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M. L. H. Arnold Snow, M.D. 1912 Chapter 6 Mechanical Vibration in Diagnosis
As one of the aids to diagnosis the mechanical vibrator should have a place in every physician's office for humanity demands that those who hold life in the balance should be progressive and acquaint themselves with all the aids that progressive science brings. MECHANICAL VIBRATION DETERMINES the following: 1. The presence and site of inflammation and pain. 2. The degree of tissue irritability as of nerve, muscle, organ or skin. 3. The presence and degree of muscular spasm in a region or part. 4. The range of mobility of a joint by the induction of lessened tension. 5. The state and degree of efficiency in respect to various reflex functions of nerves as cardiomotor, etc. Probably the greatest field for mechanical vibration in the realm of diagnosis is that of the spinal nerves. A CAREFUL EXAMINATION OF THE BACK will show signs
of a disordered nervous mechanism. Arnold ["The Importance of the
Physical Examination of the Back in General Diagnosis." Medical News,
March 18, 1905], found in all cases of chronic disease examined by him
that "there had been disturbances of the nervous mechanism of the disordered
part, usually dependent upon a deficient tonus of its blood vessels which
is the result of a deficient blood supply to the segments of the spinal
cord from which the vasomotor nerves arise." In examining the back he considered
the following:
Pathological conditions cause muscular atrophy, contractions of the muscle fibres or muscles en masse and the relaxation of interspinous ligaments resulting in "prominence or depression of one or more spinous processes." These results are to be found "in the region of the posterior primary divisions of the spinal nerves which arise from the segment or segments of the cord which supplies or supply the organ or part affected, "in consequence of which a knowledge of segmental localizations which will be considered later, is essential. AN EXAMINATION OF THE SPINE made by inspection and
palpation is then in order. The patient should be examined walking,
standing and lying, prone and supine. The plan of Goldthwait, Painter
and Osgood is recommended. It is as follows:
THE NORMAL CURVE IS A LUMBAR LORDOSIS and a dorsal kyphosis. This curve is altered by disease. There may be present an antero-posterior or a lateral curvature. Lateral deviation [Goldthwait, Painter and Osgood. Diseases of the Bones and Joints, page 49] without compensatory S-shaped curve usually comes from a cause external to the spinal column such as trouble in the sacroiliac joints or below them, or from pelvic or abdominal irritations. When the trunk is prominent on one side rotation of the vertebrae on their long axis has occurred as a rule. "ROTATION OF THE BODIES OF THE VERTEBRAE on a vertical axis," says Warren-Gould [International Text-Book of Surgery, Vol. 1, page 846] "always accompanies and is a necessary consequence of the lateral deviation. The bodies face round toward the convexity, while the spines are directed toward the concavity, so that the deviation of the spinous processes does not represent the full lateral curvature. As a result of the rotary movement, the transverse processes on the side of the convexity are directed posteriorly, carrying with them in the dorsal region, the ribs, the angles of which become very prominent. In the upper dorsal region the scapula will be pushed farther than normal from the midline. The shoulder on the side of the convexity will be elevated, and this is frequently the first sign noticed by the patient. *** On the side of the concavity the capacity of the chest is much diminished, the ribs being crowded together, whilst the breast is sometimes noted as more prominent than on the opposite site." DEVIATIONS AND DEFORMITIES below the cervical region may be caused by pleurisy, intra-thoracic growths, aneurysms, emphysema, trauma or suppurative or non-suppurative processes. They call for a chest examination. Intra- and retro-peritoneal aneurysms, or diseased viscus may result in spinal postural or structural deformity. If the scapula of either side projects it means "Paralysis of the serratus magnum of that side" or lateral curvature; if the left scapula project it may possibly mean aneurysm of the arch of the aorta [Butler. Diagnostics of Internal Medicine, page 284]. Hysterical patients may show a lateral spinal deviation which disappears in the recumbent position [Abrams. Spondylotherapy, page 45]. Conditions in other spinal diseases should be considered, such as acute osteomyelitis, concussion, after effects of traumatism, sprains or dislocations. The functions of the cord are not generally affected by lateral curvature. This examination should be followed by a CONSIDERATION OF THE VERTEBRAE, their situation, singly, and relatively, and their relation to the spinal nerves and segments so as to correctly interpret the vertebral tenderness or associated pain elicited by means of the vibrator. THE SPINOUS PROCESSES are best located by having the patient fold his arms and lean forward or by rubbing the spine when the processes will become reddened. The following tables are inserted for the operator's
convenience [Gray's Anatomy, pages 1037, 1038].
