The practice of osteopathy (part 2 of 6)

Introduction

What Hippocrates was to the Allopath, what Hahnemann was to the Homeopath, Andrew Taylor Still is to the Osteopath, and it is safe to say that when another century shall have rolled away, his fame will be equal to that of either. That he is a maker of history, even the most skeptical will admit. His teachings are revolutionary but are borne out in fact, and on that as a foundation, is built the superstructure of the young therapeutic giant—Osteopathy.

It would be of great interest to trace the history of the first inception of the thought that drugs were not only unnecessary but harmful, then view the struggle to grasp something tangible to take their place, then see the development of the idea that the human body has within it all that is needed for its upbuilding and repair until he came to this fundamental: “The power of the artery must be absolute, universal and unobstructed or disease will result. The moment of its disturbance means the period when disease begins to sow the seeds of destruction in the human body; and in no case can it be done without a broken or suspended current of arterial blood,” capped by the epoch-making discovery of the cause for this interrupted flow of the blood stream—the theory of obstruction by anatomical displacement. It is the only theory of the etiology of disease that will stand the test of science and its acceptance and practice means a revolution in the field of therapeutics.

As it is, he sets the exact date, June 22, 1874, when the light dawned and he saw the outline of his great philosophy—Osteopathy. Then came the years of adversity and struggle. With the eye of a prophet he saw the future of that philosophy, and with the firmness of a Spartan has defended it since birth. It must be a separate, distinct system. Outside the fact that it was to heal the sick and was founded on a knowledge of anatomy and physiology it had nothing in common with existing schools, and if it were ever to grow it must be alone, for his brother practitioners would have none of it and if left to their tender mercies it would have “died a-borning.” Even had it been taken up the result would have been the same for they would never have fully developed it. And so through the lean, terrible years he struggled, buoyed by the faith of a discoverer, urged on by love of this child of his brain, fanatical in his determination to win. And win he did for it was vouchsafed to him in his vigorous old age to sit on his hearthstone and see the results of his work, his struggle and his faith. It is something to know that his fame has circled the earth, to be honored and sung by millions; a boon not accorded many a sage or philosopher. Not only has the public accepted it but the medical profession is making tardy but forced recognition of certain cardinal principles of osteopathy by using them, but, of course, without credit.

Osteopathy has been defined as “that science or system of healing which emphasizes, (a) the diagnosis of disease by physical methods with the view of discovering, not the symptoms but the cause of disease in connection with misplacements of tissue, obstruction of the fluids and interference with the forces of the organism; (b) the treatment of disease by scientific manipulations in connection with which the operating physician mechanically uses and applies the inherent resources of the organism to overcome disease and establish health, either by removing or correcting mechanical disorders and thus permitting nature to recuperate the diseased parts, or by producing and establishing antitoxic and antiseptic conditions to counteract toxic and septic conditions of the organism or its parts; (c) the application of mechanical and operative surgery in setting fractures or dislocated bones, repairing lacerations and removing abnormal tissue growths or tissue elements when these become dangerous to organic life.”[1] In a word, osteopathy is adjustment and the osteopath is an anatomical engineer who knows what is wrong and has the ability to correct it. Dr. Still changed diagnosis from guess work to fact and on it his fame may well stand, for when the cause of the disease was found, treatment was easy. He has ever emphasized the necessity of thorough examination and correct diagnosis. All treatment must be based on the definite, specific object to accomplish certain definite, specific things.

“Osteopathy would expound and apply the true philosophy of manipulation. While the hands are used, it is not this alone and chiefly that distinguishes its method of operation, but the idea and purpose that lie behind manipulation.”[2]

All manipulators are not osteopaths any more than all butchers are surgeons. The need for deep study of the subject is apparent from this characteristic statement of Dr. Still’s: “Osteopathy is a science; not what we know of it, but the subject we are working is deep as eternity. We know but little of it. I have worked and worried here in Kirksville for twenty-two long years, and I intend to study for twenty-three thousand years yet.”[3] This brings us to the point of the relations of osteopathy with other manipulative forms of treatment. They are not many, for Gerdine,[4] in closing a long article on the “Physiological Effects of Mechanical Therapeutics” says: “I have striven to show that in no way is Osteopathy similar to massage either in theory or practice if Osteopathy is conceived of, according to its founder, Dr. A. T. Still, as a system of healing in which a definite lesion in form of a bony displacement is the causative factor and a removal of the same, the curative factor in disease.”

The fact that use is made of the hands to the extent it is by both osteopaths and masseurs or Swedish movement operators gives rise to the mistaken idea of similarity in treatment.

“The essential distinction,” says G. D. Hulett, “between Osteopathy and all other systems of healing based on manipulation, clusters around the etiology of disease. While these other systems, as indicated at least by their practice, look at disease from a peripheral standpoint, osteopathy views it from a central standpoint.”[5]

Massage is a small branch of manipulative therapeutics, but conceding that it is perfect and scientific it can only resemble osteopathic treatment in one ramification of osteopathic practice, viz: relaxation of muscles.

The fact that massage is often employed by osteopaths in connection with their work shows the limitations of that form of treatment. Says McConnell[6]: “In the human body, as in any delicate, complicated mechanism, there is mechanism within mechanism; and, in order to obtain certain mechanical effects, many times there is required a series of complicated movements, all of which bear a ratio one to the other according to the energy utilized and the mechanical principle involved.” No other form of manual treatment takes this principle of mechanics into consideration. It is possible, as Gerdine points out, for an undeveloped osteopath to practice massage under another name. That the two should be confounded before the public is due to his ignorance and not from any fault of the system. Massage is a valuable aid in the treatment of disease but it is not Osteopathy.

“In the bright lexicon of osteopathy there is no such word as rub[7].”

Osteopathy in its relation with medicine has little in common. From the beginning, its founder realized their paths should run divergently, so the first step, its teaching, must be considered from a different viewpoint. To quote from an address by Teall[8]: “But to adequately teach osteopathy a vast amount of original work must be done. Anatomy is anatomy but there is a vast difference in its application. Physiology must be taught to mean something more than an interesting phenomenon. Pathology has an unfilled gap between cause and effect which must be bridged. The post-mortem has a great story to tell but an osteopath must tell it. A slide of degenerated tissue under the microscope is of interest, but why the degeneration? It is described at length by the authorities, but the reason for the causes and morbific changes are not carried out. Obstetrics along strictly natural and physiological lines insuring both mother and babe against injury; gynecology, minus the knife and plus common sense; all these, and more must be put into shape to teach the osteopathic student. The archives of osteopathy were empty ten years ago. There was no precedent to follow and the ideas in teaching which had prevailed for centuries dominated. All this is changed. The colleges teach the science along strictly osteopathic lines, making the application of the truths which have escaped the notice of centuries of investigation.”

All schools recognize the wonderful recuperative power of nature, as this from the introduction of a standard allopathic text book will show[9]: “There is no scientific dogma better established than this: that the living organism is in itself adequate to the cure of all its curable disorders. This natural law sustains the medical skeptic in his infidelity, enables the homeopath to report his sugar cures, and helps all physicians out of more close places than they are generally willing to acknowledge.” But at times, as all will agree, nature is not able to overcome its maladies and assistance is needed. Here, again, is a divergence as to the method and character of that assistance. There is no system so trivial or absurd which cannot point to its cures, but a school of medicine should have a settled system with established methods of procedure. This is not true of any school employing drugs as its principal therapy. In the President’s annual address at Cleveland he says[10]: “The observant reader of the progressive medical press is struck at once by the unsettled condition in the field of modern therapeutics. The trend is emphatically away from drugs. But, in the effort to get away from medicine, the medical investigator has wandered far afield, cutting loose from nature and resorting to the artificial.” It is the last paragraph of the extract quoted which particularly emphasizes the point of divergence, natural versus unnatural methods. It must be understood at once that the osteopath admits the reality of drug action for “there is no doubt that the pharmacopeia records many drugs whose action is rapid and effective so far as securing activity or decrease of secretion is concerned, but the element of danger, i. e., their destructive power is great. Oftentimes their power does not stop at the point desired or limit its effect to the therapeutic action sought[11].” This point of unreliability of the drug is emphasized by the following from recognized medical authority[12]: “We give drugs for two purposes: (1) To restore health directly by removing the sum of the conditions which constitute disease. Here we act empirically with no definite knowledge—often indeed with little idea of the action of our drugs, but on the ground that in our hands or in the hands of others they have restored health in like cases. (2) To influence one or more of the several tissues and organs which are in an abnormal state so as to restore them to or toward the normal; with the hope that if we succeed in our purpose recovery will take place. The purpose we effect by means of the influence which the chemical properties or drugs exert on the structure and function of the several tissues and organs. Minute information, therefore, of the nature of drugs and their action is essential for their proper employment.” Osteopathy brings into action the latent or stagnant forces of nature by specific methods which are usually reliable. Naturally there being such a wide difference in theory of the cause of disease it would be also shown in diagnosis as well as treatment. The most striking points to the layman in medical procedure are: first, wide difference in the system of diagnosis and in its findings by physicians of the same school; second, the great variance in remedies employed by different physicians of the same school for the same disease.

Osteopathic diagnosis is so physical in its character, depending upon actual conditions found and not upon the subjective symptoms alone, that the same patient examined by a number of experienced osteopaths will be given the same diagnosis, and he will also be able to detect in each the same effort to correct in all their technique. All the methods of physical diagnosis are used plus the distinctive osteopathic procedure. Results wherever used bear out the effectiveness of the system.

The osteopath must and does consider the necessity of surgery, but his effort is always to prevent the operation if possible. There can be no doubt that surgery is carried to extremes and there is a strong sentiment growing that much of it is unnecessary. Says Homer Wakefield, M. D.[13]: “It is to the everlasting disgrace and mortification of the medical man that the wealthy classes who are continually under the observation and direction of eminent men, in dietary, and all life habits, in health as well as in sickness, are not only the very ones who develop appendicitis and most largely go to operation, but are almost exclusively those who attain to this distinction.” The operations of today are wonderful and the surgeon shows great skill and genius in their performance, but great as he is in these matters how infinitely greater is the man who can prevent them. The need of the osteopath today is to be trained to recognize surgical conditions and neither allow surgery unnecessarily nor make the more terrible error of not acting soon enough. Where surgery is a necessity there is always an etiological factor to be considered. The cause of the manifestation not always being removed what is to prevent a recurrence or serious sequela in spite of the operation? “The specialist ... if he has wit enough to read the lesson presented to him, that it is not sufficient to remove an ovarian tumor, e. g., and that if nothing is said at the same time or subsequently as to the causes which induced it, a positive damage may be done to the woman, who may, therefore, while considering herself cured, proceed to manufacture one on the other side, or may find herself in a few years suffering from cancer in the stump of the previous one[14].” And so the combination of osteopathy with surgery may be necessary that the cause shall be removed. Osteopathic treatment before operations in reducing congestions and inflammations, also in toning the nervous system, is particularly efficacious while the after treatment gives gratifying results. In fact, the two go hand in hand when conservatism rules both.

That diet should receive particular attention from the osteopath is not strange, for his veneration of nature peculiarly fits him to realize the necessity of correct feeding. Probably no subject is more discussed or presents a wider range of opinion than diet. There is overfeeding and underfeeding; long intervals and short between feedings. There is the no breakfast and no supper plan, mixed diet and the vegetarian, uncooked foods, and one exclusively of milk, anything you want so long as you are hungry but chew it well, etc., ad. lib. All are represented by osteopaths in their following as they are from other professions, but probably this would more nearly represent the views of them as a school. In health, first, most people eat too much and do not thoroughly masticate and insalivate. This applies to all stations of society. Second, meat forms too large an item in the daily dietary. Third, there is not enough variety and the ration is not well balanced as to elements. Fourth, not enough care is used in preparation of foods. In illness, first, the stopping, complete or partial, of food until the system can take care of it; second, the giving of easily digested foods. The man who avoids violent extremes in diet as well as in other habits of life will usually last longest. It is to be hoped that some rational system can be evolved on which all factions may agree, for the present confusion of authorities is bewildering. The osteopath gives attention to hygiene, sanitation, exercise, environment, mental attitude, etc., as they may affect the welfare of his patient.

Osteopathy can cure all curable diseases, for the same forces which will overcome one malady will overcome another when set in motion. Forces that produce a diseased condition will it normalized restore the established type.

FOOTNOTES:

[1] Littlejohn, (J. M.)—Journal of the Science of Osteopathy.

[2] Encyclopedia Americana.

[3] Booth—History of Osteopathy.

[4] Journal of Osteopathy, May, 1905.

[5] Principles of Osteopathy, p. 190.

[6] Journal of the Science of Osteopathy, Dec. 15, 1900.

[7] Osteopathic Calendar, 1900.

[8] Reported, Portland, (Me.), Advertiser, Feb. 27, 1905.

[9] Potter’s Materia Medica.

[10] Teall—Journal of the American Osteopathic Association, Aug., 1903.

[11] Tasker—Principles of Osteopathy, p. 110.

[12] Allbutt’s System of Medicine.

[13] Cyclopædia of Practical Medicine, June, 1906.

[14] Rabagliati—Air, Food and Exercise, p. 129.

OSTEOPATHIC ETIOLOGY AND PATHOLOGY

Osteopathic Etiology

Osteopathic etiology and pathology constitutes the most interesting chapter of osteopathic science. The primal divergence of the osteopathic schools from previous systems is to be found in the osteopathic interpretation of disease causes and processes, and not in osteopathic therapy as some may think. Osteopathy makes claim to an independent school because it possesses a distinct etiology, pathology, diagnosis and treatment. Thus osteopathic practice is not a mere method, but instead a system, a school, a science.

At no period of medical history have physicians of the older schools felt more keenly the futility of medical methods and the lack of an all-embracing principle of medicine than at the present. A recent writer[15] who claims to have discovered a principle that encompasses the entire field of medicine, says: “We found, we may say, that the backbone of medicine was the absent factor, and that if the patient labors of so many great minds had not proven as useful in the development of practical medicine as they should, it was because they lacked such a fundamental framework to afford a fixed nidus for each discovery, wherein its true relation to other discoveries would at once become evident.”

Since the conception of osteopathy its fundamental framework has not changed one iota as to principle, although the application of the principle has been greatly elaborated. When Dr. Still proclaimed that “the rule of the artery is supreme” he gave utterance to a basic physiological truth. But when he demonstrated that osseous and other anatamo-mechanical lesions disturbed the artery and caused disease, and that readjustment of the anatomical cured the disorder, thus allowing the physiological to potentiate and revealing that the living body contains all the attributes of a vital and physical mechanism, did his teaching contain the germ of a comprehensive philosophy; this gave osteopathic science a “backbone” with a consequent fixed nidus for all existing facts and future discoveries. And thus, it should always be emphasized that mechanical readjustment of the component parts of the vital body is the eternal keynote of the osteopathic school of healing.

=The Osteopathic Lesion.=—Broadly speaking a lesion is “any morbid alteration in a tissue whether attended by a recognizable structural change or not; but especially a change in which the continuity of some of the tissue elements is broken in upon.[16]” There are several kinds of lesions expressing the tissue involved, character of degeneration, locality of same, etc. But upon analyzing the medley of arbitrarily defined lesions the fact will be evident that much of medical etiology and pathology has not been logically and consistently sifted and arranged; and moreover, it will be found the =cause of causes= of many diseases is unknown.

Herein, arises the great significance of the osteopathic lesion, for the lesion alters the very governing and controlling tissues of the body, viz., the nervous tissue and the vascular channels. Hulett[17] defined the osteopathic lesion as “any structural perversion which by pressure produces or maintains functional disorder.” The constant maintenance of the structural perversion will, also, cause organic disease, although it is granted that functional disorder must necessarily result prior to any organic change.

The osteopathic conception of a lesion, functional and organic disorder caused by pressure from disturbed structures, does not bring us into an absolute new field. Medical literature of all ages contains references to diseases caused by pressure of tissues on nerves, blood vessels, or other channels. But the osteopathic idea is an absolutely new one in the application of this principle universally. It simplifies and makes uniform the arbitrariness of present semeiology.

Thus the osteopathic idea that many diseases originate, primarily, from anatomically malaligned, malpositioned, or malrelated tissues causing a blockage of vital processes, immediate or remote, is a theory inclusive of disturbances to all tissues. This principle is fundamental and is supported by the physiological truth that uninterrupted vital channels preserve health; moreover clinical and experimental data, as will be shown later, substantiate this fundamental. It at once places interpretation of a lesion in an entirely new light from preconceived concepts, and is analogous to and co-extensive with etiology and pathology.

=Etiological Factors.=—The osteopath believes in the potency of inherited and environmental influences. There can be no question that a few diseases and certain disease tendencies may be inherited, the principle feature, however, from the standpoint of heredity is, various organs and tissues have less vital resistance. These should not be confounded with congenital weaknesses and diathetic tendencies.

Environmental influences are very important factors. One’s surroundings and daily habits in the home, shop, or office count for much in the aggregate. Food, drink, air, rest, sleep, clothing, exercise, mental attitude, etc., are all factors in the sum total of health, and consequently ill health may be traceable to their abuse. In fact, all hygienic and sanitary measures are duly considered by the osteopath. Various abuses, over use, and disuse of the functions will certainly be followed by physiological discord.

The germ theory contains much truth, but in the very large percentage of cases where the micro-organism is a factor its significance is only of secondary consideration. Immunity and resistance comprise an important part of the health problem, of which the intact anatomical is of first consideration. Usually the micro-organism plays the role of an exciting and determining factor; before it can multiply and grow there must be a field that is first nutritionally disturbed. Nutrition of the tissue is the one great point always to be considered. The constitution of an individual is the pivot about which predisposing, environmental, and exciting factors of disease center. Health represents the integrity of the artery as well as a maintenance of that master tissue, the nervous system, and anything that produces or influences, directly or indirectly, a disturbance of physiological functioning borders on the pathological.

Hence the osteopath recognizes many of the common medical causes of disease, but reserves the privilege of rearranging their relative positions, for the osteopathic cause of disease greatly modifies their value.

=Osteopathic Etiology= distinctively emphasizes structural derangements and perversions. Of =first= importance, owing to static requirements, is the =osseous lesion=. This lesion is represented by any abnormal change of position or relation of the many bony constituents of the body. The framework of the body is subject to not only any and every physical violence of any mechanism, but moreover being the corporeal foundation of a vital mechanism is subject to both direct and indirect biochemic changes and influences.

Thus the osseous lesion is caused (a) by traumatism, e. g., strains, falls, blows, etc.; (b) indirectly by atmospheric changes, over and violent exercise, the slumped posture, debilitating habits, etc., through the media of muscle changes and imbalance; (c) by nutritional effects disturbing the elements of bony tissue; (d) by ligamentous change such as thickening of a capsular ligament; (e) by infections; (f) compensatorily and reflexly through the media of body distortions and muscular irritability or debility, e. g., an innominate lesion may be compensatory to a lumbar curvature, dietetic errors may cause dorsal muscular irritation and contraction produce a constant osseous lesion which in turn may result in chronic indigestion.

The pathological changes in the osseous lesion are commonly one of structural derangement, deviation or complete displacement. The vertebral segments are of primary consideration owing to their important relations to the spinal nerves, spinal cord centers and sympathetics; the ribs owing to the close sympathetic and spinal nervous relations; and then other osseous tissues, as the innominata, clavicles, etc., depending upon their importance to contiguous vessels, nerves and organs. It should always be remembered and emphasized that mechanical changes of the anatomical structures is the primary essential in osteopathic etiology; this is the one great inception of pathological variations from the distinctively osteopathic conception, which the osseous lesion typifies. Consequently the osseous lesion factor is actually a luxation (complete, or partial, even to a very slight degree), or malalignment of the bony constituents, which by virtue of their physical malposition impinge or irritate contiguous tissues. The essential test is the functional one, movement. The degree of involvement may be one of many gradations ranging from a slight malposition or impaction to a marked deviation or firm anchorage.

=Second= in importance from the static requirement of support is the =muscular lesion= though from the standpoints of movement and dynamics it is often of the first consideration etiologically. Many interosseous lesions are the result of spastic involvement of deep seated spinal muscles, of fibrotic changes and of tensions and weaknesses that either establish a rigidness of the segments, compromising nervous stimulus or vascular channel, or produce an imbalance of muscular tone and tension. In the latter instance some type of sidebending-rotation osseous lesion occurs, commonly anchored within the physiologic movements of the spine. The muscular lesion may be an actual dislocation of either muscle or tendon, but rarely. Commonly it is a contracted, or tensed, or contractured muscle. The muscle, also, may be diseased either from primary or secondary causes through nutritional and infectious sources and thus be an etiological feature.

The muscular lesion is caused, (a) by direct or indirect violence the same as the osseous lesion; (b) by atmospheric influences; (c) by slumped posture, debilitating habits and various errors of living; (d) infections; (e) by reflex irritations; (f) by compensatory changes; (g) by disease causing hypertrophy or atrophy; and, (h) secondary to osseous lesions, being the result of impingement to the muscles’ nervous control. The tensed or stretched muscle may result from a separation of the points of origin and insertion.

Herein the fundamental osteopathic concept is the resulting affection due to the physical encroachment, directly or indirectly, of the muscle tissue upon vascular channel or nerve fibre, or the effect upon the movement or alignment of the osseous tissue.

Muscular contractions, displacements, and tensions play a most important part in acute disorders, although muscular lesions that are secondary to other lesions are usually taken into account when treatment is given. Muscular lesions affect, (a) blood and lymph vessels; (b) nerve fibres. Muscular contractions, especially, impede mechanically the return of the venous blood to the heart. The lesions to the nerves may be manifested in innumerable ways, depending upon the location of the muscle and the function and distribution of the nerve affected.

Then there is the relaxed, overstretched, and atonied muscle. This condition results as a secondary effect to mechanical strains, these being so severe and constant as to cause direct stretching and possibly tearing of the muscle fibres. This should be distinguished from the exhausted or debilitated muscle, e. g., as found in neurasthenia and anemia.

Diagnostically there are, (a) contractions of more or less area, due to atmospherical changes; (b) the deeply seated contractions involving a very small area, caused by vertebral and rib lesions; (c) contractions due to reflex disturbances; (d) contractions caused by postural effects and deformities; (e) contractions from spasms of the blood vessels as a result of nervous irritations; (f) contractions due to toxicity of the blood. All of these characteristic muscular lesions give a direct hint as to both etiology and prognosis.

=Third=, the =ligamentous lesion=, as a lesion per se, is usually of secondary importance to the osseous lesion. In chronic cases affections of the capsular ligament and muscular fibrosis commonly maintain malalignment or rigidness. There are two features that should be noted in particular when considering this lesion; first, thickenings and adhesions; and, second, relaxations.

The tone and integrity of the ligaments cannot but be of vital concern to the stability, suppleness, and adaptability of the bony framework in all physical movements. No matter how slight the osseous lesion may be the ligament must of necessity be involved. The osseous derangements are either a source of irritation to the ligamentous tissue, resulting in congestion and inflammation and hence thickening and adhesions, or else the ligaments are so strained and tensed that in time atony may occur. Probably, in a fair percentage of atonied cases the first disturbance to the ligament is one of irritation and congestion, and from long continued involvement irritation is supplanted by debility.

Consequently the primary consideration of the ligamentous lesion from the etiological standpoint is the character of the tissue (ligament) changes. This, also, gives us a direct hint that is of the utmost value in prognosis. The independent displacement of a ligament is rare, thus ligamentous lesions from the viewpoint of purely physical displacements are secondary to if not an actual part of the osseous lesion. Ligaments, when displaced or tensed, readily impinge or irritate contiguous tissues, but the original cause of the structural perversion is commonly either the osseous or muscular lesion. Hence, whatever factors enter into the production of these lesions will at least indirectly produce the ligamentous lesion.

=Fourth=, the =visceral lesion= is frequently overlooked as being of much moment as an osteopathic lesion. Visceral displacements acting as a source of functional and organic annoyance on the physical plane (structural perversion which produces and maintains pressure) alone are not in the least uncommon.

Any or all of the abdominal viscera, or even the organs of the thorax, may be displaced (physically) pathologically. Actual displacement of the viscus is a prolific source of distinct disorders and many obscure symptoms. True it is the organs are most frequently displaced from indirect causes, but nevertheless the actual physical malposition is in turn a primary cause of still another train of symptoms and diseases.

Visceral lesions are caused by, (a) vertebral lesions; (b) postural defects; (c) direct violence; (d) nutritional disorders; (e) childbirth; (f) unhygienic measures (tight lacing, heavy skirts, etc.); (g) congenital weakness.

From the displaced heart due to valvular and debilitating influences to the displaced liver, the stomach, the kidneys, the intestines, the ovaries, and the uterus, may arise a source of direct or indirect irritations, a train of apparent or masked symptoms, or a group of nutritional disturbances that include an extremely important chapter in etiology. Moreover not only may one organ alone be involved but several may be displaced or prolapsed as a whole as in splanchnoptosis; and even these in turn may be the direct cause of further organic displacements as the abdominal viscera prolapsing upon the pelvic organs. Here is a very fruitful field for the diagnostician, for to separate cause from effect requires keen perception, an acute sense of touch, and above all, most careful weighing of all the factors that enter into the maze.

=Fifth=, the =composite lesion= is not always recognized as an extremely important osteopathic factor. By composite lesion is meant a structural lesion that primarily includes the osseous, muscular, and ligamentous tissues as a whole. This may be termed a lesion en bloc or en masse.

Composite lesions are of exceedingly frequent occurrence. Indeed, many composite lesions are overlooked and instead of treating the en bloc disturbance as a consistent whole the component factors are treated separately with no concern or attention to the whole.

Postural defects are excellent types of the composite lesion. The various curvatures, the tilted pelvis, etc., are representative of the composite lesion. Etiologically, pathologically, diagnostically, and therapeutically the contour of the spine and ribs, the relation of the innominata to the sacrum and spine, and the symmetry of the body generally should be recognized and appreciated. The relation of the part to the whole and of the whole to the part are of vital etiological concern. An incipient curvature may be easily overlooked, a pendulous abdomen neglected, and a slipped innominatum passed unnoticed wherein as a result the entire vertebral column is malaligned in relation to the physiological curves or to the perpendicular line of gravity.

Frequently attempts are made to correct individual lesions when attention should be directed to the composite lesion and vice versa, e. g., a displaced rib is usually dependent upon a corresponding vertebral lesion, and thus the transverse plane or section of the body should be considered as a whole. A single lesion may be dependent upon a composite lesion or a composite lesion dependent upon one or more single lesions. A slipped innominatum or a disordered hip joint may bring about a strain to a greater or less section of the spinal column, or a twisted vertebra may cause a curvature, whereas on the other hand postural defects may cause a strain at its maximum focal point resulting in over-stretching and relaxing of ligaments so that an osseous lesion results, or a spinal curvature cause an innominatum displacement. Thus there is a constant establishing of equilibrium, physically and physiologically, through the medium of compensation, but at some phase of the change there are apt to be pathological phenomena resulting, and very frequently physiological harmony is not reestablished but instead irritation, debility and other disease symptoms are constant effects until relieved.

Consequently osteopathic etiology is many sided and complicated. To know whether an osseous, ligamentous, muscular, visceral, or composite lesion is primary or secondary, compensatory, reflex, predisposing, or exciting, requires a command of theoretical knowledge backed by much actual clinical experience.

