Only some of the injection techniques used in neural therapy were developed by the Huneke brothers and their pupils. Others, such as the “blocks” of sympathetic ganglia, paravertebral injections to the trunk of segmental nerves, and peridural anesthesia, have been taken over from anesthesiology, orthopedia, and neurosurgery. We consider them part of neural therapy according to Huneke, like all methods that use local anesthetics for therapeutic purposes (and not for local anesthesia!).

Many of the techniques described here are used very frequently indeed, whilst others are employed only rarely. In order to indicate to those who are new to neural therapy the techniques they should master first and which they ought to concern themselves with particularly intensively, a star system has been used to mark the various injections:

*     of minor importance;

**   important;

*** extremely important.

It should be emphasized that these are not qualitative judgments! It may be the injection that has a lower classification that is alone capable of yielding results.

Quantities Stated

The quantities given in milliliters refer in each case to a suitable neural-therapeutic preparation of l–2% procaine or 0.5–1% lidocaine solution without the addition of vasoconstrictors such as adrenalin, epinephrine, Suprarenin etc. If a number of different products are used during a single session, the toxicity of the individual preparations and the maximum permissible doses stated must, of course, be observed!

Adenoids → (T) tonsils.

After the World War I the successes achieved by surgery of the sympathetic chain (Leriche) attracted considerable attention. Surgical removal of the nerve reticulum surrounding the arteries produced vasodilation in the periphery of the area supplied by them. In a number of cases, such surgery was able to deal successfully with extremely severe circulatory disturbances with threatening necrosis. But in the end the surgeons that specialized in work on the sympathetic chain discovered for themselves that para-arterial injections of procaine produced much the same effect as sympathectomy, as a result of which they abandoned surgery in most cases in favor of injection, described by Leriche as the “surgeon’s bloodless knife.” The procaine injections also have the advantage of being repeatable as often as necessary and cause no permanent damage to the nervous system, because they neither have a trigger effect in Speransky’s sense, nor do they leave an interference field behind. The effectiveness of para-arterial procaine or lidocaine injections can only be explained if we accept that the neural-therapeutic preparation acts as a regulating stimulus on the sympathetic periarterial tissue reticulum and thus restores the blood supply and other dysregulations to normality. Their ultimate therapeutic effect is similar to that of injections to the → (T) nerves (afferent).

Fig. 3.2 Aspiration in two directions before injections in the head and neck area.

1. The tip of the needle is positioned close to the interior wall of the artery. Blood is not drawn into the syringe, in spite of the intravasal position of the needle, because the internal artery wall is sucked against the opening of the needle.

2. If injection takes place at this point, the arterial wall is pushed away and the local anesthetic is injected intra-arterially, in spite of a negative aspiration test!

3. If the needle is rotated 180 and a second aspiration takes place, blood will be drawn into the syringe. This reveals the intravasal position of the needle and unintended intra-arterial injection is prevented.

4. The small quantities used in neural therapy (low concentration solutions without additives), are unlikely to cause serious complications, even in the case of intra-arterial injection. An additional safety measure in the area of the head and neck is the injection of a small fraction of the intended amount near the carotid artery and the vertebral artery. If the patient does not display any adverse reactions after a short while, the entire quantity can be injected.

Indications These are given by the carotid body’s influence on cardiac, vasomotor, and cerebral regulatory control centers. This explains, for example, the effectiveness of this injection in the prophylaxis and therapy of traumatic and post-operative shock with vasomotor collapse. This success is possible even when other therapeutic measures fail. In intestinal infarction it restores the balance in the diencephalic center of capillary regulation. It should also be tried in cerebral disturbances, lung disorders, disturbances in the conduction system of the heart, Ménière disease, therapy-resistant forms of headache, and in eye disorders where access is difficult, such as glaucoma, ophthalmic herpes zoster, painful disorders of the cornea, and others that have failed to respond to other attempts at treatment.

Carotodynia → neuralgia.

Materials Size 1 × 40 mm-long needle.

Quantity 1 mL.

Technique The injection is not difficult, but it must be carried out with the appropriate care. The patient lies on his or her back and turns the head slightly towards the side opposite to the injection site. The bifurcation of the carotid is at the level of the upper edge of the thyroid cartilage, where it can be readily identified by its easily palpable pulse. We fix the artery by pressure (not too hard!) and insert the needle vertically (without the syringe) so that when the needle is released it vibrates in time with the pulse rhythm. The assistant now carefully attaches the syringe and aspirates to check that it is still extravasal. If no blood is aspirated, we very slowly inject only about l mL of the solution immediately next to the carotid artery. Rapid injection or an excessive quantity, such as the 10 mL used by others, could be fatal! The injection must never be given bilaterally. After the injection, check the patient’s blood pressure. If the blood pressure decreases considerably and a carotid sinus reflex, caused by cranial ischemia, occurs, immediately place the patient into the Trendelenburg’s position (head slightly lowered, pelvis and legs elevated), which will normalize the blood pressure quickly and without medication (Koster, Kasman).

3. Aortic Plexus*

Para-arterial injections only!

In neural therapy according to Huneke, the injection to “Arnulf’s pre-aortic plexus” is hardly ever used. In angina pectoris, as a rule, we manage perfectly well with segmental therapy using appropriate quaddles and anesthesia of the stellate ganglion. According to Leriche, the injection to the stellate ganglion has about the same effect as that to the aortic plexus. But since the latter also forms part of the therapies using local anesthetics, it must be mentioned here.

Anatomy This plexus innervates the coronary vessels. It is located in front of the aortic arch and consists of nerve fibers of the cervical sympathetic system and of the vagus. By blocking its action, the coronary vessels are dilated.

Indications Angina pectoris, precordial pain in aortitis, myocardial infarct.

Materials 0.9 mm 100–120 mm-long needle.

Quantity In the original method, 20 mL of 1% procaine solution was used, but 5 mL should do equally well.

Technique In the technique described by Arnulf in 1940, the patient is in a half-sitting posture, with his or her head laid back and turned slightly to the right. The needle is inserted through a quaddle 20 mm above and 20 mm laterally from the left sternoclavicular joint. It is guided behind the sternum, parallel with it and about 70–80 mm obliquely down toward the interior (approximately toward the center of the sternum). It is now in front of the aortic arch, immediately next to the point where the aorta leaves the heart. The aortic pulse is transmitted to the needle. The needle is not advanced beyond this point, and the anesthetic is injected slowly after aspiration proves negative.

When 20 mL are injected (but not with 5 mL), the patient feels a heaviness behind the sternum, but this disappears rapidly. Any aphonia due to anesthesia of the recurrent nerve disappears as the anesthetic effect wears off. If this method is used there is no risk of injury to pleura, brachiocephalic (anonymous) vein, or aorta. If, exceptionally, the anonyma should be injured, apply pressure with a finger or pad in the hollow above and behind the clavicle. If the needle accidentally punctures the aorta, this does not matter (as in aortography). If necessary, the injection may be repeated three to four times weekly. Its effect will increase until it becomes permanent.

Para-arterial injections only!

Anatomy The vertebral artery runs cranially through the transverse foramina from the sixth cervical vertebra. Between axis and atlas it turns aside to the transverse foramen of the atlas, which lies further laterally. Above the atlas it again runs medially in a sulcus and penetrates the atlanto-occipital membrane and the dura mater. It then passes through the foramen magnum into the cranial cavity where it unites with the vertebral artery of the other side and becomes the basilar artery. The sympathetic supply of this artery is provided by the vertebral nerve of the stellate ganglion and by fibers of the upper cervical ganglion. The cranial nerves IX and X provide it with its parasympathetic fibers. The regions supplied by this artery are: spinal cord, pons, labyrinth, cerebellum, occipital lobe, basal portion of temporal lobe, midbrain.

Indications Vertebral-artery syndrome, sudden syncope with brief loss of consciousness and crumpling of the legs, therapy-resistant forms of migraine and cervical migraine, positional vertigo with or without nausea; nausea, vomiting, and tinnitus, Ménière, upper cervical syndrome, conditions following → whiplash syndrome and other trauma in the area of the cervical spine, shoulder pains, ataxic locomotor and static disturbances, nystagmus, visual disturbances with loss of visual field; hazy, cloudy, or distorted vision. Scheffel took the view that anesthesia of the vertebral artery could be used instead of anesthesia of the stellate ganglion and listed further indications: multiple sclerosis, post-apoplectic state, facial paresis, hiccoughs, tinnitus, glaucoma, and bronchial asthma.

Materials 40 mm-long needle.

Quantity 1–2 mL.

Technique

a. The neural therapist Auch described an injection technique to the posterocaudal surface of the lateral part of the atlas arch. With this, it is possible to reach the vertical and horizontal portions of the vertebral artery, and the suboccipital, second cervical and greater occipital nerves.

Fig. 3.3 Injection to the vertebral artery.

Fig. 3.4 The injection site on the lower lateral arch of the atlas vertebra.

b. Scheffel goes in a little further caudally, about two to three fingers’ breadths below the mastoid where the lateral process of the axis (epistropheus) can be felt at the posterior edge of the sternocleidomastoid muscle. After aspiration, inject 2–3 mL at a depth of about 15–20 mm at the dorsal portion of the epistropheus.

Thus, both these authors go into the space between atlas and axis, Auch further cranially to the lower surface of the lateral atlas arch, Scheffel to the upper edge of the axis. In their end effect these two methods are identical.

c. A third possible method of reaching the sympathetic reticulum surrounding the vertebral artery is to place a depot of 2 mL in front of the artery’s entry point into the vertebral canal in the lateral process of the (fifth or) sixth cervical vertebra. This can be easily found by palpation and is reached without difficulty from the front or side.

d. Post-ganglionic fibers travel directly from the stellate ganglion (cervicothoracicum) to the adventitial plexus of the subclavian artery. The vertebral artery can be affected through anesthesia of the stellate ganglion or perivasal injections around the subclavian artery. This way, the areas of the posterior skull sulcus and the inner ear can also be treated.

Possible complications According to Schmitt, accidental injection into the vertebral artery produces lightning-like flashing sensations in the homolateral eye, and tinnitus and hammering in the homolateral ear. A slightly comatose state disappeared after about a minute without subsequent symptoms.

5. Subclavian Artery*

Para-arterial injections only!

Indications and technique are obvious from what has been stated above and from the description of the injection to the brachial plexus (see → (T) nerves, afferent). Periarterial nerve plexuses travel from the stellate ganglion to the subclavian artery at the same location where the vertebral artery branches off. This is why Dittmar recommended the perivasal infiltration of the subclavian artery instead of the injection to the stellate ganglion for improving the peripheral blood supply and reducing hypertonicity of the body’s musculature in the region supplied by this vessel, particularly in stenocardia and in functional and organic cerebral circulatory disturbances. Because of the nearness of the cervical pleura, the needle must on no account penetrate beyond 15 mm! See also → scalene syndrome.

6. Brachial Artery*

Intra- and Para-arterial Injections

Indications Circulatory disturbances, support for the healing of fractures, injuries, burns, or congelation of the upper extremities and post-traumatic pain, nocturnal arm dysesthesias, arm plexus neuritis, Sudeck’s dystrophy, arterial emboly, acroparesthesias, causalgias, amputation/phantom pain, epicondylitis, styloiditis, tendovaginitis. If it is not possible to give an intravenous injection in small children, e.g., in otitis media, we inject to the brachial artery.

Materials Size 2 needle.

Quantity 1 mL.

Technique The brachial artery is found by palpation above the antecubital fossa and the procaine is distributed in its immediate vicinity. There is absolutely no risk attached to an intra-arterial injection into this vessel, since it leads only to the periphery. Also, perineural injection to the radial, ulnar, median, and musculocutaneous nerves will improve the treatment.

7. Femoral Artery***

This injection is also used in tuberculosis of the bone or joints of the lower extremities (in addition to the usual measures), in order to improve tissue nutrition and thus improving the body’s natural defenses against the tubercle bacillus. Dittmar pointed out that perivasal injection to the femoral artery not only stimulates the blood supply to the regions supplied by this artery and relaxes reflex muscular hypertonicity, but that via the “transition segment” L2 it also develops a therapeutic effect on the lower portion of the large intestine and the whole of the urogenital system.

When injecting procaine intra-arterially, followed by insufflation of an ozone-oxygen mix, it becomes noticeable that the increase of blood supply is extended beyond the injection site, in direction of the blood flow. After the infiltration, a vascular spasm occurs and the extremity turns pale and cold. Now the reactive vasodilation takes place. At first, hyperemic red spots appear on the skin, they begin to connect and turn the entire skin red along the vascular area. Cranially the hyperemia extends in direction of the blood flow to the umbilical level! This explains the effectiveness of the injections with → impotence (Leriche syndrome).

In the course of treatment of the lower extremities, it can be measured that the area of blood supply disturbance moves distally. This shows that a collateral circulation has formed and regulates the blood supply.

Materials About a 40 mm-long needle, not too thin.

Quantity 2–3 mL. In an emergency, it is also possible to mix the local anesthetic with Priscol, Ronicol, Actihaemyl, or similar.

Technique The patient lies on the examination couch, the legs opened slightly and rotated outward. The femoral artery is now immediately below the inguinal ligament in the fossa ovalis and can be readily found by palpation. The vein lies in a medial direction from it and the femoral nerve lies further laterally. Fix the pulsating artery between the tips of the index and middle fingers. The right hand guides the needle with a short jab almost vertically into the vessel. Aspiration is only very rarely necessary, since blood pulsating into the syringe under its own pressure usually shows when the needle is in the correct position. About 2 mL of procaine are now injected rapidly into the artery. On withdrawing the point of the needle, another l mL is given into the immediate vicinity of the artery. For the femoral artery, the intra- and periarterial injections are combined in order to reach the sympathetic fibers of the adventitia, the media, and the intima, i.e., the whole of the sympathetic reticulum of the artery, which is co-responsible for pathological vasoconstriction and other disturbances. The injection site should be kept compressed for a few minutes after the injection, using a pad, in order to prevent the formation of a hematoma.

Fig. 3.5 Injection to and into the femoral artery.

Materials Size 1 needle or longer.

Quantity l mL procaine solution.

Fig. 3.6 Injection to the posterior tibial artery.

Reversant therapies gain importance in light of the increasing number of patients with regulation disorders or regulation blocks. In addition, the growing interest in biological healing methods has brought the attention of patients and physicians back to autohemotherapy. It can be recommended as a simple and harmless addition to the repertoire of every neural therapist. It can improve the patients own → immune response and vegetative constitution. Some therapy-resistant disorders cause autosensitization through morbific agents or other factors (e. g., metabolic waste, mercury fillings). Often, the irritants cannot be identified and the number of allergens is growing by the day. Specific desensitization can take place only if the irritants that affect the autonomic basic system are recognized and turned into allergen extracts.

The patients’ blood definitely contains all sensitizing substances. Autohemotherapy makes use of the specific antibodies formed by the patients’ immune system and the information resulting from previous therapies. Thus, it is more than merely parenteral protein therapy. During hemolysis, antibodies specific to the individual are released. The products of this decomposition stimulate the immune system and increase humoral and cellular defense mechanisms. For example, erythrocatalysis stimulates increased blood formation in the bone marrow, the cytolysis of leukocytes releases immunoglobulins. Stimulation of the storage activity of the reticuloendothelial system (RES) and cell activation has been documented. More phagocytes are produced and the functions of the spleen, lymph nodes, and tonsils are stimulated. It is presumed that the allergen antibodies are processed as a form of countersensitization. All this signifies profound reversal of the autonomic constitution and reactivation of inhibited self-healing abilities.

Indications General reversal, furunculosis, carbuncle, pyodermia, acne and other skin disorders, chronic diseases of the respiratory tract, allergies, rheumatism, joint disorders, ulcerative colitis, ventricular ulcer, cerebral sclerosis, and more.

Technique Initially, 1–2 mL of blood is taken from the patient’s cubital vein and intramuscularly re-injected immediately. Every 2–3 days the amount is increased by 0.5–1 mL, depending on the patient. In the course of the next 2–3 weeks the amount cannot exceed the → fever threshold of 5–8 mL. The patient has to be informed that he or she might experience a febrile healing response for 1–2 hours, which will disappear by itself. Usually the patient does not require sick leave but should also be made aware that interference fields can be activated and that he or she needs to report every reaction to the physician. In order to increase the therapeutic effect, it does not cause harm to add biological stubstances that stimulate the immune system, such as Elpimed, Echinacin, Engystol, etc.

The same applies to ozone-autohemotherapy, where an ozone-oxygen mixture is added and in smaller amounts re-injected; in larger amounts (50– 100 mL) it is reinfused after adding citrate. There are additional therapies, including the modified autohemotherapy according to Theurer, hematogenous oxidation therapy, and the use of blood that has been potentiated or treated with ultraviolet radiation or hemolysis.

This radical reversant method should probably be used only as in-patient hospital treatment, since extensive irritation can result.

Materials Lumbar-puncture needle with mandrin or 0.8 mm diameter 80 mm-long needle, 10 mL record syringe.

Amounts We slowly inject 1 mL of 1% procaine solution from an ampoule without additives intrathecally into the liquor at the end of the pump operation. Before this, to avoid excessive irritation to the liquor-forming system, we first draw off about 8–10 mL of liquor. In the original method, only the liquor itself was pumped back and forth without the addition of procaine.

Contraindications Hypertension, tumors in the posterior cranial fossa, central vascular disorders.

Technique Absolute sterility is essential: disinfection of the skin, sterile surgical gloves.

Lumbar puncture The patient sits astride a stool. His or her head is held firmly by an assistant, bent slightly forward. Preferably, the patient should put his or her arms around the assistant. The needle is inserted between the spinous processes of the third and fourth lumbar vertebrae at the point of intersection of the line connecting the iliac crests with that of the spinous processes. A → (T) quaddle is set over the point of entry and the needle is then guided first straight ahead and then its point should continue slightly upwards and in a perfectly sagittal direction until it meets an elastic resistance. When it has passed through this, the cannula is in the correct position and liquor will drip from the needle. The needle is left in position and the syringe attached to it. Liquor is now aspirated into the syringe and the 10 mL of liquor is re-injected. The process is repeated 10 to 20 times, so that a total of 100– 200 mL of liquor is moved.

Side-effects Headache, vomiting, nausea. These symptoms can to some extent be controlled with analgesics. The removal of a quantity of liquor at the end of the treatment can considerably reduce these side-effect symptoms. Years ago, I was able to cure a woman of flaccid paralysis of both legs, which had persisted for 2 years, by means of three such liquor-pump treatments with the addition of 1 mL of Impletol, at intervals of 3 weeks. On each occasion I removed 10 mL of liquor as a prophylactic measure to relieve pressure.

Caution: Indications This method is not suitable for general practice! It should be used only by the experienced physician and if the possibility of in-patient treatment is available. It must never be used unless segmental therapy and the search for a possible interference field have proved fruitless and even then only if there is a sufficient number of subjective and objective symptoms suggesting a possible interference field in the cerebral region. Obviously, the principle that the seriousness of the clinical picture must always be in a proper relationship to the risk attached to the therapeutic intervention also applies to this injection. In the case of a cisternal injection, the risk resides less in the injection of procaine as such than in the suboccipital puncture it necessitates.

Objective symptoms:

• Positive Romberg test.

• Impaired ocular convergence.

• Dysmetria (signs of ataxia, finger-nose test).

• Snout reflex according to Wartenberg (“the Babinski of the head”): the reflex is positive, if when tapped with a reflex hammer the loosely held lips are arched forward like a snout.

• Eye test according to Reid: the patient faces straight ahead and his or her eyes follow the physician’s finger moving to the extremities of vision to the left, right, up, and down. The reflex is positive, if a fine tremor of the head results, which may be accompanied by dizziness or nausea.

• Wartenberg’s head-retraction reflex: the patient bends his or her head slightly forward. The reflex is positive if the head is briefly retracted when the upper lip is tapped with the reflex hammer.

• Other pathological reflexes, e.g., absence of the abdominal-wall reflexes.

If several such signs are present simultaneously, the cisternal injection is justified.

Anatomy The cistern is the cavity between the pia mater and the arachnoid. It is filled with liquor and opens into the fourth ventricle and, indirectly, the entire ventricular system. Almost all the cerebral nerve centers lie in the rhomboid fossa, on the floor of the fourth ventricle, including the autonomic centers of the vagus, the glossopharyngeal and the intermedius nerves. They are particularly important for respiration and circulation. By way of the cerebral aqueduct, the fourth ventricle communicates with the third ventricle of the diencephalon. There is also an indirect connection from there to the pituitary gland. The “pituitary-diencephalon-system” comprises the primary center for autonomic regulations.