A comparative table with reference to organs is also of use occasionally. TABULAR PLAN OF PARTS OPPOSITE THE SPINES OF THE VERTEBRAE (GRAY)
A SPINAL EXAMINATION BY MECHANICAL VIBRATION should be employed to determine vertebral or intervertebral tenderness which may be local 6r reflex. Reflexly, disease of the cervical region may refer the pain to the upper limbs as the hand and arm in hypertrophic types of osteoarthritis; diseases of the dorsal region to the chest or body as stomach disorders; disease of the dorso-lumbar region to the foot or leg, and diseases of the lumbar region to the lower limbs. In examining the spine if vertebral concussion is not employed, the following method is used. The ball vibratode is applied for a few seconds with a light, moderate or heavy pressure according to the tolerance of the patient in the intervertebral spaces, the patient lying face downward on a table affording a resisting surface. The arms being relaxed should hang downward on either side, in order to obtain a widened interscapular space, and to relax the muscles of the back. The method of making such an application with the vibrator consists in placing the second and first finger tips of the left hand on two contiguous spinous processes and holding with the right hand the ball vibratode in the intervertebral spaces between, first on the right side, and then on the left side, raising the index finger of the left hand out of the way, the second finger of the left hand remaining in position. Then the first finger is replaced on the same spinous process as formerly. The second finger is then moved to the site occupied by the first just as the first is moved to seek the spinous process of the next vertebra. In this manner the spinous processes of the vertebrae are more easily found and are less liable to be passed over. The index finger and thumb of the left hand are thus ever ready to steady the vibratode or modify the severity of the vibration if necessary. The index and second finger of the left hand afford a sense of touch to act as a guide. SPINAL VIBRATION SO APPLIED DETERMINES the presence and sites of pain or tenderness, which oftimes are the causes, local or reflex, of the irritability of the spine, or reflexly of an associated part, as of viscero-motor or muscular reflexes. The vertebrae may be sensitive. In vibrating the lower part of the spine over the sacrum, the ball vibratode should always be steadied with the thumb and finger of the left hand or the vibrations modified to prevent an uncomfortable percussion, unless the patient is stout, when such procedure is unnecessary. If the parts be hypersensitive, a soft rubber cup-shaped vibratode, (7) in Fig. 26, may be used. VERTEBRAL TENDERNESS may be elicited either by vibration directly over the spines or between the transverse processes of the vertebrae. Intervertebral tenderness elicited by vibration sometimes causes pain or contractions in a distant region or part similar to that from which the patient had suffered. Vertebral or intervertebral tenderness and its relation to conditions indicated by inspection, and palpation as affecting other parts, adjacent or peripheral or both, should be noted when inferences in regard to the findings should be carefully studied. These investigations will often determine an important differential diagnosis. Abrams notes that not only will a downward pressure elicit vertebral tenderness, but "when the spine is pushed to one side or lifted, sensitiveness can be demonstrated. "If sensitive places are found in the spine that correspond to the nerve supply of a viscus, the viscus should be vibrated with the disc to determine if it be sensitive also. Oftimes when the vibratode is on a sensitive spot in the administration of spinal vibration, it will cause a spasm of muscles or of parts which when vibrated are found to be sensitive, indicating a local lesion. In making such an examination the patient should lie in, as far as possible, a state of relaxation. If the head be turned with the patient facing to the right side, for example, and there is marked muscular tension of the muscles of the back, it is well to have him then turn his head to the other side to determine how much tension is due to position. Another point of importance is to determine the actual degree of sensitiveness present; for a superficial hypersensitiveness is a condition often found in neurotic conditions. This can be accomplished by a heavy vibration or by engaging the patient in conversation to make him less conscious of your work. The latter method is preferable. Under these circumstances a spot which at first seemed highly sensitive will show no tenderness whatever on vibrating it a second time. A table of reflexes is given in Chapter IV, page 72, and the subject of referred pain in Chapter XI will be of interest in the study of the causes and the interpretation of pain or reflexes elicited by mechanical vibration. WHETHER A GIVEN SENSITIVE AREA IS REAL OR SIMULATED is determined by Abrams as follows: "1. Mankopff's sign. Take the pulse rate before, during, 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 Loewi. 