In noting the above distinctive osteopathic etiologic features the student should not lose sight of the constitutional status of the patient which may be modified by inherited, congenital, diathetic, and environmental influences, all of which go to make up the predisposition of the individual and have an important relation to osteopathic factors. Then it should be recalled that disease processes may be of insidious progress, and the products and effects of pathologic changes accumulative.

Osteopathic Pathology

In the etiologic study the osteopathic characteristics have been designated structural maladjustment, although at the same time not losing sight of the angle that the body is not only a physical mechanism but also a vital organism. Structural perversions characterize the osteopathic distinction when dealing with the physical body, and remembering the vital or biochemic mechanism, mental attitude, diet, hygiene, etc., are not forgotten. To retain or attain health, thorough appreciation of both the physical and vital mechanisms should be kept in view, for there is both an independent and dependent interaction on the part of each. The living body being an entity premises a system of therapeutics both physical and vital, that acts in direct accord and harmony with physical laws and physiological functioning.

Osteopathic pathology deals with the distinctive osteopathic lesion as a factor in production and maintenance of disease. Then the province of pathology is, first, to determine whether the lesion is in reality an etiologic factor; second, the immediate character of the lesion disturbance; and, third, how organic life becomes involved.

Inspection, palpation, clinical results, dissection and laboratory experimentation include the methods employed to prove that the lesion is of practical consequence. That the lesion is an etiological factor can be known only through clinical and experimental proof; the immediate character of the lesion disturbance can be determined by dissection; and how organic life becomes involved requires the summation of histological, physiological and pathological data.

The following outline assumes that the reader is familiar with anatomy, physiology and pathology. Osteopathic pathology does not add to medical pathology an absolutely new pathology in all of the present known numerous details, but instead interprets much of clinical pathology anew, and furthermore it presents absolutely new data that is exclusive, but germane to the present general medical and surgical fields.

Nervous tissue and arterial blood are the master tissues, the controlling and governing factors in health, and disturbances of these tissues are necessarily the cause of ill health. The rule of the artery and the control of the nerve must continue uninterruptedly in order that physiological functioning remains intact. The body should be looked upon as a being complete, no more or less, each tissue and organ essential to the whole and the organism as a whole essential to every part. This is fundamental and germane to a living structure, and hence disturbance to the governing and controlling tissues, the nerves and vascular channels, must necessarily cause a break in the concatenation and disease must logically follow.

Thus in the osteopathic pathology we look to those influences that primarily disturb the nerve or artery, study the disease process or extension from inception to effect and from primary lesion to morbid results, and note action and interaction of tissue upon organ and organ upon organ.

That all parts of the body are in intimate and dependent relations each with the other through the media of the nervous and endocrine systems is a well known fact based upon histological and physiological grounds. The neurone being the physiological unit implies that any disturbance to the cell quickly disturbs any or all of its processes. It may be said that “nervous tissue is dependent for its integrity upon two things, blood supply and trophic influences. The nerve cell is solely dependent on a proper supply of blood, and dies when this is withdrawn. But the nerve fiber is more dependent on the trophic influence of the cell of which it is a prolongation. It dies when cut off from the cell but it can get along for a time with but little direct blood supply. On the other hand, if the nerve fiber is injured it reacts on the cell, leading to a partial but curable degeneration of the cell body.”[18] Here is the immediate pathologic key to many diseases. Whatever cuts off or obstructs the artery leading to the cell is a primary etiologic factor; this then leads to degeneration of protoplasmic processes and axone. It should be carefully noted that if the obstructed blood vessel is one to the nerve fiber only the resultant partial injury to the cell is curable.

“When an axone degenerates the retrogressive process involves not only the main axone, but also its terminals, together with the collaterals belonging to it with their terminals.”[19] This is an exceedingly important link in the explanation of osteopathic pathology, that distant organs may be affected by the osteopathic lesion. Moreover, “degenerations of a secondary character may occur in those systems of neurones which are more or less dependent upon the peripheral sensory neurone system for their impulses.”[20] This is equally true with the central motor neurone, or any neurone. It shows how far-reaching a degenerative process and its effects may be. It further makes clear that nerve intactness is directly and absolutely dependent upon a normal circulation, and that it is self-evident any blockage either to blood vessels or to neurones will vitally affect those tissues that govern and control the life processes of the body. The integrative action of the nervous system is one of the outstanding facts of physiology.

The above is presented so the student may see how osteopathic spinal lesions, if deeply seated and effective enough, can involve remote tissues and organs. No one will doubt that fractures and complete dislocations of the spinal column will seriously affect visceral life, or a prolapsed kidney will be a cause of nutritive disturbance, or a displaced uterus the cause of ovarian congestion, or a dislocated hip the cause of atrophy of the leg muscles, but it has remained for the osteopath to offer proof that slight misplacements of the vertebræ or ribs, incipient curvatures, postural defects, slight deformities, and unsymmetrical bodies are of sufficient etiological importance on the physical plane to affect neurone integrity and obstruct artery courses, and thus organic life.

The question at once arises, what is the immediate or direct effect upon blood vessel or nerve of the osseous, ligamentous, muscular, visceral or composite lesion? The osseous lesion will be taken as a type. The direct effect is usually one of hyperemia or ischemia, generally the former, for as physiologists and clinicians observe irritation commonly precedes debility. In the vertebral and rib lesions there may be direct pressure upon the spinal nerve at its spinal foramen exit or on the sympathetic chain directly contiguous to the heads of the ribs. This causes congestion, inflammation, ecchymosis, and degeneration of the nerve fiber, followed by macroscopic and microscopic changes as connective tissue proliferations, arterial scleroses, etc. Or, as seems probable in experimental work, the inception of the pathology may be frequently the result of blockage to nervous stimuli, which when maintained affects the efferent vasomotor, secretory, trophic and other fibers so that circulation and nutrition are definitely involved.

Thus the cells so sensitive to altered vascular changes are directly and remotely affected, and disease characteristics dependent upon structure and function of tissue, and degree of irritant are evident. This can vary, in degree only, with the muscular lesion that involves collateral spinal cord circulation, the visceral lesion that irritates sympathetic life, or the composite lesion that deforms or perverts structure en masse.

But is the physical noxa as potent an etiologic factor as the chemical or bacteriologic? Adami[21] informs us whether an irritant is physical, bacterial or chemical, no satisfactory distinction can be founded on the duration of the irritation; that a local irritation of the nervous system may lead apart from “direct reflex action, to changes of nervous origin, in the region of the injury and in the reflexes affecting associated regions, the higher centers; and through them the system at large, may become affected by paths that it is not always easy to trace.” Again he says that “centrifugal impulses alone, apart from any local injury, may originate a succession of phenomena of inflammation in a part.” And “in all probability a nervous and central origin must be ascribed to some, at least, of the sympathetic inflammations seen to occur in areas supplied by the other branches of a nerve supplying a part primarily inflamed; and again in areas supplied from the same region of the brain or cord as the inflamed organ.” Other inflammatory changes, of course, may occur independently of centrifugal nervous influences, and the vessels react independently of central influences.

This, then, presents a situation postulated thus:

1. The body follows definite structural relations and is influenced by mechanical arrangements in its morphology.

2. The integrity of tissue depends upon structural freedom of nutritive courses.

3. The above predicates a structural etiology as exact and precise as structural relations are important to nutrition.

What proof, then, of the foregoing have we to offer?

First, the =clinical proof=. Clinical results have been obtained in tens of thousands of cases that include disease of various types and lesions, and of all sections and organs of the body. The art of osteopathy has been perfected in many of its details, based upon actual experience and splendid results. The cure of the patient is paramount to all other consideration, and whereas the osteopathic school has been shown a superior system it logically follows on a priori grounds that relief and cure of suffering is of the first and final importance.[22]

Were it not for clinical results no new system of therapeutics could withstand criticism and calumny and finally triumph and be publicly, legislatively, and scientifically recognized.

Second, the =autopsy proof=. Many dissections have been made and autopsies held with the view of discovering the character and the potency of the osteopathic lesion. This very important work has borne out the osteopathic theory of disease. Vertebral and rib displacements have been noted, corresponding ligamentous tissues thickened, associated nerve tracts and vascular channels disturbed, and finally the related organ found diseased.[23]

Third, the =experimental proof=. Experimental proof appeals, logically, to the scientific mind. This proof[24] is being gradually developed.

Experimental investigation has been successfully carried out upon numerous animals. The experiments conclusively prove that not only spinal inhibitory and stimulatory manipulations (mechanical) are productive of immediate physiological changes in the viscera, but that the structural anatomical lesion or noxa is an important factor in the etiologic field. Pathological changes in several organs directly follow the artificially produced vertebral and rib lesions, showing beyond doubt the reality and effectiveness of the osteopathic lesion. This emphasizes the point that centrifugal impulses originate an inflammation in a previously healthy and uninjured tissue or viscus. And as “inflammatory phenomena may be sympathetically developed in regions innervated from the same area in the brain or spinal cord” it remains to prove the actuality of vertebral and rib lesions, i. e., structural perversions really affect contiguous nerve courses and vascular channels; and this has been demonstrated in laboratory experiments and at the autopsy. Consequently the vertebral, rib, or other lesion may be an important etiologic factor either to the nerve strand from cord or brain to viscus or from viscus to cord or brain.

Dr. Still says in his Autobiography that “all nerves depend wholly on the arterial system for their qualities, such as sensation, nutrition and motion, even though by the law of reciprocity they furnish force, nutrition and sensation to the artery itself.” It matters little in this outline whether obstruction to nervous integrity is by way of an impinged artery or by direct pressure, or both, or otherwise, for the primary consideration is the noting that the osteopathic lesion is a real and potent factor of disease. Sajous[25] informs us that “a neurone is directly connected with the circulation (via neuroglia-fibril) by one or more of its dendrites, which serve as channels for blood plasma,” that a neurone receives its nutrition directly from the general circulation, and that from the axone the blood passes into a lymph space connected with a vein. Thus in reality a part of the circulatory system is that of the entire cerebrospinal system.

The student is referred to the various publications of the Research Institute and Deason’s Physiology for experimental data confirming the validity of the osteopathic theory, although it should be emphasized that clinical evidence is quite conclusive. Malalignment injuries of the vertebral articulations, for example, ranging from imbalance of muscular tension to infections, is certain to result in some type of rotation and sidebending of the segments to an extent that apposition is compromised and abnormal anchorage supervenes. There are many factors of the pathology: muscular tension and fibrosis; damaged ligaments, particularly the capsular; interference of nervous stimuli, blockage of impulse directly and reflexly as shown by pathologic involvement in cord centers and sympathetic ganglia, and in certain cases direct obstruction of nerve fibers as revealed by Wallerian degeneration; involvement of circulation as shown by damage to blood-vessels, local edema and local acidosis, and effect upon local tissue respiration and drainage. Through a combination of these various factors circulation, nervous equilibrium and chemism of related parts are involved, both anatomical and physiologic balance is upset, and resistance of corresponding viscera affected. Reciprocal innervation and the axone reflex are also disturbed, all of which are important predisposing causes that disturb resistance of tissues and organs, upset their correlated mechanisms and render active various possible infections and toxins that otherwise a normal circulation, nervous and endocrine systems, and oxygen supply would rapidly and successfully combat and restore the organism to normal. Thus from the practitioner’s standpoint there are three points to always keep in mind: readjustment of the lesion; correction of the forces, habits, environment, etc. that produce the lesion; and hygienic attention of the body after lesion adjustment in order that normal condition may be maintained. A thorough study of the physiologic movements of the spine is a prerequisite to an understanding of the various possible abnormal appositions, though it should be appreciated that these movements are not consonant or applicable to many abnormal conditions. Pathology reveals many gradations and combinations not found in normal conditions. Frequently the key of a successful technique rests upon an understanding of the individual make up of the interosseous lesion.

It has not been the purpose of this section to go into details but rather to follow logically an outline of osteopathic etiology and pathology. The various details will be found in the osteopathic works on Principles as well as in the experimental articles referred to. It should be understood that the osteopath believes thoroughly in vis medicatrix naturae whether the indications are for stimulation or inhibition or for the basic readjustment. Generally speaking, however, therapeutic philosophy resolves itself (ultimately) into the principle that a cure depends upon giving an impetus to impaired, habitual and latent forces, which in the osteopathic field implies fundamentally adjustive manipulation whereby the resultant impetus or physiological stimulus is initiated.

In a word, osteopathy premises that the body is a vital and physical mechanism subject to derangements, structural alterations, and functional changes, as results of violence on the mechanical plane, as well as disturbances on the psychic and biochemic planes. Hence, osteopathic philosophy is inclusive of preventive, palliative and curative measure.

FOOTNOTES:

[15] Sajous—The Internal Secretions and the Principles of Medicine.

[16] Foster—Medical Dictionary.

[17] Hulett—Principles of Osteopathy.

[18] Dana—Text Book of Nervous Diseases.

[19] Barker—Reference Hand Book of the Medical Sciences.

[20] Delafield & Prudden—Hand Book of Pathological Anatomy and Histology.

[21] Adami—Inflammation, Allbutt’s System of Medicine.

[22] See Case Reports, American Osteopathic Association.

[23] Clark—Applied Anatomy.

[24] McConnell—Numerous articles Journal A. O. A. 1905-19, Bulletins Research Institute; Deason, Bulletins Research Institute, Deason’s Physiology; Burns’ Osteop. World, Aug. 1905; Basic Sciences, Bulletins Research Institute; Pearce, Osteopathic Physician, Nov. 1905.

[25] Sajous—Internal Secretions and the Principles of Medicine.

OSTEOPATHIC DIAGNOSIS AND PROGNOSIS

Osteopathic Diagnosis

In osteopathic diagnosis the spine is the first and greatest object of interest, for on the result of its examination will depend the treatment to be given which is in turn hoped to bring about recovery.

As it is the structure on which rests the weight of the body the practiced eye is able to detect at a glance, by the poise and gait of the patient, if there is an abnormal condition affecting any considerable area of the spinal column. It is well to observe these points, especially in the female, before having them prepare for examination, as it will often give a clue to sources of trouble through faulty carriage, improper dress, particularly corset and shoes. Slight changes of gait, unnoticed by the patient may be of great aid in determining the beginning of disease in the spinal cord.

No osteopath is justified in accepting a patient who will not permit every examination deemed necessary, as remote and obscure lesions are frequently the cause of disease, so preparation of the patient for the first scrutiny is of importance. This cannot be made with the patient fully clothed, as visual observation is second only to the touch in making one’s deductions. Neither can palpation be made through more than one thickness of clothing with accuracy, and examination next to the skin is always preferable. This need in no way ever cause complaint, for with the use of a loose fitting short kimono, with all outer clothing removed except the knit undergarment, and with skirt bands loosed, a complete survey of the whole dorsum from occiput to coccyx can be had without the slightest unnecessary exposure. It is well to remember that the patient has come for help and the osteopath is not justified in sacrificing thoroughness for any exaggerated feelings of modesty. With tact and care in the use of the garments the most sensitive ones need feel no hesitation in coming for treatment.

A complete history of the case should be taken before the examination begins, former methods of treatment, symptoms, environment, etc., as it will aid in the final conclusions. It is well to have blanks for keeping records of all cases.

Probably the most comfortable manner to begin physical examination is to seat the patient on a table squarely with hands placed upon the knees, then raise the garment and expose the whole back. Begin by noting the texture of the skin, if it is clear, pigmented, blotched, or has eruptions. Try the capillary reflex by pinching or stroking quickly with the finger tips or the blunt end of a pencil. Find if it is moist or dry and also outline the areas of changed temperature, if any. Then observe the general contour of the spine with the patient sitting upright, to find how near it is to the normal body curve.

Occasionally having the patient alternately sit and stand will, by comparison, throw light upon the condition. With the patient bending forward place the hands on the crest of the ilia and see if they are of equal height.

Occupation may result in over development of one side or there may be congenital asymmetry[26]. Note position of the scapulæ and habit of posture in sitting and standing.

Before taking up the subject of a critical examination of each vertebra there are certain points it will be well to consider. It is easy to know instantly, without counting, the number of the vertebra causing the lesion if these landmarks are remembered: First, the spine of the third dorsal is on a level with the spine of the scapula. Second, the spine of the seventh dorsal is on a level with the inferior angle of the scapula. Third, the spine of the last dorsal is on a level with the head of the last rib. It will save much time for the busy osteopath to have these well in mind.

The =pathognomonic symptoms= of the osteopathic lesion are: (a) maladjustment; (b) contracted muscles; (c) tenderness; (d) limited movement. To these might be added changes in local temperature and disturbance of function, but the former is not constant and the latter may be remote. Here the primary lesion is considered, for an osteopathic lesion may be, also, secondary or compensatory. Forbes speaks of compensatory changes as being an important diagnostic sign.

Diagnosis of the position of a vertebra is sometimes difficult to the beginner from its having longer or shorter spines than normal. Horsley speaks of the occasional congenital absence of a spinous process. They may be bent laterally, upward or downward and thus have all the appearances of a marked displacement, while occasionally the body itself seems much at fault. These present what might be termed normal abnormalities and make it necessary for the osteopath to be very sure of his diagnosis before attempting to correct what is not abnormal, for disappointment, at least, and injury, perhaps, may follow.

To avoid mistake, carefully palpate the transverse processes and determine if they are at right angles with the adjoining normal spine. In the cervical and lumbar vertebræ it is possible to reach the tips of the transverse processes, and on moderate pressure, if a lesion exists, pain will be elicited. Further, where tenderness is associated with other diagnostic points it can be safely assumed that a lesion exists, and by outlining the suspected vertebra with the finger and localizing the sensitive spot one can be sure of the point of greatest irritation and the character of the displacement. Associated also with these signs will probably be evidence of congestion, such as thickened tissues, contracted muscles, etc.

After having examined the condition of the spinal column thoroughly by inspection, begin at the first dorsal and examine the spinal column down to the sacrum. Place the middle and ring fingers over the spinous processes and stand directly back of the patient and draw the flat surfaces of these two fingers over the spinous processes from the upper dorsal to the sacrum in such a manner that the spines of the vertebræ pass tightly between the two fingers, thus leaving a red streak where the cutaneous vessels press upon the spines of the vertebræ. In this manner slight deviations of the vertebræ laterally can be noted with the greatest accuracy by observing the red line. When a vertebra or a section of vertebræ are too posterior a heavy red streak is noticed and when a vertebra or vertebræ are anterior the streak is not so noticeable. Thus when suspicious points are noticed a special examination of the localized point can be given. This examination simply takes into consideration the contour and superficial condition of disordered portions of the spinal column. In a few cases such an examination will not be necessary, for the symptoms and signs of the disease will be so clearly manifested that one’s attention will be called directly to the cause. Still, great care should be taken in the majority of cases, as the osteopath finds causes of disease remote from the seat of complaint. We must always bear in mind the significance of reflex stimuli and sympathetic radiation.

In making a critical and exhaustive diagnosis of the spinal condition after the foregoing general examination has been made, it will be best to have the patient lie on the side upon the operating table. When the patient is in this position a more thorough examination can be made, as then the spinal muscles are not contracted unless abnormally so, for when a person is in the upright position muscles are continually contracting first on one side and then on the other, as one of their functions is to act as a support in keeping the spinal column erect. The patient lying on his side, the physician should then stand in front of him and reach over upon the back and make a thorough examination of the affected portions of the spinal column, chiefly through the dorsal and lumbar regions.

Consideration should be given the contraction of the muscles along the back, chiefly the deeper layers of muscles. It may even be necessary to relax some of the muscles before a thorough examination of the vertebræ can be made. From a pathological point of view too much stress should not be put upon the contracted state of the muscles; although in a number of instances the contracted muscles may be the primary cause of the patient’s trouble; especially so when the affection is due to atmospheric and other changes. Contraction of the muscles may be secondary to the lesions presented in the bony frame work. For instance, a dislocated vertebra may be the cause of an irritation to the innervation of certain muscles along the spinal column and thus cause them to contract. Still, we must not lose sight of the importance of the contracted muscles from a diagnostic point of view. They are oftentimes prominent signs that a lesion exists in the immediate region and are thus faithful guides in locating the cause of diseases.

In closing the general consideration of the spinal column it is well to emphasize the importance of training the faculties to grasp at a glance the story told by the back as a region, instinctively placing the proper value on each physical sign and weaving them into a composite whole so that the patient’s condition stands out a vivid picture on the osteopath’s mind. When this is accomplished the more detailed observations are but incidental. Relative to the examination of the spinal column Clark[27] says: “To the osteopathic physician, the most important part of the human body is the spinal column. By its changes in contour and condition the various visceral diseases can be diagnosed, in most cases. I believe that every disease is characterized by extreme changes or signs, and I further believe that every chronic visceral disorder is manifest by changes in the spinal column that can be, by the practical eye and touch, readily interpreted. In short, there are various signs along the spinal column that point out the weakened or diseased parts of the body. This method of diagnosing disease, that is by noting these spinal changes, is distinctly osteopathic, and I believe the time will come when it will become such an exact science that the character of the spinal change or lesion is diagnostic not only of the viscus affected, but the way it is affected.”

Regional examinations and diagnosis will now be taken up.

=Neck, Head and Face.=—To make a thorough diagnosis of the condition of the cervical vertebræ probably requires more skill and a more acute sense of touch than of any other region of the body. The irregularities and variations of the cervical vertebræ, the numerous muscles and the passage of many vessels through the neck are very liable to mislead one.

One may examine the cervical vertebræ by having the patient either lying down or in a sitting posture. The former position is preferable, as then the muscles of the neck are passive, and besides it is much easier to relax the muscles if such should be necessary. Also one has better control of the field of examination.

It is undoubtedly best for the student when learning to examine the cervical vertebræ to first examine along the base of the skull the condition of the occipital muscles (after the patient has assumed the dorsal position upon the treating table) for any contractions; for if disorder exists in the upper five cervical vertebræ the condition will be manifested by contraction of muscular fibres along the base of the occipital bone. The muscles of the occiput are supplied by fibres from the posterior branches of the upper five pairs of spinal nerves, and if lesions exist to these upper nerves a contracted state of more or less extent of the occipital muscles will occur, no matter how slight the lesion. Thus the examiner after locating contracted fibres under the occiput has a direct clue to lesions existing somewhere in the upper five cervical vertebræ. After locating these contracted fibres of the occipital region and then still keeping the finger upon the contracted muscular fibres and following them downward until the contractions are lost and seem to enter the spinal cord, one has then located the exact point of disorder that is causing the irritation to the muscular fibres involved, and most probably the cause of the affection from which the patient is suffering, i. e., provided one has reason to suspect the trouble is in the cervical vertebræ. Simply follow the contracted muscular fibre downward until it seems to enter the spinal cord and there one will find a lesion. After the osteopath has become expert in diagnosis this will not be necessary unless he has to make a very fine diagnosis or unless he is examining a stout neck where it is hard to examine through the heavy muscles. With this method one has a firm, flat, broad surface to work on (the occipital bone) making it very easy first to locate contracted muscles and second to trace the course of contracted muscles and thus find the disorder. Otherwise the beginner is apt to get confused by trying to examine the condition of the cervical vertebræ. Later, when a student becomes more expert such a procedure will rarely be necessary only in cases that require special work in the examination.

When the point of disorder has been located the diagnosis as to the exact character of the maladjustment has to be determined. The abnormal position of the vertebra, tenderness at the point involved, local contracted muscles, and limited motion are the four diagnostic points, although the temperature of the affected part as compared with the general cutaneous temperature and the state of the local vascular channels (blood and lymphatics) will occasionally be of aid.

Owing to the irregularity of the spinous processes of the cervical vertebræ in regard to their length, great care has to be taken in the examination. Probably there is no other region of the body that will tax the patience of the osteopathic student so much in his practical work as making a diagnosis of disorders in the cervical spine. It requires patient and persistent work to become a fair diagnostician of the cervical region, and it will take much experience to become expert in both the examination and treatment.

One can depend that lateral deviations of the spinous processes are abnormal in most instances. Placing the finger upon the spinous processes of two consecutive vertebras the student can readily tell whether or not there is any lateral displacement; but telling as to other features is impossible as the spinous processes vary greatly in length. When a vertebra is lateral, a slightly twisted condition will be felt by the finger when placed upon and between the two spinous processes.

To elicit the various degrees and combinations of rotation and sidebending one should depend upon the symmetry of the transverse processes. Reaching anterior to the sternocleidomastoid muscle, or better still, pushing the cleido muscles forward and reaching posterior to them upon the transverse processes, a very fair examination can then be given the vertebras. When the vertebras are deranged, especially anteriorly or posteriorly, that is the apposition of the articular facets, a slight elevation will be felt, possibly not any larger than a very small pea, either the anterior or posterior aspects of the transverse processes, depending upon which way the vertebræ are deranged. Remember that accompanying this slight elevation will be degrees of sensitiveness of the vertebra at the point deranged. In cases where the vertebra is lateral a slight eminence will be noted along the outside of the process. Commonly disordered vertebræ are not entirely deranged in one direction but are oftentimes slightly rotated, so we may find them dislocated antero-laterally or in various combinations of sidebending-rotation. Several consecutive vertebras may be deranged in like manner of direction; this condition is chiefly found in pathological curves of the spinal column. Probably the most common general lesion is a strained condition of several consecutive vertebræ, each one being nearly intact but all of them as a whole somewhat strained or twisted. Thus there are many pathological states to take into consideration, although it is not surprising to the osteopath when he realizes that many of our pains and aches are due to anatomical derangement. Frequently bending the head strongly forward and downward, or downward pressure with slight rotation will produce pain at the point of lesion.

Subdislocations of the =atlas= are probably among the most common lesions presented to the osteopath. Owing to the articulation of the atlas and occipital bone being an anatomically weak point and the neck muscles being exposed constantly to atmospheric changes, besides the articulation between the head and neck receiving the brunt of many jars, falls and strains, the atlas is especially susceptible to derangements. On account of the intimate relation of the atlas to the superior cervical ganglion of the sympathetic and to the vertebral blood vessels it is certainly very necessary that the atlas should be well taken care of. No other tissue maintains such a significant position in relation to the blood and nerve supply to and from the brain. To diagnose correctly the position of an atlas and to be able to correct it is undoubtedly one of the most essential achievements of the practitioner of osteopathy.

The most common disorders of the atlas are anterior and lateral displacements. Next in order come “rotary” lesions of the atlas, i. e., where the atlas has been deranged diagonally or simply twisted. It may also be luxated anteriorly and laterally, or posteriorly and laterally, etc. A posterior derangement of the atlas is comparatively a rare disorder, although owing to the many lesions that are found in atlases one has, during the course of a year’s practice, several to correct. The atlas may occasionally be slightly tipped laterally, anteriorly, or posteriorly, and in a few cases it may be somewhat impacted against the occipital bone. Many times when the atlas is displaced the axis is also deranged on account of the close relation between the atlas and axis by the odontoid process of the axis.

To examine the atlas the patient may be either in the sitting or dorsal posture; it matters but little which position is taken. Possibly the dorsal position is better, as then the neck muscles are more relaxed and if necessary an examination of the cervical spine, below the atlas, can easily be made.

