553 S p o n d y t h r a p y The author wishes to emphasize the fact that the symptoms are often paroxysmal, for the reason that the aorta is not constant in caliber; a temporary increase of dilatation may precipitate a group of symptoms which dis- appear when the lumen of the vessel is restored. Fig. 122 shows the relation of the aorta to adjacent structures and is explanatory of aneurysmal symptomatology. CEsophagus Vagus nerve Phrenic nerve Vena azygos major Right bronchus Right pulmonary artery Pulmonary vein Thoracic d Phrenic ne Recurrent laryngeal ne Common carotid art Bronchial arte Pulmonary arte Left vagus nerv Left bronchi Pulmonary vei Aort Thoracic due Vena azygos ma jo FIG. 122. Contents of the mediastina viewed from the rear. (From Davis, applied Anatomy, J. B. Lippincott Co., publishers). OBJECTIVE SYMPTOMS. i. Percussion shock. Direct percussion over an aneurysmal area elicits a shock not unlike that felt when a rubber- bag filled with water is simultaneously palpated and percussed (semi-fluctuation). This sign, ori- ginal with Smith, was detected in 62 per cent, of his cases, whereas the tug, to be described presently, was present in only 46 per cent, of his cases. Grasping the cricoid car- tilage for eliciting the following sign (tugging) while an assistant percusses the chest, a direct and resilient shock is felt when an aneurysmal area is reached. Normal chest- areas reveal to the fingers at the cricoid cartilage only a distant feeble jar. 554 Objective S y m p to m s 2. Tracheal tug. This sign of Oliver is as follows: With patient standing with closed mouth and elevated chin, grasp cricoid cartilage between finger and thumb and lift it. A tug, most marked in inspiration and transmitted to the fingers, is supposed to be diagnostic of aortectasis. The latter is not correct, insomuch as it is found in conditions which cause adhesions between the aorta and air-passages. It is not infrequent in tuberculosis, pleuritis, mediastinal tumors, enlarged bronchial glands and in enteroptosis, when the heart descends with the liver, and the arch of the aorta in this way makes traction upon the bronchi. The author finds that this symptom is best elicited at the end of a forced inspir- ation. : .' 3. Inspection. Dilatation of the veins of the neck, chest and arms. Diffused arterial pulsations of the carotids and subclavians. Pulsation in the first and second inter- spaces. To detect latter, patient must be in recumbent posture in a good light and the observer's eyes should be on a level with the chest, which must be viewed in different directions. Inspection of the patient's back for pulsations is equally important. Swelling and edema of the right arm may be present from pressure on the subclavian vein and, on the front of the chest, from pressure on the internal mam- mary, azygos or hemiazygos veins. The larynx may be pulled downward and displaced to one side. 4. Palpation. In some cases, the aorta can be palpated in the episternal notch and a lift of the manubrium can be felt. Over the dilatation, one may feel a diastolic shock or a systolic thrill or both. Differences in the radial pulse are so frequent, even in the norm, that little importance can be attached to changes in the radial pulse on both sides. The author wishes to direct attention to a new sign in. 555 Spondylotherapy thoracic aneurysms, viz., extreme sensitiveness of the vagus to palpation on one or the other side of the neck. As a rule, the most tender points are located where the recurrent laryngeal nerve enters the larynx behind the articulation of the inferior cornu of the thyroid cartilage with the cricoid, and at a point between the hyoid bone and the ala of the thyroid cartilage, where the internal branch of the superior laryngeal nerve pierces the thyrohyoid membrane. The latter is the sensory nerve for the interior of the larynx and trachea. An absence of pulsation in the femoral arteries may be noted in abdominal aneurysms, due to the fact, as Osier suggests, that the sac acts as a reservoir, annihilating the ventricular systole, thus converting the intermittent into a continuous stream. 5. Auscultation. Accentuation of the second aortic tone, a systolic murmur and a diastolic murmur, if aortic insufficiency accompanies the aortic dilatation. An accen- tuated metallic second sound over the sac of the aneurysm. An important sign is either the disappearance or modifi- cation of the murmur, if present, after concussion-treatment of the seventh cervical spine (page 525). Drummond refers to a systolic murmur heard in the trachea or at the open mouth of the patient. Respiration may be feeble or absent in some part of the lung, owing to pressure of the dilated aorta (vide report of case on page 575). 6. Percussion. This is one of the most important signs if executed according to the methods suggested by the author. Percussion should be made during the time the chest in in the position of forced expiration. A number of measurements made by the author show that, during the latter phase of respiration, the sagittal diameter of the chest approximates the arch of the aorta from .3 to 1.6 cm. After 556 Objective Symptoms this manner, the elicitation of substernal dulness is facilitated (page 254). Vibrosuppression (page 80) may be required. The author now finds that the elicitation of the aortic reflex of dilatation (page 255) is no longer necessary when the arch is to be delimited. Here, the aim was to accentuate dulness of the aorta by increasing its caliber. Either of the two following methods, preferably the first, may be employed. \ GREAT VESSEL AREA FIG. 123. Normal boundaries of the heart and great vessels. The nipples in this figure are too far away from the median line (Butler's Diagnostics of Internal Medicine). The SUPRACARDIAC VASCULAR AREA containing the aorta and pulmonary artery, may be represented by drawing a horizontal line across the base of the heart (J inch below the upper border of the manubrium, the so-called episternal notch), and two vertical lines ex- tending on either side of the sternum, from the base of the heart to about the lower border of the ist rib. The ASCENDING AORTA lies behind the sternum be- tween the third left chrondrosternal junction and the second right costal or aortic cartilage. The latter point 557 Spondylotherapy represents the commencement of the AORTIC ARCH, which runs obliquely upward and backward toward the 4th dorsal vertebra, where it continues as the descending thoracic aorta. The highest point of the aortic arch in the median line is at about the center of the manubrium (about i inch or 2.5 cm. below the episternal notch). The PULMONARY ARTERY traverses the left sternal border under the 2nd intercostal space and the 2nd costal cartilage. The arch of the aorta terminates at a point in the back to the left of the third dorsal vertebra, at which point the bifurcation of the trachea occurs. VAGUS-TONE METHOD. The aortic tone is under the influence of the vagus, and when the latter is increased, per- cussion of the thoracic aorta is abetted. During percussion, pressure may be made at the yth cervical spine by an assist- ant, or, better, still, the head of the patient is placed in a position of forcible extension (page 228). I must again emphasize the importance of palpatory percussion, i. e., to determine dulness by the sense of resist- ance. In other words, to disregard the audible quality of the percussion-sound. Direct percussion of the vertebral spines (3d to 6th dorsal spines) may reveal the dulness of an aneurysm (vide, verte- bral concussion, page 79). Fig. 124 shows the normal percussion-zones of the spine. POSTURAL METHOD. When the patient stands on an ele- vation (Fig. 125), and stoops far forward, the course of the aortic arch may be easily denned by percussion. In both methods, forcible percussion must be used. The measure- ments of the aorta in the norm have been described on page 255- The fact that, a supposititious area of dulness due to an 558 D a m S n aneurysm may be diminished or increased in area by the elicitation of the aortic reflexes, may be utilized in diagnosis. DAM-SIGN. By this new phenomenon, I refer to an in- crease in the area of aneurysmal dulness (of the thoracic or abdominal aorta), when the legs are forcibly flexed on the thighs and the latter on the abdomen. Compression of the abdominal aorta or an india rubber tube applied after the Dullness Cist to 4th D.). Ostial Resonance (sthtoizthD ). Impaired Resonance (Lumbar). t Tympany (Sacral.) FlG. 124. Normal percussion-zones of the spine (Kordnyi, Da Costa). method of Momburg for hemostasis will yield the same re- sult. By any of the preceding maneuvers, the blood is increased in quantity in the aneurysmal sac and distends it. Aside from the latter maneuvers and the aortic reflexes, the area of aneurysmal dulness is diminished when the skin corresponding to the latter is irritated or when the tone of the vagus is increased by the method shown in Fig. 65. During the period of forced inspiration the diameter of 559 S p o n d y I o t h r a p y an aneurysm is increased and decreased during a forced expiration. During the former, the intrathoracic blood- vessels are filled, and during expiration, they are relatively empty (aspiration action of the thorax). FIG. 125. Illustrating the postural method of determining the course of the thoracic aorta by percussion. AUSCULTATORY PERCUSSION. Percussion of aneur- ysms, as well as the solid viscera, may be facilitated by two methods of the author described elsewhere 98 in detail: i. If, during percussion, a stethoscope is allowed to hang from the ears of the physician (no part of the instru- ment being in contact with the chest of the patient), nuances in the percussion-sound, unrecognizable by un- assisted audition, are demonstrable. Here the stetho- scope is employed as a microphone. 560 Fluoroscopy o f t h e Aorta 2. By employing the principle of transsonance. With the finger, strike directly the yth cervical spine, and while so doing, gradually approach the site of aneurysmal dulness. When the outer boundary of the latter is at- tained, the transmitted resonance is no longer in evidence. FIG. 126. Right anterior oblique position. A, clear area, corresponding to right lung; B, shadow of vertebral column; C, clear middle space; D, shadow of normal heart and aorta; E, clear area corresponding to left lung. , dilated aorta; . , small commencing aneurysm, . . , upper part, larger aneurysm; . . , lower part, position of dilated auricle. 7. FLUOROSCOPY OF THE AORTA. Radio-diagnosis may be achieved by fluoroscopy and skiagraphy. In the former method, which we will alone consider, the aorta traversed by the rays is directly examined by the fluorescent screen. With a large screen covered with glass the aorta may be out- lined on the latter by means of a pencil, such as is used in writing on glass. In the early history of radio-diagnosis, thoracic aneurysms were diagnosed more frequently than in the present state of our advanced knowledge. Thus, Sailer and Pfahler, have demonstrated that tortuosity of the aorta 561 S p o n d y I o t h e ,r a p y in arteriosclerosis strongly suggests aneurysm on fluoroscopic examination. Many errors are now obviated by an X-ray examination in the right anterior oblique position; the rays are made to penetrate the chest obliquely at an angle of 45 degrees from behind forward and from left to right; the screen is in front and to the right and the tube behind and to the left. In this position, the aortic shadow with parallel sides is observed throughout its entire length, and termi- nates in a rounded extremity at a point corresponding to the level of the sterno-clavicular articulations and the third dorsal vertebra. The picture presented in this position is illustrated (Fig. 126) after Holzknecht. Reference must also be made to the accompanying illus- tration (Fig. 127). No. i illustrates the normal aorta in the antero-posterior examination; the parallel lines show the central opacity, and the part shaded, the aorta, which ex- tends to one side of the central opacity. In No. 2 an examina- tion of the normal aorta, conducted in the right anterior oblique position, shows the vertebral shadow, represented by the parallel lines, and the shaded part, the aorta. No. 3 is the aorta examined in the ordinary antero-posterior posi- tion, and the supposition would be that an aneurysmal sac is present, but if the patient assumes the right anterior ob- lique position, the sac is no longer evident (No. 4), but the aortic shadow is broader and retains its parallel borders, hence aortic dilatation and not aneurysm exists. Nos. 5 and .6 illustrate an aneurysm, and 7 and 8 a small aneurysm arising from the under surface of the arch. Note that in Nos. 7 and 8 there is nothing in the pictures to indicate that an aneurysm exists; in fact, the appearance differs in no wise from the normal (Nos. i and 2). In all examinations for a suspected aneurysm the tube should be placed in all posi- tions. 5b2 Fluoroscopy o f t h e Aorta The shadow of an aneurysm is more pronounced, the greater the amount of organized clot. If the shadow is situated to the right of the central opacity and nearer the front than the back of the chest, the ascending aorta is in- volved ; but if the shadow is projected to the left and nearer i t / I t i t i i 8 FIG. 127. Radioscopic examination of the aorta, after Holzknecht (vide description in the text). the back than the front, the descending aorta is probably involved. The depth of the aneurysmal sac from the surface may be approximately determined on the principle that the nearer the sac is to the surface, the more defined will be the outlines and the less intensified the shadow. Hence, in rotating the patient and examining the shadow anteriorly and posteriorly, it is presumably nearer that surface where 563 S p o n d y I o t h e r a p y the shadow is the smaller and more clearly defined. The course of the aneurysm during treatment may be followed if at the primary examination a record is made by means of the orthodiagraph. Pulsations of a shadow argue for an aneurysm, but the latter does not always show pulsation; in fact, a dilated aorta may show more forcible pulsations than an aneurysm. When pulsations are absent, the inhala- tion of amyl nitrite, as I have frequently demonstrated, will bring them into existence. Neoplasms may show a com- municated pulsation from the heart or the blood-vessels. In the usual examination with the tube in the center behind the patient, one observes only the bend of the aorta projecting to the left of the sternum beneath the clavicle, whereas the ascending and descending portions cannot be seen. In dilatation of the aorta, the shadow extends either to the right or left of the sternum or both, and it persists be- tween pulsations. In neurotic individuals and when the aorta is dislocated (a condition which I shall call aortoptosis) in enteroptosis, a shadow extending beyond the ste~num may suggest aneurysm, but as a rule, between pulsations, the shadow recedes behind the sternum. In aneurysms of the innominate, there is a clear space (with a narrow shadow of the artery) between the latter and the aortic shadow. In differentiating the shadows of structures (glands, tumors, etc.) from aneurysms, the former may rotate upon their axes, but they do not show the expansion of aneurysms during systole and their contraction during diastole. An invaluable aid is furnished by the elicitation of the aortic reflexes during the fluoroscopic examination (vide report of case on page 575). I have found that an aneurysm, like the heart, responds by contracting when the skin over the aneurysm is irritated, 564 Aneurysm of the Pulmonary Artery hence cutaneous irritation is of no value in differentiating the silhouette of the heart from an aneurysm. Among other signs of thoracic aneurysm may be men- tioned: inequality of the pupils (anisocoria) due to pressure upon the sympathetic or alterations in the circulation, delay and inequality of the radial pulses, pain and persistent numbness in the shoulder and arm, signs of arteriosclerosis (thickening of the palpable arteries) and abatement of symptoms after a single seance of concussion applied to the seventh cervical spine. FIG. 128. Percussion-areas of an aneurysm of the abdominal aorta seen in consultation with Dr. Visscher. A, area of aneurysmal dullness by percussion; B and C, aorta reflexes of dilatation and contraction. Reduced. Compare with Fig. 72. Broncho-esophagoscopy may show tracheal compression and pulsation or a pulsatile tumor implicating the esophageal wall. ANEURYSM OF THE PULMONARY ARTERY. Aneurysms of this vessel are comparatively very rare. The symptoms (dyspnea, cyanosis, cough, bloody expectoration, murmur n second left inter-space, etc.) may suggest congenital heart 565 Spondyloth e r a p y disease. An X-ray examination furnishes the most trust- worthy evidence, although the affection is rarely interpreted intra vitam. ANEURYSM OF THE ABDOMINAL AORTA. This is rela- tively frequent (10-14 per cent, of aneurysms), and trauma plays an important role in etiology. The aneurysmal sac is located most often just below the diaphragm in juxtaposition to the celiac axis. FIG. 129. Apparatus for taking tracings of the abdominal aorta. The pul- sations are conveyed by a cardiograph to a registering tambour. The subjective signs are: neuralgic abdominal pains radiating in every possible direction and suggesting renal calculi, gastric ulcer and other affections. The objective signs are: expansile pulsation of an epi- gastric tumor, over which a thrill may be felt or a systolic murmur may be heard, retardation and inequality of the femoral pulses, an area of dulness influenced by the aortic reflexes (Figs. 72, 73 and 128) and an X-ray examination. The latter may be made with the fluoroscope after the patient has been freely purged for several days and lim- ited to a diet of milk. Inflation of the colon with air and the use of a "compression-diaphragm" aid the fluoroscopic diagnosis. 566 Aneurysm of the Abdominal Aorta It is the usual practice of the author to make tracings of the abdominal aorta (aortograms) as aids in diagnosis. They are made with the same ease as sphygmograms of the radial artery. The patient is placed in the recumbent posture, and, at the end of a forced expiration, during the time breathing is suspended, the cardiograph is placed over the abdominal aorta. The apparatus is shown in Fig. 129. A \AA/WVWVV FIG. 130. A, normal aortogram; B, aortogram of abdominal arteriosclerosis; C, aortogram of an aneurysm of the abdominal aorta (Fig. 128) The course of the abdominal aorta is determined by a line (aortic line) drawn from the ensiform cartilage (to the left of the linea alba) to the level of the highest part of the iliac crest. At the latter point (f inch below the navel), the aorta divides into the two common iliac arteries. The CELIAC Axis is located on the aortic line about 4 or 5 inches (10 or 12.5 cm.) above the navel. On the back, the aortic orifice in the diaphragm cor- responds to the i ath dorsal vertebra, andtheceliac axis to the lower border of this vertebra. ABDOMINAL ARTERIOSCLEROSIS. Paroxysmal pains due to this affection are diagnosed with difficulty by the conven- tional methods (page 266). Here, pathognomonic aorto- grams may be taken. 567 Spondyloth e r a p y I have noted that when the cardiograph compressed the abdominal aorta, some of the abdominal arteriosclerotics suffered from their characteristic pains. What I did by the latter maneuver was to produce an ischemia, thus accounting for the phenomenon of claudica- tion (page 226). Compression of the abdominal aorta to obliteration with the fingers may therefore be utilized as a new objective sign of abdominal arteriosclerosis. In enteroptosis with loose peritoneal moorings of the aorta (aortoptosis), in neurasthenic women and in arterio- sclerosis of the abdominal aorta, a "throbbing aorta" may suggest aneurysm of the vessel. Here, there is no definite tumor and no expansile pulsation. Tumors in the abdomen may show a communicated aortic pulsation, but the latter usually disappears in the knee-elbow position. TREATMENT OF ANEURYSMS. Nothing can be added to the method of cure suggested on page 257 et seq. The author has reported in The British Medical Jour- nal (July 8, 1911), and in La Presse Medicate (Oct. 4, 1911), forty cases in his own practice of thoracic and abdom- inal aneurysms which were symptomatically cured within a few weeks by the concussion-treatment with absolutely no other adjuvant measures (not even rest). Since then, seven other cases were treated with the same results. The cases were all advanced and there was absolutely no break in the continuity of successful results. Some of the author's cases were seen after four years with absolutely no recurrence of symptoms. It is only just that I should advert to several patients in whom minor symptoms (a slight cough, dyspnea on exertion 568 Treatment of Aneurysms and an inability to assume the recumbent posture) per- sisted. "Nothing ever gets quite well." The author's treatment of aneurysm does not and cannot eliminate the aneurysmal sac, although it is somewhat reduced in dimensions. It is impossible to conceive of a large intrathoracic in- tumescence without some mechanic disturbances incident thereto. For the latter reason, the author advisedly refers to his results as "symptomatic cures." Failures by others to elicit results could always be at- tributed to mistreatment (page 473). The incurability of aortic aneurysms has been for eons such an ide fxe, that it has graduated into an obsess- ion. Probably the most brilliant achievement of Spondylo- therapy consists in the diagnosis and cure of aortic aneurysms. Most men will agree that the cure of aneurysms should be considered one of the greatest contributions ever made to scientific medicine. But such is the cautiousness of medical minds that few reviewers of Spondylotherapy have had the faith or the courage to speak of this, its greatest achievement. Yet, nothing in medicine is now more completely proven, and nothing can be more easily demonstrated, than that Spondylotherapy can and does cure this heretofore incurable disease. The treatment in question is practically a specific. I have the reports of 12 cases (in addition to my own), from other physicians whose results practically tally with my own, despite the fact that only primitive apparatus was employed in the elicitation of the aortic reflex of contraction. The following case, reported " by Dr. L. St. John Hely, of Madera, California, is cited for the following reasons : the disease was 569 S p o n d y I o t h e r a p y very advanced, the relief was practically immediate and the primitive method shown in Fig, 2 was used. This same patient was seen after eighteen months about whom Dr. Hely reports as follows: "I am enclosing you three photographs of the patient John Artmann, whose case was treated 18 months ago. He came into my office yesterday and his condition is absolutely normal. It was so wonderful that I got out my camera and made these pictures. There are no pulsations, nor feelings of pulsations at all in the tumor and holding the hand on the tumor after climbing the stairs conveys no suggestion what- ever of pulsations. Facies normal." Dr. Hely, reported another case with "the same brilliant results." Report of Dr. Hely: "The writer presents the following history of a patient suffering from aneurysm of the thoracic aorta who was treated by the 'concussion-method' of Abrams: "J. A., age 46 years; weight, 185 pounds; a blacksmith and a moderate drinker; had no previous history of illness beyond the diseases of childhood. On the sixth of No- vember, 1909, the patient first noticed a small projection in the region of the first rib about the size of a dime. A peculiar burning sensation corresponding to the latter point was likewise noted, but the patient gave it no serious consideration until December 19 of that year, when while assisting in lifting a wagon he experienced a chok- ing feeling and the miniature projection attained an enor- mous size. The patient then sought medical counsel and the diagnosis of a thoracic aneurysm was definitely estab- lished. At this time the following subjective and objec- tive symptoms were noted: "Pronounced cyanosis which was universal, cardiac palpitation, choking, and dyspnea upon the slightest exertion, and an almost incessant cough. At night the patient could find a modicum of relief only in one posi- 570 Treatment of Aneurysms tion, viz., propped at an angle of 45 on the right side, and even then the coughing and choking would awaken him every hour. I regarded his condition as absolutely hopeless and so informed his friends. Having at this time read of the method of Abrams, I employed it first on January 21, 1910. Concussion treatment of the seventh cervical vertebral spine was executed daily for FIG. 131. Showing external tumor in Dr. L. St. John Hely's case of aneurysm of the thoracic aorta. fifteen minutes from the latter date until March 5, 1910, when treatment was discontinued. "The second night following the concussion the patient rested well, and after the fourth treatment there was an absolute evanescence of all symptoms. In the language of the patient, "I can now sleep in any position and like a baby; in fact, as natural as any one. I do not cough nor suffocate any more, and, aside from the tumor on the 571 Spondyloth e r a p chest, I would not know that there was anything at all the matter with me." "The aneurysmal tumor when first examined projected considerably and measured about 2\ inches in diameter at the base. At the end of the first week's treatment the tumor was reduced about 25 per cent, but there was no apparent further diminution in size when treatment was discontinued. It was impossible for me to continue treatment, as the patient insisted that he was well and further treatment was unnecessary. The results in this case were, however, immediate and corresponded in the main with the results obtained in the cases reported by Dr. Abrams." Two other reported cures were made by Dr. L. C. Boyd of Long Beach (New York Medical Journal, Oct. 21, 191 1) and Dr. M. L. Turnbull, of San Francisco (Medical Record, Sept. 9, 1911). Dr. L. C. Boyd reports as follows: "In the British Medical Journal (July 8, 1911), Dr. Albert Abrams, of San Francisco, reports forty cases of aneurysm of the thoracic and abdominal aorta treated by his method of concussion of the seventh cervical spine. His method is practically a specific in a disease which has heretofore baffled our best efforts, and it creates an epoch in therapeutic medicine and elevates physiologic therapeutics to a place of distinction in the armamenta- rium of the physician. "Mrs. H., age, 31. Duration of symptoms, three years. "SUBJECTIVE SYMPTOMS. Precordial pain, radiating to head and left arm. The painful paroxysms were accom- panied by great prostration. Dyspnea was constant and like the pain was accentuated by exertion, emotions or high altitude. "There was a troublesome dysphagia, insomnia and dysphonia. "OBJECTIVE SYMPTOMS. Moderate exophthalmos, 572 Subjective Symptoms vascular engorgement of face, neck and hands (notably on the left side). "The right radial pulse was retarded and weakened. "There was a slight bulging of the anterior chest-wall corresponding to the first and second intercostal spaces on the left side and a marked area of dulness on percussion. "The latter dulness could be made to contract or en- large in area at will by elicitation of the aortic reflexes. (This is an important diagnostic aid in differentiating the dulness of aneurysms from the dulness of other causes.) "Palpation yielded a slight systolic thrill over the area of aneurysmal dulness. "A loud systolic bruit was heard over the aneurysmal dulness which was propagated posteriorly along the course of the descending aorta. "There was an accentuated second aortic tone. "The heart was somewhat displaced to the left and the apex beat was diffused over a large area and dimin- ished in force. "Slight tracheal tugging was present. "Treatment was administered twice daily and com- menced on July 2, 1911, and continued until the iyth of the same month. "The following notes are based on an examination made on Aug. 8, 1911. "SUBJECTIVE SYMPTOMS. Absolutely no pains of any kind. Dyspnea, dysphagia and insomnia have disap- peared. The voice is practically restored and the patient expresses herself as being highly gratified with the com- plete relief from previous agonizing physical suffering which this treatment has afforded. "OBJECTIVE SYMPTOMS. No exophthalmos nor vascu- lar engorgement of the head and extremities. "Right radial pulse no longer retarded and restored to the norm. "The bulging of the anterior chest-wall is still present, but diminished. 573 S p o n d y I o t h e r a p y "The former aneurysmal area of dulness is fairly reso- nant but not completely so. The latter may be attributed to the induration of the chest-wall contiguous to the site of the aneurysm. "There is no longer any accentuation of the second aortic tone. "The systolic thrill and bruit have disappeared. "The apex beat is not diffused but circumscribed and has regained its normal position. "Tracheal tugging persists. "Improvement in strength and general appearance of well-being still continues. "There was no X-ray verification of the conditions in this case, but the physical signs respecting the aneurysm and the results of treatment were absolutely positive and unmistakable." Dr. M. L. Turnbull, presents the following: "The report of the following patient, I believe to be indicated, for the reason that we have heretofore regarded aneurysms of the aorta among the incurable diseases. "A. D., age, 28 years. Sent to California by his phy- sicians in Chicago for supposed pulmonary tuberculosis. "Seven years ago contracted syphilis. Entered the service of Dr. W. C. Voorsanger, at the Mount Zion Hospital, for dyspnea, pains in the chest and a constant cough and expectoration which permitted him no sleep at night without the use of narcotics. Slight dysphonia. Veins of the neck very prominent and dilated. Slight tracheal tugging. "Pronounced dulness on percussion of the upper chest corresponding to the arch of the aorta, which measures 6 cm. in diameter. "Systolic murmur over aorta propagated toward the left shoulder. "Palpation reveals a diastolic shock over the region corresponding to the orifice of the pulmonary artery. "A skiagraph shows an immense aneurysm of the thoracic aorta, chiefly implicating the arch. 574 Comments by the Author "Examination of the sputa, negative. "A vigorous course of inunctions was without effect on the symptoms. "At this time the patient presented an anemic appear- ance and his weight was 118 pounds. "Treatment by concussion daily of the yth cervical spine was commenced on April 26, 1911. After the first stance of concussion, lasting ten minutes, the systolic murmur over the aorta almost disappeared. "On April 29, the aneurysmal dulness measures trans- versely 2.6 cm. "May i, 1911, aneurysm measures 2 cm. and the patient's weight is 123 pounds. "May 3, 1911, absolutely no dulness over site of aneur- ysm, pains in chest gone, expectoration reduced about 50 per cent, but cough continues with less frequency and severity. "July i, 1911. Patient's weight is now 135 pounds. Has absolutely no symptom beyond an occasional cough, which may be attributed to a naso-pharyngeal catarrh." COMMENTS BY THE AUTHOR. On Nov. 28, 1911, this patient developed a violent cough followed by hemo- ptysis. His aneurysmal symptoms were absolutely gone, and for this reason search was made for his trouble. An apical infiltration was demonstrated with a large number of tubercle bacilli in his sputum. Previous ex- aminations of his lungs and sputa were negative. The following anamnesis is extremely interesting in illus- trating discordant views among the leading medical authorities, coupled with the fact that, the execution of a simple diag- nostic sign would have clarified a bizarre and protean clinical picture : A prominent attorney suffered for several months in San Francisco from periodic paroxysms of coughing, which were so violent as to induce attacks of vertigo, and narcotics were administered to subdue them. His 575 Spondyloth e r a p y physicians were unable to trace the genesis of the cough, and receiving no relief, he left for Europe for further counsel. During his sojourn in Europe, he suffered from atrocious pains in the chest and the left arm. Some ascribed the pains to neuritis, although there was abso- lutely no objective evidence of the latter. Repeated skiagrams of the chest demonstrated the presence of an intrathoracic shadow (Fig. 132), the nature of which was variously interpreted. Kocher, of Bern, after deliberating a week concerning his findings concluded that, the pa- tient was the victim of a spinal growth and that a serious and immediate operation was necessary. FIG. 132. Intrathoracic shadow of an aneurysm interpreted as a spinal growth (vide text). The patient almost concluded to submit to an opera- tion, but before so doing, he consulted Sahli of Bern. The latter assured him that he could find no growth and prescribed quinin, which caused the pains (which had previously resisted narcotics) to evanesce. The patient was subsequently examined by at least twelve of the leading authorities of Europe, all of whom gave varying opinions. On the return of the patient to this city, the paroxysms of cough continued with una- bated severity. My examination in brief, revealed the following: i. Dilatation of the arch of the aorta on percussion; 576 Comments by the Author 2. Slight tracheal tugging; 3. Induration and inflamation of the vocal cords and a slight arytenoid paralysis; 4. Absence of respiratory sounds over the lower lobe of the right lung; 5. On fluoroscopic examination, a shadow was seen, which was somewhat fusiform in contour and approxi- mated the spine. COMMENTS BY THE AUTHOR. The possession of an X-ray apparatus does no more in postulating a knowledge of skiascopy than the possession of a microscope of microscopy The errors perpetrated by the microscopist are no less grave than those of the skiascopist. The proper interpretation of an X-ray ^examination, coupled with correct technic, means essentially a study of chiaroscuro, or of light and shadow effects. An X-ray examination is practically an autopsy con- ducted oh the living and misinterpretation may make a verity of a metaphor. If the aortic reflexes had been elicited during the fluoroscopic examination, an error in diagnosis would have been practically impossible, insomuch as the con- traction and dilatation of the shadow would have demon- strated its association with the aorta. The fact that, the respiratory sounds over the lower lobe of the right lung were again audible after a brief seance of concussion of the seventh cervical spine, was in itself a demonstration that, the treatment contracted a dilated aorta and thus temporarily eliminated a mechanic bronchostenosis which accounted for the absent vesicular murmur. The paroxysmal symptoms of the patient suggested an aneurysm, insomuch as we know that the lumen of the aorta is not constant and is subjected to periodic fluctuations from a variety of causes (page 620). The fact that the pains were primarily relieved by quinin, 577 Spondyloth e r a p y only emphasizes the importance of this medicament in in- creasing vagus-tone and thus diminishing the caliber of the aorta which by pressure caused the pains from which the patient suffered. Two weeks daily concussion of the seventh cervical spine practically subdued the violent paroxysms of coughing and the larynx was almost restored to normal. The author finds that fusiform aortic dilatations are less amenable to rapid results from concussion than are the sac- cular dilatations. Dr. W. T. Baird, a prominent physician of El Paso r Texas, presents the following autobiography of his case (reported in the Medical Record) : ANEURYSM OF THE INNOMINATE ARTERY. "Dr. W. T. Baird. Age, almost 80 years. Practiced medicine con- tinuously for 47 years, during 8 years of which time I was A. A. Surgeon in the U. S. army. Had la grippe in 1888, and since this time have suffered from cardiac arrhythmia. During the last 5 years I have experienced almost constant coldness and numbness in my left leg. About one year ago, pains of a peculiar sickening and prostrating character were experienced in the arms and chest and they would awaken me at night. About three months ago, I felt a pressure on my trachea which affected my voice to the extent of aphonia. Since about one year, I first observed a diffused pulsation in the supra-sternal fossa. My pains increasing in severity and dyspnea becoming accentuated, I was examined by Drs. Gallagher, Brown, Calnan and Fleming, of El Paso, all of whom concurred in the diagnosis of an aneurysm. I then decided to go to Dr. Albert Abrams, of San Fran- cisco, for treatment. I certainly supposed that a phy- sician who had originated a new method of treatment for an incurable disease was best qualified to treat it. "After my very first treatment, a troublesome and persistent cough has never returned. At the commence- 578 Aneurysm of the Innominate Artery ment of treatment, my voice, which was then only a 'squeak,' was rapidly restored to normal. "After twelve treatments, I observed the following relative to my condition: cardiac arrhythmia has dis- appeared, coldness and numbness in my left leg are no longer present and the pressure on my trachea and the air-hunger have disappeared. In fact, I regard myself as perfectly restored. At about the end of a week, the supra-sternal pulsation was fully reduced 50 per cent." COMMENTS BY THE AUTHOR. My examination re- vealed dilatation of the aorta, but the arteria innoffiinata was chiefly implicated in the angiectasis. Painful and deformed fingers due to arthritis deformans were almost restored to normal after twelve treatments. The results thus attained are given explanation on page 402. The disappearance of arrhythmia and other circula- tory disturbances, can be attributed to myocardial-toning, insomuch as the method of treatment (concussion of the 7th cervical spine), evoked equally the heart and aortic reflexes of contraction. Pains in the arms from which Dr. Baird has suffered for years were caused by an osteo-arthritis of the shoulder joints. An ankylosis of the shoulder is not uncommon and the adhesions are concealed by the compensatory movement of the scapula. Any elevation of the arm be- yond the horizontal in the norm is effected by rotation of the scapula, hence, in testing the joint fix the scapula. Aside from restricted and painful motion in the joint, I have found that the sensitive points in the course of the brachial plexus, are made more sensitive by active and passive movements. In inflammation of joints limitation of motion is also due to rigid muscles, in conformity with the law of Hilton: nerves innervating groups of muscles moving a joint also furnish a distribution of nerves to the skin over the insertions of the same muscles, and the in- terior of the joint receives its nerves from the same source. Even an imperceptible ankylosis may show acute exacer- 579 8pondyloth e r a p y bations suggesting neuritis, but the absence of definite areas of tenderness in the course of the radiating pains excludes neuritis. Here, large doses of the salicylates (page 142) are effective. Dr. Baird noted attacks of intense dyspnea after riding in his automobile. After riding in larger machines such attacks did not ensue. The back of his seat corresponded to. the third dorsal spine, which, when concussed en- larges the large intrathoracic blood-vessels ANEURYSM OF THE THORACIC AND ABDOMINAL AORTA IN THE SAME SUBJECT. A gentlemen, 43 years of age, sought relief for attacks of pain in the chest and abdo- men. Intense dyspnea at night and coughing prevented sleep. Lost 50 pounds in weight. Examination revealed in brief an aneurysm of the thoracic and abdominal aorta. When the patient first came under observation a chronic parenchymatous nephritis was demonstrated and the symptoms (edema, dyspnea) becoming accentu- ated, further treatment of the aneurysms was suspended. If percussion of the thoracic aorta, were executed as a routine method of examination, a clinical in lieu of an an- atomical diagonosis would be more frequent and many apparently trivial symptoms could be traced to their real source of origin. Recently, the author examined an individual whose only symptom was an incessant desire to swallow, for which no relief was obtained. Examination demonstrated an aneur- ysm of the thoracic aorta. The non-recognition of an aneurysm is an unpardonable error in diagnosis, and the modernist can no longer seek refuge for his dereliction in the traditional classification: (a) Aneurysms with signs and symptoms, (b) Aneurysms with symptoms but no signs, (c) Aneurysms with neither symptoms, nor signs. 580 Rationale of the Author's Method RATIONALE OF THE AUTHOR'S METHOD. This is essen- tially the employment of a reflex in treatment* (page 392). The author believes that the cure of aneurysm by his method is achieved by increasing the contractility and tonicity of the aorta (page 410) and that the impulses are conveyed indirectly to the vagus (page 519 and Fig. 119). Reduction in the area of an aneurysm as demonstrated by numerous skiagrams is never in proportion to the amelior- ation of the subjective symptoms. Percussion may show an absence of aneurysmal dulness in patients symptomatically cured, yet a skiagram reveals the aneurysm but only slightly diminished in area. In the treatment of his aneurysmal cases, .the author employed concussion exclusively as a crucial test. Having established its specificity, he no longer eschews those adju- vant measures which combat aortectasis, viz., inhibition of cough by codein, the use of laxatives, anti-luetic treatment and a plenitude of physical and mental rest. The influence of the latter on aortic tonicity has been shown on page 466. One must also remember that an hypodermatic injection of pilocarpin (.0065 gm.), will accentuate the aortic reflex of contraction (page 457). One may also advise the patient to increase vagus-tonicity by forcible extension of the head (page 469). Such exercises maybe taken twice a day; thirty extensions suffice for each seance. Fig. 133, represents the primitive apparatus necessary for concussion in the absence of more elaborate apparatus. More can be accomplished with an ordinary tack-hammer than with the useless apparatus on the market. In fact, with the hammer only, cures were effected by other physicians. *Dr. H. Jaworski, of Paris, France, designates the methods of the author as verte- bral reflexotherapy. Reflexotherapy is given extended consideration on page 636. 581 Spondylotherapy Due regard must be paid to the possible consequences when concussion is executed in the treatment of aneurysms (page 640). The sinusoidal current may substitute concussion, when the stimulating action of the latter is exhausted (page 400). FIG. 133. Illustrating primitive apparatus for executing concussion. A tack- hammer, over the striking end of which is affixed the rubber-tip of a crutch and a piece of linoleum or other suitable material over the end of which a piece of rubber- tubing is fitted and which is used for pleximetric purposes. When patients are hypersensitive to electricity, the author employs rubber-cement which is painted on the skin corres- ponding to the area occupied by the electrodes. The cement must be dry before using the current. COCAIN KATAPHORESIS. This is very unsatisfactory, and the negative results suggest a very important field for research. In my investigations, I found that definite cutaneous areas rendered anesthetic by cocain (kata- phoretically and by injection) were decidedly more sensitive to electric currents than were normal cutaneous areas. In hysterical subjects, the author has found that 582 o c a i n Kataphoresis areas of anesthesia peculiar to this disease react similarly. There is much reason to believe that nerve-energy is a form of electricity and in man there are electric nerves. The demonstration of animal electricity galvanometri- cally is difficult of demonstration, but the foregoing ob- servations may suggest a new field of observation, i. e., by excluding other cutaneous sensations, the perception of electric sensation is demonstrable. After this manner, the law of specific nerve-energy (page 545), can be made manifest with reference to problematic electric nerves, S p n y t h a p y CHAPTER XV. FURTHER ADVANCES IN THE DIAGNOSIS OF DISEASES OF THE DIGESTIVE SYSTEM. PERCUSSION OF THE STOMACH DIAGNOSTIC DATA PERCUSSION OF THE INTESTINES THE GALL-BLADDER DIAGNOSTIC DATA THE PANCREAS. PERCUSSION OF THE STOMACH. Many text-books still show our traditional conception of the stomach as an organ horizontal in position, with the larger curvature as a deep pouch, and the pylorus only a FIG. 134. Normal stomach of Holzknecht (illustration to the left), and Rieder (illustration to the right). Vide text for a further description. little below the cardiac orifice (transpyloric plane) opposite the first lumbar vertebra. With the advent of the Roentgen rays, our conception of the size and location of the stomach has been considerably 584 Percussion o f t h e Stomach modified and a Roentgenographic examination (individual standing) shows the normal forms of the stomach, according to Holzknecht and Rieder, as pictured in Fig. 134. In the former, with dorso-ventral transillumination in standing and the stomach filled with bismuth, the pylorus represents the most dependent part of the stomach; a, cepha- lic pole; b, gas-bladder of the pars cardiaca (fundus); d, pars media (corpus); e, pars pylorica; c, caudal pole (identi- cal with the pylorus). The stomach is the shape of an ox- horn. fundus Cardiat orifice^ Les&ercutvatunt AnCrum, pylori FIG. 135. Diagrammatic outline of the stomach (Gray). On page 321, the author has described the vago-visceral method of outlining the stomach and Fig. 86, is only sche- matic. It is now possible to delimit by percussion practically the entire stomach excepting the cardiac orifice (Fig. 135). The latter is situated at a point on the yth left costal cartilage, one inch (2.5 cm.) from the sternum and corresponds approx- imately with the body of the nth dorsal vertebra. Delimi- tation of the stomach by the author's method of percussion is only possible with the patient standing. During the time the gastric walls are made tense by pressure in an intercostal space by an assistant (which causes reflex stimulation of the vagus), or without an assis- 585 Spondyloth e r a p y tant, by having the patient fix his head in forcible hyperex- tension, as shown in Fig. 65, the stomach yields a dull tone on percussion. The intercostal method may be used in children. The latter dulness at once becomes tympanitic when either of the two foregoing maneuvers are inhibited. During either maneuver, the dulness of the stomach is differentiated from the resonance of the lung and the tym- panicity of the intestines. Fig. 136 represents a normal stomach outlined by the vago- visceral method of percussion; the continuous line represents the stomach when empty, and the broken lines the position after the ingestion of bismuth; L, represents the lower border of the liver. If a comparison is made between the X-ray pictures of the stomach (Fig. 134) and those obtained by the vago-visceral method of percussion, one notes a discrepancy in size and shape of the organ. Now, the X-ray pictures have been determined by filling the stomach with a bismuth-paste. We note in Fig. 136, what ensues respecting the form and position of the organ before and after the ingestion of bismuth, and we are con- strained to conclude, that the X-ray pictures are artificial* and only partially reproduce the real shape of the organ. The moment food is ingested, and particularly bismuth, the stomach endeavors to evacuate its contents and the exag- gerated vertical posture of the organ is manifested. The latter conclusion was only formulated after repeated exam- inations of at least one hundred cases. In a small minority of instances, notably in severe grades of gastric atony and gastroptosis, the vago-visceral method was by no means easy, owing to atony of the musculature of the stomach. *StiIler, 101 likewise protests in accepting the radiologist's conception of the shape of the normal stomach, which, he affirms, is only the specific reaction to the ingested bismuth. 586 Percussion of the Stomach The fact that, there is no transition from tympany to dulness by augmentation of vagus-tone, may be utilized in estimating the tone of the muscular component of the stomach. FIG. 136. Percussion of the stomach by the vago-visceral method (page 321). The continuous lines represent the empty stomach and the interrupted lines, the contour of the organ after the ingestion of bismuth. L, indicates the lower liver- border. Having delimited the organ by percussion, one may easily demonstrate that, concussion of the 5th dorsal spine 587 S p o n d y I o t h e r a p y or paravertebral pressure (page 467), will enlarge the pylorus (dilatation) and that similar maneuvers limited to the 3d dorsal spine will contract the pylorus. In other words, we elicit the pyloric reflexes of dilatation and contraction.* To the average reader, these observations seem incred- ible, but they have been most carefully controlled by X-ray examinations and in other ways. The following simple test may be utilized in determining the patency of the pylorus; after careful percussion of the upper and lower border of the stomach, the patient ingests nine ounces of water and the time is noted when the organ passes from the vertical to its normal position. As a rule, this occurs in about one minute. Paravertebral pressure between the third and fourth dor- sal spines, which inhibits vagus-tone (page 472), will maintain the vertical posture of the stomach as long as pressure is continued. DIAGNOSTIC DATA. Some reference to this subject is made on page 323. In several instances, the writer has made an early diag- nosis of a carcinoma of the stomach by noting irregularities of the borders of the organ after percussion of the latter. Gastrectasis caused by pyloric obstruction may be deter- mined by noting the absence of the pyloric reflexes. That is to say, percussion by the vago-visceral method shows neither an augmented area of the pylorus after concussion or pressure at the fifth dorsal spine nor a diminished area, after like maneuvers at the third dorsal spine. *My measurements show that the location of the pylorus in the norm is 8.6 cm. from the lower border of the costal arch in the parasternal line. It has a normal width by percussion of 1.6 cm., and descends 2 cm. after a deep inspiration or after the ingestion of 9 ounces of water. The dilator nerve of the cardia is a closing nerve for the pylorus. Opening of the cardia and pyloric contraction occur simultaneously. 588 Cardiospa s m Perigastric adhesions may be surmised when percussion cf the stomach shows no descent of the latter during forced inspiration. An hour-glass stomach was determined in one patient. Spasm of the pylorus may be differentiated from hyper- trophic stenosis by elicitation of the pyloric reflexes. CARDIOSPASM (contraction of the cardiac orifice) is usu- ally associated with esophageal dilatation. Regurgitation of food may or may not be present. The food regurgitated is not from the stomach. Radiographs show the dilatation and esophagoscopic examination demonstrates the presence or absence of pathologic conditions. In cardiospasm of neu- rosal origin, pressure between the third and fourth dorsal spines by inhibiting vagus-tone (page 467), will enable the patient to swallow without difficulty during maintenance of pressure. In cardiospasm, the stomach tube (30 to 35 French scale), is arrested at a point about 8 or 10 inches from the teeth. In any obstruction of organic origin small sounds or tubes will pass a stenotic orifice more easily than large ones. The contrary holds when a spasm is functional. The etiol- ogy of cardiospasm is obscure. A few cases are associated with gross lesions (ulcers, fissures) of the esophagus or stomach (carcinoma) and neurasthenia as a factor in etiology is no doubt exaggerated. If, during the passage of a tube, the latter is obstructed owing to a spasm of the esophagus, paravertebral pressure between the 3rd and 4th dorsal spines, by releasing , the spasm, permits of the introduction of the tube. Gastroptosis may be differentiated from dilatation of the organ by noting the position of the lesser curvature of the organ in relation to the greater curvature. In gastroptosis, the pylorus and lesser curvature are correspondingly de- 589 Spondyloth e r a p y pressed, whereas in gastrectasis, it is the greater curvature which is displaced downward. By the author's method of percussion, the normal distance between the two curvatures is approximately 5 to 8 cm. Gall-bladder disease (cholelithiasis and cholecystitis), causes adhesions and definite displacement of the stomach and duodenum. The evidence of such adhesions has been demonstrated fluoroscopically in the upright position. Pfahler 102 directs attention to the fact, that the symptoms of gall-bladder disease appear during digestion when adhesions interfere with the emptying of the gall-bladder, either di- rectly or because the gall-duct has been drawn abnormally high. Vago-visceral percussion of the stomach may be equally utilized in diagnosis by noting the approximation of the pyloric end of the stomach to the gall-bladder. It is also true that adhesions would prevent the vertical posture of the stomach after the ingestion of water or food. Pharmaco-diagnostic data with relation to the stomach have been noted on page 453, and it is well to bear in mind the centers in the cord sensorially related to the stomach (page 377). If the third, fourth and fifth dorsal spines are thoroughly frozen, all subjective and objective sensations of gastric genesis evanesce from minutes to hours. Thus, one may differentiate gastric from other affections. Supple- mentary to the data on page 453, my observations show that, adrenalin dilates and pilocarpin contracts the stomach . Thus, 10 minutes after an injection of pilocarpin (gr. iV), the vertical diameter of the stomach (lesser to greater curvature) measured 2 cm., although before, it measured 5 cm. Ten minutes after an injection of 8 minims of adrena- lin chlorid solution (1:1000), the same diameter of a stomach increased from 5 .6 cm. to 9 cm. After this manner one may 590 Percussion of the Intestines determine whether gastric neuroses are under sympathetic or autonomic control. The treatment of gastric affections has been discussed on page 324. Supplementary to treatment referred to on the latter page, a comparison of concussion and slow sinus- oidalization is shown by the following results: the duration of concussion and sinusoidalization of the second lumbar spine was one minute. CONCUSSION. Degree of stomach reflex of contraction 2.8cm. Duration of stomach reflex of contraction.... 5 minutes. SLOW SINUSOIDAL CURRENT. Amplitude of stomach reflex of contraction 2 cm. Duration of stomach reflex of contraction 1 1 minutes While the amplitude of the reflex was less with the current, its duration lasted more than twice the time. PERCUSSION OF THE INTESTINES. Physiologists are divided concerning intestinal innerva- tion. The viscero-motor nerves are derived from the vagi and sympathetic chain. Clinical physiology, however, sheds some light on the subject. The different maneuvers for increasing vagus-tone (page 469) do not influence the intestinal reflexes (pages 325, 326), but the latter cannot be elicited if the vagus- tone is removed by pressure between the third and fourth dorsal spines (page 467). In this regard, the action of the vagus may be compared to the brain and cord. Irritation of the latter has no evident effect on intestinal movements during life, yet one knows that the mentality may influence the movements and that in paraplegia, intestinal motility is diminished and tympanites ensues. 591 Spondyloth e r a p y The elicitation of the intestinal reflex of contraction (page 325), causes a contraction of all the intestines and it is im- possible to differentiate individual portions. It is now possible, however, to elicit dulness of definite intestinal areas by aid of paravertebral pressure with the radicularpressor (Fig. 112). Pressure must be maintained by an assistant during the time percussion is executed and the patient must be standing. In some instances the area of the intestine yields an absolute dulness, and in other instances it is only tympanitically dull. The following pressure sites have been established: 1. DUODENUM. Pressure on both sides of the loth dorsal spine. The dulness thus elicited averages in width 4.5 cm., and extends an average distance of 5.5 cm. from the pyloric end of the stomach. Unlike the stomach, it is uninfluenced by the movements of respiration, and the site of the dulness does not change like the stomach by con- cussion of the nth dorsal or 2nd lumbar spines. 2. SIGMOID FLEXURE. Pressure on both sides of the ist dorsal spine. 3. CECUM WITH ATTACHED ILEUM ? AND ASCENDING COLON. Pressure on both sides of the i2th dorsal spine. Careful percussion demonstrates an area of dulness attached to the cecum averaging 2.5 cm. in width and 3 cm. in length. This is possibly a part of the ileum. 4. DESCENDING COLON. Pressure on both sides of the ist lumbar spine. The average area of dulness is small (6 cm. x 6 cm.) and is located above the dulness of the sig- moid flexure in the left lumbar region. 5. TRANSVERSE COLON. Pressure on both sides of the 4th lumbar spine The area of dulness extends across the umbilical region from the ascending to the descending colon. 592 D a n Its limitation at its upper part is not always clearly denned. The width of the dulness averages 4 cm. FIG. 137. Areas of intestinal dullness elicited by paravertebral pressure. The dullness of the stomach (s) was determined by the vago- visceral method (page 321), D, duodenum; C, cecum; I?, probably attached ileum; DC, descending colon; SF. sigmoid flexure; TC, transverse colon, the continuity of which is interrupted in the illustration by the stomach and duodenum. Compare with Fig. 138. Fig. 137, shows the location of the areas of intestinal dul- ness elicited by paravertebral pressure at definite spinous processes and Fig. 138, shows the normal topography of the intestines. 593 S p o n d y I o t h e r a p y DIAGNOSIS. In the norm, the abdomen is (excepting hepatic and splenic dulness) tympanitic. It is impossible with the conventional methods of percussion to distinguish FIG. 138. Normal topography of the alimentary canal (Rawlmg's landmark 8 and surface markings of the human body), i, esophagus; 2, stomach; 3, pylorus; 4, 4, 4, the three parts of the duodenum; 4 , the pancreas; 5, duodeno-jejunal flexure; 6, mesenteric attachment of small intestine; 7, ileo-cecal valve; 8, cecum; 9, vermi- form appendix; 10, ascending colon; n, hepatic flexure; 12, splenic flexure; 13, descending colon; 14, iliac colon; 15, ilio-pelvic colon; 16, gastro-hepatic omentum; 17, foramen of Winslow; 18, common bile-duct. Transverse colon omitted, a, a, and a 1 , a lateral vertical planes; b, b, transpyloric plane; c, c, subcostal plane; d, d, intertubercu\ar plane. the small intestines from the colon. With the methods sug- gested by the author such differentiation is usually possible by topographic percussion. Intestinal ptoses, tumors, dilatation of the colon and other affections may be differentiated by the foregoing meth- ods. 594 D iagnosis Recently, 103 attention has been devoted to a mobile, cecum (coecum mobile), which produces symptoms resem- bling appendicitis and at the operating table the appendix was normal. The value of topographic percussion in such instances is apparent without comment. I wish to illustrate some of the foregoing methods by the citation of a case seen with Dr. A. Gates, of Los Angeles. The patient has lost 20 pounds in weight during the past year. Has recurrent attacks of pain for years in the epigastrium of a dragging, piercing character, several hours after food is taken, which is relieved by the ingestion of more food or sodium bicarbonate. The history sug- gests a duodenal ulcer. Percussion made during the time the head was ex- tended (Fig. 65) demonstrated a dilated stomach. Pres- sure at the loth dorsal spine elicited the dulness of the duodenum. During forced inspiration, the area of gas- tric dulness descends showing that there are no perigas- tric adhesions. When the patient ingested 9 ounces of water (page 588), the stomach remained in the vertical position for 10 minutes (i minute in the norm). It was then assumed that there was a pyloric obstruction. The latter, however, was a spasm of the pylorus, for when pressure was made between the 3rd and 4th dorsal spines (which releases gastric spasms, page 589), the stomach at once assumed its normal position. The dilatation of the stomach it was assumed was likewise caused by the spasm and not a mechanic obstruction. Further con- firmation of the pyloric spasm was elicited by the fact that pressure at the 5th dorsal spine (page 588) caused an in- crease in the percussional area of the pylorus. Over the area of gastric dulness, a very tender spot (i cm. in width) was palpated which shifted upward after concussion of the 2nd lumbar spine and downward by concussion of the i ith dorsal spine and a forced inspira- tion. A tender spot of like area was located at the duo- 595 Spondylotherapy denum but which showed no dislocation on inspiration nor concussion. Freezing the 3d, 4th and 5th dorsal spines (page 377), caused the area of gastric tenderness to disappear but did not influence the duodenal point of sensitiveness. Diagnosis. Ulcer .of the stomach and duodenum. COMMENT. The presence of occult blood in the feces is a valuable diagnostic point. Exclusive rectal feeding (not even water by the mouth) causes the symptoms of gastric and duodenal ulcer to disappear in a few days and is equally diagnostic. Duodenal ulcers are frequently confused with gastric ulcer. The former occur usually in early adult life and are characterized by periodic attacks of "stomach trouble." Pain and tenderness usually extend from the mid-line to the right and the accentuation of symptoms due to ingested food occurs several hours after a meal. The so-called "hunger-pain" is a frequent symptom. Auscultation of sounds evoked by intestinal peristalsis shows that, the sounds are increased in intensity during the time pressure is made between the 3d and 4th dorsal spines and that they become less loud or are inhibited during the time pressure is maintained at the yth cervical spine. THE LIVER. The study of visceral anatomy or organology in the conventional way in the dissecting room, gives us an inade- quate conception of the topographic anatomy of the living viscera. This criticism is equally applicable in the arraign- ment of the conventional methods of percussion. The lower border of the liver may be cited as a paradigm. Percussed in the usual way and compared with the author's methods on page 598, it will be found that, it is usually 4 cm. lower than would be indicated by percussion after the accepted methods 596 The Gall-Bladder (Fig. 139). Reference to the foregoing observation must be recalled in locating the site of the gall-bladder. By what the author designates as splanchnoscopy, the observation in question is likewise confirmed. The ascent and descent of the lower border of the liver may be observed when the patient is placed with flexed knees on a table with the head against a good light. The observer stands with his back likewise to the light and fixes his vision on the epigastrium. The patient must execute forced breathing. The shadow may be traced to both sides of the median line of the epigastrium. In women, owing to the thoracic type of breathing the shadow, is less evident. The shadow may be accentuated, as the author has shown in his investigations 104 of the phrenic shadow, by painting the skin (embraced by the shadow) with a saturated alco- holic solution of gamboge. THE GALL-BLADDER. The fundus of the gall-bladder projects beyond the an- terior border of the organ. A line drawn from the right acromion process to the um- bilicus crosses the costal arch approximating the location of the gall-bladder. The latter in its long diameter measures from 7 to 10 cm., and about 4 cm., in its greatest transverse diameter. The site of the gall-bladder varies with the position of the lower border of the liver and the latter is practically always lower than the description in the conventional text- book (page 596). The reason for the latter error is obvious. The lower liver-border is immersed in an atmosphere of tympanitic sound and its edge does not exceed one centimeter in thick- ness. 597 S p o n d y I o t h e r a p y The usual methods of percussion are untrustworthy in defining the topography of the organ. Two methods are available for mapping out the lower liver- border: FIG. 139. Method of locating the gall-bladder by the postural method. The dotted line represents the lower border of the liver obtained by percussion in the usual way. The heavy line represents the lower border obtained by the postural method. It is only in this way that one can account for the different results ob- tained by clinicians in locating the lower border of the liver which is really lower than is currently supposed. i. Postural method. During percussion, the patient inclines the body backward as far as possible, and, to re- lieve the tedium of the posture, the body is supported by means of the hands resting on the hips or by an assistant. Percussion must be light (Fig. 139). The rationale of this maneuver, I have described else- 598 Diagnostic Data where 103 . In the posture suggested, the liver is approximated to the abdominal parietes. 2. V ago-visceral method. During light percussion, the head is fixed in the position as shown in Fig. 65. The rationale of this method involves the principle of visceral-tone and is described on page 451. Having located the lower liver-border by either of the foregoing methods, one seeks to locate the gall-bladder by percussing in the directions shown in Fig. 139. The tympanitically-dull area of the gall-bladder is in marked contrast with the dulness of the liver-border. In percussing the gall-bladder, the postural or vago- visceral method must be maintained. Note the following concerning the gall-bladder area of tympanitic-dulness : 1. It descends on inspiration; 2. It is diminished or disappears after concussion of the 4th, 5th and 6th dorsal spines; 3. It enlarges after concussion of the Qth dorsal spine. DIAGNOSTIC DATA. The pear-shaped dulness of the gall- bladder rising and falling in respiratory rhythm with the liver would exclude adhesions. Pain due to disease of the gall-bladder may be accurately located. Riedel's lobe (a freely movable linguiform body), which is common in chronic disease of the gall-bladder, may be de- termined by percussion. It may be on either side of, or over the gall-bladder. According to the law of Courvoisier, in cases of chronic jaundice due to obstruction of the common bile-duct, contraction of the gall-bladder signifies that the obstruction is due to a stone; dilatation of the gall-bladder suggests that the obstruction is due to causes other than a stone. 599 Spondylotherapy This law is based on the fact that in cholelithiasis, the gall-bladder is the site of chronic inflammation, and is, in consequence, contracted and not capable of dilatation. Hence, if percussion shows an enlarged gall-bladder, chole- lithiasis may, as a rule, be excluded, and it is evidence in favor of a neoplasm. TREATMENT. In the absence of a stenosis or obstruction in the common duct, concussion of the 4th, 5th and 6th dor- sal spines eventuates in evacuation of the contents of the gall-bladder. The latter maneuver is indicated in catarrhal jaundice, infectious cholecystitis and in the so-called hepatic inter- mittent fever associated with gall-stones. Chronic cholecystitis is usually of infectious origin, and infection is a frequent exciting cause of gall-stone formation. Owing to the anatomic arrangement of the cystic duct (infolding of the mucosa in the form of valves), free drainage of the gall-bladder is difficult and the method suggested in treatment may be executed. THE PANCREAS. The author, as a result of his limited investigations, finds that the secretion of the pancreas is probably increased by concussion of the 4th, 5th and 6th dorsal spines. The investigations were based on the more recent meth- ods of determining the function of the pancreas by testing for the presence of ferments in the stool. Rapid peristalsis is hastened after breakfast of mixed food by an enema and calomel (0.2 gm.) and phenolph- thalein (0.5). Activity of the pancreas is determined by the presence in the stool of trypsin and amylopsin. Their absence suggests pancreatic insufficiency or obstruction. The Wohlgemuth 106 method for amylopsin is probably 600 The P a n c r e a the most reliable. One prepares a i per cent, solution of Kahlbaum's soluble starch prepared on a water bath for about ten minutes with considerable stirring. In the absence of a fluid stool, 5 gm. of stool is rubbed up with 20 c.c. of a physiologic salt solution and after being cen- trifuged and filtered varying solutions of this stool-fil- trate are added to 5 c.c. of the starch-solution in test- tubes. Dilutions of i to 10, i to 100 and i to 1000 suffice. To the solution of the starch in the test-tubes, toluol is added and the whole digested for 24 hours (38 to 40C.). At the end of this period, the test-tubes are almost filled with tap-water and one drop of tenth-normal iodin solu- tion is added to each tube. If the starch has been com- pletely digested no blue color appears in the tube. The estimation is made in units; one unit representing the ability of i c.c. of stool-filtrate to transform i c.c. of starch. If the tube containing the i to 1000 dilution transforms 5 c.c. of starch-solution, then i c.c. of undi- luted filtrate is capable of digesting 5000 c.c. of starch- solution. This represents a normal finding (5,000 units). The minimum number of units is 100, although in the tests of Heyn, 10 ? in non-pancreatic cases, they did not fall below 250 units. In pancreatic disease, the findings may be 50 units or lower. 601 Spondyloth e r a p y CHAPTER XVI. PHYSIO-THERAPY OF PULMONARY TUBERCULOSIS. ANEMIC THEORY CLINICAL EVIDENCE TRIANGLES OF GROCCO METHODS FOR ELICITING LUNG-HYPEREMIA RESUME TREAT- MENT AUTHOR'S TREATMENT VISCERAL VASCULARITY BLOOD VOLUME. ANEMIC THEORY. According to Rokitansky, one rarely encounters pulmonary tuberculosis in association with mitral insufficiency for the reason that, in the latter disease, there was congestion of the pulmonary vessels. This contention despite its assailment still holds. FIG. 140. Semi-diagrammatic representation of the pulmonary air-vesicles (Landois and Stirling), v, v, blood-vessels at the margins of an alveolus; c, c, its blood-capillaries; E, relation of the squamous epithelium of an alveolus to the capillaries in its wall; f, alveolar epithelium shown alone; e, e, elastic tissue of the lung. Orth, observed that, kyphotics despite their limited respiratory excursions owed their immunity to tuberculosis in consequence of congested lungs. Clinical Evidence In pulmonary stenosis, tuberculosis is the usual sequela owing to pulmonary anemia. It was the belief of Bellinger, that tuberculosis showed a predilection for the apices for the reason that, they were more anemic than other lung-areas owing to gravity. The influence of posture on the blood contained in the lungs has already been noted on page 290. The vascular supply of an alveolus is shown in Fig. 140. While the amount of blood in the lungs is influenced by gravity, this static factor is not the only one. A very impor- tant factor is the activity of the organ (uH irritatio, ibi affluxus). Pulmonary suction refers to the large quantity of blood drawn into the lungs with each inspiration, and this physio- logic process has not been inaptly compared to a species of dry cupping. Chapman avers, "That if at the termination of expiration the quantity of blood in the lungs is from 1-15 to 1-18 of the total quantity of blood in the body, at the ter- mination of inspiration, it will be from 1-12 to 1-13." The pulmonary vessels expand with each inspiration and con- tract during expiration, the result being an increased flow of blood from the right heart and lungs; the dilated vessels as Campbell puts it, "actually suck the blood out of the right heart." As is known, lung-anemia aids caseation of tuberculous nodules. Tuberculous invasion of the pulmonary apices is probably due to impaired circulation; the posture of the body by gravity diminishing the supply of blood to the upper part of the lungs. CLINICAL EVIDENCE. One meets with a definite clinical picture antedating pulmonary tuberculosis and which, in reality, may be the disease itself. The lungs are hyperreso- nant and suggest emphysema, there is no postural lung- 603 S p o n d y I o t h e r a p y dullness (page 290), the heart is small and enfeebled, systolic murmurs are heard over the pulmonary artery or aorta or both, the triangles of Grocco cannot be elicited, there are zones of atelectasis (page 299) and the signs of pulmonary anemia (page 301). Tissue vulnerability is recognized in certain diseases like diabetes and we anticipate cutaneous and other complica- tions because sugar is demonstrated in the urine. In pul- monary tuberculosis, however, this tissue-susceptibility is ignored, although the pre tuberculous lung is essentially an emphysematous lung, and characterized by hyperresonance, extension of the lung-borders, unchanged percussion note during both phases of respiration and restricted movements of the diaphragm. One ascribes the percussion sound over the lungs to vibra- tion of the chest- wall and the air within the lung-alveoli, but another factor must not be ignored, viz., the quantity of blood in the lungs. One may reproduce this lung-picture of the pretuber- culous lung by concussion of the seventh cervical spine and develop an antagonistic picture by concussion of the last four dorsal spines. In the latter maneuver the maximum effect is secured at the tenth dorsal spine. In the first maneuver, we have excited the reflex of the pulmonary artery (page 526) and diminished the quantity of blood in the lungs, whereas in the second maneuver, we have dilated the pulmonary vessels (page 607), and increased the quantity of blood in the lungs. If one carefully auscultates the pulmonary and aortic sounds at the end of expiration in pulmonary tuberculosis, one will be astounded at the frequency with which murmurs of a functional nature are encountered. 604 ClintcalEvidence These murmurs are usually systolic pulmonary and aortic murmurs, the former being more frequent than the latter. No note is taken of subclavian murmurs (page 533), which are relatively frequent in phthisis. The systolic murmurs, are usually soft and blowing sounds, or merely whiffs and they vary in character and ex- tent of transmission from time to time. The murmurs in question may be due to anatomic lesions but in the majority of instances, they are functional and due to narrowing of the pulmonary artery and aorta as evidenced by the fact that they disappear temporarily after concussion of the tenth dorsal spine which dilates both vessels. The coarctation of the vessels is in part spasmodic (page 525), for the reason that the murmurs are heard at one time and are absent at another time. As a rule, however, the diminished lumina of the vessels is a permanent condition. Rokitansky noted that too voluminous lungs coupled with a small heart characterized the phthisical habitus. This observation was relegated to oblivion until revived and vig- orously defended by Brehmer. The anemia of early phthisis suggests chlorosis and has therefore been hyphenated as chloro-ammia. In 1872, Virchow, in a monograph, called attention to the fact that a diminution of the aortic lumen, attended fre- quently by anatomic changes in its walls, was the almost invariable result of an autopsy made on a chlorotic individual. In some typic instances, the aorta did not exceed a normal femoral artery in caliber. In many instances, the pulmonary artery was similarly involved, the heart was small and its constituent parts proportionately hypoplastic. Another phe- nomen was the extreme elasticity of the arterial walls. Pulmonary anemia (page 301), is one of the most impor- 605 Spondyloth e r a p y tant symptoms of early phthisis. The hematologist, however, does not concede the existence of anemia in tuberculosis, although practically every clinical symptom negatives the latter observation. It is quite probable that while the blood of the peripheral circulation may show a normal blood count, it is not necessarily so with the blood in the rest of the body. The investigations of the author show that the quantity of oxygen in the blood in phthisis is diminished (anoxe- mia) and that the increase of red corpuscles (polycythe- mia) is purely compensatory for there is always an increase in the number of erythrocytes in the blood when the normal process of oxygenation of the body is impaired (phthisis, valvular diseases, emphysema, chronic bron- chitis, asthma)* In the phthisical lung, the paravertebral triangles (tri- angles of Grocco), are diminished in area or are absent. These triangular areas of dullness are found in the norm on either side of the spine (Fig. 141); the vertical side of the triangle corresponds to the spine, the base to the lower border of the lung, while the hypothenuse extends from the apex to the outer and lowest point of the base. The triangles of Grocco are probably due to passive lung- hyperemia as shown by the arrangement of the blood-vessels in Fig. 142. The triangles are probably absent in phthisis owing to the deficiency of blood in the lungs. In the norm, one finds an area of dullness or diminished resonance on both sides opposite the 3d, 4th and 5th dorsal spines (Fig. 141). I shall designate this area as the vascular parallelogram, because it corresponds to the large pulmonary blood-vessels. It disappears, to be replaced by resonance when the yth cervical spine is concussed and is accentuated after striking the loth dorsal spine. In the norm, one may augment the dull area of the para- 606 C I i n i c a I E v i d e n c e vertebral triangle by concussion of the tenth dorsal spine (which increases the quantity of blood in the lung), or dimin- ish the area, by concussion of the seventh cervical spine (which decreases the blood in the lung). It is also influenced by posture (page 290). FIG. 141. Illustrating the site of the vascular parallelogram above and the triangles of Grocco below. Taking an average patient, one finds that in the norm, if the paravertebral triangle measures 8 cm. at the base, after concussion of the tenth dorsal spine, it may be increased to 15 cm. One may also note that the triangles increase in area at the end of a forced inspiration (pulmonary suction, page 603) and diminish in area at the end of a forced expiration. An hypodermatic injection of adrenalin chlorid (eight minims), will maintain an increased area of triangular dullness for hours. Thus, before an injection, the base of a triangle measured 8.6 cm., whereas after the injection (without previous concussion), it measured 14.5 cm. 607 S p o n d y I t h r a p y The area of the paravertebral dullness may be selected as a guide for the quantity of blood in the lungs, and the author in investigating different maneuvers for augmenting lung- hyperemia, presents the following table. The duration of each maneuver was one minute. METHOD DIAMETER OF TRIANGLE AT BASE DURATION OF INCREASED PARAVERTE- BRAL DULLNESS Concussion at both sides of the loth dorsal spine. 14.9 cm. One minute. Direct concussion of the loth dor- sal spine. 10.5 cm. One-half minute. Slow sinusoidal current at both sides of loth dorsal spine. 16 cm. Two and one-half minutes. Rapid sinusoidal current at both sides of loth dorsal spine. 14 cm. One minute. High-frequency current at both sides of loth dorsal spine. 11.9 cm. One minute and forty sec- onds. Pressure at both sides of loth dor- sal spine. 15 cm. Three minutes. Compare the foregoing with the table on page 398. The latter refers to the diffused pulmonary dullness the result of an increased quantity of blood in the lungs. The blood-supply of the lungs is derived from the pulmonary and bronchial arteries (nutriment for the lung-tissues) . Six thousand liters of blood pass through the lungs in twenty-four hours. RESUME. The author believes that, anemia of the lungs is one of the fundamental conditions predisposing to tuber- culous infection and. that therapeutic maneuvers which pro- mote active or passive hyperemia of the lungs are indicated in pulmonary tuberculosis. His method of treatment to be 608 a m n described presently is marvelously efficient in early cases of the disease, but in advanced cases, his results in the main were futile. He believes furthermore, that in tuberculosis of the joints, the surgeon will yet evolve a method of paralyz- ing the vasoconstrictor nerves of a vessel-wall so as to aug- ment the supply of blood to the implicated joint. FIG. 142. Illustrating the arrangement of the pulmonary blood-vessels (Schultze-Stewart, atlas of Topographic Anatomy). TREATMENT. Several writers, notably Kuhn and Jacoby, have treated phthisis akin to the lines already suggested. The former uses a mask of light celluloid with an adjustable 609 pondyloth r a p y valve which shuts off some of the air entering through the mask, which induces a condition of suction-hyperemia (Fig. 143). The mask is used primarily in the morning and after- noon for about fifteen minutes, but later this time is extended to an hour or even more. There are many reports concerning its great value in phthisis. FIG. 143. Mask of Kuhn, to produce suction hyperemia of the lungs. My investigations show that, the use of the mask elicits a moderate increase in the area of Grocco's triangle. By the method of Jacoby, 108 hyperemia in the lungs is induced by lowering the upper part of the trunk by a special reclining chair (Fig. 144). "Autotransfusion," as he calls his method, flushes the apices and does away with the conditions favoring the tuberculous process. With his chair the entire trunk lies horizontally, the head can be slightly raised, while the legs lie higher than the shoulders. By this arrange- ment, the pelvis is on a line with the chest, not lower than the chest according to the usual method of reclining. 610 Treatmen The pelvis can be raised a little higher than the chest by an interposed cushion which supplements the hyperemia induced by the autotransfusion with compression of the base of the lungs by the pressure of the intestines sliding down against the diaphragm. The respiration is more of the costal type, and the lungs are much better ven- tilated when the trunk is lying flat than when the patient FIG. 144. Reclining chair of Jacoby for autotransfusion. is half sitting up, possibly with the shoulders stooping forward; this actually increases the tendency to anemia of the apices. He raises the feet higher by an inch each three days, until the feet are 18 inches above the level of the head. The patients find that they can breathe more deeply and more easily and that expectoration is pro- moted. Usually the occasional sharp pains in the chest disappeared during this position treatment. The hori- zontal attitude is not so agreeable for the patients as sitting up but they soon become accustomed to it and like it, as they come to appreciate the benefit therefrom. The method has been applied in various sanatoria in Germany and the general impression seems to be favorable." The investigations of Bier show that hyperemia is na- ture's bactericide which is expressed in inflammation (page 404). 611 S p o n d y I o t h e r a p y THE AUTHOR'S TREATMENT. Every possible advantage is taken of the home-treatment of phthisis by the hygienic or open-air method which may be summarized as follows: 1. Out-door life in a pure air for every variety of case, without regard to symptoms, in all weathers and seasons, for whole days, and when possible, all night. 2. Hyperalimentation by means of nutritious food, prop- erly selected and prepared, given at definite and frequent intervals. 3. Moderate exercise stopping short of fatigue and an abundance of mental and physical rest. 4. Judicious medical supervision of every detail of the patient's daily life. The reclining chair or the bed must be inclined after the manner cited on page 292. During rest, forced inspirations (which increase the volume of blood in the lungs), must alternate several times a day with seances of rapid breathing as though an effort were made to make inspiration and expiration as short as possible. The latter exercise is similar in action to the mask of Kuhn. Daily seances of concussion at the office of the physician must be supplemented by paravertebral pressure (page 467) at the home of the patient. To protect the skin from the effects of pressure, a small piece of adhesive plaster should be fixed on either side of the tenth dorsal spine. Pressure may be made several times a day but should not exceed one minute in duration, otherwise the pulmonary artery reflex of dilatation becomes exhausted. The seance of concussion for a like reason should not exceed fifteen min- utes and must be interrupted. If the treatment employed is effective in evoking the pulmonary artery reflex of dilatation, the resonance of the 612 The Author's Treatment lung is at once supplanted by dullness on percussion, the triangles of Grocco and the vascular parallelogram like- wise show accentuated dullness and an augmented area, and any systolic murmur over the pulmonic ostium disappears. It is evident to the reader that, the rapid sinusoidal cur- rent may substitute concussion and may in fact, be more efficient but as the results attained by the author have been mostly effected by concussion, he employs the latter to the exclusion of other methods. SUPPLEMENTARY TREATMENT. A daily hypodermatic injection of adrenalin (page 607) may be employed to aid the vascularity of the lung. Another efficient aid is daily inunctions of soft green soap (sapo viridis), one dram once or twice a day. The acutely enlarged glands in scrofula often disappear very rapidly by such inunctions. The tracheo-bronchial lymph-glands are practically always enlarged in phthisis (page 79) and many of the symptoms are dependent on such intumescence. The almost miraculous results with sapo viridis in reducing the enlarged glands in scrofula have suggested to the author its employment in phthisis. It is difficult to define the rationale of such inunctions. Sapo viridis consists principally of potassium oleate. It is known that consumption is notably absent amongst laborers in lime kilns and those who drink hard water. The phenomena of life, according to Loeb, depend upon the presence in the tissues of a number of the various metal proteids, or soaps (Na, Ca, K, and Mg) in definite proportions. By aid of the calcimeter, it has been demonstrated that there are a number of diseases dependent on an excess or diminution of lime salts in the blood. When the 613 S p o n d y I o t h e r a p y estimation shows an excess of lime, citric acid is em- ployed, and calcium chlorid when the lime is deficient. The parathyroids probably control calcium metabolism. Symptoms (muscular twitching, tachypnea, etc.), fol- lowing parathyroidectomy, may be cured by intravenous injections of a 5% solution of calcium lactate. VISCERAL VASCULARITY. That one may influence the vascularity of tissues by stimulation of the seventh cervical spine or the tenth dorsal spine can be easily demonstrated. During the time that a rapid sinusoidal current was ap- plied I have had several competent oculists, notably, Dr. Wm. Hopkins and Dr. Morton Hart, examine the eyes ophthalmoscopically. All noted the immediate anemia of the fundus when the current was applied to both sides of the seventh cervical spine and hyperemia of the fundus, when application was made at the tenth dorsal spine. In this way, one could at will induce hyperemia or anemia. Expectant attention on the part of the observers was excluded by not apprising them of the object of my investigations. The same precautions were taken in a bronchoscopic examination made for me by Dr. Henry Horn, one of the most competent bronchoscopists in the world. His report is as follows: "The following is a report on the Bronchoscopic find- ings in the case of Mr. X., made this morning: The examination was made in the following way: A few drops of a 3% cocain solution was sprayed on the posterior pharyngeal-wall. An applicator, dipped twice in a 20% sol. of cocain was applied to the interior of the larynx but did not extend below the cords. EXAMINATION i. The region just above the bifurcation was very care- fully examined with the 7.5 B running's tube. The mucous membrane was very pale and pasty looking. 614 Visceral Vascularity The small folds between the rings were not injected. Gradually, occupying a time-period roughly estimated at from 3-5 seconds, the folds between the rings gradu- ally became very distinctly injected and one could see a faint rosy blush spreading over the other portions of the mucous membrane. After an interval of a minute the mucous membrane became pale again, the blush dis- tinctly faded and the injection in the small depth between the rings became paler but the injection did not entirely disappear. This phenomenon was repeated, apparently at the will of the operator who carried out some electrical manipulation which I could not follow, several times. One could distinctly tell when the pallor commenced and when the mucous membrane commenced to become more congested. The same experiment was carried out in the larynx itself. The posterior interarytenoid space was selected because there was a very tiny plexus of veins visible. Here at a given time the small plexus became dis- tinctly paler, and after a few seconds interval the veins began to fill and the blush extended distinctly downward over the posterior fold. A patient present at the time who had no idea of the object of the experiment, was told to look down the tube and tell what she saw. She also distinctly saw the plexus grow distinct 1 / pale, or injected at the will of the opera- tor." Comment by the Author, Pallor was produced with the slow sinusoidal current at the yth cervical spine and congestion, when the electrodes were applied at the loth dorsal spine. The laryngeal changes were deserving of special consideration insomuch as the mucosa was al- ready blanched by the cocain. If one inspects the nasal mucosa, one may observe anemic or hyperemic effects according to the site of the application of the current. Like vascular phenomena are demonstratable in the ear-drum. Despite the contention of the physiologist that the 615 Spondylo t h e r a p y pulmonary vessels are unprovided with vasomotor nerves, the clinical investigations of the author suggest the probable incorrectness of the dictum in question. The fact that anemia or hyperemia may be induced at will by the clinician, suggests many possibilities in the treatment of disease. Thus insomnia may be influenced, the oculist may render the eye anemic in ocular inflam- mations, or he may augment the supply of blood in con- ditions demanding it. However, the author is not in a position to speak authoritatively on the subject. He merely suggests this therapeutic resource in the treat- ment of a multitude of conditions and hopes that time and the experience of others may establish its value. He believes that hemoptysis may be controlled by application of the sinusoidal current (the rapid, pre- ferably) to either side of the seventh cervical spine and, in the absence of the current, pressure may be used. The author may be permitted to observe parentheti- cally, that amyl nitrite is the most efficient and expedi- tious expedient we possess in hemoptysis. 109 Unless it is efficient after the first administration, subsequent in- halations do no good. The value of the drug for this pur- pose has been extensively confirmed and Hare, who signalizes this drug as a specific in uterine hemorrhages, claims that it may even arrest menstruation. Atten- tion must likewise be directed to the author's treatment of LOCOMOTOR ATAXIA. He started from the conviction that, the lesions peculiar to this disease are primarily resident in the spinal vessels. Thus, the spinal sclerosis in ergotism resembles in distribution the degeneration peculiar to tabes. One also finds sclerosis of the dorsal and lateral columns associated with pro- found anemia. Now, arteriosclerotic vessels are not rigid tubes but respond to reflex influences by spasmodic contraction. In tabes, the paroxysmal pains and crises are probably caused by a transient angiospasm (paroxysmal claudica- tion of spinal cord), and the author has frequently re- 616 Comment by the Author lieved these symptoms by inhalations of amyl nitrite. In early tabes, by inhalation of the latter, he has tempo- rarily restored the lost knee-jerk. In tabes, concussion of the loth dorsal spine, which augments the vascularity of ^he spinal cord, has given me most encouraging results, coupled with concussion of the lumbar spines. The eminent clinician, Dr. H. Jaworski, of Paris, France, author of a work on "locomotor ataxia," reports several remarkable results obtained by this method. In reporting one case, he comments as follows: "Called into consultation by a confrere, I saw the hopeless case of a woman, who was unable to stand for five years. After a seance of ten minutes, she could walk without a cane and now comes daily to my office for further treat- ment. Other symptoms have improved. This case is a real miracle." Another curious fact, in connection with the author's treatment of phthisis by concussion of the loth dorsal spine, is the enormous increase in the number of red corpuscles following the maneuver. This increase varies from 100,000 to 600,000 corpuscles per cubic millimeter. At first it was supposed that this artificial polycythemia was due to some effect on the bone-marrow but other investigations demon- strated that pressure, sinusoidal and high-frequency cur- rents to the same region eventuated in like results. Concussion of the jth cervical spine, on the contrary, caused an average reduction of 50x5,000 red corpuscles. Estimations were made immediately after concussion. Whereas concussion of this spine causes an increase in the specific gravity of the blood, concussion o c the loth dorsal spine diminishes the specific gravity. BLOOD-VOLUME. The foregoing facts suggest many things in clinical pathology, notably, the causation of edema in nephritis (page 632). Concussion of the spines in question does not cause any appreciable change in the 617 Spondyloth e r a p y blood-pressure which is in accord with the physiologic axiom that, when the vessels are overfilled or contain less than the normal quantity, mechanisms are present for maintaining the blood-pressure at its normal height. My investigations suggest that the caliber of the blood- vessels is not constant and that the change in lumen, is practically a compensatory angiospasm or angiectasis to accommodate respectively a decreased or increased volume of blood. One may easily demonstrate in- creased volume of the organs after concussion of the loth dorsal spine, or diminished volume by concussion of the 7th cervical spine. The observation of the older writers of the "full- blooded" (plethora) condition of the patient, played an important part in hematology, but the observation suc- cumbed to the rigid analysis of modern methods despite the fact that, its confirmation was empirically demon- strated by the relief afforded by blood-letting. Bleeding was so inconsistently practiced by the past generations of physicians that it merited the rebuke of Van Helmont, that "a bloody Moloch presides in the chairs of medi- cine." Blood-letting is one of the lost therapeutic arts. Formerly we bled too much, but now we do not bleed enough. 