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 testicles, the pupil dilates, whereas in the tabetic in whom the testicle is insensitive, no pupillary dilatation is observable. "3. In neuroses the spine is not rigid at the points of sensitiveness. VIBRATION AIDS IN DETERMINING A PROGNOSIS as well as in diagnosing a condition. If spinal vibration is applied to a patient complaining of pain in the hips, and spinal tenderness is found in the lumbar region it is not surprising to arouse pain in the crural and obturator nerves when vibration is applied as well as in the sciatic, and the prognosis cannot be so favorable owing to an indicated involvement in the pelvis and being less accessible for treatment. If there be no spinal tenderness, but tenderness is elicited over the sacro-sciatic notch and glutei muscles by the application of interrupted vibration with the disc vibratode employing moderate or deep pressure according to the patient's tolerance, a local neuritis will be interpreted. Goldthwait's sacroiliac disease should also be considered if the diagnosis is not clearly defined. THE ELICITATION OF PAIN in the crural and obturator is accomplished by the application of interrupted vibration over the points of exit in the groin. In some of these cases in which vibration with the rubber covered disc vibratode elicits pain in both hips, it will suggest pressure on the sacral nerves - an internal trouble as a fibroid tumor or prostatic enlargement, - and lead to a pelvic examination. Interrupted vibration with the disc vibratode over the motor points of the thigh and leg muscles, or directly over the muscles, may reveal points of tenderness or tension. Spinal osteomyelitis may affect the lumbar, sacral or cervical region. IN BRACHIAL NEURITIS, an examination should be made of the cervical and interscapular region of the spine by vibrating with the ball vibratode in the regular way with fairly heavy pressure. The disc should after this be used interruptedly around and over the scapula, the posterior part of the neck, point of the shoulder, the anterior part of the shoulder, the arm, elbow, and the forearm to locate the painful sites. The elicitation of pain about the shoulder tells the operator where to place the metal electrode in applying the wave current, and the painful sites peripherally show where sparks should be applied. The painful sites in the spinal region and about the shoulder indicate where prolonged vibration will do good. IN HYSTERICAL PATIENTS interscapular vertebral tenderness is always present. VISCERAL DISEASES [Abrams. Spondylotherapy, page 186] in some instances can be distinguished from intercostal neuralgia by the elicitation of bilateral vertebral tenderness on pressure, whereas in intercostal neuralgia there will be three points of tenderness - (l) vertebral usually unilateral, (2) sternal and (3) mid-axillary. Lumbar abdominal neuralgia may be distinguished from appendicitis by eliciting painful sites including "the vertebral exits of involved nerves" and eliminating appendicitis by "segmental analgesia" obtained by Freezing [Abrams. Spondylotherapy, page 192]. THE EXISTENCE OF AREAS OF VERTEBRAL TENDERNESS ASSOCIATED WITH PSEUDO-CONDITIONS as pseudo-angina-pectoris, pseudo-oesophagismus, pseudo- nephrolithiasis, pseudo-dyspepsia, pseudo-cholelithiasis, and pseudo-mammary neoplasm was first called to the author's attention by Abrams. When there is an induration present in the breast, particularly in young people and it is difficult to make a diagnosis, apply the ball vibratode in the upper dorsal region - the 3rd and 4th interspaces - of the spine either directly over the spinous processes or in the intervertebral spaces. When the ball is used on the spinous process, the surface should first be dusted with talcum powder and the application of vibration or concussion be made over a thin pad of rubber. Sensation will be perceptible in the breast and the mass will become softened if due to tissue contraction. A direct application over the mass with a disc vibratode using a moderate rate of speed and very slight pressure will cause the mass to become still smaller, indicating that the trouble was a pseudo-mammary neoplasm probably due to contracted tissue, and was not an organized tumor. THE NERVE SEGMENT CORRESPONDING TO THE NERVE INVOLVED in a pathological condition under consideration is revealed by the elicitation of vertebral tenderness as in a brachial neuritis sensitive spots may be found by spinal vibration as before described. These spots in cases of brachial neuritis have been found between the lst, 2nd, 3rd and 4th dorsal vertebrae which correspond to the exit of certain spinal nerves as the lst, 2nd and 3rd dorsal nerves. These nerves may have their origin from the 5th cervical vertebra to the 2nd dorsal spinous process. Vibration applied between the