Materials The needle should preferably be a suboccipital-puncture needle with a mandrin, or a normal l mm diameter 80 mm-long needle; in addition, an empty 10 mL syringe and a 5 mL syringe containing l mL procaine will also be required.

Technique If possible, the patient should have an empty stomach. He or she is seated backwards astride a chair, and supports their head on their folded arms resting on the back of the chair. An assistant firmly holds the patient’s head bent forward to prevent it from jerking back. The hair is cut away over the suboccipital site, between the spinous process of the second cervical vertebra, which can be readily found by palpation, and the squamous part of the occipital bone. The area around the site is cleaned with soap and water and thoroughly disinfected.

Fig. 3.7 Injection into the cistern.

Before the injection, the patient should be warned of a number of reactions, some of which may be unpleasant, and the physician should remain with him or her for 20–30 minutes until they have subsided. Soon after the injection, the patient’s pulse rate will rise and he or she will feel nausea. This will be followed by a sensation of warmth and an outbreak of sweating. There may also be coughing, sneezing, or violent yawning, and hallucinations of taste or smell may occur. Following this reaction of the sympathetic nervous system there will be a parasympathetic phase with a slowing of the pulse, pallor, a feeling of cold and nausea.

In case of severe decrease of blood pressure, Trendelenburg’s positioning (head slightly lowered, pelvis and legs elevated), which normalizes blood pressure quicker and more reliably than short-acting analeptics, should be used. Due to the concentration and amounts used in neural therapy, a paralysis of the respiratory center is improbable. According to the Americans Koster and Kasman, the respiration center possesses characteristics that make it insensitive to the amounts of local anesthetics used in spinal anesthesia. Depending on the autonomic state at the outset, the type, severity, and duration of these autonomic reactions may vary. They disappear after anything from a few minutes to 30 minutes, when the patient’s equilibrium is restored to normal. Sometimes this injection can be given with hardly any reactive symptoms by the patient, at other times the same patient may present with severe, even excessive reactions. But no case of damage or fatal sequelae has been reported.

Following the injection, the patient should remain recumbent and under the physician’s observation for at least an hour and should not be discharged except under observation. If possible, he or she should rest in bed for a couple of days. For these reasons, in-patient treatment is desirable. If, during this period, there are symptoms of meningeal irritation such as a rise of temperature, headache, and a hint of a stiff neck, the prescription of analgesic suppositories is all that will be required.

Theoretical doubts have been voiced against the cisternal injection of procaine, some of them very weighty indeed (Janzen, Lendle, Moellhoff, Zipf) and, as a result, the Federal German Medical Association has issued a warning against using this injection. Lendle issued a massive threat by stating that “in case of accidents, a person who has used this form of therapy cannot expect to find any grounds based on theoretical and pharmacological considerations to relieve him of responsibility.” He regards it as theoretically impossible that l mL of procaine injected into the cistern will not produce paralysis of the respiratory center, collapse, etc. Against this, however, there is the fact that in practice, involving several hundred such injections, there has never been a serious incident, much less a fatality; there have, on the other hand, been cures that could not be previously obtained by any other means. If theoretical objections had always carried the day in the past, there would never have been such things as railways, airplanes, or nuclear reactors, not to mention a large number of surgical operations.

The risk of the cisternal injection lies entirely in the suboccipital puncture, in which one cannot, of course, ever be absolutely certain that there will be no complications as a result of cerebellar tumors and vascular abnormalities. Nevertheless, in neurology it is carried out for purely diagnostic purposes as an almost daily routine and with little hesitation. The introduction of procaine into the cistern does not in our experience constitute any significant additional risk. Nonetheless, it is advisable always to have a cortisone preparation in readiness for intravenous administration in case of shock or collapse, such as Solu-Decortin H or Ultracorten H (water-soluble).

Alternative terminology Extradural, peridural, or sacral anesthesia, caudal block.

• skin: anus, perineum, scrotum, penis, and the region of “saddle-block anesthesia” of the lower buttocks;

• organs: lower rectum, vagina as far as the cervix of the uterus, ureter, pelvic floor, prostate; in addition, the anal sphincter is also relaxed.

The spinal nerves that pass through the dural cavity are surrounded by thick dural sheaths. Thus, in order to produce a “saddle-block anesthesia” adequate for surgery, we need to use substantial quantities of anesthetic solution, as in any epineural conduction anesthesia (about 20 mL). The epidural space lies between the dural sheath of the spinal cord and the periosteum of the vertebrae and can hold over 100 mL. For neural-therapeutic purposes it is often sufficient to inject 5 mL of procaine, and this is soaked up by the loose tissue in the epidural cavity as if by a sponge. Experiments have shown that this solution can diffuse as far as the cervical segment.

Indications Any disorders in the areas mentioned above, irrespective of whether they present as inflammation, pain, itching, or other symptoms, principally affecting the external and, in part, also the internal genitals; sexual disturbances, enuresis, bladder disorders, encopresis in multiple sclerosis, piles.

Obstetrics form a special indication. Epidural anesthesia with 20 mL of procaine will, after about 15 minutes following administration, reduce labor pains for 1–2 hours without in any way inhibiting labor. On the contrary, expulsion of the fetus is facilitated and accelerated by the relaxation of the pelvic floor.

Reischauer explained the effectiveness of epidural and presacral infiltrations in the treatment of sciatica by their ability to damp effectively the reactions of the spinal roots and the sympathetic fibers in their vicinity, which are due to the mechanical irritation caused by the prolapsed cartilaginous disks.

Materials 1 mm 60 mm-long needle.

Quantity Depending on the object of the injection and varying from 5–20 mL of procaine solution; 10 mL remain mainly within the epidural cavity of the sacral region, 20 mL diffuse as far as the lowest lumbar segments, 30 mL as far as the level of the umbilicus (T9 to T10) and 40 mL will spread as far as T6 to T7 (lower shoulder blade). Even if as much as 40 mL of 1% procaine solution is injected, there will be no motor dysfunction of the legs, which would complicate outpatient treatment.

Fig. 3.8 Epidural (sacral) anesthesia.

Fig. 3.9 Diagram showing the epidural injection.

1. Entry of the needle through the upper part of the membrane.

2. The needle is depressed a little and advanced about 50 mm into the sacral canal; the injection is given following a negative aspiration test.

Indications All → abdominal disorders. This injection to the peritoneum of the upper abdomen will often suffice on its own; if it does not, we combine it with one to the abdominal→ (T) celiac ganglion.

Materials About a size 1 needle.

Fig. 3.10 Injection into the epigastrium (to the upper part of the peritoneum).

Alternative terminology Paracervical block, transvaginal injection to the utero-vaginal plexus (Frankenh user’s), or utero-sacral block.

Anatomy The plexus of the female pelvis travels along the interior iliac artery and the uterine artery to the lateral uterus. In its parametrium it forms the large utero-vaginal plexus (Frankenh user’s) with many ganglia. Secondary fibers of the pelvic plexus innervate the bladder, vagina, the uterus, and the clitoris.

Indications

1. Segmental therapy: For endometritis, parametritis, dysmenorrhea, abnormal menstruation, neuritis of the pelvic floor, lower abdominal pain and/or backache, dyspareunia, sense of pelvic discomfort and downward pressure, frigidity, sterility, disorders connected with the menstrual period such as headaches, autonomic pelvic disorders etc. In 1954, Goecke reported more than 247 cases of cervical hypersecretion that did not respond to any form of treatment. In 83.3% of the cases he was able to cure or considerably improve the condition with paracervical infiltrations. This also cures existing portio erosions. In the treatment of → irritable bladder, urination regulating parasympathetic and sympathetic fibers of the pelvic plexus are temporarily blocked. For this condition we also infiltrate paraurethrally at the anterior vaginal opening, 2 cm dorsally to the external vesical orifice.

c. In labor: In obstetrics, 5–10 mL of procaine solution are given on each side to relieve pain in the initial phase of normal, straightforward labor. In first pregnancies it is advisable to wait until the cervix has reached a diameter of about 50 mm; in subsequent pregnancies it should have become dilated to about 30–40 mm before the anesthetic is given. The first side is infiltrated between two contractions, and the other infiltration given two contractions (i.e., about 15 minutes) later. The pain-relieving action generally starts to take effect immediately and remains effective for 1– 2 hours. Infiltration of greater quantities blocks the pelvic plexus with its links to the presacral nerve and to the sacral plexus.

Contraindications During the period, it is advisable to avoid any transvaginal intervention, including this injection. However, there is no objection even during menstruation to an injection from the outside into the → (T) pelvic cavity.

Materials 0.8 mm 80–100 mm needle, with pilot tube like the PP needle made by Woelm; quantity 2– 4 mL, 10–20 mL for obstetric purposes.

Fig. 3.11 Injection to Frankenh user’s ganglia. The point of entry of the needle is through the lateral fornix, injecting at a depth of 10–20 mm.

When working with the needle with a pilot tube, the free hand locates the point of insertion of the needle between index and middle finger. The free hand then slides the tube to this point and places its outer end on the inside of the opposite thigh. The assistant introduces the long needle with the 5 mL syringe attached into the pilot tube without letting the patient see it. The needle is inserted as far as it will go, aspiration is carried out under the doctor’s control and 2 mL of procaine injected. The same injection is then also given on the other side.

Consequential bleeding is very rare. If it occurs, it can be stopped by compression with a cottonwool pad covered with lint. The patient remains lying down for 15 minutes. After a check, an absorbent pad is placed in position, and the patient is allowed to leave. Gynecologists are used to hooking into the posterior external os of the uterus with bullet forceps to pull the portio toward the symphysis in order to inject the local anesthetic into the tightened sacrouterine ligaments. Our experience has shown that this injection can be successfully done without hooking into the portio. However, if doing so, one should also remember to inject into the attachment site of the forceps in order to avoid scar interference field formation.

Any scars present as a result of a perineal tear or episiotomy are of course always injected at the same time. In women who have already had children, the perineum should always be infiltrated at least once at the same time as giving this injection, even if there are no externally visible macroscopic scars. The injection into the perineal tissue is painful because of the large number of nerves it contains. Scars following Emmet’s tears and in the related parametric ganglia so often form interference fields that they must be found by palpation and treated by injection. Here, too, the PP needle is used to help locate the point of insertion accurately. If the scar tissue is so hard that the needle is difficult to insert, it helps to ask the patient to cough, and the needle will enter effortlessly. It is worth taking a little trouble over this injection, since it will often be rewarded by a genuine Huneke phenomenon.

For any vaginal interventions that may become necessary in virgins, the intact hymen can be made soft and flexible enough for the speculum for about 24 hours by mixing an ampoule of kinetin (hyaluronidase) with 5 mL of procaine solution, first infiltrating under the base of the hymen with a fine needle and then infiltrating directly.

Anatomy The intercostal nerves supply the sensory nerves to the thoracic wall including the parietal pleura and the anterior abdominal wall with the sensitive parietal peritoneum. From the intervertebral foramen to the angle of the ribs the nerve runs in the middle of the intercostal space, from there to the anterior axillary line it lies directly under the rib. If the effect of the injection is inadequate, anastomoses of the intercostal nerves make it necessary to block the adjacent nerves at the same time.

Indications Intercostal neuralgia, shingles, carcinoma pain. To relieve pain and improve respiratory excursions and the coughing up of secretions in fracture of the ribs, pleurisy, pulmonary embolism, pneumonia and following abdominal surgery; pectoralis minor syndrome. If the patient is suffering persistent pain, the possibility of vertebral disorders, cancer, and tabes should also be considered.

Materials Short needle.

Quantity Procaine solution per injection: 0.3–1 mL.

Technique By inserting the needle 50 mm to the side of the spinous process and going straight down, one strikes the relevant rib. Obviously, we look for this nerve according to the site of pain, e.g., next to the spine, in the axillary line or next to the sternum. If we want to inject next to the spine, the patient needs to place their forearm onto their forehead, which moves the shoulder blade away from the place of insertion. In this section, the nerve is still located in the middle of the intercostal space. In order to affect the lateral cutaneous ramus, insertion into the posterior axillary line is recommended. Then we advance the point as far as the lower edge of the rib. To avoid injury to the pleura we maintain steady pressure on the plunger and continue another 5 mm—never more!—into the intercostal musculature. In doing so we try to obtain nerve contact. The patient needs to be prepared for the sharp pain this will produce, to avoid making any sudden defensive movement due to fear or surprise. If their symptoms recur, they will probably happily submit to this somewhat painful injection again, for nothing else can better relieve or get rid of these unpleasant and frightening symptoms. If very occasionally the pleura is accidentally perforated, a pneumothorax may be produced. Generally, this is not even noticed by the patient, but if it is, it will heal of its own accord within 2–3 days with a little care on their part to avoid overexertion, but without substantially affecting their general state of health. If more severe symptoms continue or if there is any suspicion that they might have a tension pneumothorax, an x-ray check is advisable.

Intra-arterial injection → (T) afferent arteries.

Indications Conditions following x-ray or radium therapy; in addition to the injection into the → (T) pelvic region and to → (T) Frankenhaeuser’s ganglia for any sequelae of febrile abortion, placenta accreta, cesarian section, endometritis, cervical stump following a supravaginal hysterectomy, cervical tears after labor, conization, cervical erosion etc.

Materials 1 mm diameter 100 mm-long needle, a self-retaining speculum, vulsellum, tightly fitting record syringe.

Quantity 4–6 mL.

Technique The injection described by Mink requires good fingertip sensitivity, patience, and the ability to proceed with gentle force. In addition, because it can be painful, it also calls for the ability to distract the patient verbally.

In sensitive or highly-strung women it may first be necessary to give a paracervical injection to → (T) Frankenh user’s ganglia. There is no need for a general anesthetic. Following an intramural injection into the uterus, we also inject the site where the vulsellum was attached in the cervix, and after overcoming the resistance of the musculature we allow another l–2 mL procaine to flow into the myometrium from there. Following the injection, the patient inserts a vaginal tampon to absorb any bleeding that may occur on her way home.

This injection is repeated at intervals of several days to a week. As a rule, three to five injections will suffice, even for the main indication of reactive fibrosis of the endo- and myometrium following radiation treatment for carcinoma.

Indications Intravenous injections of procaine are used:

• to relieve pain (as endoanesthetic);

• as vasodilator;

• to regulate the circulation;

• as ganglioplegic;

• to reduce vascular permeability;

• as anti-emetic;

• as diuretic;

• as anti-pyretic;

• as spasmolytic;

• as anti-allergic measure (as anti-hyperergic);

• as autonomic reversant treatment;

• to reduce inflammation (as anti-phlogistic).

By way of the blood vessels, the intravasally injected or enterally administered local anesthetics reach the internal and external sensory organ and tissue receptors or afferent structures and desensitize them by decreasing their excitability. The synapses of the parasympathetic ganglia respond to lower doses of the anesthetics than the sympathetic ganglia. This “endo-anesthesia” affects, for example, the receptors of the carotid sinus and the heart and inhibits stimulus formation and transmission in the cardiac muscle. We also reach the visceral receptors of stomach, intestinal, and urogenital system, as well as muscle and pain receptors this way.

The favorable effect of procaine on cell metabolism is based on an increased oxygen supply and the more rapid removal of metabolic products. It sensitizes the uterus to the posterior pituitary hormone. In the experimentally induced circulatory collapse using veratrin (Bezold-Jarisch reflex; Eichholtz, Fleckenstein, Muschaweck, Zipf), a spontaneous lowering of blood pressure occurs, with a reduced pulse and respiration rate to the point of collapse. We know this reflex clinically in the shape of a cardiac infarct. The collapse response can be prevented by giving procaine intravenously, because this desensitizes the receptors. The same also applies to anaphylactic serum shock and necrosis formation in the Shwartzman-Sanarelli phenomenon (Hirsch, Keil, Rademacher, Siegen). Through experiments, these authors also showed that the permeability of terminal blood vessels due to dysregulation can be reduced.

This imposing list of positive characteristics has earned procaine its title of “king of medicines.” But in addition to this, procaine or lidocaine given intravenously develop an effect so extensive that none of the attempts made to explain this from a pharmacological point of view can offer full satisfaction. In addition to eliminating vasomotor dysregulation, there can be little doubt that it also has a regulating effect on higher order control centers. It improves the patient’s general state and restores the balance in all autonomic dysfunctions. In doing so, it will depend on the initial state whether it acts as an autonomic relaxant or improves tonicity in the opposite sense. This neural-therapeutic effect tending to re-establish the normal state is set off by the healing stimulus that procaine has upon the autonomic plexus of the vascular wall. This effect is obtained with even the minutest quantities of procaine. We therefore take the view that if l mL is not enough to produce a decisive response from the reticular system, then 5 mL or even more will not do so either. But since with intravenous injections the risk of toxicity increases rapidly with the quantity administered, any larger quantities are as dangerous as they are pointless. Thus, let us stick to the single and harmless milliliter.

The intravenous injection of l mL of procaine and of a few drops given paravenously, in conjunction with injections to other sites, is indicated as a reversant and balance-restoring basic treatment for all disorders in the regions of the head, neck, and throat and of the thoracic area, and for the treatment of a large number of other pathological conditions. It affects regulation centers and vasomotion. Repeated injections have a regulating effect on the autonomic system and act as a normalizing vascular exercise for all neurovascular dysregulations and their consequences for trophism and function of the tissues:

The effect of intravenous anesthesia on the functions of the autonomic nervous system can be compared to the sympathetic blocks and the vegetative drugs used with these disorders. Sympathetic blocks and intravenous anesthesia have a longer lasting effect than the duration of the actual anesthesia (reversal of the autonomic tonus). (Leicher, Haas)

In South America, surgical operations have been carried out since 1950 on patients placed under an anesthetic induced by the intravenous administration of procaine. A barbiturate is given as a basic narcotic, together with a muscle relaxant, and 1% procaine is then administered in a 5% dextrose solution by continuous infusion. This anesthetic has been found to be adequate for most surgical operations! A report by Parada covered 300 000 cases and showed that this method is well-established and widely used.

Materials Size 12 needle.

In a court judgment given in Frankfurt in 1967, it was stated that an intravenous injection in conjunction with other procaine injections is not permissible “in view of the cumulative effect of stimuli.” Our practical experience does not accord with this. Intravenous procaine therapy has a general reversant effect on the autonomic system, which cannot be achieved to a similar extent by subcutaneous or intramuscular injections. Segmental therapy with procaine is used for other purposes. Provided the limiting dosages are observed, the two types are perfectly compatible with each other.

Technique Except in very apprehensive or labile patients who are better treated in a recumbent position, this injection can be given without hesitation to the seated patient. Contrary to what one may often read, practitioners of neural therapy according to Huneke do not inject particularly slowly. F. Huneke injected the milliliter into the antecubital vein, with tourniquet in position and then released the tourniquet. Thus, the whole of the dose enters the circulation at a stroke and thus literally constitutes a therapeutic thrust into the neurovegetative system. Before taking out the needle, always also give a few drops of procaine paravenously, as the neural-therapeutic effect is further increased if the reticular system surrounding the vein is included, since this is particularly richly supplied with autonomic terminal fibers. Procaine is rapidly metabolized in the body. In an emergency, the intravenous injection may be repeated at half-hourly intervals.

Side-effects Sometimes, following the injection, the patient may show such symptoms as slight dizziness, pallor, tremor, or sudden sweating (“initial vaso-spasm”). All these are perfectly harmless and pass off after a few minutes. When using procaine, we may very occasionally see more severe symptoms such as a tendency to collapse or unconsciousness. In such a case, we lay the patient flat and let them remain like that for 15 minutes. Do not give any vasopressors!

In over 100 000 intravenous procaine injections to date, I have never yet had a case of convulsions, coma, respiratory paralysis, let alone a fatality. Reports of such incidents are based on overdoses and on the fact that other and more toxic preparations containing procaine or modern amide-structured local anesthetics with a vasoconstrictor additive have been used! If the patient feels thirsty, he or she should be given a drink of water. Nervous, highly-strung patients should be given a harmless valerian preparation.