By placing the middle finger of either hand on the transverse processes of the atlas when the patient is in the sitting posture, or the thumbs on the transverse processes when the patient is in the dorsal posture and comparing the two sides, undue prominence of one side or the other can easily be noted. Remember the transverse processes of the atlas are slightly above and posterior to the angle of the inferior maxilla. Always, in examining one side of the patient, compare it with the other; it may save considerable embarrassment. One side may seem abnormal when by comparing it with the other side, both sides may be found the same and still be normal. With the fingers still on the transverse processes note the distance between the process and angle of the jaw, besides take into consideration the tenderness of the locality, and, also, what is of essential importance in all interosseous lesions, its articular range of movements. There should be room enough (approximately) to just comfortably wedge the end of a medium sized middle finger between the transverse process of the atlas and the angle of the inferior maxilla when both are normal. Thus with the fingers on the transverse processes an expert will be able to readily determine whether or not an atlas is lateral or anterior. If an atlas is posterior the distance between the angles of the jaw and the transverse process will be increased, besides the atlas will be quite prominent posteriorly. In conjunction with the abnormality of the tissues (prominence or depression of the bone and state of the muscles) the sensitiveness of the locality is extremely significant.

Outside of displacements of the atlas, a lesion between the =axis= and =third cervical= is most common; following next in frequency are lesions of the =skull= and =atlas=. By that is meant where all the cervical vertebræ are intact as far as their individual relation is concerned, but the skull is forward, backward or lateral upon the spinal column. This condition occurs quite frequently. To determine its condition the same methods are employed as in diagnosing a deranged atlas; for if the dislocations exist between the atlas and skull the same diagnostic points are presented as far as the skull is concerned as when the atlas, or atlas and axis, are dislocated from the occipital bone or from the axis or third cervical. Following the preceding examinations, additional examination will have to be made to see whether or not the atlas is intact with the vertebræ below. If the atlas is found to be intact with the vertebræ below and lesions are presented between the atlas and the skull, then the disorder must be between the atlas and the skull and nowhere else. Occasionally there are cases where the skull is so far posterior upon the spinal column that the angles of the jaw strike against the transverse processes of the atlas when the jaw is opened widely.

Derangement of the =muscles= of the anterior and lateral regions of the =neck= are common. Especially are contractions of the muscles on either side of the larynx liable to occur. In examining the cervical region do not pay too much attention to the superficial muscles, but examine carefully the deeper muscles. It is from these that impingements of nerves and constrictions of vessels are likely to take place in the contracted fibres. Also, imbalance of muscular tension may be the source of the resulting malalignment. In examining for contracted muscles do not gouge into the muscle nor grasp the muscle roughly, but bear down lightly (inhibitory) upon the muscles and then gradually exert firmer pressure. By carefully and firmly exerting pressure over muscular areas the deep muscles can then be felt beneath the superficial ones. Otherwise when the muscles are manipulated severely the superficial ones will contract to such an extent that the deeper ones cannot be felt. The muscles contracting on either side of the larynx tend to draw the larynx downward and thus there may arise a source of irritation. The various muscles contracting in the antero-lateral region of the neck are very often the source of chronic irritations of the pharynx or throat. The omo-hyoid muscle may become contracted and cause slight traction on the hyoid bone and thus produce an irritating cough. To examine the muscles of the neck thoroughly it is best to have the patient flat upon the back, for then all the normal muscles are relaxed.

Lesions quite frequently occur in the =temporo-inferior maxillary= articulation. The lesion may be either unilateral or bilateral, more commonly the former. The disorder usually consists of a relaxation of the muscles and ligaments about the articulation which allows a slight but perceptible dropping of the inferior maxilla on the side involved. In other cases there may be presented a spasticity of tissue, while in still others some degree of joint infection may be found. Lesions of this articulation particularly impinge upon fibres of the fifth cranial nerve. The points of diagnosis are clicking and tenderness at the articulation. These two points are the symptoms of which the patient complains; those noticed by the osteopath are a slight deviation of the jaw to one side or the other when the jaw is opened and a flinching of the patient due to tenderness when pressure is exerted over the articulation of the jaw. When the physician places his fingers around the jaw, anterior to the angles, and the thumbs over the bridge of the nose, having patient open the mouth, at the same time exerting pressure with the fingers and thumb, a sharp click may be elicited by the return of the jaw into its articulation.

In disease of the =scalp= the condition of the muscles of the scalp should be taken into consideration. The muscles are usually found contracted. The contraction of the muscles is generally due, as well as the disease of the scalp, to derangement existing in the posterior branches of the upper five pairs of the cervical spinal nerves.

In the =neck=, anteriorly the =hyoid= is the only bone to consider. It is easily palpated by standing at the head of the table and with the second finger of each hand outline both ends to ascertain its relation with the thyroid cartilage. Note carefully any contracted tissue or glandular enlargements which might cause undue tension. The tilting of either end of the hyoid from these contractions is productive of much throat irritation. At the same time the =larynx= may be examined. It may be prolapsed, causing irritation of the laryngeal group of nerves. The =thyroid= and =cervical= glands should be palpated for enlargements, and all the muscles and ligaments for contractions. Externally the =tonsil= may be felt by deep pressure in front of the angle of the inferior maxilla.

=The Ribs.=—Under the osteopathic diagnosis of the ribs will be included the examination of the clavicle and sternum. To be able to diagnose intelligently, the position of the ribs in detail is very necessary to the osteopath. Many of the diseases of the heart and lungs, besides a large number of the diseases of the digestive tract, may be traced to a deranged rib; also, occasionally diseases of different regions of the head and neck may be due to dislocated ribs. In making a thorough examination of the ribs each rib should be carefully noted as to its position. The ribs may be examined when the patient is sitting up; but it is better to have the patient flat upon the back and especially so if the floating ribs are to be carefully examined, because the muscular tissues of the side if contracted will interfere with the diagnosis. In many instances the rib lesion is secondary to a vertebral subluxation.

An expert osteopathic diagnostician will be able to detect at once by a single passage of the hands down over the ribs if there are any disorders of them. In passing the flat of the hand, especially the flat part of the fingers over the ribs, carefully observe if the intercostal spaces are too narrow or too wide, and if any of the ribs are unduly prominent or depressed. If an intercostal space is too narrow it shows that the ribs on either side of the intercostal space are too close together. Then the question arises, which one of the ribs is crowding upon the intercostal space, or whether both of the ribs are crowded together. Usually when the sternal end of the rib is displaced upward, the involved rib is prominent and when displaced downward the rib is depressed. Thus it is commonly easy to diagnose which is the involved rib. Besides finding an abnormal position of the rib there will be more or less tenderness over the rib. Finding a rib prominent or depressed and tender is generally quite conclusive that the rib is displaced. Then the range of movement as expressed through the sense of resistance is a helpful guide in diagnosis.

If a =typical rib= is placed upon a flat surface and one end of it is depressed the other end will be elevated and vice versa. This peculiarity holds true as well when the ribs (typical) are dislocated in the living body. If the anterior end is elevated the posterior end is commonly depressed and vice versa. Care should be taken in examining the first rib and the false ribs, for in these ribs this peculiarity is not found.

As a whole a very complete diagnosis can be made of the condition of the ribs by examining the anterior part of the thorax, although it is always best to examine along the angles of the ribs if for nothing more than to confirm the diagnosis made at the sternal ends. Still it must be remembered that the preceding only holds good when the entire rib is dislocated. Many times simply one end of the rib is deranged and the other end is practically intact.

Besides careful examination of the sternal end of the rib, attention should be paid to the condition of the costal cartilages. The costal cartilages may become deranged at either the articulation with the rib or with the sternum. The same rule holds good when the costal cartilages are dislocated as when the ribs are dislocated, i. e., when the cartilages are prominent, they are usually displaced upward and when depressed the cartilage is displaced downward toward its neighbor.

One is apt to think that a rib is only dislocated at its vertebral end. Although lesions of the vertebral end are generally of greater significance as far as the etiological factors are concerned, still the sternal end of the rib must not be overlooked. In examining the vertebral end of a rib attention should be paid the angles of the ribs, for at the angles a better opportunity for examination is given on account of the prominence. It will be necessary in many cases to find out whether or not the vertebral end of the rib is lying between the transverse processes instead of in front of them. In many severe lesions of the ribs the vertebral end of the rib is dislocated upward or downward from the transverse process of the vertebra and lies between the transverse processes of the vertebræ above and below its attachment. This certainly requires considerable skill in the diagnosis, for oftentimes the point to be found is barely an eighth of an inch in diameter. It is usually best before making such a close examination to relax the tissues well over the field of examination.

The =ribs= as a whole may be too transverse or too oblique upon one side. This is chiefly found in pathological curves of the spine, but still such conditions may exist where there are severely contracted muscles, especially in some cases of paralysis. Thus the contour of the ribs must be taken into consideration by comparing one side with the other.

In examining the =first rib= an examination somewhat different from the other ribs should be given. It is best to have the patient assume a sitting posture; then place the middle fingers of each hand upon the first ribs near their centers and compare one with the other. Also note the difference of the spaces between the ribs and clavicles. Generally the first rib is dislocated upward, rarely downward. Besides finding an abnormal prominence or depression of the rib at its center considerable tenderness will be noticed. Examinations of this region are every day experiences with the osteopath.

When diagnosing the position of the =floating ribs= it is best to have the patient lie flat upon the back with the thighs flexed upon the abdomen, so that the tissues about the lower ribs may be entirely relaxed. Then by placing the flat of the fingers carefully over the ribs the outline and position of them can be easily discerned. The floating ribs are oftentimes found deranged and are the source of a great deal of suffering through the iliac regions. These ribs may become dislocated from the vertebral ends and drop down obliquely toward the iliac crest, or else the free end may become locked beneath the rib above. Occasionally both ends of the rib drop down quite perceptibly and consequently is the cause of considerable distress. In such instances the rib is depressed inward so that the normal contour of the lower thorax is lost.

An examination of the =clavicle= should be carefully made. Always compare the clavicle with its fellow and examine thoroughly its articulation with the sternum as well as at the acromial prominence. Often the sternal end of the clavicle is slightly dislocated posteriorly to the sternum; although it may become completely luxated. The acromial end may be dislocated upward or downward.

In examining the =sternum= special attention should be given the articulation of the manubrium and gladiolus. This is due to the crowding anteriorly of the articulation of the sternal parts. Normally until well along in adult life there should be some movement here due to its membranous attachment. Occasionally the ensiform cartilage is turned inward, producing a tender point, but this rarely occurs. Also the articulation of the cartilages in the region of the eighth, ninth, and tenth ribs may be found considerably deranged, causing local tenderness and even stomach trouble.

=Dorsal= and =Lumbar Spinal Region=.—With the patient sitting on the table abnormal deviations can be readily noted. There may be lateral swerves, from muscular weakness, or unilateral tension, involving the whole spine or less, or a reversal of natural curves, i. e., the spine depressed anteriorly between the shoulders and posteriorly in the lumbar making the straight spine. There may be, also, an exaggerated normal curve in the dorsal region producing a kyphosis with a compensatory lordosis in the lumbar region sufficiently great to change its relations with the pelvis. By the method previously given, now outline the spinal column for lateral and bilateral scoliosis. These, frequently, are at their incipiency, and to the casual observer would pass unnoticed. It is well to make an outline of the spine before beginning treatment, and at times following, that progress may be observed. A simple method is lead tape which can be had from any plumber shop and can be molded to the deformity and traced on paper together with date of examination. H. F. Goetz has perfected an appliance for outlining and recording these deviations. Observe well the ligaments, as well as extent of joint movement, under deep palpation; from irritation they may become thickened and more or less fill the spaces about the spines and transverse processes, causing a rigid, smooth spine.

To make a detailed examination the patient should be stretched out on one side upon a treating table, although the general examination may be sufficient. Then, standing in front of the patient and reaching over him, a most careful diagnosis can be made. Do not stand back of the patient as the flat of the fingers can not be used to advantage in outlining the different vertebræ. The various contracted muscles that may be found along the spinal column will be of valuable aid in locating derangements of the vertebræ and vertebral ends of the ribs. By using contracted muscles along the spinal column as a guide for locating lesions, reference to the large superficial muscles is not made, but to the small areas of contracted fibres of the deep muscles. It is the deep muscles that become more or less contracted, and even fibrotic, when lesions of the vertebræ and ribs exist. The superficial muscles are generally contracted by atmospheric changes, slumped postures, wrong habits, etc., and are not generally the result of disorders in the osseous system. The preceding points in regard to contracted muscles cannot be too carefully observed for there is a tendency among many osteopaths to treat the contracted deep muscles as primary lesions in nearly every case. Remember that if they are not due to the motor nerve fibres of the muscles being irritated by the spinal lesion, or to a reflex stimulus, or to a compensatory change, that although the muscular tension may be the inception of the almost certain interosseous lesion, still the leverages secured through bony adjusting are very essential not only in correcting the osseous malposition but in loosening and releasing fibrous muscles and thickened ligaments.

=Thorax.=—Examination of the thorax as a region has been largely gone over in speaking of the ribs and their sternal attachment, cartilages, sternum and the clavicles, but its appearance as a whole should be carefully noted for it will be a valuable aid in diagnosis. Deviations from the normal, such as the emphysematous or barrel-shaped chest in asthmatic affections, or chronic cough, or accompanying kyphosis, the flat chest and its association with phthisis, the rachitic, etc., should be considered. Spinal deformities are reflected in the thorax by marked changes in contour, such as elevations and depressions corresponding to the spinal changes. These result in marked interference with the thoracic organs and in young subjects are of particular interest. Rib changes are frequently the result of vertebral deviations.

=Abdomen.=—The position for examination of the abdominal viscera is usually with the patient supine, head slightly elevated, knees drawn up partially and supported to relieve any muscular strain, and with the hands at the sides. In this position complete relaxation is obtained. Observe any enlargements from gas, fluid, or tumor, muscular changes, color, etc. The patient may, also, be placed upon the side, and in the knee-chest position for further verification of the diagnosis. Where the abdominal wall is much relaxed, or there is a pendulous abdomen with enteroptosis, there will be found a change of relations of the viscera by these different positions, allowing them to be palpated in another position. When there is marked tenderness it is often possible to go deeper with less discomfort with the patient in the knee-chest position. The Trendelenburg position may also be utilized. Where ascites is suspected palpation should be made with the patient in various positions in order to note changes of location of the fluid. Frequently much can be learned by inspection with the patient standing. Clues to visceral disturbance can often be had by tracing the nerve connection from the spinal lesions to the suspected part.

In examining the =liver= care must be taken that any gouging or severe bruising of the organ does not take place. The liver can be outlined by percussion and also by palpation of its lower and inner borders Congestions, atrophy, enlargement or hardening should be noted, also any change in position.

A rather complete examination can be given the =biliary tract= from the =gall-bladder= to the =duodenal orifice= of the =biliary duct=. By a careful inhibitory pressure over the duct the outline of the tract can be discerned providing the patient is not too stout. When the tract is swollen considerable tenderness will be present. The patient will complain of a stabbing or piercing pain upon pressure and manipulation if the duct is inflamed.

Usually the tenderness is greatest nearer the =duodenal orifice=. The duodenal orifice is about one and one-half inches diagonally downward to the right from the umbilicus. In cases of impacted =gall-stones= the osteopath as a rule has very little trouble in locating the stone.

The =spleen= may be percussed and when in a markedly enlarged condition its lower border can be palpated. Great care must be used in the latter condition as there is danger of rupture.

In examining the =stomach= the usual methods of inspection, palpation, percussion, analysis of the contents, etc., are employed.

Palpation and manipulation over the =intestines= are practiced a great deal by the osteopath in various intestinal diseases. By his educated sense of touch he is usually able to locate at once any =impactions= of =fecal matter=. Such impactions are generally found in the ilio-cecal and sigmoid regions. In the various acute =obstructions= from invagination, tumors, twists, adhesions, spasticity, knots, etc., many times one is able to readily locate the seat of the disturbance. There is one point to specially emphasize; that is, do not overlook prolapsed regions of the intestines; such occur frequently and are a source of considerable distress, especially constipation. Simple manipulation will never do much good, neither will spinal treatment or injections, as a rule. A specific treatment must be given and, that is, after locating the exact point of prolapse, to reach carefully beneath the fold and replace it.

In emaciated subjects the =kidneys= can be readily located, and in a few instances when they are diseased one can feel the contracted tissues about them. Be very careful not to injure the =capsule= about the kidney. Do not punch or gouge them in the least; but locate the kidneys by a careful inhibitory palpation.

=Lumbar and Pelvis.=—The intimate relation between the lumbar spine and pelvis make a consideration of them as a region necessary. Outside of ordinary curvatures involving both the dorsal and lumbar regions there are certain conditions which involve but one structure and require careful differential diagnosis to determine whether the lumbar or pelvis is at fault. In the former the fifth vertebra is a weak point and is most frequently at fault. The deviations are usually a sidebending and frequently accompanied with some rotation. Occasionally a malstructure of the lower lumbar or pathologically relaxed ligaments will approximate the spines and be misleading as to the real condition. A rotation or lateral tilting of the fifth lumbar may have the effect of elevating the crest of the ilium so that the innominatum would appear involved. There will be a difference in the length of the legs, angles of feet when patient is lying on the back, anterior spines out of line and tenderness of the muscles attached near them. However, other diagnostic points of innominate lesions, i. e., tenderness of symphysis and sacro-iliac articulation, and prominence of the posterior spine, will be lacking. Marked deviation of other lumbar vertebræ may produce practically the same effect, but the lesion will be so apparent that there will be no doubt as to the cause.

To be able to diagnose accurately and intelligently the pelvic region requires nearly as much skill as in examining the cervical region. The pelvic bones are liable to many subdislocations, especially in the female. However, it should be remembered that many apparent innominate lesions are secondary or compensatory changes due to lumbar lesions. The pelvis as a whole may be tipped anteriorly or posteriorly upon the spinal column. It also may be twisted or rotated laterally upon the spinal column. The most common lesions are subluxations of an innominatum forward, backward, upward, or downward, or various combinations of these displacements, such as a tipping forward and downward of an innominatum, or a tipping backward and upward, but these combinations do not always exist in the manner given. As a rule when the ilium is anterior, the ischium posterior, then the innominatum as a whole is downward; when the ilium is posterior, the ischium anterior, then the innominatum as a whole is upward. This is only a rule, there are exceptions to it; for in some few cases when the ilium is anterior, the ischium posterior, the innominatum may be higher, and when the ilium is posterior and the ischium anterior the innominatum may be lower.

To be able to diagnose such derangements will require skill and practice; still there are symptoms and signs that are characteristic of such disorders. In examining the pelvic bones have the patient flat upon the back at first. Be sure he is flat upon the back for a very slight variation may make considerable difference in the relation of the pelvic bones, one to the other, so far as the diagnostic points are concerned. Then go to the feet of the patient and grasp the ankles firmly, rotate laterally both legs, first to one side and then to the other, as well as pull and push both limbs slightly, and then bring the heels together directly in the median fine of the body and compare the length of the limbs at the heels. If there is any disorder whatever in one innominatum, and the thigh muscles have been relaxed thoroughly by the preceding movements and the heels are brought together in the median line of the body, a difference in the length of the limbs will readily be observed at the inner malleoli or the heels. For if the ilium is forward the ischium must be backward and as a rule the innominatum is thrown downward, thus causing an apparent lengthening of the limb which will be noticed by comparing the heels; if the ilium is backward the ischium must be forward and as a rule the innominatum is then upward, causing an apparent shortening of the limb on the affected side. A very slight variation in the pelvis will make considerable difference in an apparent lengthening or shortening of the limbs. Such conditions are generally met with several times a day by osteopaths. The object of the lateral rotary movement and the pushing and pulling of the limbs is to make sure that all the thigh muscles are thoroughly relaxed, for it is a very easy matter for contracted muscles in one thigh to produce an apparent shortening of the limb. Also be very careful in comparing the length of the two limbs at the heels where they come together that they are exactly in the median line of the body, for if they should be to one side or the other, however slightly, there would be an apparent lengthening of the outer limb as compared with the limb near the median line. While the patient remains flat upon the back it is a good plan to compare the anterior spines of the ilia. It may be readily noticed that one is higher or more depressed than the other, which will help to confirm the diagnosis. It is a good plan also to have the patient sit up squarely upon the table and compare the crests and posterior spines of the ilia; thus one may be seen to be higher than the other. Then, also, note the angles of the feet when patient is supine; an everted foot usually means that the limb is shorter due to the tilted pelvis; the opposite is commonly true when the foot is inverted. However, this is not an absolute rule. Care should be taken in differential diagnosis of possible old fracture of leg, of infantile paralysis, of asymmetry, etc.

There are =three diagnostic points= exclusive of all other signs that are quite conclusive when coupled with the preceding examination. If an innominatum is dislocated or subdislocated there will be tenderness over the symphysis pubis on the side affected, tenderness over the ilio-sacral articulation on the side affected, and tenderness along the crest of ilium where the abdominal muscles are attached. When tenderness is found at these three points it is quite conclusive that the innominatum is deranged, for at the symphysis pubis and ilio-sacral articulation tenderness must exist if the innominatum is disturbed, and by a change in the crest of the ilium the abdominal parietes will be affected, provided they are not too much debilitated. Marked tenderness of the external cutaneous nerve as it passes over the crest of the ilium below the anterior spine will be noticed on the unaffected side (Dr. Still). There will be, on rectal examination, marked tension of the tissues on the affected side. Possibly the patient may complain of pain exclusively in one side along the pelvis and limb which will be a leading symptom telling which side is affected.

=Additional diagnostic= signs will be rigidity of muscles along the ilio-sacral articulation and abnormal prominence or depression of the ilium at its articulation with the sacrum, depending upon which way the innominatum has slipped. Considerable deviation of the pubic bones may be noticed. The pubic bone on the side affected may be either thrown upward or downward.

Radiographs have repeatedly revealed subluxations of the innominate bones in many instances. This is certainly quite conclusive in confirmation of the osteopathic ideas in regard to the pelvic bones becoming dislocated.

=Sacrum.=—Examination of the sacrum is best made with the patient lying on the side, with the osteopath standing in front and with the hand palpate its posterior surface. In the sitting posture its relation with both innominates can be determined. It is displaced posteriorly but seldom, the most frequent being anterior, downward, and a combination of the two. In the anterior conditions tenderness at the sacro-iliac articulations is a good point, but it must not be confounded with an innominate lesion. The downward displacement is shown by comparison with the lower lumbar vertebræ. Observe the relation between the two, as a change in contour of the spine will also change the angle of the sacrum and vice versa.

=Coccyx.=—With the patient and operator in same position as for the sacral examination outline the coccyx, as to first, =contour=; second, =rigidity=; third, =sensitiveness=. If abnormalities are detected go to the other side of the table and with a well lubricated index finger palpate its anterior surface. Changed contour, displacements, and old fractures can be readily determined. The most common deviation is anterior at its union with the sacrum. The lateral form generally resulting from muscular contraction is next, with posterior but seldom. “If the lower part of the sacrum is rotated backward, the sacro-coccygeal articulation or angle is affected or becomes more acute, since the tip of the coccyx is not displaced, but held in position by structures attached to it. If the sacrum is displaced downward the effect is about the same. Often this sort of sacral lesion is mistaken for an anterior luxation of the coccyx.”[28] Remember that normally there should be some movement of the coccyx. It has a fibro-membranous articulation.

=Uterine=, =ovarian= and =rectal= examinations are largely of the same nature as those given by other practitioners, although osteopaths find that oftentimes other practitioners are mistaken in regard to the etiology of many diseases to which these organs are subject.

=Arms= and =Legs=.—There is comparatively little that is exclusively osteopathic in regard to the diagnosis of disorders of the arms and legs. One important feature that the osteopath finds in examining the arms and legs is that many of the disorders supposed to originate in the affected member are found to be caused from vertebral or rib dislocations. Innominate and lumbar lesions are particularly fruitful sources of trouble in the legs and feet. Always carefully examine the spine in the region of innervation to the arms and legs when they are affected. The shoulder and hip joints, as well as all joints, are subject to partial dislocations. Many times when pain or other symptoms are presented in the arms or legs the trouble is at the shoulder or hip joint or in the spinal column. There are two regions that are very apt to be overlooked in the examinations of the arms and legs and they are the elbow joint and the fibula. The small bones of the =ankle= and =wrist= as well as of the foot and hand are subject to many dislocations which are easily discerned upon examination and often overlooked. Special emphasis should be given in regard to many supposed diseases of the knee joints which are really caused by lesions in the spine or at the hip joint.

Osteopathic Prognosis

Everyone is of the opinion that to forecast the probable result of a disease is one of the most difficult problems the physician has to meet. To state the duration, course, and termination of an attack of disease as presented by its nature and symptoms implies an accurate knowledge of both disease processes and changes, and an insight into the individual’s idiosyncrasies backed by ripe clinical experience. And after each of these factors has been carefully considered to balance one against the other, nothing short of superhuman knowledge may present a sufficient insight in order to render an accurate prognosis. A prognosis represents the culmination of one’s learning, an understanding of disease characteristics, and an insight into temperament.

C. M. T. Hulett[29] says: “Only when we can know all the conditions, causative and sequential, with their possible complications and terminations, together with a full history of therapeutic results in a large number of similar cases, and carefully analyzing and weighing these various elements, are we prepared to really make a prognosis.” Nettie H. Bolles[30] writes as follows: “The prognosis depends upon the cause of the disease, the possibility of removing the cause, or the likelihood of recurrence of causes, and the chances of avoiding such recurrence. The circumstances to modify the outlook are various and deserve careful consideration.” It is not the purpose here to go into the many essential details, for that would mean an outline and forecast of all disease processes, and the effect of numerous extenuating circumstances. The medical profession have been gathering data for these three thousand years and prognosis with them is still inaccurate and incomplete. Osteopathic science will add just so much to the accuracy of prognosis as the sum total of the knowledge displayed in the fields of osteopathic etiology, diagnosis, pathology and therapeutics. Suffice it to give here a few salient practical hints as noted in the osteopathic treating room and at the bedside.

Osteopathically it may be said that prognosis depends, first, upon the true conception of osteopathy; second, upon the relative value of all factors pertaining to health and disease; and, third, upon the skill (technique and native ability) of the osteopath. The first and second being granted, the third includes a remarkably practical and pregnant field, for in no school does the physician get into as close touch and understanding of the actual condition of the patient’s disorder as in the osteopathic. Although the fundamentals and principles of the osteopathic conception of diseases are really broad, liberal, and all-inclusive, still owing to the fact that each individual (and thus each disease) is more or less a law unto himself should there not be absolute tables and prescriptions to be governed by; remember, however, this does not imply our fundamentals are not basic or our principles are not truths, but rather the application and execution of the same are as varied as the individual’s constitution, temperament, and disease. Herein rests the really difficult practical consideration of etiology, pathology, diagnosis, treatment, and prognosis. In other words, if the diagnosis and treatment are accurate the result rests entirely with the patient.

First, too much emphasis cannot be placed upon the fact that prognosis is dependent upon the osteopath—his education, training, ability, experience, and technique. One’s fitness is most important. And fitness and personality complement each other. An osteopath may know theory and still not be practical; still one cannot be practical unless he knows theory.

Second, osteopathic treatment frequently changes the usual course of acute disease. It is well known that many diseases have a certain regular course in their history. Many times the osteopath will be able to abort, lessen the severity, or cut short the ailment, thus changing the recognized symptoms and termination.

Third, the knack of treatment, or knowing how to treat, not only one region of the body but all regions, not only one temperament but all temperaments.