transverse processes of the 5th, 6th, 7th cervical and lst dorsal vertebrae will produce a "concussion analgesia which may be palliative or curative in its effect." The following case will illustrate this point. A housewife had suffered from brachial neuritis for nine years. At the time the vibratory treatment to be described was applied, she was suffering from some pain and lack of free movement. With the patient in a sitting posture, a spinal vibration with the ball vibratode applied for ten minutes, in two seances of five minutes each, was given over the spinous processes with a sheet of rubber intervening. It was applied to the 2nd, 3rd and 4th dorsal vertebrae, and in the corresponding intervertebral spaces. The pain elicited was greatest in the intervertebral spaces. These painful sites corresponded to the exits of the 2nd and 3rd dorsal nerves, which nerves may have their origins opposite the spines of the 6th and 7th cervical vertebrae. Vibration over the spinous processes of the vertebrae above mentioned, gave immediate relief; and a vibration over the intervertebral points of tenderness between the 2nd and 3rd, and 3rd and 4th dorsal vertebrae, gave a freedom of motion and relief from the pain heretofore unknown to the patient. Further investigation has led the author to vibrate in the intervertebral spaces indicated as it is more agreeable to the patient and easier for the operator. THE STUDY OF SPINAL SEGMENTAL LOCALIZATION considered in the light of the above, is essential in the diagnosis and rational treatment of certain pathological states. THERE ARE 31 SPINAL SEGMENTS corresponding to 31 pairs of spinal nerves, the segment receiving its name from the nerve root coming from it. These segments as previously stated, do not correspond to the vertebrae bearing their names and numbers. The study of the functions in the segments of the spinal cord comprehends their relation to the muscles, reflex acts, and skin sensation upon different areas. [NOTE: Numerous pages of detailed tables follow. Rather than trying to replicate each one, I have scanned the pages as graphics which can be accessed by clicking on the page numbers. David McMillin. Page 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138. Resuming text on page 139.] It seems to the author that since it has been demonstrated that a specified spinal segment does not correspond in its relation to the same vertebra in all persons, while the exits are so far as known universally uniform in site it would be preferable in the study and interpretation of disease and referred pain to note the vertebral exit of the affected nerve instead of noting its segment as is customary. WHEN A PART IS AFFECTED "THE INDICATIONS [Arnold. "The Importance of the Physical Examination of the Back in General Diagnosis." Medical News, March 18, 1905] to be found on examination correspond to the exit of the spinal nerve and not to the location of the segment of the cord in the spinal canal. For example, the sacral segments of the cord are located about the 2nd or 3rd lumbar vertebrae, but the indications are found over the sacrum at the exit of the nerve or in the muscle supplied by it." A Table of Segmental Localization is found on page 110. The following table [click here] is from Thorburnt (modified) and is founded entirely upon clinical data, doubtful muscles being excluded: Plate VII. (Howell) is a more elaborate diagrammatic illustration of the relation of the spinal segments to localities supplied by sensory neurons and muscles as well as some reflexes. The relation between the segments of cord and reflex responses is considered in Chapter IV page 72, and in Chapter XI is given the segmental distribution of referred pain and tenderness. In visceral diseases which is of importance in the study of disease diagnostically and therapeutically. Figs. 33, 34, 35, 36, and 37 give the distribution of cutaneous nerve with reference to spinal origin. Skin areas to different spinal segments are represented in Plates IX and X. In the employment of mechanical vibration for the diagnostic purposes oftimes pain or reflexes are elicited, referable to these areas. When the skin is sensitive by referring to Plates IX and X (Head) and noting the nerve corresponding to the sensitive area, and then noting with what vertebrae this segment is related and concussing or vibrating these vertebrae, or corresponding intervertebral spaces for a few minutes analgesia effect will be produced. IN THE STUDY OF SEGMENTAL ANALGESIA it has been found [Abrams. Spondlylotherapy, page 367] that: "1. Concussion and sinusoidalization stimulate the motor component of a spinal segment and subdue its sensory constituent. "2. The sensory component of a normal spine segment is less amenable to concussion, sinusoidalization and freezing than a hyperesthetic segment." Abrams also noted the association of definite spinal segments [Abrams. Spondlylotherapy, page 377] associated with visceral sensation. In his study of the reflexes he found that the physiological