618 Treatment of Whooping Cough CHAPTER XVII. TREATMENT OF WHOOPING COUGH. PERTUSSIS AUTHOR'S CONCEPTION OF PERTUSSIS AUTHOR'S TREAT- MENT RESULTS OF TREATMENT ANALYSIS OF TREATMENT. Although it is conceded that pertussis is an infectious and contagious disease, the nature of the infection has not been definitely demonstrated. A bacillus, resembling the bacillus of influenza, has been found, which many believe is the pathogenic organism of pertussis. The disease, after a period of incubation lasting from seven to ten days, is characterized by a catarrhal and par- oxysmal stage. The former stage, after a duration of from seven to ten days, is succeeded by the latter stage, in which the cough becomes more convulsive and is characterized by the distinctive and diagnostic "whoop." Including its complications, pertussis is the most fatal infectious disease in children under the age of five years. Respecting the conventional treatment of the disease, the therapeutic pessimism of Osier is sententiously expressed as follows: "Six weeks and a good big bottle of paregoric." The entire duration of an average case of pertussis is from ten to twelve weeks or even longer. Voelcker, 110 in his contribution embracing a careful study of over 550 cases of pertussis, concludes that, "the treatment of whooping-cough constitutes one of the reproaches to the art of medicine. We have no method by which we can shorten the disease, nor can we do more than pilot the case to recovery, modifying symptoms, guarding against com- 619 Spondyloth e r a p y plications, and making our patients as comfortable as we can during an illness which has no rival in its discomforts. A specific for whooping-cough has yet to be found. To all those I have tried (and they are over thirty in number), the handwriting on the wall is literally applicable; "Tekel" ("Thou art weighed in the balances, and art found want- ing.") THE AUTHOR'S CONCEPTION OF PERTUSSIS. It is an in- fectious disease in which the infection diminishes vagus-tone (chapter XIII). This reduction in tone specially impli- cates the vagus-fibers innervating the aorta. The latter ves- sel even in health does not show a constant lumen, in fact, its caliber is modified by physiologic conditions and periph- eral irritants may cause it to dilate. When paroxysms of pertussis are precipitated by emotions, sneezing, irritation of the throat, etc., there is a temporary aortectasis. Aortic dilatation follows emotional disturbances owing to an in- crease of adrenalin secretion (page 466.) I have made careful examinations of the aortic area be- fore and after irritation of the nose, throat and other regions and noted as a result of such irritation, an invariable increase in the caliber of the aorta. In an infant of eight months, the distance between the manubrium sterni and the vertebral column is only 2.2 cm., and it is quite evident that the slightest increase in the caliber of the aorta will produce pressure-symptoms on important structures. Reference to Fig. 122, will show the important structures contiguous to the aorta which are irritated by dilatation of the latter and symptoms develop somewhat analogous to aneurysm. In fact, the cough of the latter is not unlike that observed in some cases of pertussis. In children as well as in adults, one encounters in pe'r- 620 Treatment of Whooping Cough tussis, aphonia and dysphonia which we are inclined to attribute to excessive coughing, whereas in reality, they are probably pressure-symptoms. I have noted dysphagia in two adults with pertussis and one knows that the mere act of swallowing may precipitate a paroxysm in children. We have commented on the limited sagittal diameter of the chest in children. The lumen of the trachea is maintained by vagus-tone and we know that, when the latter is diminished, the trachea dilates and still further encroaches on the limited intra-thoracic area. Changes in the lumen of the trachea are more frequent in children than in adults owing to the undeveloped condition of the bronchial tree.* Bronchoscopy shows that, even in the norm, the systolic projection of the left tracheal wall by the adjacent aorta is considerable. Aside from the characteristic "whoop," or a series of ex- piratory coughs in the absence of the latter, and a marked leucocytosis (chiefly of the lymphocytes), there are no path- ognomonic symptoms of pertussis. A symptom which I have found to be almost invariably present is either an increase in the area of aortic dullness on percussion or the dullness in question is accentuated. This may be found in adults as well as in children. The area of dullness in children is about the size of a dollar and is located over the arch of the aorta at, or on either side of the manub- rium sterni. The area of dullness is increased by pressure between the third and fourth dorsal spines (page 472), which reduces vagus-tone and dilates the aorta or, by concussion of the four last dorsal spines or the loth dorsal spine, which provokes the aortic reflex of dilatation (page 255). The area of dullness is diminished or disappears by increasing vagus- tone (pressure at the seventh cervical spine or concussion of the latter). *According to Przewoski, tracheal dilatation is the rule in chronic coughs. 621 Spondyloth a p y Careful percussion of the aorta must be executed (page 558). DIFFERENTIAL DIAGNOSIS. Substernal dullness may be confounded with the following conditions : Atelectasis, zones of pulmonary congestion, bronchial glands and an enlarged thymus. HlGHT TRACHCAL LYMPH CLANO RIGHT su TRACHCO BRONC LYMPH CLMD LlfT TRACHtAl LYMPH GLANO Vl BRONCHO' PULMONARY LYMPH CIAN0 V4 INftRlOR HCO-BRONC LYMPH GLAND FIG. 145. The tracheobronchial and bronchopulmonary lymphatic glands seen from in front. The pointed (?) lymphatic glands and lymph vessels are not visible from in front, di, d2, first and second dorsal bronchial branches; vi, va, first and second ventral bronchial branches. (Sukiennikow, from Gray's Anatomy, Ed. 17.) The patches of dullness peculiar to the latter conditions show no variation in area by elicitation of the aortic reflexes. Atelectatic areas disappear when the skin is irritated (page 301). Zones of congestion disappear after elicitation of the methods cited on page 292. 622 D i f f erential Diagnosis Enlarged bronchial glands may develop spasmodic phe- nomena suggestive of pertussjs. Reference to this subject has been made on page 79. Fig. 145 shows the location of the tracheobronchial glands and suggests the sites of the areas of retrosternal dulness in intumescence of the glands. The sign of D'Espine consists in vertebral auscultation along the spine (yth cervical and ist dorsal vertebrae), when the child speaks or whispers 333. There is a peculiar resonance when the bronchial glands are en- larged and the sign is accentuated when the head is bent forward; this position brings the trachea closer to the spine. In many cases, vertebral bronchophony is present. Enlarged glands occur more often on the right than on the left side. An enlarged thymus gland was formerly associated with spasm of the glottis (laryngismus stridulus), and the attacks received the name thymic asthma. I have reason to believe that this affection as well as spasmodic croup may be caused by a dilated aorta, if the successful results of treatment (concussion of the seventh cervical spine) justify such a con- clusion. The thymus attains its greatest size at the end of the second year, then it atrophies and disappears at puberty. A persistent thymus causes localized dullness along the left sternal border from the second to the fourth rib. The normal dullness of the thymus is in the shape of a truncated cone with base at the sterno-clavicular junction and apex at the level of the 2nd rib. In the norm, the gland does not extend more than 6 cm. beyond the sternal margins. An X-ray picture may be positive when even percussion is negative. Bogg's 111 directs attention to the following sign charac- teristic of thymic dullness, based on the fact that the attach- 623 Spondyloth e r a p y ment of the gland is movable : The lower border of thymus dullness being defined (the pleximeter-finger still in place), retract the head to its fullest extent. Thymus-dullness rises upward toward neck, leaving a clear resonance on percussion. Mediastinal glands and other enlarged structures do not show this shifting dullness. Aberrant and accessory thyroids must also be taken into account in the differentiation of retrosternal dullness. THE AUTHOR'S TREATMENT OF PERTUSSIS. This, as al- ready suggested, is based on the hypothesis that there is a local vagus-hypotonia involving the fibers innervating the aorta and that, while the disease is not necessarily curtailed, its violence is minimized by subduing the factor (aortectasis) to which may be attributed many of the symptoms. There is little doubt in the mind of the writer that some infections are responsible for a like condition. Thus diph- theria is said to be complicated with pertussis (perhaps a pseudo-pertussis). Here, the vagus-hypotonia may not only be responsible for the characteristic cough but also for the heart-symptoms and paralyses peculiar to diphtheria. The suggestion having been made, the author awaits the con- firmation of his theory. The following letter was addressed to a few colleagues : "The following simple method has arrested the paroxysms of whooping-cough in a number of patients in from 3 to 7 days: "Place a pleximeter upon the spinous process of the yth cervical vertebra and strike the pleximeter a series of moderate blows with a percussion-hammer. The num- ber of blows is of little moment but the blows must be as strong as the child can tolerate without flinching. Some of the mothers accompany the blows with a nursery rhyme or song to interest the child. In the absence of a pleximeter and percussion-hammer, a strip of linoleum 624 Authors Treatment of Pertussis and a tack-hammer will suffice. To avoid cutaneous irritation, cotton may be interposed between the strip of linoleum and the spine. Each seance during the interparoxysmal period should last 5 minutes thrice daily and the harmless method may be executed by the mother or nurse. The undersigned is desirous of col- lecting reports on this method of treatment from his colleagues and to test the efficiency of the treatment, it would be well to note the number and severity of the paroxysms before and after treatment in each patient. "The undersigned will explain the rationale of the method in a contemplated contribution and will ap- preciate the reports sent to him by his confreres. "This method has also succeeded in some cases of laryngismus stridulus." Pressure (page 467), or the sinusoidal current to the seventh cervical spine, would prove equally effective but the results noted refer to the use of concussion only. A number of replies were received from physicians throughout the United States who came to San Francisco to study the methods of spondylotherapy and from others. A few replies will be cited. DR. GEO. H. BAERT, GRAND RAPIDS, MICH.: "I have cured by your concussion-method, more than twenty cases of pertussis within two weeks. Last week, a patient, Mrs. S., age 30, consulted me for whooping- cough. She received only four treatments and her paroxysms ceased after the second treatment." DR. A. L. GATES, Los ANGELES, CAL.: "Mrs. X. had approximately 24 paroxysms in twenty- four hours. After three days, paroxysms were reduced to six a day. The disease was not curtailed in duration, perhaps owing to the fact that the rapid improvement noted by the patient caused her to neglect coming to my office." .. t 625 Spondyloth e r a p y DR. E. GALLIMORE, SAN JOSE, CAL.: "Patient, age 71 years. Whooping-cough for 8 days with 10 to 12 paroxysms in the twenty-four hours. After three days, paroxysms reduced to three in twenty-four hours, of a very mild character and patient declares herself as well." "Patient, age 3 years. Seven to eight paroxysms in twenty-four hours, and very severe at night. After treatment for seven days her aunt informs me that the paroxysms are so mild and infrequent that they are not noticed." "Patient, age 4 years. Five to six paroxysms in twenty- four hours reduced to three attacks in the same time after one week." "Patient, age 6 years. Before treatment, eleven to fourteen paroxysms in twenty-four hours. Reduced in one week to five mild attacks." "Age 1 8 months. Six to eight severe paroxysms in twenty-four hours. After one week, reduced to three milder attacks." ."Age 2 years. Fifteen paroxysms before treatment. After four days, reported to have had only one attack during night." "Age 3 years. When treatment was commenced, was having six to nine attacks in twenty-four hours. After six days, is practically cured." Ten other cases are reported by Dr. Gallimore, and the results correspond with those cited. DR. L. LORE RIGGIN, OAKLAND, CAL.: "If a drug could be found to produce such a marked change, we would herald it as "The find of the day." Treatment of itself is of great value but I find need at times to give a placebo to satisfy parental minds. The great trouble is to get the parents to persist in the treat- ment and to make the percussion sufficiently hard. The results are in direct proportion to the care and attention of executing the treatment. It is very gratifying to know that the disease need not "run its course." In no 626 Analysis of Treatment in Pertussis case has there been a single complication and no patient has lost flesh. One very interesting case came under my care after suffering intensely for six weeks; the mother was very much discouraged and willing to do anything. Patient was nine years old, had lost flesh and had a bad bronchitis. This patient returned to school, with weight restored, in less than three weeks." Some random reports are as follows: "Attacks every hour during the night. Treatment commenced in third week of disease. After the fourth day no attacks at night." "Noiseless concussion-hammer (electric) used on a child, age 6 years. Treatment lasted ten minutes. No attacks after the first treatment. Sister of this patient had a continuance of attacks of less severity, even after eight treatments." "Infant. Attacks partially controlled in two, and completely after five days. In a boy in the same family, no apparent results." "The results of your treatment are in proportion to the efficiency of its execution. All my cases (14), have progressed splendidly, excepting two, in the family of a physician." "A child had lost very much in weight in consequence of vomiting following severe attacks. Vomiting no longer occurred when treatment was given just before meals, and the patient rapidly regained weight." ANALYSIS OF TREATMENT IN PERTUSSIS. An analysis of the medicinal and non-medicinal therapy of this disease demonstrates two things : An inhibition or an augmentation of vagus-tone. Reference on page 453 has already been made to the influence of drugs on the tone of the vagus. Belladonna shows its best action when pushed to its full physiologic effects. Here, the results are attained by dimin- ishing vagus-tone (page 472). Antipyrin, one of the most efficient drugs in subduing the 627 Spondyloth e r a p y paroxysms, likewise achieves its action by reducing, but not like the former drug, by annihilating vagus-tone. Many years ago, sulphate of quinin, was regarded as a specific in whooping-cough, used in solution as a spray to the mouth and throat. This method was abandoned. As a matter of fact, the author finds that quinin given to secure and maintain its physiologic action is one of the very best drugs for increasing vagus-tone (page 505). By the use of Kilmer's belt, it is claimed that the vomiting spells in pertussis are reduced from 85 to 95 per cent. A band of linen is used, 4 to 5 inches wide and 3 inches less in length than the circumference of the abdomen of the child at the navel, with two strips of elastic webbing, each two inches wide let in at each side, the whole belt lacing at the back. The belt must be tight and worn night and day. The results with the belt are no doubt effected by reflex stimulation of the vagus (page 208). We know that pressure upon the abdomen will stimulate the vagus even to inhibition of the heart. Thus, when Ho'nck, 112 recommends abdominal massage in the treatment of pertussis, claiming cures in less than three weeks, the results are probably attained by reflex stimulation of the vagus. In conclusion, attendants should learn the following simple method of inhibiting paroxysms of pertussis; press the lower jaw of the patient downward and forward as is often done during the administration of an anesthetic to bring the tongue forward. 628 Miscellaneous Data CHAPTER XVIII. MISCELLANEOUS DATA. FURTHER ADVANCES IN THE UTILIZATION OF THE KIDNEY REFLEXES PROSTATIC HYPERTROPHY REFLEXOTHERAP Y SPOND YLO- THERAPY IN THE ETIOLOGY OF DISEASE SYNOPTIC TABLES OF SPONDYLODIAGNOSIS, SPONDYLOTHERAPY AND PHARMA- COLOGY OF THE REFLEXES SPOND YLO-THERAPEUTIC ARMA- MENTARIUM. FURTHER ADVANCES IN THE UTILIZATION OF THE KIDNEY REFLEXES. On page 359, reference has been made to the kidney reflexes and it was noted that the kidney reflex of dilatation was elicited by concussion of the 6th to the 8th dorsal spines and the counter reflex of contraction, by concussion of the 1 2th dorsal spine. Since then, however, the author has found that a more decided contraction of the kidney can be evoked by concussion of the jth cervical spine, and a more decided dilatation, by concussion of the roth dorsal spine. Without entering into the details of the investigations, it suffices to say that the kidney reflexes in the primary instance (page 359), were caused by contraction and dilatation of the renal parenchyma, whereas when the yth cervical and loth dorsal spines were concussed, concussion of the former con- tracted the blood-vessels of the organ and thus diminished the volume of the kidney, whereas concussion of the loth dorsal spine, dilated the blood-vessels and thus augmented the volume of the organ (vascular kidney reflexes). In discussing the subject of visceral vascularity. on page 629 S p o n d y I o t h e r a p y 614, et seq., the effects of concussing the 7th cervical spine and loth dorsal spine were noted. The effects of concussing the latter spines were investi- gated in a dual direction ; by percussing the outer border of each kidney and by functional tests of renal efficiency. In the average subject, the outer border of the right kidney is approximately distant 9 cm. from the spinous processes and the left kidney, 7 cm. The average degree of contraction of the kidney (estimated from the outer border) after con- cuss*, on of the 7th cervical spine was 1.6 cm., and the dilatation of the organ (estimated from the outer border), after con- cussion of the loth dorsal spine was 2.6 cm. A few blows of the hammer on the appropriate spinous processes suffice to elicit the reflexes which are of short duration. FUNCTIONAL TESTS. With the kidney reflexes which con- tracted and dilated the renal parenchyma (page 359), elimin- ation was delayed. Here, contraction and dilatation of the parenchyma, as with the myocardium (page 543), contracted the renal blood-vessels. After concussion of the 7th cervical spine, which con- tracted the renal blood-vessels, elimination was likewise delayed, whereas, after concussion of the loth dorsal spine, elimination was hastened in the norm, as well as among nephropaths. In several instances, in subjects with parenchymatous nephritis, phloridzin glycosuria, which did not take place after several hours, occurred within the normal period of time after 5 minutes concussion of the loth dorsal spine. Among the simplest and most reliable tests for renal sufficiency is that with phloridzin; 1 5 minims of phlorid- zin solution (1:200) by subcutaneous injection causes sugar to appear in the urine in a healthy subject in from 15 to 30 minutes and the glycosuria continues from 2 to 630 Fun o n a T e s t s 4 hours. The most important factor is the total quantity of sugar eliminated, which varies from i to 2 grams. Diminished or delayed phloridzin-glycosuria usually in- dicates a renal disease, and a complete absence of sugar may be regarded as a sign of advanced renal disease. FIG. 146. Posterior view of the opened head, neck and trunk. The relation of the kidneys to the surface. Compare with Fig. n. (Atlas of Topographic An- atomy, Schultze-Stewart.) 631 Spondyloth e r a p y Before formulating any conclusions concerning the prac- tical value of concussion of the loth dorsal spine in the treat- ment of nephritis, succinct reference must be made to the pathology of the latter disease. Definite knowledge concerning nephritis began with Bright, in 1827, and this has been supplemented since then by the observations of pathologists and clinicians. More recently, an experimental study of nephritis has been attempted to explain the prominent symptoms of the disease. Albuminuria is caused by increased permeability of the glomerular tuft and degeneration of the epithelial cells of the tubules, thus permitting the soluble proteids in the blood to appear in the urine. The urinary casts arise either from degenerated epithelium or from albumin excreted through the glom- eruli. The paroxysmal appearance of a large number of casts ("cast-showers"), is caused by augmented renal circulation with associated diuresis, After concussion of the loth dorsal spine, cast-showers were demonstrable, even though casts were absent. Uremia is most probably caused by the retention of unknown toxic products, which in the norm are excreted by healthy kidneys. Edema has been ascribed to a variety of factors, notably, an abnormal distribution of fluid in the body (von Koranyi), which the French school attributes to the retention of sodium chlorid (there is a diminished execretion of chlorids in nephritis) in the tissues, and that the latter in consequence require a greater amount of water to maintain the salt in solution. More recently, a non-renal factor altered permeability of the cutaneous blood-vessels, has been suggested to explain nephritic edema. Here, a problematic renal toxin injures not only the blood-vessels of the kidneys, but all the blood- vessels. Hypertension and cardiac hypertrophy, have been at- 632 C o n c I u n tributed to a destruction of the renal parenchyma and to an internal secretion of the kidney. In summarizing the results thus far attained by ex- perimental methods, it is safe to conclude that they have given us no clue respecting the etiology, prevention and cure of nephritis. CONCLUSIONS. "Reasons drawn from the urine are as brittle as the urinal." Albuminuria is no more an expression of renal disease than is a murmur an expression of cardiac disease (page 525). Just as we test the competency of the heart-muscle (page 510) and disregard murmurs in a prognostic direction, so must we disregard albumin and content ourselves with de- termining whether the kidneys functionate adequately as niters. Albuminuria may occur with or without renal lesions. Thus, orthostatic albuminuria (page 122), is differ- entiated from albuminuria dependent on renal lesions by the following test: If calcium lactate (usual dose), is given for two days in succession, albumin will disappear if it is orthostatic, but will persist if renal lesions are present. It is here assumed that the orthostatic form is caused by diminished coagulability of the blood, which is increased by calcium. Concussion of the loth dorsal spine increases the func- tional efficiency of the physiologic and pathologic kidney and, by rendering the kidneys hyperemic, one is in possession of a puissant agent (page 404) in contending with renal lesions, notably those in which the blood-supply is impli- cated. The quantity of blood in the kidneys may be determined by the vascular reflexes of these organs (page 629). In diagnosis, these reflexes are equally valuable. In certain 633 Spondyloth e r a p y nephritides, when the increase in connective tissue is at the expense of the secreting structures, the vascular kidney re- flex of dilatation is either absent or diminished in amplitude. The author's theory of nephritic edema has already been discussed (page 617), and he utilizes concussion of the loth dorsal spine in the treatment of edema whether of cardiac or renal origin. Later (page 641), it will be shown that, concussion of the yth cervical spine may compromise the secretory efficacy of the kidneys. PROSTATIC HYPERTROPHY. The prostate has a fibromuscular capsule which sends a median septum inward (surrounding the urethra), dividing the parenchyma of the gland into about forty lobules. The prostatic muscular tissue, is made up of unstriated fibers and the second sphincter (vesical or prostatic sphincter), has striated as well as smooth muscle-fibers. The etiology of prostatic hypertrophy is not definitely known and recalls the observation of Sir Henry Thompson, that the best proof of our ignorance concerning the cause is furnished by the manifold factors which are made responsible for its existence. Some ascribe the hypertrophy to a chronic prostatitis usually due to gonorrheal infection, whereas others deny this relationship. The symptomatology of the disease is essentially limited to the obstruction of the urinary flow caused by the enlarged prostate. Rectal palpation demonstrates the characteristic ball-like shape of the prostate and absence of the raphe between the lateral lobes. Urinary symptoms are not always dependent on the size of the gland; a small gland may produce severe symptoms, 634 Author s Treatment of Prostatic Hypertrophy whereas an enormously enlarged prostate may be unattended by symptoms. One must also differentiate between simple hypertrophy and malignancy and recall the observations of Young, viz., that one of four cases of prostatic hypertrophy, malignancy is present. AUTHOR'S TREATMENT OF PROSTATIC HYPERTROPHY. It has been established empirically that, the best site for con- tracting the prostate corresponds to the i2th dorsal spine. The rapid sinusoidal current is used ; the interrupting elec- trode (Fig. 46) is fixed at the i2th dorsal spine and a large electrode in the sacral region. Strong currents must be employed. With the finger palpating the prostate during the action of the current, one may note reduction in the size of the gland. All hypertrophic prostates do not equally respond and when this occurs, little can be expected from this method. In the latter case, the stage of active parenchymatous and muscular hyperplasia has been succeeded by an overgrowth of fibrous connective tissue. Results, if any, are immediate, irrespective of the stage of prostatism. Treatment should be executed daily until definite results are attained. Chromium sulphate (4 to 8 grains three times a day after meals), is a useful medicament in prostatic hyper- trophy. The value of this drug was first established empirically by Kolipinski, 113 who likewise vaunts it as a specific in exophthalmic goitre and established its value in locomotor ataxia and neurasthenia. Unfortunately, this drug is destined to have only a limited use until its value has been established on a more rational foundation. My limited investigations show that it has a powerful vagotropic action (page 451), notably on the sacral au- tonomic fibers (Fig. 101). 635 Spondyloth e r a p y REFLEXOTHERAPY. Reference to the employment of reflexes in treatment has already been made on page 392. Jaworski, of Paris, digni- fies this method by the neologism, reflexotherapy and refers specifically to the methods of the author as "vertebral reflex- otherapy." All diseases are manifested by a direct and an indirect symptomatology; the latter embraces the reflex symptoms.' There are individuals who are reflexophilic, i. e., they have exaggerated reflexes. The Laborde method of resuscitation in asphyxia, by rhythmic traction of the tongue, is an excellent example of the employment of a reflex. The investigations of the author show that, such lingual traction provokes a heart reflex of great amplitude and long duration. Furthermore, it aug- ments the tone of the vagus and may be employed to secure the latter effect, in addition to the methods described on page 199. In making a comparative estimate of the methods em- ployed for eliciting the heart reflex the following results were obtained : METHOD AMPLITUDE OF REFLEX DURATION OF REFLEX Stretching neck (Fig. 65) 2.6 cm. 2 min., 10 sec. Concussion of yth cervical spine 1.6 cm. i min., 35 sec. Cutaneous irritation of precordial region 1.6 cm. i min., 10 sec. Rhythmic traction of tongue 3.6 cm, 4 min., 30 sec. The observations of Fliess (page 463), demonstrated the intimate relation existing between the nasal mucosa (locus genitalis) and the uterine reflexes. Denslow, quoting the observations of Otis, demonstrated 636 R e f I e x o therapy a multitude of reflex symptoms (paraplegia, epilepsy, mental confusion), evoked by irritable lesions of the urethra. Certain forms of rhinitis are associated with hemorrhoids and treatment of the former condition has cured the latter (Jaworski). Bonnier compares the nasal mucosa to a piano in which one can find reflexogenic keys for the entire organism. If one has carefully studied chapter xin, the foregoing statement will not be regarded as an hyperbole insomuch as there are many authentic case-records showing the cure of many symptoms (vertigo, dyspepsia, gastralgia, asthma, etc.) by appropriate treatment directed exclusively to the nasal mucosa. The latter consists essentially of cauterization of a definite reflexogenic point in the mucosa at intervals of 8 or 10 days. Perhaps the most interesting development of reflex- otherapy as employed by Denslow, Jaworski, Romero and others, concerns the treatmen^of locomotor ataxia. Denslow first directed attention to the intimate relation existing between the urethra and tabes and created in conse- quence his method of treatment by dilatation. The latter has been confirmed by a number of enthus- iastic observers, notably Jaworski. The latter, while re- garding syphilis as a prerequisite of tabes, conceives it only as a predisposing cause, and that some peripheric irritation (notably urethral), causes a primary enfeeblement of the roots of the posterior spinal nerves. The nature of the urethral lesions has not been definitely established but they correspond to the lesions of herpes zoster. They are identified with the lesions of the nasal mucosa. One frequently finds on examination of the urethra, painful elastic or spasmodic strictures. The latter may also cause a variety of reflex phenomena, notably, neurasthenia 637 Spondyloth e r a p y and asthma. It has been shown that any irritation of these strictures will accentuate tabetic symptoms. Treatment of the strictures by a meatatomy and dilatation of the urethra by sounds, does not cure tabes, but merely arrests those symptoms dependent on the urethral source of irritation.* The rectum is likewise a prolific reflexogenic territory. Louis XIV suffered from a fistula, and his reign was said to have been divided into two parts that before and that after the fistula. Some one has said that the chief function of the consultant was to examine the rectum, insomuch as it is often overlooked in our examinations. "More mistakes are made by want^of looking than by want of knowing." I recall a patient entrusted to me by an eminent colleague during his absence in Europe. He said, "The patient has a gastric cancer and all you can do is to relieve her incessant vomiting. For some reason, the rectum was examined and after the removal of an enormous scybalum, recovery was immediate. Before me as I write, is a resume of cases treated for rectal diseases by my friend Dr. W. T. Baird, of El Paso, and presented as a report to the Surgeon-General. In 85 per cent of the patients, soliciting treatment for various "reflexes," there was no knowledge of any rectal disease and only 15 per cent, of the patients complained of local or regional symptoms. The reflex symptoms embraced practically every viscus and were made up of symptomatic pictures ranging from neurasthenia and constipation to rheumatism and cardiac disease. The most frequent lesion was ulcer ation of the rectum and treatment of the latter usually resulted in complete recovery. *Those desirous of pursuing a further study of this subject should consult: "Uti nowueau traitement du Tabes;" Jaworski, and "La reflexotherapie dans le Tabes, et dans d'autres Maladies;" Romero. 638 R e f I e x o t h e r a p y The following is an extract* of a communication to the "Congress of Medicine," at Lyons, (October 10, 1911), by Dr. H. Jaworski, of the Faculty of Medicine, of Paris: "When confronted with symptoms or lesions, one is no longer permitted to forget their remote effects (reflex- opathy) . Without wishing to systematize to extremes, nor to say that all symptoms are reflexes, it is nevertheless certain that the reflexes play a primary role in the bio- logic mechanism and that, when properly employed, they conduce to useful reactions (r eflexotherapy] . Some of the reflexes are very complex and different lesions may provoke identical symptoms (asthma, epi- lepsy). From a practical view-point, the following may be regarded as the chief reflexotherapeutic methods: 1. LINGUAL REFLEXOTHERAPY (Laborde), consists o' rhythmic traction of the tongue to excite respiratory and cardiac action. 2. URETHRAL REFLEXOTHERAPY (Denslow), consists of rapid dilatation of the urethra, which may be reflexly utilized in the treatment of tabes. It is the most rapid and efficacious treatment in the latter malady. After a few seances, the tabetic experiences a strong sensation of warmth in the feet, the deep sensibility reappears, gait is ameliorated and, after a variable period of time, there is a disappearance of the pains and symptom of Romberg. 3. NASAL REFLEXOTHERAPY (Fliess, Bonnier), is based on the existence of localized reflexogenic centers in the nose, which after cauterization influence favorably, enteritis, hemorrhoids, constipation, asthma and men- strual affections. 4. VERTEBRAL REFLEXOTHERAPY (Abrams), consists of percussion of the seventh cervical spine to provoke reflex contractions of the aorta and other vessels con- ducing to the cure of aneurysms. ^Literal translation. 639 Spondyloth e r a p y Reflexotherapy has been adequately demonstrated. The means employed are simple and without danger." SPONDYLOTHERAPY IN THE ETIOLOGY OF DISEASE. One frequently encounters patients who are really suf- fering from the effects of drugs given for therapeutic pur- poses, and one is constrained to recall a quotation from Vergilius, "And he becomes worse from the very remedies used" (aegrescitque medendo). This therapeutic overaction is likewise encountered in the employment of spondylo- therapy. It must be evident to the reader that spondylotherapy is essentially a treatment in which reflexes are employed to achieve definite results (page 392) and, in the elicitation of one reflex, one may jeopardise its counter-reflex (foot-note, page 147) and thus evoke a syndrome quite at variance with the initial symptomatic picture. This spondylotherapeutic overaction has been referred to in discussing the treatment of myocardial disease (page 514). If one judiciously supervises treatment, danger may be avoided. Thus, if the test for heart-sufficiency (page 510), demonstrates that the object has been accomplished, further treatment is not only unnecessary but even dangerous. In diseases dependent on deficient vagal-tone, the tests cited on page 470, will show when such tone is restored. A patient with an aneurysm of the thoracic aorta and cured of the latter, developed pulmonary tuberculosis several months later. The treatment employed was concussion of the 7th cervical spine which likewise evokes anemia of the lungs (page 604). It is not unlikely that the diminished vascularity of the lungs contributed to tuberculous infection. Of course, this is only a surmise on my part. Treatment by concussion of the same spinous process in 640 S p o n d y I o t h e r a p y a cardiaopath and in another aneurysmal patient, eventuated in anasarcous symptoms. The treatment employed likewise diminishes the supply of blood to the kidneys and thus com- promised the functions of the latter (page 634). In both instances, the symptoms subsided after concussion of the loth dorsal spine for reasons already cited on page 617. It is quite probable that, dilatation of the heart and aorta consecutive to concussion of the zoth dorsal spine is essen- tially a reflex of accommodation (vascular reflex) as cited on page 519, and that dilatation of these structures consecutive to concussion of the 3d and 4th dorsal spines is a true par- enchymatous reflex (page 474). In concluding this subject, attention must again be di- rected to the failure of a reflex responding to one method of excitation, thus necessitating the employment of another physio- or pharmaco-therapeutic method (page 400). 644 Spondyloth a p y tn g S 8 >T 6. S O 4) 2 < o^o^gC g^jf'o- y S r 2 2 ^ o a en u tn^bou^oraol S^S^u^ W 3 5? O W O 5 I Oi _S.J'o (U ilT3*''5 "a* c ^-' u rt rj ^ ^"^ I " H S o c a ^j d,^ ^_ C J3 c '55 C C bo > !~^ X o ^^ u 2 fe *aj *+- i C O ^3 - ^'r; o 2 ~* H tj W ^ O M^3 e cg 'cS'p'-'rt 'n^QtJCajm P< jj p Q ^u" u n .2 e ^^2t! S'g'-S-S^M 3 <" w o sg 2 W *---5 M - ao >S is H ?* * >. ID'S -5 x-2 c^""o'" S - ^ Jj ""** B S ^ B j2T3 n D. " ^ s; M ^^t! * fa's? . fc H M w 2 5 2; ;: w w H < a O H (H tn ^ t/3 o_u a T3 5'Sc? ?! S 13 ?, 1 " mtUi 1 s::|s * - O > **" O 3 ? 'o rt a^u^e^ 8 ^ *'8 1 1> U w-.HcE^-^ eQcS H- 1 | g B S w ^ ai-S C TS^ 1 -^5 S x^ s^ -" E .*-! l-rftlll uj 55 OJ C '3 -.a S 3 j8 llflili- ^SL"!^ ^^ 5j >^ ^ fj O 2 o 'bb c ^ ^3 ?"rt .2 ? '3 2 ^ ^' 0^2.^ "* u O w ^ S s p< i S 13 'Sj.t! a a. O >,ShT3 *^ SS^ 3 s c^j; a g^ o ^ .2^3 < en Mu S ^ d Q 1 1 M Q Q .S -g Th |'-|||5^ s ttg8.ll C5 *s 3 ^ rt 1 " (a O " - ^ J Haj^ . O*d ^* * j < - J j2'O^-<^ S S >. *j J2 u "p ix fe G o ^-3 1 K CO ."> r> rt lo-2 U L, V r ) 8 .^355 1 ' " S O U ^52 g y < >^s^ >5 II ^ 11 aj JD O \O U 3) L ^ S^ W '^ J ;! - o 2 5^? - g 1 u c "i & \!Z? 5< /H 3 5 c/3 ^3 r-] {) B Q y vJ HH (H *"; . .. M t/3 c -< |S S t 11 *"-2 u "g ( S^rlcflQgP^g >< ^2 *o ""S -5J "".2 1 "^ ^,- 3 <3 H ~.'v K. BKBt^Sfl PH ^S s * -2 y\ u ."tl O C rt w rt x <. ^^ ^ ^ CE r"i S P^ ^ in.'! W. ^Q IS C *j?T3 a> C ' 4 6 i 1 1 * i * ^ O s 1 Ib s J3 u .g'> a jj il- g i 1 1 3 3 s.3 u rt J3 S !5 tsjO C co . <- In C ^ u S -Si; K 4_l C\ O ^ W 2 u l:ll "ll^ . > U U .g 0^^ (jMygytSWrt i < 2 BISS -|5 w S - ^d U g O -J^-g g u P r/l U5 O en "2 73 S T) t--. O a; M Q f~- ^ W g W W 1 p ^ 2 o W O P < ^ 'O & fH X Q ra S f^ H to p,/ pi! cj o s c o 09 u u o 5-0 rt ^S a 2 J3 S * ?^ 5c O A ^oo "3 _ - a CO ^ O JJ 2..; * 52 jB CU 3 ^ M g TJ M 1 fO C\J E c "o*** v^^S "5 O c vo d SMI ^ 2hJ S r "o. II c"l-2 c Q E 5 C Q "3 c ^ ^"c o d 5 i S B o TJJ If s| D II u E K |^ ^ * o o 1 C 3 rt en *^ ^ u ' OT >1 .3*0 SO +j w O 52 O .s V 60 "1 S*i CO B U D S o S Et_i C i- a oi 'O C S c Efi c "S E . _ _ rt C S u 2 c '3 ^^ o 5! "y 55 "^ > S cT c rtj3 t> c 2 -g w c -^ rt rt H T3 i a 6s n u 2 GTS O T3 1' > "c o 1st I ? 2 "3 C "H rt 1 .s a .31 .a u" > g O m bo " u W W M ^ i; _e SPONDYLODIAGNOSIS (con o I 5 i i i 3 ) ') Relieves symptoms of splanchnic neurasthenia (434) lood-vessels. Accentuates symptoms of hypertrophic stenosis of t Relieves spasm of the cardia and its concomitant gasti Dissipates dullness caused by lung-atelectasis (301). . Augments symptoms of a dilated aorta and /tear* du structures (520). 2. Rales of Asthma inhibited. 3. abdominal congestion. 4. Pains of vagal origin reli( (brief seance of concussion). 6. Increases symptor opia, amblyopia, nervous deafness). . Concussion of these vertebrae diminishes an area o gall-bladder. If pyloric obstruction is present and pylorus fails t f the pyloric region and possibly hypertrophic stenosii Pains of a distended capsule of the kidney suggestin nd decrease by concussing 12 D. spine which diminisl Failure of the gall-bladder to dilate suggests a holelithlasis. Vide, law of Courvoisier (599). . 1. Accentuates aneurysmal symptoms and augments 2. Cardiac and functional murmurs due to cardiosj and pulmonary artery evanesce. 3, Accentuates neuroses of dilatation. . Augments symptoms of plethora. . The degree of increase of the kidney-volume suggest supply (629). . Percussion of the duodenum. Dull area of the latt< concussion of llth D. spine nor upward by pressure as is the case with the stomach. Growths or painful points connected with stomach Percussion of A, facilitated. Contractility of B, d< Growths and painful points of stomach dislocated u] o -t jjjj .2 H | 1 1 rt 1 O 1 .0 U5 ^ I o n. "^ < B O Q ** j O o X a s a o T C-v i> ^ /-C. T3 I. o'c " .S "o rt rt u . CO V .S O 1> B a C 3^ o\ S^ "*-***?- E S in s D " o C o e c] C o 4-t jj u VO :TV n II ~ B c 6 c | u u M T3 . 3^ M> rt T^ "- o > j u 4J 1 M U3 o 3/-^ 5 S"o ^ 'rt nj 2 *4-l cy C r^ ^1 t "5. & CLINICAL PHY; Increases visceral sigmoid flexure. Splanchnic vaso-mo constriction (434). Contraction or pyloi ing of cardia (588 -5 * n 3 Diminishes vagus-t( presses functions innervated by the A. Contracts gall-bl; B. Contracts pancre 00 10 3 E O 1 o 5 Elicits parenchyma reflex of dilatatio Distends gall-bladde T3 O U n >> o o o .2 S ^ 3 -2^ -*-> C -^ to ^ O\ rt O (L> O g o. o p, 5 S 3 . rt-G . w .*> ,-o < m u Q u o u "E 11 A. Augments tone t B. Contracts prostai Increases tone nf Contracts liver, s tinps pnH stomnrh ding synoptic tables are o > Q U ' 1 00 jHf T3 D w S Q a-a ~ O H a O en w >7 J W S " o S /5 (^ PL, IX Q M Si o -a M Q T3 1 3 u -a. OJ * It-g Sri Q .c 1 3 c H J3 ^ fif" r^ M H H 3 f C j M -i K H 3 J " tn H H 3 * This, and 643 o n d y I o t h r a p y b 03 3 en R O BO 1 P O 3 Z r*- P* s* k, ca ai en 43 ft w p IS en W H current WHEN 5 S 2 y S CO I 9 % P-l 11 Is K H S < ^ y i** O J5 < s P4 * 8 s bofc g w W HH Sg < pq H W H J>8 - W W K en & S O ^-. (j *^ O H B g W co p < o y S O u *-* rj * g s ^^ *. Mj o a. 6S M M PH en W en en R 3 C/5 rt X] 'g o g Q S C en $a ^ P$ CO S V i ^ TABLE soidalization ( iBLY TO BOTH INDICATES T fHE OTHERS. .-SEGMENT (3; SPINE. B . C/3 ^iisi .. H S H ft Q U W Q W ^sw8 s w >5 co !< w CO ^, Q N H co U en W o __ O O *> c3 ^ ^ ^ _c t/3 C3 ^ d o D 73 & -2 2 ~ jj ~ ^ 1 d "o > " fJ'S'c 2 > O C t/i 2 >->o ?\ ^ * d tj S g u ^ J w o T3 , o ^ II a d d 0. M) P W d -= o *. o *- c 'S o cd *H "^ 5P jtn O 4 d Q 13 .5 c3 g ^.S 8 5 O O *~ 4> d ho be Si r H bb E ju ' C vS cup -c ".s s " * rt o dj > 13 & emphysem arrespondin 5 c s .0 ^- JN$, 2 - I a ||"|l < '1? Q 5 i en ll T J3 'I - ^.-2 u J "* "S ll JMuN IH "a 4) '!3 gx S Pressure " C ^ -, c o 'S t> u .S- P jj d t""P S c fc]-S to ^^II^ d 4H ^ *o (H o M ^^^. <0 'S *J* 4-l C ^ ~* '^ c t o c '~ H IO S 5^S y c 8 .ii g g 'So o *-^^ ^^".^ d " .S '3 "5. I 4 " ? E l-l^ IllilS ll X .d "fl < M c5 rt 3 C IJJ " o 2 IS 2"! x "^ t-* ^ B d O o . | ijilfSl 8 " -1 'So g i- 1 ' bo * J ^ u ^-^ ^^^ "-* .2 S .S CLINICAL PHY |ij g"| fllll Stimulation of fibers of vagus Is ft Contraction of fibers of branch ture to excite h contraction. o t 1 , ^ K~a u fill Ij ll ^ O K ^*^ fll Q it} Q CO *- Sfi O' d M ^1 1 y~C ** "O C/T *O M * "^ 3 V vo ^ C 3 r d bo s * ^^ -" 4, "o* S bo TJ- i d 'S p^ C^ ^13 ^ 8 ' ?\ i* XI e *> o a, K O 2 S 'i? B A |f 6 c H^ S ** "c c C (X, ^ J to -5^*^ u "S 'B ^ nfXi ." ^ I ci 1 > XI v 1 ^ d u" o ~ e 3 "bO 2 T3 *^ S 2 bO (U SPONDYLOTHER APY (continued). Splanchnic neurasthenia (434). Relief of intra-abd Cardiotonic angina pectoris (542), Hypertension (461} ma (hypertonic form), Enuresis (502), nervous affectiol thenopia) and ear, when caused by vagus-hypertoi mptoms caused by vagal-hyperesthesia (neuroses of id intestines). Pulmonary atelectasis and to maintain the "open lun children) in whom there is a tendency to develop broncl : areas. Catarrhal jaundice and in infectious cholecystitis (for Pylorospasm. i. Chlorosis, by counteracting hypoplasia (605). Vasoconstrictor neuroses, i. Anemia (by increasing number of red blood corp i. Bright' s disease. 2. Locomotor ataxia (616). Microgastria, Spastic Constipation, Cirrhosis of the Prostatic hypertrophy (635). Gastrectasis and dyspepsia due motor insufficiency of Constipation (328); 3. Hepatic congestion; 4. Spleno: of the uterus, uterine pseudo-fibromata (419), hemorr: abnormal positions of the uterus caused by relaxed ': Atonic conditions of the bladder caused by insumcl the bladder. f> 5 feg * TO (/) CO .5 < pa u H 3 *H "2 "3 c to* - - I ^ c c S) o lJ ^^ o> "T"! ~ .** f- o d ^ 00 C rt JgJS g 3 iU 4) =2 1 1 1 jp 00 10 en y I 2 d if 81 K SS3 C xl 1 "5 o ^ ^_ P^ 3 w r ^ *-; 4> C o y ^s 2 13 *-! "d O .5 n rl 'a c EMk5 o bo "C! ^ c" c *c5 H XI O rt Tl o o J3 t? . ^*o d y Z s splanc constricti co 0< 12| p d * be'? C O 1 * I* o u ^ S |1 *J u U ^- *- Q> *"2 4-t ^ C$ tfl-8 P 03 S Xj ^p p x; o *~% U 5 w M O i/i to 00 o dfj 15 Xj oo x? to P 'o M Xj P XI P f j f P4 W O P 4J T3 a"p XI "5 M P M M tfj XI CM CM M ro H M to 645 o n d y I h a p y tfi w W WAW " J A W H * 2 (H i 3 3L ill- 'l-cj u i.JL.^O^'O M ft) '* H H 080 gfcsS & 8 HH V - Oft2 <" O f\ | g III w - ^Is t- is ls|g^. .ogl ^f. w O >< Q O W^-O^ "S U ^ -H * H c '&-S ?! *2 -fi .S "^ rr> H < .,. B w a < o p J^ <3J fH ^^ n --" ?*- * *J ss Q o Cu*o r4<> 2 H W r &< i o Lq o< Q SH o 3 g-S d g to u B "5.^ *" ' & Ej PX^>,WOT w o X s u Q *S a p ( C O "*-* .^ ^ tfl ,^ '3 3 ^^ " *-" j C2 gg'SSjCse DC ^Q^d o w ?J " z ^ * S "" O -"S U T j * f^ , *^ ^"^ ^^ .^ ^ """^ < o w N~ o 3 .1936 55 <^ .^'13 u .. O . *- tn > [i( Z 5* M < 3 '^T'^ OO < S> "S '> "" _ tj " '5 <" 2 ji ^ -.y W < Q < H 6, < ^ T ^ N ~'y g OB .c 'S ^ u "* '*' '& >^S -Sr!b? #! H -^|- ^ 1 1 < s ~' m > H friQ H a, Jz; 646 Pharmacology of the Visceral Reflexes a-oo|- H) CO U (-; m j in QJ D u *-* to - tn tn C 'iC" H d 1 1? &$ "*-* "M u u w ^3 .13 tn 4J rt CJN (- i_( .t3 ^ C rt en u tn O j w c rt a > C! S a _u 11 o S 43 w a l> S c*-^ fe. j?'- 4) 1 ^^ rg a e3 S "^ 5, in 41 OF THE VISCERAL REFLEXES (continued). action. Atropin abolishes them, pilocarpin exag lung reflex of contraction (456), Asthma, is caused rue of spasmodic bronchostenosis (311). Adrenalin ial affections (314). Nasal sprays (310) which reliev contraction. Emphysema caused by vagus-hype :as the atonic form of the affection is ameliorated. />in abolishes the stomach reflexes. The motor nei ;o an adequate dose of atropin, whereas pilocarpin y dilating the stomach accentuates the symptoms of ,s caused by vagus-hyperesthesia. intensifies intestinal peristalsis. Many affections ncreased or diminished tone of the vagus (496). s-stimulation (497). Symptoms arising from eye-sti r cent, solution). Homatropin and atropin, do n renter and must be examined as a routine measure in agal-origin. Cocain aids in the diagnosis of emph labor and gastric pains (464). Temporary relief of i perhaps permanent relief by cauterization of susc IS PHARMACOLOGY mediated by vagal- accentuates only the '. >a) and this is also ti in spasmodic bronchi ig the lung reflex of by pilocarpin, where accentuates and atro spasms, &c.), yield t Adrenalin (590), b ameliorates symptom . s O + )-. d a" 8 is equivalent to vagu are cocainized (5 pe r reflexes. ; an important reflex ( f many diseases of v dysmenorrhea (463), , asal cocainization ani mucosa (463). V 1 a o 1 in 3 i (U .4 X^)"C ,5 ^ s - -a "' 8 52 ^ *-" O * C "3 5 ^ ^ d ' 3 CK 4$ a s S- D C C! ^.2 2 rf - . 8 r2 1^3 o bB^Jo'"^ _>, u " % % g g '"3 * KS K ?C StefJ Tfi ~ O A -5 .^ rt .^ '^ d '1 bO f <0~ to g. O $ jg Tj- .2 T? tn (. ^ 11 B u x' ^ V X in -S 4? tn u en B B X 0^ PS 8j s .2 A $ 43 y "3 a H & b 03 p * rt ^ CuD x ^* s tn r^* ^3 d 3 *-O O ^ 4_i ON u C*J j "* C 'T 1 1 O 5 647 S p o n d y l t h a p y SPONDYLOTHERAPEUTIC ARMAMENTARIUM* This hammer for evoking the vertebral reflexes (page 7), is called after the French neurologist, plexor of Dejerine. Although employed chiefly for diagnostic purposes, it may substitute a concussion-ap- paratus in spondylotherapy. Indeed, many physicians have used the plexor exclusively to attain their therapeutic results. The rubber affixed to the plexor is chiefly designed to give resiliency to the blow, an important desideratum in the elicitation of the reflexes. This pleximeter of metal, covered at one end with rubber, is employed concurrently with the plexor as shown in Fig. 2. *The illustrated spondylotherapeutic apparatus is purchasable from The Philopolis Press, 406 Lincoln Building, San Francisco. 648 Spondylo therapeutic Armamentarium The instrument with a single prong (Algesispondyloscope), is used for demonstrating areas of paravertebral tenderness (page 66). The instrument with two prongs (radicularpressor), is employed for making bilateral pressure on the roots of the spinal nerves at their exit from the intervertebral foramina. The employment of pressure in treatment (which I shall neologize as barotherapy) has been discussed on page 169, and reference to its diagnostic value (diagnostic-ba.rothera.py) has been made on page 467, et seq. The investigations of the author with barotherapy show that, the efficacy of the treatment is due to blocking of the roots of the spinal nerves. 649 Vibrosuppressor and its application to the chest. The value of vibrosuppression in diagnosis is discussed on page 80. The cushion of this instrument is provided with a small metallic button so that it may also be employed in barotherapy. By removing the button, the apparatus is used solely as a vibrosuppressor. Spondylotherapeutic Armamentarium Pneumatic hammer with concussors. This operates with a pressure of 40 pounds and yields a blow equivalent to 12 pounds. This hammer is very efficient but because it is noisy and com- pressed air is not always available, the electro-concussor of the author is preferable. 651 Spondylotherapy The author's Electro-concussor. This apparatus was constructed for the purpose of securing percussion-effects and the latter only. Practically all the instruments designed for sismotherapy are mere vibrators and are absolutely useless for executing the methods of spondylotherapy. This electro-concussor is portable, and its flexible shaft is readily attached to an "AC" or "DC" motor. At a slight expense, an extra motor may be purchased and as both motors are interchangeable, the apparatus may be used on either current. It is provided with two concussors which deliver blows to both sides of a spinous process. The reason for the latter is cited on page 395. 652 Spondylo therapeutic A rmamentarium High-frequency coil and double vacuum electrode. This coil delivers a high voltage and is equally suitable for fulguration and ozone treatment. The coil can be instantly connected with any lamp socket furnishing 100-120 volts either direct or alternating current. 653 S p o n d y I o t h a p y This is a complete sinusoidal and galvanic apparatus. A diagnostic lamp-current may also be obtained. The selection of current is simplified by means of the dial selector and any one of the ten modali- ties may be instantly selected. The apparatus is constructed to be operated with the no volt direct current; but when an alternating current only is available, a rectifier is used to change the alternating into a direct current. 654 Sp o n dylo therapeutic ^4 rm amentarium This is a simplified form of the preceding apparatus and delivers a true sinusoidal current. Operated with the direct current, this apparatus gives a galvanic, slow sinusoidal and surging galvanic current. Operated with no-volt alternating current, it yields a fast and slow sinusoidal current, surging wave and alternating current. 655 Bibliography 1. Ludlum. Journ. A. M. A., May 2, 1908. 2. Hulett. Principles of Osteopathy, 3rd Edition. 3. Abrams. Medical Record, Apr. 28, 1899; N. Y. Med. Jour., Jan. 13, 1900; Amer. Med., Feb. 15, 1902. 4. Abrams. American Medicine, Jan. 3, 1903; La Presse Medicale, Apr. 3, 1907. 5. Abrams. Diseases of the Heart, p. 155, 1900; Med. Record, Jan. 5, 1906. 6. Abrams. The Blues (Splanchnic Neurasthenia), p. 205, 1904. 7. Abrams. Medicine, Jan., 1904. 8. Abrams. American Medicine, Apr. 2, 1904; Medical Record, Sept. 16, 1905. 9. Abrams. American Medicine, July 16, 1904 and Apr. 22, 1905. 10. Langley. Schafer's text-book of Physiology. n. Studies of Starr, Edinger, Sherrington and others. 12. Lovett. Lateral Curvature of the Spine and Round Shoulders, p. 23, 1907. 13. Gould. Elements of Surgical Diagnosis, p. 363, 3rd Edition. 14. Cesiky. Deutsch. Med. Woch., Nov. 26, 1908. 15. Kust and Meltzer. Medical Record, Dec. 29, 1906. 16. Alsberg. Deutsch. Med. Woch., Nov. 7, 1907. 17. Arnold. The Medical News, March 18, 1905. 18. Ludlum. Journ. Amer. Med. Assoc., May 2, 1908. 19. Abrams. N. Y. Med. Journ., Jan. 3, 1903. 20. Abrams. La Presse Medicale, Feb. 6, 1907. 21. Rose. Journ. A. M. A., Jan. 23, 1909. 22. Garrigues. Journ. A. M. A., Jan. 2, 1909. 23. Abrams. Medical Record, Sept. 8, 1900. 24. Abrams. The Blues (Splanchnic Neurasthenia), 3rd Edition, p. 241. 25. Bailey. Diseases of the Nervous System resulting from Accident and Injury, p. 587, 1906. 26. Marshall. Journ. A. M. A., Sept. 12, 1908. 27. Lloyd. Birmingham Med. Review, Apr., 1897. 28. Goldthwait. Bost. Med. & Surg. Journ., Vol. 152, 1905. 657 Spondylotherapy 29. Schanz. Zeitschr. f. Orthoped. Chirurg. Vol. XIX, p. 115, 1907. 30. Beevor. Journ. A. M. A., July n, 1908. 31. Young. Manual and Atlas of Orthopedic Surgery, p. 63, 1906. 32. Abrams. Diagnostic-Therapeutics; American Medicine, Dec. 10, 1904. 33. Rosenberger. Amer. Journ. of the Med. Sc., Feb., 1909. 34. Irons. Journal of Infectious Dis., June 4, 1908. 35. Horsley. British Med. Journ., Feb. 27, 1909. 36. Edinger. Diseases of the Nervous System, Appleton & Co., 1908. Yawger. Journ. A. M. A., Apr. 24, 1909. 37. Noguchi. Journ. of Nervous and Mental Dis., Feb., 1909. 38. Abrams. Man and his Poisons., E. B. Treat & Co., 1906. 39. Jehle. Archiv. fur Kinderheilkunde, XLIX, Nos. 3 and 4, pp. 161-320, 1909. 40. Geyser. Journ. of Advanced Therapeutics, Oct., 1903. 41. Fraenkel. English Translation, P. Blakiston's Son & Co. Cohen. System of Physiologic Therapeutics, Vol. VII, p. 204. 42. Abrams. Diagnostic Therapeutics, 1909, p. 598. 43. Jackson & Hubbard. Medical Record, Apr. 17, 1909. 44. Snow. Mechanical Vibration, 1904, p. 64. 45. Libman, Elsberg and Neuhof. Amer. Journ. of the Med. Sc., Nov., 1908, p. 694. 46. Head. Brain, 16, i, 1893, and 24, 345, 1901. 47. Schmidt. Pain, p. 322. 48. Nathan. The Amer. Journ. of the Med. Sc., June, 1909. 49. Jones. Index of Treatment, p. 735, 1908. 50. Abrams. The Medical News, June 25, 1904. 51. Bates. American Medicine, June, 1909. 52. Abrams. Medical Record, March 26, 1898. 53. Thorne. British Med. Journ., Vol. II, p. 1238, 1896. 54. Cabot. Physical Diagnosis, p. 76. 55. Depage. British Med. Journ., p. 1004, Oct. 3, 1908. 56. Heitler. Wiener Klin. Woch., 1890. 57. Heitz. La Presse Medicale, June 19, 1907. 58. Abrams. Medical Record, Sept. 16, 1905. 59. Verhandl. d. Med. Phys. Gesellsch., Wiirzburg, p. i, 1854. 60. Auld. The Lancet, Oct. 17, 1903. 658 B i bliography 61. Abrams. Medical Record, Apr. 3, 1909. 62. Moscucci. Riforma Medica, Vol. II, p. 208, Anno 1898. 63. Aufrecht. Deutsch. Archiv. f. Klin. Med. Bd., LXVII, p. 586, 1900. 64. Abrams. Diseases of the Lungs and Pleura, p. 116, 1903 65. Abrams. The Medical News, June 25, 1904. 66. Abrams. Medicine, Jan., 1904. 67. Abrams. Amer. Jour, of the Med. Sc., Jan. 1904. 68. Mackenzie. Symptoms and Their Interpretation, 1909. 69. Hertz. Lancet, London, April 29, 1911. 70. Reed. Jour. A. M. A., March 25, 1911. 71. Pottenger. Lancet- Clinic, Dec. n, 1909. 72. Wolff-Eisner. Deutsch. Med. Woch., April 21, 1910. 73. Lawrie. Lancet, Oct. 20, 1906 74. Me Williams. Medical Record, Dec. 16, 1905. 75. Nutt. Jour. A. M. A., Jan. 19, 1907. 76. Epstein New York Med. Jour., May 26, 1906. 77. Reynolds and Lovett. Jour. A. M. A., March 26, 1910. 78. Cohen. New York Med. Jour., Feb. 19, Feb. 26, March 5, 1910. 79. O'Malley. American Medicine, April, 1908. 80. Latham. Lancet, Sept. 24, 1910. 81. Adams. Boston Med. and Surg. Jour., Jan. 19, 1911. 82. Taylor. New York Med. Jour., Feb. 8, 1908. 83. Loewi. Wiener Klin. Woch., XXIII, 274, 1910. 84. Cannon and De La Paz. Jour. A. M. A., March n, 1911. 85. Sawyer. New York Med. Jour., Dec. 3, 1910. 86. Peabody. Boston Med. and Surg. Jour., Aug. 14, 1910. 87. Beebe and Rogers. Archiv. Int. Med., Nov. 1908. 88. Boeri. Nueva Rivista Clin.-Terap., 1906, IX, No. 6. 89. Jackson. Boston Med. and Surg. Jour., Sept. 15, 1910. 90. Magyary-Kossa. Deutsch. Med. Woch., June 8, 1911. 91. Zulawski. Deutsch. Med. Woch., March 31, 1910. 92. Merklen and Heitz. Examen et Semeiotique du Coeur. 93. Vecki. Amer. Jour, of Physiolog. Ther., Sept., 1910. 94. Abrams. New York Med. Jour., Oct. 29, 1910. 95. Osier. Lancet, March 12 and 26, 1910. 96. Short and Salisbury. British Med. Jour., March 5, 1910. 659 Spondyloth e r a p y 97. Meunier. Presse Medicale, Sept. 13, 1911. 98. Abrams. Medical Record, Feb. 22, 1908. 99. Hely. Medical Record, May 21, 1910. 100. McCaskey. Jour. A. M. A., Oct. 28, 1911. 101. Stiller. Archiv. f. Verdauungs-Krank., XIV, No. 2, 1911. 102. Pfahler. Jour. A. M. A., June 17, 1911. 103. Wilms. Deutsch. Med. Woch., No. 41, 1909. 104. Abrams. Medical Record, Aug. 8, 1903. 105. Abrams. Medical News, Feb. 8, 1902. 1 06. Wohlgemuth. Biochem. Zeitschrift, XXI, 1909. 107. Heyn. Jour. A. M. A., Aug. 12, 1911 . 108. Jacoby. Deutsch. Med. Wochen., Feb. 23, 1911, Jour. A. M. A., April i, 1911. 109. Abrams. The Lancet, Dec. 15, 1906. no. Voelcker. Index of Treatment, p. 846. in. Boggs. Jour. A. M. A., June 17, 1911. 112. Honck. Fortschr. der Medizin, Feb. 17, 1910. 113. Kolipinski. Monthly Cycloped. and Med. Bull., Sept. 1908. 660 Index Index Abdomen, pendulous and backache, 87. Abdominal insufficiency, 145, 529. Kellogg's method in, 145. Abdominal organs, hyperalgesic zones for, 67. Abdominal supporters, 145, 531, 532. Acromegaly, in diagnosis of spinal de- formity, 131. Acupuncture, 146. Adjustment of muscles, 125. of cervical vertebrae, 125. Adrenalin, 451, 590, 607, 613. Alar, or pterygoid chest, the, 94. Albuminuria, 632. Albuminuria, orthostatic, 122, 547, 633. Algesispondyloscope, 649. Amblyopia, 496. Amyl nitrite, 616. Anatomic landmarks, 19. Anatomy of the spine, 17. Anemia, pulmonary, 605. Aneurysm, abdominal, 266, 566. action of drugs on, 457. and aortic insufficiency, 552. backache in, 88. classification of, 580. definition of, 550. dilatation of, 474. etiology of, 551. in spinal deformity, 131. murmurs of, 527. of innominate, 578. of pulmonary artery, 565. radio-diagnosis of, 561. rationale of treatment, 409, 518, 581- relation to other diseases, 500. reports of cases, 569, 572, 574, 578. statistics of, 551. symptoms of, 553. thoracic, 254. treatment of, 257, 568. Aneurysm, thoracic, 254. heart- reflex in diagnosis of, 210. treatment of, 257. Anesthesia, simulated, in litigation backs, 98. hysterical, 414. Angina pectoris, 221, 455, 539, 542. Allen Burns' theory of, 221. digitalis may provoke, 225. factors exciting, 221. false, 194. Angina pectoris, continued false, differentiation of, 224. heart-reflex in differentiation of false, 223. Mackenzie's concept of, 73. spinal concussion in, 223. spinal element in, 73. treatment of, 226. true, differentiation of, 224. Anginoid pains, 540. Angio-ataxia, 276. Angio-neuroses, visceral, 276. Angio-paralysis, 276, 277. Angio-paralytic affections, 278. Angio-paralytic neuroses, concussion in, 286. Angio-spasm, 275, 277. Angio-spastic affections, 277. Angular curvature, 117. Ankylosis, 579. Anoxemia, 606. Aorta, abdominal reflex of, 265. dilatation of, 550. fluoroscopy of, 561. percussion of, 558. Aortarctia, 525. Aortectasis, 525, 551, 620. Aortograms, 567. Aortoptosis, 561, 568. Aorta, spinal concussion dilates, 255. spinal concussion contracts, 256. Aortic reflex of contraction in treat- ment, 257. Aortic reflexes, the, 254. elicitation of, 279. in diagnosis, 256, 577. physiology of, 266-267. Aphonia, differential diagnosis of, 190. Appendicitis, chronic, and backache, 88- Appendicitis, pseudo, 191. Arterioslerosis, abdominal, 567. Arterio-sclerotics, classes of, 242. Arrhythmia, nasal, 463. pseudo, 195. Arthritis deformans, 401, 579. Asthenopia, 496. Asthma, bronchial, 303, 494. adrenalin in treatment of, 314. amyl nitrite in, 309. concussion in, 313. differential diagnosis of, 312. Asthma, cardiac, 212. treated by spinal concussion, 220. 663 S p o n d y I o t h e r a p y Asthma, differentiation of, 212. lung reflex of dilation in diagnosis, 297. lung reflex of contraction in treat- ment, 299. nasal, 462. Nathan Tucker remedy in, 309 and other diseases, 502. pseudo, 495. sinusoidal current in, 313. theories of cause, 306. tracheal traction, test of, 311. Asthma, treatment of, 312. Atropin, action on vagus, 453. in diagnosis, 454. Auscultation, pulmonary, 494. Auto-intoxication, intestinal, 335. Autonomic system, 411, 426, 450. Auto-transfusion, 610. Babinski reflex, 15, 16. Schneider's explanation of, 15. Babinski syndrome, 552. Backache, 53, 83. associated with indurative head- aches, 89. exclusion of kidney factors in, 83. in women, causes of, 84. lumbago, and, 84. Backache, factors in: acute infections, 89. aneurysm of thoracic aorta, 88. constipation, 84. chronic appendicitis, 88. chronic periostitis, 87. deformity of ribs, 91. faulty breathing, 85. floating kidney, 91. from foot disability, 421. gastric tympanites, 84. improper dress, 89. over distended seminal vesicles, 87. pelvic disease, 88. pendulous abdomen, 87. post-operative, 87, 93. prostatic disease, 87. Backaches, sacro-iliac, in women, 112. professional, 93. special, 93. synoptic table of, 91. Backs, litigation, 97. Barotherapy, 649. Basedow's disease, accentuated by drugs, 458. Beevor's sign, 136. Beri-Beri, 406. Blistering, 150. Bladder reflex, the, 358. Blood-pressure: causes of high, 241. drugs lowering, 247 in diagnosis, 235. in surgery, 238. in testing heart sufficiency, 241. in typhoid fever, 238. low, 250. pathology of, 232. physiology of, 232. treatment of high, 237, 461. vaco-motor factor in, 239. Bibliography, 657. Blood-corpuscles, 617. Blood-vessels, pathologic physiology of, 232. physiology of, 231. Blood-volume, 617. Boat-shaped chest, the, 94. Bone-sensibility, in vertebral pain, 67. Bradycardia, 454. Brain, sinusoidalization of the, 383. Bright's disease, spinal concussion in treatment of, 361, 632. Bromids, in diagnosis, 460. Bronchial asthma, 303. factors of, 303-304. Bronchial glands enlarged, Grancher's sign, 82. Petruschky's sign, 82, 622. Bronchial phthisis, vertebral percussion in, 80. Calcimeter, 613. Calcium lactate, 633. Cardiectatic angina pectoris, 543. Cardioptosis, 529. Cardiospasm, 589. Cardio-splanchnic phenomenon, 346. Catalase test, 513. Cecum, mobile, 595. Celiac axis, 567. Cell-stimulation, 400. Cervical plexus, 51. Cerebral arterio-sclerosis, spinal con- cussion in, 250. Cervical caries, attitude in, 96. mal-alignment, 123. adjustment, 125. Cervical rib of Hunauld, 94. Change of life, toxic conditions in, 286. Chassaignac's tubercle, 21. Chest, defective expansion of, 300. 664 n d x Chest deformities, 94. pains, 545. Chiropractic, 5, 6, 388. Chloro-anemia, 605. Chlorosis, 605. Cholelithiasis, pseudo, 197. Chromaffin system, 451. Chromium sulphate, 635. Circulation, splanchnic, 427. system, 510. Claudication, tibial artery test for, 225. Clinical observations, psychology of, 267. pharmacology, 504. Cocain anesthesia, in diagnosis, 464, 582- Cocain solution for excluding rectal fis- sure in backache, 87. Cocain test, in lung reflex of dilatation, 297. Coccygodynia, 95. Graefe's method of treatment of, 95- Cold, action of, 544. application of in abdominal affec- tions, 60. Cold applications to spine, 167, 172. Cold extremities, concussion in, 285. Collodion, in the cure of persistent mu- cous abrasions, 77. Colon, percussion of, 592. Compression myelitis, and spinal pain, 128. causes of, 133. symptoms of, 133. Concussion, spinal: in abdominal aneurysm, 262. in angio-paralytic neuroses, 285. in cold extremities, 285. in coryza, 284. in diabetes, 281. in diagnosis of malaria, 354. Concussion, spinal: in diagnosis of typhoid fever, 356. in digestion-intoxication, 285. in excitation of vertebral reflexes, 8, 9, 10. in exophthalmic goitre, 280. in migraine, 280. in hypotension, 249, 253. in thoracic aneurysm, 257, 262. in the vaso-motor neuroses, 279. in vascular hypertension, 248. more effective than vibration, 176. physiology of, 380. slow and rapid, 396. therapeutics of, 394, 409. Concussors, 177. Congestion of spinal cord, 126. Constipation, 327. a factor in backache, 84. atonic, 328. Cooper's test of, 328. spastic, 328. treatment of, 329. Cooper's table of backaches, 91. Coryza, concussion in, 284. Coughs, elicitation of reflex, 77. inhibited by freezing, 77. Courvoisier, law of, 599. Counter-irritation, for pain, 148. areas for, 148, 149. Cranial nerves, reflexes of, 440, et seq. Cupping, 149. Cutaneous areas for influencing viscera, 174. Dam-sign, 559. Dana, 7, 56. Depressor nerve, 469. Dermographism, 277. Dermatomes of Head, 58. elicitation of, 60. D'Espine, sign of, 623. Diabetes mellitus, 281, 479, 507. concussion treatment of, 283. Diet: antiputrid regime, 341. in intestinal auto-intoxication, 341. in uric acid diseases, 102. Metchnikoff's lactic acid anti- microbic, 344. Diaphragm, reflex of, 550. Diathermic spondylotherapy, 404. Digestion-intoxication, 286. concussion treatment of, 287. Digitalis, 512, 520. and diuretin, 513, 521. Diuretin, 513. Drugs, action on vagus, 505, 509. Drummond, sign of, 556. Duodenum, percussion of, 592. ulcer of, 595, 596. Dysmenorrhea, 463. Dyspepsia, pseudo, 197. Dysphagia, 473. Edema, 632. Electric concussion-hammer, 179. Electric massage apparatus, 101. nerves, 583. Electro-concussor, 652, Electro-therapy, 151. Electro-thermal pads, 175. Emaciation, 492. 665 Spondyloth e r a p y Emphysema, sinusoidalization in, 315, 495- Enuresis, 502. Esophagismus, 196, 496. Ether anesthesia in osteoaithritis, 108. Examination of the spine: cold air current in, 69. elicitation of localized spasm in, 78 elicitation of vertebral tenderness, ?6, 77- Faradic current in, 69. freezing in, 76, 77. for deformity, 44. for eliciting the dermatomes of Head, 6p. for flexibility, 41. for Head's dermatomes, 72. for rigidity, 46. for rotation, 44, 45. for spasm, 47. for vertebral pain, 66. of muscular force, 53 tuning-fork in, 67. spondylotherapy, 43. Exercises: for lateral curvature, 161. for round shoulders, 160. Fraenkel's, in tabes, 165. spondylotherapeutic, 160. Exophthalmic goitre: pseudo, 485. Spinal concussion in, 281. theory of, 280. tracings of, 493. treatment of, 490. quinin in, 505. Exophthalmos, 490. Eye, 441. innervation of, 441. reflexes of, 443, 498. signs in hyperthyroidism, 487. Eye-strain as a cause of spinal deformi- ties, 124. Faradic current, in coccygodynia, 96. for finding painful centers, 68. Faulty attitudes, 96. Faulty breathing as a factor in back- ache, 85. Fetal rickets in diagnosis of spinal deformity, 131. Fever, 390. Fibrolysin in osteo-arthritis, 108. Fibrositis, 422. Flat-back, 96. Flat-foot, 422. Freezing, in diagnosis, 188, 548. in intercostal neuralgia, 187. in spondylotherapy, 76, 77, 150, 172. in treatment of pain, 375. physiology of, 381. reinforced, 173. Fraenkel's exercises in locomotor ataxia, 165. Functional murmurs, 525. Gall-bladder: diseases of, 590, 599, 600. influenced by concussion, 599. location of, 597. Garrigues' classification of pelvic back- aches, 89. Gastrectasis, 588. Gastric ulcer, 454. Gastroptosis, 589. Gibbert's syrup in syphilis of bones, 140. Glenard's disease, 349, 529. Glycosuria, 479. Goitre, 492. Gonococcic vaccine, 141 Gonorrhoea of bones, 141. Fuller's treatment of, 141. Gout, spinal phenomena in, 76. control of pain by freezing, 76. Gowers, quoted, i. Graefe's sign, 487. Griffin Brothers, 2. Grocco, triangles of, 606, 608. Gymnasts, Swedish, 4. Hall, Marshall, 4. Head's dermatomes, 7, 58. Head, dermatomes of, 58. iailure to elicit, 71. Head, painful areas of, in visceral dis- ease, 64, 65. Headache, indurative of Edinger, and backache, 89. Hearing, disturbances of, 498. Heart: block, 454. failure, 523. functional affections of, 228. further advances in treatment, 510 hypertrophy of, 211. incompensation of, 210. inhibition of, 228, 528. insufficiency of, 210, 213, 510. murmurs, 525, 528. nerves, 518, 521. 666 n d Heart, continued percussion, 471. tonicity of, 517. valvular lesions of, 211. Heart disease, dyspnea in, 212. heart-reflex, a guide in prognosis of, 214. Heart insufficiency, spinal concussion in, 219. Heart reflex, 199, 511, 512, 514, 636. a guide to prognosis in myocardial disease, 214. amplitude of, 227. atropin on, 454. elicitation of, 201. in pericardial effusion, 209. in valvular insufficiency, 209. method for testing heart-sufficiency, 217. method of determining amplitude of, 215. mucous membranes, and, 202. myopathic, 202. of dilatation, 221,. 519. of gastric genesis, 207. of nasal genesis, 207. of rectal origin, 207. psychic, 203. practical value of, 204. pilocarpin, on, 454. vertebral concussion, and, 204. Schott treatment, a method of pro- voking, 210. Heart-strain and nervous exhaustion, 220. Heart-sufficiency, tests for, 215. treatment of, 213. Heart tonics, test for administering, 242. Heat, application of to spine, 167, 174. Hemoptysis, treatment of, 315, 616. Hemorrhoids, as a factor in backache and sciatica, 86. Hepatic toxaemia, 334. High-frequency current, 399. Hip-joint disease, differentiated from spinal disease, 128. Hollow-back, 96. Hormones, 391. Hoover's sign, 136. Hulett, quoted, 4. Hunaud's cervical rib, 94. Hydrotherapy, i. spinal, 166. Hyperalgesic zones, for abdominal organs, 67. Hyperalgesia, 416. Hyperemia, effects of, 404. Hyperesthesia, vagal, 504. Hypertension, treatment of, 246, 461. Hyperthyroidism, 482, 488. cardiac disturbances in, 485. symptoms of, 484, 488. Hypertrophy of prostate, 634, 635. Hypotension, 250. treatment of, 252. Hypothyroidism, 482. Hysteria, 466. eye-signs of, 496. hearing in, 499. spine of, 104. Indicanuria, 336. demonstration of by sinusoidaliza- tion, 336. Porter's test for, 336. Indurated muscles, from strain, 91. rheumatic, 90. Inhibition of heart, 528. Insanity, in hyperthyroidism, 486. Intercostal neuralgia as a simulator of visceral disease, 183, 186. Intestinal auto-intoxication, 330. treatment of, 338, 345. Intestinal neuroses, 330. Intestinal reflex, of contraction, 325. of dilatation, 326. Intestines, diseases of, 326, 594. percussion of, 591. peristalsis of, 596. Intra-abdominal insufficiency, 529. Intra-spinal tumors, diagnosis of, 129. Japanese method of restoring life, 515. Jiu-jitsu, 516. Kataphoresis, 582. Kellogg's sinusoidal apparatus, 154. Kelly's observation on pelvic pain, 88. Kidney: functional tests of, 630. percussion of, 359, 630. Kidney reflexes, the, 359, 629. in diagnosis and treatment, 361. Kidney reflex of contraction, 360. of dilatation, 360. Kilmer's belt, 628. Klapp's creeping exercises, 164. Knee-jerk, 14. elicitation of by sinusoidalization in locomotor ataxia, 30. In locomotor ataxia, 28. reflex arc of the, 28. Kocher-Boston sign, 487. Kuatsu, 515. Kuhn's mask, 609. 667 Spondyloth a p y Kyphosis, 115. varieties of, 116. Laborde, method 636. Laborer's spine, 107. Landmarks of the vertebral spines, 23. Laryngeal stenosis, 414. Laryngitis, 190. Laryngismus stridulus, 623, 625. Lateral curvature, diagnosis of, 129. exercises for, 161. Leduc current, 399. Leukemia and spinal pain, 129. Ling's observations, 4. Litigation backs, 97. Liver: methods of contracting, 435. pathologic physiology of, 333. percussion of, 596, 598. reflexes of, 331, 332. treatment of circulatory disturb- ances of, 337. Lithiasis, pseudo, 197. Lloyd's rules, in diagnosis of muscular rigidity in Pott's disease, no. Localization of function in spinal seg- ments, 30-34. Localization of the spinal nerves, 24. Locomotor ataxia, differentiation of in spinal pain, 130. elicitation of knee-jerk in, by sinu- soidalization, 30. Fraenkel's exercises in, 165. hypotonia in, 54. reflex arc in, 28, 29. spinal treatment of, 363-364, 405, 616, 637. Loewi's sign, in diagnosis of sensitive areas, 70. Lordosis, 115. compensatory, 116. Lumbago, diagnosis of, 84, 99. differentiation of in spinal pain, 129. traumatic, 103. treatment of, 100. Lumbar bulging, differentiation from kyphosis, 117. Lumbar puncture, 167. Lumbo-abdominal neuralgia mistaken for appendicitis, 192. Lung reflex of Abrams, 293. of contraction, 298. elicitation of, 299. of dilatation, 294. cocain test in, 297. diagnostic value of, 297. drugs on, 455. Lung-border, methods of influencing, 476. Lung-dullness, postural, 290. in treatment, 293. Lungs, atelectasis of, 299. blood-supply of, 608. edema of, 524. tuberculosis of, 602, 609, 612. Mammary neoplasms, pseudo, 198. MannkopfPs sign in diagnosis of sensi- tive areas, 70. Mai-alignment of cervical vertebrae, 123. Malaria, splenic reflex in diagnosis of, 354, 5- in treatment of, 355. Malignant disease in diagnosis of spinal deformity, 131. Massage, electric, in lumbago, 100. spinal, 168. vibratory, 175. Meningismus, muscular rigidity in, 50. Menopause symptoms, 487. Menorrhagia, 486. Mesoaortitis, 552. Migraine, nature of, 280. concussion treatment of, 280. Moros' test for tuberculosis, 139. Mucous colitis, 530. Muller's law, of projected irritation, 73. Murmurs: aneurysmal, 527. heart, 525. phthisical, 604. subclavian, 533. Muscles, of the back, examination of, 46. rigidity of, 46. sinusoidalization of, 157. Muscular conception of disease, n. exercises, 46. fatigue in neurasthenia, 52. hypotonia, 52. reflexes 12. rigidity in spinal disease, 52. rigidity in thoracic disease, 420. spasms, 417. tonus, 409. Muscular ataxia, spinal treatment of, 363, 364- Muscular paralysis, sinusoidalization in treatment of, 362. contractures, sinusoidalization in, 362. Myistides, 422. Myocardial tone, test for, 471. 668 n d x Myocarditis: differentiation of, 513, 524. symptoms elicited by spinal con- cussion, 74. Nasal anomalies and faulty breathing, 86. Nauheim treatment and the heart- reflex, 210, 218, 409. Naunyn test, 479. Neck-affections, areas of referred pain in, 64. Nephritis: experimental, 632. treatment of, 633. Nerves: muco-cutaneous, 465. specific cutaneous, 545, 583. "Nerve-tracing," 5. Nervous system: divisions of, 449. ocular, 442. Neurasthenia and heart strain, 220. hypotension in, 252. muscular fatigue in, 52. splanchnic, 252, 337,.345 34<5. vertebral tenderness in, 70. Neuralgia, 185. intercostal, 186, 546. trigeminal, 414. Neuralgia of spinal nerves simulating visceral disease, 182. Neuritis, a cause of vertebral tenderness, 73- Neuro-mimesis, in diagnosis of spinal pain, 130. Neurotic spine, 103. Noguchi's simplified . Wassermann re- action, 140. Nose, as a reflex center, 462, 637, 639. Obesity, heart failure in, 524. Orthoform, 454. Orthoform ointment in diagnosis of hemorrhoidal backache, 86. Orthostatic albuminuria, 122. Osteo-arthritis, 105, 579. Osteo-arthritis, modern theory of, 105. thymus extract in, 106. toxaemic, 106. vertebral form of, 106. spinal deformity, 131. Osteo-myelitis in diagnosis of spinal pain, 130. Osteopathic conception of disease, 4. Osteopathic traumatism, 121. Osteopathy, 4, 387. Paget's disease and spinal deformity, 132- Pain, 55. anginoid, 540. chest, 545. formula for, 546. radicular, 547. reflex phenomena of, 413. visceral, 415. Pain, pelvic, Kelly's observation upon, 88. vertebral, 66; diagnosis of, 367. segmental localization, 367-371. in trigeminus nerve, 371. neuralgic, 378. visceral origin, 379. therapeutics of, 365. concussion analgesia, 367. infiltration anesthesia of Schleich, 382. hysterical, 378. segmental analgesia of the viscera, segmental psychrotherapy, 375. segmental analgesia in, 366, 377. sinusoidal analgesia, 374. spinal nerve-trunk analgesia, 382. Painful areas about head in visceral disease, 64, 65. in affections of the head and neck, 64. Painful spinal centers, located by Faradic current, 69. by cold air currents, 69. Pains in viscera, reproduced by verte- bral pressure, 72. Pains, reflex, 56. Pains, transferred, 5, 56. Palpation, transmitted, 416. Pancreas, 600. activity of, 600. Paradoxic pulse, 537. Parallelogram, vascular, 606. Paralysis agitans, attitude in, 96. Paralysis muscular: elicitation of contractions from the spine, in, 362. spinal concussion in, 362. Paraplegia, varieties of, 134. Parathyroids, 614. Paravertebral pressure, 467. Paravertebral triangles, 606, 608. Paravertebral tenderness, 437. Patellar reflex, 14. 669 S p o n d y I t h r a p y Percussion: auscultatory, 560. shock, 554. threshold, 511. Peritoneum, nerves of, 416. Pertussis, 619. and other diseases, 501. analysis of treatment, 627. author's conception of, 620. author's treatment of, 627. Petit's triangle, 21. Phantom tumor, 418. Pharmacology, clinical, 504. Pharmacologic methods, 453. Phloridzin, 630. Phrenic nerve, 549. Phthisis, 602. thyroid in, 459. Physiology of the spinal cord, 26. Physiology, clinical, 388. Phylogenetic diseases, 500. Pilocarpin, 451, 522, 590. Placebo, 503. Plethora, 618. Pleurodynia, in diagnosis of spinal pain, 130. Pneumatic hammer, 177. Pneumonia, 515. Poliomyelitis, 406. Post-operative backache, 87. Postural lung-dullness, 290. in treatment, 293. Pott's disease, 108. Pott's disease and spinal deformity, 132. Lloyd's rules in, 109. localities of, 109. muscular rigidity in, 109. Pressure, spinal, 169, 467. and visceral reflexes, 169, 170. at vertebral exits elicits muscular contractions, 48. physiology of, 380. points of election for, 171, 473. Professional backache, 93. Propinquity, diseases of, 502. Prostatic hypertrophy, 634, 635. Prostatic disease and backache, 87. Pseudo-diseases and spondylo-diagnosis, 182. Pseudo-angina pectoris, 194. Pseudo-appendicitis, 191. Pseudo-arrhythmia, 195. Pseudo-cerebral disease, 192. Pseudo-cholelithiasis, 197. Pseudo-dyspepsia, 197. Pseudo-esophagismus, 196. Pseudo-fibroma, 419. Pseudo-hypertrophic muscular paralysis. attitude in, 96. Pseudo-lithiasis, 197. Pseudo-mammary neoplasms, 198. Pseudo-mastoiditis, 193. Pseudo-pertussis, 624. Pseudo-phthisis, 439. Pseudo-visceral diseases, explanation of, 182, 439. Psychology of clinical observations, 267. Psychrotherapy, spinal, 172. segmental, 420. Psycho-vagus tone, 466. Pulmonary artery, reflex of, 526. Pulmonary atelectasis, 299 treatment of, 302-303. Pulmonary anemia, 301, 605. Pulmonary osteoarthropathy and spinal deformity, 132. Pulmonary suction, 603. Pylorospasm, 589, 595. Pylorus: measurements of, 588. methods of contracting and dilat- ing, 588. Quincke's sympathetic sensations, 57. Quinin, 505, 628. Rachialgia, 70. Rachitic chest, the, 94. Radicularpressor, 468. Radioscopy of the aorta, 561. Rectum, reflexes of, 638. Re-education of co-ordinated move- ments in tabes, 165. Referred pain in visceral disease, seg- mental distribution of, 62. Reflex arc, components of, 26. Reflex arc of the knee-jerk, 28. Reflex, Babinski, 15. Reflexes: diaphragm, 550. dispersion of, 391. general features of, 390. inhibition of, 391. origin of, 392. regulative, 390. spinal muscular, n. symptoms, 503. tables of, 642 et seq. therapeutics of, 392, 636. varieties of, 28, 387, 417, 423, 436, 440. _ vaso-dilator of lung, 398, 526, 612. vertebral, 8. visceral, 7. 670 n d Reflexes of the cranial nerves, 440. Reflexotherapy, 581, 636. Respiration, physiology of, 288. reversed forms of, 288. sexual types of, 288. Respiratory ataxia, a frequent neurosis, 85. Respiratory mechanism, 289. Rheumatism, diagnostic pharmaco therapy of, 142. in children, 143. differentiated from arthritis defor- mans, 141. from osteo-myelitis, 141. treatment of, 142. Rheumatoid arthritis and spinal de- formity, 133. Rhizotomy, 393. Ribs, deformity of as a factor in back- ache, 91. Rickets, symptoms of, 143. Rickets and spinal deformity, 132. Ridlon's exercises in lateral curvature, 161. Riedel's lobe, 599. Rose's method, 531. Round shoulders, 96. and backache, 53. exercises for, 160. Sacro-iliac disease, in. relaxation, 111. diagnosis of, 112, 113. Saddle-back, 116. Sapo viridis, 613. Schneider's explanation of Babinski reflex, 15, 16. Schott method in heart disease, 218. heart-reflex the essential factor in, 218. Sciatica, in diagnosis of spinal pain, 130. Scoliosis, diagnosis of, 45, 115. treatment of, 115. varieties of, 114. Scotoma, 540. Scrofula: glands in, 613. nature of, 139. Scurvy and spinal deformity, 132. Senility and spinal deformity, 132. Sensitive areas: diagnosis of, 69, 70. Loewi's sign in, 70. Mannkopffs sign in, 70. Segmental distribution of referred pain in visceral disease, 62. Segmental skin-fields, 35. Seminal vesicles over-distended as a factor in backache, 87. Simulated anesthesia, in litigation backs 98. Sinusoidal current, 8, n, 151. Kellogg's apparatus, 154. uses of, 155. Victor apparatus, 155. Sinusoidalization : of the brain, 383-386. physiology of, 381. Sismotherapy, 175. Soap, green, 613. Spasm of muscles, 417. Spasm of spinal muscles, 47, 421. Specific cutaneous nerves, 545. Sphygmomanometer of Riva-Rocci, 245. Sphygmomanometers, 244. Sphygmomanometry, 244. Spinal column, lateral curvature of, 41. length of individual parts of, 40. movements of, 41, 42. Spinal cord, anatomy of, 17. compression of, 133. congestion of, 126. physiology of, 26. trophic functions of, 400. Spinal curvatures, varieties of, 113. Spinal curves, 39. Spinal deformities, differentiation of, 126, 128, 131, 132, 133. Spinal disease, muscular rigidity in, 52. Spinal diseases, diagnosis of, 126. Spinal examination for deformity, 44, 45- Spinal furrow, 19. Spinal meningitis, differential diagnosis of, 144. Spinal meningitis in diagnosis of spinal pain, 131. Spinal muscles, rigidity of, 46. spasm of, 41. Spinal muscular reflexes, n. Spinal nerves, 17. distribution of, 18. localization of, 24. Spinal pains, differentiation of, 126, 128. Spinal segment defined, 30. Spinal segments, differentiated, 31. irritable, 439. relation of to vertebral spines, 37. Spinal sprains, 119. nervous symptoms of, 119. Spinal veins, 126, 127. 671 Spondylotherapy Spine, diseases of, 44. hysterical, 104. laborer's, 107. neurotic, 103, 406. percussion zones of, 559. tender areas of, 3. the normal, 38. traumatism of, 118. tumors of the, 121. typhoid, 121. Spinous processes, definition of, 21. Splanchnic area, 429. Splanchnic nerves, 430. Splanchnic neurasthenia, 252, 337, 432. factors of, 346. treatment of, 345, 434. Splanchnoscopy, 597. Spleen, Banti's disease of, 357. reflex of, in diagnosis and treat- ment of malaria, 354-355. reflexes of, 352, 353. Splenic reflex, in treatment, 352, 355. Spondylitis deformans, 106. Spondylitis, varieties of, 117. Spondylography, 42. Spondylolisthesis, 118. Spondylopathology, 388. Spondylotherapeutic methods, physi- ology of, 379, 387. Spondylotherapy, in etiology of disease, 640. Static current in differentiation of joint- lesions, 139. Stiff back, 50. causes of, 52. Stomach, acute dilatation after opera- tions, 320. percussion of, 321, 584. dislocation of, 323. motor insufficiency of, 324. treatment of motor insufficiency of, 324. tympanites a factor in backache, 84. ulcer, spinal phenomena in, 76. control of pain bv freezing, 76. diagnostic data of, 588. diseases of, 588. further advances in treatment of, 584- pharmacodiagnosis of, 590. treatment of diseases of, 591. X-ray pictures of, 584, 586. Stomach reflex of contraction, 3 16, 332. in diagnosis, 332. Stomach reflex of dilatation, 318. Straining at stool and heart reflex, 208. Strophanthin, 520. Subclavian murmurs, 533. Sugar production, 480. Suspension, in treatment, 478. Sympathetic system, 427, 450. Sympathetic system, action of drugs on, 453, 59, 522. Sympathicotropic action, 451. Swedish gymnasts, 4. Sympathetic sensations, 57. Sympathetic system, 24. Syphilis and spinal deformity, 133. Gibbert's syrup in, 140. in heart failure, 524. of bones, 139. signs of congenital, 140. Wassermann reaction in, 140. Tabes, 405, 616. Table: of pharmacology of reflexes,646. of spondylodiagnosis, 642 of Spondylotherapy, 644. 1 'aches cerebrates, 277. Temperature, bodily, raised by con- cussion, 180. raised by pressure, 437. regulation of, 437. Tenderness in visceral disease, seg- mental distribution of, 62. Tendon reflexes, probably true reflexes, 29. Therapeutics, physiologic, 389. results of, 474. Thermo-therapy, spinal, 174, 175, 403, 405- Thiosinamin, in osteoarthritis, 108. Thymus gland, 623. Thyroid, 483. diseases of, 482. heart, 485. in phthisis, 459. Tinnitus aurium, 499. Tissue vulnerability, 604. Tobacco, effects of, 540, 541. Tonsilitis, 523. Tonus, muscular, 409. Topoalgias, in neurasthenia, 70. Tracheal tug, 555. Trophic diseases, 401. Tuberculin, in diagnosis of tubercular joint lesions, 138. Tuberculosis, joint disease in, 137. pulmonary, 602. treatment of, 609, 612. sinusoidalization in, 315. Tumors of the spine, 121. 672 n d Tuning-fork, in testing pain-suscepti- bility, 66. Transferred pains, 5, 56. Traumatism of the spine, 118. Typhoid fever, spinal concussion in diagnosis of, 356. in defervescence of, 357. Typhoid spine, 121. Ulcer, gastric, 454. Uremia, 632. Uric acid diathesis localized in muscles, 158. sinusoidalization in, 158. Uric acid, diet in, 102. foods, 102. Uric acid theory of disease, 101. Uterus reflex, the, 358. Uterus, anomalies in position, 420. Vagal phenomena, 470. Vagus: anatomy of, 446. diagnosis of tone, 453. hypertonia of, 452. hypotonia of, 452. physiology of, 448. pathology of, 448. tone and sense organs, 462. tonus of, 451. Vagus-tone: diseases caused by, 479. methods of decreasing, 472. methods of increasing, 469. Vasoconstrictor nerves, 274, 278. Vasodilator nerves, 274, 278. Vaso-dilator lung reflex, 398. Vaso-motor apparatus, the, 272. Vaso-motor ataxia, 424. Vaso-motor instability, treatment of, 279. Vaso-motor nerves, pathology of, 275. course of, 425. Vaso-motor neuroses, 275. treatment of, 278. Vaso-motor reactions, 425. Vaso-motor reflex, 273. Vaso-motor sufficiency, test of, 240. Vaso-motor temperament, 424. Veins, spinal, 126, 127. Vertebral areas, involved in muscular spasm, 49. artery, compression of, 21. column, uses of, 38. insufficiency, 122. pains, 66. percussion, 19, 559. Vertebral, continued spines, relation of to spinal seg- ments, 37. reflexes, mechanism of, 10. excitation of, 8. Vertebral tenderness: Alsberg's comments on, 71. and congestion of cord, 126. and localized muscular spasm, 78. elicited by palpation of organs, 75. elicited by irritation of skin, 78. elicited in gout, 76. elicited in stomach ulcer, 76. in neurasthenia, 70. inhibited by freezing, 75. physiology of, 72. Visceral disease, table, 74. Vibra-massage, 176, 181. Vibration, inefficiency of, 394. Vibro-suppression, in percussion of chest, 80. Vibro-suppressor, illustration of, 81. use of, 82. Visceral diseases, differential diagnosis of, 189. Visceral reflexes, 7. Visceral reflexes, elicited by spinal pressure, 170. Viscero-motor centers, 36. table of, 36. Visceral musculature, 399. Visceral pain, 415, 417, 439. Visceral phenomena, 411. Visceral tone, 462, 465, 510. Wassermann reaction, in syphilis, 140, 522. Noguchi's modification of, 140. Whooping cough, 619. Wintergreen, oil of, in lumbago, 100 Wohlgemuth, method of, 600. Wolf's law, 546. Women, backache in, 84. coccygodynia in, 95. dysmenorrhoea in, treated by spinal pressure, 358. pelvic backaches of, Garrigues' classification, 89. pelvic disease as a factor in back- ache, 88. pelvic pain in, Kelly's observation, 89. reversed type of breathing in, 86. sacro-iliac backaches of, 112. uterus reflex in, 358. X-ray diagnosis of aneurysm, 561. 673 PROGRESSIVE SPONDYLOTHERAPY 1913 A SUMMARY OF NEW CLINICO-PHYSIOLOGIC AND REFLEXOLOGIC DATA WITH AN APPENDIX ON THE PHYSIOLOGICAL PHYSICS OF THE VARIOUS FORMS OF FORCE BY ALBERT ABRAMS, A. M., M. D. (UNIVERSITY OF HEIDELBERG) F. R. M. S. HONORARY PRESIDENT OF THE AMERICAN ASSOCIATION FOR THE STUDY OF. SPONDYLOTHERAPY; CONSULTING PHYSI- CIAN TO THE MOUNT ZION AND FRENCH HOSPITALS, SAN FRANCISCO; FORMERLY PROFESSOR OF PATHOLOGY AND DIRECTOR OF THE MEDICAL CLINIC, COOPER MEDICAL COLLEGE (DEPARTMENT OF MEDI- CINE LELAND STANFORD JUNIOR UNIVER- SITY), SAN FRANCISCO; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION. REPRESENTING THE ADDITIONAL SUBJECT- MATTER INCLUDED IN THE FIFTH EDITION OF SPONDYLOTHERAPY (PHYSIO-THERAPY OF THE SPINE BASED ON A STUDY OF CLINICAL PHYSIOLOGY) PHILOPOLIS PRESS, SUITE 406, LINCOLN BUILDING SAN FRANCISCO 1913 COPYRIGHT. 1913 BY ALBERT ABRAMS TO SIR JAMES BARR, M. D., LL. D., F. R. S. E., CONSULTING PHYSICIAN, THE ROYAL INFIRMARY, LIVERPOOL, AND PRESIDENT OF THE BRITISH MEDICAL ASSOCIATION. THIS VOLUME IS INSCRIBED IN RECOGNITION OF HIS FRIENDSHIP AND OF HIS DISTIN- GUISHED SERVICES IN THE ADVANCEMENT OF MEDICINE PREFACE. THE first edition of Spondylotherapy was published in 1910 and since that time four editions of the work have been issued. To avoid the necessity of a new edition, which has become imperative, this volume is designed to substitute the latter. The subject-matter of the appendix is an attempt to further rationalize physiotherapy and to remove the stigma still associated in the minds of many with this almost empirical meth- od of therapeutics. When Spondylotherapy was first published many statements seemed incredible and only the cognoscenti could interpret its true significance. Spondylotherapy or reflex- otherapy, was equally an attempt to rationalize crude methods practised by the Japanese under the name Knatsu, and by the Chinese as Tcha-Tchin. Commenting on the latter the Abbe Grosier, at the end of the 18th century observed,, "L'efficacite de ce trait ement, est pronvee par dcs guerisons sans nombre et qui semblent surnaturelles." The data in the appendix appear equally incredible but truth is established neither by convictions nor theorization. The maneuvers suggested by the author are simple and easily exe- cuted and judgment should be reserved until they have been tried. The term force in the appendix is employed in its popular sense. Atomic energy like matter, in accordance with the law of the Conservation of Energy, is indestructible and uncreatable and must be regarded as a separate entity. Energy before as- sociation with the position of one body in reference to another is potential in contrast with kinetic energy or the energy of motion. The fact that I have solicited physiology to contribute its share in clarifying some problems should occasion no surprise. The laws of physical science are universal and apply equally to living organisms and so-called inanimate things. This iatrophysical conception demonstrates the trend of Uni- fying the various forms of force under one great principle. A. A. 246 POWELL ST., SAN FRANCISCO, CAL., APRIL, 1913. CONTENTS CHAPTER I. Page General Reflexo-Diagnosis - ... 1 CHAPTER II. General Reflexo-Therapy 36 CHAPTER III. The Circulatory Apparatus - 50 CHAPTER IV. The Digestive Apparatus 80 CHAPTER V. Miscellaneous Reflexes and Data - - 100 CHAPTER VI. Electronotherapy - 115 CHAPTER VII. Magnetic Force - 131 CHAPTER VIII. Physics of the Magnetic Force - 138 CHAPTER IX. Physiological Physics of the Magnetic Force - 142 CHAPTER X. Deductions - - - 173 GLOSSARY --.._ 209 BIBLIOGRAPHY - --_.._. 