gastric and abdominal muscles. Thus one can produce an alternating expansion and contraction not unlike that of the normal contraction and dilatation of the stomach, and this forms a natural mechanical aid to the treatment of gastric myasthenia and atony. Under ordinary conditions, both the pyloric and cardiac orifices contract as soon as moderate pressure is applied, and are relaxed as it is withdrawn, and the open outlet tube gives the air free exit. This is a sort of gastric passive exercise or massage, which, when properly administered, has an effect upon the muscular coats of the stomach similar to that produced by manipulations on the external muscles of the body, in so far as stimulating function and nutrition are concerned.

However, this action is not all mechanical. According to Bensley, "Distension seems to favor circulation, because the blood vessels are more easily injected in a moderately distended stomach than in an empty stomach. The rich venous plexus of veins within the submucosa is sufficiently large to hold a considerable quantity of blood. This must be the case when the valves within the veins coming from the stomach are temporarily closed. When the valves are closed a contraction of the circular muscles is sufficient to drive all the blood from the underlying veins. It is, therefore, possible that a rhythmic contraction of any part of the stomach may force the circulation through its walls. The arrangement of the lymphatics is much the same as that of the veins, and the above consideration applies equally well to them. When we consider the resistance to be overcome while the lymph passes through so many networks before the cistern chyli is reached, it makes it plausible to state that the circulation is favored by muscular contraction"

Both local and general effects on circulation and secretion are produced, directly influencing the nutrition and function of the organ.

In treating the stomach we should not confine our treatment to that organ alone. This is very forcibly shown by observing the following facts concerning the circulation in the splanchnic area, and the particularly close relationship between this and the functions of the abdominal crgans. The splanchnic area is the largest blood reservoir in the body, and sudden disturbances in the afflux or efflux of blood have most decided effects upon the regulating mechanisms of the heart and the circulation of the brain. The colon is closely related anatomically to the abdominal viscera, enclosing within its embrace the mesenteric vessels, which play an important role in the regulation of the circulation and general metabolism of the body. But close as is the anatomic relationship between the colon and abdominal viscera, the physiologic relations may be said to be still more intimate. Taking advantage of these facts and of the favorable arrangement of the nervous mechanism and the reflexes, Turck and others have obtained excellent results in the introduction of water at a relatively high temperature into the colon, thus producing an immediate and very marked reflex stimulation of the vasomotors centers. The blood pressure is raised, the kidneys are stimulated, the hepatic function increased, and, as Turck has demonstrated. leucocytosis is induced. The effects thus produced seem indeed to result in a general accelerated metabolism, oxidation and elimination; in short, the result is a general cell activity.

The technique of stimulation through the colon is briefly as follows: Patient in the dorsal position with hips elevated. Water at a temperature of 50 C. (122 F.) is introduced, 250 to 300 c.c. at a time, repeated three or four times. This is allowed to run off each time. The temperature of the water is then raised to 52 C. (125.6 F.) and finally to 53 C. (131 F.), using in all about three to six litres of water. A soft rubber tube with end and side openings is used. After this the patient receives a similar short treatment with water cooled down to 2 C (35.6 F.) to 3 C. (41 F.) by means of ice. Turck has extensively studied the effect of such treatment on dogs, and has used it on patients, with very favorable results.

Supplementary to these, of course, must be considered diet and general exercise. The less artificial interference the higher, as a rule, is the nutritive value and often the digestibility of food. Judicious cooking, however, will not only often improve the digestibility of food, but also afford a pleasant variety to the palate. Aside from the idiosyncrasies of taste and habit the secretory peculiarities of each case must be considered in selecting a diet. The diet should be as nourishing as possible, should occupy as small a bulk as possible, and be finely divided.

For the fermentation that may follow stagnation, antifermentatives should be used. Among the most useful and efficient are: Creosote, resorcin, menthol, salol, phenol, hydrochloric acid, salicylate of bismuth, benzonaphthol and chinosol. Riegel favors salicylic acid.