location of viscero-motor cells did not
"The viscero-motor cells control involuntary muscles aside from those of the vascular walls." [Arnold. "The Importance of the Physical Examination of the Back in General Diagnosis." Medical News, March 18, 1905] TABLE OF VISCERO-MOTOR NEURONS [page 143, 144] The genitals are supplied [Byron Robinson. "The Pelvic Brain," Medical Brief] with two kinds of nerves; spinal (cervix, vagina and pudendum) and sympathetic (corpus, fundus, oviduct and ovary). The cervix is supplied by the second, third, and fourth sacral. Freese [Johns Hopkins Hospital Bulletin, June, 1905] claims that "the musculature of the gall bladder is provided with motor (constrictor) and inhibitory (dilator) nerve fibres which come it from the spinal cord in the roots of the 6th to the 13th dorsal nerves. The maximum outflow for the constrictor fibres is in the 10th, llth and 12th dorsal nerves. The dilator fibres appear slightly higher up and are most in evidence from the 8th to the 12th dorsal nerve inclusive." This was demonstrated on animals. Arnold [Arnold. "Some of the Principles of
Manual Therapy." Its Application by the Physician. New York
Medical Journal and Philadelphia Medical Journal, May 13, 1905] found
that "repeated brief pressure along the spinal column arouses the reflex
constrictor nerves and brings about a certain amount of contraction in
the blood vessels of the skin and muscles of the back in the region of
the back treated. It also undoubtedly produces at the same time a
certain amount of dilatation of the vessels in the cord. On the other
hand, continuous pressure along the spine arouses the reflex dilators and
brings about a certain amount of dilatation of the blood vessels in the
skin and muscles of the back and a corresponding contraction of the blood
vessels in
"Arnold and Ludlum [Abrams. Spondylotherapy, page 72] 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 p divisions of the spinal nerves" but Abrams observes that "the nerves merely transmit the stimuli to the gray matter of the spinal cord (section of which 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 hyperaesthesia and hence the vertebral tenderness." In diseases of the viscera there may be present vasomotor, sensory reflexes and motor symptoms induced by paralysis or irritation. Since the study of the spine and spinal nerves affords an extensive field for investigation in the interpretation of diagnostic findings and in the selection of therapeutic treatment in the management of pathological conditions presented, a table of the vasoconstrictors and vasodilators (Arnold) is given to complete the foundation material offered in this chapter. THE REFLEXES ELICITED from concussion of the spinous processes or from vibration of the intervertebral spaces, are denominated by Abrams as vertebral reflexes. They open a field of wide study not only in diagnosis but in therapeutics. They are of prime Importance in spondylotherapy, as first systematized by Abrams, in a study which has broadened the field of medicine, both as concerns diagnosis and therapeutics. For diagnosis the vibrator, the sinusoidal current, the static wave current, the static spark, or concussion by means of a plexor with rubber as a pleximeter, a pneumatic hammer or electro-concussor are used. The author employs concussion, mechanical vibration, the static spark, the static wave current, and the sinusoidal current as mechanical means of inducing reflexes. Some of the reflexes are best excited by the sinusoidal current; others, by mechanical vibration or concussion, and some by the static spark or the static wave current localized over the vertebrae or the organ or part in question. THE MUSCLE REFLEXES respond better generally to the sinusoidal or the static current. Some of the muscle reflexes respond to mechanical vibration whereas others do not unless pathologically affected. THE VISCERAL REFLEXES respond readily to mechanical
vibration. The vibrator used by the author gives a distinct percussion
stroke, and the speed employed for this purpose is of moderate
THE METHOD EMPLOYED for vertebral concussion is as follows: Dust the surface with talcum powder over the site, hold a strip of rubber belting, linoleum, or sole leather to protect the skin over the bone. With the bar vibratode regulate the vibration to
a slow rate of speed, and apply moderate pressure vibrating or concussing
directly over the spinous process of the vertebra indicated, with interruptions
from time to time steadying the vibratode with the left index finger and
thumb. Care must be exercised to avoid too great friction of the
surface if vibration is used in order to avoid abrasion. The length
of time varies with the reflex sought. Experience seems to show that
the length of application varies also with the structure of the individual
and the organ involved. The patient may sit or lie during the seance.
The spinous processes are usually more easily found when the patient sits.