212 INDEX - - - - * 213 PROGRESSIVE SPONDYLOTHERAPY* CHAPTER I. GENERAL REFLEXODIAGNOSIS. SCOPE OF SPONDYLOTHERAPY REFLEXO-DIAGNOSIS FUNCTION- AL DIAGNOSIS VISCERAL TONOMETRY SPONDYLOPRESSOR VAGO-VISCERAL METHODS DIAGNOSIS OF INTUITIONAL ACTS BACKACHE AND VERTEBRAL TENDERNESS REFERRED PAIN DIAGNOSIS OF HYSTERIA. SCOPE OF SPONDYLOTHERAPY. My friend, Dr. H. Jaworski, of Paris, France, first suggested the name, "REFLEXOTHERAPY" (636). He further suggests "REFLEXO-SPONDYLOTHERAPY." Dr. J. Madison Taylor, and Dr. Louis von Cotz- hausen, protest against the employment of the word spondylotherapy contending that the designation is too limited in scope to do justice to the subject which embraces not only new methods of treatment but new methods of diagnosis. Dr. von Cotzhausen proposes the neologism, "REFLEXOLOGY." Spondylotherapy, may suggest exclusivism to the captious critic and so would electrotherapy and hyd- rotherapy but time has removed this stigma from the devotees of the latter methods of practice. In the preface to the third edition of SPONDYLO- THERAPY and elsewhere in the same work (387), its purport has been fully expounded. The latter is no more suggestive of an exclusive method of practice than is electrotherapy but only emphasizes the impor- tance of the spinal cord as the center for the dis- charge of the majority of reflex actions. *Numbers in parentheses refer to the pages in the last edition of SPON- DYLOTHERAPY where the subject has already been discussed. When the word "page" precedes the number it refers to the present edition of pro- gressive spondylotherapy. Progressive Spondylotherapy Throughout many works on different subjects, the author has constantly referred to his vertebral re- flexes but they were practically ignored until they were collated in his book, "SPONDYLOTHERAPY." There still lingers the doctrinaire who confuses spondylotherapy with osteopathy. With like astig- matic mentality, the orthopedist could be accounted an osteopath for the reason that he treats diseases of the backbone. Anent osteopathy, a kindly word should be said of some of the proselytes of this cult who are now recog- nizing certain errors in their early conception of disease. One of the fundamental principles of osteopathy was that diseases were caused by dislocations of the vertebrae which by exerting pressure on the spinal nerves induced derangements of functions. By push- ing and pulling the vertebrae into place, the " lesions" could be corrected. Dr. J. Madison Taylor, has studied this -subject from an unprejudiced viewpoint and quotes the high- est authorities on anatomy to show that, except when long-standing or progressive morbid processes have been the cause (lateral curvature and tubercular dis- ease), changes in the relationship of the vertebrae are practical impossibilities. This authority 1 observes : "Relaxations of the lat- eral and posterior spinal ligaments are due to nutri- tive faults. There is produced often the appearance of" dislocation, but these morphologic phenomena disappear on restoration of the tonus of the shrunk- en tissues, chiefly through mechanical stimulation. Attempts to 'replace' these so-called 'dislocated bones' and to relieve pressure on nerves, the creed of the osteopath, sometimes result in benefit, not by accomplishing the object aimed at, but through the effects wrought upon the centers of vasotonus and lymph activities by mechanical or other stimu- Scope of Spondylo therapy lation. Where, as sometimes happens, undue force is used to 'pull or push' these tissues in place, harm is often wrought of which little is said, or to which other causes are assigned. Thus any agent which causes vasoconstriction in the tissues of the back contiguous to the spinal column will produce, con- versely, dilation of the vessels in the cord and of the organs and parts beyond the line of innervation. "Any agent which produces dilatation of the ves- sels supplying the tissues of the back will, by com- pensatory action, induce constriction in the blood- vessels of the cord and parts beyond. The signifi- cance of this is at once made plain, and its value, not only as a factor in diagnosis, but in treatment, manifest. "On inspecting the back of one who is, and has always been, perfectly sound, there will be seen (if certain attitudes are assumed to bring them into prominence) the spines of the vertebrae in normal alignment, distance apart, and degree of posterior projection. If there has been a history of long-con- tinued or recurrent disturbances of the internal or- gans, these are frequently revealed by alterations in the tonus of the blood-vessels of those muscles and other tissues innervated by, or lying adjacent to, the governing segments of the cord from which the organs at fault are reflexly controlled through their vasomotor connections. The change of form exhib- ited is an atrophy of some, infiltration and thicken- ing of others, and if long continued, asymmetries of the vertebrae, the spines apparently pointing in different directions. If the lesions have become chronic, the spines are found separated owing to the relaxation of the posterior ligaments, until be- tween two or more marked depressions appear, or several are depressed below the normal line of projection. This disarrangement of the vertebrae is more apparent than real, the asymmetries being due to loss of tone and relaxation in the supporting ligaments, and this disappears under appropriate treatment." Dr. Earle Scanland Willard, one of the most emi- nent authorities on the subject of osteopathy urges academic revision of the principles of osteopathy based on most careful research work. He observes : 3 Progressive Spondyloth er apy - 2 "It -seems that the explanation of the lesion rests upon something more than mere pressure of mal- adjusted tissue upon nerve-fiber or vascular channel ; this at best can be only part of the physiological dis- turbance of the muscular, fascial, ligamentous, and osseous tissues which causes interference with the normal afferent influence to the spinal cord centers, and this is more or less permanently maintained by the lack of freedom of the joint movements. Neither macroscopic nor microscopic findings in the tissues passing through the spinal foramen war- rant the assumption that the osteopathic lesion is the result of mechanical pressure in this region." Hippocrates must have anticipated sectarian prac- tice with relation to the spine. I find in his chapter on "Articulations" that, after enjoining the physi- cian to know the spine as requisite in many diseases, he inveighs against the practice of attributing cure to the reduction of dislocated vertebrae thus profiting by the ignorance of others. Curvature of the spine, he continues, occurs even in health from natural con- formation, from habit, old age and from pains. The osteopaths have recently protested against what they regard as an encroachment on their domain and claim that I have purloined their ideas. This abuse is couched in less elegant though in more cogent phraseology. I have shown that the primal concep- tion of this cult has been discredited by its leaders. If the vertebral column and spinal cord have been patented then my researches must be regarded as an infringement and a caveat emptor should be issued. I fear however, that my detractors are in the same position as the dramatist whose manuscript was rejected. Later, he witnessed a play in which ' ' stage- Reflexo - Diagnosis thunder" was also employed and excitedly cried, "They've stolen my thunder." REFLEXO-DIAGNOSIS. Many reflex acts are so perfectly coordinated that one is constrained to believe that, in the spinal cord there exists a subsidiary brain. Man is practically an automaton and many of the phenomena of vegetative life, respiration, circula- tion, nutrition, etc., are produced in the subconscious state and without voluntary effort. Eating, drinking, walking, in short, the essential acts of life, are but a mass of habits, and eventually conform to the laws of habit. Their repetition eventuates in reflex actions. It is wise that this is so, otherwise the mind would be so occupied that acts requiring volitional deliberation could not be executed. Instinct is an adaptive impulse in the absence of intelligence, yet instinct is made up of reflex acts purely automatic and without the domain of the mind. The bee constructs a perfect cell without a mathe- matical education, and birds migrate without chart or compass. All diseases are manifested by a direct and indirect symptomatology ; the latter embrace the reflex symp- toms. There are individuals who are reflexophilic, i. e., they have exaggerated reflexes. If the life of an animal is essentially a series of reflex actions and pathology is nought else but the physiology of the sick, then the reflexes must assume primary importance in diagnosis. In visceral dis- eases, symptoms are often referred to the somatic area (411). In other instances, the reflexes are essentially com- pensatory or for purposes of defense (191). Progressive Spondylotherapy FUNCTIONAL DIAGNOSIS. Montaigne has observed, "Even as Nature makes us to see that many dead things have yet certain secret relations to life." The time was, when the chief goal of the pathologist was to discover some morbid change for every disease but the study of the living has supplanted the study of the dead and the consequence is, the passing of morbid anatomy. We no longer strive to make the clinical correspond with the anatomical findings and picture in our minds the pathologic conditions prevailing in disease. Our chief aim is to make a functional diagnosis which takes cognizance of anomalies in the physiolog- ic functions of the viscera. Physiologic fluctuations may be resident in an organ even before a path- ologico-anatomic substratum is assumed to exist. The recent advances made in pathology and thera- peutics have been mainly along the lines of func- tional diagnosis. VISCERAL TONOMETRY. I believe that, in my work on "Diagnostic-Thera- peutics," the first systematic attempt was made to study the viscera with reference to their functional sufficiency (215). Since then, by aid of a simple apparatus which will be described later, coupled with a recognition of the visceral reflexes, it is now possible to gauge the capacity of an organ to execute its func- tions, i. e., to measure its visceral tone. The utter helplessness of the physician to achieve such results by conventional methods only emphasizes the fact that conjecture often plays a predominant role in medical practice. Take so plebian an affection as constipation and I venture to say that, heretofore it was impossible to recognize it objectively. The capacity of an organ to execute its functions Visceral Ton ometry is determined by the tone of its musculature (409 and 451). THE VISCERAL MUSCLE. This is usually in the form of a membrane or sheet but in certain situations (uterus, pylorus), it is thick and well developed. Unlike the skeletal, the visceral muscle receives its stimuli not directly but indirectly through the inter- mediation of ganglion cells. The visceral muscula- ture shows elasticity, tonicity, irritability and con- ductivity. There is a distinct periodicity in the move- ments of visceral muscle characterized by contrac- tion and relaxation of the muscle-fibers. If the latter are stimulated by the induced or con- stant current, the contraction takes place more rap- idly than the relaxation, the two phases occupying 5 and 35 seconds respectively with a latent period of 0.25 second. In our treatment notably by aid of elec- tricity the foregoing facts are important. The vis- ceral musculature is plain or involuntary and does not respond to stimulation like voluntary muscle. Strong currents (notably the sinusoidal current) are necessary and the rate of stimulation to produce a tetanic contraction is slower than for cross-striped muscle. The best effects are achieved by a stimulus acting every five seconds. The slow, long-waved sinu- soidal current is best to secure such effects. THE VISCERAL REFLEXES (7, et seq.). These organ- ic reflexes are chiefly concerned with involuntary non-striated muscles which are dominated by the sympathetic nervous system and are incapable of di- rect voluntary restraint. In the norm, the visceral reflexes do not implicate consciousness. In visceral pain (415) or, when the reflex act stimulates a cere- bro-spinal sensory nerve, consciousness may be reach- ed. The latter is also evoked when voluntary muscles 7 Progressive Spondylotherapy must supplement an organic reflex. Defecation is in- voluntary respecting intestinal movements but in stimulation of the rectal mucosa, the perineal muscles are brought into action and the reflex becomes con- scious and voluntary. The scrotal reflex is a typical sympathetic motor phenomenon and, like the other organic motor re- flexes, the contraction is slow and worm-like and not brisk like the reflexes of striated muscle. In addition to the sympathetic system described elsewhere (427, 450), there are also microscopic gan- glia (micro-sympathetic ganglia), demonstrable by the microscope and located below the union of the anterior and posterior nerve roots of the spinal nerves. The function of the latter is unknown. MAINTENANCE OF VISCERAL TONE. Visceral tone is practically a reflex due to a constant flow of impulses from an organ along sensory paths and the transla- tion of such impulses into tonic discharges from the motor neurons in the cord. The foregoing represents the neurogenic tonus. It has been shown elsewhere (451), that, the tonus of the sympathetic fibers is maintained by the secretion of adrenalin but that similar internal secretion is yet to be demonstrated for maintaining the tonus of the autonomic fibers which is represented by the extended vagus (450). Meltzer and Cannon, have shown that stimula- tion of the peripheral end of the splanchnic augments the secretion of adrenalin which is indicated by dila- tation of the pupil. The latter is hardly a sufficient criterion for adrenalin action. In studying the action of adrenalin on the viscera by hypodermatic injections of adrenalin in the hu- man, the following were noted : 1. Dilatation of the pupil (452, 522). 8 Spondylopr essor 2. Evanescent increase of blood-pressure. 3. Constriction of the majority of blood-vessels. Dilatation of aneurysms (457) and the pul- monary blood-vessels (607). 4. Contraction of the lungs (314, 456). 5. Dilatation of the stomach (590). This action of adrenalin may be. duplicated in the human by stimulation of the splanchnic nerves (430, 434). The best effects are achieved by limiting the stimulation from the 4th, to the 8th dorsal spines. A like effect may be noted by stimulation of the phrenic nerve at its exit (549). Here, I have assum- ed is another source of stimulating the secretion of the suprarenal glands: the latter being supplied by the phrenico-abdominal branches. The pancreas has probably an inhibitory influence on the secretion of adrenalin (452). In accordance with this theory aided by my method of duodenal intubation (page 85), I determined that, one may augment the pancre- atic secretion by application of a stimulus to the 10th dorsal spine and that, during and f orsome time after, the tonicity of the sympathetic is reduced. If dilatation of the splanchnic vessels is accepted as a criterion of an effect opposed to splanchnic stimu- lation, its effect can be achieved by the method cited on page 55. An overproduction of epinephrin is res- sponsible for many symptoms notably, hypertension and glycosuria. SPONDYLOPRESSOR Pressure at definite paravertebral areas will ewke specific visceral reflexes (169). Practically all the vis- cera innervated by the vagus (448) may be brought to contraction by application of the stimulus to the 7th cervical spine (467). 9 Progressive Spondylo therapy The vagus includes those roots formerly specified as the "bulbar part of the spinal accessory." The latter is limited to the spinal part of the accessorius and is a continuation of the vagus nucleus in the medulla. It has been suggested (467), to make pressure for one minute. Mature experience has shown that the pressure should not exceed one-half minute, other- wise the reflex is exhausted. A curious physiologic phenomenon has been not- ed with reference to the exhaustion of neurogenic tonus at the 7th cervical spine and elsewhere. One may stimulate the vagus reflexly from a number of situations (229). As a paradigm, select the stomach reflex of con- traction (316). Within a few seconds after pres- sure is made with the radicular-pressor (649), at the 7th cervical spine, the tympanitic area of the stomach yields a dullness but, if the pressure ex- ceeds one-half minute, the dullness is again sup- planted by tympanicity because the reflex is ex- hausted. When pressure at the 7th cervical spine will no longer elicit the reflex, pressure in an inter- costal space will again evoke the reflex. The deduc- tion is evident; only the afferent paths (not the vagus itself) were exhausted. This phenomenon suggests the rationale of many therapeutic proced- ures and demonstrates how, one may utilize other afferent paths in the excitation of centers which cannot be reached by paths already enervated. Visceral tonometry by aid of the spondylopressor (Fig. 1) guages neurogenic tonus, myogenic tonus or both. With reference to the heart, if the neurogenic tonus is normal, pressure at the 7th cervical spine will not inhibit the pulse even though the pressure registers 10 kilograms. If, however, vagus tone is diminished as in exoph- thalmic goitre (page 74,) one cannot feel the pulse (during the time of pressure) when the pressure has attained 3 or 5 kilograms. In the latter affection however, the myocardium is efficient as a rule, there- 10 Spondylopr essor fore recourse must be had to another method for de- termining the sufficiency of the latter. Estimate the pressure in kilograms necessary to increase precor- dial dullness (471). As a rule, a pressure of 5 kilo- grams will augment the latter whereas in myocardial insufficiency, the full pressure of 10 kilograms fails to modify the percussion note. FIG. 1. Spondylopressor with reflexometric attachment. A, attachment for use as an algesispondylometer; B, attachment for use as an algesi- meter elsewhere in the body; C, attachment for gauging the vigor of the spinal and abdominal muscles. Atonic constipation (328) is more frequent than the spastic variety. If pressure is made at the 2nd lumbar spine the tympanitic intestines become dull if there is no constipation whereas in the presence of the latter, the full 10 kilograms of pressure will cause no change in the percussion sound.* A minimum pressure of 4 kilograms at the 7th cer- vical spine is necessary to cause a descent of the nor- mal or orthotonic lung. In the hypertonic lung (asthma), the lower lung-border descends with a pressure of 1 kilogram. Aside from the employment of the foregoing ap- paratus as a reflexometer, the author has employed it for the following purposes : *For further details concerning the employment of the spondylopressor in the diagnosis of visceral reflexes, vide pages 34 and 74. 11 Progressive Spondylotherapy 1. As an algesimeter, to measure the reaction to pain by kilograms of pressure. The attachment (A) is employed to measure vertebral points of tender- ness whereas the disk (B) is used for measuring pain elsewhere. One may also utilize this apparatus for determining the progress of a malady by the res- ponse to pain by diminished or increased kilograms of pressure. 2. As a baresthesiometer. Afferent peripheral impulses are conducted along distinct classes of nervefibers and common sensation is made up of three kinds of sensibility : a. Deep sensibility recognizes deep pressure which, if excessive causes " pressure-pain." This sensibility takes cognizance of sensations from muscles, joints and the vibration sense (66). These sensory impulses are not annihilated by division of the sensory cutaneous nerves. b. Protopathic sensibility recognizes painful cut- aneous stimuli (pin-pricks) and extreme degrees of heat and cold. c. Epicritic sensibility responds to light touches (cotton- wool) and finer grades of temperature. The foregoing differences are applicable only to the peripheral nerves (extra-spinal portion of the sensory paths) . In peripheral neuritis, the deep hyperalgesia and cutaneous anesthesia (cotton-wool touch unperceiv- ed) is diagnostic in contrast to the condition prevail- ing in locomotor ataxia, viz., association of superficial and deep analgesia. Peripheral sensory impulses pass to the spinal-root ganglia then through the posterior roots to the cord. In the latter, there is no separation of the deep and superficial pain-fibers hence in certain diseases of the 12 V a g o-V isceral Methods spinal cord, perception of pain as a whole is annihil- ated and the pain of a pin-prick or deep pressure is equally abolished. 3. For testing rigidity of the muscles of the back or elsewhere. Here, the small ring (C) rests below attachment. The pressure in kilograms necessary for the surface of the ring to attain the surface of the skin indicates the rigidity. FIG. 2. Skiagrams of an aneurysm treated by Dr. George Jarvis of Philadelphia. Also show the areas of heart and aneurysm, as determined by percussion with corroboration of the latter by the X-ray findings. A, skiagram before conclusion of the 7th cervical spine; B, diminished area after concussion; C, from same patient symptomatically cured after treatment for one month. 4. For testing the tone of the abdominal muscles in splanchnic neurasthenia (427). Fix instrument on abdominal region at a pressure of 4 kilograms and observe how many more kilograms of pressure may be recorded when the patient contracts the abdominal muscles. V AGO-VISCERAL METHODS. The inaccuracy of delimiting the viscera by topo- graphic percussion by the conventional methods (359) suggests the necessity of improved methods in physical diagnosis. The viscera are dominated by the vagus and when the tone of the latter is augment- 13 Progressive Sp ondyl other apy ed topographic percussion is facilitated. The method advocated by the author is the vago-visceral method (321). Fig. 2, illustrates the accuracy of the latter maneuver. The aneurysm and heart were primarily outlined by Dr. Geo. Jarvis, of Philadelphia, and the results of percussion were corroborated radiographic- ally. VAGO-VISCERAL INSPECTION. In thin subjects and notably in children, one may observe when intermit- tent pressure is made with the spondylopressor (Fig. 1) at the end of forced expiration during 'suspended breathing at the 7th cervical spine, the borders of the heart (page 50), the lower border of the stomach and lower border of the liver (in the anterior axillary and parasternal lines). Each time pressure is made by an assistant the stomach or liver is manifested by a bulging or shadow. As a rule, in inspecting the stomach (the patient facing a window), it is best to stand to the left of the patient and look downward. To inspect the liver, look downward from the left side. Painting the skin with a saturated alcoholic solution of gamboge will accentuate the shadows but not the bulging. The diaphragm reflex (550) ), can be seen in thin subjects in the erect posture (side of patient toward window and observer with back to light) when in- termittent pressure is made between the 2nd and 3rd cervical spines. During inspection patient must suspend breathing. The foregoing methods are conducted with the patient standing. VAGO-VISCERAL PALPATION OF THE HEART. If dur- ing the time an assistant makes intermittent pressure at the 7th cervical spine with the spondylopressor and one follows an intercostal space toward the borders of the heart, the latter give to the palpating finger a sensation not unlike that which is felt when the fin- ger is placed on the masseter muscle during mastica- 14 Vago-Visceral Palpation tion. When proficiency is acquired, it is surprising how effectually one may delimit the organ. This maneuver acquaints us with the condition of the myocardium (471) which, if efficient gives a dis- tinct impact to the finger. Vago-visceral inspection of the heart is described on page 50. DIAGNOSIS OF INTUITIONAL ACTS. An interesting brochure should be dedicated to this fascinating subject. Space forbids extensive discus- sion and it is merely introduced to awaken the inter- est of others. Every emotion is simultaneously an instinct, and every physical reaction to an emotion is the natural expression of protection. Instinct has already been discussed on page 5. In asthenopia, eyestrain is often intuitively re- lieved by stretching the neck (which increases vagus- tone) (469), by forcible closure of the eyelids or by rubbing the eyes. Pressure on the eye will augment vagus-tone (443). In cardiac neuroses, notably tachycardia, patients instinctively execute certain maneuvers (229). When the neck of the prize-fighter is vigorously rubbed, it augments the tone of the heart through the vagus. A veritable heart reflex may be elicited by friction in the region of the 7th cervical spine. To relieve an overloaded stomach the Bohemian peasantry place the knee against the back of a pa- tient seated upon a stool and make counterpressure with the hands grasping the neck. The knee-pressure is made in the region of the 5th dorsal spine which opens the pylorus (page 82). Some prize-fighters instinctively employ the liver- blow to disable their opponents. When such a blow is struck corresponding to the lower border of the 15 Progressive Spondyl other apy liver in the para'sternal line, a paralysis of the splanchnic nerve ensues and there is an engorgement, of the splanchnic blood-vessels. The cognates of instinct are becoming rapidly atro- phied from disuse and for this reason the intuition of animals is superior to that of man. In making pancreatic fistulae in dogs, the after- treatment is handicapped by the tryptic digestion of the skin around the wound. One dog suffering in this way kept on tearing down mortar from the wall to lie upon and thus relieve the condition. The in- tuitional act on the part of the dog suggests a remedy in the treatment of such fistula?. Many lessons may be derived from the study of animals. We have always known that the secretion of saliva is a reflex action but only recently do we know that the secretion of gastric juice is effected through affer- ent impulses from the senses (smell, sight, taste) passing reflexly down the path of the vagus. What has been revealed in animals respecting the secretion of gastric juice may be utilized in practice. Thus, careful investigations have convinced me that, when stimulation of the vagus is executed (7th cervical spine), gastric juice is increased and diminished, when the vagus is depressed (472). Section of the vagi in animals prevents and their stimulation aug- ments the flow of gastric juice after an interval of several minutes. Empirical knowledge has been sub- stituted by scientific facts by animal observations. Food served in an inviting way stimulates the gastric juice and its quantity is determined by the character of the ingested food. A meat diet provokes the most powerful and a milk diet, the weakest 'secretion. Many vaunted remedies like alcoholic preparations, acids, alkalies and bitters 16 Backache and Vertebral Tenderness have no greater effect when swallowed in exciting the flow of gastric juice than has water, in fact, in many instances they inhibit the flow. They act reflexly in increasing the juice by their taste and A. Randle Short, suggests that these time-honored remedies should be used as a mouth-wash, without swallowing them. BACKACHE AND VERTEBRAL TENDERNESS. Despite the fact that, this subject has already been discussed (71, 83, 422), its importance in diagnosis demands additional data. Tenderness in the spine is practically always asso- ciated with localized or more diffused rigidity and must be regarded as a protective reflex to give rest to the implicated part. The tissues involved may be : 1. Skin and subcutaneous tissues (wounds, ab- scess) ; 2. Muscles, fasciae or nerves (gout, rheumatism, neuralgia, traumatism) ; 3. Vertebrae (128, 137), vertebral joints (osteo- arthrtis) and sacro-iliac joint; 4. Cord and meninges and spinal nerve-roots. Visceral diseases and backache also demand con- sideration. Pain with tenderness on pressure emphasizes the presence of local disease. In referred pain (56), firm pressure evokes less pain than a light touch (showing skin-hyperesthesia) . Reaction of the vertebrae to pain may be tested by striking the spinous processes with a percussion- hammer. Reaction of the vertebral- joints may be determined by executing certain movements (41). In vertebral tuberculosis, tenderness is associated 17 Progressive Sp o ndyl o therapy with deformity and rigidity of the affected part and the rigidity is accentuated by movements. The pain is aggravated when the shoulders or legs are jarred or when the cathode of a Galvanic current or a hot sponge approaches the deformity. In rickets (143), there is no decided spinal tender- ness and the spinal curvature evanesces when the child is suspended by the head or arms. Secondary malignant growths often implicate the vertebrae. The Roentgen rays are often imperative in diag- nosis but it is in the interpretation of the skiagrams that the greatest skill is displayed. We shall now consider briefly the tissues involved in backache. 1. SKIN. Reference has been made to cutaneous hyperesthesia which is common in the rachialgia of neurasthenic and hysterical subjects (70). Unlike the pain in lumbago which is diffused laterally, in ra- chialgia the pain spreads upward in the line of the spine. The pain develops gradually and is influenced by various maneuvers (70). The pains from which the patient suffers may be reproduced by pressure over the sensitive area. Deformity is absent and mobility is not compromised. When the eyes of the patient are closed, localization of pain and response of tenderness to varying degrees of pressure with the spondylopressor (page 9) is characteristic. Many neurasthenics revel in their valetudinarian- ism and though desirous of counsel do not take it. Instruct such patients to take a dose of potassium io- did or other drug (which can be detected in the urine) during a paroxysm of pain and on the same day determine its presence in the urine. In hysteria, spinal points of tenderness (like peri- 18 Muscles, Fasciae and Nerves plieral points) are painful to the slightest touch, whereas deep pressure if the patient is diverted may be painless. Such pressure may excite (hysterogenic areas) or inhibit (hysterofrenic areas) and hysteri- cal attack. 2. MUSCLES, FASCIAE AND NERVES. The sole sup- ports in maintaining the spine erect are the muscles of the back and trunk without which support the spine would collapse. The region between the 9th dorsal and 3rd lumbar vertebrae is the weakest part of the spine. Sprains of the column never assume any mag- nitude owing to the compact formation of the spine and a force necessary to lacerate the ligaments would result in fracture and dislocation of the vertebrae. The latter condition without a fracture is extremely rare. Sprains are most frequent in regions enjoying the greatest mobility (cervical and lumbar) whereas fractures occur in less mobile areas of the spine. These is perhaps no disease in our nosology more frequently abused than "rheumatism." Even lumbago (84, 92) is most often a lumbo- abdominal neuralgia and freezing over the vertebral exits of the implicated spinal nerves will at once arrest the pain. Lumbago is bilateral and its diagnosis in cases of some duration should not be made until the nervous system is tested insomuch as it may be essentially a symptomatic condition. Lumbago may be associated with sciatica but more often it is a simultaneous implication of the spinal nerves. Lumbago in a woman demands an examination of the pelvic viscera, and of the rectum in both sexes. In a number of patients complaining of backache, I have found at the insertion of the gluteus maximus large movable nodules suggesting lymph-glands al- 19 Progressive Spondylotherapy though anatomists do not record their location in this region. Lymphatic drainage from the lower part of the back is through the inguinal glands (about Poupart 's ligament) . 3. VERTEBRAE, VERTEBRAL JOINTS AND SACRO-ILIAC JOINT. The vertebrae may be painful from trauma- tism, erosion by an aneurysm, tuberculosis, malignant disease, infections (gonorrhea, pyemia) and spondy- litis. The role played by uric acid in muscular and artic- ular pains (158) should be decided in several days by the use of atophan which facilitates the elimination of uric acid from the organism in all gouty and rheumatic affections. Doses of 2 to 3 grams are said to eliminate within 24 hours, double and treble the amount of uric acid and occurs independently of the fact whether purin or purin-free food is taken. The spleen is a well-known reservoir of uric acid and after concussion to elicit the spleen reflex of contraction, one can increase the output of uric acid in the urine. One may estimate the excretion before and after treatment by Gubler's method. Stratify urine upon a layer of nitric acid (volume of former to latter as 3:2). At the line of junction of the two fluids a cloudy ring of uric acid will separate out in 5 minutes or less if uric acid is increased but if diminished, it will not appear until later. Phosphotungstic acid solution is a delicate test for uric acid in the blood. 3 The movements of the spine are chiefly due to the 23 intervertebral cartilages which constitute nearly one-fourth of the entire spine. No examination of the back is complete without determining the mobility of the spine. Thus, when the back is bent forward, the lumbar spines separate and if the distance in the erect posture between the 20 Vertebrae and Vertebral Joints 1st lumbar and 1st sacral spine is 10 cm., when the back is bent forward it is 15 cm. Osteo-arthritis (105,401) is an infection frequently overlooked notwithstanding its frequency. Some contend that rheumatoid arthritis is a disease distinct from osteo-arthritis. In the former, the syn- ovial membranes and periarticular tissues are affect- ed and in the latter, the cartilage and bone. Others hold that both are varying forms of the same disease. Radiographs are valuable in diagnosis. Hyper- trophy and overgrowth of bone are noted especially in the spine. FIG. 3. The Stretcher of Cropp, with patient in the prone posture. The cartilage is eroded, disappears, or is replaced by fibrous tissue or bone, notably at the edge. The overgrowth of bone corresponds to the small hard knobs at the sides of the distal phalangesknown as H eh er den's nodes. Osteo-arthritis is often the cause of many intract- able spinal neuralgias, torticollis, lumbago and sciat- ica. The pains of this affection are more frequently caused by a neuritis than a neuralgia due either to an extension of the inflammation to the nerve or by pres- sure on the latter by the overgrowth of bone. Here, suspension (478) gives at least temporary relief. A convenient and excellent substitute for suspen- sion is "The Stretcher" (Fig. 3) devised by David 21 Progressive Sp o ndy 1 o th er apy Bertram Cropp. With this apparatus traction can be made in the prone or recumbent posture. Pain in the sacral region (sacralgia) is frequently caused by relaxation of the sacro-iliac joints (111). In the norm, motion in these joints is scarcely per- ceptible and any considerable motion is abnormal. Motion may be tested with the patient in the prone posture with the straight-leg raising test which tilts the pelvis forward or backward upon the sacrum. Motion is also determined by having the subject support the body alternately on one and then the oth- er leg. The pains are not strictly local but often diffused owing to the relation of the joint to the lum- bo-sacral cord. From pressure on the obturator nerve, the pains may be referred to the hip or knee (supplied by same nerve). While coccygodynia (95), is in the majority of in- stances a neurosis due as I believe to some anomaly of Luschka's gland (in front of the tip of the coccyx), it may also be caused by some disease of the uterus and adnexa which drag on the broad ligaments with drain on the coccygeal gland (sacral portion of the gangliated cord) . Faulty posture (186) is also responsible for pains. Any deviation from a well-balanced position strains the muscles and ligaments and alters the relationship of the viscera. Cure can only be effected by exercise and the use of proper shoes and corsets. An effect- ive corset may also correct the abdominal ptosis. In connection with faulty posture, there is sacro-iliac strain and enfeeblement of the long plantar arches. The outlines of the abdomen and back may be eas- ily determined and preserved for reference by per- mitting light to fall on a large piece of ground-glass in such a way that a silhouette of the body-contour can be drawn with chalk and then transferred to 22 FIG. 4. Normal or neutral type of posture. Distinguishing features are: (1) Line of gravity of body passes through important pivotal points; (2) the pelvis is balanced in equilibrium on the heads of the thigh bones; (3) this relation of important pivotal points with the line of gravity and this balance of the pelvis prevents muscles and ligament strains, and (4) the rear perpendicular touches the middle back and the buttocks. (After Dickinson and Truslow.) 23 Progressive Spondylotherapy paper. This method is the one I employ in tracing a struma (page 73). In the norm, the posterior per- pendicular line touches the buttocks and the middle back (Fig. 4) and the abdomen does not protrude beyond a perpendicular line drawn upwards from the anterior surfce of the thighs. 4. CORD, MENINGES AND SPINAL NERVE-ROOTS. In cord-lesions, analgesia includes deep as well as su- perficial pain whereas in a peripheral nerve-lesion, superficial may be accompanied with deep hyperal- gesia (page 12). In cord-lesions, if there is any loss to thermal stimuli, all degrees of heat and cold will be lost. Again, if the lesion implicates the posterior columns, there may be a loss of the sense of passive position and movement without loss of tactile, pain- ful or thermal stimuli. In cord and nerve-root lesions, the distribution of sensory disturbances is quite different than in impli- cation of the peripheral nerves. A zone of hyper esthesia may be found just above the area of anesthesia, in growths of the spinal men- inges, spinal caries and herpes zoster due to pressure or irritation of the posterior root-fibers. According to the theory of diaschisis, only a few symptoms are the result of the lesion itself, the balance are due to diaschisis, i. e., functional shock-like inhibition of un- injured distant areas produced by the dynamic in- fluences of a lesion anatomically connected with such areas. The symptoms due to diaschisis can disap- pear and are therefore in principle temporary. The spinal cord only extends to the 2nd lumbar vertebra. Lesions of the lower part of the cord may implicate the cauda equina (lumbar, sacral and coccy- geal nerve-roots) or the conus medullaris (that part of cord below 3rd sacral segment). In the diagnosis of the foregoing consult the table 24 Referred Pain in Visceral Disease of localization of the functions in the segments of the spinal cord (32 et seq.). REFERRED PAIN IN VISCERAL DISEASE This subject has been discussed (74). Recent investigations 4 have modified our concep- tion of visceral pain (415) with special reference to the peritoneum. Franke, shows that the autonomic system (411) of the abdominal organs is derived from the central nervous system in the mid-brain, the medulla, the dorsal cord, and the upper part of the lumbar cord. He divides the system into four parts : ( 1 ) The mid-brain autonome, represented by the third cran- ial nerve; (2) The bulbar autonome, the seventh, ninth, and tenth cranial nerves; (3) The sympa- thetic, and (4) the sacral autonomes. Each fiber is provided between the spinal cord and its peri- pheral end with one ganglion cell. They only pos- sess a centrifugal conduction power, and when the organs supplied contain sensory nerves the latter are derived from the cerebro-spinal system and have no connection with the autonomic system. The abdominal organs are innervated by the vagus, the sacral autonome and the sympathetic. Under ordi- nary conditions the abdominal organs do not reveal the least sensation, but under certain circumstances they may be the seat of severe pain, which, accord- ing to Frohlich and Meyer, is due to the stimulation of ordinary spinal nerves issuing from the posterior spinal roots. The vagus, the splanchnics, and the hypogastric nerves are free from any sensory fibers. Approaching the subject from the experimental side he finds that some difficulty is experienced when util- izing animals for the purpose. Local anaesthetics have to be avoided, as they induce a general insensi- tiveness, and it is obvious that cold air produces a loss of sensibility in regard to the abdominal organs. He, however, came to the conclusion from the reli- able evidence available, that mechanical stimuli to the intestines produce pain in the lower animals, but not when applied to the liver, spleen, or pancreas. Dogs are more susceptible than cats or rabbits. It appears further, that the stomach of these animals is 25 Progressive Spondylo therapy insensitive, but tying of vessels in connection with the organ is associated with pain. Turning to the human subject, the experience of local anaesthetics permits of a number of deductions. The parietal peritoneum is extremely sensitive, and has the pow- er of localization to some extent. The liver is absolutely insensitive to mechanical stimuli, which explains the painlessness of hepatic affections un- til the process involves the surface, and thus the peritonial covering. He could not find any records with regard to the sensibility of the human spleen or pancreas. The esophagus possesses sen- sation for pain, warmth, cold, and for pressure. This sensibility decreases downward. Further, he had no hesitation in stating that pain is felt in the mesentery, right up to the intestine. He discusses at some length the question whether the intestine is sensitive or not, and comes finally to the conclusion that normally the gastro-intestinal canal is insensitive, in contrast to the case of animals. He shows that the pain of supposed hyperacidity of the stomach is in reality due to a gastric ulcer. He fol- lows this up with an analytical discussion of the pain of colic etc., and referred this pain to pulling on the mesentery, giving a detailed account of the mode of production. He states that the gall blad- der is wholly insensitive to mechanical stimuli, but that the pain associated with biliary colic, etc., is due to the pulling on the nerves in the neck of the blad- der; this is supported by the fact that ligature of the cystic artery and the neck of the gall bladder are painful procedures. The same is true of the kidneys. The urinary bladder is sensitive, especial- ly in the trigone, and the floor is certainly sensitive to heat. It is often difficult to say whether an area of verte- bral tenderness (71) is due to a neuralgia of the spin- al nerves or to visceral disease. One must of course exclude all other factors in the production of pain and remember that tenderness in the back may impli- cate the skin, muscles, joints, bones, meninges or cord. In vertebral tenderness of visceral origin the fol- lowing data are available in diagnosis : 26 Referred Pain in Visceral Disease a. An electric current (68) or persistent friction of the skin over the tender area causes a red spot to appear which is more persistent than in the surround- ing area. b. Absence of typical points douloureux (185). c. Accentuation of vertebral tenderness by manip- ulation of the suspected viscus (75). d. Elicitation of dermatomes (58). e. Segmental-analgesia of the viscera (376). f. Tenderness is superficial and if the skin is pushed to one side, deep pressure causes little or no pain. g. Unlike the pain of a neuralgia, rubbing the part does not evoke a localized spasm of the muscle. In all true neuralgic affections, the muscles inner- vated by the nerves show* a decided weakness almost tantamount to a paresis. Vertebral tenderness of visceral origin is unaccom- panied by rigidity (diffused) or deformity of the ver- tebral column and accentuated movements (avoiding tender area) are not associated with pain. In af- fectations of the heart and aorta, vertebral tenderness or backache is accentuated by active movements and they are mitigated by diuretin or nitroglycerin, not- ably if the pains are due to an aneurysm or coronary disease. In esophageal disease, pains are accentuated by repeated acts of deglutition. In gastric ulcer, the pains are worse after eating. Thus a number of data may be elicited from the anamnesis and the execution of certain maneuvers. We must also search for tender points which are al- most characteristic of certain affections of the vis- cera : 1. Sub-mammary tenderness. Present in the left breast in the 4th or 5th intercostal space and is a re- 27 Progressive Spondylotherapy flex effect of some pelvic affection (uterus and ad- nexa). 2. Renal disease. The posterior root of the 12th nerve is associated with the renal ganglia of the sym- pathetic, in consequence of which, a tender spot at the tip of the 12th rib or soft tissues contiguous there- to is found in pyelitis and nephrolithiasis. In affec- tions of the renal pelvis and ureter, painful areas are found in the course of distribution of the llth dorsal to the 2nd lumbar nerves. The contraction of the cremaster muscle in renal colic suggests stim- ulation of the cord at the level of the 1st and 2nd lumbar nerves. In testicular affections, there is a tender area where the cord passes into the external ring. 3. Gall-bladder. Localized tenderness at the junction of the upper and middle thirds of a line drawn from the 9th rib to the umbilicus (location of fundus of gall-bladder). Enlargement of the latter occurs in the direction of this line. In the norm the neck of the gall-bladder is opposite the 9th costa cartilage but it may be as low or lower than the um- bilicus when the liver is enlarged (597). 4. Pancreas. Tenderness in the mesial line one inch above umbilicus (Bobson's point) is present in pancreatitis. Appendix. There may be several points of ten- derness in appendicitis and ceco-appendicitis ; a. McBurney's point, one and a half inches from the anterior superior spine of ileum on a line toward the umbilcus (except when appendix is not in normal position) ; b. Monroe 's point, at margin of rectus on the same line as the former (location of ileocecal valve) ; c. Morris's point, on the same line one and a half inches from umbilicus. 28 Diagnosis of Hysteria In chronic appendicitis the point of Morris is usu- ally tender, that of Monroe slightly and that of Mc- Burney rarely. In acute appendicitis the condition is reversed. A tender point to the left of the umbili- cus corresponding to the point of Morris on the right side is often present in chronic salpingitis. So much excellent philosophy has been wasted in arriving at a conception of hysteria, that the writer hesitates to express his viewpoint of this psychoneu- rosis. Among the chief conceptions of the disease are the following : 1. A state in which ideas control the body and produce morbid changes in its functions (Mobius). 2. A psychosis in which morbid states are induced by ideas (Char cot). 3. A mental condition with certain primary phe- nomena and certain secondary accidental symptoms. The essence of the primary phenomena* is that they may be produced by suggestion and may be made to disappear by persuasion or technically pithiatism (Babinski). 4. Unconscious fixed ideas in which a sexual fac- tor is concerned and, by translating the unconscious to the conscious, the impulsions which dominate the patient may be eliminated. The sexual factor arouses an emotion which is associated with some -bodily or verbal expression. The original emotion may pass from view, but the expression of the emotion lives and recurs in consciousness (Freud). From the foregoing, the following factors demand brief analysis: ideas, emotions, and suggestion. IDEAS. I have employed the term ideopath, to des- ignate an individual whose apparently sole affliction is some morbid fixed idea. A morbid idea may persist 29 Progressive Spondylotherapy even after the cause which brought it into existence has passed away. The ideogenic factors may be many but there is no idea in the mind which was not before in the senses. ' ' The idea of a disease produces disease in direct proportion to its definiteness and in inverse proportion to the strength of the idea opposing it." An idea "generates its actuality." If an individual has only one idea, the latter will express itself in some kind of external motion. The brain-cells concerned in idea-formation will discharge their force without re- straint. Man is not only an ideo-motor but an ideo- idea being. Thus with two ideas, one can inhibit the action of the other. Thought like force pursues the path of least resistance, and with the repetition of thought a habit is engendered which so masters the mind that the idea becomes pathologic, and is awak- ened into activity by the most trivial suggestions. EMOTION. This is a state of feeling fear, grief, anger, joy which is initiated like a brain-storm, and in its tumultuous force creates energetic disturbance of the entire organism. The emotions are physiolog- ically manifested by : 1. Muscular expression. 2. Bodily expression. An idea is so associated with emotion that no ab- sorbing idea can be entertained without a change of the entire body to harmonize with it. Our emotions have a rhythmic undulation depend- ent on the state of body raising or depressing the stan- dard of vitality. All feeling is necessarily mental, yet there are physical feelings originating from sensa- tions derived from the tissues and organs of the body. One may objectively demonstrate the influence of emotions on the viscera (203). 30 Suggestion Emotions are often an expression of fatigue or are fatigue-producing. The Lang-James theory refers the origin of our emotions to an organic disturbance reflexly aroused by the stimulus of the object ; in other words it is not the object, but the bodily commotion which the object excited. In hysteria one often finds physical or emotional shocks or a combination of both as exciting causes. SUGGESTION. An emotional reaction and suscepti- bility to suggestion exist in varying degrees even in the norm. In children, this condition is referred to as the "physiological hysteria" of childhood. If, how- ever, this condition of suggestion and reaction to emotions should appear in adults, it would be regard- ed as a manifestation of hysteria. If auto-suggestion is a peculiarity of hysteria ac- cording to Babinski, then no one is exempt from the disease. If a physician dwells too long on the exam- ination of an organ, it is not unnatural for him to create fixed ideas which graduate into obsessions, so that the patient carries his organ in his head, and from the latter citadel, viscero-sensorial reflexes em- anate. All hysteric symptoms are made conspicuous by the fact that they depend and react to psychic in- fluence and the term " impossible" must be "erased from the pathology of hysteria." The symptoms of the disease show mobility, varia- bility and incertitude. The disease, observed Lasegue, is a basket into which we throw the papers that we do not know how to classify. Hysteria counterfeits organic disease to such a de- gree that often the only thing you can positively ex- clude in hysteria in a female is an enlarged prostate and in a male, a diseased uterus. 31 Progressive Spondylotherapy When a symptom can neither be willed nor simulat- ed, it speaks for organic against functional nervous diseases. Such unwilled phenomena are: lost knee- jerk, reaction of degeneration, 'Babinski toe-sign, changes in optic nerve, hemianopsia, decided pupil- lary changes, unilateral vocal cord paralysis, facial paralysis, ankle clonus and incontinence of urine and feces. Suggestion is common to all psychoneuroses and is not limited to hysteria. The latter is, however, facile princeps the paragon of simulation. Let us not as- sume for a moment that it stands alone in its majes- ty, completely isolated from other diseases; on the contrary, it permeates in various dilutions every pathologic picture, and no morbid tableau is com- plete without it. There is such a disease as hysteria but there are also hysteroid diseases. Organic diseases may parade in the guise of hysteria and before the diagnosis of hysteria is justified organic factors must be excluded. It is sufficient evidence of our ignor- ance to make the diagnosis of hysteria but it is worse when it doesn't exist. The symptomatology of hysteria implicates chiefly tissues innervated by the sympathetic system. A characteristic feature of the disease is a lack of inhibition, the patient reacting to stimuli, is exces- sively emotional and changeable in disposition. Investigations show that emotional excitement aug- ments adrenal and thyroid secretion which by depres- sing the tone of the vagus (the nerve through which the emotions play their chief role) stimulate the sym- pathetic nerves. There is a certain inconsistency in our conception of hysteria when we recognize it as a disease in which will evokes morbid changes in function and ex- 32 Suggestion pect patients to control their symptoms by exercise of the will. The fact is, that the hysterical symptoms are caused by irritation of the sympathetic system and are not under the influence of the will. Man is an automaton with a dual mentality. The mind is one, but a part of it is always conscious and another part is never illuminated by consciousness. The two minds have been differentiated into objective and subjective minds. The former or supra-conscious mind takes cogni- zance of the objective world through its media of ob- servation, the senses, and represents the supreme function of reasoning; it is the mind of intelligence. The subjective or subconscious mind perceives by in- tuition independent of the senses and is the abode of memory and the emotions. In this subconscious or subliminal mentality, the phenomena of vegetative life, respiration, circulation, nutrition, etc., are pro- duced without voluntary effort. When the sympathetic nervous system is irritated, it is the subconscious mind which perceives the irrita- tion and it is likewise this mind which is amenable to suggestion. When these subconscious sensations are translated into consciousness, there is a reaction on the part of the cerebrospinal system which reaction assists in completing the picture of the hysterical condition. Let us draw on positive data in support of our view- point of hysteria. In the norm the vagal and sympa- thetic fibers are in physiologic antagonism. Vagus tone is diminished by sympathetic stimulation and conversely, sympathetic tone is diminished by vagus stimulation. The ever changing bizarre and protean pictures of hysteria and other affections are due to the state of psycho-vagus tone (466). 33 Progressive Spondylotherapy In every organism there is a vulnerable point and it is in the latter that symptoms predominate (Vide also exophthalmic goitre, page 71.) By aid of the spondylopressor (Fig. 1), it may be shown that in hysteria, the tone of the vagus is de- pressed. This depression may involve individual or- gans or it may compromise all the branches of the vagus. This condition may be reproduced temporar- ily in susceptible subjects by adrenalin (page 9). Pil- ocarpin (451), by increasing vagus-tone may arrest a paroxysm of hysteria or ameliorate symptoms of this affection. Barotherapy may likewise improve (469) or accentuate (472) the symptoms. I have frequently noted in children during attacks suggestive of hysteria, an enlarged thyroid. Amblyopia, narrowing of the visual field and dis- turbance or loss of the vision of colors (dyschroma- topsia) are often encountered among hystericals and they may be reproduced as I have shown (469) by di- minishing vagus-tone. The same refers to audition (499). When symptoms embrace the cerebro-spinal sys- tem without tangible reasons for their existence, the presence of an irritable segment of the cord made so by viscero-sensory reflexes may be surmised. Let us suppose that, in consequence of diminished vagus-tone, there is a dilatation of the heart and aorta and the patient suffers from pains along the ulnar border of the arm with cutaneous hyperesthesia. in the same area. Here, one must assume an irritable cord-segment and the pains which are essentially rad- icular are referred to the first and second dorsal areas. Viscero-motor (417) and other reflexes may be sim- ilarly explained. 34 Suggestion Many of such reflexes are really protective and may account for the so-called deception, mimicry and simulation of hystericals. This protective mimicry is a nervous instinct not unlike that observed in insects which when resting resemble the leaves of plants or those which appear dead in the presence of animals who prey on them but eschew their inanimate bodies. 35 Progressive Spondylotherapy CHAPTER II. GENERAL REFLEXO-THERAPY. IRRATIONALITY OF EXCLUSIVISM PSYCHROTHERAPY REIN- FORCEMENT OF THE VERTEBRAL REFLEXES PHARMACOLOGIC REINFORCEMENT CALCIUM THERAPY EXERCISES. / It must be again emphasized although I have done so repeatedly that, vertebral reflexo-therapy or cen- trotherapy, if one desires to so call it is only one of many methods for curing disease. If there weren't many paths leading to cure, there wouldn't be hydropaths, allopaths, homeopaths and other kinds of paths. One may enumerate seventy va- rieties of tuberculin, yet the sponsor claims sover- eignty for his particular variety. In treatment, the old rule of "curare, cito, tute et jucunde" (to cure, to do so quickly, safely and pleasantly) must be concil- iated and above all, "Nur nicht schaden" (only do no harm). The average patient is not so much concern- ed about what he has, as by what he thinks he has. In imaginary diseases he believes too much and does not believe enough in real diseases. There is always a psychic factor in treatment and the judicious physi- cian combines psychics and physics. The iconoclasts in medicine are usuaally extrem- ists who substitute nothing for what they destroy. Cure signifies nothing when unaccompanied by scientific proof, but cure is a good thing and the pa- tient wants it. In a recent editorial on "Suggestion in hyperthyroidism." cures are cited which were ef- fected by nasal operations, despite the fact as the writer assumes, the reports ' ' do not serve to alter the 36 Psychrotherapy status of hyperthyroidism or its connection with some definite disturbance of glandular metabolism." It is quite true than many remedies and methods of treatment when first employed are effective and later prove useless. It is equivalent to saying that the cal- omel of one physician is more effective than that of another. To deny that a nasal operation is theoretic- ally ineffective is to deny the important role played by reflexes in the etiology and cure of disease. Refer- ence, on page 74, to the author's methods of diagnos- ing and treating exophthalmic goitre is an attempt to place our methods on a mathematical basis. Exclusive methods of treatment suggest charla- tanry. BSYOHROTHEBAPY* The employment of cold (also known as cry mo- therapy) as a remedial measure has already been discussed (172, 182, 186). It is one of our most ex- peditious curative agents but unfortunately least em- ployed. In our method of freezing, the reaction does not exceed capillary-dilatation and erythema. There may be noted microscopically, a diapedesis of leu- cocytes with some swelling of the connective tissue- cells. No doubt phagocytosis plays an important part in cure. The tremendous edema and destruction of tissue when liquid air or carbon dioxid snow is used is never observed. There is hardly a week that one does not see some unfortunate patient who has resisted all methods of treatment and yet, after a single freezing at the proper area, immediate relief is obtained. It is true, that in some cases freezing is employed but always at *The employment of cold as a remedial measure in the treatment of pain was first reported in 1882, in my inaugural dissertation. I observed its use in the extraction of teeth during the time I was engaged in the study of dentistry. 37 Progressive Spondyl o therapy a point remote from the site of the lesion. Two re- cent incidents may be cited : Patient had her ovary and later, her Fallopian tube removed for severe abdominal pains which had per- sisted for three years. The condition was a lumbo-ab- dominal neuralgia which yielded at once to several freezings over the vertebral exits of the implicated nerves. Patient had severe pains in the left arm for two years. Skiagrams demonstrated a cervical rib to which the pains were attributed and an operation was advised. It was a case of cervico-occipital neuralgia and yielded to two freezings. To illustrate the results of freezing, in the practice of other physicians, I shall cite several instances re- ported by Dr. W. T. Baird, of El Paso, Texas, in a re- cept paper read before "The American Association for the study of Spondylotherapy:" Case I. Suffered for two years with excruciating pain in toe. "My treatment gave no relief until Abrams' method of congelation was brought to my at- tention." A sensitive point at the sacro-sciatic notch was frozen with complete relief after two treatments. Case II. Constant and severe pains in left mam- mary region. Diagnosis made of phthisis. Intercostal neuralgia found and cure after two freezings. Gained 10 pounds in one month. Pseudo-phthisis is not in- frequent (439). Case III. Excruciating pains in frontal region for sixteen years. Had all kinds of treatment including removal of a supposed abdominal growth without re- lief. With the radicularpressor one could reproduce the pains from which the patient suffered. Twelve treatments by freezing over the sensitive vertebral exits of the upper cervical nerves sufficed to cure. Be- fore treatment she was kept constantly stupefied by 38 Psych o t h a p y morphin. In this, as well as similar cases, the cer- vical muscles were rigid. Case IV. Patient with pain in left mammary re- gion. Has a valvular cardiac lesion for ten years, to which pain was attributed. Speedy relief followed freezing. The interest in this case lies in the fact that a tachycardia from which she suffered was equally cured. Dr. W. T. Baird, employs the following method of freezing : A piece of ice terminating in-a conical point is held in the hand by aid of a towel. The conical point FIG. 6. Appurtenances necessary for executing freezing- according to th method of Dr. G. Baert; brass-box, tin-funnel and wooden plunger. is dipped into common salt and then it is pressed against the vertebral point of tenderness for about three minutes. After its removal, a cup-shaped de- pression is left and this is frozen with commercial ether for 3 minutes longer. This method is tanta- mount to reinforced freezing (173). Dr. G. H. Baert, of Grand Rapids, who could not obtain satisfactory results from freezing with ether owing to the absence of compressed air in his office devised the following method. Finding that carbon dioxid snow as conventionally employed was too se- 39 Progressive Spondy 1 oth er apy vere, he found that by confining it in a metallic box (Fig. 5), he was able to keep it under perfect control. The snow is first collected in a chamois skin-bag from a cylinder in the usual way. Then it is poured into the brass-box through a tin-funnel. Next the snow is compressed with the wooden-plunger by kand (compressed by hammer, the snow loses ite freezing properties). Now wet a towel and press it against the bottom of the box containing the snow. The towel freezes to the box in 2 seconds at which time it is ready to press against the sensitive verte- bral points. By placing a dry towel over a portion of the freezing surface, one can limit the freezing to any point desired. For deep freezing a dry towel is interposed be- tween the skin and box and pressure is made for 1 A to l /2 minute ; *. e., until the deeper tissues are cooled, af- ter which a moist* towel is used according to the for- mer method. No vesication nor other untoward ef- fect follows either method. The brass box (covered with a wet towel) should be pressed on the selected spot for about 4 seconds, then removed until the whiteness due to the freezing is re- placed by hyperemia and the process may be repeated several times. The author finds no difficulty in freezing with an ordinary atomizer with metallic fittings provided a good preparation of ether is obtainable (173). REINFORCEMENT OF THE VERTEBRAL REFLEXES. In the spinal cord, there are centers for the con- traction and dilatation of viscera. In the norm, these centers are in physiologic antagonism. When neither reflex predominates a reflex equilibrium is establish- ed. The moment one reflex gains the ascendancy over its antagonist, they become disequilibrated. Each 40 Reinforcement of the Vertebral Reflexes segment of the cord is connected with fibers from the brain which subserve the function of reflex inhibi- tion. The inhibitory fibers run in the pyramidal tracts (Fig. 6). ANATOMY AND PHYSIOLOGY FIG. 6 Diagram of Pyramidal Tract and its course through the brain and cord (after Stewart). The latter convey voluntary motor impulses down- ward from the motor cortex toward the anterior cornua. If the inhibitory fibers are irritated, the reflexes are impaired owing to stimulation of inhibition and if destroyed, the reflexes are accentuated. Clinically, one may observe that, when one reflex is pathologically exalted, stimulation of its counter-re- flex does not show the same effects as obtained in the norm. 41 Progressive Spondylotherapy It occurred to me that, if one could temporarily put one reflex out of commission, stimulation of the counter-reflex would prove more potential in its ef- fects. Let us take the pupil as a paradigm. Its sphincter is supplied by the myotic tract which has its origin in the oculomotor nucleus. If this tract is stimulated the pupil contracts (myosis) and, if divided, the pupil dilates (mydriasis). Opposed to this, is the mydriatic tract supplying the dilator pupillaB (Fig. 19). Stimulation of this tract causes mydriasis and if divided, myosis. The antagonistic tonus of these two tracts belong- ing to the autonomic system (412) maintains the bal- ance of the pupil. Concussion or pressure at the 7th cervical spine stimulates the autonomic system through the vagus but such stimulation does not con- tract the pupil owing to the antagonistic action of the dilator fibers. If one inhibits the action of the dilator tract (pressure between the 3rd and 4th dorsal spines), concussion of the 7th cervical spine will cause the pupil to contract. Pressure not exceeding one-half minute stimulates but when the pressure exceeds one minute the oppo- site action ensues. One may make pressure with the radicularpressor (649), with the instrument shown in fig. 7 or a special apparatus (478). The latter (Fig. 7) is only available for pressure from the 3rd dorsal spine downwards. Suppose we are dealing with a disease caused by vagus-hypertonia (479). Let us take asthma. If the vagus is depressed in the norm by concussion between the 3rd and 4th dorsal spines (495), a retraction of the lower lung-border may be determined by percus- sion. If, however, pressure exceeding one-minute is made at the 7th cervical spine, there is no longer any 42 Reinforcement of the Vertebral Reflexes opposition to the lung reflex of contraction. Now again make brief pressure or concussion between the 3rd and 4th dorsal spines and it will be found that the retraction of the lung-border is accentuated. In the treatment of asthma, pressure is maintained for 5 minutes at the 7th cervical spine before brief seances of stimulation are executed in the paraverte- bral region between the 3rd and 4th dorsal spines. FIG. 7 Apparatus available for pressure from the 3rd dorsal spine downward and used for reinforcing reflexes. A, attachments for diffused, and B, for localized pressure. One fact deserves mention in asthma. Adrenalin chlorid (314) is only employed to check paroxysms. Having determined its action (314), I employ it as a curative agent as well by giving daily hypodermatic injections in the interparoxysmal periods. 43 Progressive Sp on dylo therapy Suppose the disease is caused by vagus-hypotonia (500), for instance, an aortic dilatation. Pressure for 5 minutes is made between the 3rd and 4th dorsal spines before stimulation of the 7th cervical spine is attempted. PHARMACOLOGIO REINFORCEMENT OF THE REFLEXES. It has already been observed (page 41) that the brain exercises an inhibitory mfluence on the spinal reflexes. We know that, the mind can inhibit or dis- turb certain habitual and unconscious actions. Con- scious attention in disturbing reflexes is illustrated by the story of the centipede. The latter was asked how he could walk with all his hundred legs and in at- tempting to explain its simplicity became so involved that he was unable to move at all. In lateral sclerosis, the lateral columns including the pyramidal tracts degenerate so that the inhibitory path from the brain to the cord is destroyed. Reflex irritability is so accentuated that slight stimulation, as the movement of the bed-clothes suffices to evoke convulsive spasms of the legs. By aid of scopolamin anesthesia, cerebral inhibi- tion may to a certain extent be eliminated. Even when small doses of the drug are given, one may elicit the Babinski reflex (15). In non-hypnotizable subjects, I have often em- ployed scopolamin. Suggestions made in this state are realized after awakening, as in hypnotism. To accentuate the spinal reflexes, it is not necessary to give the drug to produce amnesia or unconscious- ness : only give enough to produce drowsiness or suffi- cient to elicit the Babinski reflex which is accomplish- ed with comparatively small doses. In the majority 44 Calcium Therapy of cases it may be given per os combined with mor- phin (scopolamin, 1/150 grain, morphin, 1/6 grain). CALCIUM THERAPY My only excuse for discussing this subject is to direct attention to an important phase of medicine ignored in our text-books, and because this therapy may be used as an adjuvant measure in aneurysms and exophthalmic goitre. FIG. 8. Normal human blood showing crystals, prepared with the calcimeter, x 450. Sir James Barr, and Dr. W. Blair Bell, of Liver- pool, have been prominently identified with the re- cent development of this therapy. The essential bio- chemical processes in calcium metabolism are little understood. Our calcium supply is furnished with food and water and abnormally from what is stored in the tissues, especially the bones. Calcium subserves the follo.wing objects: 1. Building up of skeleton and tissues ; 2. Maintaining the movements of involuntary and preserving the normal irritability of voluntary mus- cles; 3. Controlling nervous excitability; 4. Influencing the functions of reproduction ; 45 Progressive Spondylotherapy 5. Promoting the coagulation of blood; Calcium is excreted by the alimentary tract and the urinary and genital systems. One determines calcium metabolism by estimating the relative quantity of calcium in the blood (Fig. 8) and the excretory ratio by the amount in the urine.* Thus, if the blood calcium index is high and the urin- ary calcium excretion is high, too much is absorbed or if the blood shows a low and the urine a high index, too much is excreted. Calcium chlorid increases the coagulability of the blood and is indicated to check profuse menstruation, hemorrhages and other conditions demanding an hemostatic. Chilblains, uticaria and many other affections have yielded favorably to calcium therapy. Tetany, laryn- gismus stridulus and infantile convulsions are favor- ably influenced. Lime salts have also been used in exophthalmic goitre and aneurysms (page 71). Headaches and neu- ralgias due to deficient coagulability of the blood are relieved by calcium salts. In such cases, potassium citrate will precipitate an attack for it is known that citric acid diminishes blood-coagulability. Coagulation time of the blood may be determined by placing several drops of blood upon slightly warm- ed microscopic slides which at varying intervals are tilted upward until they appear as in fig. 9. In the norm coagulation by this method should occur in from 2/^-5 minutes. Observations indicate that pregnancy is terminat- ed when the fetus ceases to absorb or receive calcium salts from the mother's blood. Calcium salts have been discredited because given Estimation of calcium salts in the blood and urine is effected by Blair Bell's ealcimeter. 46 E x s in unabsorbable form. The "Mistura Calcii lactatis recentis" of Bell, is the best method of administra- tion; Pure concentrated lactic acid, 200 grs., Precipitat- ed caleiam carbonate about, 75 grs., to which are add- ed 8 minims of chloroform in 8 ounces of distilled water. Each fluid ounce contains 29 grains of hy- drous calcium lactate. The dose is one and one-half to three ounces every night or every other night and should be taken on an empty stomach before retiring. PIG. 9. A, incomplete coagulation (tear-shaped drop); B, complete coagulation (convex drop.) EXERCISES. Exercises are employed for developmental or edu- cational purposes, to maintain physical vigor and to correct special pathologic conditions. The latter is known as corrective or therapeutic physical training. My real object in considering this subject is to di- rect attention to a neglected field in the study of ex- ercises on visceral tone (479). Definite movements of the vertebral column make traction on specific spinal nerves and such move- ments may be utilized for weal or woe (547). 47 Progressive Spondylotherapy My time has been too limited to classify my results concerning such vertebral action and I trust that, having made the suggestion, it may be exploited by another to some advantage. It has already been shown how one may augment vagus-tone by exercise of the neck-muscles (228, 447). To decrease vagus-tone in diseases caused by vagus- hypertonia, traction must be made on the spinal nerves corresponding to the 3rd and 4th dorsal spines which depress vagus-tone. Thus in asthma, which is caused by vagus-hyper- tonia, the patient leans far forward with arm extend- ed and hand grasping a support, whereas the other arm is forcibly extended in a lateral direction by an assistant (Fig. 10). FIG. 10. Exercise for reducing vagus-tone. To avoid exhausing the reflex, the exercise must be of short duration and frequently repeated. As an index of its proper execution there should be a retraction of the lower lung-border (473). To evoke the intestinal reflex of contraction in atonic constipation (330), have patient stand with 48 Exercises hands on hip and lean backwards and forwards alter- nately so as to arch the lumbar region forward as much as possible. The latter maneuver makes trac- tion on the lumbar nerves. The index of correct exe- cution is indicated by the conversion of the tympani- tic intestinal sound into dullness. Progressive Spondylotherapy CHAPTER III. THE CIRCULATORY APPARATUS INSPECTION OF PRECORDIUM TESTING HEART ANGINA PEC- TORIS ENDOCARDITIS TACHYCARDIA BLOOD-PRESSURE ANEURYSMS VASOMOTOR NEUROSES EXOPHTHALMIC GOITRE INSPECTION OF THE PRECORDIUM. Reference has al- ready been made on page 14, to vago-visceral methods and particularly to vago-visceral heart-palpation. If the identical method is employed, each time pres- sure is made, the area of the heart may be defined. This, like other shadows is accentuated by gamboge (page 14). The vago-visceral reflex is readily exhausted, there- fore if not properly seen after pressure is made sev- eral times, one must wait until vagus-tone is restored. The patient while seated faces the window and the physician views the precordium from above down- ward. During the time pressure is made, the chest should be in the position of forced expiration and breathing suspended. The outlines of the right, are less easily demon- strable than those of the left heart. After a little experience, the shadow is easily recog- nized even in moderately obese subjects. The same method is available in inspecting aneurysms. Here, a bulge in lieu of the shadow is often seen. Inspection must be from above. TESTING THE EFFICIENCY OF THE HEART. Heart-suf- ficiency (215, 510), is a neuro-muscular question and its correct estimation demands an investigation of vagus-tone and the condition of the myocardium. 50 Testing the Efficiency of the Heart Vagus-tone is determined by the method described on page 10. With the spondylopressor, myocardial tone is esti- mated by the intermittent impact of the heart against the palpating finger (page 15) each time pressure is executed with the spondylopressor. Attention has been directed on page 10, to an im- portant clinico-physiologic investigation which is available in visceral-toning. Physio-therapy is essentially a matter of eliciting reflexes and if the visceral reflexes are ignored, the scientific value of the treatment in most instances can not be guaged and the results must be empirical. Visceral reflexes may be evoked in many ways (7) therefore there are many ways of achieving results. One must remember, however, that, although one afferent channel may be exhausted by overstimula- tion, another channel may be solicited to provoke like reflexes. Pituitrin, is a most efficient agent for increasing vagus-tone. After injecting i. c. c. of the preparation of Parke Davis, the following average result was noted : Recession of stomach 3 cm. " heart (left border) 2.3 cm. " liver 1.8 cm. Descent of lung-border 2.6 cm. Pituitrin has a more marked action on the heart than pilocarpin (454). The heart reflex (199) is absent in the presence of pericardial adhesions and apparently so in pleural exudatcs. A few months ago, I was attempting to elicit the reflex for Prof. Einthoven, who was the first to employ electrocardiagrams which show electrical 51 Progressive Spondylotherapy r~ variations due to the heart contraction. No reflex was obtainable. It was subsequently determined that the subject had just recovered from pericarditis with ad- hesions. In another case seen in consultation, the apparent absence of the reflex was due to the pleura! fluid fol- lowing the recession of the heart. ANGINA PECTORIS. Dr. George Jarvis, has directed my attention to an important clinical observation which he has made, viz., that in two cases of angina pectoris he was unable to elicit the heart reflex of con- traction during a paroxysm. This observation I have since confirmed. These observations would seem to confirm my heart reflex theory of angina (222). ENDOCARDITIS. During several years I have ob- served three cases of chronic endocarditis which were apparently cured by injections of fibrolysin (108) coupled with concussion of the 7th cervical spine to elicit the heart reflex of contraction. The latter is practically a method of cardiac gymnastics. I would not have reported these apparently incredible results were it not for the fact that Dr.' Jaworski, in a per- sonal communication reported that Dr. Haffner of Zurich had achieved like results in two cases. TACHYCARDIA. This is often difficult to relieve and the physician must experiment to determine which method is most effective in influencing the chrono- tropic fibers. In some instances, I have achieved re- sults by concussing the 7th cervical spine, striking one blow per second. In other instances, I have directed stimulation on either side of the 7th cervical spine so as to influence either the right or left vagus (page 75) Some physicians have obtained good results by con- cussing the 6th or 4th cervical spine. Dr. E. W. Cox (Monroe, Washington), reports a 52 Blood s s u case of paroxysmal tachycardia requiring morphin for the attacks which were cured by concussion of the 7th cervical spine. BLOOD PRESSURE. There are some data with refer- ence to this subject that have not been fully empha- sized. In the employment of the excellent " Brown Sphyg- momanometer" (Fig. 11), one estimates (to get ac- curate results), the diastolic as well as the systolic pressure. FIG. 11. The Brown sphygmomanometer. The mercury cannot be lost and the cuff is 12 cm. in width, and 23 cm. in length. When the slightest wave is felt by the operator, this is the systolic and, when the full, normal beat of the pulse is first noted, that is the diastolic pressure. The auscultatory method is more accurate. One places a stethoscope over the radial artery just below the bend of the elbow and allows the air to escape from the valve. The systolic pressure is noted the moment a thump is heard. Allow more air to escape and the moment the thump is no longer heard, we 53 Progressive Spondylotherapy have the diastolic pressure. By subtracting the dias- tolic from the systolic pressure, the remainder is the pulse pressure. The difference between the systolic and diastolic pressure in the norm is from 25 to 40 mm. Among the common factors influencing the readings are : 1. Digestion, for 3 hours after a repast ; 2. Altitude (increases) ; 3. Exercise (rise of 20 to 40 mm. which resumes its previous level in about 15 minutes) ; 4. Tobacco, when used to excess; 5. Pain and emotions (augment pressure). HIGH -BLOOD PRESSURE (Hypertension). The term hyperpiesis, refers to simple high pressure without any evidence of cardio-vascular disease. Hypertension is caused by a multitude of diseases (234). If possible, one should always ascertain the cause including emotional factors, intestinal toxemia, anomalies in the splanchnic area and augmented se- cretion of pressor products by the adrenals. If the latter condition is present, there must be a dilation of the stomach and contraction of the lungs (page 9). We also determine that, if by increasing the secretion of the adrenals (page 9), we still further augment blood-pressure. Conversely, if there is hypotension (250), stimu- lation of the phrenic or splanchnic nerves will raise the pressure. Reduction of blood-pressure is best ef- fected by concussion, pressure or other methods of stimulation applied between the 3rd and 4th dorsal spines (461). At the latter point, we stimulate the depressor nerve (468). If, coincident with the pressure or other stimulus, percussion of the lower abdomen is executed, areas 54 Aneurysms of dullness caused by dilatation of the splanchnic ves- sels may be elicited (433). The physiologist knows that stimulation of any centripetal nerve augments blood-pressure and the essential factor in this reflex rise is vasoconstriction in the splanchnic area. The only exception to the foregoing rule, is stimu- lation of the depressor nerve, which lowers pressure by dilating the splanchnic vessels. The latter have the greatest effect on blood-pres- sure and the vessels in question are sufficiently ca- pacious to hold practically the entire blood- volume of the body. Another fact must be emphasized in the diagnosis of arteriosclerosis by palpation of peripheral ar- teries. A thickened artery is not necessarily atheromatous but is often caused by an hypertrophy of the muscu- lar coat of the artery. ANEURYSMS. In a discussion following an address before the "Los Angeles County Medical Associa- tion, ' ' one of the disputants discussed a patient with an aneurysm who was treated according to telegraph- ic instructions received from me. He hadn't any faith in my method, he argued, for the reason that al- though the method was employed the patient died three weeks later. I replied that the gentleman evi- dently had more faith in the methods of spondylo- therapy than I. I did not hope to resuscitate the dead and if the patient had died three weeks later, he was practically moribund when treatment was com- menced. This directs our attention to the importance of an early diagnosis and I am almost inclined to believe that, by my method of treatment of aneurysms 55 Progressive Spondylotherapy Aneurysma primis in stadiis semper curabilis. Aneurysms are by no means infrequent (551). Ever since Chiari 5 and Marchand 6 , described mes- aortitis (552) in syphilitics, much evidence has accu- mulated notably, the statistics of Goldscheider 7 , to justify the correctness of their conclusions. Among the early symptoms of syphilitic aortitis are ; pains of the upper-chest accentuated by exertion, constriction of the chest, palpitation, modification of the first aortic sound or the presence of systolic and diastolic murmurs or, in the absence of the latter, a ringing second sound. An increased area of dullness over the aorta is practically constant but owing to its late detection, it is regarded as a late sign. An important sign, is the intensification or repro- duction of symptoms by elicitation of the aortic reflex of dilatation (256). Relief by energetic antisyphilitic treatment (in- cluding salvarsan or neosalvarsan) is diagnostic. The iodids alone have little action. Implication of the aorta, even in the absence of a syphilitic anamnesis and with a negative Wasser- mann, should suggest nevertheless, a syphilitic aortitis. Percussion, is unquestionably the most important early sign of a dilated aorta, but such percussion must conciliate every possible aid (558). Not long ago, the writer saw a patient in consulta- tion with several skilled diagnosticans. The case was diagnosed as one of asthma. No increase in area of the aorta was noted by the usual method of percussion but when the vago-visceral method of percussion was employed, an increased area of dullness was demon- strable. It was shown that, by artificial dilation of the aorta (256), asthmatic symptoms could be evoked 56 Aneurysms and at once relieved by artificial contraction of the vessel. The subjective symptoms of a dilated aorta are paroxysmal. Orthodiagraphic tracings made by myself at dif- ferent times during the day have convinced me that the aorta is not constant in caliber and one can under- stand why a temporary increase of aortic dilatation may precipitate a medley of symptoms which disappear when the lumen of the vessel is restored. The foregoing is equally true of the heart. Recent- ly, in Philadelphia, I saw a patient with Dr. S. Solis Cohen. The patient had cardiac asthma and it was possible to provoke or inhibit the symptoms at will by decreasing or increasing vagus-tone. Attention is directed to the X-ray pictures of Dr. Jarvis (Fig.2), showing the accuracy of vago- visceral percussion. I want to call attention to certain errors of inter- pretation which may attend aortic-percussion. In splanchnoptosis, ptosis of the heart (529) is often a concomitant condition which conduces to a dislocation of the thoracic aorta (aorto ptosis). Per- cussion shows an extension of dullness beyond the norm and fluoroscopy demonstrates an extended sil- houette of the aorta. Unlike an aneurysm, the shadow between pulsa- tions recedes behind the sternum. A pathogiiomonic test is to have an assistant raise the abdomen, at which time percussion and fluoro- scopy show a recession of the dullness and shadow. The shadow of an inthrathoracic goitre may be mis- interpreted as an aneurysm. This is likely if an adja- cent blood-vessel notably the aorta communicates pul- sations. In examinations with the fluoroscope one must remember that the thyroid shows an up-and- 57 Progressive Spondylotherapy down movement synchronous with deglutition and the respitory phases whereas the shadow of the aorta is immobile. Before deciding that a dullness of the abdominal aorta responding to the aortic reflexes (262) is caused by aneurysm, have the colon thoroughly cleaned. It has been found that, the descending colon will re- spond in a like manner to these reflexes and the pres- ence of fecal matter may lead to an error in diagnosis. Disregarding the latter fact, I have made the egre- gious mistake in two instances of diagnosing an an- eurysm of the abdominal aorta. The diagnosis of an- eurysms of the thoracic aorta by inspection is facili- tated by the vago- visceral method (page 50). By aid of surgery we may anticipate much respect- ing the treatment of aneurysms. There is the ingeni- ous operation of aneurysmorrhaphy of Matas, and the wonderful work of Carrel, which leads us to anti- cipate the substitution of a " cold-storage" healthy vessel for the resected diseased portion of the vessel. There is practically nothing that I can add to my method of treating aneurysms (257, 568) which em- braces aneurysms of the innominate, carotid and thoracic and abdominal aorta. Reference however to page 68, shows that the meth- od of executing the treatment will influence results. Concussion and not vibration must be used. An effi- cient concussor recently perfected is shown in Fig. 12. Dr. C. B. Kolhousen, of New Mexico, has sent me a report of an advanced case of aneurysm of the thor- acic aorta treated by my method of concussion. He says, "After the first treatment lasting 10 min- utes, I was utterly amazed at the change of the condi- tion of the patient and after six days all his symp- toms had disappeared and he was symptamatically well." 58 FIG. 12. Dr. Abrams' concussor. One of the important advantages possessed by this apparatus is the pair of rubber grips which are placed vertically on the vertebra and which confine the application to the exact spot indicated, preventing slippage of the concussor-applicator with consequent abrasions of the skin. The Sliding Sleeve surrounding the concussor shaft serves as a con- venient handle to guide the application. This sleeve may be adjusted up- wards or downwards by means of a set screw, thus regulating the dura- tion of contact of each concussive-stroke. By adjusting the distance of the eccentric at end of transmission-shaft the stroke may be varied from zero to one inch. By a unique method of speed control consisting of a pair of inverted cones with a sliding belt, held taut by an idler-pulley with spring auto- matically taking up the slack, the frequency of stroke may be varied from 600 to 3600 per minute. The change of speed is effected by turning the milled set-screw so that the idler-pulley is drawn forward, giving a low speed; or backward, giving a high speed. The motor is of ample power to produce concussion capable of eliciting every reflex of the spine and for giving prolonged treatment without heat- ng or over straining in the least. The motor is suspended from a bracket by cord and pulleys with counterweight, enabling the operator by the han- dle to swing the concussor back and forth from the cervical spine to the sacrum with perfect ease and facility of application. The bracket can be attached easily to a door-jamb, window frame or can be firmly anchored to a studding or a plastered wall or by suitable attachments to tile-wall. For the operator who has no available wall space two pulleys can be furnished whereby the concussor can be suspended from the ceiling. For those who desire an apparatus which can be moved about from one room to another, the entire apparatus including bracket can be mounted upon a substantial pillar and tripod with casters which can be readily rolled about. 59 Progressive Sp on dylo therapy When in 1911, 1 reported in "The British Medical Journal" and in "La Presse Medicale," 40 cases in my own practice of thoracic and abdominal aneurysm symptomatically cured within a few weeks by the concussion-treatment with absolutely no other ad- juvant measure, not even rest, there was no break in the continuity of results. The cases were all advanced. Up to that time other physicians have reported in the journals and through correspondence equally good results. Since then several cases have come under my observation in which the results were modified by complications. One, referred to me by Dr. Minaker, died from parenchymatous nephritis which existed at the time of consultation, although up to the time of her death, the aneurysmal symptoms did not recur. The same was observed in a patient referred to me by Dr. Voorsanger, who, at the time of consultation had tuberculosis. In a case reported by Dr. L. St. John Hely (571), treated for about 10 days, he wrote me 18 months lat- er, that it was indeed marvelous that after this period of time, the once moribund patient was without a sin- gle symptom. One week later, he informed me that the patient had suddenly died from rupture of the aneurysm while lifting a heavy trunk. Prompted by my early results, I believed that a symptomatic cure of aneurysms could be achieved in about two weeks. Time however has discredited this outburst of en- thusiasm. Several months ago there came to my office a pa- tient with an immense aneurysm (Fig. 13). He had been treated by Dr. Chas. E. Atkinson, of Los Ange- les, who had employed my method. No results were achieved for one month, after which time, the patient 60 Aneurysms resumed his occupation. Dr. Atkinson had enjoined him to take the usual precautions but without avail, for later, in lifting a heavy automobile, the aneurys- mal symptoms recurred. FIG. 13. Patient of Dr. Atkinson with an aneurysm of the thoracic aorta. When I saw the patient, he was using morphin (/4 grain, hypodermatically, three times a day). After the first treatment by concussion, he discontinued the drug of his own accord as he no longer suffered from pains. About two months later, Dr. Atkinson, informed me of the death of the patient. At the necropsy, the ascending portion of the aortic arch was 6 inches in diameter and the rest of the aorta was very much dilated. Still another case demands citation. Dr. A. C. Ackerman, of La Fayette, Indiana, re- quested me to see with him in consultation a patient with an aneurysm whom he said, was practically mor- 61 Progressive Spondylotherapy ibund. This patient was treated by Dr. Ackermaii, for 3 weeks without any result. The case was nevertheless interesting and empha- sized a very pertinent fact. It was impossible to cor- rectly locate the 7th cervical spinous process owing to a spinal deformity. Its location was effected after his manner ; after percussing the area of dullness of an enormous aneurysm, different spinous processes were successively concussed until one was found which produced a decided reduction in the area of dullness (aortic reflex of contraction). The latter was marked and concussion executed at this point. The same method of procedure is indicated in the treatment of other affections. -There may be some anomaly even in segmental localization. Thus, in asthma, if pressure between the 3rd and 4th dorsal spines does not cause an evanescence of the rales, make pressure at other points until one is found which yields results. There is yet another matter demanding citation which may account for some of my results in aneur- ysm. A limited number of observations show that, con- cussion of the 7th cervical spine appears to increase the coagulability of the blood. The effect of concussion at this point on the num- ber of erythrocytes has already been established (617). VASOMOTOR NEUROSES: (275 et seq.}. The vasomo- tor mechanism is deserving of brief consideration. Vasomotility is under the direct influence of the sym- pathetic system. The vasoconstrictor fibers arise from the sympathetic chain of ganglia and the vasodilator fibers from the collateral ganglion system. 62 Vasomotor Neurose FIG. 14. Mechanism of vasomotility (after Bing). A, cerebro-bulbar vaso motor tract; B, bulbo-spinal vasomotor tract; C, spino-sympathetic vasomotor tract; D, sympathetico-muscular vasomotor tract; G. R. C. and W. R. C., gray and white ramt communicantcs; S. G., sympathetic and ganglion of spinal nerve. Sym. C., sympathetic chain; A. R., anterior root of spinal nerve. 63 Progressive Spondylotherapy The vasoconstrictors are found in the mixed spinal nerves which they reach by the grey rami communi- cantes. The spinal-centers for vasoconstriction lie in the ventral horns and pass from the cord through the an- terior roots along the white rami communicant es to the sympathetic chain. The spinal vasomotor centers are governed by a bulbar and a cerebral center. The implication of the latter is noted when blushing or pallor follows psy- chic emotions. Fig. 14, reproduces schematically the mechanism of vasomotility with the following neurones; cerebro- bulbar, bulbo-spinal, spino-sympathetic and sympa- thetico-muscular. Vasodilator fibers exist only in special nerve- trunks, e. g., nervi erigentes and the sciatic. Their clinical significance is not established. It is assumed that loss of vascular tone is caused by paralysis of the vasoconstrictors and an increase of vascular tone to a stimulation of the vasoconstrictors. By some, the mechanism of perspiration is conceiv- ed to be similar to that of vasomotility and, if one sub- stitutes a sweat-gland for the blood-vessel (Fig. 14), the mechanism of perspiration may be understood. The cells for the spinal sweat-centers are located in the ventral horns in proximity to the motor ganglion- cells and if destroyed, perspiration is diminished (hyphidrosis) or abolished (anidrosis). The diagnosis of cutaneous vasomotor neuroses is not difficult. The difficulty only arises in the visceral angioneu- roses and the latter may be thought of in the presence of bizarre symptoms in individuals with the vasomo- tor temperament (424). By aid of spondylotherapeu- tic methods which enable us to contract or dilate 64 Vasomotor Neuroses blood-vessels, the pathology of some neuroses should be solved. Thus, in epilepsy, the paroxysmal unconsciousness is supposed to be associated with sudden cerebral anemia, the tonic stage of a major epileptic fit, with cortical anemia and the clonic stage, with return of irterial circulation. Some physicians have informed the writer that ihey have successfully treated epilepsy by my method of mechano-vaso-dilation. An Spinal Artery ErancTvtOj br Intercostal, ArUry. branches from/ Intercostal Artery, '-' 'fissure SpinuLArtxry fosterutr jpinalArtery- FIG. 15. Illustrating the course and distribution of the terminal arteries of the spinal cord (after Gehuchten). Blood-vessels, notably arteriosclerotic vessels re- spond to all reflex influences. Thus, in cerebral arter- iosclerosis, spasm of the vessels may lead to transient attacks of vertigo, aphasia, monoplegia or hemiple- gia. In the intermittent limp or dysbasia angioscler- otica, a cramp-like pain appears when the individual 65 Progressive Spondylotherapy attempts to walk. In such cases, the skin of the low- er extremity is cold and purple or mottled red and no pulse is felt in the posterior tibial or the dorsalis pedis artery (225). Such phenomena are due to a temporary spasm of the arteries of the lower extremity. They have also been observed in the upper extremity. In the so-called cases of family gangrene which re- semble Raynaud's disease and in the family periodic paralysis, there is probably a paroxysmal vasomotor spasm of the anterior spinal artery which supplies the anterior cornua of the spinal cord (Fig. 15.) The pains and visceral crises in tabes are in my opinion often caused by a temporary spasm of the spinal vessels, a sort of an intermittent claudication of the spinal cord. In the diagnosis of these spasmodic angioneuroses, I make constant use of amyl nitrite and a rubber bandage. The former is employed by inhalation. Its action (flushing of face and cutaneous blood-vessels including veins) is manifested within 15 seconds and symptoms disappear within 3 minutes. .Any phenomena associated with angiospasm yield, at least temporarily to the action of amyl nitrite. Conversely, symptoms (headache, neuralgia) caused by hyperemia are accentuated. HYPEREMIA TEST. If an extremity is rendered anemic by* a rubber bandage for about 5 minutes and after its removal the hyperemia is observed, it will be found that in the norm, the latter reaches the toes or fingers within a few seconds. In arteriosclerosis however, the return of blood may require several minutes or if the vessels are di- minished in caliber or the capillaries are obstructed, the hyperemia is arrested at a definite point. 66 Vasomotor Neuroses This same method may be employed in a modified way for treatment. Thus, in Raynaud's disease a tourniquet is applied around the extremity above to occlude all the vessels for several minutes. After removal, the temporary vasomotor paralysis causes a diffused flushing. If, after the foregoing method, the symptoms are relieved, or if a pulse previously impalpable becomes palpable, the character of the lesion is probably a vascular spasm. Contractures of muscles may be caused by short- ening or distortion (passive or permanent contract- ures) or they may be spasmodic (temporary or ac- tive contractures). If the contracture implicates an extremity, the application of a rubber bandage (not exceeding 20 minutes) will like narcosis, cause active contract- ures to disappear but the bandage is without in- fluence on the passive contractures. All active contractures yield temporarily to the application of the bandage hence hysterical cannot be distinguished from non-hysterical contractures. Junod's blood derivations and Bier's hyperemic method (hemospasia) are likewise available in the diagnosis and treatment of angioneuroses. Vasoconstriction of the blood-vessels is best attain- ed by concussion or the use of the rapid sinusoidal current applied at the 7th cervical spine and vasodila- tion, by concussion or slow sinusoidal current to the last four dorsal vertebrae (279). In the latter maneuver, the maximum effect is se- cured at the 10th dorsal spine (604). Vasoconstrictor or vasodilator effects may be ac- centuated by recalling an established physiologic ob- servation. If a nerve containing vasoconstrictor and vasodilator fibers is stimulated with frequently re- peated induced' currents, the constrictor effect is the 67 Progressive Sp on dy 1 o th er apy more pronounced but if stimulation is effected with slowly repeated induced currents, the dilator effect is the more pronounced. In practice, when one desires the maximum vaso- constrictor action (as in aneurysms), only rapid con- cussion-blows must be used whereas vasodilator ef- fects are secured when the blows are delivered at a rate of stimulation of one per second. FIG. 16. Plethysmc 'graph of Hallion and Comte, with tracing. To effect the latter result, the plexor and pleximet- er may be used in lieu of a concussion-apparatus and time may be measured by a metronome. The action of the sinusoidal current on visceral muscle has been discussed on page 7. By reinforcing the reflexes (page 40), further aid in treatment is achieved. Let us assume a case of Raynaud's disease. Concussion or sinusoidalization of the 10th dorsal spine is ineffective in restoring an impalpable pulse of the leg. An attempt is then made to put out of temporary commission the subsidiary vasoconstrictor center (at the 7th cervical spine) when concussion is again executed at the 10th dorsal spine. By employing a simple plethysmograph (Fig. 16) 68 Vasomotor Neuro. ses and connecting it with the finger or toe according to whether the angioneurosis is located in the upper or lower extremity, one may ascertain by the amplitude of the registered curves, tfye most available spine and the best stimulus for augmenting the circulation. Thus, in some instances, the author has found that concussion (2 blows a second) between the 3rd and 4th dorsal spines is very effective in dilating the peripheral vessels. FIG. 17. Capillary Dynamomometer. The author frequently employs a sphygmomano- meter in lieu of a plethysmograph for the same pur- pose the object being to ascertain the diastolic pres- sure which represents the maximum pressure of the arterial- wall. The auscultatory method (page 53) is available for this object. The best site is determined by noting the maximum diastolic pressure after stim- ulation. Still another method is occasionally employed by the author in intermittent claudication to secure vas- odilator effects and that is, interrupted concussion blows on the sciatic nerve. An excellent method for demonstrating the capil- lary circulation is the capillary dynamometer (Fig. 17). The padded button is placed on the skin at a constant pressure for a definite time (usually 3 sec- onds). After removing pressure determine the time it takes in half-seconds for the blood and color to return capillary reflux or C. R. Time of pressure and return of color should be measured by a metronome beating half-seconds. 