Fourth, the preparatory treatment before correcting the lesion. Prevention, palliation, or cure, and thus prognosis, may be dependent upon a necessary preparatory treatment. Here is where a study of the patient’s temperament is very essential.

Fifth, a prolonged treatment may defeat one’s purpose. As a rule a comparatively short, thoroughly indicated, specific treatment is best.

Sixth, much, relative to prognosis, can be told by the tone of the vertebral ligaments. When a lesion corrects too easily or does not remain well in place it shows a lack of tonicity on the part of the ligaments and muscles. Improvement is in direct ration to the increase of tonicity.

Seventh, special care should be taken with the irritable spine. This spine commonly precedes the debilitated spine. Unless precaution is taken to apply inhibition before treating specifically a cure may be prevented or at least the disorder prolonged.

Eighth, relaxation of muscles is not always essential, although the lack of it may prevent the correction of primary lesions. The relaxation should be carried out with care in order that all shock and irritation may be kept at a minimum.

Ninth, needless stretching, traction, extending, rotation, and snapping of the neck is not only useless but may be positively dangerous. Rarely is it necessary to go through the above “movements” as many are accustomed to do.

Tenth, it may be necessary, but not always, to give as additional treatment, after the anatomical defect has been specifically treated, a certain amount of stretching and moulding of the parts.

Eleventh, owing to the close personal relations of physician and patient, personality has a powerful influence on prognosis.

Twelfth, too much emphasis cannot be placed upon the uselessness and injurious effects of over and misapplied treatment.

All of the above have a positive bearing on prognosis. The osteopath should study his technique well. He will find that it gradually changes and improves from year to year. In a word, as he gains in experience he will become more skillful by giving careful attention to the development of the sense of touch, by noting the resistance of the tissues, and a score of details that are very hard to describe but the sum total of which determines and indicates the successful osteopath.

Another practical point that bears upon prognosis as well as upon the health of the osteopath is the manner of giving treatment. First, the height of the treating table should correspond to the height of the practitioner. The table should be made for the practitioner and not the practitioner fitted and warped according to a certain table. Second, give part of the treatments on a treating stool. Here there is greater freedom of movement on the part of the patient, hence greater and more effective leverage can be obtained. Suit your treatment to the patient, not your patient to the treatment. Third, make your weight count for energy expended in the treatment. As soon as one set of muscles become tired substitute another set, e. g., the back muscles and the arms, the arms and the hands. Fourth, whenever possible substitute the weight of the patient for expended energy. Fifth, when lifting keep the spinal column straight; do the bending of the body at the knees. Hence a better treatment and a more favorable prognosis, and besides that new occupation neurosis, the “=osteopathic back=,” will be materially lessened in both severity and frequency.

FOOTNOTES:

[26] See Tubby, Deformities.

[27] Clark’s Applied Anatomy, p. 334.

[28] Clark’s Applied Anatomy, p. 331.

[29] Prognosis—Journal of the American Osteopathic Association, Jan., 1906.

[30] Prognosis—Journal of the American Osteopathic Association, Nov., 1902.

OSTEOPATHIC TECHNIQUE

The technique of treatment is, in a sense, a personal factor, for it is a well known fact no two osteopaths treat just alike. Nevertheless, the principles of technique are constant and universally applicable, and he who applies them with specificity manifestly secures the best results, and exhibits a technique that is finished and characteristically osteopathic. General manipulations are not essentially osteopathic, although by employing them a few definite results may be obtained; still such technique should not be classed as distinctive osteopathic therapy. Every case is a law unto itself and must be studied individually in order to be able to understand it perfectly. So much depends upon the ability of the osteopath in the treating of a case, that in order to meet the indications intelligently he must have command of the various anatomical details of the body, not only in his mind but upon his finger tips.[31]

The =sense of touch= should be very acutely developed and this requires months of persistent, practical experience. A carefully educated sense of touch is the keynote to both osteopathic diagnosis and operative technique. From the very nature of the osteopathic conception—the physical body viewed as a mechanism whose disordered or diseased conditions demand anatomical readjustment—it is imperative that a delicate and educated sense of touch be acquired in order to logically and successfully apply its tenets. Proficiency means not only being able to note certain small physical irregularities, and various degrees and areas of muscular contractions, and variations in body temperature, but the extent and state of vital resistance, that is, tissue condition, and the feeling of organic resistance, e. g., the heart, lungs, liver. These are the special features wherein osteopathic fingers detect disease causes and traces. To know the difference between normal and abnormal structural deviations and distortions, as well as organic changes, requires an accurate, detailed knowledge of anatomy and pathology with a systematic daily education of the sense of touch; but to realize, appreciate and know by tissue resistance feeling that nutritional condition is improving requires much more practical experience.

Thus two very practical points should be taught to and thoroughly impressed upon every osteopathic student: First, =the sense of resistance of the tissues=. This gives us an absolute clue to the vitality of the patient. As has been stated, there is a vast difference between the feel, the sense of resistance, of normal and abnormal tissues; for instance, a normal muscle and a contractured muscle, a normal liver and a congested liver, a normal intestine and a prolapsed intestine and these differences comprise innumerable gradations.

Second, =the receptivity of the patient to treatment=. This is dependent upon the vitality of the tissues. The sense of resistance to touch gives us an important diagnostic clue; the receptivity of the patient to treatment tells us much as to prognosis. After a few treatments the receptiveness will be positive or negative; that is, the patient is, or is not, responding to treatment. Consequently the receptivity of the patient usually tells much as to the state of nutrition.

Definite principles should be followed when applying the technique, for the osteopathic lesion is a “structural perversion,” thus indicating mechanical readjustment for its correction. The time is coming when the technique will be taught graphically and mathematically. This would not be a difficult thing to do, and it could not but prove invaluable aid to the student. He can then the more readily and comprehensively grasp the principles involved. To resolve and illustrate manipulative readjustment to and by the principles of mechanics would add considerable to osteopathic development. For example, how nicely the correction of certain innominata maladjustments illustrates the principle of the wheel and axle. Vertebral and rib displacements when readjusted make application of the principles of the simple machines. We are gradually approaching a more comprehensive understanding of the physiologic movements of the spine and of the etiologic role of muscle tension. This is part of the foundation work. Great care must be exercised in correlating this data with the individual case, for in therapy we are dealing with abnormalities—not alone normal physiologic changes. If our distinctive dynamics and therapeutics were taught in this manner the average osteopath would be more specific and comprehensive in his work and as a consequence more scientific. And consequently the principles involved in each and every case would stand out clearly. Hence diagnosis would be more exact, routine pommeling discarded, and better all around technique executed.

Two general rules are applicable to all dislocations, whether partial or complete: 1. Exaggerate or increase the dislocation. This is to relax the tissues about the dislocated articulation and to disengage the articular points that have become locked. 2. Reduce the dislocation by retracing the path along which the parts were dislocated. Hence to =correct= a =lesion=, for example, a vertebral lesion: (1) Exaggerate the lesion. (2) Place the fingers of the hand that are not employed in exaggerating the lesion over the extended portion of the lesion. (3) Extend the region that is flexed when the lesion was exaggerated. (4) When the lesion is being extended produce traction and slight rotation of the region. (5) At the same time extension, traction and rotation is being produced push in upon the extended portion of the lesion. To this might be added for sake of clearness and greater assurance of success: (a) Be positive the focal point absolutely corresponds to the lesion, or else most if not all of your effort will be useless. (b) Just before reaching the maximum of exaggeration have your fingers correctly placed for the readjustment, and at the very moment of maximum exaggeration or just a fraction of a second prior begin to correct or readjust, or else you will lose the vantage gained and the operation will probably be a failure. (c) The general traction and rotation are to aid in unlocking the lesion, not to readjust as some may think. Inhibiting and releasing the soft tissues, such as spasms, contractions and contractures of muscles, and stretching thickened and adherent ligaments is very important preliminary work. Then, next to securing exact leverages an essential point is to maintain the release or exaggeration until the readjusting step is incepted. In other words, coordination of all factors is the desideratum. The lack of this is the cause of many failures. Hot fomentations frequently assist in relaxing irritable and spastic soft tissues. This, however, is but a preliminary measure. All rough handling, needless snapping of parts, and excessive rotation and stretching are not only apt to tighten the lesion more, shock the system and irritate the parts, but it may be absolutely dangerous.

It should not be forgotten that the osteopath includes many measures in his treatment of various diseases, as nursing, dieting, hygiene, sanitation, hydrotherapy, antidotes, antiseptics, etc., and does not depend upon readjustive manipulation alone, although correcting disordered anatomical structures and perversions are paramount in the treatment.

=The General Treatment.=—A general treatment but accentuates the ignorance, in a majority of cases, of many so-termed osteopaths. It is a deplorable fact that there is a tendency among some osteopaths to give general treatments in every case presented. The only explanation of such a procedure that one can think of is a lack of conception as to what osteopathy really is. To give a general treatment in every case is not only actually detrimental to the patient but it is the height of folly on the osteopath’s part, for it gets him into a slovenly habit of procedure from both scientific and curative points of view, besides giving the outside world an impression that osteopathy is but little different from massage and Swedish movements instead of skillful, mechanical engineering of the human body. But a “general treatment” is not to be confused with definite attention to be a series of more or less interrelated lesions. The essential point is to normalize the body when and where distinctly indicated and after a skillful manner.

A general treatment, broadly speaking, should be given only under three conditions: (1) Constitutional diseases that are to be treated symptomatically. (2) Certain anemic cases. (3) When one is ignorant of the real cause of the disease. Each of these conditions is self-evident why a general treatment should be given. A fourth might be added, for those individuals who think they are not getting value received unless they are treated from head to foot. Such patients are usually ignorant of the philosophy of osteopathy and it is the osteopath’s duty to teach them differently.

The general treatment consists in stretching the spinal column from the atlas to the coccyx and relaxing all contracted muscles along both sides of the spinal column, besides giving special treatment to the cervical region, between the scapulæ, the splanchnics and internal and external rotation of the legs. It is no wonder that fake osteopaths do cure a case occasionally. They are quite certain to correct some disorder by pulling and hauling a patient around in such a manner. Still on the other hand they are very likely to do injury to the patient. Those who claim that no injury can come from osteopathic treatment are mistaken. One can injure a person by treatment if he is not careful. It does not stand to reason that the most delicately constructed mechanism should stand any amount of manipulation and misdirected force that may be given it.

=Positions of the Patient and Physician in Treating.=—The position of the patient when a treatment is given depends altogether upon the affection to be treated. Probably about one-half of the cases can be treated to advantage upon a table, the remainder sitting on a stool. Many osteopaths treat nearly all their patients upon a table. It is much better to change back and forth, because to correct a certain disorder may be hard upon the table, but will be comparatively easy when the patient is on a stool, and vice versa. Besides, constantly changing back and forth rests a physician greatly.

Learn to treat in various positions, because it will be impossible to have all cases assume a certain position when being treated; and especially in treating acute cases one is obliged to suit his treatment to the patient and not the patient to the treatment. There is also a tendency for one to get into slovenly habits of treating when patients are all placed practically in one position, and certainly one cannot treat all cases in one position to equal advantage. Also learn to treat as well with one hand as the other. Many times one will be in such positions that equal use of either hand will be required. Carefully educate the sense of touch in both hands.

Another point should receive consideration: learn to shift the strength exerted in treating from one set of muscles to others. For example, when one is standing for a long time he will continually shift his weight from one limb to the other. In the same manner in treating use the strength of the hands awhile, then the arms, then the muscles of the back, then the weight of the body, etc.; all in such a manner that there is a constant change by utilizing certain groups of muscles for the same work, as well as utilizing the weight of the body of both physician and patient to advantage. It rests a physician greatly and thus allows him to perform a maximum amount of work with a minimum amount of strength and labor.

It is frequently an advantage to the physician to treat upon the nude skin, thus preventing the fingers from becoming tender. Gowns can be easily made that open down the back so that the patient does not have to disrobe.

=The Neck and Head.=—In the treatment of the neck the patient may assume the sitting posture or lie flat upon the back. The latter is preferable, as then one has complete control of the neck and head. Absolute control of a part is always necessary and when this is secured the dangers are reduced to a minimum, provided always that reasonable discretion as to the amount of strength, is used. Before correcting the various deviations of the cervical vertebræ it is usually best to thoroughly relax all the muscles, superficial and deep, about the field of operation. In relaxing muscles three methods may be employed. The muscle may be firmly grasped and manipulated until relaxed, or a firm pressure may be exerted upon the muscle and thus inhibit its nerve force until the muscle relaxes, or the muscle may be longitudinally stretched. The second method is comparatively slow and is usually given in acute cases where the patients are so weak and exhausted that they cannot stand any severe manipulation. This method, however, has certain advantages when employed as a preparatory step in interosseous adjustments, though steady traction accompanied with slight rotation, if precisely localized, has many advocates.

In relaxing muscles by manipulation, grasp firmly the belly of the muscle and draw outward on the muscle several times until it relaxes. If the patient is sitting, place one hand upon the head of the patient or about the chin in such a manner that complete control of the head is maintained throughout the procedure; then with the fingers of the other hand upon the contracted muscular fibres a manipulating or kneading of the muscle can be given. It is best to flex the neck and head to the side where the contracted muscles are, so that a better hold of the muscle may be maintained; then by a series of flexions and extensions with manipulation of the contracted muscles outward, results can be readily obtained. When the patient is lying on the back the physician may stand to one side of the patient’s head and with one hand on the forehead of the patient and the other hand around the opposite side of the neck, a rotary motion of the head and neck, which is equal to flexion and extension in the sitting posture, may be given by the hand on the frontal region while the other hand relaxes the muscles; or the osteopath may stand at the head of the patient and with either hand on the side of the head and neck of the patient a series of rotary movements of the head and neck may be given with manipulation of first one side of the neck and then the other; the hands and fingers being placed in such a manner that when the fingers of one hand are relaxing the muscles on its side the other hand is executing the movements of the head and neck, each hand continually alternating in the work. This latter method requires some practice in order to do the work readily and successfully, for quite a variety of movements are required.

In the former method after one has worked on one side he is obliged to change to the other side and go through the same process. Movements may also be given to stretch the contracted muscles, thus overcoming the contraction and producing relaxation of the muscles.

After having relaxed the muscles over the field of operation, correcting the vertebræ will generally be easier to accomplish. In readjusting an atlas it matters but little whether the patient is sitting up or lying down. A firm hold of the atlas can be gotten in either instance. In correcting the middle and lower cervical vertebræ it is best to place the patient upon the back.

In correcting dislocations, as heretofore suggested, two general rules should be followed: (1) Exaggerate or increase the dislocation. This is to relax the tissues about the dislocated articulation and to disengage the articular points that have become locked. (2) Reduce the lesion by retracing the path along which the parts were dislocated. One can readily see that a dislocated ball and socket joint could be reduced only by the dislocated bone retracing the path by which it left its socket, for the capsular ligament would at once prevent its returning to the socket by any path other than that taken when dislocated. This applies to all dislocations to a greater or less extent.

After locating the exact position of the abnormal vertebra the first rule is applied, i. e., exaggerating the lesion by flexing the head in the opposite direction to which the vertebra is dislocated. Then with one or two fingers placed firmly upon the side of the vertebra in the direction dislocated, so that when the proper time comes the vertebra may be pushed or slightly rotated back into its normal position, with the other hand produce flexion of the neck, so that the angle of flexion is exactly over the involved vertebra; next produce slight traction, so as to be sure that the articular points will be disengaged; and then with rotation and extension of the head to a normal or upright posture, at the same time pushing in on the disordered vertebra, are the movements to be executed in reducing a dislocated vertebra. It takes considerable practice to be able to correct a vertebra and to know when it is corrected. The amount of force applied varies greatly in different cases. Cases of recent subdislocation require but little force unless there is marked spasticity of tissue, while in long standing cases many times the amount of force required is about all that one wishes to exert. As a rule in many chronic cases it is better to give a series of preparatory treatments in order to reduce muscle fibrosis and thickening of capsular ligament. Remember that often it is a slight rotary movement or twist given that aids the most in executing rule second. No matter to what position a vertebra is rotated or side-bent the principles applied are the same in each case.

Be very careful when flexing, extending or rotating the neck that too much strain is not brought to bear upon the ligaments. Some osteopaths seem to take delight in rotating and flexing the neck to a great degree. It is a dangerous procedure and moreover does not accomplish anything in particular. It should be kept in mind that osteopathic treatment is scientific and not a number of general movements of various regions of the body. Locate the lesions exactly and then a specific treatment can be given in every instance. To illustrate the treatment according to the preceding rules we will assume that a certain cervical vertebra is anterior, say the fourth cervical. This means that there is an interosseous lesion between the fourth and fifth. The inferior articular processes and facets of the fourth have slipped upward and forward on the opposing facets of the fifth. First, hyperextend the head in such a manner that the fulcrum comes exactly over the displaced articulating planes, thus throwing the fourth vertebra still more anterior, or in other words, exaggerating the lesion or increasing the space anteriorly between the fourth and fifth cervicals, so that when the head is flexed forward and pressure is exerted upon the anterior part of the vertebra (body or transverse process) the vertebra will have room and release enough to occupy its normal position. Second, when the head is hyperextended place a finger anterior to the transverse process of the dislocated vertebra and with the other hand around the head, that is producing the hyperextension, throw the head forward with slight traction and rotation and at the same time push posteriorly quite strongly upon the dislocated vertebra. Follow out the same principles in all cases, no matter in which way the vertebræ are deranged.

There are several methods of applying the underlying principles of adjustment. Relaxation and leverages may be secured in various ways. Preciseness, expeditiousness and skillfulness can be attained only by considerable personal experience.

In cases where the lesion is between the skull and atlas have the patient sit on a stool with the back part of his head against your chest, and reach around the head with one hand under the chin; then with the other hand around the transverse processes of three or four upper cervical vertebræ pull the spinal column toward the median line, while at the same time lifting up on the skull with the other hand and throwing the skull toward the median line. The object of lifting up on the skull is to relax and disengage the articulations, by inhibition, traction and rotation, between the occipital bone and atlas. This is one method applicable to the various lesions of the occiput, which are of frequent occurrence.

In treating the =pharynx=, =tonsils= and =larynx=, outside of correcting spinal lesions, an anterior treatment to these organs is very effective. Examine the deep muscles beneath the angle of the jaw when the pharynx and tonsils are involved; and when the larynx is affected note the condition of the muscles on either side of the larynx. After locating deeply seated contracted muscles in the region of the angle of the inferior maxilla place the fingers over the contracted tissues, and then by a downward, inward sweeping motion toward the median line the muscles may be readily relaxed. When treating the larynx relax the tissues on both sides by an upward, inward movement. These treatments are very effectual when applied directly to the disordered tissues.

Attention should also be given to the lymphatics. In simple infections treat the glands very lightly but attempt to break down the surrounding edematous barrier. Release all the tissues down to and including clavicles, first ribs and pectoral and axillary regions.

To treat slight lesions of the =inferior maxillary= articulation, stand at the head of the patient when he is lying down and hook the fingers about the jaw just in front of the angles, and with the thumbs over the bridge of the nose have the patient open the mouth while considerable force is exerted against his effort. This reduces any slight dislocation of the inferior maxilla. When the jaw is completely dislocated place a piece of wood or hard substance between the molars and exert pressure upward and backward on the chin. If the dislocation is bilateral work on one side at a time.

The object of treatment to the =face= is to stimulate or inhibit points of the fifth nerve that come near the surface (see neuralgia of fifth nerve). While the patient is lying flat upon the back carefully stimulate these various points, especially the supraorbital and nasal, with a downward and outward movement, or inhibit as indicated.

In treating the =scalp= relax the muscles over the scalp thoroughly. This is secondary treatment to correcting the innervation to the scalp at the upper four or five cervical vertebræ.

In cases of pharyngitis, tonsillitis, croup, hay fever, etc., an effective local treatment may be given through the =mouth= upon the soft and hard palate. Introducing a finger into the mouth clear back upon the roof of the soft palate, and with a downward and backward sweeping movement from the median line on either side toward the tonsils, considerable relief can be given the patient. This treatment relaxes the tissues, relieves the congestion, and gives a stimulating treatment to the local nerves. A treatment of the same nature may be given over the hard palate to affect the palatine nerves, especially in hay fever, when the itching of the palate and sneezing are extreme. In cases of young children it is best to protect the finger by wrapping a piece of cloth around it.

An osteopath should never give a manipulation or movement unless he understands why. Just as soon as one gives general imitating movements, from that moment his work is not that of a scientific osteopath, but of a Swedish movement curist and masseur and a poor one at that. The osteopath’s work is to locate the anatomical derangement and correct it, as a mechanic would adjust any disordered mechanism. General treatment amounts largely to naught, although in some few instances it is of benefit.

To give a detailed description of the treatment of all lesions that may be found in the cervical vertebræ would be impossible in this sketch; only a general survey of the work can be given. Each case calls for special treatment, but the same general principles are applicable in each case. If there is any one thing that should be eliminated from osteopathic treatment it is those mechanical routine movements of rotating, flexing, extending, and various Swedish-movement-massage-like manipulations that certain osteopaths give in each and every case. It shows that they are imitators and do not have a correct conception of osteopathic therapeutics. True it is, that routine movements will have stimulating and other effects upon the system. But does the body require such treatment? Is it lack of exercise on the part of the patient? If it is, then let the patient exercise himself. You do not want to lower yourself to be a mere “engine wiper,” or an exerciser. If it is not the lack of exercise and the system is in need of certain treatment, then seek the cause and apply a specific treatment. Do not hide behind generalities.

=The Ribs.=—In correcting dislocated ribs many methods may be employed, but all are subject to the same principles as given under the treatment of the neck and head.

One of the best methods to correct typical ribs is to have the patient upon the side with the side of the affected ribs upward. Find out exactly the nature of the dislocation, i. e., what is the relation of the dislocated rib to the other tissues. Note whether the rib is upward, downward, inward or forward, locate exactly the dislocated rib. Then, while standing back of the patient, place your fingers upon both ends of the rib. Place your fingers in such a manner that when the proper time in the procedure arrives, all that will be necessary will be to push the ends of the rib into their articulations. For instance, if the rib is raised anteriorly and lowered posteriorly, you will place the fingers on the sternal end, above the affected rib and the fingers on the vertebral end, below the rib, so that when the rib has been released from its abnormal position it may be slipped into normal position. After having placed the fingers in the exact position necessary, have an assistant take the arm and draw it obliquely across the face, while at the same time the patient takes a forced inhalation. The object of drawing the arm across the face and the deep inhalation is to exaggerate the lesion—to draw the ribs out of their locked position—so that the fingers upon either end of the rib may push the rib into normal position. Drawing upon the arm raises all the upper ribs as well as the dislocated typical rib, principally by the use of the serratus magnus; also inhalation has an effect to throw the rib outward and upward and thus away from its articulation. Thus after the lesion has been increased sufficiently to loosen the rib from its abnormal position, the arm is relaxed, the patient exhales, and the fingers upon the ends of the rib correct the dislocation. This treatment is used to the greatest advantage when there is a dislocation of a typical rib; it can be given while the patient is lying down or sitting up, although the former position is preferable.

An excellent method, when the =sternal end= of the rib is dislocated is to have the patient sit upon a stool with his back toward the physician; then by placing the knee in the back (while standing up, or easier still for the physician to sit upon an operating table back of the patient) over the vertebral end of the rib so that the rib may be held rigid posteriorly, reach around with one hand over the dislocated end of the rib and place the fingers upon the rib in the direction dislocated; so that when the rib is sufficiently released from its abnormal position it can be readily pushed into place; then with the other hand under the axilla of the arm on the affected side, pull up and back on the shoulder, so that the rib may be pulled away from its sternal articulation; and at the same time have the patient take a deep inhalation so as to aid in throwing the rib outward, upward and away from its sternal attachment; then when the end of the rib has been released sufficiently, relax the hold underneath the axilla, have the patient exhale, and slip the rib into its normal position by the fingers over the end of the rib. This is an excellent method. It is easy to give and does the work admirably.

Practically the same procedure may be gone through when the =vertebral end= is dislocated, by changing your position to the front of the patient, but there is danger of the knee slipping off from the sternum during the operation and injuring the ribs. Several other treatments may be given to correct dislocations of the vertebral ends of the ribs. For example, while the patient remains sitting the osteopath stands in front of the patient and reaches around both sides upon the angle of the ribs; then with an outward and upward movement of the fingers upon the angle of the ribs, they are pulled away from their locked position and allowed to slip into normal articulation. This treatment is applicable only when the ribs are dislocated downward, but it is one of the best treatments for such cases.

Another method oftentimes employed in correcting dislocations of the vertebral end of the ribs is to have the patient lie flat upon the side with the affected side upward; then by flexing the arm on the forearm and placing the elbow against the chest or abdomen reach over the patient upon the angle of the dislocated rib and pull it away from the vertebra; when it is pulled away from the spinal column sufficiently, push upward or downward on the angle of the ribs, as the case may demand. The elbow placed against you gives complete control of the patient and aids, by your weight, in throwing the rib upward or downward.

A treatment somewhat like the preceding one which is commonly employed, is to reach underneath the patient’s upper arm, when he is lying upon his side, with the arm extended upward across the face; then by placing the fingers of the hand underneath the patient’s arm over the angles of the affected rib or ribs and reinforcing the hand by the fingers of the other hand an upward, outward and rotary movement can be given the ribs, which pulls them out of their abnormal position and allows them to return to their normal articulations.

An effectual treatment to spread and raise the upper ribs is to have the patient flat upon the back, and with the fingers of one hand underneath the angles of the ribs and the other hand upon the elbow of the patient’s arm of the same side throw the patient’s arm across the chest transversely and bear down upon the elbow, at the same time spring upward and outward on the angles of the ribs with the other hand. By throwing the arm across the chest and bearing down upon the elbow a strong leverage can be obtained upon the upper ribs, especially those between the scapulæ. This treatment is very efficacious in certain lung and heart diseases.

Still another method of adjusting ribs is to have the patient flat on his face upon an operating table with the arms hanging down on both sides of the table and a small pillow or folded blanket beneath the upper part of the chest; then standing beside the table, or better still, with one foot upon a low stool and the knee of the other limb upon the table in such a manner that one is directly over the patient’s dorsal region one is then in a position to have full control of the vertebral end of the ribs. If the ends of the ribs are displaced downward, placing the thumbs over the angles of the ribs and pushing upward and outward on the angles, the ribs can be very readily crowded into position. If the ribs, especially between the scapulæ, are dislocated in any direction, they may be quite readily corrected by placing the hand over the shoulder posteriorly and throwing it outward and upward and away from the spinal column in such a manner that the ribs are pulled away from the abnormal position; then upon relaxing the hold upon the shoulder with the one hand, the fingers of the unemployed hand may push upward or downward, as the occasion requires, on the angles of the affected side so that the ribs may be slipped into place.