The reflexes can be elicited also by intervertebral vibration which
The following reflexes were noted by Abrams in his
use of concussion and in many instances have been elicited by the author
by mechanical vibration, usually applied between the transverse
[TABLES OF REFLEXES, page 149, 150, 151, 152] A study of the reflexes associated with pathological conditions with a view to meeting therapeutic indications is important. Their use in the treatment of disease will be considered later In the study of the diseases for which vibratory treatment is employed. IN A STUDY OF THE SPINE PATHOLOGICALLY, the following
will be found of value.
If inflammation of the bones of the spine is present it causes spasmodic restriction when the body is moved. When the ligaments of the spine are inflamed there may be no motion as anchylosis may occur "with or without alteration of the physiological curves." SPINAL PAIN is frequent in meningitis and meningeal growths. In organic disease of the vertebral bones it is almost a constant symptom. Concussion of the spine causes local pain and tenderness more often through a considerable extent of the vertebral column, or has more than one place of chief intensity and tenderness. On the other hand, pain due to organic affections of the cord is more usually referred to the neighborhood of the spine, as to the loins or the sacrum, than to the spinal column itself. Gowers calls the pains that are referred to the parts to which the sensory nerves are distributed excentrc" or "radiating pains," and he divides them into two classes. "1. Those due to the irritation of the posterior nerve roots in their passage through the intervertebral foramina, through the membranes, or through the posterior columns of the cord," which he calls "root pains." They are often intense and "correspond in level to the disease." "2. Those produced by irritation of the sensory conducting tracts," which may be acute, particularly so, if the lesions affect the "conducting tracts by pressure," but oftener they are dull in character resembling rheumatic pains. A third class of pains, - resembling root pains depend on degenerative changes in the nerve-fibres; the molecular alterations that result give rise to upward impulses of considerable intensity." These occur in locomotor ataxia, etc. They may be dull or acute and may be "in the root-fibres" or in the peripheral nerves. Root pains are most severe in vertebral bone disease and have "the characteristic that they are increased by movement, and in growths commencing in the bones (which are usually malignant). This feature is Of considerable diagnostic importance." Gowers states that in carcinoma the pain is "frequently referred to the neighborhood of the colunm, while in caries it seems more frequently to affect the side of the chest." Sometimes pain is referred to anesthetic surfaces as in vertebral disease, spinal caries, or tumors, when it results in anaesthesia dolorosa [Starr. Organic Nervous Diseases, page 197] due to the destruction of the sensory nerves causing surface anaesthesia, and to irritation of the proximal ends of the destroyed nerves resulting in painful sensations which are sent inward to the cord and referred to the anaesthetic surface. Starr also notes that in spinal cord disease as locomotor ataxia where the posterior nerve roots "at their entrances or "the sensory tracts passing upward through the spinal cord" are affected, pain is not referred to the back but is felt in the part of the body from which the irritated nerve root or sensory tract has come." He cites the following to illustrate. Locomotor ataxia generally commences in the second and third lumbar segments of the cord so the pains are usually referred to the anterior surface of the thighs. When the fourth and fifth lumbar segments are attacked the pain is referred to the feet. When the dorsal region is invaded body pain results and when the lower cervical is affected the pain is referred to the axilla, the inner side of the arms and to the little fingers, and when the upper cervical segments are affected "by the sclerotic process, the entire arms and shoulders become the seat of pain." Peripheral pain corresponding to the a affected segment of the cord also occurs in syringomyelia. Injuries to the cord, hemorrhages within the cord, spinal dislocations or fractures cause peripheral pain. In the hypertrophic type of osteo-arthritis, when the dorso-lumbar part is affected, referred pain is unilateral or bilateral as in the foot or leg; if the cervical portion is affected the referred pain is unilateral in the hand and arm, and atrophy is found on the affected side. Goldthwait, Painter and Osgood [Diseases of the Bones and Joints, pages 332 and 333] noted an important diagnostic point between this disease and true neuritis in that "there is no tenderness along the nerve trunks" as in neuritis when pressure on the trunk causes pain in the periphery. "Strains and injuries may affect the lumbosacral cord when pain and anaesthesia or hyperaesthesia are referred to parts supplied by the nerve affected, generally to the back of the thigh and lower leg." Movement of the body resulting in pressure, may