To combat the constipation our aim should be to exhaust all other measures before resorting to purgatives. Oil enemata may be employed daily for a long period of time, fine olive or linseed oil should be used. The action of the oil is two-fold: on the one hand it dissolves portions of fecal matter; on the other it stimulates peristalsis. Sterile vaseline may also be given per orum, a dram three times a day. It is inert and is not absorbed.

Riegel: Nothnagel's Practice.

Stockton: Nothnagel's Practice.

BIBLIOGRAPHY.

Turck Journal Am. Med. Assn, October 7, 1899

Turck: British Med Journal, October 29, 1898.
Turck Lancet, January 28, 1899.

T

TRAUMATIC LESIONS OF THE SPINE.

W. W. Bowen, M. D., Fort Dodge, Iowa.

RAUMATIC lesions of the spine are: 1, penetrating wounds; 2, sprain; 3, dislocation; 4, fracture, and 5, a combination of fracture and dislocation.

Penetrating wounds are caused by a thrust of some instrument or a bullet. They are dangerous for three reasons: 1, Hemorrhage which occurs frequently and is hard to control; 2, resulting fracture of a vertebra with its consequent symptoms, and 3, injury to the cord. This may be complete or only partial, involving one-half of the cord, and a consequent crossed paralysis. Strange to say, quite a large proportion of in

juries to the cord when the cord is not completely severed and the injury is a clean cut, are followed by complete recovery.

Sprains are the overstretching or tearing of ligameuts, and are the most frequent lesions of the spine. When unaccompanied by lesion of the cord, as contusion or hemorrhage, they are usually not serious, but such lesions usually heal slowly, are very painful and are the cause of the so-called "weak backs" from which many patients never recover.

Dislocation is not an infrequent lesion of the cervical region. It may be a bilateral anterior or a bilateral posterior dislocation, in which there will be a pushing forward or backward of the head, as the case may be, and more or less involvement of the cervical nerves or brachial plexus. It is often unilateral in which case there is a turning of the head to one side. The treatment is reduction under anesthesia and retention, but reduction must be done very carefully to avoid injury to the cord or cervical nerves. The occipital bone has been dislocated from the atlas, but very seldom.

Dislocation of the atlas from the axis is not so uncommon, but is always fatal. Dislocation of the dorsal and lumbar vetre bra without fracture is practically an impossibility, notwithstanding the frequent diagnoses of this lesion by osteopathic practitioners.

Dislocation with fracture produce essentially the same symptoms and require the same treatment as simple fractures, which will be described later.

Outside of sprains and penetrating wounds, fractures constitute onefifth of all lesions to the spine, dislocations one-fifth, and a combination of these three-fifths of all lesions.

Fractures occur more frequently in the cervical and dorsal regions than in the lumbar. They may be produced by direct violence, or by over-bending of the natural curvatures, by a blow on the head or a fall on the buttocks, or by a crushing force.

A vertebra may be fractured in all of its parts, or any of its parts, body, laminae, pedicles or processes.

Fracture of the processes, specially of the spinous process, is frequent, but not serious. Fracture of the body is more frequent than of the arches, and also more serious, because more deformity to the general frame occurs, and the likelihood of injury to the cord is much greater, and the gravity of all lesions of the spine is in direct proportion to the injury to the cord.

The cord is injured, 1, by displacements; 2, by fragments or spiculae of bone; 3, by hemorrhage which may be inside the cord-a hematomyelia -or in connection with the membranes-a hematorrhachis, and, by contusion, by which I mean tiny hemorrhages within the cord. Some writers describe concussion, by which they mean certain vibratory changes of nervous tissue without demonstrable lesion. This condition I doubt, or if it does exist, its effects are but transient.

Contusions are likely to be the result of very slight injuries, such as merely jars or sprains. They nearly always recover promptly, but sometimes they are followed by meningeal inflammation or by degenerative lesions of the cord, which are permanent. So that no matter how trivial

the injury to the spine may be, we should always give a guarded prognosis.