From a morphological anatomical viewpoint, the joints are merely movable links between the bones. Seen cybernetically, they also have an important control function. Their environmental sensors (receptors) not only indicate to the center the positions of the joints, they also regulate and influence their own environment via the autonomic nervous system and trigger off pain when there is an appropriate stimulus. The interlinking with other control circuits passes beyond the spinal-reflex functional circuit to affect every part of the organism. Our knowledge of these relationships should prevent us from regarding or treating any system—in this particular case the joints—in isolation.

With regard to treatment, as far as possible we prefer to do without corticosteroids and medical preparations, since they are mostly as unnecessary as they are harmful. However, we must exclude dislocations, major fractures, articular tuberculosis, and metastases from treatment with our injections or, if neural therapy is used, it should be limited to a supporting role. The standard diagnostic procedure must not on any account be omitted before treatment. X-rays and laboratory reports have in our view a purely informative function, since they can tell us little about the state of the diseased structures and nothing about the causal relationships between the pathological findings and the loss of function. This is particularly true of degenerative changes such as osteophytes and the like. At all events, unusual or even abnormal findings should not deter us from taking appropriate neural-therapeutic action.

Injections directly into the joints will only rarely be necessary! Generally, all that will be required are → (T) quaddles and deeper → (T) intramuscular infiltrations near the joint. So, for example, arthritis or arthrosis of the knee due to purely segmental causes will be cured by five simple quaddles around the knee, provided that this segmental treatment is repeated a sufficient number of times. If this treatment does not produce the desired result, then other injections in the segment hold little prospect of success. Nevertheless, it still happens time and again that injections of procaine or Xyloneural into the joint work wonders. Procaine has a desensitizing effect on the synovial membrane. But if there is an interference field at the root of the pathological changes in the joint, neither quaddles nor intra-articular injections will help to any significant degree.

As always, the needle should be inserted briskly. If the point of the needle can be moved freely, if it is easy to inject air, and if synovial fluid is aspirated, we have the assurance we need that the needle is correctly positioned within the joint capsule. If there is an existing effusion, this should be aspirated and a little of it mixed with the procaine before the injection.

Injections of procaine or Xyloneural into joints can be made irrespective of the blood sedimentation rate, the patient’s age, or the length of time that they have suffered from their disorder, and regardless of their general state of health. Even the worst possible x-ray picture is no contraindication. The function is always of far greater interest to us than this momentary photographic record of the skeleton (provided that malignant processes can be excluded). We do not intend to change anything in the bone but to improve, and, as far as possible, restore the function. Our form of treatment is far more sparing than any surgical operation. For this reason, a sufficient number of repeat injections should always be planned before any intended surgery. Before any surgery is undertaken, every possibility in the segment should be exhausted and a painstaking search for a potential interference field concluded. If a disorder is due to an interference field, any local surgery is pointless and is bound to fail.

In treating painful joint disorders we need to remind ourselves that the neural and vascular supply of all the major joints (shoulder, knee, hip, elbow) emanates from the flexor aspect of the joint. A deep injection from there as far as the periosteum is always without risk, even if we pass the needle through nerves, vessels, and joint capsules, and even intra-arterial injections are harmless and are often extremely desirable. Since, in giving such injections, we are carrying out segmental therapy, a substantial improvement is all that is required to justify repetition.

Indications: Arthritis, arthrosis, gout, all post-traumatic symptoms and partial stiffening of the joint, recurrent effusions.

Overview

The joints listed below will be covered over the following pages:

Fig. 3.12 Injection into the shoulder joint.

c. Injection from behind: The arm is put slightly into abduction and internal rotation. At the lateral end of the scapular spine the angle of the acromion is easily palpable. We insert one fingers’ breadth caudally from there, advance the needle 20 mm in the direction of the coracoid process, and inject 2–5 ml. After the injection into the joint and before withdrawing the needle, we also distribute 1 mL periarticularly. It is advisable to inject about another 1 mm to the periosteum of the anterior inner part of the humerus immediately below the shoulder joint. In cases of fibrosis of the articular capsule or of contractures, the shoulder blade should be fixed and the shoulder joint carefully mobilized directly after the intra-articular injection. A perceptible crepitus indicates stretching of the capsule. It may be advisable to fit an abduction splint and the treatment should be repeated 2 or 3 days later.

3. Acromioclavicular Joint**

The lateral clavicular joint creates the connection between the lateral end of the scapula (acromion) and the lateral end of the clavicle. It is a ball-and-socket joint with less mobility than the medial clavicular joint. The majority of arm movements are performed using both joints.

Fig. 3.13 The five joints of the shoulder. Right shoulder, anterior view.

Fig. 3.14 Injection into the elbow joint.

6. Elbow Joint*

Materials Size 12 needle.

Quantity 2 mL.

Fig. 3.15 Injection into the wrist joint.

7. Wrist Joint*

Indications Acute trauma, post-traumatic dysfunctions, before mobilizing a stiff joint. Injections to the stellate ganglion, the parts of the → (T) radial, medial, and ulnar nerves that supply the painful area, and/or intra- and periarterially and around the → brachial artery should be performed, before injecting into the wrist joint or the joints of the fingers.

Materials Needle: 20 × 0.4 mm.

Quantity 1–2 mL.

Fig. 3.16 Injection into the hip joint according to Kibler.

9. Sacroiliac Joint**

Fig. 3.17 Injection into the hip joint.

1. From the front: the entry site is two fingers’ breadths laterally from the pulsating femoral artery on a line connecting the symphysis and the upper edge of the trochanter. Go down vertically until bone contact is established, slightly withdraw the needle, then inject.

2. From the side above the trochanter major.

3. Injection to the trochanter major.

Materials 0.8 mm diameter × 60–80 mm-long needle. Skin disinfectant.

Quantity 2 mL.

Technique The patient stands with his or her trunk bent slightly forward. The joint space is found by inserting the needle three fingers’ breadths from the spinous process of S1 and advancing it at an angle of 45° to the skin in the direction of the sacroiliac joint. The neural-therapeutic preparation is distributed at a depth of 30–50 mm. A second injection is then given about two fingers’ breadths in a caudal direction into the irregular articular space and into the interosseous ligament. Thus, in Figure 3.18, the syringe should be moved to the left after entry, to enable the point of the needle to slide past the posterior iliac crest in a lateral direction to the right into the articular space. Since the periosteum of the iliac bone is generally sensitive to pressure at the same time, it is usual to inject a few tenths of a milliliter laterally to the periosteum at the same time.

10. Knee Joint**

Indications Arthritis or arthrosis of the knee, recurrent effusions of the knee joint, pain following surgery or dislocation of the knee joint, injuries to the cruciform ligaments or the cartilages (unless surgery is required).

Fig. 3.18 Injection into the sacroiliac joint (auxiliary line for orientation).

Materials 0.8 mm diameter × 35 mm-long needle.

Quantity 2 mL.

Technique The patient lies relaxed on his or her back. The knee is slightly bent by being supported on a roll cushion. The patella is now pushed slightly laterally and, after skin disinfection, the needle inserted almost horizontally on the medial edge of the lower third of the patella in such a way that it will slide behind the patella into the joint. If it is guided correctly, the needle will have no resistance to overcome. After the injection the patient is generally immediately capable of pain-free weight-bearing on the knee. The treatment should be repeated after 3– 6 days, later at longer intervals. → (T) quaddles round the knee, including one in the popliteal fossa and especially on the inner aspect of the knee can further increase the effectiveness of this treatment.

Another way into the knee is through the popliteal fossa. With this infiltration we also affect the popliteal vein and artery and the tibial nerve.

An additional safe technique leads to the suprapatellar bursa that generally fills an indentation in the joint space and, thus, has contact to the joint. After disinfecting the skin, a 40 mm-long needle is inserted two to three fingers’ breadth superior to the proximal edge of the patella. When reaching the bone, the needle is slightly withdrawn and 2 mL are injected into the bursa.

Fig. 3.19 Injection into the knee joint.

Fig. 3.20 Injection into the knee joint.

Fig. 3.21 Injection from behind into the ankle joint.

11. Ankle Joint*

Materials Size 12 needle.

Quantity 1–2 mL.

Technique

Indications

1. Segmental therapy: Acute or chronic otitis media, otitis externa, deafness of the inner ear, tinnitus and other noises in the ear, vestibular vertigo. In acupuncture, this point is also used for rhinitis and sinusitis; a needle set here immediately eases nasal breathing.

2. Interference-field search: As a test injection, if the patient’s history suggests ear complaints.

Contraindications This treatment must not be used in chronic otitis media if there is any cholesteatoma or severe damage to the middle ear, which always require specialist treatment!

Materials About a size 12 needle.

Quantity 0.5 mL each.

Fig. 3.22 Injection to the mastoid process.

Fig. 3.23 Injection to the mastoid process.

Anatomy The maxillary tuberosity is a protrusion on the dorsal part of the infratemporal area of the upper jaw, containing three to four foramina for the alveolar nerves. Anesthesia of this tuberosity blocks the upper posterior molars, those branches of the maxillary nerve that supply the maxillary cavity, and the buccal mucosa above the teeth.

The maxillary nerve (second trigeminal branch) is a sensory nerve. It passes the foramen rotundum and travels down to the pterygopalatine (sphenomaxillary) fossa where it branches out. It innervates the skin of the maxillary region, the mucosa of the posterior paranasal sinus and palate, and the gum and teeth of the upper jaw.

Indications With an injection to the round protuberance at the backside of the maxilla we block those branches of the maxillar nerve (superior, posterior alveolar nerves) that supply the upper posterior molars and the maxillary cavity:

1. Segmental therapy: Disorders affecting the para-nasal sinuses and ethmoid bone.

2. Interference-field search: Test injection when the paranasal sinuses are suspected as an interference field.

Materials 0.8 mm diameter 80 mm-long needle.

Quantity 1 mL procaine solution.

Technique

a. Using a spatula or fingers, the cheek is pulled forward. The degree of the acute angle between needle and skin should be as great as possible. The needle is inserted directly behind the bony ridge between the zygomatic bone and the first molar or the anterior edge of the second molar. Applying plunger pressure and maintaining contact to the bone, the needle is advanced posteriorly and superiorly for another 30 mm. Bone contact has to be maintained and, before injecting, aspiration is necessary to prevent injection into the venous pterygoid (sphenoid) plexus.

b. A further means of reaching the trunk of the maxillary nerve is the injection to the → (T) pterygopalatine ganglion from the mouth.

c. A simple injection to the maxillary nerve: The entry point is half a fingers’ breadth above the anterior quarter of the zygoma. The needle is inserted behind the zygoma and is then directed steeply down toward the center of the floor of the mouth, to a depth of 20 mm, l–2 mL being injected.

Anatomy: With the injection into the lower and middle nasal conchae we reach the posterior nasal nerves that originate in the second trigeminal branch, parasympathetic fibers of the → (T) pterygopalatine ganglion, and sympathetic fibers of the → (T) upper cervical ganglion. They travel together to the nasal mucosa.

Indications

1. Segmental therapy: Disorders affecting the sinuses and ethmoid.

2. Interference-field search: Whenever there is a suspected interference field in the region of the nose or sinuses.

3. Reflex-zone therapy: Especially for therapy-resistant bronchial asthma, angina pectoris, headaches, and dysmenorrhea.

Reflex zones W. Fliess was the first to report about treatment of dysmenorrheal and nervous gastric disorders through anesthesia of the nasal concha. The Frenchman Leprince established that there are four areas of mucosa that act as reflex zones for the following organs:

• zone 1: urogenital zone: anterior third of the lower nasal concha; influence on uterus, ovary, ureter, anal and bladder sphincters;

• zone 2: solar plexus zone: middle portion of lower nasal concha; influence on stomach, liver, gall-bladder and gut;

• zone 3: cervical zone: posterior (i.e., inner) third of lower nasal concha; cervical syndrome, dizziness, tinnitus, anxiety states, migraine;

• zone 4: pulmonary zone: anterior portion of middle nasal concha; asthma, pulmonary emphysema.

Materials 0.8 mm diameter 60–80 mm-long needle.

Quantity 0.5 mL.

Fig. 3.24 Injection into the nasal conchae: access to the pterygopalatine ganglion from the buccal cavity.

Anatomy With a nasal spray we are able to reach the posterior nasal nerves, parasympathetic fibers of the → (T) pterygopalatine ganglion, and sympathetic fibers of the → (T) upper cervical ganglion, which travel together to the nasal mucosa.

Materials Procaine cannot be used for anesthesia of the mucosa surface! Instead, 3–6% (!) lidocaine solutions are used, for example, Xylocaine spray. Gingicaine M (tetracaine) and 2% pantocaine must not be used in the case of para-group allergy. Anyone who does not possess a spray of any kind (including a pocket aerosol) can easily improvise with a spray-diffuser.

Indications For stopping acute rhinitis and sinusitis, chronic catarrh of the upper respiratory tract, dry irritative cough, silicosis, the start of influenza, certain forms of headache, and vasomotor dysregulatory disorders in the head (for example → cluster headache), dysmenorrhea, hiccoughs; also worth trying in rheumatoid spondylitis (Bechterew disease), asthma and angina pectoris. Also, for mobilizing the body’s own production of ACTH, e.g., in antibiotic-resistant pneumonia.

According to F. Huneke, “anesthesia of the nasal and oral mucosa has its own range of indications and can sometimes still lead to success when injection has proved a failure.” Anesthesia of the conjunctiva can alleviate the pain of ciliary neuralgia, and anesthesia of the eardrum can eliminate the onset of otitis media or mild tinnitus. Stubborn dry cough can be helped through surface application of a local anesthetic to the pharynx or the use of an anesthetic spray. Applying spray to the mucosa has an analgetic effect on injection points for testing teeth, eliminates the gag reflex in tonsil injections, removes pain from stomatitis and gingivitis, and allows these inflammations to heal faster. Knothe noted that some of the modern surface anesthetics (for example, Gingicaine and Xylestesin spray) also disinfect the mucosa.

Technique We use an anesthetic suitable for the mucosa, such as a 2% Pantocaine solution or Gingicaine, and spray this on the nasal conchae and directly on the upper posterior pharyngeal wall into the vicinity of the pterygopalatine ganglion.

Often, simple surface anesthesia of the reflex zones inside the nose, using a cottonwool swab (on a stick) dampened with 2% pantocaine or 1–4% Xylocaine solution (e.g., Xyloneural), is all that is necessary. The swab should be left in place for 3– 5 minutes. Leaving it longer does not increase the anesthetic effect.

The perforation of a nerve produces an electric pain and radiates into the area supplied by the nerve, but does not usually persist. If the pain does persist, it disappears within a few days. After we have had to search blindly, the appearance of paresthesia shows us that the needle is in the right place.

Warnings have been given against endoneural injections of pharmaceutical preparations, because nerve lesions have been observed. But this does not apply to the use of local anesthetics (without additives!). “For the relief of certain painful syndromes, injections of Novovaine (procaine) can be given into the nerves without hesitation. The risk is so small as to be negligible and need not trouble us” (Leriche). Slow infiltration with constant plunger pressure reduces the amount of fluid that travels in front of the tip of the needle. This lowers the risk that this fluid damages smaller nerves and vessels as it pushes tissue aside.

There is one possible complication, however, that must be taken into account: the tip of the needle may become bent due to bone contact and form a barb, which can cause mechanical damage to a nerve when the needle is being withdrawn. We therefore use only sharp disposable needles, which are immediately replaced after brusque bone contact. Though injuries to the nerve cable caused by the needle generally do not produce loss of function, Killian recommends avoiding intraneural injections. Anesthetic deposits should be placed directly next to nerves only. Therapeutic injections into the trigeminal ganglion and the sciatic nerve he lists as exceptions to this rule.

1. Nerve-Exit Points on the Head

Overview

The nerve-exit points listed below will be explored over the following pages:

Fig. 3.25 Injection to the lateral supraorbital nerve.

Fig. 3.26 Injection to the supraorbital nerve.

Fig. 3.27 Injection to the infraorbital nerve.

Fig. 3.28 Injection to the infraorbital nerve.

Indications Trigeminal neuralgia, facial pains, furuncles of the cheek, disorders affecting the maxillary sinuses, supramaxillary “rheumatic” pain in the absence of pathological dental findings.

Materials Short, medium thick needle (size 12–16).

Quantity 0.5 mL.

Technique

Indications Disorders of the tongue, all diseases of the mucous membranes and pain in the area that is supplied, Sjoegren’s syndrome.

Materials Cartridge syringes or a needle (size 20).

Quantity 1–2 mL.

Technique We place a 1–2 mL submucosal deposit at the lingual side of the mandible, between wisdom tooth and tongue.

1f. Injection to the Palatine Nerves*

Indications These are given by the area supplied by this nerve: the greater palatine nerve supplies a fan-shaped area forming the greater part of the mucosa of the hard palate (excluding the area of the incisors); the minor palatine nerves supply the mucosa of the soft palate. All nerves contain sensory and secretory fibers.

Materials Size 14 or 16 needle or a corresponding needle for a cartridge syringe.

Quantity 1 mL procaine solution.

Indications Pain and dysphagia, especially in carcinoma or tuberculosis of the larynx, or in neuralgia, hoarseness, whooping cough.

Materials 0.8 mm diameter × 60 mm-long needle.

Quantity 5 mL.

Fig. 3.29 Injection to the superior laryngeal nerve.

Fig. 3.30 Section of the neck at the level of the cervical plexus.

2. The Cervical Plexus

Overview

The injections listed below will be covered in the following pages:

Fig. 3.31 Injection to the cervical plexus.

Materials 40 mm-long needle.

Quantity 2 mL.

The technically easier injection to the superficial branches of the superficial cervical plexus is preferable to the paravertebral block of the deep cervical plexus described above and, in many cases, this will be perfectly adequate, especially where the deep injection poses problems in patients with a short, stout neck.

Anatomy and indications See 2a. Injections to the Roots of the Cervical Plexus.

Technique The superficial branches of the cervical plexus surface directly behind the sternocleidomastoid muscle at a point that is called punctum nervosum. We find this point when we draw a line connecting the attachments of the sternocleidomastoid muscle to the mastoid and the clavicle. Bisect this line and insert the needle here, on the posterior edge of the muscle. At a depth of 10–20 mm we inject an area of 20 30 mm with 5 mL of a local anesthetic, while checking constantly through aspiration.

2c. Injection to the Phrenic Nerve*

Anatomy The phrenic nerve is the lowest branch of the cervical plexus. Its extrathoracic path runs between the sternocleidomastoid and the anterior scalene muscle. The left-hand phrenic nerve is preferred for this injection. It runs laterally from the aortic arch, pas- ses downward outside the pericardium to the diaphragm. The phrenic nerve transmits organic pain in disorders affecting the cardiac and abdominal regions to the shoulder, neck, and upper arm.

Indications Stubborn hiccoughs, severe pain radiating to neck and shoulders in organic abdominal and thoracic disorders; also worth trying in cases of diaphragmatic hernia.

Materials 0.6–0.8 mm diameter 40 mm-long needle.

Quantity 2–5 mL.

Technique Caution: Never anesthetize bilaterally in the same session, because this would lead to total paralysis of the diaphragm! The patient turns his or her head away from the side of the injection and inclines it towards the injection. This relaxes the sternocleidomastoid muscle. The point of entry lies on the lateral edge of the muscle, about 25 mm above its attachment to the clavicle. The sternocleidomastoid muscle is held between thumb and forefinger immediately above the clavicle and is drawn in a medial direction, in order to force the carotid artery away from the phrenic nerve. The anterior scalene muscle can now be felt deeper down. The needle is then advanced under the drawn-away sternocleidomastoid muscle at right angles to the long axis of the body, i.e., almost parallel to the clavicle, obliquely in a medial direction, to a depth of about 30 mm. The finger lying medially on the sternocleidomastoid muscle is used to check the position of the needle as its point penetrates through the scalene notch at a sufficient distance from the trachea and esophagus. The injection is administered only after a negative aspiration test in two directions.

3. Upper Extremities

Overview

The nerves and techniques listed below will be discussed in the following sections:

Fig. 3.32 Injection to the accessory nerve.

Fig. 3.33 Injection to the suprascapular nerve.

3c. Injection to the Brachial Plexus C5 to T1**

Anatomy The brachial plexus has five different roots of different strength. They travel through the cranial part of the space between the scalenes, along the lateral triangle of the neck, downward between the first rib and the clavicle, and into the armpit, where they form three fascicles around the axillary artery. From the posterior fascicle, the radial and axillary nerve originate; from the lateral fascicle, the musculocutaneous nerve and the lateral roots of the median nerve originate. The medial roots of the median nerve, the ulnar nerve, and both superficial branches of the ulnar nerve of the upper arm and forearm originate from the medial fascicle.