cause "sharp, shooting pains felt in any part of the body below the lesion." Pelvic headaches according to Garrigues [Abrams. Spondylotherapy, page 89] may cause pain "(1) at the 4th and 5th lumbar vertebrae, the spinal-center for the internal pelvic organs, or (2) on either side of the 2nd sacral vertebra due to a cellulitis of the utero-sacral ligaments. "Pain [Abrams. Spondylotherapy, page 99] from the sacrum to the 3rd dorsal vertebra without limitation of spinal movement will indicate that the lumbo-dorsalis fascia is affected. Tumors of the cord cause pain "referred to the periphery from which the nerve root comes, which is primarily compressed at the site of the tumor." The parts below the site of the growth may be painful owing to irritation of the sensory tracts passing through the cord at the site of the tumor. "Lesions of the back such as trauma, sprains, etc., of spinal ligaments, vertebral fracture or displacements, any cause of compression, concussion of the cord, tumors, neurasthenia, nephritis, cystitis, calculi, - renal, binary, or vesical, - viral affections, hysteria, myelitis and spinal diseases above mentioned should be considered in a study of pain in the back. Following its elicitation by mechanical vibration, the ball vibratode being used for spinal administrations and the disc for surface work, the interpretation of pain or tenderness is important. The following is from Cyriax's, Schmidt's, Butler's, and the author's observations, and refers mostly to tenderness. For further details with reference to pain, the reader is referred to Schmidt's "Pain," Butler's "Diagnostics of Internal Medicine," and Cyriax 's "Elements of Kellgren's Manual Treatment." [SEE TABLES, page 156, 157, 158, 159, 160, 161, 162, 163] Reed ["The Autonomic Manifestation and Peripheral Control of Pain Originating in the Uterus and Adnexa." The Journal of the American Medical Association, March 25, 1911] in explaining the word "autonomic" as applied to the manifestations of pain of visceral origin states that it includes three factors: "1. Some more or less profound disturbances, functional or organic, of certain of the viscera. "2. The transmission of a painful impulse, thus originated, over or through what Head has designated as the autonomic nervous system. "3. The registration of that impulse and its expression as pain in the muscle or muscles to which the respective external or peripheral autonomic filaments (muscle nerves) are distributed." The conclusions of the same author are interesting as they are fully in accord with Dr. Wm. Benham Snow's and the author's observations during the past eight years. "1. Visceral pain, although due to pressure, when the abdomen, pelvis and thorax are concerned, is expressed chiefly but not exclusively in the autonomic algetic areas of the protective walls covering the respective viscera, such algetic areas corresponding in extent with the peripheral distributions of the autonomic nerves coincidently with the peripheral distribution of the respective spinal nerves in the muscles and subserous connective tissue. "2. These distributions can generally be determined clinically by determining the area of partial hyperalgesia. "3. The pain itself, consisting chiefly of hyper-excitation of muscle irritability, can be partially and, as a rule, entirely, inhibited by inhibiting the muscle sensibility in the hyperalgetic areas." WHEN EXAMINING AN ORGAN WITH A VIBRATOR, interrupted vibration with varying degrees of pressure limited to the patient's tolerance is used, the disc applicator being always employed. A sensitive gall bladder, pylorus, congested liver, kidney or spleen, painful stomach or colonic flexures, appendix or ovary are all revealed by applied mechanical vibration. Painful sites, anteriorly on the chest or posteriorly in the upper portion of the back along and near the spine, are elicited in cases of asthma. A clue to gastric trouble is given when spinal vibration causes eructation of gas. Vibration localizes the pain, or demonstrates the presence of unsuspected hyperalgesia. It must be recalled that pain is influenced by "position, motion, pressure, food, drugs, chemicals and organic function." When an examination of an organ or area is undertaken,
we should remember "the cutaneous expression of visceral disease as discovered
by Head. These sensitive areas on the surface "correspond to spinal
segments from which the posterior roots take their origin, and not to their
peripheral distribution." "When a stimulus is applied to an organ or tissue
with diminished