69 Progressive Sp ondy 1 o th er apy ORIFICIAL METHODS. In therapeutics, there are no exclusive methods of achieving results. This fact I have emphasized repeatedly. When my friend Dr. Jaworski, of Paris, secures benefit to his tabetics by urethral dilatation (639) he does so by promoting reflex vasodilation. When Dr. E. H. Pratt, of Chicago, dilates the rec- tum he effects the same object (638). The remarkable results achieved by Dr. Pratt, in his rectal work appeals to the writer with special ref- erence to vasodilation. Dr. Pratt, has shown that dilatation of the sphinc- ters, especially the rectum, exerts a powerful stimu- lating effect notably on the circulation. This stimulating effect on the capillaries he desig- nates as "flushing of the capillaries/' Anal dilatation flushes the capillaries universally, equalizing the circulation and relieving local conges- tions. By careful dilatation of the internal sphincter to the point of suspending respiration and then releas- ing the sphincter, respiration begins and continues and must be regarded as one of the most potential means for resuscitation from collapse caused by an anesthetic, loss of blood or surgical shock. Long continued dilatation, has on the contrary a pernicious effect. I have carefully controlled the ef- fects of anal dilatation by plethysmographic and stethometric tracings and can corroborate the obser- vations of Dr. Pratt. It is difficult by these methods to exclude the action on the coccygeal ganglion. When the latter is stimulated by the finger per rectum, there is often lightning pains through the abdomen, a de- sire to defecate, fullness in the head and occasionally flushing of the face. 70 Exophthalmic Goitre EXOPHTHALMIC GOITRE. The author's treatment of this disease has already been discussed (280,482). The study of the internal secretions constitutes one of the most important epochs in revolutionary and evolutionary medicine. The glands of internal secretion not only detoxi- cate certain products of metabolism, but furnish hormones which stimulate anabolic and catabolic pro- cesses and furnish tone to the autonomic and sympa- thetic systems. In 1859 Schiff, noted fatal results in dogs after thyroidectomy, and a cachexia strumipriva was ob- served by Kocher, after the same operations in hu- mans. Gull and Ord, demonstrated the relation of the thyroid gland to myxedema, and Murray, showed that the latter and cretinism yield to thyroid feeding. Oth- ers noted the relief of symptoms in thyroidectomized animals following subcutaneous transplantation of the gland. Symptoms, notably tetany, following thyroidect- omy are due to injury or removal of the parathyroid glands (two small pairs of glands situated behind the lateral lobes of the thyroids in juxtaposition to the trachea.) The parathyroids are supposed to regulate calcium metabolism (page 45). Revivescency of the thymus gland has been noted in exophthalmic goitre, and implantation of this gland in dogs has been followed by tachycardia and exoph- fhalmos. Exophthalmic goitre is probably caused by hyptonia of the vagus. The symptoms are supposedly caused by a hyper- secretion of the thyroid gland conducing to a species of chronic intoxication (thyrotoxicosis). The enlarg- ed glands show increased vascularity and secreting epithelium. There is practically always some hyper- 71 Progressive Sp on dy 1 o th e r a p y plasia of the gland. The anatomic changes are not pathognomonic. The symptom-complex of the dis- ease is associated with conditions of the gland rang- ing from the norm to hyperplasia, atrophy and the presence of benign and malignant growths. The thyroid provokes symptoms from deficiency or excess of its internal secretion or from irregular functional activity (dysthyroidism) . The most important principle isolated from the gland is iodothyrin. The iodin in the gland was first demonstrated by Bauniann in 1896. Iodin is prac- tically absent in other tissues, and its amount in the thyroid varies with the species and the individual. Vegetables contain iodin and it is therefore most abundant in herbivora and least in amount in car- nivora. The iodin content is increased by the administra- tion of potassium iodid, and decreased by a diet of meat. lodoform poisoning suggests thyroid intoxication and in animals dosed with iodoform, the iodin con- tent of the thyroid is augmented. In all goitres, excepting exophthalmic goitre, the quantity of iodin in the gland is reduced. Good and bad results have been reported from the use of iodin in this disease. Kocher, found in a series of 160 thyroid examinations in those known to have received iodin that there was a definite storage in the gland which was associated with an involution of tlie hyperplasia. The normal thyroid contains arsenic and thyroid ism may be prevented or alleviated by the concurred use of Fowler's solution (3 minims, three times a day). Hyperthyroidism is not always expressed by a typic symptomatic picture and a persisent tachy- 72 Exophthalmic Goitre cardia may be the only evidence of augmented activ- ity of the gland. In other instances, the frontier symptoms may be emaciation, amenorrhea, irritability, or some mental anomaly. Kolb, in a recent communication maintains that, in diarrhea without a palpable cause, one should always think of a masked incipient exophthalmic goitre. Cases of acute hyperthyroidism are characterized by rapid emaciation, pyrexia, and spleen-enlargement and tachycardia. The thyroid gland may not be enlarged but auscultation of the gland shows nearly always the presence of arterial-murmurs. Uterine myomata may provoke cardiac symptoms suggestive of hyperthyroidism. To facilitate exploration of the thyroid the method of Woodbury is to be adopted; the neck is extended and the chin rotated nearly over to the opposite shoul- der, with the side of the head slightly flexed on the chest. Search must also be made for aberrant and acces- sory thyroids, notably at the root of the tongue. This lingual thyroid is not uncommon. To estimate the degree of struma and exophthal- iios, I make tracings on a piece of ground glass which is approximated to the neck and head in a dark room with light at a fixed point and properly adjusted. One may make an immediate diagnosis of hyper- thyroidism by bearing in mind the fact that, increas- ing the tone of the vagus will ameliorate, whereas a decrease of the tone of the latter will accentuate the symptoms. For this purpose the radicularpressor (468) is used. Brief pressure (not exceeding 30 seconds) at the 7th cervical spine increases and between the 3rd 73 Progressive Spondylotherapy and 4th dorsal spines decreases vagus-tone. This barodiagnostic maneuver is illustrated in fig. 18. All human emotions may be expressed through the vagus. The tone of the entire nerve may be compro- mised but the brunt of increased or diminished tone may be borne by an individual branch (452). For this reason we can understand why certain visceral symptoms predominate. The great physicist Clerk- Maxwell was sponsor for the truism that, progress was symbolized in the clock, the balance and the foot- rule thereby implying if we could weigh, measure and time, we could offer facts in lieu of theories. By aid of the spondylopressor (page 11), we can gauge objectively with almost mathematic certainty the degree of tone of a given viscus receiving vagal- innervation. When pressure is executed at the 7th cervical spine the pulse may be inhibited. The more ABC FIG. 18. Eyes, illustrating 1 the effects on the exophthalmos in exoph- thalmic goitre, by increasing and diminishing vagus-tone; A, before; B, during time vagus-tone is diminished; and C, when vagus-tone is in- creased. (Compare by looking at depression in bridge of nose, caused from the wearing of eyeglasses.) the tone of the vagus is diminished (referring to the cardiac branches) the weaker is the stimulus neces- sary to elicit cardiac inhibition. Thus we can recognize an orthotonic, hypertonic, hypotonic or even an atonic vagus. In the norm, in orthotonia of the vagus, cardiac inhibition does not occur when the pressure exerted is less than 10 kilograms. I have found that, in 74' Exophthalmic Goitre exophthalmic goitre (notably, when cardiac symp- toms prevail) that the pulse may be inhibited at very low pressure (2 to 8 kilograms) and with improve- ment more and more pressure is necessary to inhibit the pulse. This clinical fact is in accord with physiologic observations. If a frog's heart is connected with a heart-lever by the suspension method and a 1 per cent, solution of Merck's thyro-iodin is dropped upon the heart, and one determines the threshold at which the minimal stimulus is effective in slowing the heart, it will be found that less intensity of current is necessary to produce slowing. Hyperthyroidism then , like thyro-iodin in the experiment, augments the sensitiveness of the ter- minal end-apparatus of the vagus. Experiments on dogs show that there is a qualita- tive difference in the action of the two vagi. Thus, stimulation of the right vagus causes arrest of the chambers of the heart whereas stimulation of the left vagus has a slight negative chronotropic action on the auricles. With the spondylopressor using the small attachment (Fig. 1), a difference will be noted in the pulse even in the norm according to whether pressure is made on the right or the left side of the 7th cervical spine. It is often possible to get chronotropic effects in tachycardia on one side. I have also observed the curious fact that, on the side where the struma is more enlarged or the exophthalmos more pronounced, the vagus on that side responds to smaller degrees of pressure as shown by inhibition of the pulse. In exophthalmic goitre, I assume that, diminished vagus-tone causes the sympathetic fibers to become dominant in action. Stimulation of the sympathetic roots of the 2nd to the 4th thoracic segments of the cord will cause dila- tation of the pupil, exopthalmos and tachycardia. The 75 Progressive Spondylotherapy ocular symptoms of exopthalmic goitre (490) can easily be understood by referring to fig. 19. , The cervical part of the sympathetic chain con- taining oculo-pupillary fibers innervates the dilator pupillae, Miiller's muscle and the non-striated por- tion of the levator palpebrae superioris. There are also fibers to the hyppglossal nerve and sweat and vasomotor fibers. Non-striated Muscle of upper Lid. Dilator Pupillae Gassenan Ganglion Mullera Muscle FIG. 19. Diagram of course of oculopupillary fibers of the cervical sympathetic. The pupil-dilating fibres arise from the pupil-dilating cen- ter in the medulla, and descending in the lateral column of the cord they emerge in the anterior roots of the first and second thoracic segments. En- tering the interior-cervical ganglion by white "rami communicantes," they ascend in the cervical sympathetic to the Gasserian ganglion and pass to the orbit along the ophthalmic division of the trigeminus. The other half of the diagram shows the origin and course of the cardiac nerves. The stimulus applied at the seventh cervical spine corresponds to the third dorsal segment of cord and approximately to the 2nd and 3rd dorsal nerves. The fibers to the heart emerge from the cord in the anterior roots of the 2nd and 3rd thoracic nerves. 76 Exophthalmic Goitre If pressure is made between the 3rd and 4th dorsal spines to depress the vagus, one may reproduce or accentuate the ocular symptoms of exophthalmic goitre in susceptible subjects or in those having this disease. An antithetic effect is noted by augmenting vagus- tone (and consequently depressing sympathetic tone) by pressure at the 7th cervical spine. Insomuch as the cervical sympathetic is accessible to clinical observation, it may serve as an index to the condition of the general sympathetic system and should be tested as a routine method. By pinching the skin of the neck, the ciliospinal refldx of pupillary dilatation ensues on the same side. The cervical sympathetic may be stimulated by con- junctival instillation of a few drops of cocain-solu- tion and as a result (even in the norm) there is a slight exophthalmos, mydriasis and retraction of the upper lid (in the eye in which the drug had been instilled). One may employ pharmacologic reactions in la.r- vated cases Ten minims of adrenalin chlorid so- lution (1-1000) given hypodermatically will at once accentuate the exophthalmos and diminish the size of the thyroid. Pilocarpin will ameliorate both con- ditions. One may also have recourse in diagnosis to biochemical tests. Thyroid-extract antagonizes adrenalin in its pu- pillodilator action on the frog's eye, and this fact may be employed in the clinical recognition of hy- perthyroidism. This action is obtainable with the blood in exophthalmic goitre, but is negative with blood from neurasthenic and hysterical subjects. The blood in hyperthyroidism increases the resis- tance of mice to poisoning with morphin and ace- tonitrile, thus making it possible to double the lethal dose. The blood findings in this disease (488) can no longer be regarded as characteristic insomuch as the same blood picture has also been found in simple goitre. The leucopenia is probably caused by an excess of thyroid secretion. 77 Progressive Spondylotherapy I have found that thyroid feeding in a few nor- mal subjects will eventuate in a blood-picture not unlike that found in exophthalmic goitre. Nothing can be added to my method of treatment of this disease (490). In some rebellious cases, reinforcement of the reflexes (pages 40, 44) may be tried. It is impossible to cite the favorable reports in the treatment of this disease by my method received from many physicians. FIG. 20. Illustrating the results achieved by Dr. S. Edgar Bond, by the author's method of treatment. I shall content myself by reporting the cases of Dr. S. Edgar Bond, of Richmond, Indiana, insomuch as they are accompanied by photographs. Brothers. Belonging to a family of seven, all of whom have goitres excepting a daughter. Family came from the mountains of Tennessee. William, was refused work on account of an im- mense goitre (vide photograph). He was treated by 78 Exophthalmic Goitre concussion of the 7th cervical spine for about 3 months. Other methods had failed. The other brother Oscar, had in addition to a very large goitre, dyspnea, slight tachycardia and other symptoms of hyperthyroidism. The results of treatment are noted in the photo- graphs (Fig. 20). Several failures to get results were found on inves- tigation to be due to the use of vibration in lieu of concussion. The inutility of a vibration apparatus to elicit reflexes cannot be sufficiently emphasized. One can- not evoke the knee-jerk by vibration and no more can be expected in the elicitation of the vertebral reflexes by the same maneuver. 79 Progressive Spondylo therapy CHAPTER IV. THE DIGESTIVE APPARATUS. ESOPHAGUS STOMACH PYLORUS DUODENAL ULCER DORSAL GASTRIC NUCLEUS OP RESONANCE DUODENAL INTUBATION SIGMOID FLEXURE INTUBATION OF COLON CONSTIPATION SACRO-ILIAC PERCUSSION CIRRHOSIS OF THE LIVER- GALL-BLADDER PANCREAS. ESOPHAGUS. In cardiospasm, my methods as cited (589) have been useful, but it is well to take into con- sideration recent experimental work which shows that, stimulation of the peripheral ends of the cut vagi contracts the entire esophagus but dilates the cardia whereas section of the vagi, without stimula- tion, dilates the lower part of the esophagus and con- tracts the cardia which corresponds to the condition known as cardiospasm. Therefore the vagi control the esophageal musculature and furnish a dilator branch to the cardia. In accordance with the foregoing, cardiospasm of neurosal origin would be inhibited by pressure or concussion of the 7th cervical spine. This discrepancy between my clinical and the experimental results cited is easily decided in favor of the former. To the end of an ordinary stomach- tube, I attached a balloon and to the other end a V- shaped tube connected with an inflating apparatus and manometer (Fig 21). Whether the balloon was inflated in the esophagus or at the cardia (40 cm.), the result on concussion at the 7th cervical spine was the same, viz., contraction of the esophagus and cardia. On the contrary, concus- 80 s t o m a sion between the 3rd and 4th dorsal spines (to depress vagus) resulted in dilatation of the esophagus and cardia. STOMACH. An unbiased and careful analysis of the various methods for outlining the stomach con- vince the author that the vago-visceral method (321, 584) is unquestionably the best. FIG. 21. Stomach-tube with inflatable balloon, manometer and pump for gauging the contractility of the stomach and esophagus. Auscultatory percussion is unreliable. Surgery has added nothing because the stomach in the operating room like in the dissecting room is examined in the horizontal position and an anesthestic (page 82) still further complicates the situation. Fixing the stomach by freezing and by the use of formalin reproduce the picture of an atonic and dilated organ immediately after death. Roentgen-ray pictures are equally untrustworthy (586). 81 Progressive Spondylotherapy The situs of the abdominal viscera (influenced by the position of the diaphragm) as recorded by anat- omists is unrealiable for the reason that after death there is an elevation of the diaphragm and a compen- satory retraction of the anterior abdominal wall. THE STOMACH AND ANESTHETICS. Gwathmey 8 , has shown that oil of orange added to ether produces anesthesia with less discomfort, quicker results, no preliminary excitement, rapid recovery from effects with neither nausea nor vomiting, with half the quan- tity of ether. Dr. Geo. Jarvis, of Philadelphia, attrib- utes these results which I have confirmed to the oil of orange which when mixed with ether suppresses the lung reflex of dilatation and the stomach reflex of dilatation which are evoked when ether is used alone (319). The previous inhalation of oil of orange is quite as effective as its synchronous use with ether. I have observed under the microscope that, with ether alone, the motion of ciliary epithelial cells was inhibited, whereas the addition of orange-oil to the ether seemed to augment the motion in question. Post-operative nausea and other symptoms incident to the employment of an anesthetic may be inhibited by previous nasal cocainization (207). The addition of 2 per cent, of antipyrin to the cocain solution will prolong its action. THE PYLORUS. Concussion or pressure at the 5th dorsal spine will dilate the pylorus (588). This fact has been utilized for the following purposes : 1. To relieve pylorospasm ; 2. To facilitate rapid absorption and hasten the elimination of nauseous drugs from the stomach ; 3. To eliminate the action of the gastric juice on drugs destined for action on the intestinal tract 82 The Pylorus .(intestinal antiseptics and lactic acid bacilli-prep- arations) ; 4. In the treatment of gastric affections ; 5. To aid duodenal-intubation.* As an illustration of the fourth indication, a lady may be cited whom I saw in consultation with Dr. W. B. Ryder, of Clinton, Iowa. She almost invariably rejected her meals, 2 or 3 hours after ingestion. She was very much emaciated and all methods of treatment were without avail. On examination nothing definite was elicited. Concussion of the 5th dorsal spine was executed two hours after each meal to facilitate vomiting of the food into the intestines. The results were very sat- isfactory. It is quite natural that some should doubt on scientific grounds the results as cited. Throughout my work, I have repeatedly emphasized the fact that no credence is placed on therapeutic effects without scientific proof. Let one employ Klemperer's oil-test for de- termining the motor power of the stomach. It is based on the fact that oil is not absorbed in the stomach. After washing the organ, 100 c. c. of pure olive oil are poured into the empty stomach. Two hours later, the stomach is thoroughly aspirat- ed. The difference between the original quantity of oil and that withdrawn indicates the condition of the motor function. In the norm at this time only 20-40 c. c. of oil should be aspirated. If, after the ingestion of oil pressure is made (at intervals of 3 minutes) at the 5th dorsal spine, within 10 minutes, only 5 c. c. of oil can be recovered By aspiration if the motor power of the organ is comparatively good. It may also be observed that the dullness at the *Jutte (J. A. M. A., Feb. 22, 1913), practices transduodenal lavage in enterotoxism. 83 Progressive Sp on dylo therapy lower border of the stomach caused by the oil which persists for about 2 hours disappears in about 5 minutes by the maneuver suggested. Duodenal ulcer, is characterized by pains occurring one and a half to four hours after a meal due prob- ably to passage of chyme at this period of digestion. The pains in question may be precipitated by opening the pylorus after the manner suggested. Dr. H. Jaworski, of Paris, has reported to me an observation made by him, viz., that by raising the hyoid bone, the vomiting of pregnancy can be inhib- ited. On investigating this interesting phenomenon, I found that lifting the hyoid bone or the cricoid cartilage opens the pylorus and dilates it to a greater degree than stimulation of the 5th dorsal spine. When one stimulates the 5th dorsal spine, the stom- ach assumes a vertical position and dilatation of the pylorus ensues. Another phenomenon is, that the stomach is so increased in tone that it is possible to percuss it without simultaneous stimulation of the vagus (321). Repeated analyses of the gastric-con- tents convince me that stimulation of the vagus (by concussion at the 7th cervical spine) will augment the hydrochloric acid in the stomach. The action of gases on the pyloric reflex has been investigated by Rotky. The pylorus relaxes imme- diately when oxygen is introduced into the stomach but when carbondioxid enters, there is a spasm of the pylorus which relaxes intermittently to permit its escape. In gastric tympanites, due to an excess of carbon dioxid, magnesium-perhydrol which liberates oxygen in statu nascendi should be efficient. It also neutral- izes an excess of gastric acid. DORSAL GASTRIC NUCLEUS OF RESONANCE. Ewart, 84 Duodenum describes a percussion-note of increased resonance and tympanitic quality immediately below the infe- rior angle of the left scapula (2-2^ inches in diam- eter) which he refers to the deep-seated resonance of the stomach. The severe and dangerous forms of heart disease of mechanical gastric origin is attributed by Ewart, to a dilatation of the stomach at this point. This interesting phenomenon described by Ewart in 1910, was also described by the writer in 1900 (84). The area of dorsal tympanitic resonance may be increased or diminished by elicitation of the stomach reflexes (316, 318). One may readily determine the effects- on the stom- ach of stimulation of the vagus (concussion of 7th cervical spine) by using the apparatus shown in Fig. 21. DUODENAL-INTUBATION. Several methods have been suggested notably, that of Einhorn 9 , for obtain- ing the contents of the duodenum. My method is as follows: An ordinary stomach- tube rounded at the end and perforated is introduced into the organ after the conventional manner, and some of the contents aspirated to compare it with the fluid subsequently aspirated from the duodenum. Any large glass syringe which fits into the end of the stomach-tube may be used. Next, an assistant main- tains pressure at the 5th dorsal spine, during which time the tube is passed into the duodenum. If the tube is in the duodenum, the aspirated fluid is wholly different from the fluid secured in the pri- mary aspiration from the stomach. It is alkaline in reaction as a rule, and by aid of the usual tests, the presence of amylopsin, trypsin and steapsin may be demonstrated. Prior to the introduction of the tube into the duo- 85 Progressive Spondylotherapy denum, the tube (while in the stomach) should be cleansed by aid of the syringe filled with some colored fluid. The object of the latter is to make certain the fact that the tube is in the duodenum. If the latter has been entered, aspiration shows the absence of the colored fluid. Reference to fig. 22 shows the tube in the stomach and duodenum as determined by pre- vious percussion. FIG. 22 Illustrating the gastric and duodenal areas of percussional dullness. The continuous lines represent the stomach and duodenum. The broken line represents the vertical position of the stomach during the time the pressure is maintained at the fifth dorsal spine. Pressure at the latter site not only opens the pylorus in the norm, but also augments the tone of the stomach in the vertical position. D, duodenum; S. T., stomach tube, determined by percussion. It will be noted that, when pressure is made at the 5th dorsal spine the tone of the stomach is so in- creased that it may be delimited by percussion just the same as though pressure were made at the 7th cervical spine. There is this difference, however. Pressure at the 7th cervical spine does not alter the situs of the organ, whereas pressure at the 5th dorsal spine causes a transition of the organ from a horizontal to a vertical 86 FIG. 23. Skiagram of the stomach tube in the duodenum. The intubation of the latter thus attained was effected by the elicita- tion of the pyloric reflex of dilatation. 87 Progressive Spondylo therapy position. Within one-half minute after pressure ceases at the 5th dorsal spine the stomach resumes its horizontal position. It will be noted in Fig. 22 that the stomach-tube (S. T-) may be traced a considerable distance by percussion. We have been swayed by the dogmatic dictum that a percussion blow is only propagated to a depth of 2 l /2 inches, hence any airless structure beyond this point will elude detection by percussion. This fallacy may be easily disproved if one will place a stomach- tube in contact with the posterior surface of the chest and then by percussion of the anterior surface of the latter, attempt to locate its position. As a rule, the clinician reasonably skilled in percus- sion may locate the site of the tube no matter in what position the assistant may have placed it. After introduction of a stomach-tube, one may determine by percussion its position in the esophagus from the 6th dorsal spine downwards. Duodenal-intubation as cited is a rapid method and is no more difficult than the introduction of the tube into the stomach. This method suggests many possibilities in diagnosis and treatment. Moulin, noted that one could pass three fingers through the pylorus and Knapp, observes that the duodenum may be entered with the ordinary stomach- tube in cases of complete insufficiency of the pylorus. A few words of reference to the duodenum are ap- posite. The latter is described by anatomists as the most fixed and widest part of the small intestine, hav- ing a diameter of 3.81 to 5.08 cm. and is curved like a horseshoe. From a clinical standpoint abetted by the employment of the visceral reflexes, unlike the stom- ach it does not change its situs during respiration. Whereas the duodenum shows no respiratory disloca- 88 Sigmoid Flexure tion, it is luxated downward with the stomach when pressure is made at the fifth dorsal spine. This may be ascertained if synchronous pressure is made in the latter situation and at the tenth dorsal spine (which augments duodenal tone and permits of its delimita- tion by percussion.) The clinical diameter of the duodenum varies from 3 to 5 cm., and averages a diameter of 4.5 cm. If syn- chronous pressure is made at the tenth dorsal spine (which increases duodenal tone) and at the eleventh dorsal spine (which dilates the duodenum), it will be shown that it can be made to dilate from 2 to 3 cm. In many instances, if the stomach-tube is not push- ed sufficiently far into the duodenum only a watery liquid is aspirated, whereas if it is pushed further, the fluid assumes a more intense yellow. One must recall the fact that the common bile-duct and pancreatic-duct enter the duodenum at the am- pulla of Vater, about 4 inches from the pylorus. The difficulty of passing along the horseshoe duo- denum is essentially theoretic. In some instances, a smaller rubber-tube is fixed in the stomach-tube and aspiration of the duodenal-con- tents is made through the former. SIGMOID-FLEXURE. The large intestine extends from the termination of the ileum to the anus. It is divided into the cecum (caput coli), colon and rectum. Its caliber is largest at the cecum and gradually de- creases in size until it reaches the ampulla of the rectum when it again increases in size. When the cecum is filled, it is in close proximity to the abdominal wall. * The appendix is usually given off from the pos- terior and inner portion of the caput colt about 11-16 of an inch below the ileocecal valve. The average length of the colon is as follows: 89 Progressive Spondylotherapy Ascending colon 8 inches Transverse colon 20 Descending colon Sy 2 " The descending colon begins at the splenic flex- ure and terminates at the sigmoid-flexure. The lat- ter (S. romanum}, is an S shaped curve about 13 inches in length beginning at the iliac crest and ending at the brim of the true pelvis opposite the left sacro-iliac articulation. The sigmoid is very movable and is the narrowest portion of the large intestine. It has an upper, or colic and a lower, or rectal limb. According to the measurements of anatomists the length of the large intestine from the caput coli to the termination of the rectum averages 5 to 6 feet. These figures are evidently too high for the living subject. My experience with colonic-intubation al- ways controlled by X-ray pictures shows that an ordinary stomach-tube is more than long enough to traverse the entire large intestine. Respecting the functions of the latter, much evi- dence has accumulated to show that it is a useless and dangerous structure. This latter statement was emphasized by Metch- nikoff's book on "The Nature of Man" and by Lane, who referred to the cecum and ascending colon as a cesspool and carried his conception into practice by "short-circuiting" or by excision of -the large intes- tine. INTUBATION OF THE COLON. All authorities are practically agreed that the passage of a tube beyond the sigmoid-flexure is impossible. Kemp, observes that in his experience, in -every at- tempt to pass the sigmoid it caught and coiled back. Owing to the great mobility of this structure it is pushed upward which fact suggests the passage of the tube. A flexible wire in a tube was used but the 90 Sigmoid Flexure X-rays demonstrated that the passage of the tube beyond the sigmoid was impossible. Soper, after a wide experience controlled by skia- grams avers that it is impossible to pass the tube into the sigmoid except in Hirschsprung's disease (con- genital idopathic dilatation and hypertrophy of the colon). ABC FIG. 24. Illustrating colonic-intubation; A and B, tube coiled in the rectum; C, successful attempt to pass the tube beyond the sigmoid with cable shown in Fig 25. Prof. A. Schmidt, observes that owing to the angle formed by the colic and rectal limbs of the sigmoid, it is impossible to pass any instrument. My investigations on the subject embraced pri- marily the fact that the sigmoid could be dilated by pressure at the llth dorsal spine (326) and this dila- tation could be demonstrated by percussion, if syn- chronous pressure (employing two radicularpres- sors) were executed at the 1st dorsal (592) and llth dorsal spines. For the passage of the tube, pressure by an assistant at the latter point sufficed. The pres- sure made by an assistant should not at any time exceed 30 seconds so as to avoid exhausting the reflex and during the pressure the tube is pushed (very gently) forward. 91 Progressive Spondylotherapy Some resistance is of course encountered but it is slight. The sigmoid is best straightened when the patient stands and this position is to be favored whenever possible. My primary attempts to pass the tube failed completely as shown in fig. 24. FIG. 25 An ordinary stomach-tube with flexible cable used for passing the sigmoid flexure in colonic-intubation. To the end of the cable is an at- tachment with two openings One for injecting oil and the other for in- flation with air to facilitate the passage of the instrument when neces- sary. Later, I was almost invariably successful when a strong flexible cable was introduced into the tube (Fig. 25). Theoretically, one would regard the foregoing man- euver as harmless but two deaths from perforation have ensued with recto-sigmoidoscopy. A gut with a rigid mesentery may be dangerous. Of course serious results have attended even the passage of a stomach- tube or urethral-sound. Pain is a safeguard in col- onic-intubation and due consideration must be given to it. 92 Colonic-Intubation Colonic-intubation is indicated for a variety of conditions : 1. To correct intestinal stasis ; 2. To prevent appendicitis, 3. To introduce nutrient enemata. 4. To introduce medicaments. 5. To facilitate X-ray examinations. Intestinal stasis is perhaps the greatest contribu- tory factor in the genesis of intestinal autointoxica- tion (338). Constipation is one evidence of defective intestinal drainage. Many of the patients are treated in vain for every conceivable neuropathy or psycho- pathy. Mental apathy, acute attacks of abdominal pain (often relieved by the horizontal posture), headaches, nausea, vomiting and loss in weight are some of the symptoms of stasis. C. von Noorden, has recently directed attention to wandering pains (dolor es vagi) due to fecal-stasis in the sigmoid-flexure which is very sensitive to .pres- sure. The condition is essentially an elective neuritis insomuch as the sensory fibers alone are affected. Associated symptoms are: indicanuria, arthralgias and slight elevations of temperature (99.5 to 99.86 F.) A bismuth meal shbws delay in some part of the colon. Colonic-stasis may be caused by splanchnoptosis, kinks, bands, adhesions, etc. A definite blood-picture has been found by Hoxie; hemoglobin high with normal red-blood count. Whites, about normal. With Wright's stain, the polynuclears show an increase of cells with large ambophilic granules (dark, large and purplish) . The latter decrease as the excretion of the toxins increases. The degree of intoxication is in the proportion of these dark cells to the total number of polynuclears. 93 Progressive Spondylotherapy A multitude of affections, notably, asthma, have been attributed to intestinal stasis and Eustis, has cured many cases based on this assumption. Toxic amins have been extracted from the putrefactive intestinal-contents which, when injected into animals cause bronchial-spasm. The general appearance of these patients is char- acteristic : Cold and clammy hand, pigmentation (sallow skin), abdomen is distended and tenderness in colonic-regions where the x-rays show a delay of the bismuth meal. Nodulation of the upper and outer quadrant of the breast is not uncommon and is often erroneously called mastitis (chronic). Perhaps one of the greatest contributions to sur- gery is that or Arbuthnot Lane, who by his method of anastomosis rescues many individuals suffering from chronic intestinal stasis. How much good colonic-intubation will do for these patients as well as those suffering from chronic appendicitis can only be decided by time. It is evi- dent however that as we are now able to pass the sig- moid, more thorough cleansing of the colon can be effected. Duodenal-ulcer according to Moynihan, is second- ary to microbic infection from the lower tracts of the alimentary canal but the chief role as a source of septic infection is played by the appendix. The latter structure is responsible for some forms of intestinal stasis owing to the formation of adhesions. It has been shown that in the colon where bacterial action is at its maximum, it is a predisposing factor in carcin- oma of the colon. Thus the parts most frequently attacked in order of frequency, are ; sigmoid, cecum, splenic and hepatic flexures and transverse colon. The ascending and descending portions are the least often affected. 94 Antiseptics Nor must we disregard colonic-flushing as a pre- ventive of appendicitis. No doubt infection is the invariable prelude to the latter. The appendix is practically a culture test- tube in which feces and microorganisms lodge and are with difficulty discharged. Inflation of the colon with air may reproduce the pains of appendicitis in subjects with recurrent attacks and without symp- toms. In the conventional method of examining the large intestine with the x-rays a bismuth meal is given but it takes 12 to 15 hours to reach the ileocecal valve, 24 hours to reach the transverse colon and 36 hours to attain the sigmoid. Now, one can make the examination immediately by injecting the bismuth (30 ounces) and then having the patient lie on his right side for several minutes to enable the solution to pass into the cecum. Careful investigations show that, intestinal antiseptics taken .by the mouth are without any apparent action on the bacterial inhabitants of the intestines and that the most effective means of diminishing the bacterial- content of the large intestine is by regulation of the diet with evacuation of the bowels. The "effects of disintoxicating the intestine by the recently discov- ered " Glycobacter" awaits development. CONSTIPATION. The author's method of treatment (329) in atonic constipation may be due in part to the expression from the spleen of an hormone. Zuelzer, has shown that intestinal peristalsis is produced by an internal secretion of the gastric mucosa elaborated at the acme of digestion and stored in the spleen. CECUM. In the percussion of this structure (592) during the time pressure is maintained, it will show respiratory mobility. Absence of the latter suggests cecal-adhesions. 95 Progressive Spondylotherapy RECTUM. Atony of this structure may be respon- sible for constipation. The best site for stimulation is the 5th lumbar spine and the best stimulant is the rapid sinusoidal current. The latter was determined by using an inflated vballoon (Fig 21) in the rectum and noting at which point of the spine the needle of the manometer was best deflected. For spinal sinusoidalization, I use the spondylec- trode shown in fig. 26. FIG. 26 Spondylectrode. The distance between the two electrode discs is just sufficient to span the spinous processes, making contact with the nerves on each side. When the little lever marked "A" connects the two metal plates to- gether, and the connecting cord is attached to socket marked "B", the electrode is monopolar; while an indifferent pad must be applied else- where. When the lever marked "A" is open, with one cord at "B" and one in socket "C", the electrode is bipolar. The current can be interrupted by means of the interrupter on handle; or can be made continuous by sliding the ring "D" down over the inter- rupter to hold it stationary. The two small discs are provided for diagnostic effects over motor points and two larger discs for therapeutic application to muscles. SACRO-ILIAOPERCUSSIOX. Dr. William Ewart 10 , who has displayed so much genius in devising new methods of examination has recently suggested a 96 Cirrhosis of the Liver dorsal field of percussion which includes the resonant sacral and iliac surfaces (Fig. 27). In the norm, there are as shown in fig. 27, two pos- terior iliac patches of subresonant dullness due to the common iliac blood-vessels. In appendicitis, there is a dullness extending from the right normal patch of dullness over the normal resonant sacral and iliac surfaces. The latter is often more positive than the usual abdominal examination owing to the predominance of retrocecal appendicitis. In investigating this new method, I found that a fecal impaction of fecas in the cecum will yield an increased area of dullness on the right side and fecal impaction in the rectum will increase the area on the left side. FIG. 27. Illustrating sacro-iliac percussion; N, normal areas of dull- ness; CC, dullness of "caput coli" and R. dullness of the rectum. Even in the norm, pressure with the radicular- pressor at the 12th dorsal spine will yield a dull area corresponding to the cecum and pressure at the 4th lumbar spine, a dullness corresponding to the rectum which extends from about the 3rd sacral spine to the coccyx (Fig. 27). Percussion of the cecum in front has already been studied (592). CIRRHOSIS OF THE LIVER. No inconvenience is 97 Progressive Spondylotherapy usually suffered in this affection provided the com- pensatory circulation is maintained. In cirrhosis, the various anastomoses between the systemic and portal circulations are insufficient to overcome the effects of an occluded portal circulation. Surgery has been utilized by the operation of Tal- ma, which consists of establishing a communication between the systemic and portal circulations thus causing adhesions to form between the great omen- turn, liver, spleen and parietal peritoneum. This operation is effective in about 50 per cent, of the cases. In the Routte operation, the saphenous vein is anastomosed to the peritoneum. Whether the liver is enlarged or contracted, the clinical symptoms are practically the same. I have treated several cases of cirrhosis with con- traction with relief of toxic and obstructive symp- toms by evoking the liver reflex of dilatation (338). GALL-BLADDER. I have requested several of my surgical friends to confirm my method of locating the gall-bladder (598). Dr. Geo. Jarvis, of Philadelphia, and Dr. D. C. Ragland, of Los Angeles, have corrob- orated my findings. The gall-bladder was percussed and outlined by a stick of nitrate of silver and, at the operation, it was found in the situation located by percussion. I wish to suggest the possibilities of a new "physiologic surgery" by methods for eliciting the vertebral reflexes. Thus, the location of the seg- ment for dilating the ureter. Such data are only possible at the time of an operation. Dr. George Jarvis, an indefatigable investigator on these lines found that manipulation of the pancreas increases vagus-tone as determined by slowing of the heart and contraction of the stomach. PANCREAS. Since using my method of duodenal- 98 Pancreas intubation (page 85), I have found that stimulation of the 10th dorsal spine will augment the pancreatic secretion. I do not know whether its internal secretion would be similarly influenced. This internal secretion influ- ences carbohydrate metabolism. Lesions of the isl- ands of Langerhans, are found in a large percentage of cases in diabetes. The author suggests that stimu- lation of the 10th dorsal spine be tried in cases rebel- lious to the method already advocated (283, 479). Pawlow, believed that stimulation of the vagus directly influenced pancreatic secretion. 99 Progressive Sp on dylo therapy CHAPTER V. MISCELLANEOUS REFLEXES AND DATA VERTEBRAL REFLEXES IX GYNECOLOGY PELVIC SPLAXCHXOP- TOSIS MAMMARY TUMORS PERTUSSIS COUGHS MEDULLA OBLOXGATA LOCOMOTOR ATAXIA SPLEEX EDEMA EYE SPQXDYMOBILE GAUGE. VERTEBRAL REFLEXES IN GYNECOLOGY. The follow- ing are some extracts from a very interesting contrib- ution by Charles L. Ireland, M. D., of Columbus, Ohio, read before "The, American Association for the Study of Spondylotherapy" (Nov. 12, 1912). The following clinical picture is the average one of the patient who presents herself to the physician for treatment. She is very sad, has bearing down pains in the pelvis, backache, headache, irregular menstrua- tion, leucorrhea, and pains practically everywhere. Areas of vertebral tenderness suggest valuable diag- nostic information. Thus, tenderness at the 4th lum- bar spine suggests a disease of the uterus ; 3d lumbar vertebrae, ovaries; 2nd lumbar on the right side, appendix ; 10th, llth or 12th dorsal vertebrae, renal disease, etc. Many of these so-called cases of uterine disease were treated by every available method without suc- cess until it was found that the underlying condition was essentially splanchnic neurasthenia (337, 432). Treating the latter by the sinusoidal current, it was soon found, that in the absence of adhesions, dislo- cated uteri (weighted by the large accumulation of blood in the splanchnic vessels) were restored to the norm. Subinvolution of the uterus failing to respond to 100 Pelvic Viscera the conventional treatment yields to methods for elic- iting the uterus reflex (358). "I will say here that up to one year ago I had always contended that when an ovary was prolapsed, surgery was the only recourse, and I had good reasons for so thinking. By the use of the sinusoidal current to provoke the uterus reflex, absolute cure resulted in 9 cases, *. e., reposition of the ovaries ensued". The author suggests the neologism, "pelvic splanchnoptosis" to describe ptoses of the pelvic viscera caused by relaxation of the ligaments (420). In prolapsus uteri, with its complications (recto- cele and cystocele), operations usually fail if the perineum (and not the ligaments) is regarded as the only support of the pelvic organs. All the viscera are held in place by suspension from above and the pelvic viscera are not exceptions. Eelatively speaking, the uterus has more ligaments than any other viscus and the round ligaments can sustain a weight of about 10 pounds. Even in complete laceration of the perineum the uterus may remain in place thus showing the importance of the ligaments as supports. Splanchnoptosis is further discussed on page 185. Reference has already been made to abdominal supporters (145) and the methods for testing their efficiency (146). Dr. Nathan Rosewater, of Cleveland, describes the following three distinct types of devices for support- ing the abdomen : 1. The corset type is a rigid, usually more or less metallic corset, shaped to hold and support the protruding belly. These have the advantage of fol- lowing the fashion for women, supporting the spinal muscles, also they do not allow of much motion of individual muscles. Some are too ex- pensive for the masses. Those corsets lacing in 101 Progressive Spondylotherapy front, of moderate price, answer very well provided patients are taught to put them on while lying on their hack, to secure the organs in proper place before the protrusion of the abdomen and down- ward drag of the viscera can occur. 2. The zinc oxide adhesive plaster (531). 3. Elastic or supporting belts. These are a more or less elastic supporter or belt of varied mater- ials and forms, fixed with straps and buckles for lifting, holding and supporting the protruding ab- domen and preventing its downward drag. Most of these are too complicated for description and im- practical. A simple, practical form, which Rose- water uses, is illustrated in Fig. 28. Unlike most of the others, it has no perineal support to irritate and chafe between the legs in hot weather, but the main anterior body, A, of the supporter is held anchored to its place by a strong rubber belt, buckled to it at its lower outer angle on the right, which passes outward and downward over the hip, under the gluteal folds (which prevents it from slipping up). It is buckled into the upper right margin of the supporter A, and passes upward, backward, and crossing over the back to the corres- ponding upper left buckle. These belts are instantly adjusted to any tight or loose condition required, and can be let out for wo- men during their entire pregnancy, growing stout or thin only requires adjustment by letting in or out of the rubber-belt, which is made long enough if desired. For longer periods of wear, and after laparotomy and other operations, this type of belt is inexpensive, simple, durable and practical. As will be seen in the cuts, the support secured is up- ward and backward, corresponding to the natural support given by the abdominal muscles. It is best to lie on the back in adjusting this belt, as also with any form of abdominal support or corset. The author after testing various abdominal belts uses the Rosewater belt (Fig. 28) to the exclusion of others whenever possible. Mammary Tumors. Pseudo-neoplasms (198) can be made to temporarily disappear by pressure cor- responding to the sensitive vertebral point by aid of 102 Mammary Tumors the algesispondyloscope. Insomuch as the object is to inhibit impulses in the spinal nerve, the pressure must exceed two minutes in duration. I have observed that true neoplasms of the gland appear to be larger than they are found at the time of the operation. This is probably caused by the coincident muscular spasm provoked by the presence of the growth for, if the conductivity of the nerve or nerves innervating FIG. 28. The Rosewater abdominal belt. the breast is inhibited (171) the intumescence caused by the spasm disappears temporarily and only the true growth remains. Pertussis. Dr. W. T. Baird, of El Paso, has made a most important contribution to the therapeutics of this disease. His treatment is based on the fact that the supposi- tions organisms of this affection have their habitat in the mouths of the sublingual glands. The duct-open- ings in this disease are red and swollen. The lesions are first dried and then touched in succession with a probe around which cotton is wound and carrying one drop of carbolic acid. By this treatment the disease 103 Progressive Spondylotherapy may be aborted in 24 hours in the early stages. It may be necessary to repeat the application on several successive days. Neither pain nor soreness follows. In later stages, cure is effected in about one week. In advanced cases concussion of the 7th cervical spine is advocated (624). COUGHS. Dr. D. V. Ireland, has succeeded in in- hibiting many forms of persistent cough (which had resisted conventional methods) notably in bronchitis by freezing sensitive areas corresponding to the upper dorsal vertebrae. Here, there are probably irritable foci which survive the disease (439). In tuberculosis, writers have directed attention to the low position of the diaphragm and have accounted for it in a variety of ways. In a personal communi- cation, Pottenger, suggested an ingenious reason. He believes it to be caused by irritation of the phrenic nerve innervating the pleura (549). To test the cor- rectness of his observation, I have often found in phthisis sensitive points corresponding to the exit of the nerve (2nd and 3rd cervical spines) and when the latter were frozen the diaphragm assumed a higher position. MEDULLA OBLONGATA. It occurred to the author that, if one could influence the cerebral cortex by sin- usoidalization (383), a like influence could be elicited by stimulation of the medulla. It was found that, when a large electrode was placed at the sacrum and a small interrupting electrode over the medulla and a rapid very strong sinusoidal current was used, the facial and other muscles supplied by the cranial nerves could be made to contract. This method sug- gests itself in diseases of the ~bulbar nuclei. LOCOMOTOR ATAXIA. In a report to the "French Academy of Medicine" (Aug. 21, 1912), Marie and Jaworski, reported their results with vertebral reflex- 104 Peripheral Pains otherapy (616) in advanced tabes. They observed that 10 minutes treatment by the latter method was equivalent to 6 months treatment by the methods of Fraenkel (165) and that this progress after several seances was permanent. It is impossible to delimit our conception of tabes and Schwab, has truly said that all progress in neurology is commensurate with the progress made in tabes. ' Even our present con- PIG. 29. Concussor for executing unilateral concussion-analgesia. ception of the disease as a radiculitis (implying involvement of the posterior roots), is handicapped by the fact that radicular lesions are present in other conditions, notably in syphilis. PERIPHERAL PAINS. These may be inhibited by concussion-analgesia (367). It is not necessary to evoke bilateral analgesia if one uses a special concus- sor (Fig. 29) on one side of the spinous processes. Localizing the point for concussion has been discussed (369). In paravertebral blocking of nerves (362), the vertebral point for the injection may be similarly 105 Progressive Spondylotherapy located. It is not necessary to introduce the needle very far. By injecting the Schleich formula at different depths and manipulating the peripheral sensitive point, the insensitiveness of the latter indicates that the needle has penetrated sufficiently far. Next, the syringe is detached from the needle and filled with alcohol (423) which is then injected when perm- anent effects are desired. SPLEEN. Reference has already been made to the reflexes of the spleen (352) and it has been shown that, by contracting this organ, one is able to precip- itate a paroxysm of malaria (355). At a recent meeting of "The American Electro- Therapeutic Association" (Sept. 3, 1912) Dr. Louis von Cotzhausen, referred to a physician who suffered from latent malaria for a number of years and in whom a typic paroxysm of malaria was evoked within an hour after concussion of the upper three lumbar vertebrae to contract the spleen. It is known that the agglutination test of Widal, in typhoid fever may not appear until late in the course of the disease or during a relapse. In several instances, the author has precipitated an early and more decided reaction by previous concus- sion of the lumbar spines to elicit the spleen reflex of contraction. Of course, no great value can be attached to these limited observations and Prof. Widal, has promised to give the method in question a more extended trial. FUNCTIONS OF THE SPLEEN. The functions of this organ are undetermined despite all the experiments which have been made. Taking advantage of the physiologic fact that, the spleen undergoes rhythmic variations in volume, I sought to duplicate the same by dilating the organ by concussion of the llth dorsal 106 Functions of the Spleen spine and contracting it by concussion of the 2nd lum- bar spine. Examinations of the blood were made by Dr. Al- fred Roncovieri, and the following conclusions were formulated ; Concussion of the llth dorsal spine (which en- larges spleen) produces an increase in the number of red-cells and hemoglobin. No effect was noted on the white-cells. No morphologic changes were noted in the red-cells after concussion. Concussion of the 2nd lumbar spine (which con- tracts spleen), increases the number of white-cells chiefly those of the lymphocytic type. No effect on red-cells or hemoglobin. Alternate concussion, of the 2nd lumbar and llth dorsal spines increases the red and white-cells and hemoglobin. Unless the 2nd lumbar spine is concussed last, the results as cited do not ensue but if it is concussed last, the increase in the number of red and white-cells is greater than when either the llth dorsal or 2nd lum- bar spine is individually concussed. 1. Average increase of erythrocytes after concus- sion of the llth dorsal spine only 300,000 2. Average percentage-increase of hemoglobin after concussion of llth dorsal spine only.. 5 per cent. 3. Average increase of leucocytes after concussion of 2nd lumbar spine only 2800 4. Average increase of red-cells 'after alternate concussion 650,000 Average increase of hemoglobin after alternate concussion 10 per cent. Average increase of leucocytes after alternate con- cussion 3200. 107 Progressive Spondylotherapy EDEMA. The author's conception of edema has already been cited (617). A more recent theory is that of Fisher, and which has been exploited in his book, "Nephritis; An Ex- perimental and Critical Study of its Nature, Cause and the Principles of its relief; 1912." He assumes that edema is caused by an excessive production or accumulation of acid in the cells of the kidney. His theory however, only explains the imbi- bition of fluid by the cells whereas in edema, the water is chiefly in the tissues outside the cells. Moore 11 , in an ingenious analysis of this theory concludes that it is based "on a minimum of experi- mental evidence and has no place in the practice of medicine." In my opinion, the most serious draw- back of Fisher's theory is the sweeping generalization of attributing all forms of nephritis to the same cause. Fisher used successfully solutions of sodium car- bonate and sodium chlorid by rectal injections in nephritics in coma with anuria. BLADDER. Supplementing the observations con- cerning the bladder-reflex (358), recent cystoscopic examinations made with Dr. V. G. Vecki and Dr. Henry Meyer, show that the spondylectrode (Fig. 26) is excellent for the elicitation of the reflex in ques- tion. The endoscope shows that the verumontanum is best contracted when the spondylectrode is applied at the 1st lumbar spine. I would suggest further experiments along these lines by connecting a cath- eter, with a manometer after filling the bladder with an antiseptic solution and then noting thy effects of vertebral stimulation. EYE. Amblyopia and asthenopia are often de- pendent on reduced vagus-tone (496). They may be artificially reproduced by depressing 108 Glaucoma the vagus and by augmenting the tone of the latter the conditions in question may be improved or cured. In the norm, the degree of depression of the vagus necessary to produce either condition may be accu- rately gauged by the spondylopressor (Fig. 1). While the patient is reading test types, the vagus is gradually depressed by pressure between the 3rd and 4th dorsal spines and the degree of pressure necessary to produce symptoms is noted. By this method ocular fatigue can be measured. Howe, has recently devoted himself to a like study by means of an ophthalmic ergograph. A physician in commenting on my reflex signs of ocular disturbances (443) refers to an oculist of prominence who never felt satisfied that glasses were correct until an examination of the cervical and dorsal regions showed absolute muscular relaxation. .GLAUCOMA. The exact cause of this condition is unknown and its pathology is explained by the in- crease in intraocular pressure and the coincident venous congestion. Many theories have been suggested to explain the increased tension but all that is really known is, that a disturbed relationship exists between intraocular secretion and excretion. . , ; To determine the effects of concussion in several cases, it was found that the best results for reducing tension (as determined by a tonometer) and improv- ing vision was at the 7 f h cervical spine. Here the effect was to increase vagus-tone. Vagus-tone was very much diminished in the foregoing cases. The method of treatment indicated is merely a sug- gestion. SPONDYMOBILE GAUGE. This ingenious contriv- 109 Progressive Spondylo therapy ance (Fig. 30), of Langworthy, is used for measuring the mobility of the vertebrae. FIG. 30. Spondymobile gauge. The thumb screw "C" is first loosened and the rubber feet "A" and "B" are firmly planted on two vertebrae with patient in an upright position. The circular dial is then turned so that the pointer "D" rests at "O" and the patient is instructed to stoop forward as far as possible ; the pointer advancing to the mark indicating in centimeters the mobility be- tween the vertebrae is thus measured. The reading is then recorded, the upright position once more as- sumed and with pointer at "O" and instrument ap- plied as before, the patient is requested to bend backwards as far as possible, while the reading, noted to be on the opposite side of the zero mark, is again recorded. If desired to obtain in one reading the sum of the entire forward and backward movement, the patient may be instructed to bend forward, the rubber feet applied to the vertebrae under consideration, the dial adjusted so that pointer rests at "O" and the patient requested to straighten the back and to comr tinue bending backwards as far as possible. 110 Spondymobile Gauge The scale on the dial indicates the range of movement of the vertebral column, while the figures on the curved bar show in centimeters the entire span between the vertebrae measured. Ill APPENDIX PHYSIOLOGICAL PHYSICS OF THE VARIOUS FORMS OF FORCE PHYSIOLOGICAL PHYSICS OF THE VARIOUS FORMS OF FORCE CHAPTER VI. EXORDIUM ELECTRONIC THEORY PH^SIOTHERAPEUTICS PHYSIOLOGIC PROOF REFLEXES SPINAL CONCUSSION PER- CUSSION OF THE STOMACH BIOPLASM. EXORDIUM. To thoroughly understand this and subsequent chapters, it is assumed that the reader is conversant with the preceding pages and the author's work on " SPONDYLOTHERAPY" (Physio-therapy of the spine based on a study of clinical physiology). De- spite this assumption however, an endeavor will nev- ertheless be made to simplify the presentation of the subject-matter. If technecalities are employed they will be italicized and defined in an appended glossary. ELECTRONIC THEORY. The physical world may be comprehended within the limits of Force* and Mat- ter. Force is that which acts upon matter and the latter is that by which we understand force. The whole domain of physics is tending toward a unification of the various forms of force under one great principle. This tendency is suggested by the transmutation of various forms of force such as the conversion of sound into electricity and of electricity *We shall employ the term of force as a matter of convenience. Tech- nically, the word force is wrong if used in any way that implies its ob- jectivity, insomuch as energy, is the objective thing concerned and force indicates its rate of change. 115 Progressive Spondylotherapy into heat, light, motion or chemical energy. Heat, light, electricity and magnetism are under the influ- ence of one or two mechanic conceptions: that of ether and that of ultimate particles which embody matter and electricity. Matter is an accumulation of positive and negative electric charges and the chemic elements are merely varying numbers and arrangements of these charges. Atoms are supposed to be infinitesimal oppositely charged particles known as electrons, the electric units of nature. The latter move in orbits and are thrown off from all highly heated or electrified bodies. In accordance with this theory, matter and force are identical. The electrons bombard space and its con- tents at the rate of from 50,000 to 100,000 miles per second. If one observes a particle of radium through a little instrument with a magnifying glass known as the Spinthariscope, one may see a display of scintil- lating bodies flying around like shooting stars and bombarding a little screen covered with sulphite of zinc. The light effects are caused by explosion of the rays each time they strike the crystals of zinc- sulphite. Despite the vulgar prejudice of the absolute dis- tinction of mind and matter, they are but two aspects of the same thing. It is difficult to conceive the mind as a simple think- ing organ ; on the contrary, it is psychodynamic and must be regarded as a force, like heat, light and elec- tricity. This dynamogenic of force-producing power of mind can be demonstrated (page 188). The discovery of radium has exploded old theo- ries. It was formerly supposed that a substance was composed of atoms held together by a kind of ce- ment like the bricks of a brick-wall. Every phenom- 116 Electronotherapy enon in nature is dependent upon matter in motion. A moving electron radiates ethereal waves and a flying column of electrons produces a magnetic field in circles around the moving electrons as a center. Electricity is an invariable property of matter. In this sense, electricity is not a form but a vehicle of energy which can be moved from place to place in the form of motion or of strain. In motion, it is current and magnetism; under strain, it is charge and in vibration, it is light. PHYSIO-THERAPEUTICS. The term physiatrics is used to designate the natural forces employed by the physician in the treatment of disease. The action of heat, light and other forces is so little understood and used so indiscriminately with neither rhyme nor reason that any good results attained by their use is attributed to suggestion. Suggestion is often employed as a term of reproach and is a most serious menace to progress in the ac- ceptance of medical observations. Lotze affirms that, our apprehension of the world is one prolonged de- ception and Taine, in his book on "Intelligence," as- serts that, all perception is hallucination, although in some instances it may be shown to be true. The cred- ulous in medicine believe too much and the skeptics believe too little. One must confess that drugs may likewise act as excellent vehicles for suggestion. Take a force like electricity which has been used by the physician for many years and yet its action has been questioned. Moebius, a nerve specialist of great reputation, as- serted that four-fifths of all electrical cures are de- pendent on mental influences. Beard, in his time, a leader in electro-therapeutics, observed, "If you ex- pect to get definite results from electrical applica- 117 Progressive Spondylotherapy tions, you must be sure that your patient has faith, otherwise the application will do him no good." Electricity is one of the most valuable assets that the physician possesses in the treatment of disease when it is used and not abused. The patient clamors for cure and is in no wise con- cerned how it is effected. The scientific physician clamors for proof concern- ing cures and rightly so, for all knowledge must be arranged under general truths and principles. The physician is handicapped in determining results by his lack of instruments of precision. Our senses are gross and unreliable. With the telescope and a photograph plate the presence of millions of stars may be revealed yet the light of these stars does not in the least affect the unaided eye. The ear is deaf to most things yet with a micro- phone the tread of a fly is like the march of cavalry. For our heat-sense, we need a variation of one- fifth of a degree on a thermometer to enable us to appreciate any difference in temperature yet, with the bolometer of Langley, a difference of a mil- lionth of a degree may be detected. My endeavor in this chapter is to show that the var- ious forms of force used in the treatment of disease are governed in their action by one underlying prin- ciple and that the latter is essentially mechanic. We can conceive the electrons as bombarding space with terrific speed thus giving rise to all kinds of pertur- bations of the ether. When these ethereal-waves impinge on a medium of perception, they are practically a series of infin- itesimal blows which act like drops of water piercing the rock not by the force of the blows but by their frequency. This conception of the action of the forces has sug- 118 Electronotherapy gested to the author the neologism, electronotherapy. PHYSIOLOGIC PROOF. It is not necessary to go far afield to cite examples where the reaction of an or- ganism is employed as a test for the action of certain agents. The physiologic action of currents was an accident- al discovery by Galvani, and since his time many ex- periments have been made. Protoplasm (also known as bioplasm), the fundamental basis of all living bod- ies contracts when an electric current passes through it. Protoplasm is made up principally of water, oxy- gen and nitrogen of the air we breathe and from the carbon of the food we eat. To the latter may be add- ed sulphur, phosphorus, iron and a trace of mineral salts. Protoplasm is vitally characterized by its ability to grow, reproduce and to respond to stimuli. Nerves and muscles show a definite response to the action of currents. Taste-perception is produced when the Galvanic current is applied to the back of the neck; and if the same current is passed through the cheek, the perci- pient can recognize the specific quality of each pole. Passed through the head, the same current provokes a sensation of light with color-perception, and stimu- lation of the auditory nerve with the identical cur- rent, induces sound effects. It is quite natural that nerve-force should be iden- tified with electricity. The nervous system (and its mechanisms), has its radii of lines with batteries, switches, relays, transformers, condensers, resist- ances, shunts and automatic circuits. Electricity is known only by its effects ; beyond this our knowledge does not extend. We know that electricity will decompose water, de- 119 Progressive Spondylotherapy fleet the needle of a compass and heat a wire through which it flows. Chemism, heat and light, the three great forces of Nature, are directly interchangeable in rapidity and direction of the molecular vibrations. Chemic decomposition produced by electricity is known as electrolysis and the products of such de- composition are known as ions. It is likely that the atoms composing the living animal tissues are merely ions which are the material carriers of electricity. Artificial electric stimulation of nerves corres- ponds most nearly to their natural excitation. Animal bodies create electrical currents and the effects de- pend upon the nature of the discharge. The feeblest electric stimulation of a nerve induces in it a chemical change. Thus nerve-force is a physi- cochemic process. With every contraction of muscle an electric change occurs. The discharge of an electric eel is sufficient to kill a horse but the means of producing this electric charge is unknown. The power of reacting to stimuli, called irritability, is the most conspicuous characteristic of the living organism. The action of etheric-concussion on the living or- ganism has heretofore baffled interpretation for the reason that, no account has been taken of the reflexes of the organs. Practically every organ of the body has governing centers in the spinal cord and when these centers are stimulated by the physiologist in his laboratry, organs can be made to contract or dilate. Though these results have been partially attained by vivisection, it has been shown by the author that, in the living human, like effects may be achieved by 120 Electronotherapy the use of stimuli applied to definite regions of the spinal column. The latter have been located with reference to def- inite spines of the vertebrae. If, for example, one strikes a series of blows corres- ponding to the spine of the 7th cervical vertebra, there is a contraction of the heart, stomach, liver, spleen and other organs. The phenomena thus elicited are known as reflexes. Thus one speaks of a heart, stomach, liver and a spleen reflex. These reflexes are of some duration but may be dissipated at once by colored sheets of gelatine (blue, violet or red) held in front of the or- gan. When the latter maneuver is executed, it is im- possible to elicit the reflexes of the internal organs for reasons cited on page 204. What is known as the knee-jerk, is a forward projection of the leg when one taps the tendon be- low the kneecap with a hammer during the time the leg is crossed on the knee of the other extremity. When the tendon is struck, the blow which is in the nature of a stimulus is conducted by a sensory nerve to the spinal cord. It is then transmitted to motor-cells in the anterior part of the cord where it is converted into an impulse which is then con- ducted to the muscle resulting in contraction of the latter. It is the muscular contraction which causes the knee-jerk. If the toe of an adult is pricked with a pin, the foot is pulled away in about one-tenth of a second. This is also a reflex and is very slow when com- pared with the speed of electricity or a light-wave. The latter would travel seven times the equator in a second but the nerve-wave travels at the rate of only 100 feet a second. A reflex is made up of a stimulus causing a dis- charge of force, transmission of the latter to a center whereby another force is discharged and finally, the transmission of force to the stimulated area. 121 Progressive Spondylotherapy All actions are essentially reflexes and if this view- point is carried further, it means that we have no will of our own and that our actions are simply the result of external circumstances. We are instinctively ac- tive like ants or bees and we are creatures of physical forces. All reflexes are purposeful in character. Thus, clos- ing of the eyelid and contraction of the pupil protect the eye from foreign bodies and the retina from in- tense light. Loeb* contends that, irritability and conductivity are the only qualities essential to reflexes and both are common qualities of all protoplasm (page 126). Plants possess no nerves, yet the flight of a moth into a flame differs in no wise as a reflex or instinc- tive process from plant heliotropism. What happens to a nerve when it is stimulated or when it is struck by a series of blows? After Loeb demonstrated that, muscles could be made to contract or relax under the influence of certain ions, Mathews found that, a like effect could be observed in nerves. It was Graham, who divided all substances, into those which crystalize when they solidify and those which do not. The latter were designated colloids or gluelike substances. The colloids in the body bear a positive electrical charge and are precipitated by negative ions. Now the nerves consist of colloid particles in suspension and the thicker this jelly-like substance, the better will the nerve conduct. When chloro- form or ether is inhaled unconsciousness ensues when the nerves no longer conduct sensation. Here, the action of the anesthetic is to dissolve the colloid substance and the thinner the latter the less easily will the nerves conduct. The colloid particles as intimated are positively charged and a nerve is stimulated by a current proceeding from the negative pole. The positive *The Mechanistic Conception of Life, 1912. 122 ectronotherapy and negative ions in a nerve are balanced. Now suppose the nerve is stimulated by blows, then the colloid particles coming together would have their surfaces reduced. The latter would reduce their electrical charge and releasing a number of neg- ative charges, a nerve impulse would be started. SPINAL CONCUSSION. If the 7th cervical vertebra corresponding to 3 in Fig. 19, is struck a series of blows with a rubber-hammer, the nerve-roots are stimulated and the blows are propagated to the vagus or pneumogastric nerve. When the latter nerve is thus stimulated indirectly, there is a contraction of the organs (heart, liver, spleen and stomach). Such contraction may be read- ily observed when the patient is before the X-rays and it can be demonstrated by percussion. If the blows are feeble, there is no contraction of the organs, but instead a stimulation of the vagus. Stimulation of the latter is characterized by an in- crease of tone. What is known as " TONE" will be de- scribed presently. Visceral-tone has also been dis- cussed on page 7. The vagus is the longest and most extensively distributed cranial nerve. How do we know that it is through the vagus that blows delivered at the 7th cervical vertebra contract the organs? It atropin is injected into the body before an at- tempt is made to elicit the reflex contraction of the organs, the latter cannot be evoked. This is because atropin paralyzes the motor endings of the vagus. After several hours, the paralyzing effects of atropin evanesce when it is again possible to con- tract the organs by blows delivered at the identical vertebra. PERCUSSION OF THE STOMACH. The stomach re- ceives its motor supply from the vagus, i. e., if the lat- ter nerve is stimulated, the muscular fibers of the or- 123 Progressive Spondylotherapy gan contract, in other words, the tone of the organ is increased. Now, tone is .an essential attribute of all living or- ganisms. For all practical purposes, the term relaxa- tion, may be used as the antithesis of tone. The centers in the brain and spinal cord are in a state of tonic excitation and from these centers im- pulses are constantly passing through nerves to muscles and organs maintaining the latter in a con- dition of tonic stimulation. If a decapitated frog is suspended vertically with the hind legs downward and the sciatic nerve of one leg is severed, this leg will hang down more limply than the other leg. Such an experiment shows that the tonic-impulses are no longer conveyed from the spinal cord to the muscles supplied by the severed nerve. If percussion of the stomach is attempted on an in- dividual (standing), one elicits a tympanitic sound but if the vagus is stimulated (by striking the 7th cervical vertebra), a dull sound is provoked. In our investigations we have determined the potentiality of the forces in three ways : 1 By the intensity of the dullness. 2. By the duration of the dullness. 3. By the distance at which the force is operative. A moderately thin subject should be selected for experimentation and percussion must be exe- cuted with the subject in the erect posture. If the blows are forcible, in association with the dull- ness, there is a contraction of the organ, otherwise only dullness without any retraction of the organ. Why does stimulation of the vagus convert a tym- panitic into a dull sound? Such stimulation causes the walls of the stomach to become tense (owing to in- creased tone of the muscle-fibers in the organ), thus 124 Electronotherapy putting the air or gas in the stomach under increased tension. For the latter reason, we have the physical elements necessary for the transition of a tympanitic to a dull sound. Naturally, the amplitude and length of the waves set up in the ether when light, electrical energy or magnetic disturbances are distributed will influence the results. To test the action of the forces, I employed a strip of metal. In the latter, a small opening was made which was applied over the 7th cervical vertebra. It is necessary to protect the other regions of the spine to eliminate the action on other centers. When light (used at a distance to eliminate the heat factor), heat, electricity (sinusoidal), radium, or electromagnetic waves were applied over the spin- ous process in question, the effect was always the same, vis., dullness of tlie stomach on percussion. The moment some of these forces were removed, the tym- panitic tone of the stomach was restored. In other words, the action of some of the forces was purely transitory. The electromagnetic waves from a parabolic reflec- tor were effective at a distance of several feet. Radium (10 milligrams used), was only effective when it was held in juxtaposition to the vertebra but the moment it was removed, the stomach-dullness dis- appeared. In fact, radium was the most transitory in its effects. The X-rays were effective for a brief period after their action. I always attributed shrinking of the heart during exposure to the Roentgen rays as psy- chic in origin. In other words, the contraction of the organ was attributed to emotional causes. This view demands revision in accordance with these later ob- servations. 125 Progressive Spondylotherapy The most powerful of all the forces in its duration was the magnetic force and the latter, will be the sub- ject of consideration in future chapters. LIVING BIOPLASM. All living bioplasm is distin- guished and characterized by the following proper- ties: 1. Irritability, or the power to react in a definite manner to some form of external excitation irrespec- tive of the fact whether the stimulus is electric, me- chanic or chemic. If the bioplasm is represented by muscle, the reaction is a contraction of the muscle. 2. Conductivity, or the ability to transmit mole- cular disturbances at one point to all parts of the ir- ritable material. 3. Motility, or the power of exhibiting spontan- eous movements. . Physiologists aver that, all protoplasmic move- ment is the resultant of natural causes the nature of which is not understood. We shall attempt to prove that the foregoing properties of bioplasm, which, in their summation is nought else but tone, may be reproduced by magnetic force without stimuli transmitted from the nerve- centers. Furthermore, that in such reproduction the tone exceeds that created in the organism. Summarizing the subject-matter of this chapter, the following conclusions may be formulated. 1. The therapeutic action of the various forms of force is dependent upon matter in motion. 2. The etheric-waves thus created by bombarding electrons are equivalent in their action to a species of concussion. 3. Insomuch as the action of all the forces is gov- erned by one underlying principle which is essentially 126 Elect ronotherapy mechanic, the neologism electronotherapy is suggest- ed. 4. In electronotherapy, reflexes are elicited inde- pendent of the fact whether the forces are employed at the periphery or at a spinal center. Applied in the latter situation, the reflexes are of greater amplitude and of longer duration. It is therefore evident in the treatment of disease by aid of reflexes (Reflexother- apy ) , the elicitation of central reflexes is preferable. 5. The forces like light and the X-rays, directed toward the stomach-region and at a distance, will in- crease the tone of the stomach, as evidenced by the conversion of the normal tympanitic sound into a dull one. The moment the forces cited are brought in imme- diate contact with the stomach-region their irritant effect becomes manifest and no dullness ensues. Light from the thermotherapeutic lamp which con- sists of a large incandescent bulb (50 C. P.), in con- nection with a parabolic metallic reflector, yields a stomach-dullness at a distance of 24 feet after pass- ing through two plaster-walls of my office. With a patient within a few feet from the source of illumination, the rays pass through lead, sheet-iron and other metal. In other words, if a sheet of metal is held over the stomach and the light is directed on the metal, a dullness of the stomach can be elicited. This dullness however evanesces the moment the light is withdrawn. This experiment demonstrates that there are com- ponents in light which in their penetrative power bear a resemblance to Roentgen's rays but differing from the latter, in their ability to pass through glass, lead and bone. The great mathematician, James Clerk-Maxwell, contended that light and electricity were funda- 127 Progressive Spondylotherapy mentally one. It was on this theory that Hertz, was led to discover his waves which Marconi, utilized for conveying messages. Sir Oliver Lodge, refers to light as an electro-magnetic disturbance of the ether. In other words, light is an electric vibration, the result of electric oscillitions in the molecules of bodies which are hot or in bodies without heat (phenomenon of phosphorescence). Further experiments were conducted with an or- dinary 16 C. P. incandescent bulb ; the subject stand- ing at a distance of 5 feet from the source of illumina- tion. The transition of the stomach from tympanicity to dullness being utilized as a criterion of action. The following conclusions were formulated with reference to several investigations : 1. An uncolored bulb produced dullness only dur- ing the time the light was directed on the stomach- region. 2. Filtered through blue or red glass, the results were absolutely negative, i. e., no dullness ensued. The results were equally negative with green and violet. 3. Filtered through yellow glass, a dullness (after removal of the light) ensued lasting 2 minutes. In this, as well as in the foregoing experiments, the ex- posure was about 20 seconds in duration. 4. The solar rays* were negative until concentrat- ed by aid of a large lens at some distance. Too small a focus annihilated the results. When the solar rays were focused on a sheet of lead held in front of the stomach-region, dullness of the stomach ensued just the same as when light from an incandescent bulb was passed through a sheet of lead. *Kime (Iowa Med. Jour., April, 1900), speaking of his own work on the use of the solar rays (heliotherapy), refers to Finsen, himself and myself, who working along the same lines independently, each has pur- sued his own methods. "In order of their publication," he continues, "the papers were, Abrams, March, 1899; Kime, June, 1899; Finsen, September, 1899." The treatment of laryngeal tuberculosis by the solar rays is accredit- ed to Sorgo, and called the "Sorgo Treatment." The identical method was suggested by the author many years in advance. The only reasonable ob- ject of this citation, is to establish the matter of priority in discovery. 128 Electronotherapy 5. When the magnetic flux from a small or a pow- erful electromagnet passed through any colored glass excepting yellow glass, no stomach dullness ensued. 6. When the magnetic flux passes through a yel- low medium, the stomach tonicity (as revealed by dullness), lasts nine times as long as simple exposure. Gamboge painted over the stomach-region prolongs the tonicity three times the length of time. Crude experiments conducted by the author show that, color modifies the attractive attributes of an ordinary magnet; yellow and blue increasing and red, decreasing such attraction. 7. Heat is negative through colored glass except- ing yellow. 8. When a concussion-apparatus is allowed to con- cuss the air at some distance from the subject, stom- ach-dullness may be elicited. If colored media are in- terposed between the apparatus and the subject, no dullness ensues unless yellow glass or a yellow gela- tine sheet is used. 9. A yellow medium prolongs the duration of the stomach-tonicity with heat, light and magnetism to a greater extent than when the latter are used alone. 10. When two forces are employed synchronously no stomach-dullness ensues ; one force negativing the action of the other force. Here, we are probably dealing with similarly charged forces as is the case with colors (page 204). If heat and light are used simultaneously with the magnetic force so that, the heat or light is directed toward the negative pole of the magnet (while the positive pole of the latter is directed toward the body), stomach-dullness ensues. 11. When yellow glass is placed in front of an X-ray tube some rays pass which produce, a stomach- dullness. 129 Progressive Spondylotherapy 12. If yellow glass is held in front of the stomach in ordinary light, a dullness at once ensues. This color will intensify the tone of all the organs and permits of a better definition of their boundaries by percussion. In other words, this color augments the tonicity of the organs. Other colors thus used diminish the, tonicity and decrease the boundaries of the organs (page 151). To relax the organs and thus secure a visceral rest-cure, green, violet or blue may be used and yellow when a tonic effect is desired. 13. Any variation in the proportion and charact- er of the electrolytes in a tissue is capable of impart- ing to that tissue certain properties. The chief elec- trolyte in our blood is sodium chlorid. If a muscle is put into a solution of the latter (i. e., isotonic with the muscle), it twitches rhythmically, while the addition of a soluble calcium salt prevents the twitching. My investigations show that the stomach-musculature ex- hibits like phenomena. Let a subject ingest 50Cc. of normal salt solution a persistent stomach-dullness ensues until inhibited by the ingestion of the same quantity of fluid containing 5 grains of chlorid of cal- cium. When the latter is ingested, it is impossible to impart tone to the stomach by the most powerful mag- netic flux. Chlorid of calcium may be indicated in all spasmodic conditions of the stomach-muscle. 130 Magnetic Fo CHAPTER VII. MAGNETIC FORCE HISTORICAL. MAGNETISM AND CHARLATANRY GILBERT PARACELSUS MES- MER DE PUYSEGUR PERKINS MODERN HISTORY. We are devoting special consideration to the mag- netic force for the reason that, it is convenient to use, it has no pernicious effects, it is more potential in action and it has antedated the various forms of force in the treatment of disease. The force of magnetism can lay claim to great an- tiquity. It is not strange that, "The Father of Phil- osophy," Thales, should have endowed the magnet with a soul or as an expression of life. If this mys- terious force were unknown to us, even in this day of great achievements, its discovery would awaken the same extraordinary interest and awe which Plato, Aristotle and even Homer could not evade. If Lucretius, were inspired to sing the magnet's power in his "De Rerum Natura," he could have apostrophized no greater marvel. The fact that, we are already acquainted with some of its attributes, should prove an incentive to know more about a force the nature of which is only known to us by its effects.* The medical history of mag- netism is a riotous recital of misguided judgment, defective imagination and charlatanry. Contributory to exaggeration of statement was the "It is sometimes of great use in natural philosophy," said Sir Wil- liam Herschel, to doubt of things that are commonly taken for granted, especially as the means of resolving any doubt, when once it is enter- tained, are often within our reach." 131 Progressive Spondylo therapy fact that, no attribute however mysterious could be superimposed on the magnetic force which could add to its mysteriousness. So securely is magnetism interwoven with char- latanry that, he who attempts to sever the bonds must be prepared to suffer the darts of calumny but the undaunted one, will find ample reward for his undertaking despite the fact that, in medicine, it is easier to establish a fact than to have it ac- cepted. Perhaps the greatest work ever published on mag- netism was that of an Englishman, William Gilbert, who, in the year 1600, was President of the "Royal College of Physicians." He mentions that, Discorides, believed that if a piece of lodestone, were finely ground and mixed with water it would when swallowed, benefit many disorders of the blood. Magnetic medicine however, was regarded as dan- gerous, insomuch as it contributed to melancholia and even death. The ancients who entertained curious ideas respecting the curative virtues of magnets conceived different kinds, some of which \vere bene- ficial and others dangerous. Some asserted that small quantities of ground lodestone were the true "elixir of life." It was also claimed that, lodestone taken internally, possessed the power of drawing iron arrow-heads from the body and that, this power was also effective in absorbing the arrow-head. The famous salve of Paracelsus, for the treatment of wounds caused by iron-daggers was an elaboration of this idea. The salve was essentially a compound of powdered lodestone and ordinary ointment. It was this same Paracelsus, really a great physician, in the first half of the 16th century, who regarded personal magnetism as a force not unlike that of a magnet which attracted iron. 132 Magnetic Force To him the attraction of sex was essentially magnetic. What we now call gravitation, was regarded by Kepler, perhaps the most profound thinker of his time, as magnetic attraction. To him, the magnet was the soul of the physical world and it was by magnetic attraction that the planets were held in bondage with the sun. Descartes, was likewise engaged with a theoretical study of magnetism. At this epoch, the magneto-motive force was em- ployed as a convenient vehicle for explaining all psychologic phenomena and it was extensively used in the treatment of disease. In 1766, Mesmer, published "De Planetarum Influxu," designed to show planetary influence on the nervous system and his "Ueber die Magnetkur" was the product of his studies of magnetism as a curative agent. Mesmer, supposed that a force existed which he called "animal magnetism," by means of which, one person could influence another. This " animal in- fluence," he regarded as the essential nature of mes- merism. Subsequent investigators demonstrated conclusively that, the phenomena observed by Mesmer, were wholly subjective and quite inde- pendent of any known force. Swedenborg, in 1763, claimed that, by magnetic sleep one could be raised to the celestial light even in this world, if the bodily senses could be entombed in lethargic slumber. Binet and Fere, describe the performances of Mesmer, who, with a long iron-wand would walk among his throng of patients touching the latter particularly the affected parts of the body. To energize his results, he would sometimes substitute for his manipulations strong electric currents. In 133 Progressive Spondylotherapy his manipulations, he would pass his fingers over the body of the patient time and time again, until he was assured that the magnetized person was thoroughly saturated with the healing fluid. De Puysegur, in his instructions to hypnotizers, whom he designates as magnetizers, enjoins them to regard themselves as magnets and the arms, par- ticularly the hands, as poles and to imagine the magnetic fluid as passing from one hand to the other through the body of the patient. An American, Dr. Elisha Perkins, by name, may be regarded as the prince of charlatans. He ex- ploited the discoveries of Galvani and Volta, by em- ploying two pieces of metal known as "Metallic Tractors." The latter drawn over affected parts could cure practically everything by virtue of their magnetic influence. His patented discovery gained him wealth and fame. The "tractor cure," as it was called, led Dr. Haygarth, to fabricate a pair of false tractors by which marvelous magnetic cures were likewise effected. These tractors were made of every conceivable material but results were equally good, provided the operator during their application, dis- cussed magnetism and described squares, circles and triangles with the sham-tractors. In New York, at one time, yellow fever was preva- lent and Perkins, with faith in his tractors went there to cure the disease but succumbed to the fever which he contracted. Belief in the curative powers of the magnet was promulgated by Baron von Reichenbach. He claimed to have discovered a new force from magnets which he called odic or odylic force. The latter, like the magnetic flux, was invisible and its properties could only be determined by its effects. Despite the popu- larity of the odic force in the treatment of disease, 134 Magnetic Force it was shown that the effects were caused by the influence of the mind over the body. Though the patients claimed they could see faint luminous emanations issuing from the magnet, a piece of wood so prepared to resemble a magnet yielded like results. MODERN HISTORY. The concensus of opinion of modern investigators favors the view that, magnets are endowed with absolutely no power on the human organism and that, so-called magneto-therapy is merely a delusion. Some years ago, Thomas Edison, confined a boy's head inside a colossal electro-magnet thus permitting the magnetic flux to pass through his brain. Abso- lutely no effects were observed. Later, experiments were made with the flux passing through the body of a man. The flux was sufficiently powerful to hold rig- idly heavy iron-spikes against the breast and fore- head, yet no effects either for weal or woe were noted. As a result of elaborate experiments made by Peterson 12 and Kennelly, they concluded that, the human organism was in no wise appreciably affected by the most powerful magnets and that, neither direct nor reversed magnetism exerts any apparent in- fluence upon the iron contained in the blood, upon the circulation, upon the brain, nerves or upon ciliary or protoplasmic movements. Modern literature is quite prolific with the reports of cases cured by "magnetic wave-currents," and one physician, who reports many such cases, concludes, " results are so much more satisfying and convincing than a library of theories." To account for these results many ingenious theories are invoked. One supposes that the magnetic waves have a vibratory action upon cellular life. Another, compares the action of the waves to the exchange between the poles of a Galvanic current. 