Supraclavicular Plexus Anesthesia

Materials A thin 40 mm-long needle.

Quantity 2 mL.

Technique The patient is seated on a chair with a neck support. The head is turned to the side opposite the injection and bent slightly forward. Before the needle enters, he or she must be warned to expect paresthesia, to avoid reflex defensive movements.

Fig. 3.34 Anatomy and position of needle in the subclavian injection to the brachial plexus.

Axillary Plexus Anesthesia

Alternative terminology Axillary block.

This method is not so suitable for adipose patients, but it is absolutely foolproof. Palpate along the upper arm along the brachial artery toward the armpit to the point where the pulse is still just perceptible. A total of about 5 mL of procaine is now infiltrated above and below the artery. By this means, it is possible to reach the median, ulnar, radial, and musculocutaneous nerves. The correct location of the needle is shown by paresthesia in the distribution area of the three principal nerves for the arm and hand. Do not inject if no paresthesia is produced! The rapid draining of the anesthetic solution toward the periphery can be avoided by using a tourniquet. Intra-arterial injection of the brachial artery is not dangerous. Larger hematomas are avoided by pressing a cotton pad on the point of insertion for 1 minute.

Other Methods

See also → (T) stellate ganglion, method according to Dosch, for other means of reaching the upper parts of this plexus from the cervical region.

Anatomy The radial nerve (C5 to T1) is located dorsally to the axillary artery, in the armpit. From there it spirals laterally around the posterior part of the humerus. In front of the lateral epicondyle it splits into the superficial and the deep branch. Its motor fibers supply the extensors of the upper arm and the forearm, the brachioradialis and the supinator muscle. Its sensory fibers supply the periosteum of radius and ulnar, the radial part of the back of the hand, thumb, index finger, and the radial side of the middle finger, except their distal phalanges. Paralysis of the nerve causes wrist drop.

Indications Disorders of the hand in the area supplied by the radial nerve.

Technique

a. Above the elbow, we can find the radial nerve by setting a → (T) quaddle four fingers’ breadths in a proximal direction of the lateral epicondyle and inserting the needle through this perpendicularly to the skin. At this point the radial nerve runs parallel to the humerus. When the nerve is touched, the patient reports electric pains in the thumb and back of the hand. If we fail to find it immediately, we continue until bone contact is obtained and distribute up to 5 mL up and down along the bone.

b. If only the superficial branch is supposed to be affected, feel for the pulse of the radial artery about three fingers’ breadths above the carpal sulcus. The needle is inserted radially of the artery. There would be no danger in an intra-arterial injection of up to 2 mL here. As always, we infiltrate as we advance the needle until the patient reports paresthesia and then deposit 1–2 mL at that point.

c. We block the area supplied by the branches of the superficial radial nerve by distributing 1– 2 mL procaine or lidocaine solution in the dorsoradial region of the wrist at snuffbox level.

3e. Injection to the Median Nerve*

Anatomy In the neurovascular sheath, the median nerve (C5 to T1) travels downward, along the inside of the upper arm, in the medial bicipital sulcus, which is next to the brachial artery. On the flexor side of the elbow joint, it is located medially to the brachial artery. From there, it crosses in between the two heads of the pronator muscle, remains on the palmar side of the forearm, and reaches the palm through the carpal tunnel. Its motor fibers supply the flexors of the forearm (except the flexor carpi ulnaris and the ulnar part of the flexor digitorum profundus), the pronators of the forearm, the muscles of the thenar eminence (except the adductor pollicis muscle), and the lumbrical muscles. Its sensory fibers innervate the radial part of the wrist and palm, and the first three-and-a-half fingers. Paralysis of the median nerve causes benediction hand.

Indications For disorders of the hand (pain, paronychia, whitlow, vasospastic symptoms) in the area supplied by the median nerve; see → carpal tunnel syndrome. Other pressure damage through tourniquets, narcosis paralysis, and paravenous injection can occur. Try in cases of → writer’s cramp.

Technique We find the median nerve in the antecubital fossa in an ulnar direction from the pulsating brachial artery. In the region of the wrist two tendons are tensed and clearly visible in volar flexion of the hand: the tendon of the palmaris longus muscle and directly radially to it the one of the flexor carpi radialis muscle. The needle is inserted distally, no more than 20 mm deep, between the two tendons, on the level of the ulnar styloid process, into the carpal tunnel. If the tendon of the palmaris longus muscle is missing (which is the case in 25% of people), the needle is inserted radially to the one existing tendon. As soon as paresthesia occurs in the median region, we infiltrate 1–2 mL of local anesthetic.

In patients presenting with a carpal tunnel syndrome, no more than a few tenths of a milliliter (0.1–0.3 mL) should be injected, in order not to exert yet more pressure on a nerve already damaged by compression. In such cases it is preferable to find this nerve further away from the point of constriction, about three fingers’ breadths above the intraarticular space.

3f. Injection to the Ulnar Nerve*

Anatomy The ulnar nerve (C8 to T1) perforates the medial intermuscular septum approximately one hand’s breadth proximally to the elbow joint. This brings it from the medial bicipital sulcus to the extensor side of the arm. It is located behind the medial epicondyle, directly between bone and skin. Pressure applied over this point easily causes paresthesia to the area that is supplied by this nerve (funny bone). From here, while covered by the flexor carpi ulnaris muscle, which it supplies, it wraps around to the tensor side. Along this way it sends a muscle branch to the ulnar part of the flexor digitorum profundus, one skin branch to the skin of the hypothenar, and one skin branch to the skin on the back of the hand and its fingers.

Indications Disorders affecting the area supplied by this nerve (flexor carpi ulnaris muscle, parts of the ulnar digital muscles, and skin areas in the region of the forearm and fingers), complaints of cyclists and motorcycle racers after long rides; see also → scalene syndrome.

Technique

a. Between the medial humeral epicondyle and the olecranon lies the ulnar sulcus, which can be readily located by palpation. The ulnar nerve can be easily anesthetized in this sulcus, at a depth of 10–20 mm.

b. The nerve can be found if the needle is inserted about three fingers’ breadths above the wrist joint between the ulnar artery and the tendon of the ulnar flexor muscle of the wrist, which lies in an ulnar direction from the artery. When we have produced paresthesia, we inject 1–2 mL procaine.

4. Lower Extremities

Overview

The injection techniques listed directly below may be found on the following pages:

Fig. 3.35 Injection to the lateral cutaneous femoral nerve.

Fig. 3.36 Injection to the obturator nerve. Anatomical relationships and position of needle.

4c. Injection to the Obturator Nerve**

Anatomy The obturator nerve (L2 to L4) reaches the thigh via the upper part of the obturator foramen. It supplies parts of the hip joint, the adductors, the gracilis muscle, and parts of the knee joint. It terminates in the medial cutaneous femoral nerve and provides the sensory fibers to the inside of the thigh.

Indications Arthrosis of the hip and knee, neuralgia of the obturator nerve, adductor spasms, gracilis syndrome.

Materials 1 mm diameter 80 mm-long needle.

Quantity About 5 mL.

Fig. 3.37 Injection to (a) tibial and (b) sural nerves.

1. Sural nerve

2. Tibial nerve

3. Posterior tibial artery

4. Small saphenous vein

Fig. 3.38 Injection to (c) fibular and (d) saphenous nerves.

1. Saphenous nerve

2. Deep fibular nerve

3. Superficial fibular nerve

4. Great saphenous vein

b. Sural nerve: This nerve is formed by the junction of a branch of the tibial nerve with the common fibular nerve; it supplies the heel and the adjacent part of the sole of the foot. It is reached by the subcutaneous infiltration of about 2 mL procaine into the region between the Achilles tendon and the lateral malleolus.

c. Superficial fibular nerve: If we wish to treat the dorsum of the foot as far as the toes (with the exception of the lateral half of the big toe and the adjacent half of the second toe, which are innervated by the deep fibular nerve), we locate the superficial fibular nerve subcutaneously, at the level of the ankle joint, between the anterior edge of the tibia and the lateral malleolus. There we distribute about 2 mL.

Fig. 3.39 Injection to the pudendal nerve. Diagram of perineal and transvaginal methods.

Alternative terminology Nerve block of thoracic or lumbar spinal nerves, paravertebral root block; lower lumbar paravertebral anesthesia to the area of the sciatic root (→ (T) sciatic nerve), according to Reischauer.

Anatomy When entering the intervertebral foramen, coming from the spinal canal, the fibers of the anterior motor roots unite with those of the posterior sensory roots, forming in the intervertebral foramen the short trunk of the segmental nerve with (functional part of the posterior root) the spinal ganglion. Liquor space and dura end here. The dura turns into the perineural sheath of the peripheral nerves. Directly at the exit point from the intervertebral foramen, the trunk of the segmental nerve divides into four branches:

• the anterior branch for muscles and skin of the anterior and lateral wall of the trunk of the body;

• the posterior branch for the autochthonic muscles of the back and one area of skin of the back;

• the thin meningeal branch (sinuvertebral nerve), that runs along spinal canal; and

• the (sometimes divided) white communicating branch that runs to the sympathetic trunk and sends off the gray communicating branch, which connects with the nerves that travel to the wall of the trunk.

Beginning at T12, the anterior branches are part of the formation of the lumborsacral plexus and serve primarily the supply to the legs. If the segmental nerve is temporarily blocked at the point of its exit from the intervertebral foramen, all fibers of the segment are blocked.

Indications

“Pelvic region” is no anatomical terminology. We use it to describe the functional and pathogenetic unit of uterus, adnexa, and bladder.

Indications:

1. Segmental therapy: Endo- and parametritis, dyskinesia of the genital organs, dysmenorrhea, menorrhagia and metrorrhagia, non-specific vaginal discharge, cervical catarrh, abdominal pain and backache, autonomic pelvic disorders, sensation of pressure without prolapse; also in constipation and meteorism, dyspareunia, neuritis of the pelvic floor, vomiting in pregnancy, menstruation-related disorders (such as headaches, migraine, mastodynia, exacerbation of skin disorders such as acne or facial dermatitis, abnormal irritability or depressive moods), genital pruritus, sterility, and frigidity, insofar as these disorders are segmental in origin and not due to an interference field. In many cases, we give additional injections into the → (T) thyroid.

2. Interference-field search: As a test injection in extragenital disorders of all kinds, if the patient’s history includes genital disturbances, discharge, abortion, D&C, termination of pregnancy, difficult labor, gonorrhea, pelvic inflammatory disease; also, surgical operations of all kinds involving the external and internal genitals. Even normal delivery can result in an interference field, since enlargement of the uterus leaves histologically ascertainable scars from aseptic necroses. In a surprising number of cases one finds that interference-field disorders originating in the genitals tend to occur after the second labor (Speransky’s second insult or trigger factor).

Contraindications None! Menstruation is a physiological process, not a contraindication.

Materials 0.8 mm diameter × 60–90 mm-long needle.

Quantity Two doses each of 1–2 mL.

Technique Preceding the first injection, the patient requires thorough gynecological examination because the technique might have to be adjusted to the palpation findings (for example, prolapse of uterus and vagina, myomatous uterus, adnex tumors such as large cysts, etc.). The routine examination also includes palpation of the posterior symphyseal walls, the entrance points of the → (T) pudendal nerve at the ischial spine, and rolling of an abdominal fold to locate hyperalgesic points of the peritoneum (→ (T) preperitoneal infiltration). Because scars in the segment have to be injected as well, one has to search and inquire about possible impalement traumas and episiotomy scars, vaginal tears (forceps, coital injuries, stupration), surgery scars, vaginal cysts, Bartholin’s abscess, episioperinioplasty, portio surgery, cervical tear, hysterectomy scars, etc.

Fig. 3.40 Injection into the pelvic region.

In neural therapy according to Huneke this method is used only very rarely. It should be reserved for hospital use. However, it is mentioned here for the sake of completeness, since it will enable the practiced neural therapist to use a single injection to reach several segments bilaterally. In fact, in this injection, the anesthetic reaches several pairs of spinal nerves both above and below the injection site as they pass out through the intervertebral foramina. It also acts on the corresponding communicating branches and the ganglia of the sympathetic chain.

Alternative terminology → (T) epidural and peridural anesthesia are synonyms. Thoracic or lumbar epidural anesthesia, extradural spinal anesthesia.

Fig. 3.43 Injection into the peridural cavity, showing paravertebral anesthesia and the injection to the sympathetic chain.

Ponndorf’s vaccination is a non-specific irritation therapy. It has proved its worth as a complement and reinforcement of procaine therapy, which, in its effect, is oriented in a similar direction, and its more frequent use can therefore be recommended. Vaccination in the segment can further increase the effectiveness of local therapy by producing additional hyperemia and local relaxation. Such tonus-reversant treatment can cause stubborn chronic conditions to revert to a state where they will again respond to therapeutic measures if it is possible to unblock blocked control circuits and thus to return the reactive response to normal. Ponndorf’s vaccination is one of the means available for this purpose. By a general reversal of tonicity, even desensitization, defensive capabilities are mobilized, which may break through an existing reactive weakness and make the organism again capable of responding to segmental treatment. However, in disorders due to interference fields, Ponndorf’s vaccinations in the segment will not produce any improvement.

Indications All forms of muscular and articular rheumatism, particularly primary chronic polyarthritis; arthrosis deformans, gout, neuralgia, neuritis, and general indications for irritation therapy such as asthma, hay fever, dysmenorrhea, chronic mucous-membrane catarrh, chronic eczema and dermatitis, provided that they are not due to an interference field.

Contraindications Tuberculosis, cachexia, severe renal disease.

Materials Special vaccination fork or a normal vaccination lancet; the point of a needle or an ampoule file will also do. Koch’s old tuberculin or Cutivaccine Paul Novum.

Technique We use undiluted Koch’s old tuberculin or Cutivaccine Paul Novum. The latter consists of an autolysate of bacterium subtilis with the addition of a mixture of tuberculin and glycerine.

Over particularly painful joints or areas of skin or muscle, the skin in the segment is scratched quite superficially with the vaccination instrument or the point of an ampoule file, as for a smallpox vaccination, i.e., only in the epithelium and without causing any bleeding, so that the capillary blood can just be seen showing through. We make four or five scratches over the chosen area, 10–20 mm apart and about 50 mm long, and rub in one to five drops of undiluted old tuberculin or Cutivaccine Paul Novum until dry. No bandage is necessary, but if required some gauze or cellulose wadding may be placed over the vaccination site and secured with adhesive plaster. The vaccination site must not be washed for 2 or 3 days! The vaccination is repeated at intervals of 1–2 weeks, depending on the reaction produced, and of 4 weeks at a later stage, for a total of from five to 10 vaccinations. If the reaction is negative, the vaccination area may be increased when the treatment is repeated.

The symptoms of this provocation can be anything from slight itching to pain ranging from slight to severe, and may include urticaria and skin inflammation. There may be a general reaction, such as feeling unwell, headaches; more rarely, shivering and fever. But these disappear without further treatment within 24 hours (if necessary, an analgesic may be given). The more severe the reaction, the better the effect. Blisters and papule formation, which may produce superficial necroses, are extremely rare. If there is a severe reaction, first wait for the symptoms to disappear before repeating treatment, and in that event the area of skin subjected to the vaccination should not be increased but possibly even reduced somewhat. The second vaccination generally produces the strongest reaction.

Anatomy The periosteum is a tight connective tissue membrane that covers the bone (except the joint part covered with cartilage). It is rich in nerve and blood vessels. Its inside contains osteoblasts, which are cells involved in bone formation. The neural tissue of the periosteum has many receptors that can affect the corresponding segment and the vegetative regulation through osteovisceral reflex pathways. This can be influenced through periosteum massage (Vogler, Krauss) and procaine or lidocaine injections to (not under!) the periosteum.

Materials The length of the needle depends on the depth of the intended periosteum injection, i.e., 20– 60 mm long.

Quantity 1–5 mL of a local anesthetic. Indications Pain of the periosteum can be the result of mechanical muscle overexertion and indicate a chronic inflammatory irritation. It can also indicate disturbances within the segment. Every irritation of the periosteum can produce pseudoradicular pain:

1. Segmental therapy: Perisostitis, periostoses, osteomyelitis, fractures, Sudeck’s dystrophy, headache, ear disorders, spinal pain such as cervical, thoracic, lumbar spine syndrome, angina pectoris, intercostal neuralgias, coxalgias, and many more.

2. Interference-field search: Conditions following periostitis and fractures, which are not pain-free, osteomyelitis, etc.

If we find pressure-sensitive points on the periosteum during palpation, they have to be anesthetized with preperiosteal infiltrations. This way, we can interrupt pathogenic interactions between periphery and underlying organs. Periphery and organs are connected not only through blood circulation but also through neural and humoral pathways which can be used to initiate functional and reactive changes in underlying organs. This has been confirmed by experiments.

Anatomy The perietal peritoneum covers the walls of the abdominal and pelvic cavities with a serous membrane. Abdominal organs do not possess sensitive mechanosensory innervation. Pain transmission takes place via vegetative fibers of the splanchnic nerves and the celiac ganglia or other corresponding ganglia and nerves. The peritoneum receives sensory innervation from the nerves of the truncal wall. The pain-conducting nerve fibers of the organs in the peritoneal cavity run together with the sympathetic fibers of those organs. The conducted pain manifests itself in the Head’s zones. The highly sensitive parietal peritoneum can show signs of intra-abdominal regulation disorders and inflammations, which we can locate through palpation and feedback from the patient. Due to positive reactions following our injections to hyperalgesic points in the abdominal wall, we can conclude that we can interrupt pathogenic feedback of visceroperitoneal and peritoneovisceral pathways through anesthesia. After proper repetition, the feedback can be regulated.

The list of indications includes all inflammatory and autonomic dysregulation of abdominal organs, also mucous and ulcerous colitis, diverticulitis, frigidity, etc.

Contraindications All acute surgical indications, for example acute → appendicitis and conditions without sufficient differential diagnostic findings.

Materials Needles have to be chosen according to the thickness of the abdominal wall.

Quantity 2–5 mL.

Fig. 3.44 Rolling of the abdominal fold.

Alternative terminology Parasacral anesthesia (Braun, Pendl).

Anatomy The sacral nerves S1 through S4 issue from the vertebral foramina of the sacrum and form part of the lumbosacral plexus. They also provide parts of the pudendal plexus. When we block the sacral nerves and infiltrate around the coccyx and in an anterior direction next to the anus and perineum, we anesthetize the anus, anal sphincter, rectum, perineum, urethra, and bladder. Further, in men, the penis, scrotum, and prostate are also anesthetized, whilst in women it is the vaginal introitus and vagina, the uterine cervix, the pelvic floor, the parametria, and part of the pelvic peritoneum. According to Killian, the presacral infiltration is part of the paravertebral anesthetic blocks.

Indications The indications are given by the anatomy: disorders involving the rectum, anus, perineum, bladder, and urethra; pruritus of anus and vulva, gynecological disorders, prostate, constipation due to rectal atony, sciatica, intermittent claudication, varicose ulcer, and other circulatory disturbances affecting the lower extremities, lumbago with non-specific origin.

Materials l mm diameter × 120–150 mm-long needle.

Technique The knee-elbow position is felt by some patients to be indecent; it is not absolutely essential for this injection. It will suffice for the patient to stand hard up against a table, bend their trunk forward at right angles and place it on the table. To avoid damage to the intestines, the neural therapist with little practice in giving this injection should introduce the gloved and lubricated left forefinger into the patient’s rectum in order to control the needle; with a little practice this precaution can be omitted.

Fig. 3.45 Presacral infiltration according to Pendl (topography).

Fig. 3.46 Presacral infiltration according to Pendl.

Anatomy In men, the pelvic plexus supplies anus, urinary bladder, and genitals through the vesical, deferential, and prostatic plexi and the cavernous nerves of the penis. Bradley showed that the prostate capsule (in women the vesical trigone at the base of the bladder) contains receptors that generate afferent sensory impulses. They regulate the Barrington reflex arch between muscles that allow the bladder to fill and empty. In order to regulate disturbances that originate at this point, injection to the prostate capsule is sufficient.