THE MUSCLES SHOULD BE EXAMINED and for tension and response, and the operator should note whether it is local or reflex or whether the vibration induces reflex contraction or pain in distant parts. Rigidity of the back muscles if related to diseases of the spine prohibits all motion. Interrupted vibration with the disc vibratode is employed in the examination of muscles, although spinal vibration is applied with the ball over the vertebra for testing the muscular reflexes. Gowers [Ibid. Diseases of the Nervous System, page 256] states that in connection with the spinal, cord a spasm caused by reflex action is usually produced in the legs and trunk; "the flexor spasm seems to be due to an over action of the centers for cutaneous reflex action, the extensor spasm chiefly to that of the centers for muscle reflex action" although a cutaneous impression might excite it indirectly. The following is an example of reflex spasm. Miss M. complained of contractions in the vicinity of the stomach which incapacitated her for work. They were spasmodic and increasing in frequency. An examination revealed tension in some muscles of the back, to the left of the spinal column the spinal nerve supply of which through the sympathetics caused spasmodic contractions anteriorly. Inquiry elicited the fact that she had strained herself when lifting a heavy patient which had resulted in a tonic muscular spasm of the back and reflex clonic spasms over the stomach, causing her great discomfort. The relation of tension to disease inducing muscular spasm, either directly or reflexly, tonic or clonic, is a subject yet undeveloped, but demands thought and investigation. Usually every peripheral spasmodic condition has an associated muscular spasm also in the corresponding spinal region. This spinal spasm is often overlooked. Care and practice in regulating the pressure when applying spinal vibration will elicit information that is hidden from the novice. An expert diagnostician sees with his fingers; so must an expert operator with the vibrator make his vibrator find obscure conditions. WHEN EXAMINING A STIFF HAND, interrupted vibration with the disc vibratode is employed over the affected muscles of the forearm at their origin at the elbow joint, and over the forearm, wrist and hand. When the hand is to be vibrated the patient should be directed to clench his fist as far as possible, interrupted vibration is then applied just above and below each row of joints making pressure to assist in closing the hand as the muscles relax under vibratory treatment. To test the flexibility of the hand, the operator with his hand placed directly over the patient's hand, finger for finger, slowly closes the patient's hand while the patient exhales. If the hand will nearly close after your treatment, the probability is that you can promise a complete cure. Interrupted vibration with the disc vibratode over the pleura after pleurisy will reveal sites of old adhesions. COCCYGODYNIA is diagnosed during a general examination by eliciting pain on vibration over the coccyx. In considering INTERCOSTAL NEURALGIA, CARDIAC DISEASE, ANGINA PECTORIS AND AORTIC DISEASE, Abrams, Head and Mackenzie [Spondylotherapy, page 194] have formulated the following: "In intercostal neuralagia the pain radiated to the neck and arm. In cardiac and aortic disease, the pain is referred along the lst, 2nd, and 3rd dorsal nerves. "In angina pectoris, the pain in addition may be referred from the 5th to the 9th dorsal nerves." Intercostal neuralgia will elicit "the three tender points of Valleiz, viz.: posteriorly, near the dorsal vertebrae; laterally, in one, two, or three intercostal spaces; anteriorly, in one or two intercostal spaces near the sternum, most frequently on the left side." [Reference Handbook of the Medical Sciences, Vol. V., page 454] THE HEART REFLEX OF ABRAMS is of value in diagnosis as well as prognosis. It can be induced by vibration of the 7th cervical vertebra. My observations have coincided with those of that investigation. The strength of the heart is increased and under certain existing conditions it will lower blood pressure. [Abrams. Spondylotherapy, page 248] An induction of the heart reflex is favorable as to prognosis in cardiac insufficiency. When the sphymornanometer is used to take the pressure before and after treatment, the author has noted a fall of 15 mm. after a five-minute vibratory treatment followed by a second period of five minutes; using a low frequency of vibration. VIBRATION ASSISTS IN DETERMINING WHETHER A HIGH BLOOD PRESSURE is due to a feeble heart. A boy 12 years old who had been to various clinics for heart treatment and pronounced hopeless, came under observation with a blood pressure of 135 mm. Treatment by the vibrator, using the ball vibratode over rubber, over the 2nd and 3rd dorsal spines, gave no result whereas after vibration of the 7th cervical spine, the high pressure showed a fall of '12 mm., which according to Abrams, demonstrates that it was caused by cardiac weakness and the vibration of the spine in question reduced pressure "by toning the heart, vibration of fairly low frequency being used for two seances of five minutes with a slight intermission. The heart reflex elicited directly over the heart is a test of the strength or power of the myocardium. Mechanical vibration should be used intelligently as a means to an end and not in an indifferent way. Diagnosis made by means of the vibrator may show a condition in which vibratory treatment may or may not be indicated. Drug therapy, surgery, physical measures other than vibration, such as the static, galvanic or high frequency currents, light, hot air, radium or the X-ray may be required either singly or in combination with vibration to cure or relieve the conditions found. |