Many times one is obliged to treat the ribs of one side as a whole. In such instances the ribs are almost invariably thrown downward except on one side of scoliosis of the dorsal region. Several methods may be employed to raise the ribs. Probably the best method is to have the patient upon the side and with one hand upon the angles of the ribs and the other hand holding the wrist of the upper arm of the patient, an upward lifting movement is given both upon the angles of the ribs and upon the arm of the patient while the patient inhales. The work upon the angles of the ribs is to raise the ribs directly; the work upon the arm is to raise the ribs indirectly, principally by the use of the serratus magnus. Another effective treatment is to have the patient upon the back and with one hand over the anterior ends of the ribs and the other hand over the angles of the ribs an upward movement is given them by springing the ends of the ribs toward each other and by strong inhalation on the part of the patient. This treatment is most effective where the false ribs are at fault and especially in case of hemiplegia. While the patient is upon the back an assistant may take hold of the arm and draw it upward over the head of the patient, producing considerable additional upward tendency of the ribs, and the physician giving the same treatment of the ends of the ribs as before; or the physician may take an arm in one hand and raise it above the head of the patient and with his other hand around the angles of the ribs, and the patient inhaling deeply, the ribs may be raised.

A treatment used a great deal in raising the ribs as a whole is to have the patient sit upon a stool, and reaching around the patient from the front, place the fingers upon the angles of the ribs and raise them upward on both sides at the same time. This treatment can also be given by standing behind the patient and reaching around upon the anterior ends of the ribs and lifting upward while the patient aids you by deep inhalation. Remember that many times the ribs are drawn downward by contraction of the muscles, due to atmospherical changes and slumped postures. One should begin at the upper ribs in all treatments where the ribs are to be raised, as a whole, and work downward.

To correct the =first= and the =floating ribs= a different treatment has to be given than the foregoing.

An =upward displacement= is the most common lesion of the =first rib=. To correct such a dislocation, have the patient sit upon a stool and with one hand pull the head to the opposite side in order that the lesion may be exaggerated by traction of the lateral muscles of the neck (principally the scaleni) upon the rib; this disengages the rib from its abnormal position; then with the fingers of the other hand upon a point midway of the ends of the rib, exert a downward pressure at the moment the extended head is relaxed describing a short arc. But don’t relax head until readjusting pressure is exerted upon rib. If the patient is unable to sit up, and it is not best to give the foregoing treatment, have the patient flat upon the back, with one hand take hold of the arm on the affected side and pull down and out upon the shoulder so that the rib may be somewhat drawn away from its articulation and released from its position; then with the fingers of the other hand upon the center of the rib, or its highest point, press downward when the hold upon the arm is being relaxed. Correction of an upper displacement of the first rib is an every day occurrence. =Downward dislocation of the first rib=, is rare. To reduce this dislocation, place the thumb beneath the vertebral end of the rib, and with the other hand lift up strongly on the shoulder from beneath the axilla, at the same time exerting pressure upward with the thumb on the end of the rib.

The =floating ribs= may be dislocated obliquely downward, or the free end of the rib may be caught underneath the end of the rib above. In either case, in order to correct the displacement, place the patient upon the back with the thigh on the affected side flexed upon the abdomen so that the tissues about the field of operation are relaxed; then bear down carefully but firmly over the free end of the rib with the fingers until one finger can be hooked underneath the end of the rib; then with the other hand over the vertebral end of the rib, have the patient take a deep breath, at the same time springing the ends of the rib toward each other, thus relaxing the rib from its locked position; then have the patient exhale quickly and at the same time spring the rib into its normal position. It oftentimes requires repeated trials, especially in stout persons, and quite often the operation is painful to the patient. It is necessary that one should understand this operation thoroughly, as it is one of the most common treatments in osteopathic practice. The floating ribs are very liable to dislocations and may be the cause of many pains in the side, disturbances of the vessels as they pass through the diaphragm and inflammation in the iliac region. A palliative treatment may be given the floating ribs by having the patient lie flat either on the back or on the side; then place the hand near the vertebral end of the ribs and raise them upward while the patient takes a deep breath.

Treatment of lesions between the =manubrium= and =gladiolus= are best given by placing the patient with the face downward upon the operating table, and having the articulation of the manubrium and gladiolus just over the edge of the table. An assistant should hold the patient firmly upon the table while hyperextension or flexion, as the case may require, with traction, is exerted upon the head, neck and shoulders, and manipulation of the articular points is given to reduce the dislocation. The same principles are employed here as in correcting lesions elsewhere.

Correction of the =cartilages along the sternum= is very easily accomplished by having the patient sit upon a stool and the osteopath standing behind the patient places a knee in the back; then reaching around with one hand over the cartilages and the other hand underneath the axilla, execute the same movement as given in correcting dislocations of the sternal ends of the ribs.

A treatment sometimes used to release a depressed condition of the =cartilages= of the =false ribs= is to stand behind the patient while he sits upon a stool and reach around him with fingers underneath the cartilages and raise them upward as he inhales. By having the patient take a deep breath and then exhale quickly while the fingers are over the cartilages a much better grasp of them can be obtained. This treatment should be carefully given, as there is danger of tearing the cartilages loose from the ribs.

=The Dorsal and Lumbar Spinal Regions.=—Here, as in other regions of the body, before an attempt is made to correct the vertebræ the muscles should be thoroughly relaxed. One of the easiest methods to relax the muscles is to have the patient lie upon the side, and then by standing in front of the patient and reaching over him with the fingers upon the contracted muscles an upward and outward rotary manipulation is given; or the patient may sit upon a stool while the physician stands in front with the arms around the patient and the fingers over the contracted muscles manipulating them upward and outward. Another very easy method is to stand behind the patient while he sits upon a stool and place a thumb over the contracted fibres, with the other hand underneath the axilla lifting the shoulder upward and backward so as to favor a relaxation of the muscles, while the thumb manipulates them.

In relaxing the =muscles= of the =lumbar region= have the patient on the side upon the table; then flex the thighs upon the abdomen with your weight against the knees so as to control all movements of the patient; reach over the patient with the fingers upon the contracted tissues and manipulate them outward and upward on either side until they are relaxed. A method sometimes employed to relax the muscles of the dorsal, lumbar and sacral regions is to place the patient flat on his face upon the table; then by pushing up on the muscles from above downward with the flat of the hand they are easily relaxed. This treatment should be especially given when the patient’s muscles are contracted by atmospherical changes and from standing in one position for a long time. When the muscles of the back are contracting they draw downward and many times draw the ribs with them, as well as tensing the tissues over the sacral foramina and obstructing or irritating the sacral nerves. By using the modern table longitudinally relaxing, or stretching, the lumbar and dorsal musculature saves considerable strength and effort of the physician.

To correct =vertebral lesions= of the =dorsal region= the same rules should be followed as in treating lesions of the cervical vertebræ. Treatments may be given with almost equal ease whether the patient is lying on the side or sitting up.

To illustrate the treatment of the dorsal region when the patient is lying down, assume that there exists a lateral lesion, combined rotation and sidebending, between two vertebræ; if the lesion is below the seventh dorsal use the legs as a lever, and if the lesion is above the seventh dorsal use the head and neck as the lever. Have the patient lie upon the side toward which the lesion is pronounced, either reach under the neck or around the limbs with one hand, and with the other hand upon the lesion bend the head and neck or the thighs in such a manner that the angle of the flexion is directly over the break in the spinal column; this is to exaggerate the lesion; then by lightly lifting up on the neck or limbs and with a slight rotation of this lever the flexed parts should be extended, at the same time exerting pressure with the hand over the lesion in such a manner that the vertebra is pushed forward toward its normal position.

Practically, the same treatment is given when a patient is sitting up, with the exception, of course, that the limbs cannot be used as levers. Lesions of the dorsal region or even the lumbar region can be corrected while the patient is sitting up. By this method considerable lifting is done away with. In fact, the weight of the patient can be used to great advantage by substituting it for one’s strength. No matter in what direction the lesion is, the physician reaches around the patient’s shoulders so that he just holds the weight of the patient from falling to one side or the other; thus with one hand manipulating the lesion the other arm is around the patient guiding the weight of the body in flexion, rotation and extension. It is not always necessary to lift up on the patient but just let the weight of the patient act as strength applied to the power arm. Always make it a point when working upon dislocated vertebræ in any region that just as soon as one has obtained a slight movement in the lesion =do not attempt= to correct it any more for the time being. A slight movement toward the right direction may be all that is necessary to relieve the ill effects of the lesion. In fact it might be impossible to get the lesion anatomically correct as the shape of the vertebra may have conformed in a greater or less extent to its abnormal position.

An excellent method to correct the various combinations of rotation and sidebending of the third to ninth dorsals is to have the patient sit up with the physician either sitting or standing, depending upon height of seat, back of the patient. Have the patient lean back until head is supported upon shoulder of physician, and the anterior and posterior musculature of torso, abdomen and pelvis are thoroughly relaxed. Reach around the patient’s chest with one arm, the hand of which is placed beneath the axilla. The thenar eminence of the other hand is placed upon the posteriorly prominent transverse process of the lesioned segment. Then with careful hyperextension, traction, and rotation and, sidebending of the torso, the anchorage is released, care being taken that localization is exact; this moment of coordination is accompanied with a thrust of the thenar eminence upon the transverse process. Relaxation, leverages and thrust must be precise and thoroughly coordinated.

To reduce vertebræ that are =deviated anteriorly= in the dorsal region, especially between the scapulæ, is often a hard matter. A satisfactory method is to stand behind the patient, while he is sitting upon a stool, and reach around both sides of him upon the sternal ends of the ribs corresponding to the anterior vertebræ; then have the patient relax with the head upon the chest, and at the same time take a full inhalation while pressure is exerted posteriorly upon the sternal ends of the ribs. The object of this method is to pull back the rigid ribs (the lungs being filled with air) which are attached to the anterior surfaces of the transverse processes of the vertebræ, and thus upon the anterior vertebræ pushing them posteriorly; all of the muscles of the body being quite passive and the head relaxed on the body, a separation of the vertebræ is accomplished, thus favoring a crowding posteriorly of the subdislocated vertebræ.

To correct =vertebræ= of the =lumbar region= is on the whole much easier than in the dorsal region. Here the legs can be used as levers to great advantage. By the same method of flexion, rotation, and extension, as employed in the dorsal region when the patient is lying on the side, the result can generally be obtained.

Sidebending is the most common single lesion of the lumbar vertebræ, though there may be some rotation at the lumbo-sacral juncture. Occasionally malformation is found at the fifth. To correct the lumbar lesions the following method is often used: place the patient upon the side of the rotation or sidebending with knees flexed, buttocks well back and entire spinal column straight. Next bring torso and head, with spine straight, well forward to edge of table. Then with hand upon ilium tilt it slightly forward, and with other hand upon shoulder rotate entire spine, including head, so that spine is locked and the point of localization exactly corresponds to the lesions. This brings the spine back to nearly a straight position. Next, after a moment or two of tension-relaxation, either thrust back upon the shoulder or forward upon the ilium. Again exactly coordinating localization, relaxation and leverages is the key of the method.

=The Abdomen.=—Direct treatment of the abdomen is given in many diseases of its organs. The patient should lie flat upon the back, the legs flexed upon the thighs and the thighs flexed upon the abdomen, so that the abdominal muscles will be thoroughly relaxed; and then the various organs of the abdomen can usually be manipulated with ease. Remember that in many diseases of the abdominal viscera the treatment of the splanchnics and vagi will be the primary treatment rather than direct abdominal treatments.

In treating the =liver= directly, the ribs over the liver should be raised and separated, and the lower border of the liver manipulated directly, as considerable therapeutic results can be obtained, particularly when the liver is congested and enlarged. Manipulation of the =bile ducts= is very essential in many liver diseases. The treatment relieves congestion of the ducts and removes any collections of mucus in the ducts due to the congestion, as well as freeing obstructed flow of bile. The manipulation should be a deep, downward one, directly over the path of the ducts (from about the cartilage of the ninth rib to the duodenal orifice of the biliary tract, the latter being about one and one-half inches diagonally downward and to the right of the umbilicus). Be very careful when first manipulating, and bear down lightly over the duct so that the structures superficial to it may be relaxed as the duct is deep below the surface of the abdomen. Usually the gall-gladder can be emptied by light pressure over the skin above the cartilages of the eighth, ninth and tenth ribs. The light manipulation acts, probably, by way of the spinal segment, as a stimulus to the dilators of the sphincters of the gall-bladder. Very likely through reciprocal innervation relaxing the sphincter of the bile duct will contract fibres of the gall bladder.

Manipulation of the =stomach= has considerable effect in strengthening its circular fibres and toning up the coats in general. In cases of gas formation, the gas in some instances may by manipulating over the stomach, be forced through the cardiac or pyloric orifices.

Direct treatment over the =spleen= by raising the eighth, ninth, tenth and eleventh ribs of the left side is effectual in congestion and enlargement of the organ.

In thin subjects the =kidneys= can be treated directly by pressing down carefully but deeply over the kidneys, and lightly crowding them upward and outward. This treatment also has some effect in relieving contracted tissues about the renal vessels and kidneys.

Treatment to the =intestines= through the abdomen is an effective treatment. In the various obstructions to the intestines, constipation, etc., the direct work is essential. Treatment of the intestines is to correct any abnormal position that they may have assumed, to relieve constrictions of the gut caused by contracted tissues, to relieve impactions and adhesions, to increase peristalsis and to tone up the intestinal coats in general. The treatment consists in a manipulation of the intestines, especially in the right and left iliac fossæ, and the pelvic colon, ascending colon and duodenum, as impactions and prolapses of the gut are more liable to occur at these points than in any other locality. In manipulating the intestines, work for a definite purpose and not give a general kneading treatment unless the walls of the abdomen and the coats of the intestines are weakened; in the latter case the spinal treatment is the primary one. In treating over the iliac region, draw upward and inward on the folds of the gut. It is claimed by some authorities that nerves pass from the cutaneous surface of the abdomen directly to the intestine by way of the peritoneum; if such is the case, manipulation of the abdominal walls would have direct effect upon these nerve fibres. The abdomen may be treated when the patient is sitting up, but the treatment is not satisfactory. (See Prolapsed Organs).

=The Pelvis.=—The treatment of the pelvis is easy, but the difficult work is in making a diagnosis of the position of the pelvic bones. The pelvis is especially apt to become deranged by jars and falls. Some of the most successful osteopathic results have been obtained in correcting the pelvic region.

To relax the muscles over the pelvis, the patient should be on the side or upon the face; then relax the muscles by manipulating them upward, chiefly those over the sacral foramina. It is a good rule to adjust the lumbar first owing to release secured to the nerves supplying pelvic muscles and also to the fact that many pelvic distortions are secondary or compensatory to lumbar lesions. The easiest method to correct the innominata is to have the patient lie upon his side; then by standing in front of the patient slip one hand between the thighs and grasp around the tuberosity of the ischium, and with the other hand upon the crest of the ilium, the innominatum can be moved upward or downward and forward or backward (wheel and axle principle). Simply pulling or pushing upon these two points in whatever direction necessary is all that is required providing the soft tissues are thoroughly relaxed. By having the patient flat upon the back practically the same treatment can be given, but not to so great an advantage. In cases where the ilium is posterior and the ischium anterior, the physician may stand back of the patient, while he is lying upon his side, and place one knee against the sacrum and with one hand upon the ilium, with the other take hold of the ankle of the affected side (the involved side being uppermost in all cases where the patient is lying upon his side); pressure can be exerted upon the ilium and the limb pulled backward, thus correcting the derangement. This treatment should be avoided as much as possible, as there is considerable danger of pulling back too severely and injuring the patient; the lever is long and the amount of force exerted upon it cannot be judged precisely.

Another method is, with the patient on the back, flex and evert the knee to the side so the side of the foot lies flat on the table. Grasp the ankle with one hand and with the other on the crest of the ilium of the opposite side then, by pushing down firmly on the knee the articulation is gaped and at the same time the operator pushes with his body against the knee with a sharp thrust. This may have to be repeated a few times before the articulation is released and if one is keen he will easily detect the slight concussion carried down the femur as the adjustment takes place. This will correct a forward and downward innominate. For an upward and backward one, place the patient in exactly the same position and go through the same motions except that the knee is pulled toward the operator. If the desired “chug” is not felt and adjustment is not definite, the leg may be pulled down rather smartly by the ankle to a parallel with the other. This is a technique that is easy, both for the patient and operator, and will correct any but the most stubborn.

In the case of a greatly relaxed and atonic condition of the ligaments of the pelvis much trouble is experienced, often, in making the adjustment permanent. Many suggestions have been made and most of them useless but, probably the use of a belt of non-elastic webbing about two inches in width buckled tightly around the pelvis just below the anterior spines will do as much as anything and is a procedure well to follow in all such cases. Where there is a pendulous abdomen a support in the shape of a simple belt which should be so fitted as to act as a sling will transfer the weight of the abdominal viscera from the muscles, already stretched and atonic, to the belt and put the burden over the sacrum. This prevents the pulling of the innominatum in lesion again. Overcorrection is suggested as a means on the ground that it sets up irritation and induces fibrous ankylosis and for the same reason W. W. Howard places his patient prone and with thumb works the ligaments associated with the joint until they are thoroughly inflamed. The patient is then put in bed a few days and after the inflammation has cleared up the ligaments will be found to have shortened.

To correct a rotary lesion between the pelvis and fifth lumbar the patient should be placed upon the side, and with the body held firmly, the pelvis can be forced backward or forward as the occasion demands. (See Coccyx).

=The Legs.=—The origin of many symptoms manifested in the legs, as in the arms, are due to spinal lesions corresponding to the region of innervation to the affected tissues. The derangements of the pelvic bones are a frequent source of symptoms that are referred to the legs and feet. The osteopath finds that a slight dislocation of the hip may occur which is especially likely to affect the knee. This partial dislocation is apt to be an upward-posterior one; the head of the femur resting in the upper and posterior part of the acetabulum. Many diseases of the legs and feet are due to local displacement of the bones. The method of treatment is the same as given in surgical works. (See Sprains).

A general treatment of the legs and thighs is oftentimes necessary; it consists of flexing the thighs quite firmly upon the abdomen, and executing thorough external and internal rotary movements of the thighs and legs. In a few cases both limbs are flexed strongly at the same time upon the abdomen. After giving these movements manipulation over the saphenous opening and beneath the popliteal space is performed. This general treatment tends to increase the circulation of the entire limb and to relax thoroughly all contracted fibres.

=The Arms.=—In treating the arms, care has to be taken that the affection is not due to spinal derangements; otherwise the arms are manipulated according to the disorder. Complete dislocations of the shoulder comes under the province of surgery. Many times the osteopath locates slight or incomplete dislocations of the shoulder. Partial dislocations of the shoulder are generally anterior. (See Sprains).

In cases where pain exists in the shoulder or arm, outside of locating the cause in the shoulder joint, the affection may be due to fibres contracting over the coracoid process, or a dislocation of the second or third rib, and in some instances the clavicle is deranged. Special care should be given to a possible bursitis and tendo-synovitis. Occasionally muscular fibres may slip out of the bicipital groove. Dislocations of the bones of the arm are treated according to surgical methods. The pains and various troublesome symptoms that may be manifested in the fingers or the hands are oftentimes caused by slight dislocations of the elbow, shoulder, ribs, or vertebræ, as low as the sixth to eighth dorsals.

=The coccyx.=—The coccyx, owing to its exposed position and rather unstable attachment, is subject to many injuries; more indeed than come to notice. Its injury results in many local and general disturbances owing to its close relation to the sympathetics. Successful treatment of deviations often bring startling results. They may be divided into =fractures= and =displacements=.

In =complete= or =partial= fracture of the coccyx, as well as in dislocation, if the patient can be seen with reasonable promptness after the accident much can be done for relief of the pain and the prognosis is good for complete recovery.

Examination should be made externally and internally and after the condition is diagnosed about the same procedure is indicated for any of the conditions. With the patient on the left side introduce the right index finger, well lubricated, into the rectum and carefully relax all tissue within reach of the tip. If there are spasms of the coccygeal muscles, inhibition of the anterior nerves will quiet them. When this has been done place the left index finger externally along the body of the coccyx and holding it firmly both within and without release it longitudinally and then adjust. After this has been done it is well to hold it there until all danger of returning spasm, which might displace it again, is over, when the finger can be withdrawn.

The pain following will depend on the severity of the injury, but will keep up more or less constantly for several days. When severe, relief is often given by introducing the finger and relaxing contracted tissue which is pulling it from its position. Hot water bags placed next to the part will be of benefit. The bowels should be kept confined for forty-eight hours if possible in cases of fracture. Watch carefully the progress of union that the bones are in situ so there will not be deformity.

In diagnosing the first injury be sure that there is no splitting of the first segment or splinters which may require surgical interference. In old cases of fracture where there is complete bony ankylosis it is not justifiable to attempt any change, but where there is motion and a fibrous union, after preparatory treatments about one week apart, it can usually be replaced. Look well to any muscular contractions which might interfere with it. Force must never be used nor any attempt to replace until it has been first released from its articular attachment. In the various forms of =displacement= the same technique applies as in fractures, or the finger and thumb of one hand may be used, the tip of the finger internally at the sacro-coccygeal articulation and the thumb externally at the same point. Complete control of the part is secured in this manner. Great care must always be used in treatment of any displacement of the coccyx. Contractions of its muscular attachments will often cause deviations in contour. Removal of the irritation and relaxation will allow it to assume its normal position.

=The sacrum.=—Adjustments of the sacrum as distinguished from the ilium in strictly innominate lesions are not many. When posterior with the patient on a stool the knee of the osteopath coveted by a pillow and placed against the sacrum and both hands grasping the anterior borders of the ilia, strong traction will move it into position. In a downward displacement with the aid of an assistant from behind holding the crests of the ilia firmly as the patient sits on the table, the osteopath in front clasping both arms about the patient and with a rocking motion from side disengages the sacrum and at the same time lifts it into position.

For anterior displacements use the technique described in replacing upward and backward innominate dislocation first right side and then left, which will result in correcting the lesion.

The preceding osteopathic technique includes a few of the treatments given by the osteopath. Although many osteopaths use methods not given here, those outlined are sufficient for illustrative purposes. A point which cannot be too thoroughly impressed upon the student is that osteopathic treatment is in reality =constructive= work, that is, readjustive, not only in detail, but in viewing the body structure as a whole. Detailed readjustment is an essential, still do not lose sight of the relation of the part to the whole. In our distinctive work anatomical construction is the basis of physiological function, although physiological stimulus is essential to anatomical development.

=How often to treat.=—How often to treat a case depends entirely upon the nature of the disease from which the patient is suffering. Just as in giving drugs the frequency of treatment is entirely dependent upon the seat of the disease and its severity. Acute cases require a thorough treatment at least once daily, and many times in severe cases the treatment has to be repeated several times daily. In subacute and chronic cases, as a rule, treatment should not be given as often as in acute cases; possibly once a day, but usually alternate days is better. In office practice cases are commonly treated two or three times weekly. Still it is better not to treat some cases oftener than once a week.

There is more danger in treating too often and too long than in not treating often enough. The distinctive work of an osteopath is to correct disordered anatomical structures; and when a certain derangement has been corrected the tissues should have rest and plenty of time for repair. When treatments are given often, it simply keeps the tissues in an irritated state and nature does not have time to heal the diseased tissues. Always make it a point at each treatment to correct some definite lesion, and when the work is accomplished let the parts alone until the tissues have recovered as much as possible from the effects of the previous treatment before another treatment is attempted. The reason why some cases do not get cured under osteopathic treatment is simply because the osteopath keeps the diseased tissues in an aggravated state by the constant treatment so that they do not have the least chance to heal; the physician is thus adding irritation to the disease.

It is only by experience that one can tell how often to treat. Each case is a special study; what would be quite sufficient for a certain individual with a given disease would not be at all suitable for a second individual with the same disease. As in drugs what is suitable for one person would not be adapted to another, because the make up of each individual is entirely different; but here the parallelism diverges, for in drugs there is a foreign agent introduced into the system, while in osteopathic treatment the curative agent is entirely harmonious with the idiosyncrasies of the individual. It is for this reason that experience in practice is so essential.

Most cases should not be treated, as a rule, after a meal unless the patient is suffering from some digestive disturbance; for treating other regions of the body outside of the digestive tract causes more or less stimulation of the parts treated and thereby draws blood away from the organs of digestion. Cases of disordered brain circulation, where the patient is unable to rest or sleep at night, should be treated at about their retiring time so that the circulation of the body may be equalized, thus giving the patient undisturbed rest.

To show in a practical way the methods of experienced osteopaths in this matter G. J. Helmer[32] is quoted: “I submit the following table to illustrate the frequency of treatment in one hundred cases taken from my practice: one case three times per week, sixty-three cases two times per week, twenty-two cases one time per week, nine cases once every two weeks, five cases once every four weeks. Comparing the present with the past, I find I am lengthening the time between treatments with much better results.”

Another very practical side of the question and one which will be greatly appreciated by the patient, is the lessened cost for the same result in the less frequent treatments, as well as the saving in time. With the loss in going to the office, rest after treatment, not to mention possible wait while there, three times weekly represents more time than the average person can well spare and not infrequently will deter him from continuing. More especially is this true of those coming from a distance.

=Length of Treatment and Overtreatment.=—Naturally the length of treatment depends upon the case at issue and nothing more. There is no reason why any two cases should be treated for the same length of time unless they present identical lesions and then the personal equation of the two might present such a wide difference of aspect as to forbid such a proceeding.

The question of time has no place in the matter, save that it must not exceed physiological limits and be sufficient for the needs of the case. The patient should understand at once that it is to accomplish a specific purpose that the treatment is given, just as definite as a surgical or dental operation, and when the work is done it is time to stop. He would hardly be attracted to the dentist who guaranteed to use forty-five minutes in extracting a tooth. Good judgment is required in this as in all matters pertaining to osteopathy. There is a generally expressed opinion among the older osteopaths, based on experience, that: first, a short specific treatment is productive of best results and, second, treatments given under high tension when quick work is necessary are most satisfactory. Long treatments are debilitating and over stimulation amounts to inhibition. Further, in a long treatment it is necessary to go over the whole body, thus dispersing the vital forces (which have been stimulated for healing and upbuilding the pathological area) to parts not involved, thus defeating the very purposes intended. Dr. Still always advocated and gave the short, specific treatment.

The point always to be considered is the individual characteristics of the patient, and effects of the first treatment should be carefully observed. After a patient has been under treatment for any considerable time it is well to give him a vacation from treatment, and it is remarkable what improvement will be shown at times by such a measure and how seldom he will lose ground. Dr. Still presented this subject vividly as follows: “To treat the spine more than once or twice a week and thereby irritate the spinal cord, will cause the vital assimilation to be perverted and become death producing by effecting an absorption of the living molecules of life before they are fully matured and while they are in the cellular system, lying immediately under the lymphatics. If you will allow yourself to think for a moment of the possible irritation of the spinal cord and what effect it will have on the uterus, for example, you will realize that I have told you a truth. Many of your patients are well six months before they are discharged. They continue treatment because they are weak, and they are weak because you keep them so by irritating the spinal cord.” It is not a rare experience for a patient to leave apparently with little or no improvement only to report a complete recovery a little later.