Indications

1. Segmental therapy: Adenoma of the prostate, acute or chronic prostatitis (prostatism), non-bacterial prostatopathy, micturition problems (such as dysuria, nocturia, pollacisuria, urge incontinence), therapy-resistant anal pruritus, proctitis; also to be tried in sexual disorders and irritable bladder, for example, after extensive transurethral resection up to the capsular area.

2. Interference-field search: As test injection, if the patient’s history includes gonorrhea, prostatitis, epididymitis, non-specific urethritis, and the like, but especially if he has to get up several times a night to urinate or reports corresponding micturition difficulties. In geriatrics, patients often report spontaneously that after procaine treatment of the prostate they feel younger and more efficient, and that rheumatic symptoms, coronary spasms, and other secondary symptoms have disappeared following treatment.

Contraindications Carcinoma in the area of the urinary tract, tuberculoses of the genitourinary tracts, inflammatory, degenerative, and traumatic disorders of the central regulating mechanisms of the central nervous system, and diseases of psychological origin.

Technique

Fig. 3.47 Injection into the prostate. The needle is guided from the perineum directly into the prostate, under digital control from the rectum.

b. The retropubic approach: If for anatomical reasons such as ankylosis of the hip an injection into the prostate is not possible, we inject (as in the injection into the → (T) pelvic region) to the upper edge of the pubic ramus and then deeper in a mediocaudal direction towards the prostate. When the point of the needle enters the gland, the patient reports a pain radiating to the glans penis.

If one makes use of the alternative retropubic technique by introducing the needle behind the center of the symphysis and guiding it parallel to the posterior wall of the symphysis in a caudal direction, it will reach the middle lobe of the prostate. In older patients, this often hypertrophies on its own.

The different prostate injections may also be given alternately and one then asks the patient to report on which has been the most effective in his particular case. In patients who have undergone prostatectomy, an injection into the prostatic bed will show whether this deep surgical scar is acting as an interference field.

Quaddle therapy is the best-known and most practiced form of neural therapy. It is quite effective, but usually only the initial treatment followed by additional injection techniques. If the therapist is content with this option and its results only, he or she misses greater success that results from the advanced techniques. Nobody drives a car in first gear only!

The skin is the human being’s largest and functionally the most versatile organ. “There is no disorder which can be cured without the skin playing its part” (Hufeland). Tracing back human development, epidermis, nervous system, and sensory organs originate in the ectoderm. This could explain why drugs acting on the nervous system have such an affect on these systems.

The techniques listed below will be covered in the following pages:

Fig. 3.49

1. Intracutaneous quaddle

2. Injection through a quaddle into a fibrositic nodule

1. Scalp

Fig. 3.50 Quaddles to the pelvic region.

6. Quaddles in the Pelvic Region

We distribute about four quaddles over the ventral Head’s zones of the pelvic region, i.e., over the area of the bladder and the mons pubis, for gynecological disorders such as vaginal discharge, dysmenorrhea, endoand parametritis, pelvic inflammatory disease, menoand metrorrhagia, sterility, lack of libido, and disorders affecting the urogenital tract, e.g., inflammatory, functional, and dystrophic symptoms of the bladder, prostate, and renal pelvis.

Fig. 3.51 Quaddles to the sacral region.

In the case of the knee, 2–3 mL of procaine are distributed in five or six quaddles all round the joint, as follows:

• on the outside, one over the joint line;

Fig. 3.52 Injection sites to the lower extremities.

9. Quaddles on the Thigh and Leg

Alternative terminology Trans-sacral infiltration, sacralplexus block.

Anatomy See epidural anesthesia.

Indications Sciatica, sciatica-like pain in carcinoma of the prostate and anorectal metastases, prostate and rectal disturbances, unilateral backache, circulatory dysfunctions of the lower extremities; sphincter spasm of the bladder, coccygodynia.

Materials 60 mm needle.

Quantity 2–5 mL.

Fig. 3.53 Injection to the first posterior sacral foramen.

Indications Headache, vertigo, insomnia, post-concussion syndrome, traumatic epilepsy, cerebral arteriosclerosis, central vasospastic disturbances, diabetes insipidus, paralysis agitans (Parkinson disease), preand post-apoplectic states.

Materials About a size 20 needle.

Quantity 0.5 ml to each side.

Technique For the injections to temples and parietal bone (10 mm superior to the center of the zygomatic arch [TB-22 = GB-3] or four fingers’ breadth superior to the center of the zygomatic arch, but one fingers’ breadth dorsally [ST-1]), one may first set → (T) quaddles bilaterally and then pass the needle through these, or simply insert the needle briskly and let it go down as far as (or into) the periosteum. The more briskly this is done, the less painful it is. If the patient reports other particularly painful points or areas on the skull, then these are proper sites for injection. No blueprint is possible and one should strictly avoid proceeding by rote. It is advisable to palpate the scalp thoroughly before injection and give special attention to any pressure-sensitive points. Amongst these the exit points of the → (T) supraorbital nerve above the eye and of the occipital nerve at the back of the head recur particularly frequently, and are especially important for our treatment.

In acupuncture, for regulating the blood supply to the skull, the needles are set a fingers’ breadth above the center of the cheekbone. From this point it is also possible to suppress menstruation, and injection here during the first 3 days of a period should be avoided or the patient informed beforehand of the effect to be expected.

Reference should also be made here to the hyperalgetic points in the atlas. These are found just in front of and below the mastoid process. Practitioners of manipulative therapy inject about 1.0 mL of procaine to the atlantal processes if their treatment has not succeeded in relieving pain in the atlas.

Fig. 3.54 Injection points on the head, lateral aspect.

Fig. 3.55 Injection points on the head, anterior aspect.

Fig. 3.56 Frequently used points on the back of the head, neck, and shoulders.

Indications:

1. Segmental therapy: All scars in the segment must be injected at the same time! In addition, any symptoms involving scars (itching, rash, inflammation etc.), keloids, post-operative symptoms.

2. Interference-field search: Any scar, of whatever kind and size, no matter how old it is and whether it has healed primarily or secondarily, often proves to be acting as an interference field for chronic disorders at remote sites. In cases of bronchial asthma, eczema, and other diseases that can appear during the first months or first year of an infant’s life, the first scar of every human being, the umbilicus, may be an interference field. This is particularly the case, if the health history lists omphalitis or draining umbilicus for the mother or slow healing of the umbilicus. In Chinese acupuncture, the view is held that a scar forms an obstacle to the vital force flowing through the body, and that this can be eliminated by the insertion of needles.

3. Prophylaxis: Anesthesia of surgical and injury scars, repeated twice or three times as soon as the wound has healed, is the best prophylaxis against their becoming painful and against the formation of keloids and interference fields.

Materials Short needle.

Quantity As required; for hard scars (especially on hands or feet), use a cartridge or locking syringe if possible. To keep the quantity of the neural-therapeutic product as small as possible, it is advisable to inject air into the scar beforehand.

Technique The testing and injection of scars does not present any technical difficulties. Procaine is injected quite superficially into the scar so that something like a confluent weal (→ (T) quaddles) is formed. In the case of a long, narrow surgical scar, we set a line of quaddles about 10–20 mm apart. Sometimes the preparation will run along inside the scar of its own accord, separating the tissue layers along its length so that only very few separate injections will be needed. The two ends of any scar should always be located and treated with terminal → (T) quaddles.

Extensive areas of scarring, e.g., resulting from burns, are preferably separated from the underlying tissue by first injecting air. This not only saves on the amount of procaine required, but also makes it easier afterwards to distribute the injected preparation more evenly over the area of the scar. This can be further helped by making circular massaging movements to distribute the procaine into the parchment-like crepitant skin emphysema. In the case of deeply indrawn scars, it is essential always to inject in depth. In the case of post-operative abdominal scars we go down as far as the peritoneum at one to three points. If the bone is also involved, the injection should include the periosteum; in nerve lesions and following neural surgery, we probe gingerly under continual infiltration for the nerve itself. Paresthesia will disappear following such treatment, and often the nerve function regenerates surprisingly well. There is, however, one exception to the rule: with deeply indrawn scars behind the ear after total mastoidectomy, avoid injecting directly into the crater or, if so, inject only very superficially! Because of the proximity of the meninges, too brusque an approach may produce vomiting and dizziness. In such cases it suffices to infiltrate around the scar in the surrounding area of healthy tissue and to inject to the adjacent periosteum.

In newborns and infants, the umbilical scar can create an interference field, including conditions such as umbilical spasms, colics, dyspepsia, diarrhea, pylorospasm, enuresis, eczema, bronchospasm, chronic rhinitis, restlessness, etc. We place a large → quaddle above the umbilicus and infiltrate 2 mL 10–20 mm deeper and slightly lateral, between the layers of the rectus abdominus muscle. In adults, this can be done with 2–5 mL of 1% procaine or lidocaine solution, particularly, if a test injection into the umbilicus is described as extremely painful.

Someone who is particularly thorough with regard to scars is certain to have a high success rate. Only if the whole of the scar is treated with the local anesthetic and air near the surface, and in a few places also at depth, and only if no part of it is left out, can a successful outcome be expected or the scar be safely eliminated as a relevant factor. It is even better to eliminate scars as potential candidates by injecting only the points found to produce a reaction, after measuring their electrical resistance or making an electrical skin test. Such reactive points generally lie at the two ends of surgical scars and especially on the edge of the scar. Kellner’s histological research indicates that anesthesia of a partially healed scar initiates a new granulocytic phase, which can lead to complete healing unless antigens or denatured body substances prevent the process.

The list below gives an outline of the sections to follow:

Materials 1 mm diameter 80 mm-long needle.

Quantity Between 5–10 mL preferably from ampoules, because the preservative added in multiple dose vials may cause local irritation in paravertebral root anesthesia and cerebral irritation in inadvertent injections into the liquor (for example, root diverticuli).

Level diagnosis and technique In the sciatic syndrome a major part is played by mechanical compression of the roots in the lumbosacral region, especially at L5 and S1. This must be treated first after identifying the level involved, until the acute stage has passed. The injections described under (4), (6) and (7) below are intended for treating the residual condition after the acute symptoms have disappeared, but they can also be used for purely neurogenic neuritis (lack of vitamin B, diabetes, toxemia etc.) and pseudoradicular syndromes (→ sciatica), but the latter are secondary with regard to the number of cases presenting for treatment. Before undertaking treatment, tumors, arthritis of the hip, and rheumatoid spondylitis must first be excluded.

Fig. 3.57 Injection into the region of the root of the sciatic nerve; entry point to the canal between pelvis and fifth lumbar vertebra.

Fig. 3.58 Injection into the region of the root of the sciatic nerve L3/L5

L5 Root

The compression of this root causes 80% of all lumbar sciatica due to intervertebral disks. It produces pain on the lateral aspect of the thigh (“general’s stripe”) and leg down to the dorsum of the foot and the big toe. The patient complains of compression pain on coughing or sneezing, the Lasegue sign is positive. Maximum percussion sensitivity directly above the line of the iliac crest.

Alternatively, a 100 mm-long needle may be used to go down vertically below the line of spinous processes at the lumbosacral transition point. At a depth of about 50 mm, there is bone contact with the lateral process of L5. The needle should then be carefully passed round its upper edge and advanced in the same direction with 15–20 convergence relative to the median plane, until it reaches the posterior peripheral quadrant of the vertebra. While maintaining bone contact, 5–10 mL are injected there. If the needle encounters the cartilage of the intervertebral disk, the injection must not be given until bone contact is established above or below it.

S1 Root

Irritation of the S1 root accounts for 15% (36% according to W. Scheidt) of all lumbago and sciatica. The disk prolapse presses on the lower edge of the fifth lumbar vertebra where S1 exits from the dural sheath, whilst the nerve exit as such is the first sacral foramen. The band of pain extends from the posterior aspect of the thigh via the popliteal fossa, calf, heel, and lateral malleolus to toes three to five. Maximum sensitivity to percussion is found three fingers’ breadths caudally of the line joining the iliac crests. Pain is exacerbated by coughing and sneezing, Lasegue-Bragard is positive, the Achilles-tendon reflex negative, walking on tiptoe impossible.

Fig. 3.59 Spinous processes that provide useful posterior landmarks. Posterior view.

An accidental endodural injection into a saclike protrusion of the dura mater can generally be avoided by prior aspiration in two directions, turning the needle through 180 in between. The needle should never be at an angle exceeding 25 convergence to the median plane. But if, on a rare occasion, the dura is penetrated, this is not such a serious matter, since at the worst all that can happen from L3 down is lumbar anesthesia that paralyzes both legs while it lasts. The patient should be reassured and laid flat with their head raised. Their circulation should be closely watched and if necessary they should be given a peripheral vascular stimulant.

Fig. 3.60 Injection to and into the sacral plexus. The illustration shows the guide lines whose point of intersection marks the injection site: a: the horizontal line joins the upper border of the trochanter major with the top of the natal cleft; b: the vertical line runs from the upper posterior iliac spine (the lateral dimple of the erector spinae in the small of the back) to the outer edge of the ischial tuberosity. The dotted line shows the width of the nerve plate, the dashed line indicates the direction to the anterior gluteal tuberosity in which we find the various parts of the plexus.

Fig. 3.61 Injection to the sacral plexus. Auxiliary lines to help in locating the plexus.

5. Posterior Sacral Foramen and Sacroiliac Joint

See pages 341 and 309.

6. Gluteal Region**

In the region of the buttocks the sciatic nerve lies exactly midway on the line joining the trochanter major and the tuberosity of the ischium. The patient lies on their sound side, with the sound leg extended and the affected leg flexed. The doctor now presses the left forefinger down on the site indicated and inserts the 100 mm-long needle, which must not be too thin, in front of the fingertip, guiding it in slightly obliquely upward until the patient reports a twitching sensation into the extremity. We give about 1 mL intraneurally and the same amount perineurally.

Probing pressure of the thumb on the tuberosity of the ischium tells us whether there is a bursitis that is producing or accompanying the sciatic pain. If there is, we need to deposit a small amount of procaine where the probing point of the needle produces a particularly severe pain.

Patients often complain about pain in the area of the calf, even after the sciatic disorder has been successfully treated. The sciatic nerve divides in the center of the thigh (or after its entrance into the popliteal fossa) into the tibial nerve and the common peroneal nerve. We can find the sciatic nerve before its division by palpating the popliteal artery at the level of the popliteal fold and inject one hand’s breadth above it. The nerve is located laterally to the femoral artery.

We find the tibial nerve above the Achilles tendon in the lower third of the medial lower leg by firm pressure on the musculature there. We can also anesthetize it behind and below the medial malleolus immediately adjacent to the Achilles tendon laterally of the posterior tibial artery. The patient reports a twitching sensation forward as soon as we touch the nerve with the point of the needle.

After creating paresthesias in the area that is supplied by the common peroneal nerve, we can locate and anesthetize this nerve directly below the head of the fibula. See peripheral → (T) nerves of the ankle and post-sciatic circulation disorder (lumbar → sympathetic chain).

Overview

The injections and complications listed below will be explored in the following section:

1. Sympathetic chain and its ganglia;

Following anesthesia of the sympathetic chain, after blocking the action of vasoconstrictors, the blood pressure is reduced. Hence, in the case of hypotensive patients who may be liable to collapse, they should be kept under observation and, if necessary, kept lying down for a few minutes. However, in a German prisoner-of-war camp in Russia during World War II, Gerecht made a notable observation that would seem to contradict this. Of 300 practically moribund soldiers who were consigned to the camp suffering from starvation, which had practically reduced them to skeletons, and from shock due to cold injury, the first 100 died of circulatory failure despite medical treatment, since all cardiac and circulatory stimulants failed to act. When he noticed that, after two stellate ganglion anesthetics, a patient suffering from causalgia not only became pain-free but that his circulation, which had been in a state of total collapse, also made an astonishing recovery, he immediately gave all others who had arrived in the same desolate state a procaine injection to the cervical sympathetic chain, a paravertebral infiltration, or sacral anesthesia, depending on the most severe peripheral damage, and lost only one out of the remaining 200! One is tempted to conclude that in these cases sympathetic anesthesia produced a life-saving effect in what would normally be irreversible circulatory conditions and mobilized the last remaining reserves favoring survival.

The best prophylaxis against possible complications is the use of small quantities for these injections and a perfected technique in their administration. This technique can be learned without undue difficulty. For a doctor to refrain from these injections out of consideration for his or her own safety would be so unethical that there cannot be any discussion as to whether he or she should proceed. Schmitt has said that with the right technique injections to the stellate ganglion, which for so little reason the general practitioner approaches with so much reluctance, are “no more dangerous than intravenous injections.” This applies to all the injections in this series!

In very many disorders it is immaterial whether the injection to the sympathetic chain is given in the cervical or the lumbar region. What matters most is to produce a direct thrust into the neurovegetative system via this “vital nerve,” in order to correct the disturbed equilibrium. Generally, unilateral injection will suffice, possibly alternately left and right. With the small quantity of an average of 2 mL of procaine normally used per injection (except to the stellate ganglion) there is little to fear from injecting both sides at the same time, provided this is indicated and the correct technique used. As a rule, treatment is initially repeated weekly, and subsequently at longer intervals (e.g., if the symptoms recur). These anesthetic injections are also appropriate following resection of the sympathetic chain, since the sympathetic connections re-form soon after such an operation.

We intentionally avoid describing our injections as “block” anesthesia. This term comes to us from neurology. The healthy cell is hyperpolarized by being supplied with chemical energy from the local anesthetic and is temporarily unable to respond to stimuli. This is known as an “anode block.” But in neural therapy, the decisive factor does not reside in any “healing anesthesia.” What we have to do is to produce a positive charge to chronically altered tissue whose pathologically reduced membrane-resting potential has become a permanent state. Here, the injection has an immediate recharging effect and acts to stabilize the cell potential. In other words, the cell membrane is protected against too rapid and too extensive a renewed discharge. In restoring normal bioelectrical conditions we are also reestablishing normal physiological conditions and once again link up the cell with the body’s normal information exchange system. However, this neurovegetative and bioelectrically rehabilitative effect can be produced only if we succeed in bringing procaine into previously damaged depolarized tissue. This is why the correct injection site is so important. In neural therapy we block nothing. On the contrary, we remove the block that is there and that has hitherto prevented the body’s self-healing powers from becoming effective. We need to remember again that small quantities of anesthetic are perfectly adequate for this purpose, since the healing stimulus to restore this equilibrium can be produced by quantities well below those required for anesthesia.

Anatomy The sympathetic system comprises the sympathetic chain and its ganglia, the nerves leading from it and their plexuses. The sympathetic chain consists of:

• the cervical chain with three ganglia, with branches to the carotid and subclavian arteries and to the heart;

• the thoracic chain with branches to the aorta, the subclavian artery, the lung, and the splanchnic nerves;

• the lumbar chain and its four or five ganglia;

• the sacral chain and its four ganglia.

The treatment of sympathetic nerves and ganglia is possible without blocking any spinal nerves, at the stellate ganglion, at the upper kidney pole in the region of the splanchnic nerve and at the lumbar sympathetic chain.

Anatomy The sympathetic chain runs ventrally left and right of the vertebral column, from the level of the first cervical vertebra to the coccyx. In the cervical region it has only two or three ganglia. In 70% of all cases the lowest of these is combined into a single entity with the first thoracic ganglion and together with this forms the stellate ganglion. This is 10–30 mm long and 0.3–l mm thick. The ganglia of the sympathetic chain are linked interactively section by section via the communicating rami to the spinal nerves issuing from the spinal cord. The stellate ganglion lies on the head of the first rib, about 10 mm laterally from the first vertebral joint and 25–30 mm from the median line of the body. Amongst all the sympathetic ganglia, this ganglion occupies a place of special importance, for it is the largest neural control center apart from the central nervous system. It has afferent and efferent branches leading to the sympathetic thyroid and parathyroid plexuses, the phrenic, recurrent and vagus nerves, vascular branches to the vertebral, subclavian, and interior mammary arteries, and an accelerant nerve to the cardiac plexus.

The stellate ganglion provides the autonomic innervation of the whole upper quadrant of the body. In addition to a purely regional effect, anesthesia of this ganglion alters the tonic state of the entire neurovegetative regulating system. Following anesthesia to the stellate ganglion, the quantity of blood and flow rate increase by 20% and oxygen saturation rises by as much as 50%. If repeated a sufficient number of times, this injection restores the equilibrium between vasoconstriction and vasodilation. Heppner stated that the disappearance of a cerebral edema following such an anesthetic suggested normalization of the endothelial barrier. The far-reaching importance of this control center is shown by the extensive list of indications for this injection. The therapeutic potential of treatment with local anesthetics in internal medicine, neurology, pulmonology, ENT, ophthalmology, and orthopedics is far too little used in practice. The reason for this is doubtless that many physicians are afraid of the risks inherent in this injection. This fear is groundless, as I hope to show.