135 Progressive Spondylotherapy Another, is convinced that, by permitting the waves to act promiscuously along the spine, there is a not- able effect on metabolism. Wm. Harvey King, con- ducting a series of experiments with the waves on blood-pressure, noted an average increase of the latter of 16 mm. He found that, the treatment increased the out-put of urea and uric acid with a perceptible increase of indican. Investigations with these waves on the blood demonstrated an increase of hemoglobin, leucocytes and red blood-corpuscles. Unfortunately, the foregoing observations cannot be accepted as evidence of the action of magnetic waves insomuch as the sinusoidal current taken from the magnetic poles was also employed. A very pertinent fact however, illuminates these observations of King 13 . Referring to the treatment of constipation, he says, "I have been obliged at first to use the sinusoidal current as taken from this machine until there is established a more or less regular movement of the bowels. When this is accom- plished, the patient is again placed in the regular magnetic field, with a result of continued improve- ment so far as regularity of movement is concerned and in general improvement. ' ' The insignificance of the foregoing will become apparent by reading the subsequent chapter. Magnets are now used for removing foreign bodies (iron and steel) from the eye in a simple and efficient manner. The electro-magnet is equally efficient in diagnosis. Definite sensations of pain in the eye when the circuit of the electro-magnet is made or broken, suggests the presence of magnetic metal. The sideroscope, a magnetic needle suspended upon a silk thread, will also assist in the detection of foreign bodies in the eye. Sellheim 14 , after introduc- ing a soft-iron catheter inside the uterus studied the 136 Magnetic Force movements of the latter under the influence of a powerful magnet applied outside. The force was sufficient to straighten a retroflexed uterus. The alternate lifting and dropping of the uterus was utilized as a species of massage and by mobilizing the organ, adhesions from inflammations were prevented. 137 Progressive Spondy 1 o th er apy CHAPTER VIII. MAGNETIC FORCE BHYSICS. MAGNETK! POLES MAGNETIC FORCE MAGNETIC MATERIALS DIAMAGNETISM DEMAGNETIZATION THEORIES MAGNETIC FIELD MECHANICAL EFFECTS TERRESTRIAL MAGNETISM. Only relevant data concerning this subject will be briefly discussed. MAGNETIC POLES. The north pole of the magnet, is also called the positive or plus ( -f- ) pole and the south pole, is also known as the negative or minus ( ) pole. One of the fundamental laws is that : Like magnetic poles repel one another and unlike poles attract one another. This is similar to the law of attractions and repulsions of electric charges. The two poles are inseparable, *. e., a magnet with only one pole is impossible. MAGNETIC FORCE. Force is that which moves or tends to move matter. The force which a magnet attracts or repels another magnet or magnetic material is known as magnetic force. The force exerted between two magnetic poles is proportional to the product of their strengths and is inversely proportional to the square of the distance between them. MAGNETIC AND NON-MAGNETIC MATERIALS. Any substance in which magnetism may be induced and which is therefore attracted by a magnet is known as magnetic material. The following are recognized as magnetic: iron (the strongest known magnetic material), steel, nickel and cobalt. Salts of iron and 138 Physics of Magnetic Force other metals, porcelain, paper and oxygen are feebly attracted by a powerful magnet. Materials which are neutral as regards magnetism are referred to as non- magnetic. DIAMAGNETISM. Diamagnetic bodies refer to sub- stances (bismuth, antimony, phosphorus, copper) which are apparently repelled from the poles of a magnet. INDUCED MAGNETISM. If magnetism is communi- cated to a magnetic material without actual contact, the substance is said to be magnetized by induction. Induction takes place along certain directions known as lines of magnetic induction or lines of magnetic force. The latter act through a vacuum and air and through all materials excepting those in which mag- netism may be induced. Magnetism set up by an electric current is known as electromagnetism. DEMAGNETIZATION. If a magnet is struck by a series of blows or heated to a temperature about red heat, for unknown reasons, the greater part of its magnetism disappears. According to Bidwell, light falling upon a recently demagnetized iron produces an immediate revival of magnetism. COERCIVE FORCE. Some materials are more easily magnetized and demagnetized than others. In such instances it is assumed that, there is some force known as coercive force or retentivity, opposing magnetization and demagnetization. SATURATION. A magnet when fully magnetized is said to be saturated. When the latter has been attained, it grows weaker for a definite time and if left alone, the magnetism finally becomes permanent in strength. THEORY OF MAGNETISM. Magnetism is not a fluid. When a magnet magnetizes steel it loses none of its Progressive Spondylotherapy own magnetism. A fluid is incapable of propagating itself indefinitely without loss. The theory now ac- cepted is that, molecules of magnetic material are magnets by nature and when unmagnetized, the molecules are arranged in a haphazard manner so that they neutralize each other's external magnetic effects. If this material is now subjected to the in- fluence of magnetic force, the molecules become so arranged that their poles point in the same direction (Fig: 31). MAGNETIC FIELD. The space surrounding a magnet pervaded by the magnetic forces is known as the magnetic field and is most intense near the poles of the magnet. FIG. 31. Illustrating the theory of magnetism. In the upper figure the molecules owing to their disorderly arrangement have lost their mag- netism but when the molecules are arranged end to end, so that the N- seeking poles all point in one direction and the S-seeking poles in the other as in the lower figure, the molecules are magnetized. MECHANICAL EFFECTS OF MAGNETIZATION. When an iron bar is strongly magnetized it increases by 1 / 720000 of its length, and when the magnetizing force is stronger, it again contracts. The increment in length is due to the molecules setting themselves with their longest directions parallel to the length of the bar (Fig 31). Nickel contracts slightly when mag- netized. When a bar is magnetized or de-magnetized, a faint metallic click in the bar is heard. These observations prove that in magnetization there is a disturbance in the arrangement of the molecules. In what is known as the magnetization of HO Physics of Magnetic Force light, it has been found that a ray of polarized light passing through certain substances in a magnetic field has the direction of its vibrations changed. TERRESTRIAL MAGNETISM. The earth is a powerful magnet and has its magnetic poles. From the earth's north magnetic pole in the Southern Hemisphere, a huge stream of magnetic flux is constantly flowing through the atmosphere until it reaches the earth's south magnetic pole in the Northern Hemisphere. These magnetic streamings pass along paths of least resistance. The presence of magnetic oxides of iron and masses of iron or steel facilitates their passage. Thus, the flux-streams are concentrated around structural steel buildings and railroad tracks. . A compass needle so suspended as to be able to move either in a vertical or horizontal plane inclines or dips toward the earth. There is no dip on the earth's magnetic equator but it increases toward the poles. Directly over the latter, the angle of inclination is exactly 90. Iron bars set upright for a long time acquire mag- netism from the earth. The earth's magnetism varies from place to place on the surface of the earth and there are daily, annual, secular and irregular varia- tions, which are associated with modifying solar activity. Magnetic storms have been attributed to a number of unusual spots on the sun, volcanic eruptions and electric currents in the atmosphere. Many attempts have been made to explain the cause of the earth's magnetism. It has been attributed to the presence of large quantities of magnetized iron below the earth's surface, to induction from the sun (which Biot claimed is itself a powerful magnet), and to currents of electricity flowing .around the earth. The latter, the theory of Ampere, is the most suggestive. 141 Progressive Spondylotherapy CHAPTER IX. MAGNETIC FORCE PHYSIOLOGICAL PHYSICS ANIMAL TISSUES MAGNETISM AND VISCERAL TONE ACTION ON VOLUNTARY MUSCLES VISCERAL ATTRACTION AND REPUL- SIONVISCERAL DEMAGNETIZATION LOCAL DEMAGNETIZA- TION TRANSMISSION OF FORCE MISCELLANEOUS EFFECTS. It is the object of the author in this chapter to submit a few observations in a direction believed to be substantially new, and to present succintly in the subsequent chapter some conclusions based on these premises. The writer acknowledges the incomplete- ness of his observations which have only extended over a period of three months and he also admits that his limited knowledge of physics deters him from interpreting more fully the observed phenomena. Hypotheses have been eliminated and only facts are presented. When Kirchoff, thrust between the image of the sun from the heliostat and the tinted band of his spectroscope, a flame of sodium vapor, and instead of the expected brightening, saw the band darkened, he left his laboratory hastily with the words, "That seems to me a fundamental fact." If certain fundamental facts have been established by the author he anticipates their elaboration by physicists, psychologists and others more competent than himself. Some of the author's observations would have been impossible of attainment, if it were not for the fact that the reflexes of the organs (page 120) can now be recognized objectively. 142 Physiological Physics Considering the discredit cast on the therapeutic employment of the magnetic force, all consideration of this subject will be evaded, so that the reader is constrained to formulate his own conclusions. My investigations were made with feeble and powerful magnets (Fig. 32). Animal tissues. Any material in which magnetism may be induced and which is therefore attracted by a magnet is magnetic material. FIG. 32. Giant and smaller electromagnet. The giant magnet has a lifting power of approximately 400 pounds to the square inch. The smaller electromagnet has a little over one-fourth the strength of the giant mag- net. If any of the human tissues are suspended on a light silk thread near a magnet, the latter will attract one pole of the tissue and repel the other. The north pole of the magnet repels the north pole of the tissue and attracts its south pole. The foregoing effect varies with the tissues em- ployed and is best exhibited by nerves, whereas the least effect is noted with the spinal cord. The same magnetic attraction is exhibited by the membranous coverings of the nervous system, 143 Progressive Spondylo therapy organs and muscles. It has always been contended that these membranes act as electric insulators to retain the normal quantity of electricity in the fore- going structures. One knows that, magnetism induced in a bar of iron may induce magnetism in another piece so that a magnet may be made to support a number of nails end to end, each of which has become a magnet by induction. The foregoing effect may also be observed with the tissues. An ordinary bar or horse-shoe magnet will also at- tract the tissue although the force thus exhibited is very feeble in comparison with an electromagnet. The iron-content of the tissues has without doubt some effect on the results yet, the liver and spleen which in the norm show a high content of iron exhibit a feebler power of attraction than the nerves. Even after the tissue has been immersed In a solution to dissolve any iron which may be present, the tissue is attracted to the magnet although less readily than before. Here one must assume some change in the molecular arrangement of the tissue. Fresh tissues do not show the foregoing properties of attraction or repulsion. The tissue must first be allowed to dessicate naturally. If the tissues are artificially dessicated the results are compromised. The tissue must be deprived of blood. The latter although containing iron is diamagnetic. Experimenting largely with nerves, the' results were never uniform. This may have been caused by varying degrees of dessication or for other reas- ons which I do not know. Thus, as this manuscript is about to go to press, I repeated my earlier ex- periments with negative results. Unfortunately, time will not permit me to determine the cause for this discrepancy. Severed nerves in chloroformed animals prox- 144 Physiological Physics imally connected with the spinal cord, exhibited less magnetic attraction than nerves removed from the body and suspended by a thread. The reason for this is noted on page 159. About the year 1819, Oersted, in investigating the relation existing between magnetism and electricity found that, when an electric current flows through a conductor, a magnetic flux is created which makes the conductor a magnet. The conductor loses its niag- netic properties as soon as the current ceases to flow. The nature of the material through which the current flows is of no importance. In my investigations using various organs and tissues as conductors, a decided difference was noted in the deflection of the needle. The close resemblance between electricity and mag- netism was further emphasized by the discovery of Faraday, in 1831. The latter found that, whenever lines of magnetic flux are caused to cut or pass through conductors so connected as to form closed circuits, currents of electricity are generated. ACTION OF MAGNETISM ON VISCERAL TONE. On pages 62 and 124 reference was made respecting what is understood by tone of the organs. Perhaps the most conspicuous physiologic manifestation exhibited by the forces is that of increasing vital tone. In this respect, the magnetic force is insuperable. On page 121, the reflexes of the organs were like- wise discussed. It was noted that different stimuli applied to definite regions of the spinal cord would cause either a contraction or dilatation of various organs. The stomach was employed as a vehicle for the exhibition of such effects. When the stomach-tone is employed as a test for the action of the forces, a moderately thin subject must be selected and the. entire abdomen must yield a tympanitic tone on pe.r- 145 Progressive Spondylotherapy cussion. A normal subject must likewise be selected otherwise the results will be modified. Percussion must be executed during the time the. patient stands. No results can be expected in any other posture. Now, in the application of the stimulus to the region of the 7th cervical vertebra, two effects could be elicited: increased tone of the stomach or the latter plus contraction of the organ. FIG. 33. Illustrating the area 9f the stomach by percussion before (continuous line) and after concussion of the 7th cervical spine (broken line). The reduction in area is known as the stomach reflex, of con- traction. The former effect was ascertained by dullness on percussion (page 123) and the latter, by dullness plus recession of the lower border of the stomach. Heat, light, radium, X-rays and magnetism, when permitted to act in the region of the 7th cervical 146 Physiological Physics spine produced a dullness corresponding to the stomach approximating the anterior abdominal wall. With all the forces excepting magnetism, this dull- ness was of brief duration and was soon succeeded by the normal tympanitic tone on percussion. If the stimulus employed was concussion by aid of an electric hammer striking a series of rapid blows vary- ing in strength from 6 to 12 pounds, in association with dullness of the stomach the organ became contracted (Fig. 33). The latter, known as the stomach reflex of contrac- tion, remains contracted for about 15 minutes after which time it gradually resumes its former position. The longest duration of the latter reflex noted by concussion was 20 minutes. It is evident that the duration and the amplitude of the reflex are determined by the vigor of the muscular fibers of the stomach. When the magnetic flux is permitted to act on the region of the 7th cervical vertebra, unlike the other forces which are transitory in action, it will produce a dullness of the stomach lasting for many hours without causing the stomach to recede. All forces show this action (of temporary dura- tion), on the tone of the stomach applied at the spinal region mentioned or at a distance from the subject but the magnetic force will exhibit such action lasting for hours and at a greater distance. Thus, with the small electro-magnet (Fig. 32), this dullness of the stomach can be elicited at a distance of 30 feet and with the large magnet (Fig. 32), at a distance greater than 60 feet. In both instances the dullness per- sisted for a variable period of time after the magnetic flux has ceased to flow. If a patient enters a room in which the magnetic flux has been allowed to flow for several minutes, a 147 Progressive Spondylotherapy stomach previously showing a tympanitic tone on percussion; will yield a dull sound within 20 seconds. The latter dullness is of considerable duration. One of the most important observations concerns the con- veyance of the magnetic force by an individual. If an individual exposes himself for about one minute to the flux of a giant magnet and then enters another room (time should not exceed 30 seconds), and stands alongside an individual with exposed abdomen, per- cussion will demonstrate in the latter a dullness of the stomach. This dullness will last for several min- utes. FIG. 34. Apparatus for recording wireless messages with the leg of a frog; A, nerve; B, muscle. The attached tracing represents a record. No dullness ensues until the individual exposed to the flux is alongside of the person examined. It is evident therefore that the action is one of propinquity and not due to the influence of the flux at a distance. The augmented tone of the musculature of the stom- ach may be. accepted as a delicate physiologic test for the presence of the magnetic force. In other words it can be used as a magnetometer. 148 Physiological Physics A frog is used as a delicate physiologic test for strychnin and the same animal is used for detect- ing adrenalin which dilates the frog's pupil. An- other delicate test for adrenalin is the increased tone produced in the stomach-musculature of the frog whereas in mammals, the effect is to relax the muscle. Fig. 34, shows a frog's-leg receiver recently employed by a French physiologist for recording wireless messages. The sciatic nerve of the leg is __ connected into the microphone^circuit of the receiver. One end of the leg is fixed to a base and the other end connected with a pivoted lever which records on a drum revolved by clock-work, the con- tractions of the muscles caused by the electrical impulses. If the region of the 7th cervical vertebra is first concussed and then the body (in proximity to the magnet) is exposed to the magnetic flux, the stomach will remain contracted for hours. In other words, the magnetic force will fix the organ in the position in which it has been placed by concussion. One may employ the same maneuver in fixing the heart, aorta, liver and other organs either in a state of contraction or dilatation. These effects may be pro- longed by color (page 130). The best results however, are attained by allowing the magnetic flux to act for several minutes at the regions of the spine where the reflexes are elicited by concussion. The researches of the author show that the organs may be made to contract or dilate by irri- tating the skin over the organ. The reflexes thus evoked explain our empirical methods of treatment by liniments, poultices, water and a host of physical remedies. The skin reflexes are infiinitesimal in amplitude and duration when compared with the reflexes evoked from the spinal region which last for hours. The skin reflexes may, however, be fixed for a greater duration of time if the magnetic flux is al- lowed to flow during their elicitation. 149 Progressive Spondylotherapy Thus, the heart reflex of contraction by scratch- ing the skin over the heart (allowing the magnetic flux to act only during the scratching process) will last 5 minutes compared with a duration of 20 sec- onds before the flux is allowed to flow. All the skin reflexes after the patient has been exposed to the flux are greater in amplitude and duration. One may formulate the following constant: The duration and amplitude of a visceral reflex is in direction proportion to the intensity of the magnetic flux and its proximity to the spinal region governing a given reflex. FIG. 35. Tracings of the pulse; A, before the tip of the electromag- net is placed at the 7th cervical spine; B, during the time the flux is first allowed to flow and C, about 30 seconds thereafter. The effect of the flux on the heart is easily ascer- tained by palpation of the pulse before and during the action of the flux. With the patient in juxtapo- sition to a large electro-magnet, the pulse becomes feeble and is inhibited or nearly so. These effects are accentuated when the magnetic force is allowed to act directly on the region of the 7th cervical vertebra. (Fig. 35). It is indeed strange how little of the magnetic flux is necessary to increase the tone of the organs. An or- dinary bar or horse-shoe magnet impinging on the stomach, heart or any of the organs will at once (by increasing the tone of the organs), bring out an area of increased dullness. The organs are ordinarily in a varying state of tonicity. The tone of the organ may be normal (orthotonic), increased (hypertonic), diminished (hypotonic) or absent (atonic). 150 Physiologi c a 1 Physics A relaxed organ will yield a smaller area of dullness than an organ which is in a state of tone. To accurately reproduce the area occupied by an organ, it must be put in a condition of augmented tone, otherwise percussion will yield untrustworthy results. FIG. 36. Illustrating the employment of an ordinary horseshoe mag- net for outlining the boundaries of the heart and liver. The broken lines show the boundaries before, and the continuous lines, after the use of the magnet held by the patient in the center of the organ. The stomach in the norm cannot be defined by percussion owing to the tympanitic quality of its sound. In this illustration, the magnet placed in the stomach region caused a dullness of the organ thus permitting its delimitation. In Fig. 36, the organs are percussed before and after an ordinary magnet is held by the patient in the region of the organs. 151 Progressive Spondylotherapy In Fig. 37, the aorta, heart, liver and spleen are percussed before and after the flux of an electro- magnet is allowed to flow. In the latter instance, the patient stands in juxtaposition but not in con- tact with the magnet. FIG. 37 Percussion of the heart and liver before (broken lines) and after (continuous lines) the subject is in proximity to a giant magnet. The outline of the stomach was determined during the flow of the mag- netic flux. In a subject with a responsive stomach-muscle, one may increase the tone of the stomach (as shown by dullness on percussion) at a distance of over 80 feet. The foregoing stomach-reaction represents the basis of most of my investigations. The stomach cannot be defined by our usual methods of percussion. The tympanitic tone of the 152 Physiological Physics organ cannot be accurately differentiated from the tympanitic tone of the intestines. It must be ob- served that the tympanitic tone of the intestines is partially changed to dullness by the magnetic flux (owing to the tone imparted to them), but the dullness is not as pronounced as that of the stomach hence the possibility of differentiation by percussion. It has been shown (page 123) that, by artificial stimulation of the vagus, one may, by increasing the tone of the stomach, cause the latter to yield to a dull- ness on percussion. If, however, one injects 1/60 grain of atropin (which paralyzes the motor endings of the vagus), artificial stimulation of the vagus after the manner cited is incapable of increasing the tone of the stomach. In other words, one cannot elicit the stomach reflex. If, after atropin is injected and the patient's body is in proximity to a powerful electro- magnet, the tone of the stomach is nevertheless re- stored as evidenced by the dullness on percussion. The foregoing is noted with reference to all the or- gans supplied by the vagus and is surprising consid- ering the fact that the magnetic force can restore tone quite independent of nerve-force. This statement demands modification as shown on page 164. If an individual is in an electromagnetic field be- tween like poles of two electromagnets no dullness of the stomach can be elicited and the same effect is man- ifest if the poles are unlike (Fig. 38). If the dullness of the stomach is evoked by expos- ure to the streamings of either the north or south pole of a magnet, it can be made to disappear at once by exposure to the pole opposite to that which first caus- ed the dullness. The foregoing is in accordance with one of the laws of magnetic force, the poles of opposite name neutral- ize one another. 153 Progressive Spondylotherapy Exposure of the subject to two like poles of a mag- net multiplies the intensity of the dullness; the streamings being concentrated anteriorly on the stomach-region. FIG. 38. Illustrating the forces producing attraction between unlike poles and repulsion between like poles. The interposition of the body in both instances yields negative results owing to neutralization of unlike poles and the repulsion of like poles. It has been observed that whereas the magnetic force increases the tone of the organs it neither con- tracts nor dilates them. In my earlier investigations errors of interpreta- tion ensued with reference to the foregoing. Thus, when the magnetic force was allowed to act for several minutes in the region of the 7th cervical spine, prolapsed stomachs were hauled up a consider- able distance. In all such instances, I was dealing with relaxed (hypotonic or atonic viscera) organs. In the norm, however, such effects are not observed ; the 154 Physiological Physics tone of the organ is augmented but there is no change in its position. An important fact in the use of the magnetic force is that there is no danger of exhausting the tone of the organs nor in fixing a reflex from excessive stimula- tion and furthermore, in increasing the tone and in fixing a reflex, a seance, need not exceed five minutes. Physicists have demonstrated the fact that, under constant magnetizing force the magnetism will go on slowly and slightly increasing for a long time, a phe- nomenon called magnetic creeping. ACTION ON VOLUNTARY MUSCLES. In considering the action of the magnetic flux on the organs, we were dealing with visceral muscle (pages 7 and 147). It is not easy to gauge the action of magnetic force on vol- untary muscles insomuch as it is difficult to exclude expectant attention and the personal equation. How- ever certain phenomena are quite evident. The magnetic force is in no sense an excitant but a tone-producing force. Making and breaking the cur- rent of an electromagnet is without any effect and im- parts no tone to the organs. With the patient ap- proximating a giant magnet, fully 10 seconds elapse before the tympanitic sound of the stomach is con- verted into dullness. The magnetic force permitted to act on voluntary muscles gives absolutely no evidence of its action de- spite the fact that augmented tone is imparted to them just as it is to visceral muscle. If, one percusses any voluntary muscle during the time the percussed part is adjacent to the source of the magnetic flux, the muscle bulges and in suscept- ible subjects a spasmodic contraction ensues which may persist even after the flux ceases to flow. The biceps (arm) is a suitable muscle for such ex- 155 Progressive Spondylotherapy perimentation. The same phenomena may be observ- ed in the exposed muscles of a vivisected animal. If a relaxed scrotum is exposed to the flux there is no retraction of the testes but, if during the tune of the exposure, the cremasteric reflex is elicited several times, the scrotum shrinks quite perceptibly. The use of electricity is more exact. One may note that, the reaction of the muscles is ac- centuated when the electricity is applied during the time the part is in proximity to an electromagnet. The augmented reaction is quite evident and per- sists after the magnetic force is discontinued. The foregoing results are only noted after the parts have been exposed to the magnetism for about one minute. The augmented reaction depends on which pole of the magnet is directed toward the part acted upon by the electricity and which pole of the latter is used. If the muscle is first demagnetized (page 161), the intensity of the muscle-reaction becomes less evident. VISCERAL ATTRACTION AND REPULSION. If one first determines the lower border of the liver by percus- sion, and fixes at a definite point below the site of dullness, the tip of a giant electromagnet and again determines the lower liver-border, the latter will be found to descend one or more centimeters during the time of the flow of the magnetic flux. The moment the flow of the latter ceases, the liver-border regains its former position. The following facts were determined : 1. The tip of the magnet placed below the stomach, spleen and kidneys will elicit the same phenomenon during the flow of the flux. 2. Placing the tip above the anatomic site of the 156 Physiological Physics abdominal organs cited, the organs rise only during the flow of the flux. 3. If the liver (and the same applies to the other abdominal organs), is first charged (for about one minute) with the north pole of the electromagnet and the tip of the latter pole is placed below the liver- border, instead of a decent of the latter, it rises. In other words, it is repelled. 4. If the liver is first charged from the south pole, the degree of its descent with the north pole is greater than when it is not charged at all. i 5. If any of the spinous processes are concussed (excepting the 7th cervical spine), for one or more minutes, it is impossible to cause any descent of the liver, stomach or spleen. It is known that jarring or a few sharp strokes of a hammer may cause the great- er part of the magnetism to disappear in a magnet. If one however, concusses the 7th cervical spine which stimulates the vagus and causes the liver, spleen and stomach to contract (reflexes of contrac- tion), the mechanic agitation is counterbalanced by the stimulating impulses conveyed to the organs in question. If the region between the 3rd and 4th dorsal spines is concussed and the tip of the magnet is placed at a fixed point below the liver, the latter is repelled. Con- cussion of this region stimulates the sympathetic nerves (at the expense of the pneumogastric nerves), and has a conspicuous action in reducing the nerve- tone of the organs (page 162). The heart has an important influence on the posi- tion of the abdominal organs as one can readily deter- mine (selecting the liver for demonstration) by per- cussion. This influence is modified according to 157 Progressive Spondylotherapy whether the heart-region is positively (N-pole) or negatively charged (S-pole). 6. If the tip of the magnet is placed at a fixed point below the spleen, the descent of the latter is greater at its anterior extremity than in the center of the organ. Regarding the spleen (like other organs) as a mag- netic structure, its greatest attractive force would be at its anterior and posterior ends. In attempting to control by the X-rays the results obtained on the organs by percussion, I found it was often impossible. It was found that the X-rays in a powerful magnetic field were deflect- ed from the target of the tube first in one and then in the other direction according to whether the north or south pole of the electro-magnet was pre- sented toward the tube (Fig. 39). These effects were only observed after the tube had reached a certain degree of hardness. The original theory of Stokes, that the Roentgen rays consisted of sets of ether-ripples was generally accepted despite the fact that there was no evi- dence of refraction, reflection or diffraction. Fail- ure of the most powerful magnetic fields to create deviation favored the etheric rather than a corpus- cular theory. More recent investigations of Bragg 15 , seem to prove that the X-rays are of two kinds ; reflecting and non-reflecting rays. Electro-optical phenomena are many. Fara- day, discovered that a wave of light polarised in a certain plane can be twisted round by the action of a magnet so that the vibrations are executed in a different plane. In 1877, Kerr, showed that a ray of polarized light is likewise rotated when reflected at the surface of a magnet. Kundt, demonstrated that the plane of polariza- tion of light-waves is also rotated if the light traverses an almost transparent film of iron placed transversely in a magnet field. Attempts to prove visceral attraction and repulsion in animal-experiments were negative. Further inves- 158 Physiological Physics tigations demonstrated the reason for the latter. In the human, a few whiffs of chloroform or ether even when mixed with oil of orange (page 82), destroys at once any downward pull of the viscera by the mag- netic force. If a solution of cocain is used in the nose, the organ (e. g., liver) instead of being pulled down- FIG. 39. Illustrating deflection of X-rays in a powerful magnetic field The upper tube shows the rays before the flux is permitted to flow. This illustration inadequately exhibits the pronounced deflection asso- ciated with a tube of a definite degree of hardness. ward is actually repelled. Fright or fear likewise de- stroys the downward pull on the organ. The emotions increase the adrenalin in the blood which annihilates the tone of the organs (page 8). Experiments with the exsected stomach were equal- ly negative in accordance with the well-known physio- logic observation that, smooth muscle cut out of the body passes at once into a state of tonic contraction lasting for hours. 159 Progressive Spondylotherapy The physiologist who discredits observations made without the domain of his laboratory seems to 'forget that disease is practically an experiment of nature under abnormal conditions. All physiologic experiments made in the laboratory are equally con- ducted under adverse conditions. FIG. 40. Helix and coil of wire (indicated by arrow) for demag- netization. VISCERAL DEMAGNETIZATION. Demagnetization is effected by magnetizing in opposite directions and, by decreasing the intensity of the current, the magnet- ism is gradually reduced to zero. In other words, to demagnetize an object, one subjects it to a series of cycles of diminishing intensity. With the alternating current, a rheostat is the only adjunct necessary for demagnetization. If only the constant current is at command, one 160 Physiological Physics may use a transformer or a cheaper substitute con- sisting of a double-throw pole-switch arrangement and gradually reduce the current by means of a water-rheostat. To demagnetize the body, the author employs a un- iversal and a local method. In the universal method, a demagnetizing coil is used consisting of a helix 6 feet in length and of sufficient diameter to enclose an individual. It consists of 188 turns of bare copper wire wound on a wooden frame (Fig. 40). In the local method, a coil of wire is wound around a piece of soft iron (Fig. 40). If an individual enters the helix and demagnetiza- tion is executed for several minutes, it is impossible to percuss the stomach even though the vagus is stim- ulated artificially. This action may persist for hours. The abdominal organs (liver, spleen, stomach), lie lower and it is impossible to elicit visceral attraction and repulsion (page 156). LOCAL DEMAGNETIZATION. It has been shown that the organs are dominated by two sets of nerve-fibers which are opposite in action and which for conveni- ence may be grouped as vagus and sympathetic-fibers. The vagus-fibers maintain the organs in a state of contraction whereas the sympathetic-fibers strive to keep them in a state of dilatation. When both sets of fibers are in a state of physiologic tone the organs are neither contracted nor dilated but in a condition of equipoise. If we stimulate the vagus-fibers at the 7th cervical spine, we contract the heart, aorta, stomach, li ver and spleen. If one stimulates the sympatheic-fibers at a point between the 3rd and 4th dorsal spines, there is a dila- tation of the foregoing structures. 161 Progressive Spondylotherapy By the foregoing maneuver, we have imparted tone to the vagus or sympathetic fibers. The magnetic force is the equivalent of tone (page 124) insomuch as by its use a like effect is attained. Demagnetization corresponds to the removal of tone. If one applies the extremity of the iron rod (Fig. 40) to the 7th cervical spine and executes de- magnetization for several minutes, the tone of the or- gans supplied by the vagus-fibers is annihilated and the action of the sympathetic-fibers on the organs be- comes dominant. In consequence of the foregoing, percussion will show: 1. Dilatation of the heart and aorta ; 2. Enlargement of the stomach, liver and spleen ; 3. Dilatation of the intra-abdominal veins. If one removes the tone of the stomach by de- magnetization, how can one demonstrate enlarge- ment of the organ by percussion? The magnetic force neither contracts nor enlarges an organ but merely fixes it in a definite position. After demag- netization of the vagus, the flux is directed toward the region of the stomach until it acquires sufficient tone to yield a dullness on percussion. After this manner, dilatation and descent of the organ may be demonstrated. The abstraction of tone from the vagus is easily demonstrated. First of all, one must know that, if pressure is made in the region of the 7th cervical spine the pulse can no longer be felt if a certain degree of pressure is exe- cuted. The greater the tone of the vagus, the more pressure is necessary to stop the pulse. If, in a given case, 10 kilograms of pressure are necessary to arrest the pulse at the wrist by means of 162 Physiological Physics my spondylopressor (Fig. 1), after demagnetizing the vagus at the 7th cervical spine, the pulse will be inhibited with a pressure of 3 or 4 kilograms. FIG. 41. Illustrating the area of stomach-dullness incident to the in- gestion of water. With the ingestion of 9 ounces of water, this dullness continues for about one minute but it persists if the tone of the organ is removed by demagnetization of the vagus. Another simple method is to ingest 9 ounces of wat- er. In the norm, this produces a dullness (Fig. 41) not exceeding one minute. If, during the time the water is ingested and demagnetization is executed at the 7th cervical vertebra, the dullness will persist dur- ing demagnetization and for some time thereafter until the vagus which controls the output of water from the stomach has again acquired tone. The lat- ter may be acquired at once by exposing the subject to the magnetic force. 163 Progressive Spondylotherapy If one desires to remove the tone of the sympathet- ic fibers, the rod of the instrument (Fig. 40) is fixed between the 3rd and 4th dorsal spines and the effects noted are : 1. Contraction of the heart and aorta ; 2. Contraction of the liver, stomach and spleen ; 3. Contraction of the intra-abdominal vessels. In the latter maneuver, the vagus-fibers become predominant. After the tone has been abstracted from the vagus or sympathetic fibers it may be restored at once by charging the former with the magnetic flux at the 7th cervical spine and the latter, between the 3rd and 4th dorsal spines. It has already been shown (page 156) that, there is such a condition which I have referred to as visceral attraction and repulsion. If one demagnetizes the spleen or liver by applying the rod of the apparatus (Fig. 40) over either organ, neither visceral attraction nor repulsion is possible. In demagnetizing the liver after the foregoing man- ner, the organ drops lower but does not enlarge. When demagnetization is attempted over the heart- region, there is a drop of all the abdominal organs including the kidneys. TRANSMISSION OF FORCE.* When one strikes a series of blows corresponding to the 7th cervical spine, the vagus is stimulated (page 123). Physiologists have always contented themselves with the general statement that, if a nerve or muscle is irritated a stimulation ensues. My observations show that, stimulation is equiva- lent to the discharge of force. The latter statement can be readily demonstrated. Energy, vide preface and page 115. 164 Physiological Physics If during the time the 7th cervical spine of one sub- ject is struck a series of blows with a rubber-hammer, and the stomach-region in another subject standing in juxtaposition to the first subject is percussed, a dullness can be demonstrated. This dullness is of lim- ited duration (about 30 seconds), but can be made to reappear by repetition of the blows. It will also be found that, the increased tone produced by the trans- mitted force increases the tone in all the organs sup- plied by the vagus hence, delimitation of the latter by percussion will be facilitated (page 184). Such increase in the tone is of limited duration (30 seconds) hence the execution of percussion must not be delayed. Concussion of other vertebrae is negative insomuch as the effect is tantamount to demagnetization (page 160). Force may be shown to be transmitted in the following ways : 1. By contracting the muscles of one arm in jux- taposition to the stomach-region. When the two arms are forcibly flexed, no dullness of the stomach ensues. It is necessary to determine the reason for the latter, as it will explain a host of phenomena. Physiologists have established the following facts : a. Electrical currents appear in the body when a muscle or nerve is active and such currents are inti- mately associated with the functional condition of the tissue. b. These action-currents correspond to the gen- eral law that, every active portion of nerve or muscle maintains a negative relation toward the resting part. In other words, the active muscle and nerve show a negative electrical reaction toward the resting muscle and nerve. c. The action-currents of muscle and nerve are sufficiently strong to have a stimulating action of their own. 165 Progressive Spondylotherapy It is assumed by the author that, the force gener- ated say in the one arm is negative and in the resting stomach-muscle it is positive the result being contrac- tion of the stomach-musculature.- When the muscles of both arms are synchronously contracted a number of times, there is a discharge of two negative forces which neutralize one another with negative effects on the stomach-muscle. If two north or two south poles of two magnets are directed in the region of the stomach, no dullness of the stomach is elicited. The foregoing will explain subsequent phenomena. 2. If the muscles of one arm of the subject (in proximity to his stomach-region) are brought to con- traction by an electric current, a dullness of the stom- ach ensues but if the muscles of both arms are simul- taneously contracted, there is no dullness. Using one person as a subject and contracting the muscles of another subject (while the arms are in proximity to the stomach-region of the first subject), like effects may be noted. Striking the arm-muscles is negative in its results. 3. If any part of one subject is brought in prox- imity to the stomach-region of another subject no dullness ensues except when the heart-region is brought into such relation. The contact must be im- mediate. If, however, the activity of the heart is augmented by inhalation of amyl nitrite, the effect is noted at a distance of several inches. 4. Stimulation of the muscles of a dead frog (the muscles still responding to electricity), will produce the effects noted when stimulating living muscles. 5. If the beating heart of a frog is removed from the latter, and placed on glass or a board and brought in immediate contact with the stomach-region of a subject, dullness of the stomach is at once elicited. 166 Physiological Physics Thus, with an exposure of one-half minute of the beating heart to the stomach-region, the dullness of the stomach will persist for one-half minute. F FIG. 42. Apparatus for recording stomach-contractions incident to the action of transmitted energy. It consists of a stomach-tube to one end of which a rubber-balloon is fixed and to the other end a pump for inflating the balloon in the stomach. The pump and stomach-tube are connected with a piece of V-glass tubing. The stomach-contractions are transmitted to a tambour, the lever of which makes the record on a re-' volving cylinder. 6. If, say a leg-muscle of a frog is removed and then divided by bringing the cut surface into contact with the longitudinal surface of the muscle a number of times in proximity to the stomach-region of a subject, dullness of the stomach is at once elicited. The force thus propagated is analogous to the electric currents from muscles. 367 Progressive Spondylotherapy 7. The same phenomenon is exhibited by metal (page 179) and plants. Thus, if the stomach-region is brought in almost immediate contact with a growing palm, dullness of the stomach ensues. If, a leaf from a living palm is severed or, if the transverse cut surface is brought in contact with the longitudinal surface of the leaf a number of times (in proximity to the stomach), the same phenomenon of dullness is ex- hibited as when a muscle removed from an animal is similarly manipulated. The effect cited by the maneuver with the leaf of the palm may be elicited at a distance of 5 feet from the patient and the force passes through a sheet of metal held in front of the stomach. The transmission of psychic force is discussed on page 188. With the apparatus shown in Fig. 42, an attempt was made to make a record of the stomach-contrac- tions with the results shown in Fig. 43. The effects of emotions on the stomach-muscula- ture are shown in Fig. 44. The use of the apparatus for making these records is no more difficult of execution than making records of the pulse. MISCELLANEOUS EFFECTS. It is difficult in the ab- sence of a reflexometer to accurately guage the action of magnetization and demagnetization on the reflexes. The following effects are however apparent : 1. If the motor area of the brain on the right side is demagnetized, there is an apparent increase of the reflexes on the opposite side. 2. If the same area is magnetized, the reflexes on the opposite side become less evident. Temperature. If the temperature of the body is 168 Physiological Physics below normal, exposure of the individual to the mag- netic flux raises the temperature one degree or to the normal. FIG. 43. Tracings of the stomach with the apparatus shown in fig-. 42. A, normal curves dependent on respiratory excursions; B, normal curves due to transmitted pulsations of the aorta; C, curves caused by con- cussion of the 7th cervical spine; D, curves caused by contraction of the stomach due to making and breaking of the current leading to an electro- magnet in proximity to the subject; E, curves caused by transmitted energy from one subject (by concussing the 7th cervical spine) to an- other subject; F, curves due to transmitted psychic energy from one sub- ject to another subject. During the making of records C, D, E, and F, breathing of the subject from whom the records were taken was tempor- arily suspended. The records of transmitted energy were made during the time one subject was in proximity but not in contact with the other subject. To express this matter in terms of greater pre- cision one instance may be cited. An individual with tuberculous kidneys shows a temperature of 169 Progressive Spo ndy 1 o th er apy 96.2 F. He is then placed within 3 inches (without contact) of a powerful electromagnet (Fig. 32) for a period of 3 minutes. At the end of the latter time, the thermometer registers 98.6 F. No influence is noted on temperature if the latter is normal. * FIG. 44. Physiological manifestations of the emotions as exhibited by contractions of the stomach; A, joy; B, fear; C, great agitation. These tracings were taken from different subjects in whom these emotions were expressed by aid of the apparatus shown in fig. 42. Practically iden- tical records were made in other subjects under like emotional conditions. In my investigations it has been noted that, electrolysis is accentuated by the magnetic flux. This may easily be demonstrated by aid of a solu- tion of potassium iodid. The brown coloration (due to the liberation of the iodin) is more intense with than without the magnetic flux. Microbiology. Notwithstanding a number of investigations, no microbicidal action of the mag- netic force could be demonstrated. The results on photographic plates were likewise negative. Attempts were made to determine whether diges- tion was facilitated by the magnetic force and re- tarded by demagnetization but I dare not venture to 170 Physiological Physics cite my results for the reason that they were not conducted over a sufficient period of time to just- ify any formulated conclusions. Demonstration of stomach-border. If what is known as a triple O capsule is filled with ferrum re- ductum (reduced iron), and well covered with wax (to prevent its solution by the gastric juice), is swal- lowed, its location may be determined by a powerful electromagnet. With the patient standing, the tip of the magnet is placed in immediate contact with the skin of the abdomen approximating the supposed po- sition of the lower border of the organ. In the average subject (without an excess of ab- dominal fat), when the current of the magnet is on, the capsule may be seen (and felt) to approach the tip of the magnet but disappears with every break of the current. The best effects are noted with make and break of the current. The capsule is best located outside of the rectus muscle. The impact of the capsule can be localized by the patient. Making and breaking the current during the time the tip of the magnet is moved about the region of the stomach is another method of localization. Another method is to have the patient swallow a soft perforated iron-capsule about the size of the end of an average stomach-tube and connect it with rubber-tubing of small caliber. The capsule is better attracted if it has been previously magnetized by the pole opposite to that which is used for at- traction. To facilitate the localization of the capsule, a special method of percussion is employed. The finger is placed not on but just above the skin and then struck with the other finger. A peculiar flopping sound is heard in the region of the capsule. By placing the tip of tbe magnet in the region of Progressive Spondylotherapy ^3 the duodenum during the time pressure is made at the 5th dorsal spine (page 85), the capsule can be drawn into the duodenum. To show that it is in the latter situation, have the patient drink some colored water. If the capsule is in the duodenum, a glass syringe attached to the rubber-tube will as- pirate a fluid differing in color from the ingested water. 1Y2 Deduction CHAPTER X. DEDUCTIONS. HYPOTHESES THE REFLEX NATURE OF MAN TONICITT ANI- MAL FORCE LIFE PROLONGATION AND REINFORCEMENT OF REFLEXES TOPOGRAPHIC PERCUSSION VISCERAL ATTRAC- TION AND REPULSION NEUROSES SPLANCHNOPTOSIS PSYCHIC FORCE COLOR POPULAR QUESTIONS SUMMARY. Hypotheses are essential in formulating conclu- sions based on all knowledge concerning scientific in- vestigations. Prior to the promulgation of the Newtonian hypo- thesis of gravitation and the laws of Kepler, astron- omy was in a hopeless state of chaos. The atomic theory in chemistry is incapable of demonstration yet, as a working hypothesis, it has created a revolution in this science. The fact that an hypothesis is only demonstrable by its results in no wise compromises its value. Hudson, observes, "That most that can be said of any scientific hypothesis is that, whether true in the abstract or not, everything happens just as though it were true. When this test of universality is ap- plied, when no known fact remains that is unex- plained by it, the world is justified in assuming it to be true, and in deducing from it even the most mo- mentous conclusions." The author is fully alive to the apothegm, a single antagonistic fact militates against the value of the most ingenious theory ever evolved. A careful study of the subject-matter of the pre- ceding chapter directs attention to the pertinent fact that, the phenomena cited suggest the close identity of so-called animal-force with the various forms of force. 173 Progressive Spondylotherapy Everything tends to show the identity of the vari- ous forms of force, notably, the conservation of en- ergy, the advances in the study of radioactivity, the kinetic theory of gases and the transmutation of elec- tricity into heat, light, motion or chemical energy. Selenium changes the electrical resistence under the influence of light. In its crystaline condition, its sensitivity to light is increased especially to green- ish-yelloiv rays. This property of selenium has led to the construction of the photophone. The proof adduced by the author concerns chiefly the phenomena incident to the elicitation of the vis- ceral reflexes and the tonicity of the organs, notably the stomach. In accepting the reflexes as demonstrative evidence one interrogation seems apposite: Are the visceral reflexes acknowledged phenomena? For many years, physiologists have been able to contract and dilate organs in vivisected animals by stimulating definite nerves of the spinal cord. What the physiologist has done in the laboratory has been successfully attained by the author in the living hu- man. In 1898 16 , the writer first demonstrated by aid of the X-rays what are now known in the literature as the " heart reflexes of Abrams." The latter signify contraction or dilatation of the heart incident to stim- ulation of definite regions of the spinal cord. After this, a large number of his eponymic reflexes were discovered and his observations have been con- firmed by some of the leading clinicians of the world. Man is essentially a reflex animal (page 5). The phenomena of vegetative life, respiration, circulation, nutrition, etc., are produced in the subconscious state, and without voluntary effort. Consciousness is not 174 Deductions co-extensive with mind and the work of mentality can be accomplished without consciousness, just as the machinery of a clock might work without a dial. Man portrays his automicity in his reflexes and the latter are controlled by a force over which he can ex- ercise no conscious control. The dead birds found about light-houses are drawn by the glare to strike against the heavy panes. The moth flies straight for a flame and if the pushing effect of the heat balances the attract- ive force of the light, it will circle the flame. A flower in a room will direct its petals towards the fight The reflex acts of the birds and moths differ in no respect from the reflex acts of the flower. The same force is dominant. Even though the author vaticinates the skeptic re- ception which will at first be accorded to his ob- servations, he could not possibly have relinquished the many toilsome though delightful hours which he has devoted to a study of this subject. The force which inspired his instinctivity differed in no re- spect from that which activates the work of the ant or the bee. TONICITY. The contractility of the stomach-mus- culature and the transition of tympanitic resonance to dullness on percussion was also adduced as proof of the identity of the various forms of force. Tonicity has already been discussed CP a S es 6 and 124). Muscle in a state of tension which is practi- cally its tonus is a conspicuous example of living matter. In consequence of this tension, the efficiency of the stomach as a motor organ is increased. Muscle- tonus is a reflex and is caused by stimuli acting on the skin (and elsewhere) conveyed by nerves to the cord and from the latter, impulses are carried to the mus- cles. This tonus disappears if either the posterior 175 Progressive Spondylotherapy roots of the spinal-nerves or the afferent nerves from the muscle are cut. Important functions of tonicity are the production of heat and the maintenance of metabolism. ANIMAL-FORCE. The actual connection between magnetism and currents of electricity was not defi- nitely determined until 1820, when Oersted, publish- ed the fact that a magnetic needle is disturbed by the presence of an electric current in its neighborhood. Magnetism set up by an electric current is known as electromagnetism. There is no difference in the magnetic force pro- duced by a permanent magnet and that produced by an electric current. The magnetic field surrounding the flowing current consists of a kind of magnetic whirl and is strongest nearest the current. Investigations concerning animal electricity began with the famous experiment of Galvani, in 1786, who observed contraction of the frog's thigh when touch- ed in two places with the ends of a metallic arc. This discovery led physiologists at that time to believe that the vital force was at last discovered. Notwithstanding Volta's observation that, the con- tractions were caused by the dissimilarity of the two ends of the metal touching the moist conductor and upon the production thereby of a Galvanic arc, later investigation demonstrated that electrical differences of potential do occur in the animal body. In every active nerve or muscle electrical currents are produced, and the latter are intimately associated with the functional condition of the tissue. Every active part maintains a negative electrical relation toward the part at rest. Elecrical phenomena are encountered in other tis- sues and in plants. 176 Deductions If a shaded and exposed part of a green leaf be con- nected with a Galvanometer, an electric current is de- veloped when the light falls on the exposed part. The electrical organs of electrical fishes are essen- itally metamorphosed muscles and the force of the electric current in the cramp fish amounts to 31 volts. For many years, the subject of animal electricity was in disrepute owing to the charlatanry associated with it, but thanks to its scientific investigation by physiologists, notably, Du Bois-Reymond and Her- mann, it was partially rescued from evil. It is questionable whether animal-magnetism is de- rived wholly from animal electricity or the earth's magnetism or whether both are concerned in its pro- duction. The theory of Ampere, supposed that the cause of the earth's magnetism was due to currents of electricity flowing around the earth. One may conceive the sun as a gigantic cathode negatively charged giving off corpuscles like all in- candescent bodies. These corpuscles coming under the influence of the earth's magnetism travel along the line of the earth's magntic force. It is even prob- able that the corpuscles whirling about on their own axes create a magnetic field in their vicinity. It is reasonable to assume that, the molecules of an- mal tissues are inherently or naturally magnetized; each molecule showing a north and south polarity. This polarity may be caused by closed circuits of ani- mal electricity or from the magnetic flux in the at- mosphere. In the act of magnetization, like poles face in the same direction (Fig. 31). We may further assume that every electrified molecule is a magnet with vary- ing degress of magnetic force and what is known as chemical affinity is nought else but the magnetic properties of molecules. 177 Progressive Sp o ndy 1 o th er apy Energy is essentially the mechanics of the ether and force is anything which moves matter. LIFE. Scientists are disposed to group the natural sciences into the biological sciences dealing with liv- ing things and the abiological or physical sciences dealing with lifeless matter. It was a great concession when the vital phenome- na of animals and plants were studied equally with man in determining the field of life. Of all vital phenomena, motion furnishes the most suggestive impression of living. Thus, a child would regard a steam engine as a living thing. The conception of life has always varied with the development of the human species. The primitive conception was associated with the wind, waves, fire, in fact with anything in motion. Vital-force was primarily employed to signify a mystical power resident in the living and differing from electric, thermic and other forms of energy. At present, vital-force signifies energies resident in living matter. The hypothesis of vitalism, supposed that the phe- nomena of life are inexplicable apart from a special vital-force resident in organisms and different from the chemico-physical energies of the inanimate world. The neo-vitalists maintained that it was impossible to furnish a complete chemico-physical restatement of any observed function. Vitality was a complex adaptive synthesis of mat- ter and energy, the secret of which was unknown. Foster contended that what we call structure and composition must be approached under the dominant conceptions of modes of motion. The qualities of liv- ing matter are expressions of internal movements. Our present conception of vital phenomena (in ani- mals and plants) refers the vital energy to a single 178 Deductions inorganic force drawn from the sun. The sun is an inexhaustible source of physical energy and main- tains the activity of all living things. The forces which exist in nature may be transformed but not created by living things. The forces of organic and inorganic matter are identical. The distinguished Calcutta physicist, Bose, be- lieves that in some obscure degree, all matter lives. It is difficult to distinguish a dividing line between the animate and inanimate. Bose, regards as a true test of life in an object, its capacity to respond to an external stimulus L e., its irritability or sensitive- ness. Iron is as irritable as the human body as ' shown by a galvanometer. Metals have periods of activity and rest like animal matter ; they show curves of fatigue when stimulated excessively, and stimulants and narcotics have an action on metals similar to that observed in living animal matter. The forces emanating from chemical reactions and metal show the same action as the force discharged from the organism. Dissolving common salt in a vessel of water or striking steel with a hammer in proximity to the stomach-region, will at once evoke a transitory area of stomach-dullness. With the salt undergoing so- lution a tremendous force is developed (page 181). Striking the steel mechanically agitates it and de- magnetizes it. Why a few strokes of the hammer causes the greater part of the magnetism to dis- appear cannot be accounted for by physicists but in the light of my investigations it would appear to be caused by a discharge of force from the metal. To avoid air-concussion, the metal was struck with a rubber hammer. Life is dependent on external conditions of the earth's surface and is in a sense a function of the de- velopment of the earth. In the ceaseless and intricate dance of the molecules constituting living matter, the question of personal identity must be considered. 179 Progressive Spondylotherapy Matter is essential to consciousness. Matter changes constantly but consciousness shows no solution of con- tinuity. As one writer observes, ' ' Constancy of form in the grouping of the molecules, and not the con- stancy of the molecules themselves, is the correlative of this constancy of perception." There is no reason to question the belief that, if one could gather the molecules and put them in the same relative positions which they occupy in the organism and endow them with identical forces and distribution of forces and motions and distribution of motions, this organized molecular concourse would constitute a sentient thinking being. Identity is no less an attribute of inorganic than it is of organic matter. The property of assuming more than one elemen- tary form is known in chemistry as allotropism. The diamond, graphite and amorphous carbon are identi- cal in composition although showing different prop- erties. Here identity is not only a question of a dif- ference of the number of atoms in a molecule but a difference in the arrangement. When crystals of urea were first discovered in the body they were regarded as products of vital energy but this theory was exploded when urea was formed outside of the body by synthesis. Scientists recognize a law of change and a law of continuity. They deal with energy which is neither created nor destroyed. Respecting mentality at death, we do not know what part of the cosmos takes it up. The latter is a problem of psychology. The chemic theory of Pflliger suggests that the real difference between dead and living proteid lies in the grouping of the nitrogen in the molecule. In the physics of life, the origin of energy predi- 180 Deductions cates an understanding of the law of the conserva- tion of energy. . Chemic action is demonstrated by different forms of energy; it may be heat, light or electricity. A chemic reaction is not only a rear- rangement of matter, but also a transformation of energy. The epoch-making researches of Loeb, suggested the identity of electricity and vitality. Common salt dissolved in water makes the latter a conductor of electricity. Arrhenius, demonstrated that by this solution the molecules are torn asunder with an enormous electrical charge on the atoms (one set being pos- itively and the other set negatively charged). The electrically charged atoms are known as ions. In the contraction of a muscle, the negatively charged atoms start the contraction and the posit- ively charged atoms arrest it. The chief value of food is to produce electricity ; heat and other objects are of secondary importance. In deducing from the observations of the preceding chapter concerning the force concerned in vital phe- nomena, we are constrained to conclude that it is an electromagnetic force. Whether the electromagnetic force is derived from animal electricity or the latter is of magnetic origin is a mere question of logomachy. Before the time of Oersted, the intimate relations of electricity and magnetism were not recognized and until the time of Faraday, it was impossible to con- ceive of the enormous storage of electricity from spinning magnets. In accordance with Ampere's theory of magnetism, which may be paraphrased with specific reference to the organism, one may regard the animal tissues as molecular magnets around which an electric current is continually flowing. In other words, the molecules 181 Progressive Sp o ndyl o therapy of tissues are nought else but rotating portions of electrified matter (Fig. 45.) In the study of all vital phenomena, the cell must be regarded as an elementary organism. It is the be- ginning and source of the entire body. It is the pri- mary anatomic and physiologic unit of the organic world. The essential constituent of the cell is bio- plasm, the characteristics of which have already been discussed on page 126. FIG. 45. Illustrating Ampere's theory of magnetism. Each molecule has a current of electricity circulating round it. This figure represents the N-seeking pole and the currents move in the direction opposite to that of the hands of a watch (after Poyser.) We have noted that the magnetic force will repro- duce the phenomena of bioplasm and in this action it is superior to all the other forces employed in our in- vestigations. In assigning to electro-magnetic force the source of vital energy, we dare not deny the trans- mutation of the various forms of force. PROLONGATION OF REFLEXES. It has already been shown (page 125) that the magnetic force will pro- duce reflexes lasting for many hours. In this respect other known forces in comparison are relatively inert in action. This prolongation of the reflexes is equivalent to the supply of tone (page 124). REINFORCEMENT OF REFLEXES. Reading of the sub- ject matter on page 40, will elucidate the purport of 182 Deductions this caption. The magnetic force may be employed in lieu of the mechanic methods cited. When a subject is exposed to the flux in a magnetic field, the organism displays its specific attribute of selection ; the sympa- thetic-fibers and vagus-fibers appropriating an amount sufficient for their individual use. If, how- ever, one charges the vagus-nerve at the 7th cervical spine, this power of selection is defeated and the tone acquired by the vagus-fibers will be in physiologic excess of the inherent force present in the sympa- thetic nervous system. Life, said Sir Thomas Browne, "is a pure flame and we live by an invisible sun within us." . The organism may be regarded as an animal ma- chine. Ostwald speaks of a benzine motor which regulates its benzine-supply by means of a ball- governor in such a way that its velocity remains constant, as having exactly the same property as a living organism. If such a machine could work constantly and could receive an inexhaustible supply of benzine,, we would be compelled to regard it as a living organism. In our mechanistic conception of life, we fail to pay due regard to the regulatory mechanism of the organism by which it regulates its supply of force (as expressed in tissue-tone) and what physiolo- gists call force. The selective attribute of supply- ing and discharging force to the organs is probably mediated by the autonomic system (page 25). If during the time this system is demagnetized (at the 7th cervical spine), it is impossible with the most powerful electromagnetic flux to elicit any stomach- dullness ; i. e., no tone can be imparted to the stom- ach or for that matter to any of the other organs. It is not unlikely that, the sympathetic system is purely negative in action like the vasodilator nerves (page 64) ; its activity only becoming manifest when the force resident in the autonomic system becomes diminished. At any rate, force as a factor in the animal machine is an important one. 183 Progressive Spondylotherapy TOPOGRAPHIC PERCUSSION. Augmenting the supply of tone to the organs by increasing the rigidity of their muscular components will yield a more pro- nounced dullness on percussion (page 150). After this manner we may delimit the organs in a manner almost equivalent to their delimination by the X-rays without any of the errors or inconvenience incident to the use of the latter. To attain these results, all that is necessary is to have the patient stand in prox- imity to the source of the magnetic force. In this respect, either pole is sufficient. In the absence of a large electromagnet, one may fix an ordi- nary horse-shoe magnet in the center of the organ which is to be delimited (Fig. 36). The right border of the heart which is conceded to be difficult to delimit is readily outlined provided percussion is executed at the end of a forced expiration. VISCERAL ATTRACTION AND REPULSION (page 156). No conclusions have been formulated respecting these phenomena exhibited by the organs in morbid condi- tions. Sufficient data however, have been accumulated to show that further investigations will furnish im- portant facts concerning this subject. Drugs have an important influence on the phe- nomena in question (page 159). In hysteria, asa- fetida, valerian and allied drugs, have been found empirically to possess a remarkable sedative action. Such effects have never been explained other than by saying that, all malodorous drugs are grateful to hysterics. In hysteria, I have found that the organs show little or no magnetic attraction but after adminis- tering a drug like valerian the attraction is aug- mented ; that is to say, the liver will be found to descend lower after than before the administration of this drug. 184 Deductions TRAUMATIC NEUROSES. After accidents, symptoms of neurasthenia or hysteria or both develop. The con- dition is often known as "railway brain" or "railway spine. ' ' As a rule there is no anatomic change pres- ent to account for the symptoms. It has been shown on page 157, that concussion of the vertebrae is equiv- alent to demagnetization but whether the latter has any bearing on the condition is a matter for further investigation. Mere concussion of an organ like the liver will not only prevent its descent by an electromagnet (page 156) but will actually cause its repulsion, i. e., percus- sion shows a rise of the lower border of the organ. SPLANCHNOPTOSIS. Many ingenious theories have been suggested to account for prolapse of the abdom- inal organs. Among the theories are: 1. Pathologic reversion of the location of the ab- dominal organs to an embryonic state; 2. The abdominal organs are supported by liga- ments and when the firmness and rigidity of the latter are impaired the equilibrium of the organs is disturb- ed. This theory is defective for the reason that, all the ligaments in the abdomen are insufficient to sup- port even the liver ; 3. The abdominal organs are kept in place by in- tra-abdominal pressure. 4. The organs are kept in position by negative as- piration of the thorax ; 5. The position of the organs is maintained by pressure and ligaments ; 6. The organs are maintained in position by the normal tone of their muscular tissue (page 8). The author finds that the latter theory is probably the correct one as can be demonstrated by the f ollow- 185 Progressive Spondylotherapy ing investigations. If one demagnetizes (which is equivalent to the abstraction of tone) the region cor- responding to the 7th cervical spine, tone is removed from the pneumogastric nerve which supplies the abdominal organs. In consequence of this loss of FIG. 46. Illustrating a fall of the organs (aorta, heart liver, spleen and stomach) after removal of vagus-tone by demagnetization at the 7th cervical spine. The broken lines indicate the position of the lower bor- ders (excepting heart and aorta) before and the continuous lines after demagnetization. tone or energy, there is an immediate drop of the liver, stomach and spleen (Fig. 46). A more decided drop is noted if demagnetization is executed over the region of the heart. The latter is probably the chief source of the energy of the organism (page 164). In consequence of the latter maneuver, the heart likewise drops. If one now charges the vagus with magnetic force at the 7th cervical spine, the organs at once resume their former position. 186 Deductions It has already been shown (page 154) that mag- netic force only fixes but does not raise normal vis- cera, hence, by this method we have a simple means of determining the presence of prolapsed organs. If, by charging the 7th cervical spine, any organ rises in position, it must have been prolapsed. Demagnetization attempted over the liver or spleen causes only a descent of the liver or the spleen. If one demagnetizes between the 3rd and 4th dorsal spines, the tone of the vagus is no longer counter- acted by the tone of the sympathetic nerves (page 161) and the organs occupy a higher position than when the magnetic force is conveyed to the vagus at the 7th cervical spine. The behavior of the kidneys was quite contrary to my expectations. Demagnetization at the 7th cervical spine causes a rise in the position of the kidneys and a contrary effect when demagnetization is executed between the 3rd and 4th dorsal spines. It is possible that although the normal position of the other organs is dominated by the vagus, the sympathetic influences the normal position of the kidneys. Forc'e of the heart. Electrical variations to the contractions of the heart (Fig. 47) may be -deter- mined by electrocardiagrams. Here, the contraction of a ventricle is comparable with a simple muscular contraction (page 165). The hands of the patient are immersed in jars containing 0.9 per cent of sodium chlorid solution. The jars are connected in circuit with a very deli- cate Einthoven thread-galvanometer and the move- ments of the latter are recorded photographically. This apparatus is chiefly employed in detecting ir- regularities in the rhythm of the heart. 187 Progressive Spondylotherapy An important avenue of study consists in deter- mining the force of the heart by the method indicated on page 166. Here, force may be calculated by the in- tensity and duration of dullness plus the distance from the subject in whom dullness of the stomach is evoked. PSYCHIC FORCE AND ITS TRANSMISSION. On page 165, reference was made to definite facts concerning action-currents. The following investigations show that the psychic action-currents conform to like laws. FIG. 47. Showing variations of electrical potential associated with the beat of the human heart and their distribution n the body (after Waller). These electrical currents generated by the activity of the heart diffuse throughout the entire body according to the usual laws. The action-current is associated with the process of excitation and is produced by all kinds of stimuli but varies in strength with the strength of stimulation. 1. If one side of the head of a subject is struck a series of blows by means of a rubber hammer, a stom- ach-dullness in the subject ensues. Here a force is generated not unlike that evoked by striking the 7th cervical spine (page 164). 188 D u t n 2. If, however, the blows are struck on both sides of the head of the subject, no stomach- dullness can be elicited. The two negative currents apparently gener- ated neutralize the production of psychic force. Con- cussion of the head in the median line is likewise negative. 3. If, while sitting in proximity to the exposed stomach-region of the first subject and one side of the head of another subject is concussed, a stomach-dull- ness can be elicited in the first subject. Such dullness R/ghr 3/cfe, FIRST SUBJECT Left 6/c/e SECOND SUBJECT FIG. 48. Illustrating positive and negative reactions on the stomach musculature by stimulating like and unlike sides of two subjects. however, is not evoked if the head of the second sub- ject is concussed in the median line or first on one and then on the other side. If subject one is faced by subject two and the right or left side of the head of both subjects is simultane- ously concussed, no stomach dullness ensues. If, how- ever, opposite sides of the head of both subjects are concussed, dullness ensues. A similar phenomenon is 189 Progressive Spondylotherapy noted when the arms of both subjects are voluntarily contracted (Fig. 48). This experiment suggests that our bodies may be likened to a horseshoe magnet, positively charged on one side and negatively charged on the other side. Further, that the circumambient ether in proximity to our bodies is similarly polarized. In accordance with the law of attraction and repul- sion (page 138), the positive and negative reactions in the foregoing experiments may be explained. Electrotaxis illustrates this attraction and repul- sion. If a Galvanic current is allowed to flow through a trough filled with water and containing animals, the latter move in the direction of either the positive or of the negative current. 4. These maneuvers are negative with moderate electric stimulation. 5. If during the time the center of the head is be- ing demagnetized, concussion on either side of head is negative with reference to the elicitation of dullness. If, however, only one side of the head is demagnet- ized, concussion of the other side elicits the stomach- dullness. If demagnetization is executed over the region of the heart, concussion of the head is negative in revealing stomach-dullness. The probable source of the force in the organism is from the heart. 6. Thought yields a force the presence of which can be exhibited ~by stomach-dullness. This force however, is not revealed if the brain functionates in its entirety unless a special maneuver is tried. It is necessary to demagnetize one side of the brain during the time of thought. In demagnetizing, it is not nec- essary to reduce the intensity of the current (page 160) ; the mere change of polarity suffices. The best effects are noted when the rod of the demagnetizing instrument is placed on the side of the frontal region. 190 Deductions With the first subject in one room with closed doors and the other subject in another room, the force pro- voked by thought may be transmitted from the latter to the former over a distance of forty or more feet as revealed by stomach-dullness in the first subject. Psychic force passes through metal and all other media thus far tried. Anger and emotions yield a force which may be transmitted over a distance of eighty feet. The potentiality of the psychic force is determin- able by the intensity and duration of the stomach- dullness and the distance of the subject from the per- son engaged in thought. The position of the recipi- ent with reference to the person occupied in thought is of no moment but the recipient must be standing to elicit the reaction of stomach dullness. In my experiments, the person engaged in thought was instructed to pe/f orm examples in mental arith- metic. The Cartesian conception that, matter cannot act where it is not, was overthrown by Newton, in his law of universal gravitation. 7. COLOR influences the transmission of psychic force as can be noted when the person engaged in thought holds large clored sheets of gelatine in front of the head. Green and violet obstruct the passage of the force whereas blue and notably yellow inten- sify the action of the force as revealed by the inten- sity and duration of the stomach-dullness. Light act- ing on the head through a yellow medium minimizes psychic activity (page 200). Some writers work better in proportion as the heat and light are more intense. Some cannot think well in the dark. Red excites some individuals and most animals. Witness the matador as he excites the infuriated bull to charge by manipulations of his red cloth. There is reason for the foregoing. Electric light 191 Progressive Spondylotherapy thrown on one side of the head stimulates like a blow and excites the stomach to contract. Directed on the center of the head, it is negative. Light passed through a red medium covering the head is negative when directed on one side of the head but produces a powerful contraction when directed on the center of the head. This exciting effect on protoplasm is the same whether resident in muscle or brain. Psychic force may be transmitted to another (as revealed by stomach-dullness), if during thought, the head is covered (covering other parts does not suf- fice) with some red material or, if the latter is held in front of the stomach of the second subject. This experiment dispenses with the necessity of de- magnetising one side of the head. Furthermore, the stomach of the patient engaged in thought may be used provided any red material is thrown over the head or held near the stomach-region. If red paper or any other red material is thrown over the head of an intelligent dog, the stomach of a subject in proximity to the animal shows dullness and the latter disappears when the colored material is removed. The force thus transmitted differs in no respect from the psychic force of the human as far as its physiologic effects is concerned. The foregoing experiments may explain some of the phenomena of telepathy. Thought-transference is a reality despite the fact that the most we know about it is that we know nothing about it and are not sure even of that. The proceedings of the "Society for Psychical Re- search," reveal many pertinent paradigms which demonstrate that in man there is a faculty which per- mits him at times to communicate directly with the consciousness of another individual. I have purposely italicized "at times" for the rea- 192 Deductions son that my investigations show that, the force is only propagated during the time one side of the brain is temporarily incapacitated (unless color is employed, page 192). It is necessary to show in further experi- ments if it is possible for an individual to inhibit vol- untarily one side of the brain. If in my experiments I have utilized the stomach- - muscle as an index in revealing force and its trans- mission, conventionalism has not been disregarded. Frogs' legs are now employed for recording wire- less messages (Fig. 34). Psycliists have accepted the contracting muscles of the frog as the first definite index of thought-transference. Our nerves and mus- cles are more complex and responsive than those of a frog. "Cheiro," in his "Language of the Hand," describes an instrument for measuring psychic force and maintains that, the indicator-needle of his instrument establishes the reality of thought. Careful investigation by two members of the "Society for Psychical Research" demonstrated that the results were due to other causes. The "sthenometer" of Dr. Paul Joire, is sup- posed to fulfill the same indications as the former. A more thorough understanding of psychic force may explain the phenomena of telekinesis. It is reasonable to suppose, considering the data already presented that the force of the organism may be compared to the magnetic force. Magnets act at a distance although there is no apparent medium connecting them with the object acted upon. The most tenable theory supposes that, the flux of the magnet passes out at its north pole and re- enters it at its south pole. In other words, the magnet at one pole is like a force-pump and at the other pole, it is like a suction-pump. After this manner attraction and repulsion are explainable. 193 Progressive Spondylotherapy COLOR. The experiments on page 130, direct atten- tion to the influence of color on tonicity of the organs. The therapeutic value of colors (chromotherapy) has been acknowledged on empirical lines. Percussion demonstrates that in the light, the or- gans show more tonicity and better delimitation (page 184) than in the dark. Respecting the action of color on the tonicity of the stomach, vide page 129, Fleming, in his book "Waves and Ripples" shows that there are many more ether-waves than are cur- rently supposed in the solar spectrum and with the diffraction spectrum of Langley, it has been shown that the greatest heating power is not found in the . infra-red, but in the orange or orange-yellow. We found that these colors will augment the action of the forces (pages 129 and 191). In the spectrum one finds radiations varying in length from several miles long (oscillations of Hertz) to less than .000009 of an inch (violet rays). Light is an electromagnet disturbance of the ether. It is in this way only that one can account for the penetrat- ing effects of light as shown in my experiments. I am assuming that, light is positively or negatively charg- ed and colors are probably only different charges (page 203.) Dullness produced by yellow (page 128) is at once dissipated by violet, blue or green.* Why red permits the transmission of psychic force with the brain acting in its entirety, I cannot say oth- er than to suppose that it is oppositely charged to the two hemispheres of the brain. *In my works on "Autointoxication," (page 245), and "Diagnostic- Therapeutics," color in diagnosis (chromodiagnosis), has been discussed. 194 Deduction POPULAR QUESTIONS PERSONAL MAGNETISM. Although this phrase is now employed figuratively, at one time it had a liter- al significance. It was supposed that ia physical force equivalent to that exhibited by a magnet passed from one person to another. This conception of per- sonality was Abandoned when science was unable to demonstrate a so-called transmitted vital force. If one reviews the history of medicine one finds that, the great men in the profession owed their success to their personality. ''Successful treatment," said Hu- f eland, "requires one-third science and two-thirds savoir-faire." Science and heart are so nicely blend- ed in the truly great physician that neither is opera- tive separately. "Cheer is a powerful drug, for a merry heart doeth good like a medicine. ' ' The so-called personal magnetism has been chiefly exhibited by "healers" who were not physicians. Their presence or manipulations seemed to arouse the latent energy of the patient and endow him with increased vitality. With the facts presented are we in a position to deny teledynamics or a transmission of energy ? What is known as induction of magnetism is the communication of the latter to a piece of iron with- out actual contact with a magnet and by this process the piece of iron will have two poles ; the pole nearest to the pole of the inducing magnet being of the oppo- site kind, while the pole at the farther end is of the same kind as the inducing pole. This inductive action is like that observed when a nonelectrified body is brought under the influence of an electrified one. (Vide, page 139.) Can we deny that the animal-force of one individu - al cannot act on another by induction ? 195 Progressive Spondylotherapy Magnets have their likes and dislikes as exhibited by attraction and repulsion. All matter has the same attractive force. Every molecule is a magnet and is electrified. Some are powerful and others feeble. As a rule, a natural lode stone cannot lift its own weight yet Sir Isaac Newton, had a lodestone set in his hand ring which although weighing but three grains could lift 233 times its own weight. Chemical affinity is probably only the magnetic properties of molecules. My friend, Carl Snyder, in his remarkable book, "New Conceptions in Science," observes: What we used to call loves and hates of the chemical "affini- ties" was but a name for the action of electrically charged atoms. Thus chemistry like light will be an- nexed to the wide domain of electricity. Lord Kelvin, refers to matter as minute whirls of " vortex-rings." These rings are like the smoke-rings from a locomotive or from tobacco. Two smoke-rings attract each other like little worlds and if stopped by an obstacle in a room, they will move on again when the obstacle is removed. Gravitation is a relatively weak force when compared with the enormous mole- cular forces. In accounting for personal magnetism due regard must be paid to the vibration-rate during transmission of the force and to the fact whether the recipient is properly attuned to these vibrations. Personal likes or dislikes may only be questions of individuals in or out of tune (page 206). Music AND NOISE. Every phenomenon in nature depends on matter in motion or vibration. In music we are dealing with vibrations which create pleasant mental images and emotions. The physical reaction of the organism to music is manifested by changes in the pulse-rate and blood-pressure. Quiet and restful 196 Deductions numbers reduce the latter. Horace, in his Thirty- second Ode, Book 1., concludes his address to the lyre : "O laborum, dulce lenimen, mihicumque salve. Bite vocanti." (O, of our troubles the sweet, the healing sedative). A line of poetry is nought else but simple physical processes ; it means the rate of heart-beat and regu- larity or irregularity of breathing of the author at the time the verse was written. Bacon, Milton and others, recognized the value of music as a stimulant to intellectual work. By aid of the ergograph it can be shown that, when the fingers are fatigued, music will restore their vigor. Sad mu- sic will have a contrary effect. Experiments on dogs demonstrated that music increases the elimination of carbonic acid, increases the consumption of oxygen and augments the functional activity of the skin. In consequence of its acknowledged physiologic action, music has been employed (musicotherapy) in the treatment of mental and nervous affections. In the classics, we recall that the singing of birds was the method employed to cure the insomnia of Maecenas. The author is inclined to regard the pathology of many nervous affections as the physics of abnormal vibrations. Recalling the observations on page 156, respecting visceral attraction and repulsion, it has been found that music and the vibrations of a tuning-fork will increase the descent of the liver whereas noises will not only destroy this attraction but may cause an act- ual repulsion of the organ. Many popular expressions like, " shattered nerves," " nerves in tension," and " upset nerves," are employed to describe the sensations of nerves in disorder. The foregoing expressions may be literally true if we regard the structures of the body as infini- 197 Progressive Spondylotherapy testimal magnets with modified polarity (Vide, page 182), or bear in mind the molecular vibration of nerve-tissue and the response of such tissue to the vibrations of tuning-forks as shown on page 206. Molecular vibration is a universal law. COSMIC INFLUENCES. It is generally conceded that the cosmic forces exhibit a potent influence upon the organism. The nature of this influence is but little understood. The pains of rheumatic and gouty sub- jects are modified by conditions of the weather. Edward Dexter 17 , has contributed an important monograph bearing on the mental and physiological effects of metereological conditions. In a living organism a part of the available energy is necessary for the vital processes of living, while the reserve energy goes into the intellectual processes. Weather-conditions play on the reserve energy by affecting oxidation, which is the chemical basis of life. Inhabitants of hot climates are apathetic and improvident. An equable, moist temperature weakens body and mind. The most favorable tem- perature for health, with its aggressive energy, is about 55 degrees F. and this is found in the temperate zones. The dominant peoples are shown between the 25th and 55th parallels. The effect of weather has been shown upon human conduct by marked fluctuation of immoral acts. We find ourselves out of sorts on hot, humid, cloudy, and perhaps rainy days. We have always known the influence that weather-changes play in the causation of disease, especially in the so - called barometric neuroses. The total atmos- pheric pressure at sea level on an adult body is about fifteen tons. Variations of this pres- sure are compensated by resiliency of the blood- vessels, which equalizes the circulatory disturb- ances. In the old, however, the diminished arterial elasticity accounts for the headache, rheu- matic pains, drowsiness, etc., resulting from altered pressure. Relative rarity of the air with oxygen deficiency induces exhaustion. Electric storms produce headache. Positive atmospheric 198 Deductions electricity stimulates and the negative variety present in inclement weather depresses the indi- vidual. Arrhenius, has striven to show that various physio- logical processes, notably menstruation, are related to electrical variations of the atmosphere and the chem- ical changes thereby effected. At the suggestion of this celebrated savant, experiments are now being conducted upon 50 school children in Stockholm, to determine the effect of electricity upon the growth of children. The application of electric currents to the soil has been shown to increase the quantity and quality of its products. The influence of terrestrial magnetism (page 140) on the physiologic processes must be an important one. The phenomena of terrestrial magnetism as exhib~ ited in magnetic storms and the auroral light seems to have their analogies in the "brain-storms' and phot- isms. CLOTHING. Light-hunger, and may we add light over-feeding, are potent factors in disease. A poverty of light is no less pernicious in its effects than the ex- cessive light of the tropics. Tropical neurasthenia has been attributed to overstimulation by the actinic rays of tropical sunshine. In our experiments we have noted that, relaxation of the organs (diminish- ed tonicity) ensues when the solar rays are focused on individual organs. At a distance the rays augment the tonicity of the organs (page 128). We have found that the rays contracting the stomach act through black clothing and that the action of these peculiar penetrating rays may be inhibited by violet, green or blue. It is therefore suggested that for light-hunger, 199 Progressive Spondylotherapy yellow (page 130) garments should be used and the other colors when the light is too intense. We have found that each time the light from an in- candescent bulb is allowed to act on the head, the stomach of the subject shows dullness. The latter en- sues with all colors excepting yellow. It is therefore suggested that this color should be utilized as a lining for hats when it is desired to minimize brain-activity due to the influence of light. Magnetic rings, belts, etc. Magnetism is frequent- ly exploited by the unscrupulous advertiser who sells to the unwary rings, belts, pads and garments sup- posedly endowed with magnetic virtues. These have been repeatedly tested by the author with results which were invariably negative. What is obvious cannot compete with what is ob- scure in the treatment of disease, hence the success of the charlatan. If magnetism is desired, the expenditure of a few cents would purchase a really efficient magnet. DEXTRAL OR SINISTRAL SYMPTOMS. For some rea- son, patients will complain of symptoms predominat- ing either on the right or left side of the body. Such complaints I have heretofore regarded as ridiculous. The cortical sensory areas dominate opposite halves of the body. If the skin on the right side of the body is irritated, stomach-dullness ensues but the latter cannot be elicited if the skin of the left half of the body is irritated. The tonicity of the right lobe of the liver is increased by irritating the skin on the left side and a like action is exhibited by the left lobe of the liver when the skin on the right side is irritated. A few inhalations of some anesthetic prevent the foregoing effects. 