=Misapplied Treatment.=—Probably in spinal treatment more risks are taken than in any other region of the body. To us as a school it is by far the most important and interesting area we have to treat, consequently it is not surprising that various general treatments and methods have been devised with the idea of getting quicker and easier results. Herein lies the danger outside of mistaken diagnosis, for short cut treatments can never take the place of time and skill. Technically speaking, if one thoroughly understands the philosophy of osteopathy and is conversant with the underlying principles of its therapeutics, there is absolutely no danger of even the slightest injury. It is the one who takes chances by not properly diagnosing and by not being cautious enough with delicate persons when applying his treatments that is apt to overstrain some tissue or organ and otherwise do bodily harm. Of the treatments considered dangerous not one of them is without merit if judiciously applied, but unfortunately in many cases they are in general and indiscriminate use. It is well to remember that we are moving structures which have never been moved before and that time enough has not elapsed to observe what the ultimate result may be. Again, in adjusting a subluxation of the spine do not forget that the force necessary for that adjustment, if misapplied, is sufficient to produce a lesion, and there is no doubt that this has happened. Your patient’s interests are above everything and must never be sacrificed for any reason whatever, so if at any time there is uncertainty always give the patient the benefit of the doubt. On the other hand the osteopath must have the courage of his convictions and fortunately when these are coupled with good judgment the results are all that could be desired. The following should be used with great caution if used at all:

First, =Indiscriminate stretching= of the spinal column with the aid of an assistant. It is not good osteopathy although there are some cases where it may be beneficial. While not specially dangerous, generally, in delicate patients, elderly people, arteriosclerotic conditions, and in some stages of Pott’s disease it is absolutely contraindicated. Moreover in most spinal cases except impacted vertebræ and symmetrical curvatures the stretching of the vertebral ligaments locks the lesion firmer.

Second, =Extreme rotating= of the cervical region. This cannot be considered good treatment in any case with the exception of the muscle stretching. On the contrary it is dangerous; first, it is not osteopathy for it is not specific; second, the nervous shock is severe, an important consideration in delicate people; third, the cervical ligaments become stretched and the vertebræ are easily displaced, while damage to a diseased vertebra, an aneurism or in arteriosclerosis would be irreparable. No other region of the body should have greater care in treatment than the neck.

Third, =Hyperextension= of the spine with the patient on his face. This treatment is rarely indicated. In fact, it is barbarous and a relic of an early day. Possibly more cases have been injured by this treatment than all others combined.

Fourth, =Rough separating= of the vertebræ and ribs while the patient is on his face. This is a most excellent treatment in many cases, but great judgment is necessary. Delicate patients, heart disease, and necrosed vertebræ and ribs should be carefully excluded.

Fifth, =Innominate adjustments= such as placing the patient on the side and putting the knee against the sacrum while grasping the leg at the knee. Or, the placing of the patient face down with one hand on the sacrum and the other holding the knee. In both these there is a tremendous leverage and in the latter the strain is at the lumbar rather than where needed. There are other unnecessarily risky methods for this operation, while it is easy to perform in most cases and without danger.

Sixth, =Abdominal treatment= gives wonderful results when intelligently applied, but it may be productive of great harm in conditions of tumors, malignancy, and pus formations.

=Misapplied treatment= is always dangerous, no matter to what part of the body given, and it is proof of wrong diagnosis when given. As a rule treatment is given without proper diagnosis in such cases, so a misapplied treatment has two interpretations—first, ignorance; second, laziness. In the former lies the greater danger for ignorance coupled with force and lack of skill is an appalling combination.

Cases are frequently reported where tumors have passed from the vagina, rectum, nose, etc., the osteopath thinking it was the result of good treatment, without considering that it was simply the breaking of a long pedicle with great danger from hemorrhage. The greatest care should be exercised in treating cases where aneurism, osteomalacia, and arteriosclerosis are present, also in the leg treatment of tabes dorsalis and in the weak, thin ribs of elderly people and those with a gouty or rheumatic diathesis. Imagine treating an abscess directly, yet it has been done, as have varicose veins with the terrible danger of rupture and embolism. Aneurisms have been ruptured in the same way.

One could go on indefinitely with this subject, but to sum up: if the osteopath is not familiar with the feel of the living anatomy in its giving and resisting under treatment both in health and disease and does not know his osteopathy, nothing can prevent him doing harm. A successful practitioner means an understanding of pathology, then experience plus common sense.

FOOTNOTES:

[31] See Ashmore’s Osteopathic Mechanics.

[32] Journal of the American Osteopathic Association, Dec., 1903.

OSTEOPATHIC CENTERS

“Osteopathic spinal centers” was a term commonly used in the early period of osteopathic development. From the facts, first, that a few centers have been actually determined in the cord, viz., genito-urinary, vasomotor, etc.; second, that the innervation from the spinal segment to various thoracic, abdominal and pelvic viscera correspond with a considerable degree of accuracy to certain vertebral sections, and third, displacements of tissues of the spinal column affect viscus integrity, depending upon the locality of the structural perversion as to the organ involved and is a clinical observation of great import, arose the misnomer “osteopathic centers.” For one to ask what “centers” should be “treated” in this or that disease shows a lack of the conception of osteopathy as if he asked what “movements” to give when “treating” a certain disorder. It is as unosteopathic, as it is unscientific, broadly speaking, to suppose osteopathic technique implies the application of movements to certain nerve centers.

Osteopathic Stimulation

“Osteopathic stimulation” is another term loosely used without extensive clinical experience to support it. Mechanical stimulation is frequently utilized in the physiological laboratory. But to employ it extensively and comprehensively in the treating room or at the bedside the therapeutic potency of it will be found wanting; that is, to employ it to the exclusion of that most important basic treatment, readjustment, is a great mistake.

Clinically, the pathologically slowed heart may be stimulated by a stimulus to the cervical sympathies, the gall-bladder emptied by a stimulus near the costal cartilages of the ninth and tenth ribs (this is probably via the spinal segments), etc. Normally, these organs and others may be temporarily stimulated. Experimentally, Burns[33] of Los Angeles and Pearce[34] of San Francisco have shown the potency of osteopathic mechanical stimulation. For example, stimulation (mechanical) in the middle and lower dorsal regions irritates and increases peristaltic action and vaso-constriction in the stomach and intestines.

Osteopathic Inhibition

Likewise the term “osteopathic inhibition” has not always been scientifically employed. Mechanical inhibition is probably used less frequently than stimulation but still it is of more importance. Probably the true interpretation of considerable of so-termed stimulatory and inhibitory efforts, is simply one of normalization of tissues, physiologic equilibrium resulting from such changes.

Clinically, to relax contracted muscles by inhibition, to relieve neuralgia by impinging nerve courses, to relax the cardiac orifice of the stomach by pressure at the ninth or tenth dorsal vertebra on the left side, etc., are excellent examples of the therapeutic value of inhibition. Experimentally Pearce and Burns produced the opposite results to that of stimulation. Inhibition in the middle and lower dorsal region caused relaxation of the muscles of both the stomach and intestines, decreased peristalsis, and caused dilatation of the blood vessels.

The employment of stimulation and inhibition rounds out to a certain extent our therapeutics, that is, makes it more practical and specific. We should not, however, over-rate the relative value of stimulatory and inhibitory treatment as compared with the readjustive treatment. Not but what the former is of considerable practical importance, but the point to be emphasized is that it gives a scientific demonstration of how pathological effects result, if long continued, from the various osteopathic lesions. In a word, it shows the physiological process from cause to effect, or rather a step in the beginning pathological (perverted physiological) in many disturbances.

Therapeutically, all will agree with Cherry[35] that “stimulation and inhibition should be employed in all forms of acute disease as palliative measures until such time as the primary lesion may be removed.”

As a preparation for adjustment of any bony lesion there is no question but that simple inhibition for a brief time in the area will bring about relaxation of soft tissues in a much more satisfactory manner than the usual massage like method. McPherson, Montreal, has developed a technique of sacral pressure which he uses exclusively in his practice. Without going into the merits of his theory there is no doubt that inhibition at the second and third sacral will bring about relaxation of the muscles of the lower trunk in a most gratifying manner. Another thing, if there is difficulty in introducing the finger in making either a vaginal or rectal examination, a minute’s pressure at these points will, in most cases, cause the sphincter to relax so as to cause no discomfort to the patient. This pressure will, also, have a great effect on the hypogastric plexus and the pelvic organs.

Osteopathic Readjustment

Readjustment or adjustment is many times particularly emphasized in this work as the key to osteopathic therapeutics.

If the theory of readjustment can not stand the most searching tests of science osteopathy will have to be relegated to a most subservient place, on a par with massage, Swedish movements, and various medical gymnastics. Consequently the readjustment theory is again referred to, and especially so when the subjects of osteopathic centers, stimulation and inhibition are outlined.

No doubt many stimulatory (so-called) and general treatments exert their greatest influence by inadvertently readjusting tissues. Then how much more effective would the readjustment treatment be if applied intelligently. In certain acute disorders, e. g., “colds,” immediate relief is often obtained by relaxing muscles through either stimulation or inhibition; in reality the final result, as far as the muscle is concerned, is one of readjustment. Likewise in stretching and rotation of tissues and sections of the body the effect may either be stimulatory or inhibitory, and still it may be, also, readjustive.

After all has been said the ultimate physiological effect of any of these treatments, if of any therapeutic value, must be one of stimulation to a part or to the body generally. But there is a vast difference between physiological stimulation and the one method of obtaining the same termed mechanical stimulation. It is not the purpose here to enter into anything like an exhaustive survey of stimulation and inhibition but simply to outline a few practical hints on the relative values. Everyone is aware that overstimulation is equal to inhibition, and even applying it to very delicate subjects the therapeutic end we may wish to obtain may be lost and as a consequence the patient exhausted; whereas at the same time readjustment possibly could have been employed and real permanent effects secured.

So we should whenever possible utilize the basic principle of our therapeutics, readjustment, for this represents in the majority of cases, first, permanent results; second, a saving of much time, and third, less exhaustion on the part of both patient and physician.

McConnell[36] has shown in his series of laboratory experiments on animals the reality and potency of the readjustment fundamental. The effect of malaligned vertebræ and ribs upon contiguous vascular channels and nervous tissues, not only affects immediate skeletal muscles by simple contractions but even produces interstitial myositis. Through narrowing of the intervertebral foramina and tension upon the fibrous tissue anchoring the spinal nerve in its exit, and through pressure and strain on the sympathetics in contact with the heads of the ribs, which are secured there by the parietal layer of the pleura, organs in corresponding cavities become diseased. Some of the diseases produced in the series of experiments were catarrhal and parenchymatous changes in the stomach and intestines, congestion of the liver and spleen, acute nephritis, goitre, inflammation of the lymphatics, edema of the cornea, and degenerations of nervous tissues. Still too much emphasis should not be placed upon the narrowing of the foramen for certain pathologic changes are shown to be due to other conditions than Wallerian.

The osteopath, as stated, may inadvertently correct osteopathic lesions. Vis medicatrix naturae undoubtedly corrects many osteopathic lesions; this is evident from the fact that many bodily strains, sprains, and injuries are overcome naturally or involuntarily, that is, without any voluntary assistance from an osteopath. On the other hand all osteopathic lesions are not due to outside influences or forces, e. g., in pneumonia the severely contracted dorsal muscles often partially dislocate the vertebral ends of the ribs and thus increase the seriousness of the disease; and this is true in many acute conditions wherein visceral changes will reflexly contract spinal muscles and also through these contractions produce osseous lesions. Here is where osteopathic treatment in acute diseases will not only correct the primary lesion but also these secondary ones and thus abort, or shorten, or lessen severity, or prevent complications of the disease. But it should always be borne in mind that when certain disease processes occur it will take a definite time at best for curative changes to predominate. In other words pathological changes are just as real and potent as physiological facts or anatomical data and the character of the same should always be considered.

Consequently in readjustment work a distinctive etiology and pathology has to be taken into account. The color, contour (whether the lesion is simply a local one or there is a composite or group lesion), condition (irritation, debility, contractions, and tenderness), and movement of the several regions, and the spine as a whole should be noted. And the student should always keep in mind that the osseous vertebral lesion may be, (a) a twist between two vertebræ (this generally means a rotation of one section of the spine on another section), (b) malalignment of several vertebræ (the composite or group lesion), or (c) the impacted or strained lesion, (this is a lesion that Clark attaches considerable significance to, wherein there is injury to the articular surfaces and ligaments without osseous derangement, followed by exudation and other inflammatory products, limited motion, etc.).

VasoMotor Nerves

It is extremely important that the osteopath should be thoroughly conversant with the regions where he may affect the vasomotor nerves to various tissues and organs. Many anatomical derangements undoubtedly involve the vasomotor nerves, and it is therefore necessary to know where they may be affected. The following table is taken mostly from the physiology of Landois and Stirling, but many of the statements have been noted at various times; it is, therefore, impossible to give full credit.[37]

The vasomotor center is in the medulla, consequently the osteopath gives cervical treatment to influence this center. Treatment of the upper cervical region has undoubtedly a marked effect in tending to equalize the vascular system of the body, when it is disturbed.

=Head.=—The cervical sympathetic for the same side of the face, eye, ear, salivary glands, tongue, etc., and possibly the brain. Lesions are found in all the tissues about the cervical region, but usually in the vertebræ, which influence these nerves. Deep contracted muscles oftentimes involve them. The spinal vaso-constrictors for the vessels of the head are from the first five or six thoracics. Many lesions are located in the upper five or six dorsal vertebræ, or corresponding ribs, that have apparently a direct influence upon the vessels of the head. Not only congestive headache and congestion of the brain tissues are influenced by lesions in this region, but disease of the eye, ear and face occasionally arise from such derangements. It is always best when the head, neck or even the arms are involved, to examine carefully this region. Vaso-dilator fibres for the face and mouth are found from the second to the fifth dorsals; these fibres unite almost entirely with the trigeminus, and pass from the superior cervical ganglion of the sympathetic, to the ganglion of Gasser. This fact is of great importance to the osteopath, for oftentimes when inflammation of the face and mouth occurs, lesions may be located along the upper dorsal vertebræ or ribs, or in the deeply contracted muscles of this region. Observation revealed in several cases of erysipelas that the causative lesion was located in the upper dorsal region; and the cases were cured by correcting these lesions, thus showing that probably the vasomotor nerves were the seat of the trouble. Other dilator fibres arise apparently in the trigeminus, for stimulation of this nerve between the brain and Gasser’s ganglion causes dilatation of the vessels of the face. The lingual and glosso-pharyngeal nerves are the dilators of the lingual vessels. The sympathetic and hypo glossal are the constrictors; these arise in the sympathetic and reach the nerves by way of the superior cervical ganglion. Stimulation of the cervical sympathetic causes constriction of the retinal vessels. This point is extremely interesting to the osteopath, because diseases of the retina and optic nerve are oftentimes due to subluxated cervical vertebræ, usually the atlas or third cervical. The retinal fibres leave the sympathetic at the superior cervical ganglion and pass along the communicating ramus to the ganglion of Gasser, from whence they reach the eye through the ophthalmic branch of the fifth nerve, the gray root of the ophthalmic, the ganglion and the ciliary nerves. Almost all the fibres to the anterior part of the eye are found in the fifth nerve; this, also, is another important point for the osteopath’s consideration. Cases of conjunctivitis, keratitis, corneal astigmatism and diseases about the eyelids and tear ducts are usually caused by lesions to the fifth nerve, due to a deranged atlas or third cervical. The vaso-dilators for the anterior part of the eye, and also dilating fibres to the iris may be affected at the first and second dorsals. This point is also taken advantage of by the osteopath, for lesions of these fibres occur oftentimes at the upper dorsal. It is claimed that important fibres that aid in the control of the metabolism of the retina, may be affected at the fourth and fifth dorsals.

=Lungs.=—Reflex constriction by stimulation of the intercostals, central end of the sciatic, abdominal pneumogastric and abdominal sympathetic. There is not a rich vasomotor supply.[38] The essential feature to the osteopath is that the vaso-constrictors to the lungs and bronchial tubes are very likely to be interfered with by rib and vertebral dislocations, from the second to the seventh dorsals, inclusive, but chiefly at the third, fourth and fifth. The heaviest innervation being from the third, fourth and fifth spaces, probably explains why asthma is often due to a dislocation of the third, fourth or fifth rib.

=Heart.=—First to fifth thoracic via ganglion stellatum and inferior cervical ganglion. Vasomotor fibres to the coronary arteries are found in the vagi.

=Intestines.=—Sympathetic, chiefly through the splanchnic nerves. Vaso-constrictors of the jejunum from the fifth dorsal down, for the ileum slightly lower and for the colon still lower. There are none below the second lumbar. Dilators are present in the same sheath, but more abundant in the last three dorsals and the upper two lumbars; all probably end in the solar and renal plexuses.

=Receptaculum Chyli.=—Stimulation of the splanclinics causes dilatation.

=Liver.=—The splanchnics chiefly on the right side. The vagus contains vaso-dilators. There are also fibres from the inferior cervical ganglia of the sympathetic.

=Kidneys.=—Vasomotor nerves from the sixth dorsal to the second lumbar, but principally from the ninth to twelfth dorsals, inclusive. In the large majority of kidney diseases, lesions are found from the tenth to the twelfth dorsals. Stimulation of the sciatic centers causes contraction. There are also fibres from the superior cervical ganglion.

=Spleen.=—Vasomotor fibres are in the splanchnics, third dorsal to third lumbar, principally, on the left side. There are some fibres direct from the brain. Stimulation of the vagi contracts the spleen.

=Portal System.=—Fifth to ninth dorsal.

=Generative Organs.=—For Fallopian tubes, uterus, vagina, vas deferens and seminal vesicles, vasomotor fibres are found in the lower dorsal, and the second, third, fourth and fifth lumbar nerves, principally.

=Coccyx and Immediate Region.=—Third lumbar down.

=Back Muscles.=—Dorsal Posterior branches of the lumbar nerves and intercostal nerves. These nerves arise from the gray ramus of the corresponding sympathetic ganglia.

=Arm.=—From the brachial plexus, the sympathetic, inferior cervical ganglion and first thoracic ganglion, and sometimes lower.

=Leg.=—Second dorsal down, the sciatic and crural nerves, and the abdominal sympathetics.

Sensory Nerves

Inhibition of various regions along the spinal column is frequently given by the osteopath to lessen pain. It is only a temporary or palliative treatment, but many times gives great relief. One should inhibit usually over tender points and contracted muscles. These (tender points and contracted muscles) are signs to the osteopath that disturbances exist at these points. The following table is taken from Quain, which is Head’s classification:

=Heart.=—First, second and third dorsals.

=Lungs.=—First, second, third, fourth and fifth dorsals.

=Stomach.=—Sixth, seventh, eighth and ninth dorsals. Cardiac end from sixth and seventh. Pyloric end from ninth.

=Intestines.=—(a) Down to upper part of rectum, ninth, tenth, eleventh and twelfth dorsals. (b) Rectum, second, third and fourth sacrals.

=Liver and Gall-bladder.=—Sixth, seventh, eighth, ninth and tenth dorsals.

=Kidney and Ureter.=—Tenth, eleventh and twelfth dorsals. Upper part of ureter, tenth dorsal. At lower end of ureter, first lumbar tends to appear.

=Bladder.=—(a) Mucous membrane and neck of bladder; (first) second, third and fourth sacrals; (b) over distension and ineffectual contraction, eleventh and twelfth dorsals, and first lumbar.

=Prostate.=—Tenth, eleventh (twelfth) dorsals. First, second and third sacrals, and fifth lumbar.

=Epididymis.=—Eleventh and twelfth dorsals and first lumbar.

=Testis.=—Tenth dorsal.

=Ovary.=—Tenth dorsal.

=Appendages, etc.=—Eleventh and twelfth dorsals, first lumbar.

=Uterus.=—(a) In contraction, tenth, eleventh and twelfth dorsals, and first lumbar. (b) Os uteri; (first) second, third and fourth sacrals (fifth lumbar very rarely).

Other points are used by the osteopath to relieve pain of certain regions, for such the reader is referred to the article on neuralgia; besides many tender points are found along the spine by the osteopath, where inhibition gives relief to the patient, provided such points have a connection with the case in question.

Hot fomentations if property applied, through reciprocal relationship of the nervous system, are of value in relieving pain, releasing spastic musculature and normalizing visceral function. Frequently, in both acute and chronic cases, this is an excellent preparatory measure, to be followed by careful adjustment. It will be recalled that the functional test, movement of a vertebral lesion is of primary consideration.[39]

FOOTNOTES:

[33] Burns—Partial Report of Experiments upon Visceral Reflexes. The Osteopathic World, Aug., 1905.

[34] Pearce—Some Laboratory Demonstrations of Osteopathic Principles. The Osteopathic Physician, Nov., 1905.

[35] Stimulation—Leslie E. Cherry, Journal of the American Osteopathic Association, Feb., 1905.

[36] McConnell—The Osteopathic Lesion,—Journal of the American Osteopathic Association.

[37] See also Gaskell, The Involuntary Nervous System; Pattenger, Symptoms of Visceral Disease; Mackenzie, Symptoms and Their Interpretation.

[38] MacLeod, Physiology and Biochemistry in Modern Medicine.

[39] See Luciani, Human Physiology, Vol. III; MacLeod, Physiology and Biochemistry in Modern Medicine.

PATHOLOGICAL SPINAL CURVATURES

SPINAL CURVATURES

Any deviation of two or more consecutive vertebræ from the normal curves of the spinal column is usually termed by the osteopath a pathological curvature. Of the common pathological curvatures of the spinal column there are found: (1) scoliosis or lateral curvature, (2) kyphosis, or excurvation, an antero-posterior curve with the convexity backward, and, (3) lordosis, or incurvation, an antero-posterior curve with the convexity forward.

=Osteopathic Etiology.=—Of primary importance in the causation of pathological curvatures of the spinal column, are injuries to the spine, such as strains, falls, blows, and various physical forces, acting directly or indirectly, as injuries to the chest, pelvis and limbs. The osteopath in his daily work finds more curvatures, as well as acute and chronic diseases, resulting from some simple injury to the spine, as a slip, strain or twist, than from any other cause. The dire effects of any violence to the spinal column cannot be overestimated.

Among =predisposing causes= may be mentioned, continued ill health, general weakness, rapid growth, rachitis, tuberculosis, etc. Any habitual one-sided position may result in a curvature. An injury to the chest, adhesions from pleuritis, chronic liver disease, obliquity of the pelvis producing unequal length of the legs, carrying heavy weights on one side, and various morbid growths of the chest and abdomen, may all produce curvatures. Many cases are found in school children who are growing rapidly, and whose muscular strength and development do not keep pace with their growth. Unilateral atrophy of the muscles, due to central changes or overuse, may be the cause of deviations of the spinal column. Sacro-iliac disease in some instances is a potent factor. Thus there may be a great variety of causes productive of the incipiency, and the spine being strained or irritated at a single point and in a certain way gradually develops a curvature. Every spinal and innominate lesion should be considered as a potential cause for a curvature.

=Scoliosis.=—This is the most common spinal deformity and is characterized by lateral deviation from the median line. In most cases the curve is to the right in the upper dorsal region, with a compensatory curve in the opposite direction in the lumbar region. The curve being to the right in the majority of cases, is probably due to the fact that most people are right-handed.

=Morbid Anatomy.=—The vertebræ in the region involved are rotated so that their spinous processes point toward the concavity of the lateral curve. The bodies of the vertebræ on the side next to the concavity are thinner, due to absorption; the intervertebral discs are made thin on the same side by pressure and absorption. The ribs are considerably distorted, depressed on the concave side and prominent on the convex side. The ligaments on the concave side are contracted, and stretched on the convex side. The muscles on the concave side are more or less contracted, and on the convex side they are stretched, causing atrophy and fatty infiltration of their tissues.

=Kyphosis.=—This may be a slight posterior curve really amounting to nothing, or it may be a very grave pathological condition as in Pott’s disease. Therefore it is very necessary that one should make a most careful diagnosis (see Pott’s disease).

The most common =causes= of kyphosis are Pott’s disease, rachitis, occupation, general weakness, rheumatism and old age.

In Pott’s disease, the posterior curve is characterized by a sharp angle, and by the spine being very rigid. This, taken in conjunction with the history and other symptoms should be sufficient to enable one to make a diagnosis. Radiographic examination should be made.

The condition of round shoulders, which in time produces marked kyphosis, is rarely a habit as it is usually termed. In nearly every case it indicates either a weakness of the back muscles or, what is more apt to be the cause, a strained posterior condition of the dorsal vertebræ, commonly of the lower dorsal region.

=Morbid Anatomy.=—In mild cases there is simply a relaxation of the ligaments of the vertebræ and a separation of the laminæ and spinous processes. In severe forms there may be absorption of the anterior portion of the intervertebral discs and the bodies of the vertebræ (Pott’s disease).

=Lordosis.=—This may be a congenital condition, especially when occurring in the lumbar region. Anterior curves of the spine are generally found in the lumbar or cervical regions, but occasionally occur in the dorsal region, causing the spinal column to be more or less straight, and thus weakening the individual. This curve is commonly compensatory to kyphosis, hip-joint disease and congenital dislocations of the hip.

=Treatment= of =Spinal Curvatures=.—The treatment of pathological curves of the spinal column, by osteopathic methods, has been highly satisfactory to both osteopath and patient. The success of the osteopath in these cases has been due to his comprehensive and exact knowledge of each vertebra, and of the spinal column in general. He recognizes curvatures that the ordinary practitioner, and it is safe to say the orthopaedic specialist, would not even notice or recognize. On account of the highly developed sense of touch of the osteopath, he is capable of detecting the slightest deviation of one vertebra from another, and of the spine in general from the normal. Thus by the uniqueness and peculiarity of his work he is capable, not only of discovering a curvature, but also of reducing a curve when found.

The work consists of, first, relaxing any muscles that may have become rigid over the seat of the curve. Then follows a treatment to each vertebra involved, by attempting to replace it, and treatment to the curve in general by springing it toward its normal position. At each treatment effort should be made to accomplish something toward correcting the spine; too many treatments are given in a “general” way, and being unspecialized amount to nothing. One must become familiar with the exact location of each vertebra involved, to attempt a correction of a curvature intelligently. Upon this one point it is impossible to speak too strongly, for a great many treatments have been wasted and improvement of cases retarded by not paying enough attention to the details of the diagnosis, either from pure slothfulness or from an imperfect conception of osteopathy. Corrective exercises are always of value in addition to treatment.

These remarks refer to incipient and certain moderate curvatures. In other cases radical measures (Abbott) should be employed if age and conditions permit. Remember, however, that the practitioner in his daily work of adjusting the many combinations of rotation and sidebending lesions corrects innumerable actual and impending curves.

=Lateral curvature= in the dorsal region is undoubtedly the hardest to correct on account of the ribs, which complicate the condition. A marked curve in the dorsal region is sure to be accompanied by a dislocation of the vertebral end of one or more ribs. Treat each distinct lesion separately, follow by general stretching, replacing and molding of the tissues. A good method to stretch tissues and adjust a moderate lateral curve is to utilize the swing, or in lieu of this have the patient stand just at arm’s length from the wall with concave side toward the wall with straight arm at right angles and palm resting against the wall. Stand in front of patient whose feet are firmly on the floor and reach around with both hands upon the spine. As the patient sidebends toward the wall it tends to correct the deformity, so if the operator coordinates his adjustment with that lateral movement of the patient, precise fulcra can be obtained and a certain, definite correction secured. The significance rests with the stretching of tissues and the definite fulcra obtained, thereby securing a maximum sidebending and rotation toward correction.

The =dislocation= of an =innominate= sometimes complicates matters, but is a simple point to remedy, and should not be overlooked.