Indications Of primary interest are all arterial (not merely vasospastic) and venous circulatory dysfunctions, lymphatic occlusion in the head, the cervical region, and the upper part of the body, with their many possible sequelae, including pain due to autonomic causes, and trophic or tonic tissue changes:

1. In the upper half of the body: Frostbite, burns, slow-healing fractures, angiospastic circulatory disturbances of the Raynaud type, venous dysfunctions, lymphatic occlusion, puerperal mastitis, and hyperhidrosis; all pain symptoms in the head, chest, and arms, herpes zoster; to improve circulation after surgery.

2. Head: Pre- and post-apoplectic syndrome, cerebral edema and embolism, intracranial vascular spasms, certain forms of headache and migraine, post-concussional syndrome, dizziness, traumatic epilepsy, paralysis of the facial nerve, persistent facial edema following erysipelas; as supportive therapy in meningitis; venous thrombosis of the sinuses.

3. Eyes: Occlusion of the central retinal artery, thrombus of the central vein, diseases of the vascular membrane, abnormal pigmentation of the retina, degenerative disorders of the macula, ophthalmic herpes zoster, glaucoma etc.

4. Ears: Allergic disorders, frostbite, chronic suppurative otitis media, pressure in the ear, Ménière disease, deafness of the inner ear, tinnitus, sudden onset of deafness, otic zoster etc.

5. Nose: Vasomotor rhinitis, ozena, chronic suppuration of the sinuses etc.

6. Throat and neck: Hyperthyroidism, neuralgia, goiter, osteochondrosis of the cervical spine, cervical syndrome and all symptoms resulting from irritation of the cervical sympathetic system and of the nerve roots, rheumatic torticollis, septic tonsillitis, tonsillar abscess, tubercular laryngitis; to relieve pain in inoperable carcinoma of the larynx and hypopharynx.

7. Shoulder: Shoulder-arm syndrome, scalene syndrome, capsular arthritis, arthrosis deformans, subacromial bursitis, cervical migraine, post-traumatic stiffening of the joints, etc.

8. Arm: Brachialgia, causalgia, phantom-limb pains, brachial-plexus neuralgia, post-traumatic osteochondrosis; periostosis such as epicondylitis, styloiditis, tendinosis, painful joint dysfunctions, thrombosis and embolism in the arm, lymphatic edema following mastectomy, slow-healing wounds of any kind, acrocyanosis, Raynaud disease, obliterating thrombo-angiitis, joint pains, post-phlebitic edema and other circulatory disturbances; conditions following arterial injury. Also for diagnostic-prognostic testing before vascular surgery.

9. Lungs: Bronchial asthma, pulmonary hemorrhage, perforating injury to the lung, pulmonary edema (also in malignant hypertension with cardiac insufficiency in nephrosis and pre-uremia), tuberculosis of the lung, pneumonia, pleurisy, herpes zoster etc. In pulmonary embolism, procaine is injected bilaterally, with an interval of about 25 minutes between the two injections.

11. General disorders: Eclampsia (in addition to injecting to the stellate ganglion, an injection should also be given to the abdominal → (T) sympathetic chain at the upper renal pole), epilepsy, status epilepticus, hyperhidrosis in the upper part of the body, and other autonomic disorders.

Possible contraindications Warning: caution is required in the case of bronchial asthma approaching decompensation. Fatal incidents have been reported! Anticoagulant therapy is an absolute bar against injections into the vicinity of any vessels. If possible, in recurrent nerve paresis, pneumothorax, or contralateral lung resection, the unpracticed should refrain from giving this injection, on the grounds of safety. In pulmonary emphysema and apical cavities, the only method that should be used is the one I recommend.

Statistics The surgical unit of the Leipzig university hospital has confirmed the efficacy of stellate-ganglion anesthesia for disorders of the upper extremities. Two hundred and fourteen patients suffering from post-traumatic osteoporosis, cervical-spine syndrome, disturbed peripheral blood supply, epicondylitis, and humeroscapular periarthritis were treated eight times on average. An improvement was achieved in 76% of these, of whom 44% became completely symptom-free and in the other 32% all pathological changes regressed.

There can be little doubt that any neural therapist with a perfect command of the method would have been successful in at least some of the 24% failures, by combining this with other injections in the segment or by the elimination of the interference field responsible.

Materials For Herget’s or Leriche’s methods, 0.8–1 mm × 60 mm needle; Dosch: 0.7 mm × 32 mm (size 12) or 0.9 mm × 40 mm (size 1); Reischauer: 1 mm × 100 mm.

Quantity 2–5 mL of a local anesthetic suitable for use in neural therapy is all that is required! The amount of 20 mL of 1% procaine solution used by surgeons is too large and can produce dangerous reactions simply by causing pressure on the nerves.

Technique The relevant literature describes a total of 34 methods using the anterior, lateral, and posterior approaches! We shall limit ourselves to considering three of these that have proved themselves over the years:

Herget’s Method*

Fig. 3.62 Diagram showing the position of the stellate ganglion in front of the head of the first rib.

Fig. 3.63 Finding the entry point for the injection to the stellate ganglion according to Herget.

a. Divide the length of the sternocleidomastoid muscle into three equal parts. The entry point lies on the anterior edge of the muscle at the transition from the caudal to the middle third.

b. At the level of the mid-point between the first ring of the trachea and the upper edge of the sternum, thence laterally to the anterior edge of the sternocleidomastoid muscle.

The needle is withdrawn only about 1 mm, since an injection under the periosteum can result in considerable post-traumatic symptoms. If the needle enters the ganglion itself, the patient feels a dragging pain in the shoulder region. In that case, the needle should also be withdrawn 1 mm. Surgeons inject 10–25 mL, in order to “bathe” the ganglion and to include the middle cervical and the four uppermost thoracic segments of the sympathetic chain in the block. We know that such a large quantity can produce a dangerous carotid-sinus reflex when the neck is hyperextended back in this way, and believe that this is responsible for some of the accidents that have been reported.

We inject only 2–5 mL of 1–2% procaine or of a 0.5–1% lidocaine solution such as Xyloneural. One reason is to avoid any risk of complications due to too large an amount of fluid; another is that the intended neural-therapeutic effect can be achieved equally well with these small quantities of low-concentration solutions (without the addition of vasoconstrictors!), amounts well below the threshold level for anesthesia. If the patient has a goiter, this can be pushed to one side, but no harm is done if the needle passes through the thyroid.

Fig. 3.64 Injection to the stellate ganglion according to Herget. The division into three equal parts of the length of the sternocleidomastoid muscle and the clavicle is marked. The dotted line shows the apex of the pleura.

If we want to block the cervical sympathetic chain directly, the needle should be lowered slightly in a caudal direction. But this is riskier and offers no advantage compared with that to the stellate ganglion, and is thus not recommended! We are already familiar with the most important safeguards. Caution: always aspirate before any injection in a cranial direction from the heart! Injection (particularly of larger quantities) into any vessel leading to the brain or into the liquor cavity can lead to dangerous complications!

In order to avoid such complications and run no risk of accidentally injecting intra-arterially, we aspirate, turn the needle through 180 and aspirate again. It could happen that the needle is tangential and so close to the carotid or vertebral artery that the inner arterial wall is aspirated and closes the opening. In that event the patient could still receive an intravasal injection despite a negative result from aspiration. An added safeguard against the accidental administration of a relatively large quantity intra-arterially is therefore to inject only a few tenths of a milliliter of the local anesthetic while closely observing the patient for a few seconds. If they show no reaction, which might suggest an accidental intravasal injection or intolerance (nausea, vertigo, somnolence, tinnitus, or flashing in front of their eyes), the remainder can be injected briskly.

After the injection, the patient should be kept under medical observation until they are once again fully fit for the road. It is part of the physician’s duties to draw their attention to this fact. When procaine is used, this will take about 30 minutes, in the case of lidocaine (because of its delayed resorption) this will increase to about 2–3 hours. With Carbostesin, 6–12 hours will be needed.

When procaine is used, the Horner syndrome appears and disappears quicker. With lidocaine, the onset is slower but it lasts longer. This has no impact on the neural therapeutic effects. In patients who suffered apoplexia a long time ago, and patients with other nerve damage, the Horner syndrome does not take place with the initial infiltration, but during the course of the treatment it increases in appearance. It seems as if buried pathways are excavated and revived.

For most therapeutic indications, a series of eight to 12 injections will be necessary, rarely more. The contralateral side should occasionally also be anesthetized. Normally, the injection is given only unilaterally. If it is intended to treat both sides in one session—required, for example, with pulmonary embolisms—we allow an interval of 30 minutes before the second injection when a 1% procaine solution is used.

The Technique According to P. Dosch***

For several years, I applied the Herget technique as demonstrated to me by a surgeon using 10 mL Impletol. I did this until two incidents occurred in one day. I aspirated in one direction only and must have accidentally injected into the common carotid artery. I terminated the injection immediately when the patients fell unconscious for a few, never-ending minutes. One of them went into brief spasms. They finally came to with a retrograde amnesia but neither situation led to negative consequences. I was horrified and searched for a way to avoid pushing the needle blindly for several centimeters into the neck, which is rich with vascular and neural tissue, until contact with the bone is made. In a text by Leriche, I discovered a technique with an antero-lateral approach.

In the original technique using an antero-lateral approach, which was developed jointly by Leriche, Fontaine, and de Seze, the patient lies flat on their back and turns their head only slightly to the opposite side. A felt pen or skin pencil is used to draw a line two finger breadths above and parallel to the clavicle and another along the lateral edge of the sternocleidomastoid muscle. The 60 mm-long needle is inserted at the point of intersection of these two lines and advanced almost vertically downward with only a slight deviation in a medial direction, until after 30–40 mm it makes bone contact with the head of the first rib or the lateral process of the seventh cervical vertebra. After a negative aspiration test, 10–20 mL of procaine (but we only give 2–5 mL!) are injected.

I have adopted the lateral approach but have modified it considerably over time. The positioning of the patient’s head is different, the point of injection is approximately 2 cm higher and slightly more lateral, and the injection is not made directly to the ganglion but in front of the transverse process of the sixth cervical vertebra. By pressing down with the fingers, possible complications with the lungs, vessels, and liquor space are avoided. The injection fluid descends on the fascia of the throat down to the stellate ganglion. The onset of the Horner syndrome confirms this. This method is considerably simpler, safer, and can be used in daily outpatient practice. It worked for me for 35 years without complications. My sons and students apply this technique, which greatly expanded their therapeutic options.

Technique In my method, the patient is seated on a chair with a neck support. If a neck support is not available, they simply lean their head against the wall after a pad has been placed under the back of their neck. They should lay their head back as far as they can and then turn it as far they can without difficulty in the opposite direction to the side to be treated. Now, the carotid tubercle should be easily palpable. On no account should the patient be allowed to turn the shoulder forward when they turn their head in this way or to draw in the neck out of fear!

Fig. 3.65 Diagram showing the position of the needle in carrying out the injection to the stellate ganglion according to Dosch.

The finger in the cranial position on the neck can now feel the carotid tubercle of the sixth cervical vertebra as a small bony prominence and the patient pulls a face, because the pressure on the neurovascular bundle (formed by the common carotid artery, jugular vein, and the vagus nerve) against the bony substrate is unpleasant. Difficulty in locating the correct injection site can arise only if the patient has a very short, thick neck. In such a case, it is best to palpate the head of the rib by inclining the patient’s head to the side to be injected and thus relaxing the soft tissue. We leave the palpating finger in place and then incline the head back and to the opposite side into the prescribed position. If there is a goiter, this is pushed aside, but no harm is done if the needle goes through it.

Only a 30–40 mm needle is used. This is inserted a short distance, immediately above the cranial finger, and is then guided deeper as far as bone contact, which is made practically subcutaneously! Even in the case of an adipose patient, if the needle fails to make bone contact at a maximum depth of about 20 mm, its position must be corrected without fail! The most important rule, by which we can avoid the only danger—that of accidentally injecting intradurally—is: throughout the injection with our short needle the palpating finger must maintain contact with the transverse process of the sixth cervical vertebra, and we must ensure that the point of the needle also remains in loose contact with it and does not slide further in!

In view of the limited depth at which we need to work, a 20 mm-long needle would be adequate. But since this also has a diameter of only 0.4 mm, it provides no assurance with regard to the aspiration test. We therefore use a needle 30–40 mm in length and 0.7–0.9 mm thick, but this must not, of course, be inserted all the way.

After bone contact, we withdraw the needle 1 mm, to avoid injecting subperiosteally, and aspirate in two directions by turning the needle through 180. After a negative aspiration result, in which no blood, air, or liquor must be aspirated, we inject a few tenths of a milliliter of the product and wait a few seconds while closely observing the patient. If they show no reaction that might indicate an intra-arterial injection or intolerance (nausea, vertigo, somnolence, tinnitus, flashing in front of the eyes), the rest of our 2–5 mL can be administered swiftly. Whenever the position of the needle is changed, or if the patient talks, swallows, or moves, we must aspirate again. In the seated patient, the local anesthetic descends along the prevertebral fascia to the stellate ganglion (cervicothoracicum).

If, as the needle is inserted, the patient feels an electric shock radiating to their fingertips, then the needle is too far in a lateral direction amongst the strands of the brachial plexus. After correcting the needle’s position and observing the precautions stated, we may proceed with the injection. We sometimes seek out the brachial plexus intentionally for therapeutic reasons, but in such cases it is better to use a different method that includes all parts of this plexus (→ (T) nerves, afferent).

If, on occasion, blood or liquor is aspirated, something that has never happened to me in 35 years, the needle must be removed at once and the injection should not be attempted again that day. With a little practice and used correctly, this beneficial injection is no riskier than an intravenous injection (Schmitt).

After the injection of procaine, the patient remains sitting in the waiting room another half hour before being seen once more by the doctor and then being allowed to go home without hesitation.

Fig. 3.66 Diagram showing the injection site for the injection to the stellate ganglion according to Leriche’s method as modified by Dosch. The head of the seated patient is turned in the opposite direction to that of the injection and bent back. Two or three fingers of the left hand press in above the sternum on the outer edge of the sternocleidomastoid. The head of the first rib now lies almost subcutaneously above the topmost finger. In boxing, a blow to this area can produce a carotid-sinus reflex and may result in a knockout.

Fig. 3.67 Injection to the stellate ganglion according to Dosch.

From 1978 to 1982, Werthmann performed 2681 stellate injections and doubled that number in the following 4 years. In 8000 stellate anesthesias in children he did not experience one patient with an adverse reaction to procaine or any other type of complication. In some patients blood was aspirated; consequently, the injection was not performed on the same day.

As particularly indicated for this type of injection, the experienced neural therapist lists the following:

1. Diseases of the respiratory tract are common in children. They are generally obstructive in nature. The Tiffeneau test immediately shows that the stellate infiltration improves air volume from 40–50–70% and more. This is objective proof of the positive results. In the case of mucoviscidosis (cystic fibrosis), the secondary symptoms can be improved.

2. In the case of sinusitis and sinubronchitis, secretolysis of the mucous membranes is also stimulated.

3. Until 18 months of age, developmental disorders with persistent foramen ovale and cardiac septal defects show improvement in 50–60% of the patients. Stellate injections support this improvement. Also, deeper breaths following the injection produce the hypobaric pressure necessary for spontaneous closure. The result is auscultatory and can be shown through phonocardiography (missing holosystolic murmur).

4. Spastic torticollis—in addition to local trauma of the head–neck area, the cause is damage to the extra-pyramidal system through encephalitis.

5. Reversible traumatic brain damage with motor restlessness or increased desire for sleep without desire to drink, following birth complications; in older children, post-concussional syndrome or conditions following meningitis and encephalitis.

6. Hearing disorders can be improved if they are detected and treated early. Every improvement is a success for the development of the child. This can be shown through children’s audiometry.

Dittmar takes the view that perivasal infiltration around the → (T) subclavian artery with 2 mL of procaine is a complete substitute for the injection to the stellate ganglion. The post-ganglionic neurovascular fibers travel directly to the adventitial plexus of the subclavian artery. This way they reach the area supplied by the subclavia. By way of the → (T) vertebral artery this would include the area of the posterior cranial fossa and the inner ear. Although we hold this to be unlikely from theoretical considerations and, in the light of many years of experience, do not share his misgivings over the injection to the stellate ganglion, we are bound to point out this possible substitute.

Reischauer’s Method*

To avoid the possible risks of an accidental intradural injection, Reischauer found a dorsal approach.

1b. Injection to the Upper and Middle Cervical Ganglia**

Anatomy The area of the neck is crowded with many, primarily autonomic afferent and efferent fibers. The upper cervical part of the sympathetic chain is located dorsally to the common and internal carotid artery, in front of the transverse processes of the second to fourth cervical vertebrae, embedded in the deep fascia of the neck. The vagus nerve, located slightly lateral to it, runs in the sheath of the large vessels.

It branches out at the larynx and the heart and is connected to the cranial nerves IX (glossopharyngeal nerve), X (vagus nerve), and XII (hypoglossal nerve). Together with the external and internal carotid artery and the jugular vein, they also travel to the head. The vascular branches of the internal carotid plexus accompany all the branches of the artery to the inside of the skull and provide autonomic supply to the brain and the eyes. The caroticotympanic nerves branch off this plexus and form the tympanic plexus together with branches from the glossopharyngeal nerve. From here the minor petrosal nerve originates, which travels to the Gasserian (otic) ganglion and to the parotid gland. Another branch, the deep petrosal nerve, ends at the pterygopalatine ganglion. The external carotid nerves and their plexuses wrap around the artery of the same name, forming the external carotid plexus, which supplies the skull and its soft tissues, the larynx, and the thyroid.

The visceral rami of the upper cervical ganglion are part of the cardiac plexus. Together with branches of the vagus and glossopharyngeal nerve, they form as pharyngeal rami the pharyngeal plexus, which supplies the pharynx, while the laryngeal rami enervate the larynx after connecting with the upper laryngeal nerve.

Those areas of the head that receive their blood supply through the common carotid artery and its branches are affected by the upper cervical ganglion. Other areas that receive blood from the vertebral or basilar artery are innervated sympathetically by the stellate ganglion.

Indications and materials Due to the anatomic circumstances, there is a long list of indications. This injection reaches the sympathetic and vagus systems, their ganglia and anastomoses, the glossopharyngeal nerve, the pericarotid plexus, the aortic and carotid depressor nerves, the carotid body, the hypoglossus and spinal nerves. Thus, the indications are equivalent to those listed for the stellate ganglion, the vagus, and glossopharyngeal nerve. It is used for cerebrosclerotic and vasospastic circulatory disorders in the entire area of the head, particularly the brain; also for central stress caused by a cerebral interference field due to encephalomyelopathias with headache, vertigo, and depression. In this way, it is a substitute for the → (T) cisternal procaine injection, which is actually illegal in Germany. It is also indicated in therapy-resistant complaints in the area of the cervical spine, migraine, and trigeminal neuralgias, particularly of the first branch; also for all allergic disorders (bronchial and cardiac asthma, eczema, hay fever, chronic urticaria). If simple injections fail, it is also recommended for pharynx, larynx, thyroid, ears, and eyes. It is indicated for interference fields in the head area, if they do not respond well to other measures because of secondary irritation of the head ganglia.

Fig. 3.68 Reischauer’s method. The entry site in the method according to Reischauer lies between the spinous processes C6 and C7 40 mm laterally of the line of the spinous processes.

Fig. 3.69 Anatomy and position of needle in the injection according to Reischauer.

• Nervous reactions: These reduce the nociceptive centripetal stimuli, the centrifugal commands of autonomic reactions and badly adapted stimuli of a large number of regulatory systems by about half; they “relieve” the reticular formation and the cerebral cortex of an excess of subtle stimuli and prevent some hypothalamic reactions.

• Hormonal, particularly pituitary reactions: It is surprising and at the same time exciting to find that disorders that retrostyloid anesthesia influences favorably and that are regarded as adaptation disorders respond to this quasi-physiological reactivation of what Selye calls the pituitary-cortex-suprarenal axis and that this is achieved without exogenous corticotherapy.