200 S u m m a SUMMARY* 1. The trend of scientific opinion is to reduce all force to a single underlying principle and to unify as it were, the various forms of force (115). The theory of the Conservation of Energy, showing the transmutation of force (116) corroborates the foregoing. The Aristotelian conception of "Soul" as "the vital principle" or the generally accepted distinction of Descartes, between mind and matter (res cogitans and the res extensa) is no more acceptable than the belief of theologians that, there existed in man an im- ponderable, incorruptible and incombustible bone which was necessary for the nucleus of the resurrec- tion body. One may speculate with metaphysics, but science invariably investigates and progresses along the lines of sense-impressions. Science never transcends human intelligence, nor does it invoke in the interests of its doctrines any suspension of nature's laws; for after all, "Facts are the words of God. ' ' The religionist denies that science offers consola- tion to the soul. Applied to the ignorant, this conten- tion may be true but the educated cannot reconcile doctrines in conflict with progressive science. The doctrine of "Immortality" is by no means alluring. Annihilation of self is, according to the religion of Buddha, perfect rest, and is not to be feared when old age has come with its inevitable assemblage of infirm- ities. Haeckel, relates the legend of the unhappy Ah- asuerus, who vainly sought death after finding his eternal life intolerable. The orthodox doctrine of the *The number or numbers in parentheses refer to the page or pages in this work respecting the subject-matter from which conclusions have been formulated. Progressive Spondylotherapy soul supported by spiritualistic philosophers is that, it possesses none of the properties of matter ; that it is created simultaneously with the body, and that it is capable of itself, independent of any other cause, of controlling the bodily functions. We must regard life as a force active on and through matter. 2. The electronic theory (115) employed in expla- nation of physiotherapeutic action, supposes the re- sults to be effected by the interplay of moving parti- cles electrically charged. The action in question causes the discharge of reflexes. 3. Stimulation predicates a discharge of animal- force (164), and one of the evidences of the latter, is augmented tonicity of the organs and tissues (123). 4. The chief source of animal-force is probably derived from the heart (164) and its distribution in the organism is one of the functions of the autonomic nervous system (25). The sympathetic system is probably only negatively active. 5. Animal-force, as far as its physiological action is concerned, cannot be differentiated from the other forms of force. It is a form of energy like light, heat, electricity, magnetism and the X-rays. Electricity is an invariable property of matter but matter and electricity are so intimately associated that they are practically the same. The organism may be regarded as an aggregation of electrified corpus- cles and in this sense, all life-processes (vitality) and electricity are identical. What we regard as animal force or energy may be the electrical charge of the in- dividual atoms whereby one set is positively charged and the other negatively. Here, force must be regard- ed as a vehicle of energy : in motion, it is current and magnetism, under strain, charge and in vibration, light. Animal-light, peculiar to luminous fish, crus- 202 Summary taceans and zoophytes may thus be explained. Phot- isms (glossary) are likewise explainable. 6. Assuming the electronic theory to be correct (115), the atoms of matter constituting the organism are negatively and positively charged and that, if an electron is withdrawn from the atom the latter is left positively electrified. The organs exhibiting attraction and repulsion (156) conform to the law that, bodies charged with one kind of electricity repel those charged with the same kind, but attract those charged with the oppo- site kind. 7. The organs are maintained in their normal po- sition by an electromagnetic attractive force. If the latter is partially removed (186), the organs fall, and rise when supplied with any of the various forms of force, the most potential of all being the magnetic force. Color likewise influences the relative position of the organs as will be subsequently noted. 8. My experiments with light and colors (127 and 194) seem to prove that, the so-called spectral-colors consist objectively of very rapid transverse electro- magnetic vibrations of the ether, ranging from ap- proximately 400 millions of millions per second for red to 760 millions of millions for violet. This theory assumes that waves of light are not mere mechanical motions of the ether, but that they are undulations partly magnetic and partly electrical. In addition to this theory, I assume that colors represent differ- ent electrical charges. The visible spectrum of " white light" is only about one-tenth of the actual measurable solar spectrum. The sense of color is probably variations in the amount of energy. Thus, the energy necessary to pro- duce the sensation of red must be 100,000 times as 203 Progressive Spo ndy 1 o th er apy great as the energy necessary to produce the im- pression of green. Two spectral-colors producing by their mixture the sensation of white are known as complementary col- ors. They are as follows : Red and green-blue ; Golden yellow and blue ; Blue, green and violet. It has been shown (153) that the positive or north pole or the south or negative pole of a magnet will, by increasing the tone of the stomach transform a tympanitic into a dull sound (reaction) but if the two poles are employed synchronously, the poles are neu- tralized and no dullness ensues. Like poles yield a reaction ivhen presented in the same direction. When colors were used with the poles of a magnet, the following was observed : a. Yellow with the negative pole, no reaction ; Yellow with the positive pole, a reaction; b. Green with negative pole, a reaction; Green with positive pole, no reaction ; c. Violet with negative pole, a reaction ; Violet with positive pole, no reaction ; d. Blue with negative pole, a reaction ; Blue with positive pole, no reaction ; e. Red gives a positive reaction with both poles. From the foregoing, one is constrained to conclude : Yellow is positively charged, whereas green, violet and blue are negatively charged and red, is both posi- tively and negatively charged. We know that an intense white light (from an in- candescent lamp) will produce stomach-dullness when directed on the gastric region (128). All of the complementary colors yield a positive reaction. When the positive pole of a magnet is directed to- 204 Summary ward the stomach, it yields a positive reaction, but, if the subject swallows 2 grains of medicinal methy- lene blue, there is no reaction. This latter experiment may aid us in elucidating the disputed photo-chemical theories of color-per- ception and may show that the retinal excitation of colors is dependent on positively or negatively charg- ed electromagnetic vibrations. The gastrologist may utilize this method for deter- mining many obscure problems. Thus, if a blue colored substance is ingested with the food, the dura- tion of digestion (or the time when the food leaves the stomach) may be determined by the reappearance of stomach-dullness when the stomach is exposed to the flux of the positive pole of a magnet. My investigations suggest that, the position of the organs is influenced by color, and it is not improbable that, the red color of arterial blood and the blue color of venous blood were destined in part for the specific object of hastening the circulation. The light of a red incandescent lamp over the heart and a blue lamp over the region of the liver causes the latter to ascend. By reversing the position of the lamps, the opposite condition ensues the liver descends. 8. The X-rays are not different from ordinary light when the physiological test suggested (148) is established as a criterion of action. Indeed, there are media impervious to the X-rays which permit of the penetration of light. 9. The transmission of energy from one organism to another has been established (164). The energy developed in contracting a muscle dem- onstrates the same physiologic action as the energy generated by thought. The content of thought like color is probably dependent on the number of waves 205 Progressive Spondylo therapy in a second of time or by the corresponding wave- length. Thus, we may speak of the physics of thought. It is within the range of probability that some means may be discovered for modifying the vibra- tions of the psychic force and thus establish the con- tent of thought. 10. The recognition of animal-force and the util- ization of like forces suggests many possibilities in the realms of science, notably in the direction eluci- dating many obscure problems in pathology. We may eventually define pathology as the physics of abnormal vibrations. By aid of appropriate vibra- tions we may restore the equipoise of the body by a rearrangement of the molecules or by raising their vibration to a normal standard of frequency. This action corresponds to tone-vibrations which set other bodies in motion. Thus, if the A-string of a violin is struck, the A-string of a piano standing near sounds in harmony with it. It is not improbable that inves- tigations along lines here suggested will demonstrate that each organism has its normal standard of vibra- tion and this will be modified by disease. In my lim- ited observations, it was found that, the transition of the tympanitic sound to the stomach-dullness in the norm was effected with tuning-forks with a vibration- number of 256. When the vibrations were very much above or below this standard the results were nega- tive. By increasing the tone of the vagus (page 123), the stomach responds to higher or lower vibrations. In making the tests the tuning-fork is held in proxim- ity to the stomach. Faith cures may be attributed to the creation of energy or the rearrangement of tissue-molecules by powerful emotions. Thus, we may speak of the physico-chemistry of cures. 206 Summary 11. The dominant action attributed to the reflexes (5 and 40) in our mechanistic conception of the life- processes, is in accordance with our belief, that in- stinct is a mere expression of the various forms of force. The phenomena of the animal-body are vital demonstrations of chemistry and mechanics, and are as irresistible as the force which causes the magnet to attract iron filings. The bee constructs a perfect cell without a mathematical education and birds mi- grate without chart or compass. 12. In accepting the reaction of the stomach-mus- culature as a basis for our varied deductions, we are employing bioplasmic matter (126), the most prim- itive and sensitive substance for exhibiting the phe- nomenon of vitality. The reaction manifested by in- creased tonicity is absolute, definite and easy of inter- pretation by a recognized method of examination known as percussion. Other organs (notably, the heart) exhibit increased tonicity but the stomach is preferred for the reaction insomuch as any change in its sound is easier of in- terpretation. Contractions of the stomach may be easily demon- strated by aid of a manometer (Fig. 21) or a record- ing apparatus (Fig. 42). By aid of the gastrodiaphane, one may note a dim- inution in the area of the stomach-illumination by approaching the region of the stomach with an ordin- ary horseshoe magnet. Transillumination in this way however, is too gross for recognizing the transmission of energy. Any electrical difference of potential (that is, dif- ference in amount of positive or negative electricity) is indicated by the swing of the needle of the Galvan- ometer. To further prove the correctness of my observa- 207 Progressive Spondylotherapy tions, a stomach-tube converted into a non-polaris- able electrode was introduced into the stomach and the hand of the subject immersed in a salt-solution. Tube and vessel were connected with a very sensitive Galvanometer. When a yellow light or a horseshoe magnet ap- proached the stomach-region, the readings were in- variably negative to the original electrical potential. Green light yielded no results but psychic energy through a red medium covering the head of another subject (page 192), gave the same effects as the mag- net and yellow light. The magnet caused the great- est deflection of the needle. 208 GLOSSARY BIOPLASM. Any living matter. Also known as protoplasm, sarcode, biogen and cytoplasm. It always contains the following 12 essential elements ; calcium, carbon, chlorin, hydrogen, iron, magnesium, nitrogen, oxygen, phosphorus, potassium, sodium and sulphur. CREMASTERIC REFLEX. Drawing up of the scrotum and testicle when the skin on the inner side of the thigh is irritated. ELECTROLYSIS. Decomposition of a salt, a chemi- cal compound or certain tissues of the body by aid of electricity. The substances so decomposed are known as electrolytes. ELECTROTAXIS. The reaction of protoplasm (ani- mal or vegetable) to one or the other electric pole. Positive electrotaxis refers to the living body attract- ed toward the cathode (negative pole) or repelled from the anode (positive pole). The reverse process is called negative electrotaxis. ERGOGRAPH. An instrument used for recording the value of work done by muscular-contractions. The ergodynamograph records muscular-force in addition to the value of the work effected by muscu- lar-contractions. ETHER. A highly tenuous medium filling all space as well as solids and liquids and supposed to be the vehicle for transmission of the various forms of force. GASTRODIAPHANE. A small electric-light bulb in- troduced into the stomach. Examinations show trans- illumination of the anterior wall of the organ. HELIOTROPISM. Also known as heliotaxis and a form of phototaxis. Growth or movement toward (positive h.) or away from (negative h.) the sun or the sunlight. 209 Progressive SpondylothSrapy IONS. Groups of atoms conveying charges of elec- tricity. Ions charged with negative electricity (from the positive pole or anode), are known as anions and those charged with positive electricity (at the nega- tive pole or cathode), are called cations. LODESTOXE. Iron ore attracting other pieces of iron. Specimens of lodestone are natural magnets. METABOLISM. A term employed to signify tissue- change and embraces the sum of the chemical changes subserving the functions of nutrition. It includes con- structive (anabolism) and destructive (catabolism) changes. PEECUSSION. An important method of diagnosis first employed by Auenbrugger, a Viennese physician in 1761, and appearing in his work, Inventum Novum. The basis of percussion consists of differentiating resonant from dull sounds. By its aid one can deter- mine the density and tone of organs and define the situation of the latter. Resonant notes are produced over organs containing air whereas airless organs yield dull-notes. PHOTISMS. Subjective phenomena of luminosity. Individuals feel as though a dark-room became sud- denly illuminated. Photisms have been coincident with many conversions. Saint Paul had a blinding heavenly vision. The observation that rays similar to the N-rays are given out from the body and detected by a fluorescent screen has never been confirmed and the same refers to the colored rays of Hooker. POLARIZED LIGHT. A change effected in a ray of light passing through certain medium (e. g., tourma- line) called a polariser. The transverse vibrations occur in only one plane in lieu of in all planes as in the ordinary ray of light. 210 Glossary PROTEID. Also known as protein. A group of sub- stances making up the greater part of animal and vegetable tissues and formed chiefly by plants. PSYCHISTS. Believers in psychic force or tliose engaged in psychical research. The term psychic is also used to designate an individual who is endowed with the power of communicating with spirits (spir- itualistic medium). Psychism as a doctrine refers to a universal soul animating all living beings, the difference in their actions being due to the difference of individual organizations. REFLEXOMETER. An instrument for measuring the force necessary to excite a reflex. SPLANCHNOPTOSIS. Also known as Glenard's dis- ease and visceroptosis. Refers to an abnormal sink- ing down of the abdominal organs. SUGGESTION. Implanting an idea in the mind of another person by some act or word on the part of the operator. This is tantamount to the artificial produc- tion of a certain psychic condition. Experimenters are frequently influenced by the same condition (au- to-suggestion) and, in their state of expectant atten- tion, they frequently perceive what they expect to perceive. TELEKINESIS.- An alleged spiritisic manifestation whereby movements of objects are effected without contact with the mover. TYMPANITIC. Refers to the sound elicited by per- cussion over organs containing air (stomach and in- testines). The pitch of a percussion note over the stomach depends chiefly upon the tension of its walls enclosing the air. When the tension of the walls is in- creased, a tympanitic is converted into a non-tympan- itic or dull sound and the latter is again converted into a tympanitic note, when the walls of the stomach are relaxed. 211 BIBLIOGRAPHY 1. Taylor. Monthly Cyclopedia and Med. Bull., Feb., 1911. 2. Willard. The Journal of Osteopathy, March, 1912. 3. Folin and Denis. Jour. Biolog. Chem. Jan. XIII, No. 4. 4. Franke. Berl. Klin. W., Oct. 14, 1912. Brit. Med. J., Nov. 30, 1912. 5. Chiari. Verh. d. deutsch, path. Gesell., 1903, p. 137. 6. Marchand. Hid., p. 197. 7. Goldscheider. Wien. Med. Klin., No. 12, 1912. 8. Gwathmey. J. Am. Med. Ass., Dec. 17, 1901 and N. Y. Med. Jour., Sept. 14, 1912. 9. Einhorn. Medical Record, Jan. 15, 1910. 10. Ewart Brit. Med. Jour., Dec. 28, 1912. 11. Moore. J. A. M. A., Aug. 10, 1912. 12. Peterson. N. Y. Med. Rec., Dec. 31, 1892. 13. King. Medical Century, Sept., 1910. 14. Sellheim. Jour. A. M. A., May 10, 1906. 15. Bragg. Nature, Dec. 12, 1912. 16. Abrams. Medical Record. March 26, 1898. 17. Dexter. Weather Influences, 1904. 212 INDEX Abdominal supporters, 101. Accessorius, 10. Action currents, 165. Adrenalin, 8, 32, 34, 43. Algesimeter, 12. Amblyopia, 34, 108. Ampere's theory, 181. Amytl nitrite, 66. Anesthesia, scopolamin, 44. Anesthetics, 82. Aneurysms, 50, 55, et seq. Aneurysms, skiagrams of, 13, 14. Angina pectoris, 52. Animal electricity, 176. Animal force, 176, 202, 206. Animal tissues, 143. Aorta, abdominal, 58. Aorta, dilated, 44, 57. Aortitis, 56. Aortoptosis, 57. Appendicitis, 94, 97. Appendix, tenderness of, 28. Asthenopia, 108. Asthma, 12, 42, 43, 48, 56; 62; 94 Asthma, cardiac, 57. Atomic theory, 173. Atoms, 116. Atonic constipation, 11, 48. Atophan, 20. Autointoxication, 93 Automaton, 33. Autonomic system, 25. Backache, 17. Bibliography, 212. Bioplasm, 126. Bismuth meal, 93, 95. Bladder reflex,' 108. Blood, after spleen reflexes 108. Blood, coagulation of. 46, 62. Blood, in hyperthyroidism, 78. Blood, pressure of, 53. Bolometer, 118. Bose, investigations of, 179. Cachexia strumipriva, 71. Calcimeter, 46. Calcium, action on stomach, 130. Calcium, therapy, 45 et seq. Capillary dynamometer, 69. Capillaries, flushing of, 70. Cardiospasm, 80. Cecum, 95. Centrotherapy, 36. Cervical sympathetic, 76, 77. Cirrhosis of liver, 97. Clothing, 199. Cocain, 82. Coccygeal ganglion, 70. Coccygodynia, 22. Colloids, 122. Color, 194, 203. Color, effect on reflexes, 128. Color, on tonicity of organs, 130. Color, and stomach dullness, 205. Color, and psychic force, 191. Colon, carcinoma of, 94. Colon, intubation of, 90, 93. Colonic stasis, 93. Complementary colors, 204. Concusspr, 59. Concussion, spinal, 123. Consciousness, 174. Constipation, 10, 95. Contractures, 67. Cosmic influences, 198. Coughs, 104. Crymotherapy, 37. Demagnetization, 139, 160, 161, 187. Depressor nerve, 55. De Puysegur, 134. Diagnosis, 6. Diamagnetism, 139. Diaphragm reflex, 14. Diaschisis, 24. Digestive apparatus, 80. Dolores vagi, 93. Drugs, 184. Duodenal-intubation, 85. Duodenal ulcer, 84, 94. Dysbasia angiosclerotica, 65. Dyschromatopsia, 34. Dysthyroidism, 72. Edema, 108. Electricity, 119, 202. Electricity, animal, 176. Electricity, and magnetism, 145. Electricity, and suggestion, 117. Electrons, 116. Electronic theory, 115, 202. Electronotherapy, 115, 119, 127. 215 Progressive Spondylotherapy Electro-optical phenomena, 158. Emotion, 30, 32, 159, 191. Endocarditis, 52. Energy, 115, 164, 178, 201, 205. Enterotoxism, 83. Epilepsy, 65. Esophagus, 80. Esophagus, percussion of, 88. Exercises, 47. Exophthalmic goitre, 10, 36, 71, et seq. Eye, 20. Faith cures, 206. Fluoroscope, 57. Force, animal, 176, 202. Force of heart, 187. Force, and matter, 115. Force, physics of, 113. Force, psychic, 188. Force, transmission of, 164, et seq, Force, vital, 178. Freezing, 39. Frog, 106, 149, 193. Gall-bladder, 98. Gangrene, family, 66. Gastric juice, 16. Gastrodiaphane, 207. Gauge, spondymobile, 110. Gilbert 132. Glaucoma, 109. Glossary, 209. Goitre, intrathoracic, 57. Gubler's method, 20. Gynecology, reflexes in, 100. Heberden's nodes, 21. Headaches, 46, 66. Heart, force of, 187. Heart, inspection of, 50. Heart, reflex, 51. Heart, tests for, 50. Heart, vago-visceral palpation of, 14, 50. Heat, 129. Heliotropism, 122. Hippocrates, 4. Hirschsprung's disease, 91. Hydrochloric acid, 84. Hyperemia test, 66. Hyperpiesis, 54. Hypertension, 54. Hyperthyroidism, 72. Hypotheses. 173. Hysteria, 184. Hys-teria, diagnosis of, 29 et seq. Hysteria, pains of, 18. Ideas, 29. Ideopath, 29. Immortality, 201. Inhibition, reflex, 41. Instinct, 5. Intermittent limp, 65. Intubation, colonic, 90. Intubation, duodenal, 85. Intuitional acts, 15. lodoform, 72. lodothyrin, 72. Ions, 122. Kidneys, 187. Klemperer's test, 83. Lavage, transduodenal, 83. Life. 178, et seq. Light, 127, 202. Liver, cirrhosis of, 97. Locomotor ataxia, 104. Lodestone, 196. Lumbago, 19. Magnesium perhydrol, 84. Magnetic force, and animal tissues, 143. Magnetic force, historical, 131, 135. Magnetic force, mechanical effects, of, 140. Magnetic force, and percussion, 150. Magnetic force, physics of, 138, et seq. Magnetic force, physiological physics of, 142, et seq. Magnetic force, and stomach-border. 171. Magnetic force, and stomach-tone, 145. Magnetic force, theory of, 139, 181. Magnetic force, and visceral tone, 145. Magnetic force, and voluntary mus- cles, 155. Magnetism, personal, 195. Magnetism, theory of. 181. Magnetic ring=, etc., 200. Magnets, in diagnosis, 136. Mammary tumors, 102. McBurney's point, 28. Medulla oblongata, 104. Mesmer, 133. Metal, phenomena of, 179. Microbiology, 179. Monroe's point, 29. Morris's point, 29. Muscles, rigidity of, 13. Music, 196. Myocardial insufficiency, 10, 50. 216 n Nerves, blocking of, 106. Nerves, stimulation of, 122. N.crvi erigentes, 64. Neurasthenia, 18. Neuritis, 12. Neuroses, barometric, 198. Neuroses, .traumatic, 185. Noise, 196. Odic force, 134. Orificial methods, 70. Osteoarthritis, 21. Osteopathy, 2. Ovary, prolapse of, 101. Pain, 17, 38, 46. Pain, peripheral, 105. Pain, points of tenderness, 28. Pain, visceral, 25, 26. Pancreas, 98. Pancreas, tenderness of, 28. Pancreatic secretion, 9, 16. Paracelsus, 132. Paralysis, periodic, 66. "Parathyroids, 71. Percussion, topographic, 184. Perkins, 134. Perspiration, 64. Pertussis, 103. Physiatrics, 117. Physiotherape-utics, 117. Pilocarpin, 34, 51. Pithiatism, 29. Pituitrin, 51. Plethysmograph, 68. Posture, faulty, 22. Precordium, 50. Protoplasm, 119. Psychic force, 188, et seq. Psychrotherapy, 37, et seq. Pupil, 42, 77. Pylorospasm, 82. Pylorus, 16. 82, 88. Pyramidal tract, 41. Radium, 116, 125. Raynaud's disease, 67. Rectum, 95. Reflexes, 174. Reflex actions and life, 5. Reflex, explanation of, 121. Reflex, miscellaneous, 100, 121. Reflex, prolongation of, 182. Reflex, reinforcement of 40, 44, 183. Reflex, scrotal, 8. Reflex, skin, 149. Reflex, stomach, 146. Reflexodiagnosis, 5. Reflexology, 1. Reflexophilic. 5. Reflexotherapy, 36, 127. Rheumatism, 19. Robson's point, 28. Rubber-bandage, 66. Sacralgia, 22. Sacrp-i-liac percussion, 96. Salpingitis, 29. Selenium, 174. Senses, unreliability of, 118. Sensibility, forms of, 12. Scopolamin anesthesia, 44. Sideroscope, 136. Sigmoid-flexure, 89. Solar rays, 128. Sorgo treatment, 128. Spinal cord, vessels of, 65. Spinal cord, concussion of, 123. Spinthariscope, 116. Splanchnic nerves, 9. Splanchnic neurasthenia, 13. Splanchnoptosis, 185, et sea. Splanchnoptosis, pelvic, 101. Spleen, functions of, 106. Spondylectrode, 96. Spondylopressor, 9, 34, 51, 74. Spondylotherapy, 1. Spondymobile gauge, 110. Sthenometer, 193. Stomach, 81. Stomach, action of salt on, 130. Stomach, dorsal resonance of, 84. Stomach, percussion, 123, 145, 152; 153, 163. Stomach, records of contractions, 167. Stomach, reflex, 146, 147. Stomach, ulcer , 128. Stretcher, 21. Suggestion, 31, 36, 117. Supporters, abdominal, 101. Sympathetic, cervical, 76. Sympathetic, demagnetization of, 162. Symptoms, 200. Tabes, 66. Tachycardia, 52, 75. Telekinesis, 193. Temperature; 168. Terrestrial magnetism, 140. 217 Progressive Sp on dylo therapy Tetany, 71. Thought, 190. Thyroid extract, 77. Thyroid gland, 71. Thymus gland, 71. Thyrotoxicosis, 71. Tone, 8, ISO, 162. Tonicity, 175. Tonometry, visceral, 6. Tractors, 134. Tuberculosis, 104. Tympanites, gas-trie, 84. Tympanitic, sound, 124, 147. Uric acid, 20. Uterine myomata, 73. Uterus, prolapse of, 101. Vagus, 10, 74, 75, 153, 161. Vagus, enervation of, 10. Vagus, visceral methods of, 14. Vasoconstriction, 67. Vasodilation, 67. Vasomotor mechanism, 62. Vasomotor neuroses, 62. Vertebrae, reaction to pain, 17. Vertebrae, 'tenderness of, 17. Verumontanum, 108. Vibration, 206. Visceral, attraction and repulsion, 156, 184, 203. Visceral, demagnetization, 160. Visceral, disease and backache, 17. Visceral, muscle, 7. Visceral, pain, 25, 27. Visceral reflexes, 7. Visceral, tone, 8, 150. Visceral, tonometry, 6, 10. Vital- force, 178. Vomiting, of pregnancy, 84. X-rays, 125, 129, 158, 205. PROGRESSIVE SPONDYLOTHERAPY 1914 CONTENTS Spondylotherapy Spondylotherapy in General Practice Vertebral Tenderness and Visceral Disease The Circulatory System - Angina Pectoris Cardiac Insufficiency Heart Reflex - Blood-Pressure The Digestive System - The Pylorus Gall-Bladder - Splanchnic Neurasthenia - Miscellaneous Data Poliomyelitis Trigemmal Neuralgia - Cerebrasthenia - Radicular Roentgenotherapy - Urticaria and Migraine - Pigmentation of the Skin Movable Kidney - - Malaria - - - - - Pelvic Level - Prolapsus Uteri ... Painless Labor .... PERISCOPE OF PROGRESSIVE SPONDYLOTHERAPY* 1914 SPONDYLOTHERAPY. J. Madison Taylor, A. B., M. D., of Philadelphia, in the Monthly Cyclopedia and Medical Bulletin (July, 1913), in a contribution, "An Appreciation of the Teachings of Dr. Abrams," refers to the detached and fragmentary atten- tion accorded to the "spinal reflexes" by the medical profession. He continues: "Dr. Abrams has focused our attention on one, in my opinion, likely to yield increasingly valuable re- turns that of the scope and significance of the spinal reflexes. In his book will be found an impressive aggre- gation of convincing evidence gleaned from the whole realm of scientific medical findings. He has digested this, analyzing and bringing together detached facts, displaying their significance, their practical interrela- tionships, and subjoining his own pronouncedly original interpretations and recommendations. To this achievement he has added the products of a ripe experience and knowledge gathered from the best sources, not only of his own but the personal and hospital service of domestic and foreign leaders in opinion. He *Numbers in parentheses (not italicized) refer to the pages in "SPONDYLOTHERAPY" where the subject has already been discussed. When the numbers in paren- theses are italicized, they refer to the pages in "PROGRESSIVE SPONDYLO- THERAPY," 1913. Progressive Spondylotherapy has presented his postulates, inferences, and conclusions to the candid criticism of those whom we have learned to regard as competent judges of survival values. Although he has made a deep impression upon the consciousness of many a reputable physician, the very brilliance of his findings, the simplicity of his remedial principles, the unusual promptitude of his results in many heretofore-called incurable states, induce sus- picion and doubt in the minds of those who refuse to examine the evidence or give him a fair hearing. How- ever, the ground for my welcoming this new angle of vision, this novel explanation of long-obscured phenom- ena, did not grow overnight, but is the logical result of much browsing along unfamiliar paths, noting appear- ances, and studying illuminating principles of physiology and therapeutics. It seems to me, there is now soon to be reduced to an exact science the genus and differentia of a domain of clinical medicine which will warrant the judicious consideration of all whose aspiration it is to relieve the sufferings of mankind. The significance of reflex irritation as an etiological factor in physiological disorders is obviously a large one, demanding the most thorough investigation. There exists here a vast array of findings awaiting expert study. When we come to the domain of psychopathies the re- search has only begun. At the present time, medical literature is full of contributions from psychopatholo- gists and those who enjoy the conviction that they come within this class. These are not only those who really know something about psychopathic and neurotic phe- nomena, but a larger group convinced of the adequacy of psychopathological findings to explain and cure any malady. Freud and his disciples offer much ground for curing through psychoanalysis, accepting as their ques- tionable credo the sexual impulse and its endless divaga- tions. Sidis shows plainly that the fear instinct domi- nates all other causal agencies. So of other lines of evi- dence. Back of all lies the domain of physical deter- Progressive Spondylotherapy minants of [psychopathic [phenomena. And the major portion of these are sources of reflex irritation causal agencies working through spinal nerves. Among the more recent and promising propositions is the postulate of Upson, of Cleveland, that dental irri- tation, especially non-sensory forms of irritation im- pactions, deformations, latent abscesses, and the like offer ground for the elucidation of physical deteriora- tions, psychopathies, insomnias, and even insanities. My experience leads me to feel great confidence in this view. In brief, we have no right to abandon hope, in a host of baffling conditions, until all avenues of possible reflex irritation are searched. Until we have greatly amplified our knowledge in many directions, we cannot search confidently or hopefully. The light which Dr. Abrams' researches afford is the largest source of illumination and I, for one, welcome it with thankfulness." S. Edgar Bond, B. L., M. D. of Richmond, Indiana, in The American Journal of Clinical Medicine (Aug. 1913), in an article, "Spondylotherapy; a New Therapeutic Method," deplores the inability of the world to appreciate an innovation which disturbs preconceived notions. The medical profession is particularly bitter against anything new and the individual who proposes any advance to cure an incurable disease (so-called) becomes the object of such abuse that he is indeed a lion-hearted man who ventures to face such opposition. In consequence of this attitude many brilliant discoveries are lost to the profession. "The fact that men and women foremost in the ranks of scientific medicine are investigating and using Spondylotherapy in hospitals and daily practice with such remarkable success in the cure of so-called incurable diseases has aroused the inter- est of the medical profession as few things have done in the last few years." 3 Progressive Spondylotherapy Thanks to Dr. Albert Abrams, who originated the term "Spondylotherapy, "his scientific findings have rescued spinal work from vague uncertainties and unscientific pretensions which have marked the reign of the charlatan and narrow misguided spine and bone manipulator. "We realize that some self-constituted 'censors' of medi- cine who, without study of the breadth of Spondylotherapy and investigation of the spirit of its founder, are fearful there is a new "cult" appearing upon the alreadv overcrowded medical horizon." Spondylotherapy is the most scientific adjunct to the practice of medicine and will turn back clinical medicine into its own. No one using Spondylotherapy employs it exclusively. The spine has heretofore been regarded from an ana- tomic and physiologic viewpoint, but we must now look at it from the clinical standpoint representing as it does, centers from which reflexes may be evoked to be utilized in the treat- ment of disease. Almost positive proof of our diagnosis may be obtained from the fact that vertebral tenderness (71) at definite spinal segments is indicative of certain visceral affections. Thus: tenderness over the 4th lumbar spine of the female suggests uterine disease; at the 3rd, ovarian; on the right side of the 2nd lumbar, appendix; at the loth, nth and i2th dorsal, the kidneys, etc. "A well-known, albeit recent student of reflexotherapy enthusiastic with his results was bewailing his failure to trust its keeness of diagnosis and related an experience. 'I was called to see a patient who was suffering keenly from an acute pain in the region of the appendix. My only thought was an immediate operation until examination of the spine failed to reveal any tenderness over the segment related to 4 Spondyloth e r a p y the appendix (2nd lumbar) although extreme tenderness was present over the segments related to the kidneys. On the third day, chemical examination of the urine by another physician demonstrated nephritis and by aid of spinal methods the patient quickly recovered. Complications following the proposed operation would I am sure, have proven fatal." "Recently, a friend of mine, after he had seen the eyes of an exophthalmic patient recede and protrude under the excitation of the reflexes (74) and had the same comfirmed by a third physician, said, 'I saw it but don't believe it.' "Spondylotherapy cannot supplant scientific medicine but is its handmaid and the greatest foe to the careless use of the unreliable galenicals and shotgun prescriptions, and of the patent-medicine vender, just as broad scientific medicine is always a foe to quackery in all its forms." Sir James Barr, M. D., L. L. D., F. R. S. E., in his President's address at the i8th annual meeting of the British Medical Association, referred to reflexology as follows: "The versatile genius of Dr. Albert Abrams, who has come all the way from San Francisco, to do honor to this meeting of the British Medical Association, has taught us how best to cure intrathoracic aneurysm and he has shed light on the nature of the cardiac and respiratory reflexes. In the treatment of diseases of the heart and lungs his work does great credit to the new Continent and he has also given us further insight into methods of prevention." In his thesis (Contribution a V6tude de la REFLEXO- THERAPIE (636, 1} presented to the "University of Toulouse," Jean Vaquier, comments on the remarkable therapeutic re- sults achieved by reflexotherapeutic methods. 5 Progressive Spondylotherapy In attempting to explain these results, he quotes Brown- Sequard who said with reason, that it is impossible to irritate any sensory region of the organism without causing some disturbance of nearly the entire nervous system. The same observer remarked that it often only sufficed to seize a cat by the skin in the cervical region to evoke an epileptic paroxysm. Physiology is nought else but a summation of reflexes. In pathology we are likewise dealing with a series of reflexes; the presence of intestinal parasites will produce meningeal symptoms; cold acting on the feet may conduce to tympanites and colic and cutaneous burns may lead to ulceration of the intestinal mucosa. The President, Dr. Remond, and the Dean, Dr. Jeannel, in commenting on the thesis of Vaquier observed that it was quite impossible to attribute the results achieved by reflex- otherapy to suggestion or the impressionable state of the subject. Assuming for argument, however, that suggestion is the basis of the therapeutic methods, then the latter should be employed nevertheless for the chief object of the physician is to relieve or cure his patients. SPONDYLOTHERAPY IN GENERAL PRACTICE. The following abstract is from a contribution by Charles L. Ireland (Columbus, Ohio), which was read at the recent convention (Sept. 30, 1913) of "The American Association for the Study of Spondylotherapy" Chronic SUBINVOLUTION, chronic ENDOMETRITIS, VER- SIONS, FLEXIONS, PROLAPSED UTERI, PROLAPSED OVARIES and RELAXED VAGINAE are as a rule easily corrected and cured by the intelligent use of Spondylotherapy (100). The same applies to atonic and spastic CONSTIPATION (327). 6 Spondylotherapy in General Practice In the examination of a patient one must primarily search for vertebral tenderness and the localization of the latter is dependent on the organ involved (71). By aid of Spondylotherapy relief and cure are now more easily attained than heretofore. A case of METRORRHAGIA may be cited: A woman has been flowing and dribbling for six months. All methods of treatment have proved futile. If the uterus is not ectopic or there is no fibroid, excitation of the UTERUS REFLEX (358, 1 06) will after several treatments bring about complete relief. If in confinement there is HEMORRHAGE caused by a re- tained placenta, excitation of the uterus reflex by pressure or concussion of the first three lumbar spines will arrest the bleeding. This method to control hemorrhage and expel the placenta is more efficient than Crede's method or the use of ergot. In AMENORRHEA (notably in young girls), sinusoidaliza- tion for the treatment of SPLANCHNIC NEURASTHENIA (434) is most efficient. The later condition is frequently responsible for malposi- tion of the uterus owing to the added weight of the accumu- lated blood in the splanchnic area. PROLAPSED OVARIES (without adhesions) may be re- stored to their normal position by concussion or sinusoidal- ization of the loth, nth and i2th dorsal vertebrae. This latter appears chimerical but is nevertheless true. In the differentiation of APPENDICITIS and OVARITIS, definite localization of the areas of vertebral tenderness (75) is invaluable. In the treatment of RECTOCELE, sinusoidalization at the 4th lumbar spine, in CYSTOCELE at the ist lumbar spine and at the latter spinous process in ENURESIS, is very effective. Progressive Spondylotherapy In HEPATIC CONGESTION, by evoking the liver reflex of contraction (331) and contracting the gall-bladder ' V 6oo), relief is secured in a few minutes whereas the use of calomel is only effective after 24 hours. The latter observation sug- gests the query, Why use calomel^ The pains of a DUODENAL ULCER are relieved in a few minutes by concussion of the loth dorsal spine to augment the flow of pancreatic juice (pp) and thus alkalinize the chyme which has escaped into the duodenum. In GALL-STONE COLIC, concussion of the gth dorsal spine (599), by securing a larger opening for gall-stones is often effective. In two patients with CARDIOSPASM (80, 589) who suffered from regurgitation of food, prompt relief was secured by sinusoidalization between the 3rd and 4th dorsal spines. Opening the PYLORUS (82) by mere pressure with the thumb on the right side of the 5th dorsal spine will give almost immediate relief in gastric indigestion. This method is also available in the use of nauseating drugs (82). Instead of employing the nauseating stomach-tube for lavage, the patient is instructed to ingest two quarts of water (containing some antiseptic if necessary), and then by pressure at the 5th dorsal spine, the contents of the stomach are evacuated into the duodenum. In the diagnosis of DUODENAL ULCER one may at once precipitate an attack of pain by pressure at the 5th dorsal spine for reasons already cited (84). Many cases of duodenal ulcer have been cured by other physicians and myself by sinusoidalization or concussion of the loth dorsal spine (99) with the object of increasing the flow of pancreatic juice, thus subjecting the ulcer to a con- tinuous bath of alkaline secretion. 8 Spondylotherapy in General Practice Many paroxysms of HAY-FEVER may be jugulated by concussion of the yth cervical spine and repetition of this maneuver on subsequent days is often curative. Symptomatic cure has been achieved in two cases of PROSTATIC HYPERTROPHY by suiusoidalization of the i2th dorsal spine (634) supplemented by chromium sulphate(635). In early PHTHISIS excellent results may be achieved by increasing the vascularity of the lungs (602). "When a nursing mother finds her milk deficient in quantity and fears that she will have to wean her baby, in lieu of augmenting the diet to produce more milk, concuss or sinusoidalize the 3rd and 4th dorsal spines. Three or four treatments usually suffice to stimulate the mammary glands to normal activity." This treatment for AGALORRHEA has been employed suc- cessfully in a number of patients. "There is one class of patients that I am anxious to en- counter, and that is cases of apparent ELECTROCUTION from contact with high tension electric wires. In the case of every electrocution, death has been produced by profound shock of the vasoconstrictor nerves sup- plying the heart and blood-vessels. An electric current sufficiently strong to produce death will contract the arteries to such an extent that the heart is unable to pump any blood through them. Here I would apply a powerful sinusoidal current or concussion to the vaso- dilator centers, viz., 3rd, 4th, loth, nth and i2th dor- sals; alternating this treatment with concussion or sinu- soidalization of the 4th cervical and 8th dorsal spines to contract the diaphragm, and force air from the lungs to assist in breathing. Then I would use the interrupted sinusoidal current at intervals of one minute at the vaso- dilator centers. Should the heart not respond, I would alternate with the sinusoidal current or concussion at the centers corresponding to the vasoconstrictor and vaso- dilator nerves of thejieart. 9 Progressive Spondylotherapy In conclusion, I want to add one more thing to Spondylotherapy which I believe will alleviate much suffering. This refers not only to painful menstruation but also to child-birth, viz., DILATATION OF THE CERVIX. After experimenting with about fifty cases, I find that by concussion or rapid sinusoidal current applied to the loth dorsal vertebra, you will get a rapid dilatation of the cervix. By this aid you may assist nature to accom- plish this dilatation more rapidly than by depending upon the labor pains alone and hasten the time of con- finement by reducing the pain to a minimum. Some of you may think that by rapid dilatation the patient is in danger of hemorrhage, but by having the vasocon- strictor nerves under your control you can easily obviate any seriousness of that nature. Before this treatment is tried the operator must have a full knowledge of the vasoconstrictor and vasodilator centers." Dr. B. E. Dawson (Kansas City, Mo.), contributes the following concise report: "Cullen said, 'There are more false facts than theo- ries in the world.' It certainly is true, that many state- ments labelled, 'Facts,' are soon relegated to oblivion. Many laboratory facts are false in the sick-room; many facts in the test-tube are false in the human system; the enthusiast with one idea often presents 'facts'? that are absolutely false. We are living in an age of doubt, demanding demon- stration. Facts must be confirmed by the rigid test of experience. A great fact may be so obscured with so- called facts, as to retard its progress or mar its utility. While all truth is eternal, and all truth is Divine, it may be prostrated and lie supine, held there by error, until rescued by those searching for it. No man makes truth, he reveals it. After it is revealed, it must often fight for recognition. Innovations are usually unwel- come and meet with strong opposition. Dr. Abrams has more recently discovered and re- vealed to the world another great and marvelous truth 10 Spondylotherapy in General Practice that of making a switch board of the spinal column, whereby we can send a message to any viscus. We thus get the reflex of contraction or dilatation; we reach the sympathetic via the cerebro-spinal. This truth is fight- ing over the same battle-ground as did its predecessors for recognition. The orificialist can readily grasp the truth of Spondylotherapy, because he has made a close study of the law of reflexes. He is ready to receive it and test it out; he has been waiting for Spondylotherapy as an aid to his own work. Speaking somewhat loosely, or, in a limited way, using the license of liberty, granted in figures of speech, 'Orificial Surgery' sends a massage to the mother of the body household economy, and she then commands the children. Spondylotherapy speaks to the children, commanding or encouraging them to do their proper work. What a boon to the mother, when a child is in the dumps, or fired with anger is working too fast, or doing the wrong work, to have a kind friend assist in setting things right. What a great help when Orificial Surgery has sent the message to the mother, and she is doing her best to get the children in line, to have |this Jbig brother step in among these children and render his assistance. I attended Dr. Abrams' class last November, and was delighted with his instruction and charmed with his demonstrations. He told us that concussion of the spine of the fifth dorsal vertebra would empty the stomach into the duodenum (5 88, 82). On the morning of the last day of his class, I got up with a violent sick headache, a very unusual thing with me. I braced up and went to the class room, where in a short time I felt impelled to leave the room for emesis. I informed Dr. Abrams of my condition, when he requested me to come forward, take a seat before the class and remove my coat. He then concussed the spine of the fifth dorsal, for a few seconds, when to my surprise and relief, my nausea was all gone. This confirmation was intensely personal, and the evi- dence of the witness was indubitable. 11 Progressive Spondylotherapy The next morning, on the train, on my way to Kan- sas City, the negro porter rushed into the wash room of the sleeper, asking: 'Is dar a doctah in heah? Bar's a mighty sick lady in de cah wants a doctah!' I followed him down the aisle to the patient, who had been suffer- ing all night with a sick headache; she was retching with extreme nausea. With my plexor and pleximeter, I con- cussed the fifth dorsal spine, which gave her immediate relief. The next morning after my arrival, my daughter came to me for relief from a severe neuralgic pain in the left subscapular region, also extending to the shoulder, greatly interfering with motion. Remembering the therapy that Dr. Abrams taught me in handling these cases, I searched along the spine for tender spots and found and froze them with prompt and permanent relief. That same evening a lady, eight months enceinte came into my office suffering with PLEURODYNIA. She walked with great difficulty, holding her hand to her side, unable to stoop. I found the tender spots and froze them with the same prompt relief as in the preceding case. As she was readjusting her clothing, she was very much surprised and delighted to find she could stoop or bend the body in any direction without pain. Two cases of CARDIAC ASTHMA, in old men, were readily relieved by concussing the spine of the seventh cervical. One old gentleman would stagger into my office, gasping for breath, unable to talk. As soon as I began to concuss the spine he would almost shout with ecstasy, for the immediate relief obtained. At this writing I am treating a case of EXOPHTHAL- MIC GOITRE, which came to me a few days ago from Iowa. She was recently operated on at Rochester, Minn, but received no benefit (only in reduction of the gland). Her nervousness is much aggravated since the opera- tion; insomnia, crying, great fear of impending danger, hot flushes, choking, etc. With four treatments of pres- sure on each side of the seventh cervical, she has calmed 12 Vertebral Tenderness and Visceral Diseases down, sleeps most of the night, all symptoms are im- proved and the exophthalmos is less pronounced. Other cases could be related, but these are sufficient for the scope of this brief paper. Spondylotherapy has come to stay; it is a help to the physician and a boon to the patient. The diagnostic feature of Spondylotherapy, to the earnest physician, is as bread to the hungry man; mathematically accurate, it is as a compass to the sur- veyor; stumbling in darkness, it is to us a bright light. Every orificial surgeon needs Spondylotherapy; it is a great aid to his work. Great is Spondylotherapy." VERTEBRAL TENDERNESS AND VISCERAL DISEASES. This subject has been fully discussed elsewhere (74, 376, 17). The Griffin brothers (2) in 1834, associated spinal tenderness with certain symptoms. At one time, a number of itinerant physicians relied solely on vertebral tenderness in definite regions in the diagnosis of disease. This method of diagnosis was based on a chart (Fig. i) published by Dr. Sherwood in 1841, in his work, "Motive Power of Organic Life." The clinical findings of Dr. George O. Jarvis, are inter- esting and are embodied in the following contribution : "The reported cases were subjected to operation during the past six months. None are included except those in which two separate diagnoses were made; one based on what one might term 'clinical' evidence and the other determined by such reflex signs as vertebral tenderness and the results of percussion by the vago-visceral method (321, 14) of Dr. Albert Abrams. By 'clinical' evidence is meant such signs as subjective tenderness, palpable tumor, muscular rigidity, fever, and the leucocyte-count. Nearly all of the cases were frozen one or more times over 13 Progressive Spondylotherapy the areas of spinal tenderness, both to relieve painful symp- toms and to assist in diagnosis. Freezing over the Qth thoracic or 2nd lumbar vertebra will, in APPENDICITIS, miti- gate the pain and abdominal tenderness. This relief lasts from a few hours to a few days according to the severity of the attack. In the so-called /PSEUDO-APPENDICITIS' (191), Comcal vertebra. FIG. i. Illustrating Sherwood's method of diagnosis oy pressure along the spinal column to find tenderness at various points corresponding to morbid condi- tions of the organs. in which the difficulty is a lumbar neuralgia with spasm of a segment of the rectus muscle, a few freezings suffice to cure as was pointed out by Dr. Abrams (Loc. Cit.}. In OVARIAN NEURALGIAS, freezing at the level of the 3rd lumbar vertebra produces marked and immediate relief. "None of these cases came to operation unless they had passed through previous attacks and were unrelieved by 14 Vertebral Tenderness and Visceral Diseases treatment or unless the leucocyte-count and other symp- toms made the presence of an abdominal abscess almost cer- tain. Indeed, all those in whom the spondylo-diagnosis pointed to appendicitis, except two chronic ones with thickened appendix, proved to be pus cases. The areas of spinal reflex tenderness were found to co- incide with those ascertained by Dr. Abrams and Dr. Chas. L. Ireland and are as follows: Tenderness at 5th and between 5th and 6th thoracic spines, Gastric disease; Tenderness at loth to I2th thoracic spines, Renal disease; Tenderness at nth thoracic and tip of nth rib, Chole- cystitis; Tenderness at 2nd lumbar on right side, Appendicitis; Tenderness at 8th or Qth thoracic, Appendicitis; Tenderness at 3rd lumbar (on side of disease), Ovarian disease; Tenderness at 4th lumbar, Uterine disease; Tenderness just below 3rd lumbar spine seems to indi- cate tubal difficulty; though in this case the diag- nostic information obtained has not been clear. The area of spinal tenderness usually extends both above and below the point or points of greatest tenderness; that is, above and below the segment of the cord with which the sympathetic nerves of the diseased organ communicate. This is in accord with the well-known fact that irritation of a spinal segment which is either powerful or prolonged will produce a hypersensitive state in the neighboring nerve cells which will be evidenced by pain and tenderness and some- times exalted function. This is noted in angina pectoris.* *Mackenzie: Symptoms and their Interpretation. 15 Progressive Spondylotherapy In some instances of angina, muscular rigidity and spinal tenderness can be found from the occiput to the lumbar region of the cord and excessive secretion of saliva is not at all uncommon. As a rule, however, the points of greatest tenderness will be limited to those cord-segments directly connected with the sympathetic nerves supplying the heart. It will, be noted from the accompanying table that TUBAL DISEASE was not diagnosed in five out of ten cases by 'clinical' methods. OVARIAN DISEASE was thought to be present only once 'clinically' but five times by spondylodiag- nosis. APPENDICITIS proved at operation to be the only difficulty in six out of twelve cases. In the other six it was associated with and may have been caused by pus in the Fallopian tubes. In one case appendicitis was missed 'clinically' and diagnosed by spinal tenderness; while in another, it was thought to be present by 'clinical' methods and declared to be absent by spondylodiagnosis. In both instances the reflex findings were found correct at operation. One case, the nature of which was not determined clinically except that there was a pathologic condition in the abdomen demanding surgical intervention, was correctly diagnosed by extreme tenderness at the right side of the fifth thoracic vertebra as perforated gastric ulcer, probably located in the pylorus posteriorly, "j" It may be thought that such wide errors in diagnosis as are here recorded are scarcely permissible; but this is not an apology it is a statement of fact." tit is often possible to locate in consequence of unilateral vagal hyperesthesia (504) the site of gastric lesions (anterior or posterior stomach-wall) by recalling that the right vagus innervates the posterior and the left vagus the anterior sur- face of the stomach. 16 Reflexo-Clinical Table of Vertebral Tenderness .2 "rt 1 i, i M gs . a '5 !s 5 o 3 'H *- a a D. S "s "3 u ^ in CO 5 i [3 '3 _'H ^ s _>>:= >. 1 h "u "3 ^ a> "jj tn "S s X "2 c * >, j? Js 1 i 8 t/i O i 1 o a S s^S. I 1 's * o) T3 i I ,? '1 g 1 l|g o s s O ' 1 ^ 5s'| a & 2 a 1 o J3 M a o 1 g 1 a a> "3 y o *^ " C Q. .Sg c . a !S *S . o C Q |l O P3 . raj= _i be -< O as 1 e j -i "1 E i-l 1^ a y .g | a o u | O S> *** o B *" d O f| II is ii o" 11 O o o a m 'i I II s M "J IS" w O O rf o 1*1 C e I g B a 6 2 1 CJ 1 % > o S a - O 2 13 2 3 2 Q Z z o 's 3 T3 d c -H 0) o 2 C 5 .2 O T3T3 g M a Pus -tubes dicitis. g-5 Ovarian a disease Pus -tubes appendl Cholecyst! Pus-tubes appendl Appendici Pus-tubes Appendici Uterine ai ovarian %j 2 B o o i | 2 en a> . V 2 < a 1 s- 2 2 'o '% 3 i "o s S 3 a * S c 3 to 1 o a 3 e 1 5 S 1 1 II i B "o J3 a I B 1 o. 1 .0 JC f- 1 Di < U < u o M ol Z H "^00 M* ** 00 "i ^ ->VO Q' M U n a w" >^ N S" ci N 9 J d" d" . M to S M -, 1 " s o .2 2 2 , M % $ 9 2 * S i 2 S S 17 Progressive Spondylotherapy .a g-g i*Ji ||| |SS 3 a y*^ ** C ,&]1| 1-al "S tl C 11 3 ** a 0" ^s^ _S5^ 1 " J o| . 2 4~ Bfljg C O CJ.O T S c c* >* O rt=3 ^ I '-I as o z ^ S u'cS C i Ijlf Ft I . lUs M "H" """^ C .XI O-u g^'gx 13 a~ S a,Jl C.-- ts.S i y ^i sVl llK a e ' ? & >-^<^ '^.o_c > (J . ft -r t!.o a _o "rt ^ & ** 1> 3 C C CJ_N Q 55-0 7. o n" 1 |T3U |2^ < i c &. CO a a ^3 "3 = 12 o H CO u &ia o ^IH TION FOUND A OPERATION % a o 2 j u i fl with gangren ad adhesions an abscess on le erine pregnan 5 and uterine inning cancer 1 1 | d I 'i kidney on rig tube on right s ; appendicitis I Appendicit sions i| o Tabo-ovari pendicea Pus-tubes widespre |^| -5"5>- 2 u'C s 3 C -j 2? "ta-* 3 O Tubercular and pus- High grade ^ c -^ -- *a *-[ TJ- i a (*3 ' *J ,A POINTS OF GREATEST TENDERNESS 9 thoracic on right sid o B o _a "a *" 2 -/i ^ 3 SJ !L a ^ S thoracic and 3 and lumbar 4 lumbar on both side J TJ ii o u 10 and ii thoracic, lumbar and just lx low it (both on rigt side) o 1 a K" "5-5 .sg g "3 u 'C.2 ^ J3 a SPONUYI-O- D1AGNOSIS .52 3 a 1 1 tubes and pendicitis ll-abscess 11 11 ine disease 2 If 1 & "o 3 a jl 4 M M "o n 4** J ^ S 3 rt 3 Jl U H D O U 00 1 3 l| ^ & 31 S ^ a 1 1 g o Q 2 2 tn S -o T ex u c-S j 2 ^1 *C a "C _S -' S3 3 *y =a 1 1 I ? 1 fl 1 1 1 III 3 I a a a e i a C 5 u Z H * s ^ s* Hoc * c/i o H^ * P. fa " c/3 w "" (-i" i-;' z N < " h-;'* K " Jo 2 2 2 Jl d 2 2 2 1 H 2 2 5 2 2 J 2 2 2 18 Reflex o-Clinical Table of Vertebral Tenderness REMARKS ze, shape, and position of gall-bladder found at operation to tally with re- sults of percussion by vago-visceral method. terine disease missed by clinical diag- nosis. ersistent pain at 2 lumbar for 6 weeks after operation relieved by one freez- ing. his case would have been hard to diagnose without vertebral tender- ness; which was so marked that patient jumped from bed when the S thoracic was pressed upon. ze, shape and position of gall-bladder found by vago-visceral method of percussion found correct at operation. umbar muscles rigid on right side. Case diagnosed by cystoscopy and segregation of urine. Outline of kid- ney determined by percussion found correct at operation (350, 630). enderness at 2 lumbar did not develop till 2 weeks after first examination while waiting for an interval to operate. his case was really operated for hernia; the nephrorrhaphy was only incidental. ^ze, shape and position of gall-bladder determined by vago-visceral percus- sion found to be correct at operation. tr> D A H BJ J H H CO G s 1 4 1 5S S "3 < 3 T3 "2 .2 8 u *5 c Is T3 J3 o "3 1 5 *.| a O 1 c 1 .o_>, 1 ^'B J3 8 u a CONDITION ] OPERA-; 1 "3 n Ovarian cyst on uterine fibroid Gangrenous appe Perforated pyloi uated posterior a o 1 a S J" Infected kidney and appendici wide-spread ad Appendiceal absc Mobile kidney Gall-stones and bladder S MO -o e -a 6 u a 12 ^ElJJ a J "3 a 01 ^G SiS "> tT 3 3 r* 3 a OINTS OF GREA1 TENDERNESS :horacic and tip rib and n thor lumbar on right and 4 lumbai both sides " a i 1 111 1 a o M J> - ?> c c o *M o s "O fc- 3 fl Jrf C 3s es_u c .2 T3 *M "^ il s a .2 ( j 1 J5 Z'G .2 frw S El J3 a =si cd 2 3 u 1 3 "3 O v 2 r 3 a 12 1 a H 'N i a ^ a." 1 | a i-c 3 "3 u o u aj y U ' II T3-2 2 2" ~j CO 8 a c < " 5 ^ 4? t} Z .2 a .2 2 Vj >l 0*^*0 . "5 ^ 31 2 .^i ij 5 fl 'o r" g a *c x 3 "tj x a o 5! a i 1 | c 1 u o, v o, M I a |=S J3 U u il *! 9 5 S3 . ^ 00 *s M "u 0^ w &< f < *J fed O w Pi 01 < jj i , J . jj d S s % 2 S S ^ ^ s 19 Progressive Spondylotherapy If B '1t * 1 5 ' i '! >.. ^ * I o .2 Illl J4 n) ^ Z d fc rt & S. '" O.^"u G.% O S_2 o'c '*J t/: C . 3 ti &^l V O C N *"" 'Z t~C !75 H H 3 1 V a o O 2 a 55 !f 1 1 O H > in 8 ! S fl tj S| 2 li MT3 13 . *r 1 H a o _bo U < 'S C U [5 2 o o ? i | .y x w rt c Q P M ^2 o r* u O 11 2||. K o O fr d C o ! Jo 1 < So It M rt c 3 V E^d 1 o to | c c Q -~- _0 "CLINICAL" DIAGNOSIS ome kidney lesi (Mobile kidnej tone and infect right kidney in in 3 Q o a & < < ^> H * ^ U 1 S 3 S 20 The Circulatory System Dr. Jarvis formulates the ensuing conclusions respecting his observations: 1. Of the 30 cases in about 30 per cent the "clinical" diagnosis was incorrect as to the organ affected, though cor- rect as to the presence of some difficulty requiring surgical intervention. 2. In no case would conclusions based on the spondylo- diagnosis have led one astray as to the organ involved; although it is difficult to decide from the reflex findings be- tween an ovarian, a tubal, and a tubo-ovarian affection. 3. Spondylodiagnosis alone does not usually yield a complete pathologic diagnosis; but it does accurately point out which organ is involved and, in connection with other "clinical" findings, permits of the greatest accuracy. THE CIRCULATORY SYSTEM. ANGINA PECTORIS.* Dr. George O. Jarvis (Ashland, Oregon), in a study of this subject observes that the phenom- ena accompanying an attack have received little accurate study for the reason that the patients are in such stress that circumstances demand definite action rather than deliberate consideration. After occlusion of a large branch of the coronary artery, blood-pressure falls and the myocardium passes into a state of fibrillation (delirium cordis). In all fatal cases of angina, Osier finds a chronic endarte- ritis with narrowing of the openings of the coronary vessels, Fibrillation is the result of a block produced by inter- ference with the nutrition of a considerable part of the myocardium. A like condition may be evoked by freezing the apex of the ventricle or by stimulating the surface of the *Note the author's classification of angina pectoris (539). 21 Progressive Spondylotherapy ventricle at a rate greater than that which can be taken up by the ventricle as a whole. One may assume that during a paroxysm there is not a sufficient blood-supply to the myocardium but this does not take into account the fact that vagal tone (445) is progres- sively exhausted and is diminished in the interparoxysmal periods. One often finds very low blood-pressure (under 100) when the patient is recovering from a seizure. If the cause of angina were only a mechanic obstruction in the coronary arteries then measures to improve vagal tone would fail to relieve the suffering and we could not under- stand why emotions are more frequent provocative factors of an attack than physical exertion. Emotions and physical exertion by augmenting adrenalin in the blood (33) decrease the tone of the vagus. Asthma is associated with hypertonia of the vagus and adrenalin hypodermically by decreasing vagus-tone will abort an attack (314). On the contrary, by augmenting vagus- tone, one may precipitate an attack of asthma (494). One finds after an attack of angina and between the at- tacks, diminished vagus- tone (10). In all cases of angina examined by Dr. Jarvis during an attack, cardiac dilatation could be demonstrated and the relief of pain coincided with the regression of the dilatation. In all the cases auricular fibrillation was present. The following may be cited as a typic case of angina: The patient was a woman of 72 years, five feet and one inch in height, weighing 100 pounds. There was slight emphysema of the lungs, marked visceral ptosis, constipation, and indigestion. The urine shows % per cent, albumin, fatty casts, 22 The Circulatory System and has a specific gravity of 1015 to 1022. The amount in 24 hours is between 25 and 30 ounces. The case was diagnosed by two other physicians as angina pectoris. She had a number of attacks during the past ten years. These attacks follow mental or physical exhaustion and shock and are sometimes pre- ceded by a premonitory dizziness. There is a sudden onset, she falls to the ground, and fears to move lest she die. There is acute, sometimes agonizing pain in the left arm and shoulder. The lips become swollen and dusky, the face drawn, great dyspnoea with distention and pul- sation of the veins of the neck ensues. The liver is swollen and may be felt to pulsate. There is pain and oppression in the left chest with a feeling of weight and a choking sensation in the throat. The pulse increases in rapidity till it beats 140 or 145 per minute. After the attack has progressed for a short time, the skin and muscles over the left chest, and inner side of the left arm, and the left side of the neck become painful and tender to pressure. The blood-pressure is high. In one attack it was when first taken 220; it then dropped to 215; rose again to 220; once more dropped to 210. It averaged through- out the first half hour about 215. Just after the attack the blood-pressure was 155 and the pulse, which was more rapid the higher the blood-pressure, and ran from 120 to 140, had dropped to 82 per minute. During the time when the pulse was beating 140 per minute there would be an occasional slow ventricular beat; though the auricle was in fibrillation from the be- ginning to the end. The transverse diameter of the heart was 18 cm. when seen the day after an attack at a time when the pulse was 90 per minute and was considerably greater during the pains; dilating till it seemed to fill the whole chest with irregular, heaving waves of pulsation. Heart-block and irregular heart-beat were found in 23 Progressive Spondylotherapy all cases which 1 examined and in one case which I saw about a year ago, the pulse was so slow that I believed there was a 'spasm of the heart muscle' or 'spasm of the coronary arteries'; 'spasms' which I now believe to be non-existent. On examining the same patient in a sub- sequent attack it was found that the auricle was enor- mously dilated and in a state of fibrillation. The ven- tricle was also dilated though not to the same degree as the auricle. The pulse was rapid no to 125; but with periods of slow pulse 50 to 60 per minute. It was found that heart-irregularity increased and decreased pari passu with the increase and decrease of the dilatation; so that there was a relation between the amount of distention of the heart and the degree of its irregularity. a, When it was attempted to reduce the cardiac dilata- tion by concussion at the seventh cervical vertebra, ac- cording to the method of Dr. Abrams' (Spondylotherapy), it was found that concussion for one minute produced much less proportionate effect than the same amount of concussion would in patients whose hearts are dilated but who were not at the time in an anginal paroxysm, or in the same patients during the interval between attacks. The woman whose case I have just instanced, re- quired morphin in. doses of % gram repeated two or three times to relieve the pains in the arm and chest during the more severe seizures and even with this amount the pain lasted for several hours. Concussion at the seventh cervical vertebra employed during the attack reduced the diameter of the heart 5 cm. and of the aortic bow 4 cm. on two separate occa- sions with relief of pain in about 10 minutes, so that the patient soon fell asleep without the administration of any hypnotic. Concussion was more prompt and efficient for relief of pain than morphin. Concussion alone was not as efficient as concussion combined with a hypodermic of i-io grain of pilocarpin (grams 0.0065).* *Vide pages 451. 522, 590. 24 The Circulatory System Pain and tenderness which persisted after the cessa- tion of the actual attack were relieved by freezing at the level of the cord which connected with the sympathetic nerves of the heart. Conclusions: 1. All cases of angina pectoris which I have had the opportunity to examine showed marked dilata- tion of the heart with auricular fibrillation. 2. The cause is arterial disease with blocking of the coronary arteries. Associated with this is a vagal hypotonia which becomes more marked the longer the attack lasts. 3. The blood-pressure is high at the beginning, sometimes dropping to 100 mm. or less at the close. 4. The pains are due to a viscero-sensory reflex and may be relieved by freezing at the appropriate areas of the spine. 5. The most efficient method [of treatment is by concussion at the level of the seventh cervical vertebra, associated with the hypodermic use of some drug such as pilocarpin to increase vagus tone." The author has found that in MYOCARDIAL INSUFFIC- IENCY, the ingestion of cold water will dilate the heart. This explains anginoid symptoms after or during the ingestion of food. Dr. J. A. Hirsch (Edwardsville, 111.) has successfully treated ANGINOID PAINS by concussion of the four lower dor- sal spines (227). The same writer reports a case of PALPITATION due to motor insufficiency and dilatation of the stomach in which the attacks were relieved by concussion of the 5th dorsal spine to open the pylorus (83) and the patient was cured by concussion of the first three lumbar spines to overcome the motor insufficiency of the stomach (317). 25 Progressive Spondylotherapy Dr. Hirsch also reports a patient with TACHYCARDIA who was cured by concussion of the yth cervical spine. The duration of treatment was one month (52). C. and G. Minerbi (Rivista Critica di Clinica Medica, Firenzi) contribute important researches on the subject of the AORTIC REFLEXES (254). CARDIAC INSUFFICIENCY. The author's treatment of this affection has already been noted (510 et seq.}. Dr. J. A. Hirsch, reports a case of MITRAL INSUFFICIENCY with cardiac dilatation which was symptomatically cured by concussion of the 7th cervical spine. Dr. Edward S. Smith (Bridgeport, Conn.), reports a case of cardiac dilatation with a systolic murmur at the apex suggestive of mitral insufficiency which disappeared per- manently after one treatment by concussion of the yth cervi- cal spine (525). Dr. Myer Solis-Cohen (Philadelphia), reports as follows: "A pathetic incident occurred at the 'Philadelphia General Hospital' last winter. While contracting the heart of a patient, I noticed a patient with CARDIAC ASTHMA in the next bed fighting for breath. Three minutes percussion (at the 7th cervical spine) gave the latter complete relief. I asked the resident who had just come on the service, if I should not leave the hammer with him for use in a subse- quent attack but he said he would rather see me demonstrate its use. At my next visit, I was informed by the nurse that on the following night the patient had succumbed in another dyspneic paroxysm and clamored for the hammer which was not obtainable." HEART REFLEX (Influence of posture). Reference has been made to the heart reflexes (199 et seq.}. The cardiac sign of Gordon (Brit. Med. Jour., May 31, 1913) in CANCER 26 The Circulatory System has prompted me to study the amplitude of the heart reflex of contraction as influenced by posture. Gordon's sign consists in a great diminution of the cardiac dulness in the recumbent posture as determined by digital percussion. In a patient with cancer, the cardiac dulness in the recumbency begins above about the 4th or 5th costal cartilage, has its right margin one-half or one inch to the left of the mid-sternal line, and measures across less than 2 inches at the level of the 5th costal cartilage. In many cases it measures less than one inch across. In many cases there is no cardiac dulness at all. In 1908 the author studied a series of 103 cases, in all of which there was suspicion of cancer. In 38 of these cases, in which a presumable cancer was accessible to direct examination, or was examined at operation, or post- mortem, 89 per cent, showed the cardiac sign. In 46 cases which were not supposed to be cancerous, it was present only in 24 per cent, of cases. In another recent series of 107 cases, it was demonstrated that, whereas in cancerous cases the sign is present in a very large majority, in non-cancerous cases it is even rarer than the first series suggest. Gordon's explanation of the phenomenon is unsatisfac- tory. It is most probably caused by the elicitation of the heart reflex of contraction by the negative discharge of energy from carcinomata (84 et seq.). Why is the reflex in question only in evidence in the recumbent posture? My investigations demonstrated that the heart reflex when evoked has double the amplitude in the recumbent than in the erect posture owing to the fact that the tone of the cardiac musculature in recumbency is rela- tively diminished and in consequence it more readily re- sponds to influences which evoke the reflex. The foregoing fact is of importance in cardiotherapy when it is necessary to elicit the reflex in question. Thus, 27 Progressive Spondylotherapy in the treatment of cardiac dilatation the results are more effective and rapid when concussion of the yth cervical spine is executed during recumbency. AUGMENTED BLOOD-PRESSURE. Blood-pressure has al- ready received consideration (234, 53). In women pressure is approximately 1015 mm. lower than in men. In athletic men it may be 10-15 mm. higher than in moderate development. Normal pressure may be roughly estimated by allowing i mm. of mercury for every year after the age of 15 and adding 100 to the number. Thus, in a patient whose age is 60, one should expect a normal pressure of 160 mm. Reduc- tion of hypertension is not always indicated as is illustrated by the following case: An individual has a blood-pressure of 260 mm. In his case renal insufficiency is present. In estimating the urea in the urine, one must remember that its percentage varies with the amount of proteid food ingested. Before concluding that the urea is diminished (hypoazoturia) an ample mixed diet must be given. If during one day a test diet of 500 grams of meat, 8 eggs and 200 grams of bread (a total of 172.25 grams of proteid) is given, the excretion of urea in the norm should be 59 grams. This amount of urea was excreted in our patient with a pressure of 260 mm. When the latter was reduced to 200 mm. the amount of urea excreted with the diet in question amounted to 30 grams and the patient suffered from minor symptoms of uremia. By aid of a purin-free diet only, the pressure fell to 220 mm. Rest in bed is one of the most important aids in the treatment of the hypertensionist. One not infrequently observes that an individual having a blood-pressure of 200 mm. or more, when up and about may show a pressure of 28 The Digestive System 140 mm. or less when at rest in bed. This is important insomuch as continued hypertension may conduce to arteriosclerosis. Relative to the permanency of results secured in hyper- tension by concussion (249), Dr. H. C. Sawyer (San Fran- cisco), reports the following case: "Widow 62. Had hyperchlorhydria, polyneuritis and a blood-pressure of 210 mm. Was treated for many months at a sanatorium by rest, diet, Nauheim baths, etc., without any result in bringing the pressure at any time below 160 mm. Concussion executed every other day between the 3rd and 4th dorsal spines for two months eventuated in a reduction of pressure ranging from 128-130 mm. where it has remained permanently for one year (the pres- ent time of writing), 'excepting that on several [occasions after emotions the pressure rose to 140-145 mm. for a day, returning, however, to 130 mm." THE DIGESTIVE SYSTEM. Dr. F. J. Roemer (Waukegan, 111.), reported the follow- ing anamnesis of PSETJDODYSPEPSIA (197), which I shall per- mit him to tell in part in his own inimitable w T ay: "Anypain, the cause of which cannot definitely be located is called rheumatism; so also, any trouble, ache, pain, or discomfort near the epigastrium is called stomach trouble, and if we are entirely at sea and have lost chart and compass, or rather never had them we say : 'Oh, that is Reflex-stomach trouble? or 'Nervous dyspepsia.' But really, diseases of the stomach have been divided into two great branches: First. Such that we know all about; Second. Such that we ought to know all about. The diseases of the second branch are in the majority and are called: 29 Progressive Spondylotherapy 'Nervous diseases of the stomach' The etiology, path- ology and symptomatology of this great branch can be found (?) in any of the latest and best books on stomach diseases. I am reporting just one case : "Miss M. had been complaining of a pain in the ex- treme north-west corner of the left lumbar region for at least thirteen years. Pain like a ball pressing there, which would increase gradually for twenty-four hours in severity. When pain was at its height, vomiting of in- gested food if recently taken, or just glairy water or mucus ensued, which gave slight relief for a time. The attacks would last from two days to two weeks, and were modified by rest and aggravated by work or even by walking. If an attack were subsiding and she got on her feet too soon the pain was increased and all the symptoms returned. She had to be careful of what she ate and how she ate it. (At least she thought so.) Hot dry applications gave some relief. Any food or liquid, either hot or cold, would be immediately vomited if taken while pain was present. At times she would go for six months without an attack ; during which time there was no pain from eating or drinking but a continual nauseous feeling as though it might be easy to vomit, although she would not vomit. There was no particular pain in stomach or anywhere else. She never could tell what precipitated an attack. On lying down or when lifting heavy objects she had noticed a pain in her back in the lower dorsal and upper lumbar region, with discomfort in back present all the time, but it never seemed to get worse at time of pain in abdo- men, so it was never thought of in connection with abdominal trouble. It had become very much worse for the last three or four years, although she had been treated by many prominent men who diagnosticated her trouble as splenic, ovarian colonic, etc., etc. The treatment ranged 30 The Digestive System from osteopathy, pure and simple, to morphin straight, and the patient was getting no better. Returning to my office and having discovered areas of vertebral tenderness incident to a spinal neuralgia, I sprayed her back three times and on the fourth morning I asked her how she felt and the answer was: 'It is the first time in three years that I could eat my breakfast without thinking of what I ate and how I ate it. I enjoy eating once more.' And then the office girl gasped 'Well, how did you do it?' A repetition of freezing several times eventuated in absolute relief of the symptoms." Why do I report the foregoing under the head of STOMACH REFLEXES? "Very evidently the real reflex to the stomach was being irritated because it was not labeled 'STOMACH,' and because it came under the second grand division of diseases of the stomach, and because the men who had tried had not been able to interpret the call of the tissues, nor had they been able to locate the real cause; they thought the trouble was where they thought the pain was, and they thought the pain was where the patient thought it was. They allowed the patient to think for them, to diagnose the case, and they only proceeded to give oh, ye gods! MORPHIN; because morphin is good for pain. L. A. Z. Y. does that spell it? They were honest, honorable men. I think so; really I do. They were practicing medicine as she is taught in some colleges, even today. One should remember that often, at least sometimes pain is felt at the end of the nerve when the cause of the pain is near to or at the origin of the nerve; and loss of function comes first, and a pathological condition comes second." THE PYLORUS. Paravertebral pressure at the 5th dorsal spine or concussion of the latter will open the pylorus (588, 82) and cause the stomach to assume a vertical position. 31 Progressive Spondylotherapy In Chicago, this was recently demonstrated fluoroscopi- cally by Dr. Patrick S. O'Donnell. The latter observes that after the ingestion of the conventional bismuth meal, it takes approximately one hour and fifteen minutes for the stomach to void its contents, whereas after concussion of the 5th dorsal spine, the stomach voids the bismuth in i% minutes. Lebon and Aubourg recently presented before the "Soci& de Radiologie Medicale de Paris" comparative radiographs showing modifications of the large intestine after concussion of the spinous processes of the lumbar ver- tebrae. They also show that vertebral reflexotherapy (639) has given good results in CONSTIPATION. They had ascertained upon administering castor oil, then a bismuth suspension, and finally examining the subject with the x-rays, that electrical stimulation of the right pneu- mogastric nerve in the neck caused contractions of the as- cending colon, sufficiently marked to be plainly visible on the screen at each excitation of the nerve. Similar stimula- tion of the crural or sciatic nerves produced little or no change in the colon. Upon applying one electrode to the right pneu- mogastric and introducing the other into the stomach as a sound, spasm of the ascending colon occurred. Vigorous percussion of the seventh cervical spinous process was found to cause the cecum to rise and the ascending colon to become broader; such effects were observed in all persons examined except one a woman with marked enterospasm and con- stipation. Percussion of the dorsal spines had no effect on the colon until the lowest ones were reached; percussion of these, or of the lumbar spines, brought about contractions of the colon in all its divisions. GALL-BLADDER. The location of this structure by new methods of percussion (598, p), has received repeated con- firmation. Dr. Laurence Selling (Portland, Oregon) reports 32 TA D igestive S y stem as follows; "Only a few days ago, I had occasion to observe the value of gall-bladder percussion by your method. The patient was a woman who had been having indefinite abdominal symptoms for months with occasional presence of bile in the urine. An abdominal examination was abso- lutely negative. The gall-bladder was enlarged as demon- strated by percussion. The operation confirmed the per- cussion-findings; the gall-bladder was enlarged due to the impaction of a large calculus at the opening of the cystic duct." FIG. 2. The upper illustration shows how the erect posture of man forces the heart to pump against gravity whereas in the lower figure the work of the heart is minimized. GALL-STONE COLIC. Dr. D. V. Ireland (Wilmington, O.), reports the following case: "In November, 1912, I was called to see a patient suffering from gall-stone colic who had heretofore only found relief by means of hypodermatic in- jections of morphin. Concussion of the 4th to the 6th dorsal spines with the object of contracting the gall-bladder (599) was executed and within five minutes the pain was arrested. Within 48 33 Progressive Spondylotherapy hours she had a recurrence of the paroxysm which was simi- larly influenced." SPLANCHNIC NEURASTHENIA. Augmented experience of the author demonstrates the frequency of this affection and there is perhaps no one who does not show some minor manifestation of this affection however varied may be its expression. The postural mechanism of the human is so complex that it demands an enormous amount of energy to keep it upright. Our simian ancestors with vessels horizontal and nearly on a level walking on all fours (Fig. 2) put relatively little strain on the heart. The erect posture of man (Fig. 2) forces the heart to pump blood against gravity. MISCELLANEOUS DATA. POLIOMYELITIS. Dr. W. B. Ryder (Clinton, la.j, pre- sents the following report concerning five patients with this disease who were treated by the methods of spondylotherapy : Two sisters (10 and 14 years of age) afflicted syn- chronously. The younger had complete paralysis of the arm. Concussion primarily over 4th, 5th, 6th and yth cervical spines followed later by use of sinusoidal current to the same area. Result: absolute restoration of the arm two months later. The other sister had complete paralysis of both lower limbs. Like treatment employed over 8th to nth dorsal spines. Absolute restoration of the affected extremities. Equally good results ensued in a girl with involve- ment of the right lower extremity and in a boy after one month's treatment." At the same tune in an epidemic in Clinton, two patients who were under the care of other physicians, one is wearing an orthopedic apparatus and the other gets around by means of a chair and is unable to walk. 34 Miscellaneous Data TRIGEMINAL NEURALGIA. Dr. G. O. Jarvis (Ashland, Oregon), referring to the treatment of this affection alludes to the fact that if there is a central factor in trigeminal neu- ralgia (374, 414, j#), a tender spot will be found over the great occipital nerve just behind the mastoid process and also occasionally, over the two upper cervical vertebrae. "No other nerve in the body has such an extensive deep origin in the brain as the trigeminus its nuclei of origin reach from the upper part of the mesencephalon above to the upper end of the column of cells which constitute the sub- stantia gelatinosa Rolandi of the cord. This nucleus is at the level of the second cervical vertebra. The first posterior division of the spinal nerves is rudi- mentary or, occasionally, altogether absent, but the second the great occipital nerve is larger than the corresponding anterior division and furnishes us a route along which we may influence the upper segments of the cord. Dr. Albert Abrams, of San Francisco, was the first to place treatment of neuralgic affections by means directed to the central portion of the nervous system on a scientific basis. He showed that a number of supposedly surgical abdominal affections are actually neuralgic in character and that they yield to freezing applied at the appropriate level of the spine. Neuralgia of the spinal nerves is much more amenable to this or any other treatment than neuralgia of the fifth nerve, but Dr. Abrams suggested freezing over the site of the Gas- serian ganglion, just above the zygoma, and also over the two upper cervical vertebras in trigeminal pain. He advises, in addition to the freezing, the use of the slow sinusoidal cur- rent applied with one pole over the site of the Gasserian ganglion and the other over the upper cervical vertebrae. As 35 Progressive Spondylotherapy everyone does not possess a sinusoidal apparatus freezing is of more general service. Freezing is done as follows: Ether is sprayed on the part to be frozen, from an atomizer, operated either by hand or by compressed air. Trial has shown that Malinkrodt's ether is perhaps the best made for this purpose. If the air contains much moisture it may be necessary to start the freez- ing with a little ethyl chlorid sprayed on before the ether is begun. Dr. W. T. Baird, of El Paso, Texas, employs a chunk of ice, dipped in salt, and pressed against the point of verte- bral tenderness for about three minutes. The depression left may then be frozen with ether spray. Dr. Guild, of Des Moines, Iowa, says that this method is superior to that with ether spray as it may be maintained for a longer time and with less sloughing or desquamation. Freezing should be done thoroughly and continued for two or more minutes, and repeated at intervals of three or four days till the desired effect is produced. The frozen skin will become hyperemic and a little sore, so that it may be necessary to wait some days between treatments. Painting the skin after f reezing with collodion mitigates somewhat this skin irritation and, by freezing over the collodion at the next sitting, a second treatment may be applied sooner than would otherwise be the case. The great occipital on the affected side is the more ten- der and treatment will be first directed to that point; but, from the fact that both great occipital nerves are connected with the same cord segments, freezing on either side will pro- duce a similar though not as marked effect. This point may be remembered with advantage if one desires to apply the method frequently and yet fears the skin irritation pro- duced by rapidly repeated freezings. In freezing over the' site of the Gasserian ganglion, 36 Miscellaneous Data which is a decidedly more painful procedure than over the spinal centers, one cannot make use of either side at will, but is compelled to spray over the affected side." (The Pacific Dental Gazette, August, 1913). In a more recent communi- cation (Pacific Dental Gazette, December, 1913), Jarvis and Endelman, comment on the employment of freezing, which for promptness and efficiency is surpassed by no other therapeutic or operative method in the treatment of pain of dental origin, or any structure of the face innervated by the trigeminus. In post-extraction pain, the freezing method acts as if by magic. Their conclusions are based on a series of 200 cases of pain of varied degrees of intensity When the pain arises in the lower teeth, the area to be frozen lies behind the ear at about one-half inch behind the posterior border of the mastoid process. This post- mastoid area is frozen to an area corresponding to the size of a fifty cent piece. If pain arises in the upper teeth, the latter area in addition to an anterior auricular area (in front of the ear about three-quarters" of an inch from the tragus) is frozen. This technique applies to any neuralgia of the trifacial nerve. Dr. W. A. Guild (Des Moines, Iowa), comments on the great value of freezing in the treatment of neuralgic affec- tions but emphasizes the fact that its specificity can only be realized in uncomplicated neuralgia and when freezing is executed near the point of origin of the involved nerve close to the site of the lesion. CEREBRASTHENIA. Dr. W. T. Baird (Chicago), presents an interesting paper on this subject and directs attention to the important part played by the splanchnic circulation (346) in the .etiology of this affection which has also been called PSYCHASTHENIA. 37 Progressive Spondylotherapy His conclusions are as follows: Cerebrasthenia is not a rare disease; The dividing line between it and insanity has not been clearly denned; Cerebrasthenia is the result of vicious reflexes; The symptoms of both affections do not give a clear dif f erentation ; The true test is that, if irritated peripheral nerves can be located, and the reflexes inhibited, the symptoms disappear; To accomplish the latter, it is necessary to investigate the condition of peripheral nerves or areas at the onset of symptoms; The nature of the disease is revealed by the result of the inhibition of peripheral irritation ; Cerebrasthenia and splanchnic congestion are often associated; Splanchnic congestion is in almost every instance, asso- ciated with exposed nerve-endings in the rectum; These exposed nerve-endings transmit stimuli to the cells in the anterior horns of the spinal cord resulting in paralysis of the vasoconstrictors (splanchnic) ; This paralysis augments the blood supply in the splanch- nic area; The splanchnic congestion decreases intra-abdominal pressure ; Intra-abdominal pressure being lessened, a diminished amount of blood is forced through the portal vein and liver to the heart; The heart as a consequence is unable to send the normal blood-supply to the brain; This condition causes cerebral anemia; The irritated nerve-endings in the rectum may and often do transmit reflexes to the vasoconstrictors of the cerebral 38 Miscellaneous Data cortex, which are additional factors in the etiology of cerebral anemia; This vaso-constriction of the cortex inhibits its function and thus causes diminished cerebration. RADICULAR ROENTGENOTHERAPY. The x-rays are en- dowed with analgesic properties and this fact may be utilized in the treatment of neuralgic affections by directing the rays over the segments corresponding to the radicular origin of the implicated nerves in neuralgia and neuritis (371 et seq.) Thus, in affections of the BRACHIAL PLEXUS the rays are directed between the spinous processes of the 3rd cervical and ist dorsal vertebrae (emerging points) and a little higher for the segmental origin (20). SCIATICA; 4th, 5th lumbar vertebrae and ist, 2nd and 3rd sacral (emerging points). TRIGEMINAL NEURALGIA; at the Gasserian ganglion (374). No effect can be achieved if the site of the lesion is peripheral to the segmental origin or sites of exit. One must exercise care in the exposures by this method of radiotherapy which is marvelously efficient in neuritic and neuralgic affec- tions which have resisted all other methods of treatment. URTICARIA and MIGRAINE. Dr. Myer Solis-Cohen (Philadelphia), refers to the instantaneous relief secured by concussion of the 7th cervical spine in a severe case of urticaria following the use of diphtheria antitoxin. Itching and rash quickly evanesced. The same method of treatment was successfully employed by him in a rebellious case of MIGRAINE (280). PIGMENTATION OF THE SKIN. Cutaneous pigmentation associated with neuralgic affections may be regarded as a tropho-neurosis. Drs. Jarvis and Boslough (Ashland, Ore- gon), observed such an instance (Fig. 3) of pigmentation in a 39 Progressive Spondylotherapy patient with adhesive mediastinitis who was relieved of pain with almost complete evanescence of pigmentation by freez- ing over the sites of vertebral tenderness (5th to gth dorsal). Dr. Edward S. Smith (Bridgeport, Conn.), reports a case of CHLOASMA of face, neck and arms which "cleared up in a wonderful degree by concussion of the 4th and 5th dorsal spines (which showed paravertebral areas of tenderness be- fore treatment)." FIG. 3. Patient of Drs. Jarvis and Boslough with pigmentation of the skin in whom evanesence of the pigmentation was effected by freezing the vertebral areas of tenderness. MOVABLE KIDNEY. Dr. D. V. Ireland (Wilmington, Ohio), at the convention of "The American Association for the Study of Spondylotherapy" (Sept. 30, 1913), presented a series of interesting cases and among the number, the follow- ing one of MOVABLE KIDNEY is selected for citation inso- much as it suggests a novel method of treatment for this affection : "Mrs. B., about 50 years of age, of slender build and nervous temperament, applied for treatment, complain- 40 iscellaneous Data ing of a continuous burning pain in the epigastrium which, at times, nearly drove her to distraction. The liver was fully double its normal size, the bowels obstinately constipated and breath offensive. Und^r elaterium the bow: Is relaxed and the liver resumed its normal size. As the liver receded, I found the right kidney prolapsed until its lower border was on a line with the crest of the ilium. While the condition of the liver was much improved, the burning pain, the coated tongue and offensive breath continued as before. At this time a surgeon had recommended an immediate operation for the mobile kidney. She came again to consult me. I commenced con- cussion of the i2th dorsal spine, giving her daily treat- ments and to my surprise and delight, after the third treatment I found the kidney had ascended to its normal position where it has remained permanently fixed for nearly a year. I gave her in all forty-six treatments in order to anchor the kidney permanently; but what pleased us most of all was that the burning pain in the epigastrium (which I attributed to ulceration of the stomach at the pyloric orifice) gradually passed away, the tongue cleared and the bowels moved regularly." (NOTE: The foregoing observation is original with Dr. Ireland, and the author disclaims any reference to this subject in any of his writings. Dr. Ireland em- phasizes the fact that the i2th dorsal spine has the same importance in relation to diseases below the diaphragm as the 7th cervical spine to diseases above it). MALARIA. Attention has already been directed to the spleen reflex of contraction in the diagnosis of malaria (355). In Kansas City, the author recently examined Dr. Boyce, in whom splenomegaly was demonstrated. An examination of the blood by Dr. Purdue before and after concussion to elicit the spleen reflex demonstrated the presence of plasmodia in the blood only after concussion. Dr. Boyce writes as follows: 41 Progressive Spondylotherapy "Eight days after your concussion (Oct. 17, '13) almost to the hour, the chill appeared; a regular old-fashioned one. I consider the case unique insomuch as it is fully 15 years since I had a chill although I had malarial symptoms 5 years ago which yielded to quinin." PELVIC LEVEL. This (Fig. 4) was described by Smith (Lancet, Jan. 21, 1911), and is employed for comparing the standing height of the legs in cases of SCOLIOSIS. The patient stands erect, boots off and hips exposed. A dot is placed over each anterior superior iliac spine with a dermatographic pencil, and the pelvic level is applied so that its upper straight edge passes through both these dots. FIG. 4. Pelvic level for comparing the standing height of the legs in cases of scoliosis. If the spirit level then indicates horizontal, the legs are equal as regards standing height. If it does not, blocks of wood of known thickness are placed beneath the foot on the shorter side until the hori- zontal is reached the sum of the blocks used gives the dif- ference between the two legs. This method is very simple and very exact, and presumes only that the pelvis is symmetrical as regards the height of the anterior spines above the acetabula. PROPSUS UTERI. The following report concerns a patient with this affection: "The occasion of my addressing you pertains to the value of the uterus reflex (zoo). The patient in question has suffered for many years from prolapsus uteri which, having 42 Miscellaneous Data resisted conventional treatment, she had made preparations to go to Denver for an operation. After the second seance of concussion, the uterus was raised to within one inch of its normal position and after the third seance it regained the norm and has remained there ever since." Dr. D. V. Ireland, regards sinusoidalization of the i2th dorsal spine of greater efficiency for prolapsus uteri than the 2nd lumbar spine (358). The author, from further observation, justifies Dr. Ire- land in his contention and observes furthermore that sinu- soidalization of the 2nd lumbar spine is the site of choice to secure dilatation of the cervix uteri. PAINLESS LABOR. Several physicians engaged in obstet- rical practice have informed me that during labor one may demonstrate paravertebral points of tenderness correspond- ing to the lumbar vertebrae and that pressure (170) at these areas will in most instances either mitigate or arrest pains and thus contribute to painless labor. HUMAN ENERGY CONTENTS Page latro-Physical and Chemical Schools - 49 The Modern Knowledge - 49 Human Energy - 53 Energeiagenic Centers - 60 Energy-Discharge Without Conductors - - 64 Sympathetic Irritation - 64 Photographic Action - - 70 Sexual Polarity - 72 Diagnosis of Sex of the Fetus - 78 Determination of Sex 81 New Concepts in Diagnosis - - 82 Neoplasms - 84 Normal and Pathological Energy - - 89 Syphilis 90 Dementia Paralytica - - 91 Tuberculosis - 94 Electronic Reactions (Table) - - - 96 Epilepsy - .... IO o Diagnosis of Death ------- 100 INTRODUCTION The author's new physico-diagnostic methods are not theories but physico-clinical facts. They have been repeatedly corroborated by necropsy, skiagraphy, at operations and by histological examina- tions. The laws of physical science are universal and apply equally to living organisms and so-called inanimate things. This iatrophysical conception demonstrates the trend of unifying the various forms of force under one great principle. The electronic theory demonstrates the electrical nature of matter. Radio-activity is a universal property of matter. In disease, the rearrangement of the electrons is associated with the evolution of energy which is either neutral or endowed with a definite polarity. The author's stomach reflex is employed as a delicate physiological test for the presence of this energy. PERCUSSION OF THE LOWER STOMACH-BORDER. A correct interpretation of physico-diagnosis predicates an under- standing of the author's method of delimiting the lower border of the stomach in apposition with the abdominal parietes and this is only possible with the subject in the erect posture. The principle involved in the elicitation of the stomach reflex of Abrams is as follows: In the norm, a tympanitic sound is elicited but if the tone of the gastric musculature is augmented the walls of the organ become tense, thus putting the air or gas in the stomach under increased ten- sion. For the latter reason, we have the physical elements necessary for the transition of a tympanitic to a dull sound. Until a better acquaintance with this method is attained, a healthy subject must be selected with moderately thin abdominal walls and in whom a tympanitic sound is demonstrable by percussion over the entire abdomen. The stomach shows a varying state of tonicity; it may be normal (orthotonic), increased (hypertonic), diminished (hypotonic) or absent (atonic). 