The correction of a curvature presents a special study to the osteopath, whether it be scoliosis, kyphosis or lordosis, and special rules cannot be laid down for treatment. Cases of rare occurrence are what might be termed “symmetrical” curves; i. e., no vertebra presents separately a marked lesion, the column on the whole being simply bowed. Such cases can be treated by springing back the spinal column, and by the use of methodical exercises. Unfortunately most curvatures are characterized by various lesions between the vertebræ, and thus each lesion requires special work.

In simple curves the use of braces, jackets, and the various mechanical appliances are of very little use to the osteopath, in fact, more harmful on the whole, than beneficial. Naturally they would apply to a “symmetrical” curve, or where the patient is too weak to sit or walk, but they can be of very little use to the average patient, in place of correct osteopathic treatment. Mechanical appliances confine the movements of the patient, interfere with the development of the muscles, and impinge to a greater or less extent the spinal nerves. Due attention to hygienic surroundings and diet are certainly of aid. Proper exercises and occupation for the sufferer should be advised. Special care should be taken in examining (radiographic) for infectious lesions (arthritis).

=Straight Spine= is a term used particularly by osteopaths for a condition seldom recognized by orthopedic surgeons. The following is from H. W. Forbes[40]: Straight spine is “a departure from the normal in the conformation of the chest; characterized anatomically by bilateral diminution in size, decrease in the antero-posterior diameter, relative increase in the transverse diameter and flattening of the anterior and posterior walls; characterized clinically by diminution of respiratory capacity, lowered lung and heart resistance, impaired general nutrition and predisposition to neurosis.

“Of the many possible manipulations that may be used to lift and overcome the morbid bend of the ribs I will attempt the description of but one.

“Relax the musculature of the back and chest. Rotate, flex and extend the dorsal spine. Examine all the ribs on each side and loosen any that do not move freely. Having done this, the patient is prepared for the specific treatment. Have the patient sit on a stool and lean forward on a table. Have him separate the elbows, flex the forearms, place one hand over the other and his forehead on the hands. Tell him to relax all the muscles of the shoulders and arms and to breathe deeply without using the muscles. After a few trials he is able to fully expand his chest without contracting the muscles connecting the upper extremity with the trunk. The physician then takes a position at side (either side) of the patient and places the weight of his trunk on the ribs of the side he is on, a little external to their angles. He passes his arms around the patient’s body; the arms passing across the front of the chest are carried around far enough to allow the hand to be placed on the ribs just external to their angles. The other hand is placed on the top of this one. In this position the physician’s body on one side, and his hands on the opposite, occupy similar positions. The patient is now told to inspire deeply and at the same time to relax the shoulder muscles, as before instructed. As the chest expands drop the weight of the trunk on one side and make pressure forward (forward meaning toward the anterior surface of patient’s body) with the hands on the other side. This lifts the ribs to a greater extent than the patient unassisted could lift them. At the end of inspiration and during the first third of expiration the chest is compressed laterally. The compressing force, if applied correctly, will fix the ribs in a position of less obliquity and will also correct the increased lateral bending of them. The dorsal spine becomes more convex posteriorly at the moment of lateral compression of the thorax, if correctly made. Great force should not be used at the beginning. Repeat the manipulation five to twenty times each treatment. Give treatment three times a week. A similar movement may be given on the table.

“The greater number of flat chests in patients under thirty years of age may be corrected. If the patient is above thirty, although complete correction may not always be accomplished, the results are satisfactory. Two to six months treatment is required.”

=A “typhoid spine”= comes as a sequel to typhoid fever. There is constant pain, tenderness along the lumbar region and rise of temperature. The pain is generally increased when the spine is moved forward or sidewise. Such a condition is clearly understood by the osteopath. There are always found distinct vertebral lesions along the region that is tender on pressure. In fact these very lesions may have been the predisposing cause of the attack of typhoid fever. The treatment is rest and the indicated manipulation to correct the derangements. It is of great interest to note that where the typhoid patient is treated osteopathically the condition just described seldom results. Observations by C. M. T. Hulett confirm this statement.

The =Neurotic Spine= may be the result of injury but the subject is usually of a nervous, neurasthenic type. It occurs from the age of puberty to adult, much more often in females than males.

The patient has dull pain in the back of the neck or in the lumbar or sacral region, complains of a constant tired feeling and often of a sharp neuralgic pain in certain parts of the spine. Generally there is a drooping posture in the upper dorsal with shoulders thrown forward, which is a sign of weakness. There is extreme tenderness along the spine and usually the pain is confined to the sensitive places.

Treatment consists of a constitutional toning up, and increasing muscular strength through judicious exercise. The posterior curve may be pushed toward the median line by laying the patient on the face; also with the knee in the back and the flat of both hands on the sternal ends raise the ribs; or by the arms making use of the pectoral muscles accomplish the same result. Deep breathing is also effective. Relief can usually be given and a cure will depend upon the patient’s general condition.

The =Hysterical Spine= is usually considered the same as the neurotic spine, but there are many cases which have the sensitive spine without being hysterical. There is more deformity usually present, particularly in the lumbar region. Probably there will be a history of some injury.

The treatment is to correct the curvature and build up the general health. These conditions are stubborn and progress is slow. In both the neurotic and hysterical spines the ligaments of certain areas will be found atonied and relaxed. This is especially noticed upon attempting to spring a group of vertebræ when all of a sudden the section relaxes. In either of these spines the lesions will irritate or obstruct nervous courses, produce venous stagnation or arterial starvation, and disturb lymph channels. H. F. Goetz has observed that in functional nervous diseases the dorsal spine is flat, while in visceral displacement the dorso-lumbar spine is posterior.

The =Spine of the Aged= wherein is found stooped shoulders and a rigid spinal structure, can be distinctly improved by slow, cautious traction. This tones weakened muscles, releases contractures, separates the compressed intervertebral discs, and definitely tones the viscera. Careful work is imperative.

FOOTNOTES:

[40] Journal of the American Osteopathic Association.

POTT’S DISEASE

An article on Pott’s disease does not really come within the province of a practice of medicine. Still it will be acceptable to the practitioners and students of osteopathy, as one of the objects of osteopathic work is to improve, not only medical and obstetrical practice, but also surgical practice, and besides the osteopath will have many cases of spondylitis to treat. “Pott’s disease, or caries of vertebral bodies, was first described by Percival Pott in 1779. It consists of a destructive ostitis affecting the spongy tissue of one or more of the bodies of the vertebræ. The ostitis is tuberculous, and is similar in character to tubercular ostitis seen in the epiphysis of the long bones. Owing to the superincumbent weight of the head and shoulders pressing upon the carious vertebral bodies, the spine and trunk become peculiarly and characteristically distorted. The morbid process is limited, as a rule, to the bodies; the transverse, articular, and spinous processes are rarely primarily affected.” (Park).

The first consideration in the =treatment= of Pott’s disease is rest. If the disease is a progressive one, rest in bed in the recumbent position is necessary. Naturally, the object of the treatment is to secure resolution of the tubercular ostitis as soon as possible. To do this, careful manipulative treatment should be applied to the diseased vertebræ. The treatment must not be harsh, for there would be danger of greater irritation to the parts, and possibly infected particles from the destroyed tissue might gain entrance to the vascular system. The osteopath must be extremely careful how he manipulates the spinal column in Pott’s disease. The object of the manipulation is not primarily to overcome the deformity, as some may think such an act possible, but to separate the vertebræ enough to allow a freedom of the circulation, and to remove impingements of the nerve tissue. It is impossible to overcome the deformity to any extent when part of the body of the vertebra is destroyed; but if one could treat the case at the incipiency, most probably deformity would be prevented. There is another danger in treating cases too severely, and that is causing exhaustion of the patient. Treat the spinal column not only to separate each articulation slightly, but to carefully crowd the diseased vertebræ toward their normal position. When the disease is in the dorsal region, considerable attention has to be paid to the ribs, as they are invariably involved when the spinal curvature is great. Hence it is necessary to treat each rib separately, and try to correct them at least, and remove any obstruction to nerve fibres or vessels that may be found. One of the strongest arguments against the indiscriminate use of braces, jackets and various mechanical appliances in spinal deformities, is that they tend to straighten the spine, by simply crowding the vertebræ and ribs as a whole into place, besides interfering with the cutaneous circulation. The osteopath should realize that each vertebra and rib has to receive special treatment, in order to correct the spinal column, and that mechanically exerting pressure upon all the vertebræ at one time tends to lock the vertebræ and ribs all the more securely. It is like trying to correct a certain subdislocation of the cervical vertebræ by pulling and twisting the neck instead of applying specific treatment—the lesion is all the more firmly fastened. Young, in his Surgery, makes this observation: “Like chronic abscess or chronic bone disease, this affection has its origin in the fact that the tissues of the anterior parts of the bodies of the vertebræ have been partly deprived of their nutrition because of luxated ribs or subluxated or twisted vertebræ.”

After the tissue destruction has been limited, and the deformity corrected as much as can be, an ankylosis should be secured if possible. Promotion of ankylosis depends altogether upon the preceding treatment—rest and an improved nutrition of the parts. A truss or brace, if correctly applied, is often beneficial in such cases. The treatment of spinal abscesses is entirely in accordance with surgical treatment.

In all cases the general health of the patient has to be well taken care of. The osteopath must not be over zealous for quick results. It takes many months to perform a cure; however, there is always a tendency toward a cure. Treatment of the spinal muscles and of the limbs, and pure air, sunlight, massage and good food are very necessary.

SPRAINS AND FRACTURES

SPRAINS

The osteopath is often called upon to treat sprains of various sections of the body as well as to relieve after effects of fractures and restore function to the part. The osteopathic treatment is very effectual; therefore, an outline of the purpose and method is given.

Sprain is defined by Dorland as “the wrenching of a joint with partial rupture or other injury of its attachments, and without luxation of bones.” From an osteopathic viewpoint the above definition is not fully explanatory, for there is in most cases a partial luxation of the bones. The most common cause of a sprain becoming chronic is the presence of partial bony displacements. Rupture of tissues may be the cause of a chronic state but is not nearly so frequent as the bony dislocation. In most sprains, the wrenching causes a displacement of the bony tissues, which may or may not return to normal position and relation. The function of the muscles is not primarily to hold the bones in place; this is left to the ligaments, so when a wrench of a joint is so severe as to cause rupture of muscles or tearing of ligaments, partial luxation of the bones is almost certain to follow; and even where such damage does not occur a change in the relation of the bones is a frequent occurrence.

Unless a sprain can be seen very early it may be difficult to detect just what has happened; whether it rests with a rupture of the areolar and connective tissues, a displaced cartilage, tendon, or bone, a torn ligament, or ruptured muscle. Hemorrhage and swelling take place so rapidly that no time should be lost in critically examining the joint. When in doubt as to the structural disturbances, particularly in acute cases if there is a possibility of a fracture, and in chronic cases any supposition that tubercular involvement is present, have a radiographic examination.

There is comparatively little to be found in medical literature relative to the =pathology= of sprains. Probably Moullin in his excellent monograph on Sprains has given as good an outline as can be found[41]. He says that “generally speaking, the tissues on one side of a joint are overstretched and torn; those on the other compressed and crushed together; but there is always so much twisting, and such a difference in the strength and power of resistance of various structures, that unless the part is examined with the greatest care it is almost impossible to say what actually has given way.” Hemorrhage due to torn vessels is the cause of most of the swelling within the first few hours. Later on, there is considerable lymph mixed with the blood. There is not only extravasation of blood into the surrounding tissues but also into the synovial wall and cavity. This causes considerable irritation and pain owing to the roughening of the membrane, and the joint becomes inflexible. And if the joint or any strained tissue is kept too long at rest the mass becomes organized and is the cause of much discomfort and annoyance.

Similar changes may occur in the bursæ due to the extravasated blood. Strong ligaments may be torn across, but not frequently. The tear is usually a separation from the bone. Occasionally interosseous ligaments, as for instance in the knee, may be injured.

The muscles may be severely torn, but more often they are “hurt by their own sudden and spasmodic effort at recovery than by anything else.” In a few cases the tendons and muscles will be found bruised, lacerated, and dislocated.

The veins occasionally rupture and thus results more or less effusion, so that rigidity and edema may persist for a long time. The bones are very frequently damaged. This may be a simple bruising of the tissue but more often, as osteopathic diagnosis shows, there is partial displacement of the bony structure.

A point of great importance that every experienced osteopath will agree to is the following from Moullin: “Diseases of the spine, hip, and other joints in children may be due, in great measure, to some constitutional taint, though it is open to question whether the influence of this is not overrated; but it is quite certain that the immediate starting point in nine cases out of ten is some chance sprain, often so slight as scarcely to have been noticed at the time.”

Before treating a sprain there are one or two points the osteopath should carefully note: first, that there is no complicative fracture; second, in children that there is not an epiphysial separation; and, third, note peculiarities of a constitutional character that would complicate matters. Whatever is done, always give the patient the benefit of the doubt.

If the patient can be seen early, before swelling has reached the maximum, many times a very quick cure can be secured. Do not at once put the part at rest and apply cold, but examine the sprain most carefully and thoroughly and readjust first of all any bony defects; then replace the softer tissues if displaced, and next relax contractions; follow this by light massage and passive movements to reduce and combat hemorrhage and swelling. This treatment alone in a fair percentage of cases will be all that is necessary provided frequent subsequent treatments of massage and passive movements are continued to reduce and counteract inflammation and to prevent rigidity and stiffness of the softer tissues. Where the osteopathic treatment is distinctly indicated is in the readjustive manipulation. This is the reason why the treatment is so efficacious, and the patient is cured in a fraction of the usual time, and few sprains result in complications and become chronic. In sprains that have become chronic there will be found almost invariably some osseous tissue slightly displaced. After correcting this, apply careful and thorough manipulation and massage and movements to break up adhesions, to remove effusions and extravasations, to relax muscles, and to promote normal circulation. Care should be taken that there are no displaced cartilages, ligaments, tendons, or muscles.

It is well to keep in mind that the osteopathic readjustive manipulation is not an exercise or movement, but definite, specific correction of the tissues anatomically. Do not treat the displacement by any general “pommelling,” but apply the mechanical principles indicated as in any dislocation. This will mean much to the patient in more ways than one, and especially so should the sprain be so severe and complicated as to demand anesthesia for correction.

There is no objection to the employment of cold and heat; in fact, both are beneficial. Cold to prevent extravasation and swelling, and heat to remove and relieve the same, is a sound and practical method. But do not apply a wet bandage. Pouring cold water over the sprain is the best method; even better than immersing the part. An ice bag is another good way to apply cold. When the skin begins to look blanched and dull the maximum amount of benefit has been secured. Heat at the very first may be employed instead of cold, for it has a tendency to prevent bleeding and inflammation, but the temperature of the application must be hot as can be borne or else the desired effect will not be obtained. Later on to relieve pain and rigidity, and to relax the muscles so that a better circulation will be secured, moderate heat will be beneficial. Then the application of heat and cold alternately will be of service, employed as a douche for a tonic effect, when the part is weak, inactive, and powerless after the elapse of several days. It should always be remembered that the employment of heat and cold is only of temporary benefit, so if used too long opposite effects to those desired will result.

Bandaging the sprain may be helpful, but not always. Great care should be taken as to how pressure is applied. Bandaging from periphery toward the trunk, seeing that the bandage is smooth, and padding all depressions so that the bandage does not touch bony prominences only, are necessary. Unless the bandage is applied so that an even pressure is secured, the material used not too warm, and the bandage attended to each day, the effectiveness will amount to but little.

Next, do not make the mistake of resting the injured joint too much. The function of a joint is movement, and it has been observed that prolonged rest of a healthy joint may result in rigidity, stiffness, and distension of the soft part, and even serious organic changes in the ligaments, synovial membrane, and cartilages have occurred. Consequently continued passive movements should be kept up from the inception of the injury, although it must not be carried to extremes so that inflammation, hemorrhage, or laceration will be aggravated. Moullin says: “As a rule, passive movement may be commenced from the second day with the certainty of preventing adhesions, and without the least fear.” Osteopathically, with due attention to readjustive manipulation, and care as to correct position and rest, passive motion will be allowable usually from the first day.

There is much corroborative evidence in current medical literature that bears in a general way upon part of the foregoing. The International Text Book of Surgery says: “Massage should begin early, in order to avoid, as far as possible, weakness of the muscles, and to ensure security to the position of the joints by the retention of a proper tone in them;” besides, early movement tends to reduce the effusion into the tendon sheaths around the articulation, which in some cases, particularly the ankle and wrist, may be a very prominent feature. The Reference Hand Book of the Medical Sciences voices the same opinion; and Mumford is referred to as follows: “Immobilization for more than a few days, as under the older methods, is objectionable because adhesions are apt to form, thus causing impairment of function, and because when there is a =tubercular taint=, proper conditions for a localized tuberculosis are established.” Among other statements Holder Sneve in the Journal of the American Medical Association of June 1, 1901, says: “Immobilization of muscles is not rest. On the contrary, in all sprains the muscles should have passive exercise the first few hours and days, and active exercise after that. In the majority of cases active exercise should be instituted from the beginning. The plaster cast should not be used at all, even in cases where we have a fracture, unless it be impossible to maintain a proper position of the joint.”[42]

Again quotation is made from Moullin. These quotations are taken from the chapters on Manipulation and Massage. It will be observed he makes a distinction between the two methods. And the osteopath should carefully keep in mind not only the difference between the two, but beyond these the more fundamental treatment, readjustment. The characteristic feature of osteopathy is anatomical readjustment, and this in sprains should be supplemented by massage (superficial work), and also manipulation (deep and more or less forcible work) in order to remove stiffness, rigidity, and fibrous ankylosis.

The following is relative to forcible manipulation: “Manipulation is much more useful than division; it can be employed for such a variety of purposes. In the early stages it prevents the occurrence of stiffness or the formation of adhesions. Later, when the swelling and heat have disappeared, it is no less successful in restoring freedom and ease of movement, and afterward, when all mechanical obstructions have been cleared away by its use, it is one of the most effectual methods known for bringing back the circulation and nutrition of the part, and giving again to the muscles and nerves the energy which has so long been wanting....

“To carry this out effectively two things are needed beyond all others. The one is a sense of touch so delicate that it can appreciate the least resistance or irregularity of movement; the other an accurate knowledge, not merely of the ordinary anatomy of the part, but of the different degrees of tension that fall on the ligaments in every position of the limb.

“Each joint requires a different kind of manipulation according to its construction....

“There should be no jerking. The movements must be vigorous and forcible, but perfectly smooth; and they must be carried out thoroughly, the joint being moved to its full extent in all directions that are natural to it. Each kind of action should be combined successively with the rest, one by one, so that the tension may fall in turn upon all the different parts of the capsule.

“Movements which are especially restricted or painful, of course require most attention, but the others, though they may not be affected to the same extent, are not to be neglected. It sometimes happens if these are dealt with first, that a considerable proportion of the main obstruction is cleared away, as it were, by side attacks, so that when its turn comes it yields more readily than it otherwise would.

“Recent slight adhesions give away at once without a sound, though the sensation is generally conveyed to the hand. When they are older the noise may be as loud and clear as when a bone is broken....

“The after treatment of these cases (cases where there has been tearing and breaking of adhesions) should be in all respects the same as that of a recent sprain, only if passive motion at an early date is advisable to prevent the occurrence of stiffness in the one, it is absolutely necessary in the other.”

The following pertains to massage of sprains: “Massage, in the strict sense of the term, is a great deal more efficacious, especially with older sprains. Its action is not limited to the skin and superficial structures. These undergo immense changes, it is true; they become softer and finer while under manipulation; their strength and elasticity increase, the extreme tenderness diminishes, and the natural appearance and texture return. The surface loses its dry, harsh character and becomes warm and moist again; the livid bluish color gives away to a brighter hue, and the deeper layers of fibrous tissue yield and stretch, so that the hide-bound, shrunken condition that is often present after long disuse gradually passes off. But the good effect is not by any means limited to, or even most conspicuously shown by, this. When properly carried out, massage exerts a simultaneous influence on muscles, nerves, and vessels; in fact, on all the tissues within its reach.

“The circulation is the first thing to feel its power. It has already been explained how, after prolonged rest, the blood, as it were, lies almost stagnant in the tissues, slowly circulating through them, and neither giving them sufficient for their nutrition, nor removing from them the waste products of their action. This is changed at once. The life of the part is quickened. The veins and absorbents are emptied first, and the fluid they contain driven out into the heart, which fills more rapidly, and contracts more vigorously and firmly. Then the pressure falls in the smaller vessels, and the tiny irregular spaces, full of lymph, which extend in all directions through the tissues. These, in their turn, are compressed and mechanically emptied, their contents being driven on into the empty vessels, from which any backward flow is prevented by the valves. The circulation becomes more rapid; nutrition is carried on with greater energy, and the actual amount of the blood in the tissues at any one time so much increased that they become full and soft to the touch and regain the even and rounded contour of active health....

“It is most essential to commence as gradually and as gently as possible, working on the deeper tissues only after the more superficial ones have become thoroughly accustomed, and have been unloaded of their surplus fluid. The skin, the soft subcutaneous tissue, the muscles, and the deeper layers, must all be worked in turn. Nor should the manipulation be confined to the injured part. In a sprain of any standing, the whole of the limb is affected more or less. It is usually better to devote attention first to the parts nearer the trunk than to deal with those around the injured area, and only afterward, when the circulation is thoroughly reestablished, to manipulate the joint itself.

“The tendency is to make the sittings last too long. Deep manipulation itself rarely requires more than =five minutes=; but in dealing with a recent injury it may be advisable to spend a longer time than this over the friction and other preparatory measures, so that a quarter of an hour soon passes by. When the tenderness is very great, and the amount of swelling excessive, much longer than this may be necessary, but short, frequently repeated sittings are of greater benefit than one long one. A skillful operator, too, will often effect more in a few minutes than an ordinary rubber will in as many sittings.”

A summary of the general treatments of sprains would be as follows:

1. Readjustment of parts and removal of obstructions. Osteopathy is especially adapted in these cases, for two of the primal therapeutic factors in all cases from an osteopathic viewpoint are to readjust the anatomical and to remove obstructions. One should constantly keep in mind, “a temporary displacement followed immediately by a return to place, constitutes a sprain.” The osteopath often finds that a perfect returning does not take place, and even remote lesions may affect a joint.

2. Manipulation, and massage of soft tissues, to restore circulation and to prevent and remove debris from rupture of vessels and inflammatory products.

3. The employment of cold, heat and pressure, and a certain amount of rest.

4. Anatomical readjustment and manipulation in chronic cases to break up adhesions, remove exudates, overcome the organized products of inflammation, and cure synovitis.

5. Movements both passive and active to stimulate and exercise functions of the joint.

=The Spinal Column.=—The osteopath is especially cognizant of the fact that many sprains occur to the spinal column. These may affect a single joint, or more or less of a section may be involved. The bones, ligaments, tendons, muscles, or spinal cord may be found injured. Even distant organs, through involvement of the circulation to the cord, or through irritation or impingement of spinal nerves and sympathetics, are frequently disordered. It is not necessary to go into detailed description, for the points bearing upon this will be found under Osteopathic Diagnosis, Etiology, and Technique, and the general description will, also, apply. Readjustment, strapping, heat, massage, manipulation, ironing, stretching of muscles, fomentation, etc., have their place. There is no doubt that sprains, strains, and blows to the spinal column are the cause of many spinal disorders and consequent visceral disturbances.

=The Ribs.=—Sprains of the vertebral ends frequently occur, resulting in a partial luxation, stretching of ligaments, contraction of muscles, and exudative formation in the joint structures, which often is the cause of irritation to the sympathetic nerves. The costal cartilages are frequently strained, and may so irritate the intercostal nerve as to cause considerable pain both locally and reflexly. The treatment is essentially one of replacement, and relaxation of the softer tissues. Adhesive strips to limit movement due to respiration may be helpful.

=The Innominata.=—Sprains of the innominata are also commonly met with. Besides being a source of discomfort to the patient they are an important cause of pelvic disorders and leg affections. Partial displacements are the rule, the correction of which gives quick relief. Where there is considerable spasm of muscles, examine carefully the lumbar alignment. In chronic cases fibrosis of muscles and adhesions may complicate matters.

=The Hip Joint.=—Sprains involving the hip joint may be readily corrected, and again may be the exciting cause of serious involvement. Previous tubercular disease can be aggravated in this manner, or syphilitic changes in the joint disturbed. Care should be taken that there are no complicating displacements of the innominata or irritations to the spinal nerves. Possibly the hip may be so strained as to cause a twist of the femur in the socket and thus simulate a partial dislocation; this, in fact, would probably be termed a partial dislocation. Strain of one set of muscles about the hip joint is somewhat rare, and spinal lesions may disturb the innervation to one set of muscles. In cases of =intracapsular fracture= considerable can be done by careful massage and manipulation after union has taken place, to secure greater freedom of movement and strength of the limb. Likewise in =hip-joint disease=, after the disease is healed, massage and manipulation will be very beneficial. Care must be taken if the treatment causes spasticity of the muscles; this shows the treatment is irritative and should be stopped until the spasticity has ceased. Where the limb is shortened from either hip-joint disease or intracapsular fracture apparent lengthening may be secured by careful abductive and hyperextensive stretching.

=The Knee.=—The knee is the most complicated joint, and sprains are apt to be very serious. The usual treatment for sprains is employed. Occasionally the semilunar cartilages are displaced and may be a source of difficulty in diagnosis; likewise injuries to the patellar tendon and lateral ligaments. Another joint frequently overlooked is the innominate. In a number of knee cases that terminate in chronic synovitis there will be found a displacement of the innominate that is preventing recovery. A villous synovitis may arise in strains from faulty posture, especially in the obese. Injury to the hip-joint, also, may cause strain or irritation at the knee. Occasionally tender points about the knee, especially at the inner side, are due to irritation at the hip, or possibly from the spine. Referred pain of the knee joint is of frequent occurrence.

=The Ankle and Foot.=—The ankle is often sprained. One should examine carefully for a possible fracture of the malleolus, and for fracture of the tibia. There may be a dislocation of the fibula, also a separating of the tibia and fibula at the ankle. The common bony displacement takes place between the astragalus and os calcis. Then the cuboid is frequently displaced, and occasionally the navicular. The treatment should first of all be directed to correction of the osseous lesions. The arch of the instep may be weakened from the ligamentous strain and be an immediate step in the production of =flat foot=. Teall is of the opinion that lumbar and innominate displacement are common predisposing causes. Faulty position of the foot in walking may be an underlying factor.

=Bunions= result from a malposition of the joint. =Morton’s disease= due to a pinching of the metatarsal nerve will often yield to osteopathic treatment alone. There is generally displacement of the metatarsal bone. A pad worn directly under the painful point will be of benefit. In many of the local neuralgias, some anatomical displacement will be found as the exciting cause. =Hammer-toe= if not complicated with gout, rheumatism, etc., will yield to treatment if kept at persistently, otherwise surgical interference will be necessary.

Likewise various deformities of the foot and resulting neuralgias may be traced to local sprains, ill-fitting shoes, or anatomical maladjustments higher up of such a character as to affect the pedal circulation.