The far-reaching effect of this injection becomes obvious when one considers that the upper cervical ganglion also supplies the pituitary and pineal glands (hypophysis and epiphysis) through the periarterial sympathetic pathways of the internal carotid plexus.

Pituitary and hypothalamus form a morphological and functional control-circuit, i.e., centers in the hypothalamus are reached that are superior to the autonomic nervous system. They control, for example, temperature, blood pressure, and respiration, genital functions, wake–sleep cycle, lipo and hydrogen metabolism, and perspiration. The hypophysis produces approximately 20 different hormones and monitors and coordinates the finely tuned collaboration of all peripheral hormone glands.

The endocrine pineal gland secrets noradrenalin, serotonin, and melatonin, which is exclusively produced there. Its secretion depends on the circadian rhythm: light reduces the melatonin and adrenalin production and increases the serotonin effect, which regulates the stimulation of the smooth muscles. Melatonin reduces the activity of the thyroid and stimulates the parathyroids.

According to Pelz, anesthesia of the upper cervical ganglion has the following effects through the epiphysis alone:

1. Anovulatory cycle disorders, such as primary or secondary amenorrhea are eliminated.

2. Retardation of growth is removed, as long as the epiphysial plates are not closed.

3. The calcium level is increased through the parathyroid glands.

4. Thyroid hypertrophy, including Basedow, is normalized, if it is caused by pituitary or hypothalamus disorders.

5. Sclerodermia and Dupuytren’s contracture improve due to positive change in trophicity.

6. Some types of anemias and leukemias improve due the effect on the blood-producing systems.

7. Cerebral circulatory disorders improve; also post-traumatic epilepsy, optic neuritis following alcohol and nicotine abuse, etc.

Contraindications In patients with dangerously high blood pressure with the risk of a stroke, an injection to the upper ganglion should be avoided. If the x-ray shows the sella turcica to be substantially constricted, severe headache must be expected to follow the injection, since the anesthetic produces vascular dilation in the pituitary region. Procaine allergy and the use of long-term anticoagulants (Marcumar, Sintrom, etc.) or other coagulation disorders prohibit this injection, so do diseases of the central nervous system, such as cerebral atrophy, brain damage with loss of tissue, multiple sclerosis, amyotrophic lateral sclerosis, and pyramidal signs (positive Babinsky reflex).

Materials Needle: 60–80 mm length, 0.8 mm thickness.

Quantity 2 (–5) mL.

Technique

Fig. 3.70 Injection to the upper cervical ganglion (according to Goebel). Anatomical drawing: the ganglion is located in front of the transverse process of the second or third vertebra behind the internal carotid artery.

Fig. 3.71 Injection to the upper cervical ganglion (according to Goebel). Drawing of the paratonsillar injection site in the posterior pharyngeal arch.

Gagging and pain upon injection can be lessened and the mucous membranes disinfected through mucous membrane anesthesia with Gingicaine or Xylestesin spray. The patient needs to hold their breath while the spray is applied.

Fig. 3.72 Injection to the upper cervical ganglion. The injection site is located at the intersection of two lines: a vertical line downward from the anterior edge of the mastoid process and a horizontal line one fingers’ breadth cranially to the jaw line (technique according to Orsoni).

Fig. 3.73 Injection to the upper cervical ganglion.

a) Following Goebel’s technique, coming diagonally from the front, the needle travels perorally through the posterior pharyngeal wall, and ends behind the internal carotid artery.

b) Following Orsoni’s technique, the needle travels first from the point of insertion (1) toward the opposite mastoid until it reaches the tip of the posterior tubercle of the third vertebral transverse process. From there (2) it needs to be advanced another 10 mm ventrally, in front of the transverse process. Injection after aspirations tests in two directions.

Fig. 3.74 Topography and position of needle in the injection directly to the sympathetic chain.

1c. Injection to the Lumbar Sympathetic Chain**

Alternative terminology Lumbar “block,” lumbar sympathetic “block.”

Indications All chronic circulatory disturbances of the lower extremities, irrespective of their origin, form the classic domain for injections to the lumbar sympathetic chain, such as arterial occlusive disorders with possible gangrene formation, conditions resulting from burns, frostbite, varicose ulcers, ulcerating scars, ulcers due to x-rays or bedsores, causalgia, slow-healing amputation stumps, amputation-stump neuralgia, phantom-limb pains, hyperhidrosis, painful stiffness in the joints, post-traumatic osteoporosis, Sudeck dystrophy; in vascular spasm for opening a collateral circulation. Further indications are venous insufficiency with acute or chronic thrombophlebitis and post-phlebitic edema, embolism; in impotence, for improved blood supply to the genital organs. The injections are also worth trying in spinal motor paresis.

When the technique is used correctly, the patient reports a sensation of warmth in the leg on the side of the injection, and this can also be felt objectively. In addition to effecting an improvement in the arterial blood supply, we also achieve an interruption of the sympathetic pain-transmission channels that is maintained well beyond the limited duration of the anesthetic effect.

Fig. 3.75 Position of the sympathetic chain in the thoracic and lumbar area.

Injection to L3 in Post-sciatic Circulatory Disturbances

Reischauer found that 26% of patients who had suffered from L5 intervertebral-disk sciatica, one of those that occur most frequently, also had “post-sciatic circulatory disturbances.” These are characterized by sciatica-type pain in the sacrum and the outer and flexor sides of the thigh, and dysbasia (intermittent claudication) with poor circulation in the lower extremity. There are no compression symptoms (pain is exacerbated when the patient sneezes or coughs), the vertebral column is mobile, the spinous processes are not percussion-sensitive and arteriographic findings are negative. The patient’s history includes references to lumbago and sciatica.

The only recommended treatment consists of repeated injections of procaine or lidocaine to the lumbar sympathetic chain at L3. The radiating pain reminiscent of sciatica, dysbasia, and the circulatory disturbances disappear immediately following the injection. The latter, of course, are not due to any organic damage to the vascular wall but a sympathetic irritation caused by compression of L5, which maintains spastic vasoconstriction in the capillary terminal reticulum. This can be eliminated only by this therapy. Treatment should initially be repeated at intervals of 1 or 2 days, and at ever-increasing intervals as the condition improves. If these injections fail to provide relief, several → (T) peridural anesthetics should be administered in hospital. These are even more effective.

Materials 1 mm × 100–120 mm-long needle.

Quantity 2–5 mL.

Incidentally, it is worth remembering that the thoracic sympathetic chain is located more on the lateral surface of the thoracic vertebrae, whilst the lumbar sympathetic chain lies further on the anterolateral surface. See Figure 3.75.

Warning! We have to caution against injections to the thoracic sympathetic chain ganglia because they are prone to complications. In this area, an involuntary subdural injection causes life-threatening complications!

The pelvic part of the sympathetic chain contains three to four sacral ganglia and, at the caudal end, the solitary ganglion impar. In this ganglion, both sympathetic chains come together in an arch-like shape. We inject to this ganglion when we treat → coccygodynia. The ganglion is located in front of the coccyx. To reach the ventral side of the coccyx, we need a bent needle. Before removing it from its packaging, we bend the 60 mm disposable cannula into a semi-circle.

1e. Possible Mistakes and Complications with Injections to the Sympathetic Chain

Outdated statistics may create the impression that injections to the sympathetic chain and its ganglia are full of risk for both doctor and patient. Out of 10 000 stellate-ganglion anesthetics, Luzuy reported only a single fatality (in bronchial asthma with marginal decompensation). Leriche wrote:

The risks of injections to the stellate ganglion have often been exaggerated; even sudden death has been reported. Personally, in several thousand stellate blocks, I have observed nothing of the kind. I attach a certain amount of importance to the psychological state of the patient. It is an important part of our duties to reassure him and not to awaken in him the impression of a difficult and dangerous act on our part. Further, one must be completely familiar with the technique.

A survey made amongst neural therapists with an average of 20 years’ experience showed that in 1.75 million anesthetics to the sympathetic chain and its ganglia we had not a single case of irreversible damage as a result of our therapy, much less a fatality. These included about 500 000 (estimated) injections to the stellate ganglion. In these, there were 12 (1 in 41 667) accidental intra-arterial injections, which produced brief convulsions with loss of consciousness, all of which were without sequelae and required no further treatment. One colleague admitted that he had completely omitted to aspirate before the injection. The method can hardly be blamed for such gross negligence. On 20 occasions (1 in 25 000), there was a pneumothorax. These healed within a few days, some of them under the supervision of a specialist, the rest with only minor symptoms and without treatment. In about 500 000 injections to the upper renal pole, there were 25 cases of macroscopic hematuria and one renal colic. Three cases of severe after-bleeding were referred to hospital as a precaution, but all patients were able to be discharged 2 or 3 days later.

Only on one occasion was there a massive retroperitoneal hemorrhage, which called for lengthy hospital treatment but also resulted in no permanent damage. This patient suffered from a previously unrecognized coagulation defect. Our figures are not statistics; they merely provide a general view. As far as I know, there has not been a single fatality attributable to the method in over 65 years of neural therapy. If the technique is used in accordance with the rules, and if the physician has an adequate mental picture of the topography and reasonably sensitive fingertips, complications can be easily avoided.

Nevertheless, no matter how well things may have gone on so many occasions, these injections must never become a light-hearted routine matter. We must concentrate fully on what we are doing whenever we administer them to our patients and proceed in a thoroughly responsible manner. Only if we do this, will nothing happen. Every medical intervention harbors a certain element of risk, and it is essential to know what it is in order to reduce it to its absolute minimum.

Caution: If the prothrombin value (Marcumar) is below 45% (–70%), do not give any injection to the sympathetic chain!

1f. Possible Mistakes and Complications with Injections in the Region of Neck and Chest

Particularly when there is an occlusion or considerable narrowing of the internal carotid artery, blood might reach one of these vessels indirectly. In rare cases, existing anastomoses can cause retrograde blood flow into the skull. There is a greater chance for this to happen if large amounts of fluid are injected quickly with high plunger pressure! In the area of the head and the face, the number of vascular anastomoses is rather large. Anastomosis can take place, for example, in the area of the nose, between the terminal branches of the internal carotid artery, such as the ophthalmic artery, and the terminal branches of the external carotid artery. In the circle of Willis, the internal carotid artery and the vertebral artery form anastomoses at the base of the midbrain. As a result: we never inject larger amounts bolus-like, but, particularly in the area of the head, slowly and cautiously. With a little experience it is easy enough to acquire the proper “feel.”

• Incidents occurring with injections in the cervical region need not, however, necessarily be due to an accidental intravasal or intradural injection. The cervical region is a great deal more sensitive than any other part of the body. Especially in the hyperergic form of reaction encountered amongst autonomically severely disturbed patients, the carotid-sinus reflex can lead to unpleasant shock reactions with loss of consciousness and tonic-clonic twitching. Such incidents are exceedingly rare, but they can be fatal if the amount injected is excessive. Fortunately, they generally pass off without treatment. It has been stated that such a state of shock can be arrested by the intravenous administration of soluble corticosteroid preparations (e.g., Solu-Decortin H). Instead of 15–25 mL, we use only 2–5 mL without the addition of vasoconstrictors, which increase the toxicity of the local anesthetic by a factor of 10. By pressing in with the fingers (Dosch method) we avoid injury to vessels and the apex of the lung.

• According to Koster and Kasman, the frequently voiced concerns about damage through ascending procaine to the medullary centers resulting from unintentional sub- or intradural injection are unfounded! Even during complete anesthesia of the upper extremities and the head, the amounts and concentrations required for spinal anesthesia never affect the respiratory center. The authors concluded that the respiratory center possesses properties that make it insensitive to procaine. However, one ascertains by aspiration before injection that the needle is not lying intradurally. Because paravertebral injections and injections to the sympathetic chain in the thoracic area are prone to complications, we prefer to replace them with anesthesia of the stellate ganglion.

Occasionally, when the anatomical conditions are unfavorable, the dural sheath may extend as far as the intervertebral foramina. In these extremely rare cases, one need not penetrate into the foramina in order to place the needle intradurally. If this happens due to inattention or if an injection is made into the spinal cord, irreversible damage, even death, may occur. When injecting to the stellate ganglion, this can be prevented not only by aspiration in two directions but also by using a short needle and maintaining constant bone contact with the head of the first rib or the carotid tubercle of the sixth cervical vertebra.

• In cases where hypotonic patients have been given procaine injections, a dangerously reduced blood pressure has been observed, which has been due to peripheral vasomotor paralysis and damage to the nerve centers. With procaine and the extremely small quantities we use, there is little risk of this. Larger quantities can produce a carotid-sinus reflex. Nor should the pressure exerted with the fingers to move aside the bundle of vessels and nerves be too brusque or maintained for too long. I have had personal experience of this reflex in three autonomically labile patients, including a perforation of the carotid artery (but without injecting into it): nausea, blackness, and a spinning sensation in front of the eyes, throbbing in the head, and buzzing in the ears, pallor, and dilated pupils. These symptoms passed off without further treatment after lying the patient flat for a few minutes. If there is a more severe reaction, none of which I have ever experienced personally, although I have given countless injections into this area, the intravenous administration of a cortisone preparation (e.g., Solu-Decortin H) would be indicated.

• Setting a pneumothorax by perforating the apex of the pleura. This complication can be avoided by pressing the palpating finger into the carotid tubercle of the transverse process of the sixth cervical vertebra, injecting while maintaining loose bone contact (Dosch) and inserting the needle in full expiration. Often enough the patient does not even notice that he or she has a pneumothorax, and it will heal by itself with no further treatment, without affecting the patient’s general condition to any extent; at worst it may require 2 or 3 days in bed or perhaps reduced activity. A tension pneumothorax is hardly likely. Should it occur, it would present with symptoms of chest pains, an irritable cough, a sensation of constriction, shortness of breath, and blood in the sputum. In addition to the administration of sedatives, the patient should be referred to hospital for in-patient treatment (paracentesis, decompression).

• Hoarseness or loss of voice following injections in the cervical region. The injection has been given too far medially, and the recurrent nerve has been anesthetized. This is harmless and passes off quickly. The same also applies to anesthesia of the phrenic nerve, which temporarily stops movement of the diaphragm. Care is therefore recommended if injections are given bilaterally.

• If the injection is accidentally given into the vertebral artery (and this is easily avoided by prior aspiration!), the patient will temporarily have tinnitus and/or flashing in front of the eye on the side of the injection. This, too, passes off quite rapidly and does not call for treatment.

2. Parasympathetic Ganglia of the Head

2a. Injection to the Ciliary Ganglion**

Alternative terminology Retrobulbar infiltration, ciliary anesthesia.

Anatomy The ciliary ganglion has a length of 2–3 mm. It is not always found in the same position in every patient. Its location is about 10–20 mm behind the eyeball (which has a diameter of about 24 mm), generally directly laterally of the optic nerve and medially of the origin of the lateral rectus muscle of the eye. Directly behind the ganglion, the ophthalmic artery comes from a lateral direction to turn around the optic nerve and continues above it. This ganglion receives sensory fibers from the nasociliary nerve, parasympathetic fibers from the oculomotor nerve, and sympathetic fibers from the upper cervical ganglion, via the internal carotid plexus and the ophthalmic plexus. The fibers of the ciliary ganglion run to the eyeball and supply the vessels of the choroid and sclera, and some of their branches run to the ciliary muscle, the sphincter, and dilator muscles of the pupil and to the iris and cornea. The ciliary body produces intraocular fluid, which nourishes large parts of the eye, including the external layers of the retina. The intraocular pressure depends on the balance between production and drainage of this fluid. This regulation is based on sensible information coming from ganglion cells that are located in the ciliary body.

Indications

1. Segmental therapy: All acute inflammatory and chronic eye disorders, e.g., neuritis of the optic nerve, scleritis, keratitis, iritis, iridocyclitis, retinal periphlebitis with vitreous hemorrhage, rheumatic–allergic reactions and post-traumatic dysfunctions, glaucoma (except for hydrophthalmia), venous thrombosis of the retina. In addition, for cases of the following, where simpler injections (intravenous, quaddles, nerve-exit points) have failed to produce results: conjunctivitis, ophthalmic herpes zoster, all forms of corneal disorders, disorders of the retina (except detachment), incipient cataract, certain forms of headache and recalcitrant neuralgia in the region of the eye.

Apart from eliminating the inflammation and reducing pressure on the eye by regulating the autonomic state, both of which are of great importance, we are also able to improve the blood supply to the optic nerve, retina, and the anterior parts of the eye.

2. Interference-field search: As test injection, if the patient’s history suggests the presence of an interference field in the region of the eye, e.g., due to eye injury, eye surgery, persistent or repeated inflammatory conditions.

Materials There is no need for a specially curved needle, a straight one 35 mm to a maximum of 40 mm in length will do. If it is 40 mm long, it must not be inserted all the way! Ophthalmologists use a special straight 35 mm needle available commercially, with a slightly rounded tip.

Quantity 1.5 mL procaine solution, e.g., 1% Novocaine for therapeutic use made by Hoechst Pharmaceuticals. The more recently developed local anesthetics based on amides are less suitable for this injection, at least for outpatient treatment in a general practice, because they have a longer-lasting anesthetic action.

Fig. 3.76 Injection to the ciliary ganglion. Orientation on the bony skull.

Fig. 3.77 Injection to the ciliary ganglion.

Anatomy After leaving the skull through the oval foramen, the mandibular nerve divides into several branches. The strongest branch is the inferior alveolar nerve that supplies the teeth of the lower jaw and continues as the mental nerve to the lower lip and the chin. Another main branch is the auriculo-temporal nerve. The lingual and buccal nerves supply the mucous membranes. The motor branch supplies the mylohyoid muscle and the muscles used for mastication including temporalis, masseter, lateral, and medial pterygoid muscle. The branch that supplies the latter is located most medially and supplies the tensor tympani and veli palatini muscles. At this nerve branch lies the parasympathetic Gasserian (otic) ganglion. It supplies the parotid gland and the buccal glands and receives its pre-ganglionic fibers from the vagus nerve. We also anesthetize this ganglion whenever we inject to the mandibular nerve.

Indications: → ear. Indications Trigeminal neuralgia, if injections to the → (T) nerve-exit points have failed to produce the desired results; trismus, pain due to malignancy in the area supplied by this nerve; also worth trying with headaches of uncertain origin.

Materials 0.8 mm diameter × 60 mm needle.

Quantity 1–2 mL.

Fig. 3.78 Injection to the oval foramen (Gasserian [otic] ganglion). The patient holds his or her mouth half open. The needle is inserted below the center of the zygomatic arch above the mandibular notch and is then advanced to the center of the base of the skull to a depth of 40–50 mm.

Fig. 3.79 Injection to the oval foramen (Gasserian [otic] ganglion). Orientation on the bony skull. The point of the needle lies in front of the separation of the mandibular nerve into its two branches.

2c. Injection to the Pterygopalatine Ganglion and the Maxillary Nerve**

Anatomy:

• The parasympathetic pterygopalatine ganglion is located in the pterygopalatine fossa, directly below the maxillar nerve. The ganglion has three roots: the parasympathetic major petrosal nerve that originates in the facial nerve, the sympathetic petrosus profundus nerve that originates in the carotid plexus (which also provides a connection to the ciliary ganglion), and the sensory pterygopalatine nerves that originate in the maxillary nerve. Post-ganglionic fibers run with branches of the maxillary nerve to glands that are located in the mucous membrane of the palate, nasal cavity, and paranasal sinuses. After traveling along a complicated pathway, they reach the lacrimal gland.

Indications Hay fever, vasomotor rhinitis, dacryorrhea, photophobia, facial pains, disorders and paresthesia of the oral mucosa. Try also in cases of therapy-resistant forms of headache, other results of skull fractures, and maxillary “toothache” in the absence of pathological dental findings. Trigeminal neuralgia, especially where the second branch is affected. Neuralgia of the pterygopalatine ganglion with pain at the interior angle of the eye, the root of the nose, in the nose, in the upper jaw and palate accompanied by attacks of sneezing.

For hay fever, it will normally be sufficient to give this injection three times at a few days’ intervals at the start of the pollen season. In vasomotor rhinitis a greater number of injections will normally be required (whenever the symptoms recur).

Materials 0.8 mm diameter × (pterygopalatine ganglion) 40 mm or (maxillary nerve) 60–80 mm-long needle.

Quantity 1–2 mL.

Technique Orientation on the bony skull is essential before the first injection!