Fractures of the spine are recognized by the usual signs of fracture, crepitus, deformity and preternatural mobility, but one or all of these signs are often absent, then we have in addition shock, great disability, local injury, tenderness and pain, girdle pain and signs of injury to the spinal cord, which are: paralysis, both motor and sensory, and loss of reflexes below the injury. By a careful study of these three conditions, we can tell approximately and often accurately the location of the injury, but to do this requires an accurate knowledge of the anatomy of the spine, the spinal cord, and the peripheral nerve distribution.

The spinal cord is the path of conduction from the brain to the periphery, and is also the main location of reflex centres. These reflexes are

FIG. 1.-Diagram to illustrate the location of the different reflex centres in the spine. The deep reflexes on the left, the superficial on the right.

superficial and deep. Superficial reflexes are those stimulated by a slight irritation to the skin, or a tap on a muscle or tendon, the deep reflexes are those connected with visceral functions. The accompanying diagram illustrates the locations of these reflexes better than any explanation (Fig. 1).

In the sacral region we find the plantar reflex and a reflex of the skin about the anus. The centre for erection extends downward as far as the sacrum, but is mainly located in the lumbar.

In the lumbar region there are the tendo-achilles, gluteal patellar and cremaster reflexes, together with the centre for emission of semen in the male and for parturition in the female, also the centres for micturition and defecation, the last two are located both in the second lumbar vertebra.

In the dorsal region we have the abdominal reflex from the 12th to the 7th vertebrae and epigastric from the 7th to the 4th. To elicit these reflexes make a slight stroke over the lower abdomen or epigastrium respectively, and it will be followed by contraction of the abdominal muscles. There is also a respiratory centre in connection with each dorsal nerve. The respiratory centre proper in the medulla, but there are also secondary centres connected with the spinal nerves, as far as the 12th dorsal.

In the cervical region we have the reflexes of the shoulder and arm, viz., the palmar, the ant. and prost. wrist, scapulae and supinator longus. The centre for dilatation of the pupil is in the brain, but fibers from it pass down through the cord as far as the 7th cervical and pass out to unite with the cervical sympathetic, so that a lesion in this region causes dilatation of the pupil.

Fibers regulating erection also pass down the cord as far as the 7th dorsal, so that a lesion in the lower cervical or upper dorsal regions is followed by priapism, which is brought about through the sympathetic, for in such a lesion the erection centre in the lumbar region is destroyed.

Motor paralyses can be located by remembering the nerve distribution, viz., the lower part of the lumbar plexus and a little of the sacral to the lower extremities, the spinal nerves distributed in girdles about the body, and the brachial plexus to the upper limbs. But we must bear in mind. that the dorsal nerves exceed the vertebra in number-there being thirtyone pairs, and that they descend inside the spinal canal some distance before making their exit between the vertebrae, and that this distance is longer the further the nerve is from the head. The cord proper ends at the 2d lumbar, but the nerves are continued as the cauda equina as far as the coccyx.

Sensory paralyses follow very nearly paralyses of the motor nerves, but they appear quite different because the muscles are extended more or less by tendons which are often attached peculiarly, and when contracted produce effects quite distant fom the muscle itself, while the sensory effect is directly at the nerve distribution.

The accompanying diagrams (Figs. 2 and 3) show the distribution of the sensory nerves. They are not as complicated as they look, and a little study will impress them permanently on the memory. Beginning from below upwards we have only to remember that the sacral nerves supply the "saddle area" or the portion of the anatomy which comes in contact with the saddle when on horseback, and the external genitals. The 1st and 2d sacral nerves include all the "saddle area, "and the others supply areas smaller in extent, as the tip of the coccyx is approached.

The 1st and 2d lumbar nerves supply the loins and the upper portion of the hips; the three lower lumbar supply the thighs, legs and feet. These two zones are all that is necessary to fix in the mind.

A small portion of the sacral nerves enter the lumbo-sacral cord and are ultimately distributed to the feet. Through them the plantar reflex occurs, but the cutaneous distribution is so small that barring the reflex it is unnecessary to remember it.