47 n t r o d u o n For the foregoing reason, in executing the electronic reactions an individual with known stomach-tonicity may be employed as a test- subject. In the latter instance, the energy is conveyed from the patient by means of an insulated copper-cord to the stomach-region of the subject. For esthetic reasons, the subject may be screened from the patient. The subject must stand on a flooring of unvarnished wood. Car- pet interposed between the latter and the feet of the subject is not objectionable. To increase the tone of the gastric musculature sufficient to elicit dulness, two simple maneuvers are available: 1. While the patient or an assistant directs either pole of a bar- magnet at a distance of about 4 inches from the presumable location of the lower stomach-border, light percussion is executed from below upward until dulness is elicited; this is the lower border of the stomach and its position should be marked with a dermograph. 2. During the time energy is conveyed from the heart-region of the subject to the stomach-region by means of an insulated cord of copper as shown in Fig. 7, execute percussion after the manner cited in the first maneuver. Finger-finger is preferable to instrumental percussion but those unskilled in the former may avail themselves of the plexor and plexi- meter as shown in Fig. 6, which have been specially devised by the author to substitute maladroit percussion. The lower border of the stomach having once been determined, one may proceed with the electronic test. The stomach reflex is easily exhausted and one must ascertain in the course of the examination if it is still present by conveying energy from the heart or by the use of the bar-magnet. ALBERT ABRAMS. 291 GEARY STREET, SAN FRANCISCO, CAL., JANUARY, 1914. 48 HUMAN ENERGY* IATRO-PHYSICAL AND IATRO-CHEMICAL PERIODS OF MEDICINE. At one time in the history of medicine, the period of medical mysticism, physics and chemistry were invoked to explain the actions and functions of the body and to recon- cile the dogmas of physics and chemistry with empirical methods in the treatment of disease. The iatro-physiochemical doctrines endowed with ex- clusivism failed to survive the lapse of time. Recent researches which I have made bearing on the question of human energy seem to emphasize the importance of the laws of physical science in the investigation of disease and the physician is constrained to correlate his data with this new knowledge. THE MODERN KNOWLEDGE. The forces found in the living body correspond with those which govern the inanimate world and the theory of *Abstract of an address by Dr. Albert Abrams, of San Francisco, before "The American Association for the Study of Spondylotherapy," at its meeting in Chicago, Sept. 30, 1913, and repeated with demonstrations before the "Chicago Hospital College of Medicine," Thursday evening, Oct. 2, 1913, to the medical profession of Chicago. A special work dealing more specifically with this subject will be published by the author early in the year 1914. Numbers in parentheses (not italicized) refer to the pages in SPONDYLOTHERAPY where the subject has already been discussed. When the numbers in parentheses are italicized, they refer to the pages in Progressive Spondylotherapy, 1913. 49 Progressive Spondylvtherapy vitalism (178) has been abandoned. Physical science by reason of the universality of its laws dominates practically every phase of medical research. The circulation of the blood is a matter of hydraulics; the changes of gases in the lungs and tissues correspond to the physical theory of gases and heat-regulation conforms to the physical theory of heat. Aseptic surgery and anesthesia are chemical contribu- tions to our storehouse of medical knowledge. The "Cell Theory" and "Cellular Pathology," embodied the conception that the activities of an organism are the sum of the activ- ities of its component cells which were regarded as the most elementary form of organized substances incapable of further reduction other than by mechanic or chemic means. "Cellular Pathology," does not emphasize in accordance with the "Electronic Theory" (115) the ultimate atomic divisibility of matter and I shall later exploit this theory to suggest the inauguration of a new diagnosis and pathology which I shall respectively neologize as "Electron Diagnosis" and "Electron Pathology." The time is fast approaching when the activities of living cells will find explanation on a physico-chemical basis and when the biologist shall know the laws that govern cell- growth with the accuracy of the scientist knowing his laws. It will be then that prevention and cure will be questions of scientific accuracy. As physicians we dare not stand aloof from the progress made in science and segregate the human as something apart from the other entities of the physical universe. Our differentiation of matter is largely morpho- logic. Whether the object of our differentiation is a human or a germ, we are only dealing with a congregation of vibrat- ing atoms which in their varied combinations are the basic constituents of all that exists. 50 The Modern Knowledge There are three physical entities: 1. Matter, 2. Energy, 3. Ether. The electron or corpuscular theory which most fully accords with modern investigations concerning the physical basis of the material universe conceives matter to be made up of molecules; molecules to be composed of atoms and atoms to consist of electrons (116). The electrons or corpuscles are charges of electricity. The atoms of matter are individ- ualized masses of positive electricity diffused uniformly over the area of an atom, spherical in shape and one two-hundreth millionth of an inch in diameter. Throughout the spherical mass are some eight hundred minute particles of negative electricity all alike flying vigor- ously about, each repelling every other particle yet all con- tained within their orbits by the mass of positive electricity which constitutes only about one per cent, of the atom's mass. The number of electrons in an atom are proportional to the atomic weight of the element. When the crowding of the electrons becomes excessive as in radium, thorium or uran- ium, the atoms become radioactive owing to collisions between the electrons, some of which are constantly shot away (116). Radiation refers to a change in the velocity of an electron which causes ripples in the surrounding ether. Whenever the velocity of an electric charge is increased, diminished or changed in direction, Roentgen rays, light and all other radiations result. As I shall show you, practically all atoms of matter are radioactive, assuming that the streams of radiations also consist of ethereal vibrations as well as flying particles. The following data may be summarized concerning electrons: 51 Progressive Spondylotherapy 1. The electron is the smallest entity known to science and is a thousand times smaller in mass than the smallest atom. 2. It is a sphere of positive electrification enclosing a number of negatively electrified corpuscles which counter- balance the positive electricity of the enclosing sphere. 3. The electrons are characterized by the uniformity of their vibrations. This is demonstrated by the sharpness of the lines of light making up the spectrum of an element. These lines originate from the vibrations of electrically charged systems and if the vibrations of different atoms were not attuned to each other, the spectral lines would be blurred and diffused. 4. Light and other radiations are dependent on dis- turbances in the surrounding ether (209) caused by a change in the motion of the corpuscles. We refer to perpetual motion as impossible, yet the whole universe is nought else. Matter is only an effect of a definite kind of motion. During the revolutions of the electrons, thousands of millions of times per second, an electro-magnetic field of energy is created but the rhythmic changes in the field of energy thus transmitted by the ether have thus far eluded all instruments for their detection and study. Everything in nature is in a state of perpetual motion and the latter is continually changing from one velocity to- another. The power to change the state of motion of a body is ENERGY. The total energy contained in matter depends on the extent to which it can be changed. Energy is the universal commodity on which all life depends. All forms of energy whether derived from heat, electricity, magnetism or gravitation are interconvertible and represent 52 Human Energy practically different varieties of motion. Energy, like matter can neither be created nor destroyed. The energy in all matter is enormous and it has been estimated that one gram of hydrogen possesses sufficient energy to raise one million tons through a height exceeding three hundred feet. Electrons are only electricity and nought else is in exis- tence but electrons. In gases, electricity is conducted by free corpuscles flying bullet-like and with velocities often approximating 100,000 miles per second. In liquids, the conduction is only about an inch an hour. In metallic conduction, the atoms are relatively fixed and their only power is that of vibration. Certain corpuscular aggregations will hold in an unstable condition a few more corpuscles than exactly suffices to balance the surrounding sphere of positive electricity. The atom thus constituted is negatively charged. Others hold a few less corpuscles than suffices to balance the positive electricity. This leaves the atom Dositively electrified. If these two types of atoms are free to move and they unite and neutralize each electrically, we have chemical union. HUMAN ENERGY. The present age marvels at man's conquests of the forces of nature. Yet, this age of energy can only be triumphant when man can know and then direct and control the more important forces within himself. Epoch-making discoveries in science usually date from, the discovery of a sensitive mechanism which reveals some phenomenon of the atomic world. The radium emanation has been detected by the elec- troscope. 53 Progressive Spondylotherapy The latter is a million times more sensitive than a spec- troscope yet the latter will detect the millionth of a milli- gram of matter. The delicacy of Einthoven's string-galvan- ometer has established the principles of electro-cardiography. The physiologic mechanism which I employ for detecting human energy is the living stomach and which may be designated as "gastrometer." It is essentially a stomach reflex which I have discussed at length (316, 321, 584, 123, 145, 146, 147, 153, 163}. In accepting the reaction of the stomach-musculature as the basis for our varied deductions, we are employing bioplasmic matter, the most primitive and sensitive substance for exhibiting the phenomenon of vitality. The pupillary response to light is an energy-contraction not unlike that under consideration. A frog's muscle is now used for record- ing wireless messages (148) . I have referred to the sensitiveness of the electroscope. The latter is less sensitive than the stomach reflex. The stomach reflex will detect the rays emanating from radium at a greater distance than will the electroscope. Modifications in the tone of the stomach when the region of the latter is exposed to the various forms of energy are demonstrated by percussion and tracings (167, 169, 170}. Percussion, however, is more easily executed. Much difficulty will be encountered at first in eliciting the dulness of the stomach. It must be recalled that the stomach is immersed in an atmosphere of tympany, therefore the percussion-blow must be localized, otherwise the vibration of surrounding tissues will mask the dull or tympanitically dull area of the lower border of the stomach. The best results are secured by finger-finger percussion; 54 H u m a n E n g one finger acting as a pleximeter and the other finger as a plexor. After this manner one can appreciate the resistance of tissues percussed (palpable percussion). To localize the percussion-blow, the second finger (usually employed) acting as a pleximeter must be held rigid with the ungual phalanx slightly raised (Fig. i). FIG. 1. The upper figure represents the correct position of the finger when used as a pleximeter. The cross indicates the part of the digit to be struck by the other finger acting as a plexor. The lower figure indicates the incorrect position of the finger in eliciting dulness of the stomach. If the latter precaution is not taken and the terminal phalanx rests on the abdomen, the blow will be transmitted to the contiguous area and the tympanitic tone elicited will obscure the stomach-dulness. When difficulty is encountered by the method of percus- sion indicated, one may employ the method already shown (511) or one may use an ordinary glass rod which is held at 55 Progressive Spondylotherapy the same angle as the finger and then percussed. For those unskilled in finger-finger percussion, the plexor and pleximeter shown in Fig. 2 have been devised by the author. Light blows with the plexor yield the best results a sound almost woody in character when the lower border of the stomach is attained. FIG. 2. Plexor and pleximeter for the use of physicians unskilled in finger- finger persussion. The dark area in the pleximeter represents a small quantity of wax. The latter eliminates all adventitious sounds likely to disturb the elicitation of stomach-dulness. A light blow yields the best results and when the lower border of the stomach is attained, an unmistakable woody sound is audible. It is best to first define the lower border of the liver (Fig. 3) ; next define the lower border of the stomach by aid of the conducting cord. Observe that when energy is con- ducted from the heart to the epigastric region the liver- border may be found lower for reasons cited (150). After the conveyance of an excess of energy which occurs in disease, the lower border of the stomach is retracted (Fig. 3). The dulness of the stomach may be accentuated by hav- ing the patient firmly fix with his hand the lumbar spines to suppress their vibration (80). 56 H u m a n E n r g y The stomach reflex (gastrometer) is exceedingly sensitive although the latter varies with the tone of the organism. When its tone is impaired and its sensitiveness is in conse- quence diminished, I convey the energy from the individual examined to the stomach-region of another individual, with a stomach-tone of known sensitiveness. When the stomach fails to respond promptly to the action of energy, it may be made more sensitive by definite maneuvers which I shall demonstrate later. Fie. 3. Illustrating method of conveying energy from the heart to the stomach-region. Continuous line, lower border of stomach; dotted line, retracted stomach- border; broken line, lower liver-border. I have specified the energy of the human organism as anthropodynamic because it is a specific electronic energy. A nerve-impulse resulting from the action of a stimulus lib- erates energy stored within protoplasm. Heretofore, the only evidence of the liberation of energy was the electrical change; the wave of negativity. This energy was supposed 57 Progressive Spondylotherapy to be electrical but this is disproved by the measurement of its velocity. Atomic differentiation as I conceive it, is only a question of vibration-frequencies and each atom is endowed with a specific rate of vibration. Colors are the effect of particu- lar frequencies of vibration. The stomach does not respond (as revealed by dulness) to all degrees of vibration (206} . I set in action at some dis- tance from this patient a tuning-fork with a vibration- number of 256. Note that dulness of the stomach at once ensues, but observe that the dulness is at once dissipated when the negative pole of a bar-magnet is held in proximity to the stomach, whereas the positive pole presented to the organ maintains the dutness. In consequence of the fore- going we must conclude that the vibrations are positive. The nerves of taste and smell must be endowed with specific electrons which are only attuned to different vibra- tion-rates hence the differentiation of taste and smell like the differentiation of color (203). The energy evolved from the human is as characteristic of the human as the energy evolved from the lower animals is distinctive for the lower animals. Furthermore, one man differs from another man only in the sense that his electrons show varying rates of vibration. The diamond, lampblack and charcoal are all practically identical in composition. Oil of roses and coal gas have the identical composition (4 atoms of hydrogen and 4 atoms of carbon), yet the mephitic odor of the one and the delightful odor of the other is merely a question of rate- vibration. Now the attunement of the organism shows a physio- logic rhythmicity at different periods of the day and further- more this attunement is modified by disease and tempera- 58 Human Energy ment. These facts have been established by tests made with Galton's whistle (Fig. 4). You will observe that by modifying the tone of my voice, I can elicit varying nuances of stomach-dulness. The re- sponse of the stomach is so sensitive that it faithfully records the dots and dashes from an ordinary transmitter operated at a considerable distance from the subject (Fig. 5). The gastrograph (167} was employed for making the records. FIG. 4. Gallon whistle. This consists of a steel tube in which air is caused to vibrate. The note produced by it becomes higher as its length is diminished and ranges from 6,481 vibrations per second to the highest perceptible tone-limit. In atomic differentiation we must also take into consider- ation the POLARITY of ENERGY. The oils of orange and cloves have the same chemical composition 16 atoms of hydrogen and 16 of carbon yet each has its specific odor and taste. I now expose the oil of orange to the abdomen approximating the stomach and you note no change in the percussion-sound of the latter. However, if I carry out the same maneuver with oil of cloves, the tympanitic sound of the stomach is at once con- 59 Progressive Spondylotherapy verted into dulness and furthermore the dulness is main- tained by the positive pole of a bar-magnet and is dissipated by the negative pole, hence the polarity of the energy is positive.* FIG. 5. Dots and dashes from a transmitter recorded by the contractions ot the human stomach. ENERGEIAGENIC CENTERS. There are definite areas of the body which are constantly discharging energy and the energy thus discharged differs in polarity in the two sexes. Fig. 6 represents the centers of energy in a male and Fig. 7 illustrates the centers in the opposite sex. Both figures are marked by-f- (positive), (negative) *Opposite poles of bar-magnets directed toward t.ie stomach dissipate the dulnes of the latter whereas like poles multiply the intensity of the dulness (/5J, ij-,') Energeiagenic C e n t e r s and O (neutral) signs, indicating the polarity of the energy emanating from different regions of the body. The discharge of energy with reference to the extremities only occurs at the tips of the fingers and toes. J-AU AKTtRIES POSITIVE ENC.K6V NEGATIVE __ POSITIVE FIG. 6. Normal energeiagenic centers FIG. 7. Normal energeiagehic centers in a male. in a female. Common to both sexes in the norm there is: 1. A positive (+) discharge from the arteries. 2. A negative ( ) discharge from the veins. 3. A neutral (O) discharge from the 7th cervical spine and positive discharge from the ist lumbar spine. 61 Progressive Spondylotherapy 4. A negative discharge from the regions occupied by the kidneys. The epigastric area discharging neutral energy is limited to the central line of the abdomen and extends upwards to a distance of about 5 cm. above the navel. FIG. 8. Normal energeiagenic center? in the back common to both sexes. From any of the foregoing centers one may conduct the energy by means of an ordinary flexible insulated cord (approximately 80 cm. in length) of copper, or aluminum wire. Insulated aluminum wire is the most effective material for conducting human energy. The metal tips of the conducting wire in contact with the fingers must be insulated. Placing one tip of the cord (which must not be insulated) to any center of energy and the other tip in contact with the stomach-region or several 62 Rnergeiagenic C e n t e r s inches away (if the energy conveyed is of sufficient potency), an immediate dulness of the stomach is elicited and by aid of the bar-magnet one may determine the polarity of the energy during the flow of the latter. It is wise to first determine the lower border of the stomach by aid of the energy from the heart. This is done by fixing one end of the conducting wire to the heart-region and the other end to the region of the stomach* (Fig. 3). In a male and female subject, dulness of the stomach is evoked from all areas of energy shown in Figs. 6, 7, and 8. I wish to direct your attention to a new OCULO- GASTRIC REFLEX which likewise differs in the sexes. Looking through a red medium, stomach-dulness in the male is only elicited when the right eye is thus employed, whereas in the female gazing through red with the left eye produces dulness. The influence of color on the tonicity of the organs has been discussed (199, 200). One may measure the intensity of conveyed-energy by: 1. The intensity of stomach-dulness. 2. The distance which the tip of the cord approximating the stomach-region will produce dulness (i. e., whether the tip must be in immediate contact with the abdomen or sev- eral inches away). 3. The duration of dulness. 4. The degree of stomach-retraction. The last method of estimation is the most convenient and reliable. Thus, one may gauge the energy of the heart, the testicles, ovaries, etc. (166, 188} . *By interposing an insulating material between the floor and the feet, the trans- mitted energy is incapable of eliciting the stomach or any other visceral reflex. In other words, the individual must be grounded (earth-connection). 63 H u m a n E n g Another index of energy is the degree of descent of the lower border of the lung (472) by conveying the energy to the yth cervical spine. The physician reasonably skilled in percussion may utilize the heart or the lower border of the liver as indices of conveyed energy (150, 184}. In this patient, by conducting the energy from his epigas- trium to his 7th cervical spine by aid of insulated aluminum wire, his pulse can be inhibited. FIG. 9. Calbrated tube of glass with connecting cord for measuring the intensity of energy-discharge. Another method, not mentioned, for measuring the in- tensity of energy is based on the principle that the further away the tip of the end of the conducting cord is from the source of energy eliciting stomach-dulness, the greater is the energy-discharge. For this purpose I employ a calibrated glass-tube (Fig. 9) through which the wire passes and which is gradually withdrawn until the energy-discharge is no longer able to produce stomach-dulness. Thus in the average male, dulness of the stomach from energy derived from the left 64 Sympathetic Irritation psychomotor region is rarely elicited if the end of the con- ducting cord is further distant than one-quarter inch from the region in question. SYMPATHETIC IRRITATION. The epoch-making work achieved by Dr. E. H. Pratt, with relation to the orificial reflexes prompted me to devise some diagnostic method whereby one could recognize sympathetic irritation, provoked by some anomaly of the orifices (rectum, urethra) . In the norm, there is a discharge of energy from the yth cervical and ist lumbar spines. From the former situation the area discharging energy ex- tends on either side a distance of 3 cm. from the spinous process; in the latter situation (ist lumbar spine), it extends a distance of 2cm. from the spinous process on either side. In sympathetic irritation from orificial or other lesions implicating the sympathetic, a discharge of neutral energy may be obtained in the entire region of the dorsal vertebrae at a distance of 5.6 cm. on both sides from the spinous pro- cesses. In other words, no energy-discharge is elicited until the end of the wire attains a point 5.6 cm. distant from the spinous processes and this discharge is obtainable equidis- tant from the latter throughout the dorsal region. DISCHARGE OF ENERGY WITHOUT CONDUCTORS. There are many individuals notably temperamental ones, whose mere presence will evoke the stomach reflex. Let such a one, if a male, point his left finger at the region of the stomach of the subject and the stomach will imme- diately dull. A temperamental female will achieve the same object with her extended right finger. Let either one touch the yth cervical spine (228, 469) with either finger and after the lapse of several seconds there 65 Progressive Spondylotherapy is decided retardation of the pulse of the subject which in some instances amounts to temporary inhibition. In executing this experiment a subject with a feeble pulse should be selected. The results of such an experiment are best determined by sphygmography (Fig. 10). I have already discussed psychic energy (ipo). FIG. 10. Illustrating the effect on the pulse before and during the time an index finger is placed at the 7th cervical spine. The transmission of thought is only possible when one side of the brain is put out of commission. Several man- euvers have been suggested for this purpose (zpo, 192), but the latest and simplest maneuver is to place the fingers of the left hand on the left psychomotor region or the fingers of the right hand on the right psychomotor region. Individuals who show no spontaneous discharge of energy may be made to discharge the latter by standing on an in- sulating substance (rubber, glass) or by placing on the head any red material so as to include both psychomotor regions Here, it may be mentioned parenthetically, if you desire to prevent the escape of energy from a neurasthenic, you may do sc by a strip of yellow across the head so as to include both psychomotor regions. This strip of yellow prevents the discharge of energy from all of the energeiagenic centers and in no wise inter- feres with the reception of energy from the environment. Do not subject this simple expedient to theoretic criti- cism until you have given it a trial. Individuals who spontaneously discharge energy or those 66 Discharge of Energy Without Conductors insulated after the manner cited may, by applying the finger at different vertebral spines (where visceral reflexes (7) are discharged) provoke the reflexes in question. Here is a subject on whom this can be demonstrated. You will observe that when this physician placed his finger at the yth cervical spine, he elicited the heart reflex of contraction (199). I shall now ask him to place his finger at the 5th dorsal spine and you note that the stomach becomes tipped (demon- stration by percussion). At the latter vertebral point you open the pylorus (588, 82) and the stomach empties its contents into the duodenum. Dr. Patrick O'Donnell, who has achieved fame as a Roentgenologist, like many others doubted the correctness of this observation but he has repeatedly demonstrated by skiascopy and skiagraphy, the correctness of this clinco- physiologic phenomenon. The latter will be demonstrated by the fluoroscope (demonstration by Dr. O'Donnell). The "Royal Touch" and the laying on of hands for the cure of disease may be regarded as mythical by those who are ignorant of the visceral reflexes and the potency of human energy. It is asserted that external applications do no good for the reason that there is no cutaneous absorption. The latter plays only a minor role in the foregoing method ; it is chiefly a matter of eliciting reflexes. On this hand placed in front of the stomach-region, I shall rub an indifferent liniment. Observe as a result an immediate elicitation of the stomach reflex. By the latter maneuver, frictional energy was developed. I constantly discharge a large amount of energy. You know that the region for exciting the depressor nerve is between the 3rd and 4th dorsal spines (472). 67 Progressive Spondylotherapy If my fingers are placed at the latter region for several seconds, the lower border of the lung will ascend (473). You already know what can be done with a giant magnet in visceral attraction and repulsion (156, 184, 203). With this magnet, I cause the liver to descend. If I now charge this liver with the positive energy of my left hand and attempt to attract the lower border of the liver with the positive pole of the magnet, there is a rise in lieu of a descent of the liver on the principle that like charges repel. There is a work by Buchanan on "Therapeutic Sarcog- nomy," which is a marvelous treatise in the matter of de- ductive reasoning. For the latter reason, it can never gain any scientific distinction. Buchanan, however, subjectively evolves many important truths concerning human energy which he specifies as Nervaura. Thoughts are things. With Dr. O'Donnell's aid I shall show you that pschyic energy concentrated by aid of a large lens, on the 5th dorsal spine will cause the stomach to tip and discharge its contents (bismuth) into the duodenum.* Those of you who doubt the important role played by color in physiology and pathology, give attention to the oculo-gastric reflex (440) to be observed in this patient. The patient declares that any purple color creates nausea. Observe that when she gazes at purple, after a lapse of several seconds, the stomach assumes a vertical posi- tion such as is noted in nausea (443). All forms of energy are interconvertible and there is a constant circulation of energy in nature. Here is a subject who discharges no energy, yet if he takes *One of the observers remarked that the appearance presented by the stomach could be likened to the flow of water from an inverted pitcher. 68 Discharge of Energy Without Conductors electrodes for several minutes in either hand from a moder- ately strong galvanic current and then directs his fingers at a distance of many feet from another subject he can elicit in the latter the stomach reflex. This ability to discharge energy will continue for several minutes. A like effect may be noted with the energy from a magnet (148) or the energy from an electric lamp. Human energy passes out of the body in straight lines and is partially deflected by a magnet. It can be refracted by aid of a double convex lens. If the hands are wet no energy is discharged and dry hands discharge more energy than moist hands. Similarly, less energy is discharged in humid than in dry air. One may charge a Leyden jar with human energy by placing one hand on the outer coating of tinfoil and the fingers of the other hand to the metal knob. The jar thus charged contains an energy which is neutral. By attaching an insulated aluminum or copper wire to the knob the energy may be conducted for hours from the jar and the energy thus conducted may stop the pulse when the end of the wire is applied at the yth cervical spine or, if conducted to the upper abdomen, it evokes the stomach reflex. Touching the knob with the fingers discharges the jar and no more energy can be conveyed from the latter. The energy output of an individual is modified by many factors. Alcohol is one of the greatest depressors of the vagus. By aid of the spondylopressor (9, 34, 51, 74) you can accurately gauge the depressing action of alcohol. Note that before receiving an ordinary glass of whiskey, the pulse is inhibited (by pressure at the yth cervical spine) at 3^ kilograms. Immediately after ingesting the whiskey, 69 Progressive S p ondylotherapy it takes 6 kilograms of pressure to inhibit the pulse but after 15 minutes, the pulse is inhibited with a pressure of i kilogram. The effects of anesthetics on energy may easily be determined. A few inhalations of chloroform or ether will inhibit the output of energy but if to the ether or chloroform, oil of orange is added, I shall show you there is little or no effect on the energy output. To Dr. George Jarvis, credit must be accorded for having solved the problem why oil of orange is beneficial as an addition to ether in anesthesia (82}. PHOTOGRAPHIC ACTION.* In studying the photochemistry of psychic energy it was found to vary in different individuals. In those who spon- taneously discharge large quantities of energy by placing a very sensitive film (inclosed in a black envelope) and inter- posing a medium which resists the penetration of psychic energy, one may practically always obtain an impression on the film. These impressions I have neologized as psycho- grams. At the present time the impressions are so faint that they cannot be illustrated in this work. It is reasonable to hope, however, that further experimentation will achieve better results. Time of exposure depends on the subject discharging psychic energy. The most satisfactory time varies from 30 seconds to 5 minutes. **My experiments do not refer to mentoids (thought forms or bodies). Yamaguchi refers to a woman having the mental faculty of autohypnosis, who was re- quested to hypnotize herself and strongly suggest to herself a word spelled in Japanese letters. She did and remained hypnotized during one hour. Sensi- tive dry plates held near her head, upon development, revealed the negative of the word spelled in Japanese. 70 Photographic Action The discharge may be augmented by placing a strip of red material across the head and the action of the psychic rays on the plate may be intensified by interposing between the forehead and the plate a strip of aluminum. The mater- ial for obstructing the rays may be a thin layer of shellac or the insulating tape used by electricians. The shellac may be painted on the forehead or envelope (prior to the intro- duction of the film), and similar disposition may be made of the tape. I have endeavored to obtain similar pictures of the bones of the hand. The results thus far have not been satisfactory but there is reason to believe that further efforts with new developers may eventually be successful. The hand is placed on the film or plate and covered with a sheet of aluminum. The fingers of one hand touch the center of a large lens (in focus) which is placed directly over the object to be photographed. The time of exposure depends on the individual discharging en- ergy and is usually about 5 minutes. The quantity of energy discharged may be augmented by wearing a strip of red across the head and insulating the feet by aid of rubber, glass or shellac. The HUMAN AURA so adequately portrayed by Dr. Walter J. Kilner in his work, "THE HUMAN ATMOSPHERE," is evidently only -a discharge of energy.* My investigations show that the aura may be augmented in area and density by concussion of the 7th cervical spine (164). *In a letter received from Dr. Kilner, the latter makes the following observation; "Your opinion that the aura is only energy emanating from the body corre- sponds entirely with mine, only I have expressed it in a different manner. I have tried to see it on *he dead body but have always failed to do so." 71 Progressive Spondylotherapy The utilitarian of the future will not permit human energy to go to waste. Permit me to show you how it may now be utilized in TOPOGRAPHIC PERCUSSION. The heart and aorta discharge energy. By means of an insulated cord to the stomach-region, note that when I approach the borders of the aorta and heart with the other tip of the cord, an immediate dulness of the stomach ensues. After this manner demarcation of the organs discharging energy, notably, the right border of the heart, is compara- tively easy. SEXUAL POLARITY. The present tendency is to refer all phenomena to a sexual basis and the odd and even numbers are regarded as the mathematical sexes. Anatomy has heretofore been invoked to differentiate the sexes. If I appeal to the electronic theory, there can be no abso- lute differentiation. Humans are mere aggregations of electrons and there must be transitional forms of humans just as there are transitional forms of metals and non-metals. It has been sugge >ted by Steenstrup, that sexual char- acters are present in every part of the body and that every cell in the body has its definite sexual significance. The electrons characterizing masculinity and femininity are so grouped that definite areas in a woman provide a sexual stimulus for the male and definite areas of the latter for the female. The law of sexual attraction, "that every male type has its female counterpart with regard to sexual affinity" appears to me to be based on the definite law that, "Like poles repel 72 Male and Female Types of Polarity and unlike attract." Sexual attraction and repulsion must obey this law. Weininger,* referring to the fertilization of some sea- weeds, speaks of the lines of force between the opposite poles of magnets as no more natural than that which irre- sistibly attracts the spermatozoon and the egg-cell. In the attraction between the inorganic substances, strains are set up in the media between the poles, whereas in the living matter the forces are confined to the organisms. When the spermatozoa approach the egg-cells they over- come the force exercised by light, hence the chemotactic is more potent than the phototactic force. Sexual adjustment cannot abrogate the laws of the universe. The adjustment of differences in potential in the sexual sphere are as inviolable as when iron-sulphate and caustic potash are brought together; the SO 4 ions leave the iron to combine with the potash. Attention has already been directed to the differences of polarity in the sexes. We must first make clear what I have differentiated as the MALE and FEMALE TYPES of POLARITY. First localize the PSYCHOMOTOR AREA (384). If the subject (female) touches the left psychomotor area with the tips of her fingers of her left hand (Fig. u), the stomach reflex ensues and one may demonstrate dulness of her stomach. This is the female type of polarity. The male type of polarity is the opposite of the female type; dulness of the stomach only ensues when the tips of the fingers of the right hand are placed on the left psychomotor area (Fig. 12). *Sex and character. 73 Progressive Spondylotherapy A male facing a patient (male or female) produces stomach dulness by touching the left psychomotor region with the fingers of his right hand. A female similarly located with reference to the patient (male or female) can only produce like dulness by touching the right psychomotor region with the fingers of the right hand. FIG. 11. Illustrating the female type of polarity. Only the tips of the fingers should touch the psychomotor area. FIG. 12. Illustrating the male type of polarity. The female type of polarity characterizes the normal sexual life. At the menopause this type disappears, provided all sex- ual feeling has been lost. In two instances where the ovaries had been removed, the male type of polarity was present but the latter could be reversed to the female type when ovarian extract was administered. It would seem that the sexual apparatus is merely a vehicle for the elaboration of an internal secretion which by its action on the electrons of the body endows them with a distinctive polarity. 74 Male and Female Types of Polarity There are typical and atypical men just as there are typical and atypical women, and humans will eventually be subjected to a biologico-physiological differentiation of posi- tive (+), negative ( ) or neutral (O) polarities. Color as I conceive it represents different electrical charges (20 j). In the case of woman whose ovaries were removed, her male type of polarity could be changed to the female type by placing a strip of yellow material over her right psycho- motor area. Magnetic attraction or repulsion is preceded by induction. The latter refers to magnetization or electrification in a body by the mere proximity of magnetized or electrified bodies. The induced magnetization or electrification is always of opposite kind to that of the inducing pole or body on the side nearest the latter and of the same kind on the farther side. I have on several occasions elicited the same type of polarity in husband and wife. When alone each presented the normal type of polarity. Together, when the attraction of the wife was greater than that of the husband, the mere propinquity of the latter caused in the wife a reversal of polarity, i. e., a male type of polarity by induction. Simi- lar observations have been made on men who demonstrated a preponderance of affection for their wives. Is affection only a question of polarity? Can the sex problem be solved by the foregoing observations? Can we predict sex by the type of polarity shown oy the pregnant woman? These are the problems which we must investigate. They await demonstration by repeated observations. 75 Progressive Spondylotherapy Draw an imaginary transverse line from the anterior superior spine of the ilium to the linea alba. Midway between this line on both sides an area (approximately 2 inches in circumference) is found which discharges positive energy*. This area changes when the ovary is dislocated. The total energy contained in matter depends on the ex- tent to which it can be changed. Here change predicates functional capacity and if an ovary discharges no energy, its incapacity may be functional or due to disease. Is HOMO-SEXUALITY (sexual inclination toward members of the same sex) a mere question of polarity? My limited observations incline toward the latter opinion. Several homo-sexualists whom I examined demonstrated the female type of polarity. In not one of these individuals could I change the polarity by administering the different extracts of the testicle. If however yellow material was placed over the right psychomotor area or the latter was painted with some yellow solution (gamboge), the polarity could be reversed to the normal male type. Up to the time of writing two homosexualists in whom this maneuver was tried no change in the sexual feeling was noted. Sexual differentiation is never absolute. There is a permanent bisexual condition, however vestigial and rudimentary. If I suggest to an individual in an hypnotic condition that he is a woman and endowed with some of her attributes, I can reverse his polarity to that of the female. I have *Determined by dulness of the stomach when a connection is established between this region and the epigastrium by aid of an insulated cord of copper. 76 Homo-Sexuality frequently reversed this polarity by suggestion even in the non-hypnotic state. If I approximate a male plant to the epigastrium, a dulness of the stomach ensues and one can determine that the energy discharged from the plant is negative. Like experiments with female plants demonstrate a 'positive discharge of energy. If a strip of yellow is placed on the right side of the plant, the polarity of a female plant is changed to that of a male plant and a male plant to that of a female plant. By keeping the yellow strip on the right side of a male fern for several weeks, it presented all the characteristics of a female fern. If one end of an insulated conducting cord is placed at the meatus of the penis and the other metal end (insulated except at the extreme tip) in proximity to the stomach ,the latter becomes dull on percussion and there is a retraction of the organ in proportion to the energy discharged from the penis. . In individuals with strong sexual power, this retraction was as much as 3 cm. In cases of IMPOTENCY the energy discharged is not sufficient to elicit the stomach reflex. From both testicles, there is a discharge of positive energy. If one of the testicles is made functionless in consequence of previous disease it yields no discharge of energy. In the child before the advent of puberty no sexual polarity by my method* can be demonstrated. *Vide methods of determining male and female types of polarity. Progressive Spondylotherapy DIAGNOSIS OF THE SEX OF THE FETUS. This is one of the possibilities of the future based on the determination of the polarity of the subject. The determination of fetal sex at one tune advocated has been abandoned as unreliable. It was based on the supposition that a rate of 120 140 in the minute of the fetal heart-beat indicated the probabil- ity of a male fetus whereas a more rapid heart-beat was indicative of a female child. The variability in the fetal heart-rate makes the foregoing untenable. The discharge of energy from the tips of the ringers varies in both sexes. In the male subject the fingers of the right hand discharge negative energy whereas the left hand discharges positive energy. This is reversed in the normal female; fingers of right hand, positive energy; fingers of the left hand, negative energy. These types are reversed in left handed individuals. These types are not demonstrable in either sex before puberty. These types are usually maintained in ambidextrous individuals. These types are usually lost at the menopause and in elderly males. In syphilitics, no polarity after the method to be shown can be demonstrated. In the norm if a male extends the fingers of his left hand directly on' a line with the exposed epigastrium of another individual (male or female) at a distance of one or more feet, the stomach reflex (as elicited by dulness) may be demonstrated (Fig. 13). This dulness is maintained only during the time the fingers are extended. 78 Diagnosis of the Sex of the Fetus The latter dulness can only be provoked by the female when the fingers of the right hand are extended. In those incapable of discharging energy, some red material placed across the psychomotor areas (192) will excite the discharge. In the prediction of sex, the pregnant woman extends first one and then the other hand in the direction of the exposed epigastrium of another individual in whom per- cussion is executed. FIG. 13. Illustrating the method of eliciting the stomach reflex by directing the extended fingers in the direction of the epigastrium. My investigations of this method are limited and permit me to formulate only tentative conclusions: 1. Prior to the 4th month, the pregnant woman shows no polarity, i. e., extension of either the right or the left hand fails to elicit dulness of the stomach. 2. After the 4th month, if the extended fingers of the right hand evoke stomach-dulness (normal polarity), a female fetus may be diagnosticated. 3. If after the same period only the extended fingers of the left hand cause stomach-dulness, a male issue may be predicted. 79 Progressive Spondylotherapy 4. For a variable period after confinement, no polarity can be demonstrated by the foregoing method. The following incomplete record has been made by the author: DATE DURATION OF PREGNANCY PLACE POLARITY PREDICTION RESULT Oct. 9, 1913 Mrs. T. 6 months Kansas City (Dr. Craig) Female Female Female Oct. 9, 1913 Mrs. C. 6 months Kansas City (Dr. Craig) Male Male Male Oct. 9, 1913 Mrs. V. 3 months Kansas City No polarity Oct. 20, 1913 Mrs. L. 7 months Patient yields electronic test for syphilis San Francisco (Df. G.) No polarity Oct. 17, i9 J 3 Mrs. E. 9 months San Francisco (Patient of Dr. Koerber) Male Male Male Oct. 20, 1913 Mrs. G. 9 months San Francisco Mt. Zion Hos- pital Female Female Female Nov. 7, 1913 Mrs. J. 9 months San Francisc* City & County Hospital Female Female Female Nov. 7, 1913 Mrs. S. 9 months San Francisco City & County Hospital Male Male Male Investigations should be instituted to determine if absence of polarity (if previously present) may be employed in the early diagnosis of pregnancy. 80 Determination of Sex DETERMINATION OF SEX. The law governing the production of sex has been the subject of much speculation. Hippocrates believed that the right ovary produced boys and the left ovary, girls. In accordance with the foregoing women who desired male offspring should during coitus lie on the right side and vice versa. The question of sex is dictated by two theories; the one supposing that sex is determined before impregnation; the other, that the embryo is possessed of the elements of both sexes until either one acquires a dominant influence in consequence of factors present during early pregnancy. The latter theory has been evolved from a study of lower animals and plants and is supported by the fact that the elements of both sexes in the human embryo are apparently present in equal force at the commencement of embryonal life. Reference has already been made to the author's experiments concerning the sexuality of plants and it is mere conjecture which prompts him to suggest the possi- bility that wearing any material of yellow over the right psychomotor area (which reverses polarity from the female to the male type) soon after conception until the 4th month may eventuate in a male issue. In pregnancy before the third month, even though po- larity is absent, a male type of polarity may be demon- strated when yellow material is placed over the right psychomotor area. 81 Progressive Spondylotherapy NEW CONCEPTS IN DIAGNOSIS. THE PRACTICAL APPLICATION OF THE ELECTRONIC THEORY IN THE INTERPRETATION OF DISEASE. ELECTRONIC PATHOLOGY. The creation of a modern pathology based on my in- vestigations respecting the recognition of energy and its polarity evolved in different diseases seems apposite. I am also utilizing human energy in the treatment of various diseases with most encouraging results but several years must elapse before my investigations concerning "ELEC- TRONOTHERAPY" can be published. Each atom of our or- ganism is endowed with a definite vibration-rate. Just as there is a "Periodic Law" with reference to the periodicity of the atoms of the elements so may we antici- pate a law with relation to morbid processes (500). The periodic law emphasizes the relationship of atoms and periodicity of properties and shows that family relationships of atoms is as assured as are the organisms of the biologist. At present I am attempting to determine the vibration-rate in different structures but cannot as yet present concrete data. We must at present content ourselves in determining the energy evolved in a quantitative and qualitative direction. The former is determined by the intensity of the stomach reflex (retraction of the organ) plus the distance at which it is discharged from the source of energy (conductor) and the latter refers to the polarity of the energy. In disease like hi health, the discharged energy may be: 1. Positive. 2. Negative. 3. Positive and negative. 4. Neutral or isoelectronic. 82 Diagnosis of the Sex of the Fetus All the forces in nature are positive and negative. We do not know what positive electricity really is. However, if you conduct the energy evolved from the positive pole of a galvanic current by means of a single cord to the stomach-region, a stomach reflex is evoked and and it can be shown that the conveyed energy is actually positive in character. By aid of the commutator, you can produce a negative form of energy. A unit of negative electricity in motion carries with it some of the surrounding ether. It is this bound ether plus the moving negative unit which we call mass. As before remarked the atom is a sphere of positive electrification enclosing negatively electrified corpuscles and the negative electricity of the corpuscles exactly bal- ances the positive electricity of the enclosing sphere. We are confronted with another problem, viz., the arrangement of the corpuscles in the sphere. The arrange- ment of the corpuscles in groups to form atoms confers on the latter their specific attributes. If, owing to some external disturbance, one or more corpuscles within the sphere is detached, then the atom will assume a positive charge owing the loss of a negative corpuscle. The stability of an atom is dependent on the number of corpuscles it contains. When the stability of an atom becomes extreme the corpuscles of the outer ring may lie on the surface of the atom in which case it assumes a negative charge. In other instances the atom becomes neither electro- positive nor electro-negative. The configurations of the corpuscles in an atom depend in general on the energy they contain. If the corpuscles 83 Progressive Spondylotherapy rotate with a velocity beyond a critical period, they slowly biit surely lose their energy and then there occurs a sudden convulsion or explosion with the evolution of a large quan- tity of kinetic energy. When the crash comes, this atomic cataclysm results in disintegration. I fully realize that I have given you an incomplete pic- ture of intra-atomic energy and atomic disintegration. My real object in exploiting the electronic theory is to account for the augmented energy and changes in the po- larity of the latter occuring in certain diseases. The molecules of our body consist of more than a thou- sand atoms and the atoms themselves are grouped and re- grouped and then grouped again in such a way as to make the molecules of the body highly mobile and quite unstable. The slightest external disturbance will change the sta- bility of the atom and it will assume a positive, neutral or negative discharge of energy. With the discovery of radium, a new property of matter known as radioactivity was discovered. It meant that matter possessed the property of emitting rays. Then followed a differentiation of the rays into alpha (positively charged), beta (negatively charged) and gamma (neutral) rays. My physiologic reaction (stomach reflex), shows that radioactivity is not limited to radioactive elements but that it is a universal property of matter. NEOPLASMS. My observations have this far been limited to the diag- nosis of carcinomata. The method of procedure may be illustrated as follows by citing two cases: 84 Neoplasms A patient has only recently observed a vaginal discharge. One end of a conducting cord was fixed by the patient in the region of the lower border of the stomach* which was previously defined by percussion and its border marked by a dermograph. The other metallic end (which is insulated except at its extremity which is brought into apposition with the skin) was gradually passed over the abdomen until a site was attained which yielded stomach-dulness. The latter was demonstrated just above the symphysis pubis occupying an area about the size of a dime. The polarity of the energy-discharge was found to be negative"]'. Dr. C. G. Levison, made the gynecologic examination and found a polypoid mass protruding from the cervix uteri which on examination by the pathologist, Dr. Dannen- baum was found to be a perithelioma. At the operation (performed by Dr. V. G. Vecki) the cervix was densely infiltrated and indurated throughout its entirety. The body of the uterus was not implicated. A woman occasionally passes blood in the urine with symptoms suggestive of vesical hematuria. A negative discharge of energy may be led off at a point to the left side one inch above the symphysi pubis as re- vealed by stomach-dulness plus retraction of the lower border of the organ. A cystoscopic examination by Dr. This metallic tip may be fixed to the skin by means of adhesive plaster. The patient must stand on a flooring of wood or other non-insulated substance. tThe polarity of energy (153, 154) may be determined by a bar-magnet. If dulness of the stomach is elicited by conveyed energy from the morbid site, have an assistant or the patient hold first one end marked N (positive) and then the other end marked S (negative pole) in the direction of the stomach during percussion. If the dulness persists with the N pole and is dissipated by the S pole, the energy conveyed is positive. The opposite also holds good. 85 Progressive Spondylotherapy V. G. Vecki, revealed a supposititious malignant growth at the left ureteral opening.* One could multiply such records in carcinoma and other affections corroborated by necropsy, skiagrams, operations and iristologic examinations. Thus Dr. Geo. O. Jarvis writes "diagnosticated cancer of the uterus which was confirmed at the operation. It gave little evidence of its presence beyond the electronic reaction." In the diagnosis of visceral malignancy, there are at least eleven diagnostic methods ranging from the anti- trypsinic properties of the blood to the meiostagmin test. It is not my purpose to deprecate these methods as imprac- ticable or unreliable but to emphasize 'the fact that the methods aim at generalized in lieu of localized diagnoses. My observations on polarity seem to clarify several problematic questions concerning neoplasms. "The vast assemblages of atoms comprising the heaviest atoms are unstable. As their kinetic energy decreases the aggregation explodes and the corpuscles rearrange them- selves with the evolution of energy and the projection of some of the products of the rearrangement." The slightest external disturbance will alter the stability of the atom. In other words, irritation is the most frequent etiologic factor in carcinoma. At the period of life when neoplasms develop most fre- quently, one finds a decrease in the discharge of energy. The polarity of the energy in cancer is negative. It is a physiologic fact that every active or injured part shows a negative electrical reaction toward every other part which is at rest or inactive. *Six weeks after transference of her own energy to the site of the lesion, a cystoscopic examination by Dr. Vecki revealed the disappearance of the bladder-tumor. 86 N e o p I a s m s If we apprehend malignancy from the viewpoint of the physicist, one must assume that the discharged energy is due to chemical dissociation of atoms into negative and positive ions and electrons. A tissue at rest is in a condition of electric equilibrium (isoelectric). If this equilibrium is disturbed by some traumatic fac- tor, a difference of potential is established and the altered tissue becomes electronically negative to the normal. The sensitive living cells are at the mercy of their environment and this refers in all cogency to changes in the constituent elements of the fluids in which they are bathed. The beneficent action of radium on new growths is not explained. The gamma or neutral rays are the most efficient in reestablishing a normal cell-balance in carcinomata. The beta rays (negative) stimulate cell-growth and have been shown to augment the growth of carcinomata. From the data already presented it does not seem diffi- cult to explain the action of radium. Cancer developing in people who live together (cancer a deux) suggests contagion. Just as radium confers radioactivity on other substances, so may a cancerous person by induction alter the polarity of another individual. Thus, if the negative energy from a cancer is conveyed to the stomach of a normal individual, the stomach-dulness of the latter may persist for some time after the source of energy is removed and it will be found to possess a negative polarity. In carcinomatosis (generalization of cancerous growths), the arteries which in the norm yield a positive energy demonstrate a negative energy. 87 Progressive Spondylotherapy SUMMARY. 1. The electronic diagnosis of cancer is an early sign. Cancer in its early stage irrespective of its localization is apparently an insignificant lesion (Bloodgood), hence the importance of an early diagnosis. The condition in question corresponds to what was once called the pre-cancerous stage which is in reality cancer without positive signs. Morbid cell-activity may temporarily discharge a nega- tive energy as I have occasionally observed in gastric and duodenal ulcer but this variety of energy ceases when the condition is improved. The present morphologic concep- tion of a neoplasm is destined to be supplanted by an elec- tronic conception when energy-discharge will signalize a tendency toward the development of a neoplasm. 2. The energy-discharge in cancer is negative and provokes the stomach reflex of contraction. The degree of malignancy may be gauged by the ampli- tude of retraction of the lower border of the stomach. 3. The electronic test localizes with exactitude the area involved and metastases if present may be demonstrated. 4. At the time of the operation, the electronic test may be employed to indicate the extent of invasion and to show that the involved tissues have been extirpated. 5. It is best to employ another subject in executing the test and to select one in whom the stomach reflex is normal and not easily exhausted. 6. In eliciting the electronic reaction proximity of the subject to intense light must be avoided (127), light being a form of energy is capable in itself of evoking the stomach reflex. 7. When pain is present a neutral energy may be elic- 88 Summary ited. This reaction of real pain may be utilized in differen- tiating it from pseudo-pains in malingerers. 8. In testing for normal or abnormal energy, the sub- ject must be grounded (either patient or subject on whom the test is made). If the patient or the subject stands on insulated material (porcelain, varnished floor, glass, etc.), no stomach reflex is obtainable. The latter is important when the tests are executed in an operating room with a floor of porcelain tiling. In such instances the subject and patient must be grounded by a single wire from the foot to a con- venient faucet or radiator. 9. The presence of fluid in the stomach or bladder yields a neutral discharge of energy, hence these organs must be empty before conclusions are formulated. 10. The process of elimination must be exercised in every possible direction. Thus, a kidney which yields in the norm a negative energy may simulate a neoplasm if luxated. NORMAL AND PATHOLOGICAL ENERGY. In the employment of electronic diagnosis the following facts will assist in the recognition of normal and abnormal energy : 1. Normal energy may be determined by its polarity. 2. A few whiffs of chloroform will at once dissipate normal energy, i. e., it is insufficient in potential to evoke the stomach reflex whereas no amount of chloroform ap- pears to deprive abnormal energy of eliciting the same reflex. Even under complete anesthesia the energy discharged from neoplasms persists. 3. To convey sufficient normal energy to elicit the stomach reflex, the tip of the cord must be in contact or not in excess of one inch from the part supplying the energy. 89 Progressive Spondylotherapy Morbid energy however may still be conducted even though the metallic tip of the conductor is more than one inch distant from the source of energy-supply. 4. When the stomach is the object of investigation another subject should be selected for the elicitation of the stomach reflex. SYPHILIS. Since the discovery of the spirocheta pallida, this organ- ism has been found in the brain of paretics and in the cord in tabetics. Many tests have been suggested for syphilis: i. Complement fixation or deviation test of Wasser- mann; 2. Noguchi or butyric acid reaction; 3. Cobra venom hemolysin test. 4. Control of the Wassermann by measuring the amino- nitrogen of the blood-serum; 5. Luetin reaction. In the Noguchi-luetin reaction, the test is not appli- cable in the primary and secondary stage; the chief response is in the treated and late cases. The Wassermann is not absolutely specific for syphilis insomuch as it is not dependent on syphilitic antibodies in the blood but upon admission to the latter of abnormal products from morbid tissues. The Wassermann reaction has been found positive in scarlatina, appendicitis, cancer, typhoid, sepsis, phthisis, diabetes and other diseases. The electronic reaction for syphilis (congenital and ac- quired), is as follows: Energy conducted from the liver, spleen and vertebral column (site selected, yth dorsal spine), causes a stomach reflex (ascertained by dulness) and the dulness is dissipated 90 Dementia Paralytica by the + and poles of a bar magnet; i. e., the energy is neutral or isoelectronic. Energy conveyed from the arteries, veins and heart is also neutral but insomuch as this reaction is obtainable in other diseases, the foregoing the reaction as first cited should be accepted. The exact site of the primary lesion may be also be as- certained by this method*. Ascertaining the site of the primary lesion is of value as corroborative evidence and may aid us in treatment. Thus in a case seen in consultation with Dr. F. S. Hae- berle (St. Louis), it was impossible to elicit the electronic reaction after the primary site of inoculation was submitted to several mercurial inunctions. The reaction was obtainable in every case of syphilis notwithstanding salvarsan, neosalvarsan, mercury and various organic arsenic compounds had been employed.* The electronic reaction was positive despite the fact that in many cases the Wassermanh and luetin reactions were negative. DEMENTIA PARALYTICA. Noguchi demonstrated the spirocheta pdllida in the stained specimens of the brain in general paralysis. Forster and Tomasczewski, demonstrated living spirochetes in 8 out of 20 cases examined by aspiration of the cortical sub- stance. The author has examined a large number of paretics and ascertained the following invariable electronic reaction ; when a connection is made between either frontal eminence *This was demonstrated to the eminent syphilologists, G. Frank Lydston of Chicago, V. G. Vecki, of San Francisco, and many other physicians. *In only five patients among many hundreds examined, a negative reaction was obtainable. Here, it is interesting to observe that in these patients anti- syphilitic medication was executed at the time of the primary lesion and maintained for periods varying from one to five years. 91 Progressive Spondylotherapy of the subject and the gastric area, dulness of the stomach immediately ensues and the dulness is dissipated by both poles of a bar magnet. Aside from this neutral energy, one may obtain the same reaction from the liver, spleen and spine. FIG. 14. Illustrating the cerebral sinuses and psychomotor area (4x6 cm. in area) where energy is normally discharged. The sinuses yield a negative discharge. In the norm no discharge is obtainable from the mastoid, a fact of importance in eliciting the reaction for pus. In the norm and in syphilis (without cerebral involv- ment), no energy sufficient to dull the stomach is obtain- able from the frontal eminences. In dementia precox, a positive energy is obtainable from the frontal eminences. Great care must be exercised in recognizing the many areas on the head from which energy is normally discharged (Fig. 14). 92 Dementia Paralytica Error may be eliminated by consulting page 41 of this address and furthermore by recalling the fact that the energy-discharge of other areas is positive or negative and not neutral as in syphilis. It is true however, that if the tip of the conductor is directly over an artery or vein, one may elicit the reaction of a neutral energy (in syphilis) but if the frontal eminence is alone selected, errors of interpretation may be avoided. The syphilitic shows no polarity and it is impossible to obtain sufficient energy to dull the stomach (as in the norm) from the left psychomotor area in the male and from the right psychomotor area in the female. Many cases of insanity examined by me at the asylums were found to be cases of brain-syphilis and this was notably the case in patients diagnosticated as dementia precox. The electronic test is destined to serve of great value in the differentiation of a host of mental maladies. Already the serological diagnosis of syphilis bears re- sults in the passing of paresis. The close relationship between syphilis and the latter has always been recognized but with the distinction how- ever that paresis was a parasyphilitic affection due to the indirect action of toxins whereas it is now known that the treponema pallidum is directly concerned in its production. The passing cf parasyphilis emphasizes the fact that, within a fev weeks after the primary inoculation the spiro- chetes invade every tissue of the body and to prevent spirilloses of the nervous system heretofore designated as parasyphilitic, energetic treatment must be commenced at the time of the primary inoculation. The foregoing suggest the value of the electronic reac- tion in the early diagnosis of syphilis. 93 Progressive Spondylotherapy TUBERCULOSIS. It is generally conceded that the tuberculin reaction is a phenomenon of sensitization. There are many limitations to the tuberculin test which time will not permit me to review. The electronic reaction in tuberculosis yields a neutral energy. One may localize with absolute certainty the site of the lesion and ascertain its area whether located in the lung, larynx, lymphatic gland, bone, joint or other structure. Observe that the reaction is that of syphilis, but the reaction cannot be obtained from the liver, spleen or spine (provided these structures are not implicated by tubercu- lous lesions). It may be difficult for you to differentiate between an active and a healed tuberculous lesion. In the latter, the reaction is only obtainable when the tip of the cord is in immediate contact with the site of the lesion, whereas in an active lesion, the reaction is obtain- able when the tip is held several inches away from the site of the lesion. The potentiality of the energy-discharge is in direct ratio to the bacterial or toxin content of the lesion. When tuberculosis is generalized, the arteries and veins yield a neutral energy. Pus (streptococcic reaction) may be detected practi- cally anywhere in the organism and by the immediate dem- onstration of these foci of suppuration, the so-called "cryp- togenetic septicemia" is destined to be regarded as an avoid- able diagnostic error. 94 Electronic Reactions ELECTRONIC REACTIONS. In the subjoined table an attempt has been made to summarize a variety of affections yielding electronic reactions. In erysipelas and meningitis, further control-tests are necessary before accepting the reactions as final. The reactions in typhoid and malaria may be present for years after recovery from the primary attack. I must caution you against the error in diagnosis of accepting as conclusive so-called pathognomonic symptoms. No physician can assume skill in diagnosis until he has mastered the rules and principles of logic. By aid of these reactions one is not only able to make a diagnosis but it will be possible as in pertussis to localize the debatable site of infection. 95 Progressive Spondylotherapy i/T cu "o a fi d jjj CU 3 ^ CU C rt .S "rt O fx i c cd en ed B 6 S 1 1 '3 rt M i 1 1 2 M) i in H M cu a 3, . en jj en cd 1 "?^ t 5b * "o u cu CX *o "S "o cd"& i c^jn en jjj 0? 3 1 8 g S a CU M g.S ,S-d cxc in cd in :he sites |s| O in _aj m S ^ Q O 1 1 9 in IM O S '55 'i(5 *. C cT o eJ 1 Q In.- CU IU 6 3 W) cu g S e 2 .> > 2 _g o < O cu tj cd^> O cu cu ^ cd cd ** l~l f-t 2 H bfl S.I 3 in ri 3 cd to s '35 cd bO i o CU cu'" cu O K CU cu cu cu Pi ^ 5? * PH 8 PH a o 4, ^ *O "o 'o ^ > cu -a Pi rt ^ 3 rt d .S cu C c M O aintenai of dulm ill issipatio dulness en in _tn cu & _C issipatio dulness en *i m g 3 6 S.& cu in C.S2 3-0 ulness maintai ulness maintai a Q Q Q Q Q Q Q Q H O a d "o d c "o TJ cu T3 cu T3 D POSITIVE P Dissipatio dulness Dissipatio dulness Dissipatio dulness Dulness persists Dissipatio dulness Dissipatio dulness Dulness maintai Dulness dissipat Dulness dissipat T3 i . Q cu g o 5-s ^ O E H t3 ed cd en cu tj M a H *o E i p 2 c s in en en en % in" 8 II 8 % cu 8 cu CU B cu o # g 9 o O m K M H 15 v *** O CJ o w a fe X QJ S H "~" H p^ M M y E M t/3 ^^ w ^^ H M D ^ <: & ^~~^ z fe U H Q H PM PH 2 96 El ectronic R e a c t i o n s 1 /5 n C p, C o ll;.i 'cu J ^S ^ r^ 2n G g d d G* ,o C *^_ *S 4) 03 G [25 .2 .0 O ^""^ *r i ^ en en ^O W u 5J '2 u Z! 1 1 u .1 3^ _G _G I O !s !i !s cu C en ^f-^ 2 b" *** """* cu ^3 H G H i "o "o "o -1 S-o-g^^ cu cu U "ft *o P O '33 cu '33 '33 O. a < O g o3 > 03 _> CU cu CU cu 73 CU cu 5 w ** > 03 > 03 i-< ^H 2 ^^ < 2 03 '^3 W) '5 W) 03 ' 03 j g W bO CU g c ft '3! e o ft 6C 'en 1 bo 1 3 cu bo cu '33 Pn jj cu *s cu 8 "O m _c .S ^G _c cu JU cu '3 '3 'o3 "3 ttl en o3 en i w H O en *2 tn C 11 11 Is tn G G '3 3S L^^ c'3 36 CU "in C ^ en ^en |l IS a cu'35 G tn 3-a tn _en 33.9- JJ H P P P P P P P P Q hJ O s 1 -o CU 3 1 3 cu -a cu PH "o3 3 5 "oj '3 tnt ta oS tn c 8.9- en G en G en S L^.9- tn Q, 1^.2 CU en 4).S eu '33 cu 'en CU en cu '3J i 3 '-5 .S c' 3 H 3 i ** 3 1 C.S3 3-3 ,3'- 3^3 3 a o ft P P p P P P P P P c!> u i 6 cj.2 o S 03 03 03 cd * a ^ & & G **2 U en en tn en tn L^ L^ en tn Ln O, G 2 < O g cu 1 < ^ S w 1 1 3 1 1 3 .> 3 3 "rt is 'S ce) El 1 "3 n 3 cu o * AH 5 fe 1 H 3 o fi "S 'S 13 1 | "8 u -r Cj J3 rt *2 4B cij exj ta ta en ^d 'S S en _en 83 .& en Qi en Q, 83-^ 83 ^ ^j- M H O i'83 3 '-3 ** '8l 11 cu '35 ,5 " cu en CU 'in C .23 || g 2 11 cu 'in 3^ "o a P p P P P P P P P f^. a H 1 O 3 13 cu cu 3 13 cu T) cu 13 cu 13 cu eu 8 H c en ^ en "^ en "* cd "S en ^ "S en ^ en ^ en ^ en _cn '3 i eu 'en C .2 eu 'en C .2 cl 11 C fc eu 'en C .2 5 M 3-0 3^3 3 "^ 3 ^3 3 a 3 "^ a O P P P P P P '| U. eu c E Ul '5 1 s 2 2 -^tg i 7 ^ J.O^ | W ^ +j ^ o | en o X en n -*-* S S o"C en en O en en en eu en en CU 1 i "| C O C eu 3 -3 tx > 3 3 3 3 M en P P P P P P i en Z w M H 9 W t> < H S H c g 2 z a w^' a J H P J S 99 rogress i^e Spondylotherapy EPILEPSY. All theories concerning the nature of epilepsy are un- proved hypotheses. The majority of writers concede that the paroxysms are discharged from the cerebral cortex, notably the cortical motor regions. Before presenting my conclusions concerning a large number of epileptics whom I examined, certain fundamental facts must be reviewed. We know that from the left psychomotor area in the male and from the right psychomotor area in the female, sufficient energy can be conveyed to the stomach to evoke dulness of the latter. We also know that when the end of the connecting wire is distant beyond ^4 inch from the psychomotor area, the energy is insufficient to elicit stomach-dulness. All epileptics discharge a neutral energy from both psycho- motor areas and this electronic reaction is characteristic of this affection. My measurements show no increase in the energy-discharge either from the psychomotor area normally discharging energy nor from the area which in the norm discharges no energy. Before puberty where polarity is not yet expressed, there is nevertheless a dis- charge from the right psychomotor area in the male and from the left psychomotor area in the female. DIAGNOSIS OF DEATH. The author in his "Transactions of the Antiseptic Club," refers to the fact that it is unfortunate that the generality of physicians neglected the important duty of diagnosing death. 100 Diagnosis of Death The application of one positive sign of death should be made obligatory by law. We now know that the living body constantly discharges energy from definite areas, notably the heart-region. If sufficient energy cannot be conveyed from the latter area to evoke stomach-dulness, it is practically a certain sign of death. SYNOPTIC REVIEW OF SPONDYLO- THERAPY* SPONDYLOTHERAPY. This neologise was primarily employed in my book on this subject, the first edition of which was published in 1910. It referred to physiotherapy and pharmacotherapy of the spine based on a study of the visceral icflexes of Aibrams. Spondylotherapy was first interpreted as the exploitation of an exclu- sive system and it was identified with osteopathy and chiropractic. To make confusion worse confounded, some so-called drugless healers ex- ploited the term spondylotherapy to abet their exclusive methods of practice. In the preface of my book, an emphatic protest is made against exclusivism in medicine which is a composite practice and demands the employment of all the resources of science bearing on the treatment of disease. Osteopathy which preceded the birth of chiropractic, is a system of anatomic abnormalities and their correction. "'Its nosology is a lesion, its symptomatology, a subluxation." Chiropractic presumes disease to eman- ate from displaced vertebrae which pinch the spinal nerves. The spinal centers are referred to in osteopathic and chiropractic text-books "with a dogmatism and certainty 'begotten of beneficial results." .The myth and fetish of the dislocated vertebra is nevertheless exploit- ed. 1 have made skiagrams of patients whose vertebrae were said to have been "dislocated" by competent osteopaths and chiropractors and in not a single instance could this diagnosis be confirmed. When the spinal manipulator in his "adjustments" elicits the "pop" he causes the sudden separation of ankylosed articular surfaces. The frequency of bands and adhesions in joint lesions are ignored by us; hence the presitige of the spinal manipulator. Spondylotherapy concerns itself only with the excitation of the func- tional centers of the spinal cord t>y different methods, which may be" executed and demonstrated with the same certainty in the living subject as is done by the vivisectional experimentalist. This phase of medicine, I have neologized as clinical physiology. Thus human, and not animal physiology, is made the basis of clinical physiol- Reprinted with additions from the last edition of "Reference Hand- book of the Medical Science*." Wm. Wood & Co., New York. 103 Progressive Spondylotherapy ogy. In this way, one may disprove by clinical observations many apodictic data created in the laboratory. The pathology of spondylo- therapy (referred to by J. Madison Taylor, 1 as reflexopathology), is found- ed on clinical physiology and its methods embrace the therapeutics of the reflexes. The committee on Standardization of the American Electro- therapeutic Association, reports (Sept., 1914) as follows: "In spondylotherapy the employment of mechanical vibration fills one of the most useful roles in therapeutics. It is easily controlled and as practical and effective of application in the hands of those familiar with the methods of employing it as spinal percussion." Each segment of the spinal cord must be regarded as a unit endowed with motor, sensory, vasomotor, trophic, and reflex functions with regard to the peripheral distribution of the roots of the nerves which emerge from and enter it. Man is* essentially a reflex animal and even con- sciousness depends! upon the action of the reflexes. The physiologic mechanism designated as a reflex surpasses in its sen- itivity any apparatus' yet devised by human ingenuity and it was the utili- zation of the reflex which enabled the writer in a recent book 2 to demon- strate the electronic nature of matter and to advocate supplanting the archaic cell-doctrine -by the electronic theory. Many reflex acts are so perfectly coordinated that one is constrain- ed to believe that, in the spinal cord, there exists a subsidiary brain. All diseases are manifested iby a direct and indirect symptomatology; the latter embraces the reflex symptoms. Pharmacology and physiotherapy are utilized in inhibiting or exciting reflexes to cure disease. When the oculist contracts or di'latesi the pupil, he employs reflexes in treatment. Thus, in iritis, the most important remedy is atropine because among other effects, the eye is put at rest owing to the factitious irido- plegia. Vasomotor pharmacotherapy is exhibited by the use of the group of nitrites for inducing vasoconstrictor paralysis, or the ergot group for effecting contrary results. Surgery has invaded a like reflexothera- peutic field in the treatment of spasticity by rhizotomy. Here, the object is to inhibit afferent impulses from the muscles which excite the cells of the anterior horns of the cord to send out excessive motor reflexes to the muscles. The mechanism of a reflex is receptive, conductive (embracing nerve fiber and central cell), and effective (action of the peripheral organ). In medical literature, I have repeatedly referred to certain visceral reflexes evoked by cutaneous irritation. The reflexes* in question are endowed with more than mere physiologic interest. Such reflexes react on the vis- cera and the reaction may be utilized in a diagnostic and therapeutic di- rection. The evidence heretofore adduced in explanation of the results achieved by electric, hydriatic, mechanic, and balneary .treatment of disease 104 Review of S p o n d y 1 o t h e r a p y was naught else than a mere array of words conceived only in conjecture. The visceral reflexes may be elicited from forces employed at the periphery or at a spinal center (over the segments or where the spinal roots emerge). Applied at the latter situation, the visceral reflexes are of greater amplitude and of longer duration. It is, therefore, evident that in the treatment of disease by aid of reflexes, the elicitation of central reflexes is preferable. In the spinal cord there are centers for the contraction and dilatation of the viscera. In the norm, these centers are in physiological antagonism. When neither reflex predominates a reflex equilibrium is established. The moment one reflex gains the ascendancy over its antagonist, the reflexes become disequiliibrated. Demonstration of the Visceral Reflexes. 'Prior to the advent of roentgenology, the conventional physical methods were employed to demonstrate the visceromotor reflexes (contraction and dilatation of the viscera). The Roentgen rays have given a decided impetus to the recogni- tion and acceptance of the visceral reflexes of Aibrams. Lebon and Au- bourg presented before the Societe de Radiologie Medicale de Paris, com- parative radiographs showing modifications of the large intestine, after stimulation of different vertebral spines by my methods. They had ascer- tained upon administering castor oil, then a bismuth suspension, and finally examining the subject with the x-rays, that electrical stimulation of the right vagus in the neck caused contractions of the ascending colon, sufficiently marked to be plainly visible on the screen at each excitation of the nerve. Similar stimulation of the crural or sciatic nerves produced little or no change in the colon. Vigorous percussion of the seventh cer- vical spinous process caused the cecum to rise and the ascending colon to become broader ; such effects were observed in all persons examined excepting one a woman with marked enterospasm and constipation. Per- cussion of the dorsal spines had no effect on the colon until the lowest ones were reached; percussion of these, or of the lumbar spines, brought about contractions of the colon in all its divisions. Dr. Patrick S. O'Donnell and other expert roentgenoscopists have shown that, after the ingestion of the conventional bismuth meal, it takes approx- imately one hour and fifteen minutes for the stomach to void its contents, whereas after stimulation of the fifth dorsal spine, the stomach voids the bismuth in one and one-half minutes. Snow 3 shows by a series of excellent skiagrams the diminished volume of the heart and aorta by stimulation of the seventh spine, and observes; "The heart, aorta, stomach, liver, or spleen may be made to contract at the will of the operator, producing effects available for the correction of impaired functions. If the skilled practitioner will use vibration in cases to which it is applicable, he will be rewarded 'by results which cannot be 105 Progressive Spondylotherapy attained by drug-therapy." A number of cases reported by Snow demon- strate the correctness of the latter conclusion. Dr. George Jarvis, whose accuracy as an observer and skill as a sur- geon are conceded, authorizes me to say that, in his research work em- bracing a new departure in surgery the publication of which is antici- pated, in anesthetized subjects at the operating taible, the visceral reflexes may be elicited with a strong sinusoidal current (one electrode at the sacrum, and the other over definite vertebral regions) as described in Spondylotherapy. The stomach reflex is elicited (contraction of the or- gan) to approximately one-fourth of its original volume. Associated with the latter reflex is a marked anemia of the stomach. The gall-bladder reflex of contraction is likewise evocabk. The subjects were under narcosis with nitrous-oxide and oxygen, and in addition, in some instances, even scopolatnine and morphine were used. When spinal anesthesia was alone employed, although visceral reflexes could be elicited, they were not as accentuated as under narcosis. With the ophthalmoscope, bronchoscope, or cystoscope one may note that one can at will produce anemia or hyperemia of the retina, 'bronchial or vesical mucosa, by stimulation of definite spinous processes. Methods. For the purpose of stimulating or inhibiting the functions of the spinal segment or radices of the nerves, only brief mention can be made of the following methods in order of efficiency: 1. 'Concussion or percussion; 2. Electricity; 3. Pressure; 4. Freez- ing. 1. Vibromassage or Mechanical Vibration. This has achieved some distinction as a remedial measure, but owing to its indiscriminate applica- tion without regard to physiological principles, most of the results at- tained by its use must be attributed to suggestion. The manipulation of definite vertebral spines corresponds with the elicitation of definite re- flexes, but if the vertebrae are promiscuously handled counter-reflexes are evoked, which may often accentuate the reflexes in action and thus intensify the coexisting symptoms. In the therapeutic elicitation of the visceral reflexes by spinal concus- sion the only kind of apparatus which is effective is one giving the percus- sion stroke; all other motions (oscillations, shaking, friction) interfere with the results. In other words, it is concussion or percussion and not vibration which is effective. The neurologist utilizes percussion and not vibration for eliciting the tendon reflexes and a like argument holds when the visceral reflexes are solicited, In the absence of a reliable apparatus, effective results may be achieved by aid of a pleximeter and plexor; the former being placed in apposition 106 Review of S p o n d y 1 o t h e r a p y with the vertebral spine and struck with the plexor. The results are even more effective with a pleximeter encroaching on both sides of a spinous process. It must be emphasized that, in the employment of a stimulus), if the lat- ter is too prolonged the visceral reflexes become exhausted and a con- dition other than that sought for ensues. It is known that nerve-cells discharge their motor impulses with a rhythmicity comparable to the rhythmic beats of the heart. Planck, uses a sinusoidal apparatus in connection with a compressing armlet thus enabling the current to be delivered rhythmically with each 'beat of the patient's heart. 2. Electricity. The sinusoidal current is used almost exclusively by the writer for evoking the visceral reflexes. Many of the sinusoidal machines cm the market are such in name only and do not achieve the results. The method of application in general is to place one large electrode at an in- different point (sacral region), and the other over definite spinous pro- cesses. Practically all the tendon reflexes may ibe elicited by percutaneous ap- plication of a rapid strong sinusoidal current to definite spinous processes. The reflexes are bilateral, in contradistinction to the conventional cutaneo- peripheral reflexes, which are unilateral. This centrotherapeutic appli- cation of stimulation will elicit tendon reflexes in some instances even though they are otherwise absent, and explains some of the immediate effects secured in locomotor ataxia and in poliomyelitis to restore nutri- tion of the implicated muscles. By sinusoidalization of the skin over definite regions of the cortex, using an interrupting bipolar electrode, it is possible to obtain contractions of the muscles of the arms and face. The galvanic and faradic currents, the interrupted low-tension current of Leduc, and thermopenetrating currents are of little or no value in the elicitation of visceral reflexes by vertebral excitation. The high-frequency current, applied by means of a double vacuum electrode, to either side of definite spines, will elicit visceral reflexes of great amplitude and long duration. 3. Pressure. Visceral reflexes may be excited by deep pressure at the vertebral exits of the various spinal nervea Visceral pains and the pains of intercostal neuralgia may be thus inhibited by continuous pres- sure. Pressure is of great value in spondylodiagnosis. At one time, cer- tain itinerant physicians won great renown in diagnosis, by eliciting ten- derness in definite vertebral regions based on a chart published by Dr. Sherwood in 1841. In 1834, the Griffin brothers, English physicians of 107 Progressive Spondylotherapy prominence, sought to popularize vertebral tenderness as. a diagnostic aid. My investigations, and a synopsis of the same is presented : Disease Points of greatest tenderness Appendicitis Bladder, rectum, and anus. Cholecystitis Gastric disease Heart Disease Ovarian Disease . Renal Affections Tubal Disease ... Uterine Disease 8th or 9th dorsal, or 2nd lumbar, right side. 1st to 3rd sacral (both sides). 10th and llth dorsal (right side) and tip of llth rib. 4th to 7th dorsal spines painful on pres- sure when lesion (like an ulcer) is located on lesser curvature between cardia and pylorus. At spine or side of 10th dor- sal, lesion of the fundus. From 10th to 12th dorsal, lesion is at greater curva- ture close to pylorus. 3rd to 6th dorsal, left side. 3rd lumbar, on side of disease. 10th to 12th dorsal spines on side of disease. At or below 3rd lumbar, on affected side. 4th lumbar spine. Spondylodiagnosis. (1) Electric current or persistent friction o*f the skin over tender area causes a red spot to appear. (2) Absence of typical painful points. (3) Accentuation of vertebral tenderness by manipula- tion of the suspected viscus. (4) Elicitation of dermatomes. (5) Segmental analgesia of the viscera. (6) Tenderness is superficial and if the skin is pushed to one side, deep pressure causes little pain. (7) Unlike tender- ness of a spinal neuralgia, rubbing the part does not provoke a localized spasm of muscle. (8) In tenderness of visceral origin, there is no de- formity nor rigidity of the vertebral column and movements are, as a rule, painless. In a large number of cas-es examined by Dr. George Jarvis, with rela- tion to vertebral tenderness in visceral disease based on the foregoing table and corroborated surgically, the following conclusions are formu- lated; (1) In no case would conclusions based on the spondylodiagnosis have led one astray as to the organ involved; (2) Spondylodiagnosis alone does not usually yield a complete pathological diagnosis ; but it does accu- rately point out which organ is involved and, in connection with other "clinical findings," permits of the greatest accuracy. 4. Freezing. In the treatment of localized areas of vertebral tender- ness, nothing in the experience of the writer exceeds cold as a remedial 108 Review of S p o n d y 1 o t h e r a p y measure. The technique of psychrotherapy is fully described in my work on Spondylotherapy. In trigeminal neuralgia, freezing is executed over the site of the Gas- serian ganglion and over the two upper cervical vertebrae. Jarvis and Endelman, observe that for promptness and efficiency, freezing is sur- passed by no other therapeutic or operative method in the treatment of pain of dental origin, or any structure of the face innervated by the trigeminus. In postextraction pain, it is magical. Their conclusions are based on a series of 200 cases of trigeminal pain. Comparison of Methods. It is only possible in -a general way to say what is the most efficient method for eliciting the visceral reflexes. Like all cells, the neurones do not react to the same stimulus. Weak stimulation as a rule increases, and strong stimulation decreases the activity of the cells. Unfortunately few physicians are sufficiently skilled in physical diagno- sis to determine for themselves the amplitude and duration of the visceral reflexes. Thus, in a patient with an aortic aneurysm, the following com- parative results were obtained in eliciting the aortic reflex of contraction: Method Duration of treatment Duration of reflex Concussion 1 minute to 7th cervi- 12 minutes. Rapid sinusoidal cur- rent - cal spine. 