Fig. 3.80 Injection (b) to the pterygopalatine ganglion. Orientation on the bony skull.

Fig. 3.81 Injection (b) to the pterygopalatine ganglion. The needle is inserted above the center of the zygomatic arch, then advanced obliquely toward the pterygopalatine fossa, which lies at a depth of about 60 mm.

Fig. 3.82 Injection to the celiac plexus.

2. Interference-field search: As a test injection, when an interference field is suspected in the liver, gallbladder, gastric, or kidney regions and that may be due, for example, to hepatitis, gall-bladder disease, gastric ulcer, pancreatitis, dysentery, cholera, typhoid fever, chronic diarrhea, chronic nephropathy, diverticulitis, after abdominal surgery, and the like.

Fig. 3.83 Overview of autonomic ganglia and plexus in the abdomen and pelvis.

Materials Needle: 80–100 mm 0.8–1.0 mm (thinner needles are too flexible!).

Quantity 2–5 mL.

Technique

a. Original method according to A. W. Vishnevski (1933). In this, the patient is placed on their side on a roll cushion, as for a kidney operation. The 100–120 mm-long needle is inserted at right angles to the skin surface through a quaddle in the angle between the 12th (!) rib and the long extensor (erector spinae) muscle of the back. The needle is advanced under constant plunger pressure through the musculature and the posterior renal fascia into the posterior interfascial space. The neural-therapeutic solution can now flow out of the syringe without meeting any resistance.

The large quantity of 150–200 mL 0.25% Novocaine (procaine) solution pushes the anterior and posterior layers of the transverse fascia apart and the product can thus spread in a cranial and caudal direction. It eventually arrives in front of the kidney as far as the renal and supra-renal plexus and beyond as far as the nerve structures of the abdominal organs and especially the sympathetic chain. This method has been used not only for adults but also in children from the second month of life. According to its author, no negative consequences directly attributable to this method were observed.

b. We have slightly modified Vishnevski’s method and made it safer. The patient strips to the waist, stands close to a table, and places their trunk flat on it. This is the easiest way for them to relax. If this arrangement is not possible, it will suffice if they support themselves on their fully extended arms in such a way that the trunk is bent slightly forward. If we palpate from the posterior axillary line along the lowest palpable rib (i.e., the 11th rib!) medially towards the spine, we reach the bundle formed by the long extensor muscles of the back, about three finger breadths from the line of the spinous processes. The entry site is in the depression that can be felt there between the lower edge of the 11th rib and the muscle bundle. We set a quaddle over this point, in order to make the entry of the needle painless. The patient does not feel the needle as it is advanced in depth. To make doubly sure, it is advisable first to percuss the lower limit of the lung and mark the injection site two finger breadths below it. Before giving the injection, we ask the patient to breathe deeply in and out and then to hold their breath for a few seconds when we tell them to. With patients who are slow to understand or hard of hearing, this may need to be practiced a few times. We then tell the patient to breathe in deeply and swiftly and painlessly pierce the skin as they do so.

The 80–120 mm-long needle tends to bend on entry. This can be avoided by first impaling a sterile swab and using this as a support and guide by holding it between the left thumb and forefinger. Alternatively, the needle may be held near its point in a pair of sterile forceps to guide it through the skin.

We now ask the patient to breathe out fully and hold their breath, so that the lower border of the lung will move up as far as possible. The needle is then advanced from its entry point about 30 medially to the sagittal and 60 cranially to the transverse plane, i.e., obliquely rather more up than inward, in the direction of the normal position of the contralateral nipple, only until (depending on the adiposity of the patient), after overcoming the resistance offered by muscle and fascia, one has the distinct sensation at a depth of some 80–100 mm that the needle has penetrated into a void. If one learns to advance the needle under steady pressure on the plunger, it is easy to know when the correct depth is reached since the contents of the syringe then flow out without resistance. The point of the needle is now in the interfascial space near the upper renal pole, in the vicinity of the important suprarenal gland, below the dome of the diaphragm and thus in the neighborhood of the pre-aortic and other ganglia mentioned previously, and of the upper lumbar sympathetic chain. The needle must not be inserted any deeper than that! After aspiration we now inject only about 2 mL and never more than 5 mL. Here, as elsewhere, it is less the quantity that is decisive than the site of the injection! If the injection is not located correctly on the upper kidney pole, we cannot expect it to produce a satisfactory result. In view of the possibility in this case of missing our target at such a depth, it is advisable to repeat the injection once or twice if there is no healing reaction the first time.

It is generally best to combine the injection to the major splanchnic nerve with a → (T) preperitoneal injection into the → (T) epigastrium. These two injections should be repeated whenever required, as a rule if there is a recurrence of the symptoms.

3a. Possible Mistakes and Complications with Injections in the Abdominal and Lumbar Regions

• If we aspirate arterial blood here, we have gone too deep and too far medially, and have entered the aorta. After the needle is withdrawn slightly, we can inject without risk. Penetration into the aorta is not dangerous, not even the injection into it, and this may be given intentionally for therapeutic purposes in circulatory disturbances affecting the lower extremities.

• In connection with injections close to the vertebrae (sympathetic chain, paravertebral, sciatic root anesthesias), we cannot always avoid unintentional penetration of the spinal meninges, spinal dura mater, even when using the correct technique. When exiting the spinal canal, the nerves can be accompanied by leptomeningeal pouches and the needle can penetrate these. For this reason, it is mandatory to aspirate in two directions (twisting the needle 180) before injecting. Direct penetration of the spinal canal is only possible when using a false technique. This type of injection should only be chosen and applied with due caution if simpler measures and less demanding techniques have failed.

If liquor is aspirated, the needle went too far medially and entered the spinal canal or it ended up in a liquor pocket of the nerve sheath. The needle is immediately withdrawn and no injection is given at this level on the same day.

When using the small amounts of procaine recommended by us, accidental intrathecal injection in the lumbar region would merely produce lumbar anesthesia, which remains without any consequences as soon as it passes off. The specific gravity of liquor is 1.0070, lidocaine is 1.0035, and procaine 1.0055. Hypobaric solutions ascend in the liquor space, hyperbaric descend, and isobaric show the tendency to remain at the location of injection. Again, pressure, concentration, amount, and catabolism of the injection have to be considered. After an unintentional spinal anesthesia, we have the patient lie down with the head in a lowered position. We comfort the patient and assure them that the paralysis will not last long (1–4 hours, depending on the local anesthetic used). The circulatory system has to be monitored. Lumbar anesthesia is not dangerous if the local anesthetic does not contain additives. It needs to be remembered that, due to its speedy resorption and catabolism, procaine acts anesthetically for a shorter period than lidocaine or mepivacaine.

Severe headache can be the result of perforation of the nerve root sheath, due to liquor leaking through the puncture opening. The same can happen in the case of lumbar punctures. Entering skin cells, blood, or antiseptics may cause non-bacterial infection.

Another cause for severe headache has been found (Krauseneck). The use of combination preparations and local anesthetics from multiple dose vials in the area of the spine should be avoided. Multiple dose vials contain a bacteriostatic additive (methylparaben = methyl p-hydroxybenzoate), which can cause immediate irritation, such as ataxic gait and a tingling sensation in the legs, when entering the nerve root diverticuli. On the day after the injection, the preservatives may cause intoxication symptoms including headache, vertigo, vomiting, nausea, nystagmus, loss of blood pressure, and meningeal syndrome. This is why we use pure local anesthetics without additives only, and refrain from the use of combination preparations for this type of injection. We have to ensure that the ampules that we use for this purpose are also free of bacteriostatic additives.

The above-mentioned complications are rather rare and I have not encountered them in 40 years of practice. Nevertheless, they have to be listed in a textbook and their occurrence considered. When following the described protocol, it is almost guaranteed that the irreversible complications reported by Stoehr and Mayer can be avoided.

In the countless cases I have treated I have seen only a few hematurias, which passed off without further treatment or any later sequelae after 3 days’ bed rest with an increased fluid intake. Surgeons subject the body to a great deal more when they lay free the kidney, pre-luxate it and split the capsule, not to mention the urologists who intentionally perforate the kidney with a substantially thicker needle during a percutaneous needle biopsy in order to obtain tissue material for their purposes. In both these cases the generally insignificant amount of after-bleeding is accepted as perfectly normal. Compared with the value of this very frequently used injection of ours, the risk is insignificant. To any patient, blood is always an alarm signal. In hematuria, the mixture of blood with urine (and with water in the toilet pan) always suggests a far greater loss of blood than does in fact occur.

In my many years of work as medical referee, only three cases have come to my knowledge where a renal hemorrhage has been so severe following accidental perforation that the patient had to be admitted to hospital. It is possible for a massive hematoma in this location to exert pressure on the splanchnic nerves, which can cause symptoms of an adynamic ileus: vomiting and bloated abdomen with lack of peristaltic sounds. F. Huneke published such a case. In 40 years of practice, he saw only a single case in which “a massive hematoma developed several hours after an injection into the renal bed, with severe reflex symptoms, which for a time resembled a peritonitis. Fortunately, no surgery was undertaken. Over the next few days the hematoma was again completely resorbed. The only thing that persisted was the cure of the patient’s previous stomach disorder for which the injection had been given.

This kind of thing can neither be foreseen nor avoided, and looked at in the light of day, it is not as tragic as the patient may perhaps feel it to be. The situation described above shows that responsible observation through clinical supervision could be better than the rash decision to perform surgery.

In his book Peripheral Nerve Block Pharmacologic by Local Anesthesia, Jenkner wrote:

Although perforation or passing a needle through an organ in the abdominal cavity (e.g., also the kidney) seems in theory possible and even necessary, there has never been any negative report on this in publications. For example, in 3000 closely investigated splanchnic-nerve blocks, not a single case of hematuria, peritonitis etc. has been found. Thus, such perforations can produce only minor or unrecognized symptoms. The celiac ganglion should not be blocked in patients whose general condition is poor.

This last remark applies to our technique only in a few exceptional cases. Jenkner uses 20–25 mL 0.5% Scandicaine, generally with adrenalin, an additive that we absolutely reject.

• If one meets a bony resistance at a depth of 30–40 mm, this is the lateral process. The needle is withdrawn slightly and is then advanced again either above or below the lateral process. If the patient reports a shooting pain down into the legs, we have found a spinal nerve. The position of the needle needs to be corrected by a small amount. If, following an injection into the lumbar sympathetic chain, the patient is temporarily slightly unsteady on his or her legs, this indicates that the motor root fibers have been partially paralyzed. This condition is also harmless and, if procaine has been used, will pass off again within about 30 minutes.

• In the injection to the abdominal sympathetic chain, if the wrong technique is used (the needle is too long, the needle is advanced too steeply or inserted too deeply, the patient continues breathing), it may on rare occasions penetrate the diaphragm and reach the lung (if it is inserted too far). In this case the patient coughs immediately and tastes blood, and there will be blood in his or her sputum. This is no cause for concern. Any pneumothorax produced in this way will disappear after a few days without further treatment, provided the patient takes a little care to avoid overexertion. With prior percussion to ascertain the limits of the lung (entry point two finger breadths below), due regard given to the recommendation that immediately before the injection the patient should breathe out and hold their breath, and particularly when remembering not to advance the needle after the myofascial resistance ends and the anesthetic solution flows freely, this will in fact happen only on the very rarest of occasions.

Contraindications Apart from extremely rare cases of procaine allergy, there are no contraindications. In such cases we use a preparation based instead on lidocaine (e.g., Xyloneural). In view of the small quantities we use, neither age, a reduced general state of health, nor heart or liver disease are contraindications. With aspiration and a little care, any potentially dangerous complications can be avoided. Nothing much can happen. Anyone who takes the trouble to learn to use this effective weapon will be rewarded a thousandfold for his or her pains.

Fig. 3.84 Injection to the dental root (from a buccal direction).

Fig. 3.85 Injection to the dental root (from a palatinal direction, to the periosteum of the maxilla).

Fig. 3.86 Granuloma.

Fig. 3.87 Infected residual root.

Fig. 3.88 Foreign body.

Fig. 3.89 Alveolar pockets.

Fig. 3.90 Devitalized teeth.

Fig. 3.91 Cyst.

Fig. 3.92 Widened periodontal space.

Fig. 3.93 Residual osteitis.

Fig. 3.94 Displaced tooth.

Materials For anesthetizing the injection sites, Gingicaine surface anesthetic (spray) or the Dermo-jet with the dental attachment can be recommended; for injections to the periosteum beyond the alveolar margin, a cartridge or locking syringe is best. If one of these is not available, a size 18 or 20 needle firmly attached to a normal syringe can also be used.

Quantity Only about 0.2 mL of procaine solution or Xyloneural from a cartridge ampul is used per injection.

Technique

a. Injection to the periost above the dental root: We use only 0.2–0.3 mL (infiltrating into the gingiva down to the periost), both palatinally and bucally, for the injection to each dental root to be tested. The injection is given submucously, intramuscularly, and infiltrating all the way down to the periosteum. There is no need to use penicillin, Anthroposan or the like as an additive. In the injection, a millimeter or two may be decisive for the result. The point of the needle should be taken particularly into the hyperalgetic points and into the middle of scar craters following dental extractions. Occasionally, it will sink all the way into the maxillary sinuses without meeting any resistance. This is also an appropriate place to remind the reader of the importance of residual osteitis. When carrying out dental tests, the neural therapist should always include rest periods to enable the patient to assess the results if any and thus localize the culprit within as narrow a range as possible.

Fig. 3.95 Intraligamental anesthesia to a molar.

Indications: → thyroid disorders, Basedow disease, thyrotoxicosis, hypo- and hyperthyroidism (including “la-tent hyperthyroidism” according to Dosch), goiter, anxiety, a sensation of pressure or of a lump in the throat, heart palpitations, “essential hypertonia,” sleep disorder, menstrual disorders, signs of miscarriage, habitual abortion, menopausal complaints, primarily hot flushes; also try in alopecia, tachycardia or extrasystoles with increasing anxiety; also in fever of unknown etiology, loss of weight and exhaustion with loss of hair, excessive sweating, → neurodystonia, “nervous” abdominal and digestive disorders, increased nervousness and excitability, especially when accompanied by trembling or compulsive weeping, but also when presenting with signs of vegetative overexcitability, including temperature regulation disorders (e. g., increased temperature, flushes, dermatographism, intense sweating, cold feet); hyperemesis gravidarum; in psychological disturbances following castration or in ovarian insufficiency. In acupuncture, these thyroid points are also treated in speakers or singers suffering from hoarseness or loss of voice.

In all indications it is irrelevant whether the basic metabolism is normal, increased, or reduced. When an interference field is subjecting the pituitary centers of the diencephalon to stress, this is also frequently accompanied by a substantial reaction of the thyroid. Similarly, due to the mutual relationships within the hormonal system, an interference field in the pelvic region can often also involve the thyroid. A series of injections into the gland, initially weekly and later at longer intervals, will clearly restore the subjective and objective equilibrium in such women. Our thyroid treatment proves to be an effective complementary treatment for → alcoholism. It helps to alleviate the neuro- and psychovegetative side effects of withdrawal (Dietz). It is also helpful in → geriatric disorders. If a thyroiditis has left an interference field, this injection can effect a cure via a lightning reaction.

Relative contraindications Radioactive iodine treatment reduces the parenchyma by irradiation. The success of this form of treatment can be assessed only weeks or even months later. During this period, one should refrain from procaine treatment, because the regulating function of the thyroid remains blocked by the radiation damage it has sustained while its effects last. In such cases, the response to the procaine injection may be unusual and can often be paradoxical. In other words, the gland may be over-stimulated to the point of hyperthyroidism.

Materials The needle should be as fine as possible, about size 18; quantity 0.5–1 mL of 1–2% procaine (without additives!) for each lobe of the gland.

Technique It is best to inject the patient when he or she is lying down, since the gland then protrudes forward. The patient is asked to swallow, and the position and size of the thyroid is observed and palpated. The fine needle is inserted quickly and 0.5 mL (never more than 1 mL) of procaine is then injected on each side into the parenchyma of the gland at a depth of 10–20 mm, after checking by aspiration that the point of the needle is not intravasal. This could easily happen, since the thyroid is rich in blood vessels; in such a case, all one need do is to correct the position of the needle and to inject only when it is outside any vessel. If the isthmus is clearly enlarged, a similar quantity is also injected there, but only superficially.

If, following the injection, a Horner syndrome is produced, this is a welcome side-effect but indicates too deep an injection. Compulsive weeping may occasionally occur immediately after the injection and indicates that a psychological component of the disorder has been eliminated and that emotional blocks are now being released, to give way to a more balanced state.

Injections into the thyroid should initially be repeated at about weekly intervals and, if successful, should then be given at longer intervals determined on an individual basis. Generally, the patient will know by their own observations and state when further treatment is required.

In women, treatment of the → (T) pelvic region given in addition will often increase the effectiveness and the result. The interaction between thyroid and ovaries is well known. In cases of hyperthyroidism, repeated → (T) intravenous procaine injections reduce the metabolic rate.

Fig. 3.96 Injection into the thyroid.

1. Palatine Tonsils***

Indications

1. Segmental therapy: In treating chronic tonsillitis, recurrent sore throat and peritonsillar abscesses, sensation of a foreign body in the throat.

2. Interference-field search: As a test injection in patients whose clinical history indicates scarlet fever, diphtheria, frequent or severe sore throat, tonsillar abscesses, tonsillotomy or tonsillectomy.

Materials 0.8 mm diameter 80 mm-long needle, short-beveled. If the needle is too short and accidentally comes off the syringe, it may be aspirated or swallowed. Moreover, an unobstructed view of the working area is impossible if the syringe is in the mouth.

There is also a special tonsillar test needle according to Strumann, with a plate soldered in position, to prevent the needle from going deeper than 5 mm. Normally it is perfectly possible to dispense with this. Moreover, the soldered connection may melt under frequent hot-air sterilization. In an emergency, it is easy enough to cut off the end of the plastic tube protecting the disposable needle so that the needle projects only 5 mm, thus making it impossible to insert it further when giving the injection. The quantity of solution used for each tonsillar pole is 0.5 mL.

Fig. 3.97 Injection to the tonsils.

Technique First remove any loosely fitting dental plates and false teeth. If possible, the patient should be seated on a chair with a neck support, or their head should be supported by an assistant or by leaning it back against a wall. This injection should not be attempted if the head cannot be firmly fixed. Good light is another essential prerequisite for good results.

The patient should open the mouth wide without sticking the tongue out. The spatula should not be placed too far back, about the middle of the tongue, and should not be pressed down too hard. If the patient is kept distracted by being asked to breathe deeply in and out on command, this will help prevent the undesirable gagging reflex and simplify the physician’s task. It is still easier if the patient pants, i.e., takes continual shallow breaths in and out. If this is still not adequate, we anesthetize the pharyngeal wall with Xylocaine spray and push the base of the tongue aside in a medial direction about level with the wisdom teeth.

Particularly for the first test injection, we inject both the upper and lower tonsillar poles, in order to reach as much of the tonsillar tissues with the injection as possible and reduce failures to a minimum. For this the procaine is injected submucously above and below the tonsillar poles. Textbooks caution that, in the case of retrograde blood flow through anastomoses (Bolus injection too fast and paratonsillar infiltration too deep), there is a possibility for the local anesthetic to be pressed through the ascending palatine artery and the external and internal carotid artery into the skull. I have never experienced this scenario. For the injection to the lower poles, the base of the tongue is pressed aside in a medial direction at the end of the alveolar ridge and the anesthetic is then injected submucously between wisdom tooth and the root of the tongue. By this means we prevent tissue damage with the point of the needle, which, in this bacteria-laden tissue, could easily lead to abscess formation. It is perfectly safe to swallow any procaine that runs down.

To stimulate the lymphatic flow, we may also set one to three → (T) quaddles in a caudal and medial direction from the mandibular angle. Figure 3.97 shows an injection to the tonsils.

If the patient has undergone tonsillectomy, the injection is not given to the tonsillar poles but always into the middle of the scar tissue, directly under the surface of the scar. Sometimes, after the injection under a hard tonsillectomy scar, a Horner syndrome is observed. This is a sign that the numerous autonomic nerve fibers in this area are closely connected with the stellate → (T) ganglion.

Fig. 3.98 Injection to the trochanter major.

Materials Size 1 needle for slim patients, correspondingly longer for adipose patients.

Quantity 2 mL of procaine solution.