1 minute to both sides of same spine. 36 minutes. Take again the normal stomach reflex of contraction and we have the following results: Method Duration of treatment Duration of reflex Slow blows directly to spinous process Slow blows to 'both sides of spinous pro- cess One-half minute. One-half minute. 3 min., 35 sec. 16 minutes. Slow sinusoidal cur- rent to both sides, of spine One-half minute. 8 minutes. The vasodilator lung reflex employed by the writer in pufmonary tuber- culosis may likewise be cited. The duration of the reflex refers to the duration of dulness and the stimulus is applied to the tenth dorsal spine. 109 Progressive Spondylotherapy Method Duration of treatment Duration of reflex Concussion 1 minute. 45 seconds. Rapid sinusoidal current Slow sinusoidal current- High-frequency current.. Paravertebral pressure- 1 minute. 1 minute. 1 minute. 1 minute. 6 minutes. No result. 4 min., 10 sec. 10 minutes. When pressure exceeded one minute., the dullness was of short dura- tion. The reflexes are more easily exhausted by pressure than by any other method. For discharging visceral reflexes, the rapid sinusoidal current is always more efficient than the slow current. With different sinusoidal machines one secures discordant results. Pharmacological Methods. Insomuch as adrenalin acts exclusively on the sympathetic, and pilocarpine on the autonomic fibers, these drugs are used by the writer as synergists to augment the amplitude of the visceral reflexes. Physiology of Spondylotherapeutic Methods. 'Physiologists are not in accord whether the spinal cord, like the peripheral nerves, reacts direct- ly to stimuli. The clinician, however, has evidence to show that the spinal cord is excitable to direct stimulation. Experiments show that most nerve cells discharge their motor impulses at a rate of albout ten per second and if these cells are stimulated arti- ficially the motor discharge is aibout the same rate as the normal. This reaction of the nerve cells is endowed with a definite rhythm which has been compared with the rhythmical beat of the heart. (At a meeting of the American Association for the Study of Spondylotherapy on Sept. 20, 1916, Planck exhibited a sinusoidal apparatus connected with a compress- ing armlet, thus enabling the current to be delivered rhythmically with each beat of the patient's heart.) Concussion. 'This, is a mechanical stimulus and is equivalent to a blow, pressure, pinching, or section. Concussion of short duration augments the excitability of the spinal segments or nerves, but when prolonged the excitability is diminished or abolished. Sinusoidalisation. This is the equivalent of an electric stimulus. The rapid sinusoidal current is stimulating, whereas the slow sinusoidal cur- rent yields a series of electric shocks. In the application of the latter cur- rent to the spine, motor effects are only exceptionally observed, the action being limited to subduing the sensory component of a spinal segment. 110 Review of S p o n d y 1 o t h e r a p y Pressure. This, when executed upon a mixed nerve, paralyzes the motor earlier than the sensory fibers. If the pressure is applied gradually, the nerve may be rendered inexcitable without demonstrating any evidence of its 'being stimulated. Pressure on a mixed nerve extinguishes reflex conduction sooner than motor conduction. Freezing. 'Notwithstanding a series of histological examinations made by myself to explain the rationale of this method as a remedial agent, no definite conclusion was attained. The leucocytic infiltration of the tissues which followed the freezing may possibly implicate the process of phago- cytosis which in turn would suggest the infectious nature of many neu- ralgias in which affections, owing to the rapidity of action, freezing may be regarded almost as a specific. The initial contraction of the vessels and tissues is followed iby a greater dilatation and turgescence. When the temperature is sufficiently low, the excita/bility of all the nerves is dimin- ished, 'but the limited duration of the reduced temperature in psychro- therapy excludes this factor. THERAPEUTICS OF THE REFLEXES. Heart Reflex. Attention was first di- rected in 1898, to the phenomenon now known as the heart reflex of Abrams. 6 This reflex which is easily demonstrated by percussion and the x-rays, has .been confirmed 'by Zulawski, in Germany, Merklen and Heitz? in France, Sir James Barr and Sir Thomas Allbutt in England, and by notable investigators elsewhere. In a communication iby Cohen (May 24, 1915) to the College of Physi- cians, Philadelphia, forty-three illustrations were presented demonstrat- ing the effects of concussion of the seventh cervical spine on the heart and aorta. He comments!, "One of the phenomena that has been neglected by many who might be supposed to seek every means at their command to help those who come to them for relief is the heart reflex of Abrams." The reflex in question is a contraction of the myocardium of short dura- tion in health (longer duration in myocarditis) and attains its greatest amplitude and duration iby stimulation (usually concussion) of the sev- enth cervical spine. The heart reflex of contraction is of great diagnostic value. The murmurs in relative valvular insufficiency may be made to disappear temporarily by concussion of the seventh cervical spine which, by causing myocardial contraction, reduces the size of the cardiac orifices, thus. enabling the valves to close the ostia. In many instances, even in the norm, concussion of the seventh cervical spine may elicit a systolic murmur varying in duration from one-half to three minutes. The duration of a normal heart reflex is approximately two minutes; in myocardial disease it may persist for several hours. In the treatment of cardiac insufficiency, elicitation of the heart reflex, yields immediate results or none at all. My experience with this reflex in car- 111 Progressive Spondylotherapy diopaths enables me to conclude that if in its elicitation no results are achieved, very little may be anticipated from cardiotonic medication. The reflex just described is that of contraction but there is counter- reflex, known as the heart reflex of dilatation, superinduced by concus- sion of the ninth to the twelfth dorsal vertebrae, or better still by con- cussion between the third and fourth dorsal spines. Minerbi, at the University of Rome, finds a prompt retraction of the sound heart when the precordial region is tapped, the retraction in normal persons amounted to a total of 4 cm. for the entire heart in the course of 3 minutes. The retraction is due to the autonomic excitability of the muscle tissue independent of the diastole proper. By aid of the heart re- flex, he learned that the auricle and the atrium can contract independently of each other as well as of the ventricle. Angina Pectoris. In the form of this affection which I have called the cardiectatic variety dependent on cardiectasia, immediate relief frequently follows elicitation of the heart reflex of contraction but in the conventional variety, this reflex will accentuate the symptoms. In the latter variety, one may achieve results by evoking the heart reflex of dilatation. Bitfield (/. A. M. A., Feb. 3, 1917), inhibits the pains of false angina by having the patient thrust the little finger firmly into the external auditory meatus. This maneuver stimulates the aural 'branch of the vagus which, indirectly elicits the heart reflex. Concussion is the more effective method as I have shown in "Physico-Clinical Medicine (March 1917, p. 78.) I have noted that some patients will intuitively suppress an attack by pres- sure on the eyeball. They excite the oculocardiac reflex. In the norm, pressure on the eyeball slows the pulse through vagus inhibition. An ac- celeration or retardation of 10 beats or more a minute is abnormal. The reflex arc of this phenomenon consists of afferent impulses by the ophthal- mic branch of the 5th nerve to the nuclear cells of origin of the vagi in the 4th ventricle. When one irritates the nasal mucosa by various inhalations, etc., the heart reflex of contraction ensues. The value of amyl nitrite inhalations in the treatment of angina pectoris is universally conceded, ibut when this drug fails to bring relief, the failure may be attributed to irritation of the nasal mucosa which, by inducing the heart reflex of contraction, still fur- ther accentuates the paroxysm. In such instances and, in fact, in nearly all instances, the action of amyl nitrite is aided by previous cocainization of the nasal mucosa, which eliminates the irritant factor of the inhalations. Functional Cardiac Neuroses. These, if they are dependent on vagus hyptonia, are often amenable to treatment by concussion of the seventh cervical spine which acts by stimulating the vagus. If the neuroses are dependent on vagus hypertonia, equally good results may ibe achieved by stimulating the depressor nerve. The writer has empirically established the 112 Review of S p o n d y 1 o t h e r a p y fact that stimulation of the latter is best effected between the third and fourth dorsal spines. It is known that some functional forms of arrhythmia may arise from vagus stimulation, which not only shows the heart rate, but may also create irregularities in rhythm. By eliminating this vagus influence by the atropine test, 8 the irregularities will disappear thus demonstrating the neu- rogenic character of the arrhythmia or bradycardia. This test may be eliminated by pressure for one-half minute between the third and fourth dorsal spines which maneuver, like atropine, depresses the vagus action. Hypertension. Tn 1904, I directed attention 9 to the fact that, hyperten- sion is often a condition which is desirable and not to be opposed, inso- much as the vasoconstriction may compensate a failing heart. This view- point has since then been conceded. In such instances, vasoconstrictors are injurious and the correct course to pursue is to strengthen the heart and the blood-pressure will fall of its own accord. A single seance of concussion of the spinous process of the seventh cervical vertebra will at once reduce the pressure provided it is due to cardiac enfeeblement. When there is no cardiac enfeeblement, pressure may often be reduced by concussion between the third and fourth dorsal spines. At the latter point we stimulate the depressor nerve. If, coincident with this stimu- lation, percussion of the lower abdomen is executed, areas of dullness caused by dilatation of the splanchnic vessels may 'be elicited. The physi- ologist knows that stimulation of any centripetal nerve augments blood- pressure and the essential factor in this reflex rise is vasoconstriction of the splanchnic area. The only exception to the foregoing rule, is stimula- tion of the depressor nerve, which lowers pressure by dilating the splanch- nic vessels. The Splanchnic Circulation. Many factors are concerned in hyperten- sion but the splanchnic vessels are practically ignored. The latter have the greatest effect on blood-pressure and the vessels in question are suffi- ciently capacious to hold practically the entire bloodvolume of the body. It is many years since I first directed attention to the splanchnic circu- lation. 1 Since then, many writers have added to the literature on the subject, notably, Robt. T. Morris, 11 and more recently, A. B. Hirsch, in a communication to the College of Physicians of Philadelphia on Jan. 25, 1915. The splanchnic circulation may cause hypertension or hypotension, more frequently the latter. In the former instance, cardioptosis is nearly always associated with a defective splanchnic vasomotor mechanism which causes cardiac enfeeblement, and to compensate the latter there is a constriction of the vasomotors which causes hypertension. In such instances, a forcible lifting of the abdomen during the time ibloodpressure is taken will cause a fall in pressure. If hypotension is present, the latter maneuver wiM cause the pressure to rise. 113 Progressive Spondylotherapy Sir James Barr, England's master clinician, referring to "Cardiac In- sufficiency" (British Med. Jour., April 15, 1916), refers several of its symptoms to a gravitation of blood into the abdominal cavity. "These phenomena," he continues, "have been aptly termed Cardio-Splanchnic pa- resiS by Albert Albrams and an abdominal belt worn tightly does good." Constriction of the splanchnic vessels may be attained by concussion of the fifth, sixth and seventh dorsal spines, whereas stimulation of the de- pressor nerve will cause the converse condition". Aneurysm Since the writer reported 12 , 13 forty cases in his own prac- tice of thoracic and abdominal aneurysm symptomatically cured, the "Abrams method," has been extensively employed toy others* in this country whose reports may be found in the literature. No other adjuvant meas- ure, not even rest, was employed. Snow's contribution 3 is specially in- teresting insomuch as a series of radiograms are shown illustrating varia- tions in volume of aneurysms superinduced by elicitation of the aortic re- flex of contraction (concussion seventh cervical spine.) The Minerbis, of Italy, Houlie, in France, and other foreign writers have contributed to the literature on the subject. After the lapse of years, the enthusiasm of my early reports has been modified by conservatism which enables me now to conclude that in early cases, the "Abrams method" is practically a specific, but in late cases* all that can be achieved is a relief of symptoms, and that can be done more rapidly than by any other known method. Exophthalmic Goiter. In this condition, concussion of the seventh cer- vical spine is practically a specific. Even after a single seance of concus- sion one may note a reduction of the pulse from ten to thirty beats per minute, and likewise a diminution in the size of the struma. From many reports of physicians, the results have been practically uniform. The fol- lowing is an excerpt of a letter from a physician who has successfully treated many cases : "It is only a question of time when physicians will and must recognize your specific treatment, and when it will be regarded as criminal negligence for the physician to invoke surgery before giving your method a trial." Respecting the rationale of the method, the reader is referred to my work on Spondylotherapy and to a contribution in International Clinics*, vol. iv., 22d series, p. 35. Goiter. Among many letters received from physicians one question is paramount: Will concussion of the seventh cervical spine cure simple forms of goiter? The reply to this question may be given as> follows: In goiters showing vascularity of the gland (soft and tender with systolic blowing or pulsation) there is some chance of reduction, but when there is fibrosis of the gland no results can be expected. Enlargement of the thyroid is frequently a compensatory phenomenon like kidney hypertrophy 114 Review of S p o n d y 1 o t h e r a p y tc compensate for the secretory deficiency of its fellow, or when polycythe- mia occurs in high altitudes to make the -most of the deficient supply of oxygen. Similarly, the thyroid enlarges because it is required to supply itself with iodine conveyed to it .by the blood. Here iodides or thyroid extract if given early prove curative. Lung Reflexes. The lung reflexes of contraction and dilatation may be elicited by stimulation of definite spinous processes. 'G. Auld, 14 in com- menting on "The Lung Reflexes of Abrams," observes, "it was not, how- ever, until recent years that anything like a satisfactory demonstration of the presence of bronchodilator, as well as bronchoconstrictor fibers in the vagus was made by Roy and Brown, and during the present year this seems to have been conclusively established 'by the work of Dixon and Brodie. But it undoubtedly stands to the credit of Abrams, to have prov- ed, at least seven years since, 'by a simple clinical observation that the vagus must contain bronchodilator as well as bronchoconstrictor fibers." "The Clive Riviere Sign" (The London Lancet, Aug. 21, 1915) is based says the author, "on the lung reflex of contraction originally described by Albert Abrams. It is impossible to refer in detail to the value of the lung reflexes in diagnosis and treatment and we must be content with a consideration of the author's methods of treating bronchial asthma. Asthma. The author's theory of asthma has been discussed elsewhere (iSpondylotherapy, p. 309). By concussion or sinusoidalization of the fourth and fifth cervical spines, one may elicit the lung reflex of con- traction and it is this maneuver which is employed .by the writer in the treatment of essential asthma. This method may also be used to arrest a paroxysm. While my results are comparatively good, they do not tally with the enthusiastic reports from others who employ in preference the sinusoidal current; one electrode over the spines of the fourth and fifth cervical vertebrae and the other electrode over the sacrum. Perhaps the climatic conditions in San Francisco may have much to do with my re- sults. Owing to the enfeebletnent of the bronchial musculature in asthma some time may elapse before results are achieved and, until that time has arrived, it is necessary to employ a palliative for the relief of the patient. Cardiac Asthma. This may be confounded with bronchial asthma but concussion of the seventh cervical spine by inducing the heart reflex of contraction should inhi'bit the paroxysm, but will accentuate it if of bron- chial origin. Stomach Reflexes. 'The stomach reflex or contraction elicited by stimulation of the spines of the first three lumbar vertebrae is of un- doubted value in the treatment of motor insufficiency of the stomach. Concussion of the fifth dorsal spine will dilate the pylorus (pylorui: reflex). This fact has 'been utilized for the following purposes: (1) To 115 Progressive Spondylotherapy relieve pylorospastn ; (2) to facilitate rapid absorption and hasten the elimination of nauseous drugs from the stomach; (3) to eliminate the action of the gastric juice on drugs destined for action on the intestinal tract; (4) in the treatment of gastric affections; (5) to aid duodenal in- tubation. In my method of duodenal intubation, the ordinary stomach tube will pass directly into the duodenum during the time pressure is made at the fifth dorsal spine. Cardiospasm may be overcome by sinusoidalization between the third and fourth dorsal spines. Dr. H. E. MacDonald (Los Angeles) comments on the pylorus, reflex as follows : "I believe that Albrams' pylorus reflex will revolutionize gastroenterology. I have cured stomach troubles of many years duration by instructing the patient to drink a couple of glasses of water 3 or 4 hours after eating. Then to lie on the right side while a member of the family percusses the 5th dorsal spine. A patient practically moribund from inanition (incontrollable vomiting) was a'ble to retain his milk when the pylorus reflex was elicited immediately after ingestion of the milk." He further observes, "It appears to me that we should worry no longer about the Vomiting of Pregnancy." Dr. W. J. Caesar (Richmond, Cal.,) has made many observations with the pylorus reflex in the latter condition and knows of no simpler or more efficient method in the treatment of this intractable affection. After the ingestion of food, the pylorus reflex is elicited before the pregnant woman rises (Medical Record, Nov. 24, '17.) Intestinal Reflexes. That of contraction (stimulation of first three lumbar spines) is utilized in the treatment of atonic constipation and the reflex of dilatation (stimulation of eleventh dorsal spine) in spastic con- stipation. Since using my method of duodenal intubation, I have found that stimulation of the tenth dorsal spine will augment the pancreatic secretion. The pains of a duodenal ulcer may be precipitated by opening the pylorus which permits of the passage of chyme. Augmentation of the pancreatic secretion 'by the method cited will arrest the pains of a duo- denal ulcer as such maneuver al'kalinizes the chyme. Authorities are practically agreed that the passage of a tube beyond the sigmoid flexure is impossible. By pressure at the eleventh dorsal spine which dilates the sigmoid flexure, colonic intubation is possible. I have recently investigated the action of vertdbral concussion on the appendix and found by fluoroscopic examination (bismuth subcarbonate previously ingested) that concussion of the tenth dorsal spine empties it and that concussion of the first lumbar spine will dilate it. I have already utilized the foregoing maneuver with excellent results in several cases of chronic appendicitis. Like observations have been made by many com- petent clinicians. Concussion of the twelfth dorsal spine contracts the cecum. This lat- 116 Review of Spondylotherapy ter observation is of importance in bearing on the recent observations of Reed 15 concerning the etiology of essential epilepsy. Liver Reflexes. 'These consist of contraction and dilatation of the organ. The former is utilized in the treatment of hepatic toxemia and is likewise available in intestinal autointoxication. The latter is available in early hepatic cirrhosis. Contraction and dilatation of the gall-bladder may be attained by vertebral stimulation over definite spinous processes. Splenic Reflexes. The splenic reflex of contraction is employed in the treatment of splenomegaly. In latent malaria, one may precipitate a typical paroxysm by discharging the splenic reflex of contraction (concus- sion of the second lumbar spine). It is assumed that the occurrence of the latter is due to the mechanical extrusion into the circulation of the plasmodia which have lodged in the organ. In suspected malaria, one may find plasmodia in the blood after inducing the splenic reflex of contraction even though absent before this maneuver is executed. Con- cussion of the eleventh dorsal spine enlarges the spleen. Examinations of the blood made for me by a competent hematologist (Alfred Roncoveieri, M. D.) developed the following: (1) Average in- crease of erythrocytes after concussion of the eleventh dorsal spine only, 300,000; (2) average percentage increase of hemoglobin after concus- sion of eleventh dorsal spine only, five per cent.; (3) average increase of leucocytes after concussion of second lumbar spine only, 2800; (4) aver- age increase of red cells after alternate concussion of second lumbar and eleventh dorsal spines, 650,000; (5) average increase of hemoglobin after the latter (alternate concussion), ten per cent. The ubiquity of syphilis, emphasizes the dictum of Fournier General pathology should ibe made a mere annex to syphilography. The Wassermann test is uninfluenced by this reflex of contraction, but not so with the Noguchi reaction. In a number of observations thus far made,* I may safely conclude that if aibsent it may be present after evo- cation of the reflex. If previously present it is invariaibly accentuated. After the 'blood is removed in the usual way by a trocar the latter is oc- cluded by the finger and after concussing the second lumbar spine for one minute a second specimen oi blood is allowed to flow. Elsewhere, I have shown that in malaria, daily elicitation of the splenic reflex of con- traction coupled with quinin, is the most efficient treatment. My present investigations in syphilotherapy show like results. The spleen is practi- cally a "dead corner" of the organism and the usual depository for the virus of all infections. Elicitation of the splenic reflex hastens the ex- trusion into the circulation of virus favoring its elimination and per- mitting its more certain destruction by remedial agents. *ABRAMS: Medical Record, Oct. 6. 1917. Frauchiger (Physlco-Clin. Med. Dec. 1917), in two series of 10 cases each taken at random shows like results. 117 Progressive Spondylotherapy THERAPEUTICS OF MISCELLANEOUS REFLEXES. Gynecological. The uterus reflex may be discharged by stimulation of the first three lumbar spines. Sinusoidalization is the preferable stimulus. The degree of uter- ine contraction is determinaible by palpation or directly through a specu- lum. An anemia of the uterus accompanies the contraction and eleva- tion of the ovaries. Chas. L. Ireland, M. D., comments as follows: "I will say that up to one year ago I had always contended that when an ovary was prolapsed, surgery was the only recourse and I had good reasons for so thinking. By the use of the sinusoidal current to provoke the uterus reflex, absolute cure resulted in nine cases, i. e. reposition of the ovaries ensued." In a later communication Ireland prefers stimulation of the tenth, eleventh, and twelfth dorsal vertebrae for the reduction of pro- lapsed ovaries. Dislocated uteri without adhesions are amenaible to the same treatment. Uterine hemorrhage, relaxed vagina, and rectocele are amenable to treatment by spondylotherapy. In- agalorrhea, concussion or sinusoidalization of the third and fourth dorsal spines, will, after three or four treatments stimulate the mam- mary glands to normal activity. ^Several of my students engaged in obstetrical practice contend that during labor, one may demonstrate paravertebral points of tenderness corresponding to the lumbar vertebrae and that pressure over these areas will in most instances either mitigate or arrest the pains and thus con- tribute to painless labor. Dr. D. V. Ireland contends that by concussion of the twelfth dorsal spine he has in several instances restored a movable kidney to its normal position. Vasomotor Reflexes. Vasoconstriction of the blood-vessels is best attained by stimulation of the seventh cervical spine and vasodilation, by stimulation at the tenth dorsal spine. These effects may be observed with the ophthalmoscope and bronchoscope. In one case seen with Marie, in Paris, in an individual with a defect in the cranium, contraction of the meningeal vessels could be directly observed during concussion of the seventh cervical spine. The vasomotor reflex of contraction has been utilized in various ways, notably in the control of hemoptysis (sinusoidalization), migraine (angio- paralytic form), urticaria, etc. Thus, Dr. Myer Solis-Cohen refers to the instantaneous relief secured by concussion of the seventh cervical spine in a severe case of urticaria following the use of diphtheria antitoxin; itching and rash quickly evanesced. Cohen used the same method of treatment successfully in a rebellious case of migraine. Dr. Hugo Summa and Louis Schrei/ber recently presented before the Ophthalmic Society of St. Louis a patient with corneal ulcers of many years' duration which had resisted treatment by many competent oculists. 118 Review of S p o n d y 1 o t h e r apy Acting on the theory that, by provoking the vasomotor reflex of contrac- tion, not only would contraction of the vessels ensue but likewise aug- mented tone, concussion of the seventh cervical spine (seances daily) re- sulted in cure within one week. Bladder Reflex. Contraction of the wall of the bladder and its sphinc- ter may be observed with the cystoscope when stimulation of the fifth lumbar spine is executed. The bladder reflex may be utilized in atonic conditions of the bladder misculature. Prostate Reflex. Stimulation of the twelfth dorsal spine with a strong rapid sinusoidal current causes a reduction in the size of the prostate. With the finger palpating the gland during the action of the current with an in- terrupting electrode, this effect may be observed provided the stage of active parenchymatous and muscular hyperplasia has not been succeeded by an overgrowth of fibrous tissue. Results in treatment (provided the latter is not present) are immediate, irrespective of the stage of pros*- tatism. Thymus Reflex. This has been utilized by the writer in the treatment of pertussis, and the reflex is invoked by concussion of the seventh cer- vical spine. According to numerous reports received from physicians throughout the United States, this method of treatment has arrested the paroxysms in from three to seven days. In the latter reference, the sub- sternal dullness noted by me in pertussis was ascribed to an aortectasia but since the writer's method of defining the thymus gland has been per- fected, 2 the paroxysms of pertussis are referred to hypertrophy of this structure. Paralysis Agitans. Parathyroid insufficiency is the most recent accept- ed theory concerning the etiology of this affection. By my methods of electronic diagnosis, one may measure the intensity of energy emanating from the parathyroid glands and my investigations, show that concussion of the 6th cervical spine will augment the functional activity of the para- thyroids. REFERENCES 1. Taylor: "An appreciation of the teachings of Dr. Abrams;" Cyclo- pedia and Medical Bulletin, July, 1913. 2. Abrams: New Concepts in Diagnosis and Treatment, 1916. 3. Snow: International Clinics, vol. iv., 23d series, 1913. 4. Abrams: Chart of Spondylotherapy. 5. Jarvis and Endelman: Pacific Dental Gazette, Dec., 1913. 6. Abrams: Medical Record, March 26, 1898. 7. Merklen and Heitz: Examen et S6meitoque du Coeur. 8. Abrams: Diagnostic Therapeutics, Rebman Co., p. 300. 9. Abrams: Am. Journal of the Med. Sciences, November, 1904. 10. Abrams: Splanchnic Neurasthenia (The Blues), E. B. Treat and Co., New York, 4th edition. 11. Morris: Archives of Diagnosis, Jan., 1913. 12. Abrams: British Medical Journal, July 8, 1911. 13. Abrams: La Presse Mgdicale, Oct. 4, 1911. 14. Auld: Lancet, Oct. 17, 1903. 15. Reed: Journal A. M. A., May 2.6, 1916. rip THE ELECTRONIC REACTIONS OF ABRAMS* By ALBERT ABRAMS, A.M., M.D., LLD. San Francisco, Cal. PRELIMINARY Diagnosis is the most exalted and yet the most difficult task of the physician Qui bene dignoscit, bene curat. A correct diagnosis in many important diseases falls below 50 per cent, in recognition and in some be- low 25 per cent. This is because medical practice is only 50 per cent, effi- cient. Until the physician can weigh, measure and express his knowledge in numbers, his art has scarcely attained the dignity of a science. Physical science, by reason of the universality of its laws, dominates every phase of medical research and knowledge, irrespective of its source must be invoked to participate in the development of our art. Descartes, a philosopher discovered the reflex; Leonardo, an artist, dis- covered the function of the heart; Hales, a clergyman discovered arterial pressure ; Leeuwenhoek, a "bedell" discovered the capillary circulation ; Wren, an architect, discovered intravenous injection and Priestly, a clergy- man discovered the function of the green plant. The human must not be segregated as something apart from other en- tities of the physical universe. There is only one physics, one chemistry and one mechanics governing animate an inanimate phenomena, and the latter must be studied by physico-chemical methods. Vital phenomena are dynamic and the actions of organisms should be regarded as pro- cesses and not as structures. All vital phenomena are subject to the same laws governing the cosmos. Every atom is a microcosm teeming with Titanic forces and our scientific conception must embody hylozoism all nature, including the world itself, is alive. Even though one admits a special vital or "biotic" energy, it must be *Reproduced, with additions, from International Clinics (Vol.. I, 27th series, 1917); "A quarterly of clinical lectures by leading members of the medical profession throughout the world." In the previous article in this book (Spondylotherapy), "Human Energy," the stomach reflex was utiliz- ed but owing to the difficulty encountered in its elicitation, the splanch- nic reflexes are here substituted. This subject is elaborated in detail in the author's recent book "New Concepts in Diagnosis and Treatment" and all progress made on the subject is incorporated in the author's Journal "Physico-Clinical Medicine," Numbers in parentheses refer to pages in "New Concepts in Diagnosis and Treatment," where the subject is more fully elaborated. When "S" precedes the number it refers to the page IB Spondylotherapy. 120 Electronic Reactions disregarded except when converted into recognized forms of chemical or physical energy in equivalent amount. All problems hi medicine not in accord with the progress made in physical science are doomed to perish. Successive innovations have completely altered the physiognomy of medical practice. The doctrine of cells and protoplasm, gave a decided impetus to the formulation of modern biology and pathology, but it has suffered many vicissitudes notably that, in the interpretation of vital phenomena, one must look deeper than simple cell-structure as revealed 'by the micro- scope. In this sense the Zeitgeist demands an abrogation of this misalliance of medicine and cytology. The cells constitute a superstructure guided in their acitvity by physico-chemical forces'. The cell is only the micromor- phologic unit of plant and animal organization. The universality of the laws of physical science are in accordance with the accepted electronic theory viz., that the ultimate atomic -divisibility of matter is represented by the electron and not the cell, hence, the archaic cell-doctrine must be superseded by the electronic theory (3). THE ELECTRONIC THEORY* The actual nucleation of the electron theory forty years ago in its ex- planation of matter is perhaps the greatest contribution ever made to scientific knowledge. . The units of our organism, the electrons, are charges of electricity. In their incessant activity they produce the phenomenon known as radia- tion. The physicist limits the latter to a few elements simply because his ap- paratus lacks sensitivity. It can be demonstrated by aid of the reflexes that radiation is a universal property of matter. REFLEXES OF ABRAMS Every phenomenon, in nature, is dependent upon matter in motion or vibration, and energy is employed to designate the modes of motion in the universe. All matter responds to stimuli, and is known as irritability. In investigating the physiological physics of the various forms of energy, the visceral reflexes of the author which are physiologic constants are employed. Energy is susceptible of exact measurement and as all forms are convertible into heat, physicists measure it as such. The writer meas- ures energy by his reflexes. In accepting the visceral reflexes as the ibasis for our diagnostic reac- tions, bioplasmic matter is employed, the most primitive and sensitive *Prof. Thomson (Cambridge, England), received in 1916, the Nobel prize for his theory of the electrons. Prof. R. A. Millikan, (University of Chicago), succeeded in isolating and weighing electrons, the ultimate units of electricity and the most unthinkably minute particles ev- thought of by man. 121 Electronic Reactions substance for exhibiting the phenomena of energy. The physiologic mechanism designated as a reflex, surpasses in its sensitivity any apparatus yet devised by human ingenuity. The lungs antedated the bellows; the heart, the pump; the hand, the lever; and the eye, the photographic camera. Telephonic and telegraphic apparatus duplicate, mimetically, what has always been done by the nervous system, and, always by aid of the same energy. The animal machine is equipped, by its sense organs, as receivers for practically all kinds of energy. Olfaction (20) surpasses, in sensitiveness, the most impressible scientific ins'truments and the retina is approximately 3000 times as sensitive as the most rapid photographic plate. In the author's recent work, "New Concepts in Diagnosis and Treat- ment," the stomach reflex is almost exclusively employed for the detection of energy, but owing to the difficulty encountered by others in its elicita- tion, it is here substituted by other reflexes. Consideration will, at this time be only accorded to the diagnosis of carcinoma, syphilis and tuber- culosis. The diagnosis of other affections are and have been reported in the writer's Journal, "Physico-Clinical Medicine." SPLANCHNO-DIAGNOSIS* The successful employment of this method predicates a knowledge of percussion, which not only means the delivery of blows but the interpre- tation of sounds- differences of pitch and resonance. The method is no more flamboyant than the elicitation of dulness over a consolidated lung area, and, if the former is unrecognized, I doubt the physician's ability to interpret the latter. SPLANCH NO-VASCULAR REACTIONS. Strong stimulation of the depressor nerve dilates all the abdominal vessels. An individual nerve hasi different functions. When we perceive a variety of colors, it is due to definite vibratory rates conducted by specific fibers which are natural detectors of energy. When the physiologist stimulates a nerve or muscle, the total energy (irrespective of wave lengths) is employed. When the depressor nerve is stimulated by the radiant energy of disease, the abdominal vessels respond by vasodilation in specific abdominal areas as revealed by dulness on percussion. This nerve may be stimulated between the third and fourth dorsal spines. The latter area was first determined empirically and later, by animal experimentation. The action referred to is not unlike that in spectroscopy by which composite radiations' are analyzed. *There are other splanchnic and pulmodiagnostic reactions discovered by the author. 122 Electronic Reactions The following angiodiagnostic reaction is easily executed :f Take a culture of tu'bercle bacilli and direct the opening of the tube (without removal of the cotton) to the region between the 3rd and 4th dorsal spines (depressor nerve) and note that within 10 seconds, flushing ensues in the region of the infraorbital foramen just below the infra- orbital ridge (Fig. 15). The area in question represents a streak. Apply FIG. 15. Site of vasomotor phenomena incident to the employment of cultures of the tubercle bacillus and pneumococcus. the tube to the 1st dorsal spine and in about 10 to 20 seconds a streak of pallor ensues. The latter is less conspicuous than the former. The face of the subject should be directed toward the light and the observation is to be made during the time an assistant directs the tube to the definite spinal areas. It is a bilateral phenomenon if the tube is directed to the spinous processes, but is unilateral if applied to either side of the specified spinous process. Pallor and flushing are more diffused in individuals with the phthisical habitus if used for the test. It is also evocable when energy is conducted from a tuberculous lung. Like phenomena are noted with a culture of the pneumococcus. This experiment may be elaborated to cause a more diffused redness or pallor by aid of a conducting cord with two electrodes. To accentuate the flushing, fix one electrode at the first dorsal spine and allow the other electrode to come in contact with a grounded metal plate. Conversely, to accentuate the pallor, fix one electrode at the area between the 3rd and 4th dorsal spines and the other on the ground plate. 'Grounding is execut- tWith other forms of pathological energy, reactions invariably occur in definite areas of the ear and face and substantiate the rationale and definite localization of the areas in splanchno-vascular diagnosis. (V 4 ^e in the latter part of this contribution, the use of the ear of a white rabbit). 123 Electronic Reactions ed during the time energy from the culture tube is applied to secure flushing or pallor. It is assumed that in the foregoing experiments and the assumption is verified by the results that, the center for vasodilation of the vessels of the face is between the 3rd and 4th dorsal vertebrae, and that of vaso- constriction, at the 1st dorsal spine. In the norm, both centres are in equilibrium and the vessels are maintained at a definite caliber. When we ground the area of vasodilation (between the 3rd and 4th dorsal spines), the energy necessary to maintain dilation is abstracted and the other center (vasoconstriction). has undiminished play and pallor is accentuated . when the culture of tubercle bacilli (energy) is directed to- the 1st dorsal spine. The converse is likewise true when one grounds the 1st dorsal spine. Dr. George O. Jarvis, who confirmed the visceral reflexes of Abrams, at the operating table, executed several investigations during laparotomies bearing on the conveyance of energy from tuberculous and carcinomatous material to the region between the 3rd and 4th dorsal spines. Within several seconds each time after the electrode was brought in apposition with the latter area, there was a decided vasodilatation in specific intra- abdominal areas. This observation was confirmed by Drs. Parsons, A. W. Boslough and others. 'In experimental work on animals, the writer found that the slightest augmentation of vascularity of the stomach or intestines caused a transi- tion of the percussion note from tympanicity to dulness. METHOD. A healthy person (subject) other than the patient is used for making the electronic diagnosis. Exceptionally, the patient may be used (vide autoelectronic reactions later). The reactions are alike in both sexes. Select a subject with thin abdominal walls- in whom a tympanitic sound is demonstrable over the entire abdomen. When a suit- able subject is found (usually a boy), he may be used daily for diag- nosis. The subject must face the west (standing).* The splanchno re- flexes cannot be elicited in the recumbent posture. The subject stands on a plate of aluminum which is connected by an insulated wire to a faucet, radiator or gas fixture. The modern combination fixture is unsuit- able for grounding owing to its insulation near the ceiling. Percuss and mark the entire lower liver border of the subject (anterior- ly). Select an ordinary flexible conducting cord of copper to both ends of which electrodes are atttached. Aluminum electrodes are most effect- ive. An assistant or the patient places one electrode (receiving elec- trode, R. E.) over the source of radiation (energy) and the other is *When an intermediary is used (subject) or when reactions are elicited from the patient (autoelectronoic reactions) both must stand facing the west in such a way that the body is parallel with the earth's axis. Any deviation from this position will abrogate the areas of dulness. Owing to the magnetic declination one must conceive the earth's axis in relation to the true geographical poles. 124 Electronic Reactions placed by an assistant exactly between the third and fourth dorsal spines of the subject. Within thirty seconds, a specific area of abdominal dulness will be elicited and the latter persists during the energy flow. The dul- ness disappears during deep inspiration but reappears with ordinary breathing by the subject. For esthetic reasons, a screen may be placed between the subject and the patient. Until the necessary skill is ac- quired, a diagnosis should not be made. Preliminary practice may be at- tempted with cultures, blood and tumors. Thus, a culture of tubercle PIG. 16. Method of conveying energy from the spine (area corres- ponding to 7th thoracic spine usually selected) in a patient with sus- pected syphilis to the vertebral region of the subject. An assistant holds both electrodes. In the absence of an assistant, the metallic tips of the conducting cords (electrodes removed) may be attached by adhesive plaster and the conducting cord may be connected with a push button for making or breaking the circuit which may be controlled by the hand or foot of the physician. Note that, owing to the high frequency and voltage of the energy unipolar conduction suffices. To secure uniform results, patient and subject during the execution of the tests should face the west. bacilli yields the same reaction as tuberculosis and the blood from a syphilitic yields a reaction similar to syphilis. Cultures or a carcinomatous growth may be directed to the vertebral area cited without the use of conducting cords. 125 Electronic Reactions LOCATION AND MENSURATION OF DULL AREAS* (Fig. 17)) Location Vertical Transverse Diameter Diameter Carcinoma Left hypochrondriac region just below and merging into lower liver border. 4 cm. 9 cm. Syphilis. Just above the navel extending to either side of the median abdom- inal line. 6 cm. 5 cm. Tuberculosis. Just below the navel. 3 cm. 5 cm. PRECAUTION Do not permit the fingers to come in contact with the metal of the electrodes am! direct them away from the latter as in hold- ing the magnet (Fig. 24). f Colors on the subject, patient or in the room should be excluded. Differences in percussion sounds (change from tym- panici'y to dulness) may surely be acquired by practice. Exclude the personal eq lation in percussion by having contact made "with the R. E. without your knowledge and note if you can tell by the appearing dulness when this is done. Short conducting cords of large diameter conduct more energy and accentuate the areas of ventral dulness; the resistance of the cord depends directly upon its length and inversely upon its sec- tion. When the energy is measured by the rheostat (Fig. 25), uniform measurements can only be secured by cords of the same length and section. Pressure on the dorso-lumbar spine or metasternum during percussion accentuates ventral dulness (S80). If the physician places his foot on the ground plate during percussion dulness is accentuated. Equally effective is the execution of percussion at the end of forcible expiration. The elec- trode approximating the area between the third and fourth dosal spines should not exceed \ l /2 inches in diameter. In denning the lower liver border and the splanchnic reactions, use a barely audible uniform percus- sion blow With a strong blow the liver border will be found lower than with a light blow, and the intestinal reflex of contraction (S325) also evoked would yield a dulness which would be misleading. It is a recog- nised law of sense perception that the less loud the initial sound, the simpler it is to recognise its variations. The sense of greatly increased resistance is associated with impaired resonance. The subject must directly face the west; many reactions cannot be elicited when this rule is violated. All pathological specimens must foe removed from the vicinity of the cords and electrodes to eliminate their possible conduction. *Thcse measurements were determined in a man used as a subject. If a boy is used, the areas would be less. The topography of the areas may vary in a subject with splanchnoptosis, but they may always be pre- determined by cultures and specimens. tTouching the conducting cords or crossing of the same (in using biodynamometer) must be avoided to prevent short-circuiting of the energy. 126 Electronic Reactions A subject with reddish hair must not be selected. If colors approxi- mating this shade are placed across the cranium of the subject, many reactions cannot be elicited. Short-circuiting the brain (.109) will obviate the foregoing interference. Normal energy does not traverse a non-conductor but pathological energy does. Certain areas of the body (72) discharge energy in the norm and the polarity of the latter may prevent the elicitation of the splanch- nic reflex. When such regions are encountered, it is always advisable to FIG. 17. Elicitation of ventral areas of dulness when specific patho- logical energy is conveyed to the area between the 3d and 4th dorsal spines. C, cancer area; S, syphilitic area; TB, tuberculous area. The in- tensity of dulness is in direct proportion to the potentiality of the con- veyed pathologic energy and thus serves as an index to the severity of the disease. cover the electrode in contact with the spine (between the 3rd and 4th dorsal spines) with thin dental rubber dam when executing the tests. Always note the percussion note over the abdomen before executing a test, for owing to the sudden accumulation of gases the transition of resonance to dulness may cause a misinterpretation of the reaction. Do not exhaust the subject; the accumulation of blood in the abdomen, an attendant of enervation, will cause ventral areas of dulness. To accentuate the areas of ventral dulness when necessary, connect 5th 127 Electronic Reactions dorsal spine by a conducting cord to the ground plate on which the subject stands during the time energy is conveyed to the depressor nerve. The 5th dorsal spine corresponds to the splanchnic nerve and when its tone is removed by grounding, its opposition to the dilatation of the splanchnic vessels is partially removed. SYPHILIS. In this disease though quiescent and in any stage and irre- spective of treatment, the reaction is always elicited from any part of the spine, liver or spleen.* It is also obtainable over any active luetic lesion elsewhere. With the electronic reactions, the ubiquity of syphilis can be demonstrated and recalls what the eminent syphilographer, Fournier said of it General pathology should be made a mere annex to syphilography. The German diagnostician avers : "Was man nicht -diagnosbe noted that when the energy is conveyed from the spine or liver of the patient, there is, in addition to the epigastric area of dulness, an area measuring 10 cm. vertically and 12cm. horizontally beginning midway between the navel and the symphysis pubis and extending to the latter* (Fig 18). It is now known that there are distinct strains of the spirocheta; with one strain, eye lesions in rabbits may be produced, whereas another strain never produces' these lesions. Investigators have shown that syphilis may affect the heart alone (spirocheta present) without histological lesions or FIG. 18. Site of additional area of ventral dulness in congenital syphilis when energy is conveyed from the patient to the subject. spirochetes elsewhere. In a considerable percentage of newborn infants, spirochetes at the autopsy have been found in the aorta. Bacterial localization emphasizes the fact that there must be a great variety of species or sub-species among the spirochetes and that the elective localization of lesions is dominated by this facl.J In addition to this general reaction, there are specific areas of dulness *The subject's bladder must be empty to eliminate the impaired reson- ance of the distended viscus. {Specific strains in tuberculosis have also been noted by the author by aid of his reactions. 129 Electronic Reactions which seem to indicate the tissue for which the spirochetes show a predilection. If these additional areas are present, either the structure is already invaded or its invasion may 'be predicted in the event the luetic proce&s is uninfluenced by treatment. The areas thus far elicited are shown in Figs. 19 and 20. Under energetic antiluetic treatment, the reaction from the frontal eminences in dementia paralytica (172) may disappear. FIG. 19. Ventral areas of dulness in syphilis when the spinal energy in this disease is conveyed to the area between the 3rd and 4th dorsal spines. A, area in all cases of syphilis irrespective of the special struc- ture invaded. In addition to the latter, the area B, is present in cardio- vascular lesions; C, lesions of spinal cord and nerve roots; D, eye lesions; E, pulmonary lesions. Fournier, observed that 98 per cent of the children of syphilitic parents are syphilitic. The electronic reactions show that they are all syphilitic, The tale of syphilitic parents may be inscribed as follows : 'Sterility, Still- births, miscarriages, abortions, progeny dying in infancy of marasmus, meningitis, convulsions, etc. Familial syphilis is suggestive if any of the following diseases have occurred among relatives : Tabes, paresis, aneurysm, apoplexy (before 50 years of age), cardiorenal disease (before 50 or 55 years), headaches (not relieved by the usual means), nervous- ness (without obvious cause), rheumatism (obscure) and tuberculosis in several members of the same family, 'because hereditary syphilis accord- 130 Electronic Reactions FIG. 20. Site of area in dementia paralytica from energy conducted from the spine of the patient to the subject. This site was determined from a study of three luetics who, after a lapse of approximately, two, three and four years developed paresis. This site is also present in de- veloped cases. ing to Fournier, strongly predisposes to tuberculous infection later in life. Congenital syphilis is unfortunately identified with its manifestations at birth and we forget that it may not develop until adolescence or late in life (syphilis tarda). I wish to direct attention to certain stigmata which, with the evidence of the electronic reactions prove to be fairly constant in hereditary syphilis : 'Argyll-Robertson pupil, tubercle of Caribelli and the auricular and digital signs of Abrams. The Argyll-Robertson pupil is regarded by many as positive proof of nervous syphilis. No attention has been directed to the slow or sluggish pupil (reflex to light), which I find to be fairly constant in hereditary syphilis. It may be more marked in one eye. Testing for tha Argyll-Robertson pupil de- mands circumspection (Vide Physico-Clin. Med., Dec. 1917, p. 41). The tubercle of Carabelli is a supernumerary cusp (Fig. 21) demon- strable on the palatine surfaces of the upper first large molars. The latter yield the electronic reaction of syphilis and radiograms which I had made of a number of them show diminished density (deficient calci- fication) in contrast with the other teeth. 131 Electronic Reaction A- JVormal -Molar.- 3: Tubercle j of FIG. 21. FIG. 22 Auricular Sign of Abrams. Incidentally, I may mention that the Hutchinsonian teeth also show the electronic reaction for syphilis whereas the other teeth in the same mouth do not. The auricular sign of Abrams consists of a distinct ridge running from the antitragus downwards toward the lobule (Fig. 22). This ridge when palpated has a cartilaginous consistency. The digital sign of Abrams (Fig. 23) is fairly constant. It is an incurvation of the little linger (usually implicating the second phalanx). 132 Electronic Reaction FIG. 23 Digital Sign of Abrams. ELECTRONIC REACTIONS WITH BLOOD* A few drops of blood taken from a patient and allowed to dry on a slide or white paper will, when presented directly to the area between the third and fourth dorsal spines of the subject, yield the characteristic splanchnic areas of dulness. This holds for active tuberculosis, syphilis ("active or quiescent), and carcinoma. In the affections cited, the dried blood yields a reaction for about ten days, whereas in syphilis a reaction is obtainable for several weeks. The latter fact is important when an acquaintance with the luetic reaction is studied. After this manner, diag- noses may be made from blood sent from long distances. The iblood re- action is a general one. Thus, if the blood yields a tuberculous reaction, it suggests tuberculosis somewhere in the organism; the localization of which is possible by the method cited elsewhere. In presenting the specimen side of the paper or slide to the spine, grasp it with a long pair of forceps (wood) or have the assistant hold it at its extreme edge during the time percussion is executed. POLARITY. Radiant energy in disease has a distinctive polarity (cor- Reactions are executed at the writer's "Physico-Clinical Laboratory," from blood sent from different parts of the United States. All that is necessary is to forward several drops of blood (covering the area of a 25 cent piece) from the patient, absorbed by clean white filter paper. For further data concerning these methods the reader may consult the last pages of this book. 133 Electronic Reactions roborative evidence) and is detected by presenting a bar-magnet about four inches away from the area of ventral dulness. The magnet must be held at the extreme end as shown in fig. 24. If the dulness persists with FIG. 24 The lower figure represents the correct way of holding the magnet or electrodes. The upper figure is incorrect owing to modification of polarity from the finger tips and approximation of the latter to the metal which causes short-circuiting and interferes with conveyance of energy. The magnet should be held at the extreme tip. W.hen held in the center, it fails to yield either positive or negative energy sufficient to determine the polarity of the ventral ara of dulness. Be sure that the magnet is correctly marked which is easily determined by aid of a compass. the positive pole (marked N) thus presented and disappears with the negative pole (marked S), the polarity of the energy is positive, and vice versa. If it persists with both poles, it is positive and negative and it it is dissipated by both poles, it is neutral (isopolar). 134 Electronic e a c t i o n s The polarity of the energy in carcinoma is positive and neutral, in syphilis and tuberculosis. POTENTIALITY OF REACTION We are constrained to employ electrical terms and electrical methods of mensuration until our knowledge of pathological energy is better understood. To paraphrase the law of Ohm, the strength of pathological energy varies directly as the energy and inversely as the resistance. A crude method for measuring the energy intensity in diesase is to note at what distance the R. E., is from the source of energy before dulness appears. An ohmmeter is more exact. The rheostat (Fig. 25) for this purpose is wound to carry 100 milliamperes with a voltage of 20. The scale is grad- uated from 1/25 of an ohm to 1 ohm and then up to 50 ohms. To use the rheostat, place the R. E. (say over a cancer) and the other electrode (between the third and fourth dorsal spines. At zero of the scale, the specific dull area is present. Now interpose more resistance until the dulness disappears. If the dulness does not disappear until the index registers 10 ohms, then the energy from the growth has a potentiality of 10 ohms. After this manner, the progress of a growth and the results of treatment may be gauged. FIG. 25. Ohmmeter (biodynamometer) for determining in ohms the potentiality of energy. The resistances are as follows: 1/25 of an ohm to 1 ohm, 1 to 10 ohms and 10 to 50 ohms. PB, is the proximal electrode (vertebral application) and RE represents the electrode for receiving the energy at its source. Three receiving electrodes are shown of different sizes. This set of electrodes is known as Abram's electrodes for the electronic test. 135 Electronic Reactions In carcinoma, the potentiality varies from 1 (incipient cancer) to 30 ohms, The reaction in syphilis is always present and in this sense it exceeds in value the serological tests. In quiescent syphilis the potentiality rarely exceeds 2/25 of an ohm; in active syphilis, it may exceed 10 ohms. The splanchnic reaction is elicited even over a healed tuberculous lesion but the energy from it never exceeds a potentiality of 2/25 of an ohm. Active lesions may show a potentiality of 20 ohms. Without an ohm- meter at our disposal, in healed tuberculosis, the reaction is present cnly when the R. E. is in contact with the skin. If a reaction is elicited at a distance exceeding one inch from the skin surface, the lesion is active. Thus, in one patient, when the R. E. was held at a distance of seven inches from the tuberculous lesion, the ohmic resistance was 6 ohms.* VIBRATORY RATE. Using the rheostat after the manner indicated, it will be found that the dull abdominal areas will only appear at definite points on the scale. At zero always, and up to the potentiality of the energy. Otherwise, the dull areas will appear at the following indices of the scale: Carcinoma, 30 or 50 ohms. Syphilis, 20 ohms. Tuberculosis, 15 ohms. The writer wishes to asseverate that, if splanchno-diagnosis is approach- ed with a prejudiced mind, it is better not to attempt it, for there are "none so blind as those that will not see." It is chiefly indifference that has relegated to oblivion many important truths. New knowledge is always viewed critically by the formalist and tra- ditionalist and so it should be, particularly when the innovationist creates discontinuity in the transition to new knowledge. Recent developments in science, however, have shown that discovery is not always cumulative in effect but there are also precipitous mutations. The theory of light and electricity as vibratory movements of the ether, was not established until the discovery of the Hertzian waves and finally led to the creation of wireless telegraphy. The discovery of radium demolished precipitously the established theories of matter and force so that chemistry was forced to tie rewritten and our conception of the constitution of matter completely changed. The transmutation theory espoused by medieval alchemy and the object of ridicule prior to the discovery of radium appears to be a reality after "a.11. All the precautions cited must be sedulously regarded in the execu- ,'s : JOfte :of the main bove the navel) disappears temporarily when the head is extended or, after repeated deep breathing. One may measure the potentiality of the energy in auto like in hetero- 139 Electronic Reactions splanchnodiagnosis.* Another valuable discovery connected with these reactions is the auscultatory phenomena -noted over the dull lung area (whether the subject or the patient is employed). Over the area of dulness one may hear a distinct and faint hum, atelec- tatic crepitation or bronchovesicular respiration. These varied auscultatory phenomena must be carefully studied or otherwise, they may escape de- tection. Phonendoscopic stethoscopes should not be used as the confus- ing sounds indigenous to them may conduce to error in the interpretation of the pulmonary sounds. Note the resumption of normal respiration when the positive or negative pole of a bar-magnet is presented to area of dulness in syphilis or the negative pole to the area in carcinoma. In auscultating, avoid pointing the fingers in the direction of the stethoscope. The energy from the fingers may nullify the dulness. When auto-electronic reactions are contemplated, attempt to secure an abdomen free from dulness by purgation and enemata and by abdominal massage and forcible inspirations to eliminate intraabdominal congestion. These reactions constrain us to study symptomatology from an electronic viewpoint. A symptom is invariably a reflex superinduced by the radiant energy of disease (always of a definite vibratory rate) acting upon definite cerebrospinal structures. Just as radium confers radioactivity on other substances so may a can- cerous person by induction alter the polarity and vibratory rate of another individual (184).. Take a cancer specimen, place the corked end of the bottle containing it against the leg or any part of the body of an individual and note that, after a few minutes the splanchnovascular, enterodiagnostic and pulmodiagnos- tic reactions in that individual may be elicited during the time the bottle is in contact with his body. VASOMOTORIAL DIAGNOSIS Reference has been made (vide antea) to vasomotor reactions. The ear of a white rabbit is admirably adapted for this purpose. After the animal is hypnotized by stroking its back, place the animal's ear between two squares of white glass held in a support. View the ear directed to the light (artificial light will nullify the reactions) which must not be too intense. Note the pallor or flushing invariably in definite regions of the ear (Fig. 28) when the energy of disease is conveyed respectively to the 1st dorsal spine or the area between the 3rd and 4th dorsal spines. These *If one grounds the area between the 3rd and 4th dorsal spines, the 2nd lumbar spine or the area between the 4th and 5th cervical spines in executing the autoelectronic reactions, one causes to disappear the splanchnovascular, enterodiagnostic and pulmodiagnostic areas of dulness. Using an ohmmeter, the areas of dulness reappear at the vibratory rates of the different diseases. 140 Electronic Reaction St>{ ^OCOCCUi IJJ.WM FIG. 28. Specific areas of pallor or flushing of the ear of a white rabbit. The dotted lines represent the blood-vessels. spines are easily counted in the rabbit. Cultures of streptococci or tubercle bacilli may substitute the energy. If a healthy subject faces the west and the ocular conjunctiva is ob- served, note that on grounding the 1st dorsal spine, the blood vessels dilate and conversely, they contract when the area between the 3d and 4th dorsal spines is grounded (vide antea). These phenomena also noted at definite vibratory rates enable one to differentiate disease. FIG. 29 Area of pallor or flushing: in a syphilitic superinduced by grounding the vasodilator or vasoconstrictor center in the cord. The area represents a streak slightly above the lower border of the lobulus -of the auricle. 141 Electronic Reactions Grounding after the manner indicated in a person afflicted with disease and observing the ear opposite the light (person facing west), one may note pallor or flushing in definite areas of the ear (Fig. 29). Tuberculous energy (Fig. 15), syphilitic and carcinomatous energy thus applied to the vertebral regions in question may produce pallor or flushing in definite regions of the ear when a subject is used (Fig. 29), and these phenomena may be accentuated by grounding (vide antea). Symptom's are only reflexes ; definite responses to definite vibratory energy rates acting on definitely attuned centers. CARDIAC AND PUPILLARY REACTIONS Cardiac and pupillary reflexes may be utilized in diagnosis. In both, one employs the ohmmeter at the vibratory rates of disease. In using the heart, select an individual with a regular pulse and note that when the electrode is fixed in the 3rd right intercostal space contiguous to the stern- um (sinus node location) and energy of disease is conveyed at the vibra- tory rate, there is a momentary inhibition of the pulse. The writer has succeeded in obtaining specific pulse curves in different diseases (patho- sphygmography). The mydriatic pupillary tract (97) may be stimulated when energy is conveyed to the 1st and 2nd dorsal spines. Mydriasis follows such stimulation at the vibratory rates specific for each disease. Other reflexes are described in "New Concepts in Diagnosis and Treat- ment." HOMO-SEXUALITY* My recent observations only emphasize the importance of regarding vital phenomena as processes and not as structures. Every tissue pos- sesses its own definite radioactivity which may be readily demonstrated by aid of the electronic reactions. Specifically, the ovary yields definite areas of ventral dulness and this is likewise true of the testes. Six homosexualists (males?) thus far examined yielded from anatomic- ally perfect testes an ovarian reaction in four instances and in the other two subjects (bisexualists), an ovario-testicular reaction (ovarian by measurement predominating). These phenomenal facts are of stupendous importance and justify a more intensive study of this interesting subject. Anatomy is no aid in differentiating sexuality. Many believe that both sexes are potentially existent in both the female and male germ cell. The rudiments of the accessory apparatus (Wolffian and Miillerian ducts) are common to both sexes. The sexual glands also consist (in addition to the specific glands of generation) of Leydig's interstitial tissue (epithelioid cell accumulations imbedded in the sexual glands of the male). Tide page 76. 142 Electronic Reactions Insomuch as recent observations show that these interstitial glands are directly responsible for the primary and secondary sexual characters, an histologic study of the testes as ordinarily pursued cannot aid in the dif- ferentiation of testicular from ovarian structure. ELECTRONOTHERAPY Just a few words should foe accorded to the writer's new concepts in treatment (193 et seq.) Electromagnetic waves have no effect on olbjects which are incapable of vibrating with them and as Abderhalden observes, "Bodies out of har- mony with the tissues are either not absorbed or changed before ab- sorption." Wireless transmitters and receivers can be "tuned" to respond to elec- trical impulses of specific wave length alone. It is this principle of sympa- thetic vibration which has been applied to the control of machinery at a distance and the guidance of boats. The writer has demonstrated by aid of the biodynamometer (Fig. 25) that all of the specific drugs have the same specific wave length as the diseases for which they are employed. This refers to syphilis, malaria, gout, and polyarthritis. My investigations show that ideal pharmaco-dynamics in disease aims to change the polarity of the soil (I have called this polaritherapy) and to use radioactive drugs which show the same vibratory rate as disease (I have specified this process as oscillatotherapy). Both methods are embraced under the general neologism, Electronotherapy. Like many others of the so-called "Regular School," I ridiculed the doctrines of homeopathy -but now the writer is constrained to retract an opinion based on belief and not on fact. The Hahnemannian doctrine of attentuation is not a myth. It can be demonstrated by aid of the 'biodynamometer and the reflexes' that the mechanical subdivision of drugs or their dilution will augment their radio- active potency. From what has been said, the law of similars (similia similibus curantur) is a verity. Pharmacodynamics is identified with what I have called homovibrations and drugs of dissimilar vibrations (hetero- vibrations) are without remedial value. ELECTRON VLOGICAL DATA* EI.ECTRONOLOGY. Like radioactivity, this is a new primary science and bears no allegiance to cytological medicine. This drastic innovation in diagnosis, pathology and therapeutics, predicates a knowledge of the recent developments in physicochemistry and it would be puerile to assume *The subject-matter under this caption has been developed by the author since the publication of "New Concepts in Diagnosis and Treat- ment" and some of it is more fully elaborated in his Journal, "Physico- Clinical Medicine." 143 Electronic Reactions that, its mastery can be attained without painstaking study preceded by the conviction, however, that anything can be true however marvelous. Electronology is destined to solve problems in science and medicine in par- ticular before regarded as insoluble. Electronic diagnosis appeals to the uninitiated like the mythical fabrications of an Homeric poem in which with a blow of the hand, the heroes destroy worlds. The simple story of its evolution can be inscribed in three chapters : 1. Discovery of the vis- ceral reflexes; 2. Recognition of the fact that electrons and not cells are the ultimate constituents of the organism and that in the incessant activ- ity of the electrons, radioactivity or its equivalent energy is evolved, which has an invariable vibratory rate; 3. That the reflexes surpass in sen- sitivity any scientific contrivance for the recognition of this radioactivity. MULTIPLICITY OF REACTIONS. In hetero or autoelectronic diagnosis, sev- eral reflexes may be present synchronously; thus in tuberculosis with mixed infection, the tuberculous as well as the streptococcic areas of dulness can be elicited. In heterodiagnosis, the subject must be exempt from the disease for which the reaction is sought. SPHYGMOMANOMETRIC INDEX. Using a sphygmomanometer (with an aneroid barometer) and conveying the energy to the heart (vide cardiac reactions) of a subject, note that, at the vibratory rates of syphilis (20), tuberculosis (15) and cancer (30 or 50), there will be a slight and tran- sitory inhibition of the oscillations of the needle followed by an infinitesi- mal deflection of the needle toward a higher point on the scale (85). Exe- cute these observations when the needle shows its maximum oscillations and remember that the heart will soon exhaust itself when used for these test purposes. ARGYLL-ROBERTSON PUPIL. 'This is claimed to be due to a break in the reflex arc. This is not true. When it is partial, ground the mydriatic pupillary tract (vide pupillary reactions) and note that the light reflex is more responsive during than before grounding. I assume that the toxinosis of syphilis has a selective action on the mydriatic tract thus opposing the action of the myotic pupillary tract. IMMUNODIAGNOSIS. The electronic reactions enable one to say whether the individual possesses a natural or acquired immunity to certain diseases. Thus typhoid bacilli (culture) yield a definite area of ventral dulness. The blood of all patients who have had typhoid fever will dissipate this dulness. This is not so with many persons who have not contracted the disease. Many other diseases are similarly amenable to immunodiagnosis (Physico- Clin. Med., Sept., 1917). Vide Specific Medication. CONGENITAL SYPHILIS. The general pulmo-diagnostic reaction has been noted. In the hereditary form, there is an additional area of dulness at the manubrium sterni. With the enterodiagnostic reflex, there is in this form, a finger-breadth dulness located in the epigastrium at the outer 144 Electronic Reactions border of the rectus abdomini's on the left side. Congenital, is no abso- lute protection against acquired infection. We have found that the po- tentiality of the suprapublic area of dulness may be lower than the epigastric area. In the norm in the congenital form, both areas show the same potentiality. TUBERCULOUS LYMPHADENITIS. Normal lymph glands and the tonsils yield the reaction of tuberculosis (pseudotuberculous reactions) not at 15, of the scale of the ohmmeter, but at 3, and the polarity is positive. These structures contain bodies immune to tuberculosis. Vide specific medication. SPECIFIC MEDICATION. "The diseases of which we know the least path- ology are the diseases which we treat successfully." Many of our most potent drugs are of empirical genesis. The electronic reactions aid us in interpreting medicamentous action. Syphilis and malaria evoke definite ventral areas of dulness and like areas are produced by mercury and quinine. The latter drugs will dissi- pate the dull areas of syphilis and malaria. Pharmocodynamics is thus identified with homovibrations (homovibratotherapy). This action of drugs is exemplified by the physical analogy of resonance. Disease, like other entities, has a natural period of vibration and if we approach an object with a source of vibration of the same vibratory rate as itself, the object will be set in vibration. This forced vibration of the object may attain such magnitude as to fracture and utterly destroy it. Investigating the action of drugs used in syphilis after this manner, I found that the splenic extracts were the most efficient and in the treatment of this disease, I use in combination with the specific drugs concussion of the 2nd lumbar spine (thrice daily) with two objects in view: forcing the spirochetes and their toxins from their "blind" habitat the spleen and forcing from the latter into the circula- tion, its immunizing bodies. Eosin is a marvelous remedy in the treatment of cancer. I can employ no other word to justify this conclusion based on the observations of others and myself. By virtue of its neutral rays, it neutralizes the positive soil (193 et seq.) of cancer. In gonorrhea and gonorrheal rheumatism, its action is equally efficient by neutralizing the positive and negative soil of the disease. Gamboge painted on the chest in lung tuberculosis is practically a spe- cific in this disease and incipient cases are symptomatically cured in sev- eral weeks. In the latter citations, the pharmacal effects are secured by polari- therapy. The inefficiency of radium (compared with eosin) in the treatment of cancer is due to the fact that, the alpha or positively charged rays which possess over 95 per cent, of the energy evolved from radioactive sub- stances only serve to contribute to the growth of a carcinoma which like- 145 Electronic Reactions wise shows positive radioactivity. Owing to the action of specifics in modi- fying the reaction of a disease, say mercury in syphilis, measurements to determine the progress of the disease while the patient is undergoing treat- ment must be made with two rheostats. The index of one rheostat must be placed at the vibratory rate of the disease (20 in syphilis). After this manner, the potentiality of the disease will be uninfluenced by the mer- cury or other preparation used. TELEDIAGNOSIS Radiant energy may be conveyed over a telephone wire. After this manner sucessful diagnoses (with patients whose diseases were unknown to the author) were made between Los Angeles and San Fran- cisco, a distance of 475 miles. FIG. 30 (1) Splanchnovascular reactions of lead (A) and steel (B): (2) Enterodiagnostic reactions of lead (A) and steel (B). FIG. 31. (3) Splanchovascular reactions of the tetanus bacillus (A) and the bacillus aerogxmes capsulatus (B). (4) Enterodiagnostic reac- tions of the tetanus bacillus (A) and the bacillus aerogones (B). CANCER AND INFLAMMATION. These border-line affections may be dif- ferentiated. Inflammation yields a reaction like carcinoma, but the latter 146 Electronic Reactions does not produce the inflammatory reaction in the area similar to congeni- tal syphilis (Fig. 18). The inflammatory reaction in the carcinomatous area is only reproduced at the vibratory rate of 40, and not at 30 and SO, as in carcinoma. The latter only, yields an additional dulness strictly limit- ed to the navel. The foregoing refer to the splanchnovascular reactions. PLANTS. Smith (U. S. Dept. of Agriculture), suggests that crown gall, a cancer of plants is due to the bacterium tumefaciens, 'Specimens received from him yield reactions identical with human cancer. When the stem of a flower is torn (not cut) from a growing plant, or the stem of a fresh flower is torn, the electronic reactions of pain may be demonstrated, hence, plants suffer. GUNSHOT WOUNDS. Lead and steel are the essential elements of pro- jectiles and their electronic reactions may be noted in fig. 30. Vide also fig. 31. POSTURAL POLARITY. In all electronic reactions the patient and subject must face west (body parallel with the earth's axis). Our earth is a gigantic magnet with magnetic poles. It is generally accepted although the reverse may be true, that out of the earth's north magnetic pole in the Southern Hemisphere a stream of magnetic flux emerges which traverses the atmosphere until it attains the earth's south magnetic pole. If the patient or subject with cancer faces north, the dull areas peculiar to can- cer persist but they are dissipated, when a posture facing south is as- sumed; the magnetic flux from the south is negative and neutralizes the positive energy of cancer. UTILIZATION OF THE HEART IN DIAGNOSIS. Reference has already been made to this subject. Characteristic sphygmograms are shown in fig 32. FIG. 32. A, shows the tracing in cancer and B, the tracing in tuber- culosis. The departure from the normal curves as shown by the dotted lines is constant in both diseases and is of great significance to the physician skilled In the interpretation of pulse tracings. LAW OF COLLES. This law may be sustained by the electronic reactions. In several instances where the fathers were syphilitic and the mothers yielded no reaction for syphilis the energy transmitted from the preg- nant uteri and from the latter only, the reaction of syphilis could be elicited. 147 Electronic Reactions AUSCULTATORY PERCUSSION To facilitate recognition of dulness by elec- tronic diagnosis, utilize the method described elsewhere in this book CS560). ELECTRONESTHESIA. Recently, I have found that the zones of dulness in splanchno and enterodiagnosis, show modifications in epicritic and protopathic sensibility (S12) during the time the energy is conveyed (within 10 seconds) in subjects and when the patient is examined (auto- electronic diagnosis). These cutaneous changes in sensibility are strictly limited to the areas of dulness when the patient is facing west (grounded) and standing. Either patient or subject must be told to concentrate (an- swering sharp or dull each time skin contact is made), informed of what is to be expected and the very slight modifications of sensation which will ensue. These suggestions can later be controlled during the examination when the eyes of the subject or patient are closed and the areas of modi- fied sensibility delimited by a pencil. Repetition of the examination will show the limitations of the areas. The enterodiagnostic areas show greater modifications than the splanchnovascular areas. Use a wooden probe wound loosely with cotton-wool at one end and pointed at the other end. Direct fingers away from the areas (Fig. 24). The epicritic sensibility shows hyperalgesia and the protopathic sen- sibility, diminished sensibility (hypesthesia). Exercise care by making uniform strokes with the cotton and guide the uniform depth of pressure with the pointed end of the probe by aid of the fingers. The phenomena cited are not unlike the hyperalgesic dermatomes (S58) and are similarly explained. When the pulmodiagnostic areas are investigated they show hypesthesia strictly limited to the dull areas. 148 INDEX Abrams, Electronic Reactions of, 120 Abrams, Reflexes of, 121 Abrams, Signs of, 132, 133 Agalorrhea, 9, 118. Alcohol, 69 Amenorrhea, 7 Aneurysm, 5, 114 Anesthetics, 70 Angina Pectoris, 22, 25, 112 Appendicitis, 14, 16, 116. Appendix, 116 Argyll-Robertson Pupil, 131, 144 Arrhythmia, 113 Asthma, 12, 22, 26, 115 Attunement, 58 Aura, 71 Autoelectronic Reactions, 139 Baird, 36 Barr, Sir James, 5. Ill, 114 Blood-pressure, 28, 29 Blood Reactions, 133 Bond, 3 Boyce, 41 Buchanan, 68 Caesar, 116 Cancer, Diagnosis of 87, 136, 137, 140, 146 Cancer, Heart in, 26 Cancer, of Plants, 147 Carabelli, 131 Cardiac, Insufficiency, 26 Cecum, 116 Cellular Pathology, 50 Centers, Energy, 60 Cereforasthenia, 37 Cervix Dilatation, 10 Chiropractic, 103 Chloroform, 89 Circulation, Splanchnic, 113 Circulatory System, 21 Cirrhosis, 117 Cohen, 26, 39, 111, 118 Colles, Law of, 147 Colors, 58, 66, 77, 126, 127 Concussion, 110 Conduction, 53 Constipation, 6, 32 Cystocele, 7 Dawson, 10 Death, 100 Dementia, Paralytica, 91 Dementia Precox, 93 Depressor Nerve, 112, 113, 114, 122, 123 Diagnosis, 82, 120 Diagnosis, Precautions, 126 Diagnosis, Splanchno, 122 Diagnosis, Vasomotorial, 140 Digestive System, 29 Duodenal Ulcer, 8, 116 Dyspepsia, 29 Electrocution, 9 Electron, 51, 52, 83 Electronesthesia, 148 Electronic, Diagnosis, 88 Electronic, Reactions, 95, 120, et seq. Electronic, Theory, 50, 121 Electronic, Therapy, 143 Electronological, Data, 143 Energy, Human, 49, 52, 53, 68, 69 Energy, Pathological, 89 Enterodiagnostic Reactions, 138 Enuresis, 7 Eosin, 145 Epilepsy, 100 Exophthalmic Goitre, 5, 12, 114 Freezing, 36, 108, 111 Freud, 2 Gall, Bladder, 32 Gall, Stones, 33 Galton's Whistle, 59 Gamboge, 145 Gastrograph, 59 Gastrometer, 54 Goitre, 5, 12, 114 Gonorrhea, 145 Gordon, 26, 27 Griffin, 107 Guild, 36, 37 Gunshot Wounds, 147 Gynecology, 6, 118 Haeberle, 91 Hay Fever, 9 Heart, Dilated, 24, 25 149 n e x Heart, in Diagnosis, 147 Heart, Neuroses, 112 Heart, Reactions, 142 Heart, Reflex, 26, 111, 112 Hemoptysis, 118 Hepatic Congestion, 8 Hirsch, 25, 113 Homeopathy, 143 Homosexuality, 76, 142 Houlie, 114 Human Aura, 71 Human, Energy, 49, S3, 68, 69 Hutchinson Teeth, 132 Hylozoism, 120 Hypertension, 113 Hypoazoturia, 28 Impotency, 77 Immunodiagnosis, 144 Inflammation, 146 Intestinal Reflexes, 116 Ireland, 6, 33, 40, 43 118 Irritation, Sympathetic, 65 Jarvis, 13, 21, 35, 70, 106, 108 Kidney, 40, 118 Kilner, 71 Labor, 43, 118 Lebon and Aubourg, 32, 105 Level, Pelvic, 42 Levison, 85 Liniments, 67 Lung, Reflexes, 115 Lydston, 91 MacDonald, 116 Malaria, 41, 117 Medication, Specific, 145 Mentoids, 70 Metrorrhagia, 7 Migraine, 39, 118 Minerbi, 112 Mitral Lesions, 26 Modern Knowledge, 49 Morris, 113 Movable Kidney, 40 Neuralgia, Trigeminal, 35, 109 Neurasthenia, 34 Oculocardiac Reflex, 112 Oculogastric Reflex, 63 O'Donnell, 32, 67, 105 Ohmmeter, 135 Osteopathy, 103 Ovaries, 7, 14, 16 Painless Labor, 43, 118 Palpation, 25 Pancreatic Secretion, 116 Paralysis Agitans, 119 Parathyroids, 119 Pathosphygmography, 142 Pelvic Level, 42 Percussion, 54, 148 Pertussis, 119 Photography, 70 Phthisis, 9 Pigmentation, 39, 40 Pleurodynia, 12 Planck, 110 Plants, 77, 147 Polarity, 59, 82, 133, 147 Polarity, Sexual, 72 Polaritherapy, 143 Poliomyelitis, 34 "Pop", 103 Pratt, 65 Potentiality, 135 Prediction of Sex, 75, 78, 80, 81 Pregnancy, 80 Pregnancy, Vomiting of, 116 Pressure, 107, 111 Prostate, 9 Pulmonary Reactions, 137 Pupillary Reactions, 142 Purdue, 41 Pylorus, 8, 11, 31, 32 Pylorus, Reflex, 115 Rabbits' Ear, 141 Radiations, 51 Radium, 53, 84, 87, 145 Rate, Vibratory, 136 Reactions, 95 Reactions, Autoelectronic, 139 Reactions, Cardiac, 142 Reactions, Electronic, 95, 120 Reactions, Multiple, 144 Reactions, Potentiality, 135 Reactions, Pupillary, 142 Reactions, Pulmonary, 137 Rectocele, 7 Reflexes, of Abrams, 121 Reflexes, at Operation, 106 Reflexes, Bladder, 119 Reflexes, Intestinal, 32, 105, 116 Reflexes, in Treatment, 104 Reflexes, Irritation, 2 Reflexes, Liver; 117 150 n x Reflexes, Lung, 115 Reflexes, Miscellaneous, 117 Reflexes, Oculocardiac, 112 Reflexes, Prostate, 119 Reflexes, Spinal, 1 Reflexes, Splenic, 117 Reflexes, Table, 17 Reflexes, Therapeutics, 111 Reflexes, Thymus, 119 Reflexes, Vasomotor, 118 Reflexes, Visceral, 105, 115, 121 Reflexotherapie, 5 Rheostat, 135 Roemer, 29 Roentgenotherapy, 39 Roncovieri, 117 Royal Touch, 67 Ryder, 34 Sawyer, 29 Selling, 32 Sex, Polarity, 72 Sex, Prediction, 75, 78, 80, 81 Sexuality, Homo, 142 Sherwood, 107 Short-circuiting, 126 Shreiber, 118 Sinusoidalization, 110 Smith, 26, 40 Snow, 105, 114 Specific Medication, 145 Spine, 4 Spirocheta, 91, 93, 129 Splanchnic, Circulation, 113 Splanchnic, Neurasthenia, 34 Splanchnodiagnosis, 122, 124 Splanchnovascular Reactions, 122 Spleen, 128 Spondylodiagnosis, 21, 108 Spondylopressor, 69 Spondylotherapy, 3, 6, 10, 11, 103 Spondylotherapy, Electricity in, 107 Spondylotherapy, Methods of, 106, 109 Spondylotherapy, Review, 103 Stimulation, 110 Stomach, Diseases, 30 Stomach, Dilatation, 25 Stomach, Reflexes, 31, 54, 57, 115 Summa, 118 Symptomatology, 140 Syphilis, 117, 128, 136, 138, 141, 146 Syphilis, Congenital, 128, 144 Syphilis, Fournier, 130 Syphilis, Optic Nerve in, 129 Syphilis, Polarity, 78 Syphilis, Tests, 90, 93, 128 Sympathetic Irritation, 65 Syphilotherapy, 117 Tachycardia, 26 Taylor, 1, 104 Telediagnosis, 146 Tenderness, Vertebral, 15, 17, 108 Testicles, 77 Thoughts, 68 Trigeminal Neuralgia, 35, 109 Tubercle of Carabelli, 131 Tuberculosis, 94, 136 Tuberculosis, Healed, 136 Tuberculosis, Lymph Gland, 145 Tuberculosis, Strains of, 149 Upson, 3 Urea, 28 Urticaria, 39, 118 Uterus, 6, 42 Vagus Tone, 47 Vasomotor Reflex, 109, 118 Vasomotor, Diagnosis, 140, 141 Vaquier, 5 Vecki, 85, 91 Vertebra, Dislocated, 103 Vertebra, Tenderness of, 4, 13, 17, 108 Vibration, 58, 106, 145 Vibratory Rate, 136 Vomiting of Pregnancy, 116 Wassermann, 128 151 2135 SACRAMENTO ST. SAN FRANCISCO, CAL., U. S. A. PHYSICO-CLINICAL LABORATORY OF Dr. Albert Abrams FOR THE ELECTRONIC TESTS OF ABRAMS IMMEDIATE AND ACCURATE DIAGNOSIS. These tests permit of an immediate and accurate diagnosis of SYPH- ILIS, CANCER, SARCOMA, TUBERCULOSIS, TYPHOID FEVER, MALARIA, PREGNANCY, GONOCOCCIC and STREPTOCOCCIC IN- FECTION, COLISEPSIS and other diseases. VIRULENCY GAUGED IN SYPHILIS (nervous system, cardiovascular apparatus, eyes, lungs), and in TUBERCULOSIS (Glands, lungs, bone) the SPECIFIC STRAINS of the organisms in these diseases may be determined, show- ing implication of definite structures or the invasion of the latter may be predicted. The VIRULENCY of DISEASE may be GAUGED with MATHEMATICAL ACCURACY. Thus, it can be determined whether SYPHILIS ("which never dies but only, sleeps") is active or quiescent, and when treatment should be continued or discontinued. It is also possible to say whether SYPHILIS is congenital or acquired. BLOOD ON PAPER, NO SPECIAL INFORMATION NECESSARY. To execute these diagnoses all that is NECESSARY is to send sev- eral DROPS OF BLOOD from the patient ABSORBED by a CLEAN WHITE BLOTTER or filter paper. Blood examinations only, do not permit of the localization of lesions, and to achieve the latter an exam- ination of the patient is imperative. Neoplasms, sputa and other tis- sues are equally available for diagnosis by the same tests. NO IN- FORMATION concerning the patients from whom the blood is ob- tained is necessary (other than in tests for pregnancy), thus, unlike the laboratory tests, the electronic tests permit an unprejudiced opin- ion. These tests will be appreciated by your patients. To treat them without a correct diagnosis is only adding insult to injury. A diag- nosis in the usual way by skilled diagnosticians shows 50 per cent, of errors and in some diseases 75 per cent. A FEW REFERENCES Full information concerning these methods may be found in "INTER- NATIONAL CLINICS" (Vol. 1, 27th series), the "REFERENCE HANDBOOK OF THE MEDICAL SCIENCES" (Vol. VIII, 3rd edition), and "NEW CONCEPTS IN DIAGNOSIS AND TREATMENT" (Abrams). All the tests are controlled by the "Sphygmopathometer," an instru- ment devised by Dr. Albert Abrams. ONLY ONE IN FIVE Laboratory diagnoses are notoriously fallacious. There is only ONE CHANCE IN FIVE that a specimen of blood submitted to ten serol- ogists will result in an agreement. The negative results with the W.as- sermann are fully 50 per cent., and positive reactions with this test are elicited in non-syphilitics (2.6 to 18.1). Positive reactions may occur in tuberculosis, acidosis, malaria and other affections. Collins (A. J. M. Sc. 1916), estimates that 15 per cent, of paretics and 70 per cent, of ce.re- brospinal syphilitics fail to give a positive Wassermann in the spinal fluid. Physicians of prominence no longer rely on the Wassermann test. The same fate is destined for the reactions of Abderhalden, when one-third of all MEN yield the test of pregnancy! NEARLY 100 PER CENT. POSITIVE Geo. O. Jarvis, A. B., M. D. (formerly of the University of Pennsyl- vania), found that the electronic tests of Abrams were POSITIVE in nearly 100 PF.R CENT, of syphilitic affections (hereditary or acquired). VECKI "I have witnessed marvelous results," observes Vecki, the noted syphilologist in his SEXUAL, IMPOTENCE (W. B. Saunders & Co., 1915) "in the diagnosis of syphilis by the ELECTRONIC TESTS OF ABRAMS." The tests embody the employment of the visceral reflexes of Abrams. FROM ENGLAND Sir James Barr, in his Presidential address at the 18th annual meet- ing of the BRITISH MEDICAL ASSOCIATION (BRITISH MEDICAL JOURNAL, July 27, 1912), observes as follows: "The versatile genius of Dr. Albert Abrams, w*ho has come all the way from San Francisco to do honor to this meeting of the BRITISH MEDICAL ASSOCIATION, has taught us how best to cure intratho- racic aneurysm, and has shed light on the nature of the cardiac and respiratory reflexes. In the treatment of diseases of the heart and lungs, his work does great credit to the new Continent and he has given us further insight into methods of prevention." CANCER Prof. Perdue, Director of the largest laboratory for cancer research in America, observes: "Nothing in recent medicine has been so revolutionary in diagnosis as the reactions of Abrams. For many years the profession has looked to the laboratory for exactness in diagnosis, and out literature has been full of the Wassermann reaction and the Abderhalden tests for preg- nancy and cancer. In the midst of all this came the diagnostic me.th- ods of Abrams. Methods so simple, so scientific, so exact, so prac- tical, at once made the PROCESSES of the LABORATORY OBSO- LETE and historic in medicine. I have NEVER SEEN the reactions of Abrams fail or be misleading." INCIPIENT TUBERCULOSIS Dr. W. J. CAESAR, Richmond, Cal., observes as follows: "Like many physicians, I had heard of but had never investigated Abrams' Electronic tests. At the solicitation of Dr. W. R. Scroggs, who had studied the reactions, I was induced to bring one of my pa- tients (a chronic neurasthenic?) to San Francisco for diagnosis. To my utter amazement, the diagnosis made was that of INCIPIENT TUBERCULOSIS, which could never have been demonstrated by the conventional methods. The results of treatment (rapid recovery of the patient and weight increased from 140 to 171 Ibs.) by Dr. Abrams' method of polaritherapy, fully justified the diagnosis. Since then, I have witnessed the confirmation of many other diagnoses by the same tests. I have taken Dr. Abrams' course, and am constantly using his methods of diagnosis, and I am fully justified in saying that, were I compelled to hark back to the accepted methods of diagnosis, I would rather relinquish practice than to continue it." DIAGNOSIS AT THE VERT BEGINNING "It is many years since the medical profession has shown such in- terest in any new discovery as they have in Electronic diagnosis, first discovered by Dr. Albert Abrams, of San Francisco. To be able to DIAGNOSE AT THE VERY BEGINNING tuberculosis, carcinoma, syphilis, pus formation, and so on, and not have to rely upon doubtful laboratory methods, is almost beyond comprehension or belief." George Starr White (AMERICAN JOURNAL OF CLINICAL MEDICINE.) In another communication to the same Journal, George Starr White observes as follows: "This same human energy can be used to diag- nose disease in its early stages better than any other known method. To Dr. Albert Abrams is due the credit for this epoch-making dis- covery. It is the external counterpart of the Abderhalden reactions." SPECIMENS Blood specimens should be placed on a paper or blotter enclosed in the specimen container or envelope and mailed immediately. Examina- tion will be made at once, and reported on fully and promptly. Fees should accompany specimens. Special correspondence is invited, with a view to informing you in detail about any part of the work of the Laboratory which may not be clear to you. FEES (Which include all diagnostic information necessary.) Blood examinations which include tests for all diseases $10.00 Subsequent blood examinations to gauge the course of the disease 5.00 Examination of patients 25.00 (With full instructions to the physician for executing Abrams' meth- ods of Electronotherapy. By the latter, most uncomplicated and inci- pient forms of tuberculosis are amenable to symptomatic cure within a few weeks.) Course to physicians on Electric Diagnosis $100.00 (Limited to reputable physicians in possession of the M. D. degree.) STATEMENT OF W. J. CAESAR, M. D. "After taking Abrams' course on Electronic Diagnosis I am able to accurately detect and measure the virulency of tuberculosis, syphilis (and to differentiate the acquired from the congenital form of the latter), oolisepsis, streptococcic infection, cancer, sarcoma, gonorrhea, etc. The functional activity of the organs including the ductless glands may be mathematically gauged. The topography of the vis- cera may be accurately denned. The foregoing has been formulated after mature deliberation based on therapeutic results and corrobor- ation at the operating table." Victor 6. Veckt, 3U. 3D. PHYSICIANS 1 BUILDING 516 SUTTER STREET. COR. POWELL SAN FRANCISCO. CAL. June 13th, 1917. Albert At rams, M.D. 2135 Sacramento St., San Francisco, Cal. My dear Dr. Abraias: It conforms only with exact and plain truth to say that in all cases submitted to you for diagnosis "by means of your electronic reactions your findings were absolutely correct and justified by subsequent therapeutic results. Sincerely yours, When I firet began to investigate the subject of Electronic Diagnosis, I found the work moot confusing but further investiga- tions at the Physico-Clinieal Laboratory of Dr. Abrams, convinced me from therapeutic results observed, of the correctness of his diagnoses. It is impossible to form a very intelligent opinion of these methods from reading about them. One must cone to Dr. Abrams' laboratory and watch him at his v;ork and hear his explanations and comments and if he approaches the investigation in an unprejudiced frame of mind the physician will soon discover that he has found something- that rill be of vast usefulness to him in his medical work. I consider the last five months that I have spent in this investira- tion as the best spent time of ny medical life and would heartily advise any of my confreres to pursue a like course. Very sincerely, 1st. Lieut. Medical Corps U. S. Army. OR. HARLEY E. MACDONALD PHYSICIAN AND SURGEON 1521 So HOPE STREET LOS ANGELES CALIFORNIA %/L<