Flat Foot

Flat foot or weak foot is one of the common disorders that the osteopath is constantly called upon to treat. In the first place the patient should be taught to walk correctly. The feet should be parallel in walking so that the weakened muscles may be developed and strengthened. This will be difficult at first, but recovery depends upon this important point. In addition to this, special exercises, like turning the toes under and tip toe exercises, should be persisted in for a few minutes two or three times daily. Upon the other hand, do not overdo the exercises but always carry them to a point of fatigue. These two features, walking correctly and exercising, are essential complementary measures to the adjusting treatment. In conjunction with the above, the Scotch douche at the end of the day will prove of considerable benefit.

In the technique work, first make certain that there are no innominate or spinal lesions that bear upon the circulation and innervation of the feet. Then frequently faulty walking is due to these lesions.

In recent cases, simply remolding the arches of the foot will be all that is necessary, providing correct walking and foot exercising is maintained. But in the more chronic cases considerable adjusting and remolding of the tissues, bones, ligaments, muscles and fascia, are demanded. Perfect apposition between the astragalus and navicular bones, the highest point of the longitudinal arch, should be first secured. Attention should also be given the other articulating structures down to the metatarsal bones. This reestablishes the arch and overcomes the everted tendency. Considerable repeated force is often demanded to release the fibrotic tissues, but it is the important part of this technique.

With the patient on the table, supine, place your thumb firmly at the articulation of the navicular and astragalus. Then with the other hand around the metatarsals to be used as a lever in extending, rotating and inverting the foot with the fulcrum at the thumb of the first hand, spring, thrust and adjust the arch. This requires considerable strength and exactness of application. The tissues must give freely before the result can be secured. This is often painful to the patient but should be continued and repeated to the furthest point of motion until recovery is complete. Treat as often as the condition permits. Substituting the crotch of the thumb and forefinger or the knee for the thumb will give added advantage. Follow this with thorough springing of the plantar tissues by thumb and fingers.

If this is kept up with suitable exercises and correct walking, and proper shoes (Munson last), excellent results will be obtained in the great majority of cases. Same pair of shoes should not be worn two days in succession.

Many times the anterior arch is involved, jointly or separately. Persistent adjusting and remolding of the arch tissues will secure satisfactory results unless the bones are markedly deformed and the weight of the body is relatively too great. In this disorder, aside from paying special attention to the metatarsal articulations, the great toe requires a particular technique. For this grasp the toe firmly, exert traction until the tissue gives slightly and rotate it inward, toward the median line of the body, on its longitudinal axis. Have the patient frequently turn the toes under, or attempt to do it until the exercise can be easily accomplished.

Do not employ arch supporters except in hopeless cases. They simply splint the foot and thus further weaken the foot muscles. If the above methods are persistently followed to the point of actual adjustment, accompanied by releasing of fibrous tissue and actual strengthening of muscles through exercise, a very large percentage of cases will recover. In a few cases adhesive strips will be of benefit.

=The Shoulder.=—Exclusive of muscular and other strains there may be a partial dislocation. In these cases the acromial end of the clavicle is frequently dislocated, and owing to a general lack of muscular tone may be very hard to keep in place. The lower and inner part of the capsule is often affected, so that freedom of function is lacking and there is considerable pain. This is due to the thinness of the capsule and the large amount of soft tissue, so that when the arm hangs at the side the tissue is thrown into folds; and being very vascular is easily injured, so that the vascular lymph readily organizes and the part becomes stiff and unyielding. It requires patient, laborious treatment to break up and absorb this fibrous tissue. Then the long tendon of the biceps in some shoulder sprains is dislocated, but rarely. In shoulder injuries, examine also, the upper ribs.

=The Elbow.=—The elbow is another complicated joint. One should be careful that there is no fracture, and in children that there is not =epiphysial separation=. Extending, flexing, pronating and supinating the arm will aid much in the diagnosis. Examine well the rotation of the radius at the elbow joint, and be positive that the olecranon process drops normally into its fossa at the end of the humerus.

=The Wrist and Hand.=—The wrist is another joint commonly sprained. Here, also, care should be taken that a fracture does not exist. Colle’s fracture is frequent. The bursal and tendon sheaths are usually markedly involved. The scaphoid and semilunar are apt to be displaced; also, the os magnum and the unciform.

Sprains of the =fingers= are often met with. Outside of strains to the muscles, ligaments, and other tissues the joint is apt to be somewhat impacted. Traction will correct the latter. Care should be taken that a fracture is not present. =Dupuytren’s contraction= occurs from sprains or injuries, as the result of contraction of the fascia. The ring and index fingers are members usually affected. In some cases the affection will be found in both hands (symmetrical), and a spinal lesion will be the predisposing factor. Treatment every day, by straightening the fingers and stretching the tissue will at least retard the deformity, but in a number of cases surgery will have to be resorted to.

A =ganglion= or “weeping sinew” is a swelling in connection with the tendon sheath. It presents a round, firm outline, usually upon the back of the wrist. There is generally found a displacement of one or more of the wrist bones. If treatment of the joint and tendon sheath does not remove the ganglion, surgery may be utilized. =Trigger-finger= is a rare disorder. There is usually a history of local strain, which probably resulted in some thickening of the tendon. Manipulation and passive motion if continued will generally give relief.

Fractures

Immobilization and rest have been the paramount points with most physicians in the treatment of fractures and sprains. They have claimed that a sprain should be manipulated but rarely, much less a fractured bone. Rest, quiet, and fixation of an injured joint or bone have been rules that should not be violated under any consideration. In cases of sprain the great cry has been to let the joint alone for fear of spreading a possible =tubercular infection=. It is well to recall Mumford’s statement that if immobilization is too long continued, should there be a tubercular taint, proper conditions for a localized tuberculosis is established. And still a word of caution here, that an osteopath should not be over zealous and should carefully weigh all possible factors, both local and constitutional, may not be amiss. In previous tubercular, syphilitic, and other diseased states discretion should be employed.

Reducing rest and immobilization to a minimum means much to the patient, not only in the loss of valuable time but in annoying and serious after effects. Many cases of sprains and fractures come to the osteopath. In sprains that have become chronic through too much rest of the part and improper treatment, almost invariably there is found displacements of bone and adhesions that should never have existed; then has followed organized exudates and chronic synovitis. In fractures and even in complete dislocations the osteopath continually observes that too much rest has been given the part, resulting in unnecessary adhesions, contractions, atrophy of muscles, and impairment of function. Treatment almost always cures the condition, or at least materially relieves. How much better if the proper treatment had been first instituted and thus a large percentage of cases prevented from becoming chronic.

Of particular interest to the osteopath is the paper prepared by Eisendrath on “Early Massage and Movements in the Treatment of Fractures and Sprains,” and the discussion that followed before the Chicago Medical Society. The Illinois Medical Journal, December, 1903, contains a report.

Eisendrath said in part: “The former routine of immobilizing all fractures and the adjacent joints for a period of four to six weeks must, I feel, be subject to slight modification in the light of recent experience, and it shall be the aim of this paper to show what these changes are. When we are called to a case of fracture, it should be one’s first duty after its reduction to consider how can I best aid the patient in recovering the usefulness of his or her limbs? Can we shorten the long convalescence with its resultant loss of valuable time and earning capacity? How can we most rapidly restore to the limb its normal joint functions and prevent an atrophy of muscles and an ankylosis which will require many months to overcome?...

“The use of massage and of active and passive movements in the treatment of fractures and of severe sprains has been gradually gaining in the number of its advocates through the writings of Lucas-Championniere of Paris. We owe him a great debt for calling the attention of the profession to the employment of these methods in order to prevent atrophy and ankylosis as well as to promote healing....

“Before taking up my subject in detail permit me to recall a few salient points in the surgical pathology of fracture. Soon after the injury the blood clot around and between the ends of the fragments is absorbed and replaced by a jelly-like mass of young connective tissue cells called the callus. It corresponds to the solder which the plumber places over the ends of two pipes he desires to join. Bone begins to form at the periphery of the callus about the tenth day and advances toward the center rapidly, forming a ring of bone around the ends of the fragments so that by the end of the third week there is but slight abnormal motion at the point of fracture (exception to this is the femur). This entirely disappears by the end of the fourth week, especially in young people, and the union is firm. In the case of the femur it requires six or eight weeks. The greater the displacement of the ends of the fragment, the larger the callus and the slower the healing of the fracture.

“During these changes (callus formation) the muscles which supply the immobilized joints atrophy and the circulation in the skin and neighboring tissues is sluggish, resulting in swelling, etc., of the limb. The enforced rest causes more or less fluid to accumulate in the tendon sheaths and joints. This becomes organized and results in fibrous ankylosis of the joints and great impediment to the free action of the tendons within their sheaths. It is this atrophy, fibrous ankylosis and tenovaginitis which interfere with the restoration of the normal functions of the limb....

“Can we decrease the amount of wasting of muscles and control the stiffness of joints and tendons after fractures?

“It is the belief of the writer, based on a large experience, that the earlier use of massage, active and passive motions, will to a great extent eliminate the above conditions, which retard convalescence and in some cases cause permanent disability.

“Massage of an injured limb increases the amount of blood supplied to it, promotes the absorption of the swelling and prevents atrophy of muscles. In the case of a joint injury the exudate rapidly disappears and the articular surfaces can be again approximated so that movement is facilitated. By the cautious use of active and passive movements, either with or without the aid of apparatus, the normal functions of a joint can be rapidly restored....

“The active and passive movements of the limbs can be carried out immediately after the massage, but should only be permitted for a period of =five minutes= at first and the time then gradually increased. When a severe sprain, say the elbow or ankle, is first massaged, the pain seems to be almost unbearable, but this discomfort as well as the swelling rapidly disappears, and it is surprising to those who have never applied this treatment how quickly the normal function of the joint reappears. The same applies to the synovitis which accompanies fractures in close proximity or even into joints.”

The relief given these cases by massage, movements and manipulations by the osteopath is a daily experience, and results to him are not surprising. Then in addition to what the surgeon would do, the osteopath applies his principles of careful detail readjustment.

Eisendrath continues his paper by referring to the principal varieties of fractures and giving the treatment for each. He says that if correct treatment is carried out with proper massage and movements in fractures of one or both bones of the leg, the patient will be at work in six or seven weeks instead of three or four months, that in Colle’s fracture some surgeons do not employ a splint, and that in fractures of the olecranon, massage from the first week on is of the greatest use. This part is very interesting but space forbids giving it.

He then concludes his article with citation of several very interesting cases of fractures and severe sprains. These cases are exceptionally interesting to the osteopath, but still the same good treatment and results are duplicated every day in the osteopathic school.

The doctor’s contraindications to the use of early massage in fractures or sprains are the following:

“1. Tendency to displacement of fragments in oblique fractures. Under such conditions it is best not to begin either massage or movements until the union is firm (fourth to fifth week).

“2. In compound fractures until the wound is healed.

“3. Whenever the condition of the skin is such as to permit of infection; for example, the presence of blebs, or extensive abrasions.

“4. The presence of fragments which project but do not penetrate the skin.”

His conclusions are:

“1. Massage, active and passive motions prevent atrophy of muscles, tenovaginitis and ankylosis so frequently accompanying and following fractures, especially those close to the shoulder, elbow, wrist, knee and ankle joints.

“2. They give far better results than complete immobilization in the majority of fractures.”

In the discussion that followed Henrotin said that for some time, “I have never put a restraining apparatus of any kind, nor have I used any lotions on any sprain, no matter how severe....

“It has taken many years to bring this subject before the profession. It is a method that is absolutely effective as regards sprains and some forms of fractures. I have treated several hundred such cases with the greatest success.” He also said that, “In treating an inflamed joint it is improper to use a restraining apparatus of any kind. I consider that the plaster cast is the bane of all inflamed joints unless there is a =specific form of infection=, a traumatic condition.” Neither does he believe that an inflamed joint should be put at rest. He says the patient is a good judge as to the amount of quiet the joint needs. He has treated Colle’s fractures and fractured clavicles without bandages or apparatus.

To sum up, the osteopathic procedure in the treatment of fractures would be as follows:

1. Immobilization in those cases especially demanding it, from the character of the fracture, until formation assures solid and firm union.

2. Manipulation and massage and movements of parts at an early period, compatible with the above, to render soft tissues pliable, to remove stiffness and adhesions, to restore a normal circulation, and to exercise and function the parts.

3. In cases of laceration of soft tissues, abrasions, etc., great care should be taken so as not to infect the parts.

4. Great care should be taken where fracture is compound, and where fragments exist.

5. In all cases, both acute and chronic, critically examine for slight anatomical deviations locally and remotely.

In dislocations the fundamentals of the above are applicable. Do not let chronic stiffness, or rigidity, adhesions, or synovitis supervene if possible to prevent.

An important consideration in all cases of sprains, fractures, and dislocations that become chronic is the probable effect upon dependent tissues by way of nerve impairment and vascular obstruction; for examples, the sprained back may readily impair organic life, the fractured elbow prevent use of the arm, the injured leg predispose to flat foot. (See J. B. Littlejohn—Osteopathic Surgery, including Treatment of Fractures, Journal of the American Osteopathic Association, Nov., 1905.)

FOOTNOTES:

[41] See also Jones’ latest work, Injuries to Joints.

[42] See also Wharton Hood, Sprains and Fractures.

POSTURAL DEFECTS

A postural defect is any abnormal position, congenital or acquired, of the body, assumed in sitting, standing or walking. This leads to a symmetrical development, causes structural changes, and as a sequel, disturbance of function and organic life results.

Defects in posture are of very common occurrence. A perfect posture, in fact, is somewhat rare. Considerable is being accomplished, especially of late years, by the laity through various physical methods and exercises to correct the many defects of position in sitting, standing and walking. The originators of the many so-termed systems of exercises have gone so far as to even advertise to cure various diseases of the body as well as attempting to improve the normal tissues and structure.

Exercises, undoubtedly, have their place, particularly in the life of those of sedentary habits. Most of us do not exercise enough, neither do we as a rule get enough fresh air and pure water. But there are many defects of the anatomical that mere gymnastics can not adjust. And there are still other defects that gymnastics may decidedly aggravate. In these cases the mechanism of the body has become so deranged and disturbed that nothing short of actual readjustment can be effective.

In the consideration of postural defects there are a few points that should be particularly emphasized. First, these defects may not only be the result of laziness or carelessness, but of more frequent occurrence is some previous strain or injury to the spinal column or other parts of the body framework. Some defect of position or symmetry of the body may easily follow as a result. Here gymnastic work may reduce the defect to a minimum, but rarely can the compensatory forces of nature entirely obliterate the structural disorder, unless assisted by actual, specific readjustment. Second, in the examination and treatment of the patient due attention should be given the symmetry and figure of the body as a whole so that relation of the part to the whole and vice versa may be rightly proportioned. Remember that the spinal column is only one part of the body outline, thus one should consider the transverse section of the body in relation to the spinal column and not the spinal column alone. In a word, correction of postural defects implies both structural rearrangement and molding of the contour. Do not make the mistake, for example, when correcting a deformity that involves the chest, of paying attention to the spine alone, but take into consideration the thorax as a whole of which the spine is only a part.

Round Shoulders

=Round Shoulders= are a defective posture with which everyone is familiar. How many children have escaped the parents’ criticism to sit, stand, and walk erect? And not a few of the afflicted have not succeeded after persistently doing their best.

Round shoulders or stoop shoulders are commonly attributed to indifference. Probably a few cases are due simply to laziness and indifference, and others may be carelessness, and usually when they arrive at an age where pride of their physical demeanor and powers enters as a life factor, the child soon overcomes the postural weakness. With still others the correct, persistent physical training, as exemplified in military schools, will readjust the defect. But there is a class, and by far the largest, where round shoulders are a very real and active weakness of the physical body. And the weakness is not primarily in the shoulders as nearly everyone thinks. The stoop is a result. The origin is in the lower dorsal spinal column. Here will be found a posterior curvature that involves nearly the entire dorsal and lumbar areas. This is the real, the original cause of the larger number of round shoulders.

This backward curve of the spinal column, instead of the forward curve as it should normally be at the waist, obliterates the brace or truss of the spinal column that is so essential in maintaining an erect posture of the shoulders. It allows the individual to “fall into his stomach,” to drop the shoulders, and as a consequence the chest cavity is depressed. The spine is one continuous backward bow, and when he does try to sit straight, and it is always with a constant effort, the normal, the physiological curves of the spine are not apparent.

First, then, there is a spinal weakness in the region of the innervation to the digestive organs. Indigestion of various forms is a common accompaniment. Second, there is lessened lung and heart capacity. The ribs are depressed, interfering with perfect aeration and elimination on the part of the lungs and with normal activity and tone of the heart muscles. Phthisis is predisposed. Is it any wonder the child’s blood is impoverished and anemia results from the insufficient aeration and poor digestion and assimilation? Costogenic anemia may also be a result. And, third, the shoulders are “round” from the spinal weakness and flattened chest, really an effect; but while the most noticeable, it is the least serious.

It is evident from careful observation and study of these cases that the treatment resolves itself into the treatment of a posterior spinal curvature. Shoulder braces, steel braces and jackets, and casts have very little place, if any, although there may be diseased bone of such character and severity that a cast will be necessary; this, however, would refer to treatment of Pott’s disease and similar conditions.

Hence, the =treatment= is, first to replace and readjust the malaligned vertebræ. There must be an actual physical manipulation in order to correct the vertebræ at fault. This is the essential, and by far the primal, treatment for the key to the truss or brace that holds and retains the body in an erect position is then replaced.

Second, raising the depressed ribs. Remember the depressed ribs are dependent upon the spinal condition. The thorax should be treated as a comprehensive whole, not the spinal column alone.

Third, exercises are a valuable aid. The individual’s part is as necessary, in a way, as the physician’s, for in order to accomplish the maximum there should be consistent and appreciative work on the part of the patient. Holding the shoulders back, the head erect and the chin in, drawing the abdomen in and up, all with deep breathing by the use of the chest muscles, the patient will be able to retain the correction obtained during treatments. “Setting up” exercises are helpful. Developing the muscles of forced expiration is excellent. Thus the patient must be conscious of the work required of him and act in concert with the physician. Minute instruction on the requirements of each case is demanded.

Good food, pure water, and fresh air are necessary, particularly in the anemic. Right living and correct environment are always in order.

Painful Shoulders

Under this heading may come a variety of conditions affecting one or both shoulders causing much distress and, at times, total disability. The conditions may be the result of direct injury to the joint, systemic, or from spinal lesions. Anatomically the shoulder offers frequent opportunity to injury as it has the greatest range of motion of any joint, is least secure in its articulation, and is most vulnerable from location. Once the shoulder has been dislocated it is rarely back to normal functioning again as this injury tears the capsular ligament and stretches the structures in relation. Many times there is only a =subluxation= in which the head of the humerus is driven upwards in the fossa, usually from a fall or blow on the point of the elbow. As a rule, after such an accident, the only thing done is to rest the joint and apply a liniment and, after a time, begin the use of the arm. It is, however, painful and to save himself, the patient each time restricts movement until he reaches a point where he is unable to dress without assistance. It is then found that normal motion is reduced fully one-half and even this will be accompanied by pain on movement and in bed. A radiograph will, usually, show the condition. Articular crepitus and fibrous adhesions are present while the adjoining structures have undergone changes so that a reduction is impossible without certain preparation. Very often a trivial cause will disable a joint; a sudden movement which finds the muscles about the shoulder unprepared and the resulting lesion is so slight as to, often, defy detection. At first there will be swelling and pain but, in time, it settles down to a limited motion with more or less distress.

=Bursitis.=—This is a condition in which the subdeltoid bursa is involved or where there have been a number of bursæ formed from overuse of the joint. One authority reports as many as twenty-five in a shoulder. There may be, also, tenosynovitis primarily or from extension. These conditions may not be easily diagnosed at first.

=Brachial neuritis= (chronic) beginning with or without an acute attack is usually from a cervical lesion involving the brachial plexus but most frequently it is the 5th and 6th cervicals at the origin of the circumflex nerve. From this the deltoid is particularly affected and its contraction leads to pressure on the nerve and subsequent partial or complete paralysis. Brachial neuritis is found in an increasing number of osteopathic practicians and is the result of overwork of the arms and to strain of the upper dorsals and lower cervicals. There are contractions of structures about the joint constantly limiting motion and pain when a strain is put on them.

Many methods for the treatment of the conditions described have been employed, all involving the same principle but none of them systematized. C. H. Spencer has worked out a technique which, while originally intended for bursitis, has been found well adapted to all conditions described. It gives a stretching of all structures and gradually breaks up adhesions, both in the joint and in the tendon sheaths, so there is no resulting irritation which could easily result if suddenly done. His technique is[43]:

“First: The patient on the side, the affected shoulder up; operator facing the patient, places one hand on the top of the shoulder, does nothing more than fixing it; with the hand grasping the forearm above the wrist, push the elbow backward, the arm parallel to and almost in contact with the body, then pull forward in the same plane. Second: Elevate the elbow with the hands of the operator in the same position as before, carry the elbow in as wide a circle as possible. Third: With the hands still in the same position, extend the forearm with traction; carry it as high in front of the patient as possible. The foregoing are designed to relieve the congestion about the shoulder, bring pressure to bear on the subdeltoid bursa and moderate traction on the supraspinatus, infraspinatus, subscapularis, teres minor and major, latissimus dorsi and the tendon of the biceps. These manipulations will be all that is possible in the more aggravated cases for some considerable period of time. As the tenderness subsides, the second group may be cautiously started, the hands in the same position as above noted, with the arm extended as nearly as possible at right angles with the body, carry the arm in as wide a circle as the pain will permit. Again, with the arm flexed at the elbow, one hand of the operator on the point of the shoulder and the forearm of the patient across the forearm of the operator, the other hand of the operator resting on the point of the patient’s elbow, push down toward the middle line of the body and carry the elbow toward the head. Then flex the arm and place the back of the hand behind the patient, flexing the shoulder in front with one hand grasping the point of the elbow and pull forward. This group of movements accomplishes with greater force the same ends obtained in the previous, and the first in this group is the most effective in overcoming swelling of the subdeltoid bursa. Direct manipulation of the muscle masses and this bursa is desirable from the first.” It will be noticed in all these movements that the joint is protected by one hand of the operator while the other is grasping the arm of the patient. This is desirable as it makes the technique absolutely safe. An additional treatment will be found very effective, especially where the deltoid is involved. With the patient on the well side, facing the operator, locate the quadrilateral space which is bounded by the subscapularis above, the teres minor below and the long head of the biceps medially and the surgical neck of the humerus externally, and the circumflex nerve can be easily palpated along with the artery. If these structures are stretched and the deltoid lifted from the shoulder it will be found to free the action of both nerve and artery, one supplying the joint with nutrition and the other innervating it.

Certain conditions for which these movements are contraindicated arise and the following differential points by H. Glasscock are well to remember[44]: =“Rheumatism=: Fever in the joint, with redness, swelling and other joints involved. =Tuberculosis=: Daily temperature and other tubercular foci. =Neuritis=: Pain in the neck and shoulder muscles, also near insertion of deltoid and in the forearm, particularly musculo spiral. Pain worse at night. No pain on movement. No swelling. =Bursitis=: No pain in neck. Pain in anterior and posterior part of joint and on motion. Pain near insertion of deltoid. Arm held close to the body, motionless. =Infection=: Chill, limited motion, severe pain with temperature. =Dislocation=: Deformity with preternatural mobility. =Dislocation= of =acromio-clavicular= joint: Tenderness over articulation. Arm cannot be raised beyond right angle with the body, but elbow may be brought across the chest with external rotation of arm and raised perpendicular with the body without pain.” The infected joint should never be manipulated and all conditions showing swelling, redness and pain on touch should be viewed with suspicion. Remember that all other conditions will almost invariably have vertebral lesions, primary or secondary and a permanent result will depend upon their correction.

The Prominent Hip

A hip that is prominent and larger than its fellow is of frequent occurrence. It may not be necessarily conducive to a defect in posture, but it often is. The female is more frequently afflicted with this anatomical irregularity than the male. In the first place, the female pelvis is not so stable and rugged as the male pelvis, i. e., a mechanical wrench or fall will more easily displace the relative position of the tissues in the female. Then, in the second place, the dress of the woman accentuates irregularities of the figure, so that possibly in some instances the defect, from a diseased or deformed point of view, is more apparent than real. But of still more importance is the fact that many cases of a prominent hip are due to a lateral curvature of the lumbar spinal column. Lumbar curvatures are of common occurrence in the woman; first, the spinal column is not so strong as in man, simply on account of the physique not being so robust; second, modern dress constricts the waist by the use of corsets and many waist bands, and the weight of heavy skirts upon the waist, hips and abdomen; and, third, severe strains from childbirth. Care should be taken that there is no congenital abnormalities of the lumbar spine, or that congenital asymmetry of one-half of body, or trunk or leg is not present.

Thus the principal =cause= of a prominent hip is the lateral lumbar curvature. This, through compensatory action, renders the hip on the concave side prominent and high, while the hip on the convex side is depressed and less pronounced in appearance. Dressmakers and tailors are all too familiar with this feature of the irregularly outlined figure, and, consequently, have to resort to “padding” to round out the symmetry of the body. The mere irregularity of the figure, unfortunately, is by far the less serious part of the defect. Many ailments and diseases can be readily and directly traced to this. Not that the prominent hip itself necessarily always plays a leading part, but rather the lumbar curvature is the cause of very much suffering and misery. To enumerate the many disorders that arise from malaligned lumbar vertebræ may be unnecessary but a few will be given. A point to be emphasized is that the prominent hip often plays the role of a sign or symptom, or an effect, that an ailment or disease may be elsewhere.

In the female one of the most common causes, if not the most common cause by far, of disorders of menstruation, whether painful, profuse, or irregular, is irritation or obstruction of the lumbar spinal nerves due to lumbar curvatures. It is well known the lumbar spinal nerves control, to a large extent, the pelvic organs; consequently the osteopath pays particular attention to this area. Then certain intestinal disorders, such as appendicitis, typhoid fever, dysentery, rectal diseases, owe their origin to predisposing lesions here; also, bladder ailments, and sexual diseases of men, and many affections of the legs, as sciatica, varicose veins, etc.

In a number of instances the prominent hip will be due to a displaced innominatum. Then a lumbar curvature will result as a compensatory condition. This reverses the compensatory act as heretofore referred to; the prominent hip, in this instance, is the cause and not the effect. To diagnose which is cause and which is effect will frequently require considerable technical knowledge and experience. The slipped innominatum then produces symptoms and disorders directly from its changed anatomical relations; the points of diagnosis are given in the chapter on Diagnosis. The prominent hip can easily be detected when the subject sits down upon an even, firm surface, or stands up, and the one side is compared with the other. In some cases where the prominent hip is due to a lumbar curvature, and the prominence is a secondary feature, the legs will be found uneven in length, but not always, for the lumbar curvature may straighten out when the patient lies flat upon the back. To diagnose the cause from effect and to differentiate the maze of signs and symptoms that may be present is not always easy even for the skilled practitioner.

The =correction= of a prominent hip is not ordinarily a difficult matter. In the cases where lumbar vertebræ are principally at fault, and these include the greater number, the problem is one of correcting the spinal curvature. Lumbar curvatures are the easiest of any of the curvatures to correct, for one is not hampered by the rib articulations, and the lumbar section presents an area where a leverage can readily be obtained. Where the innominatum is primarily at fault it is simply a matter of readjusting this, with probably some attention to the lumbar region. Care should be taken that the prominent hip is not caused by a tubercular sacro-iliac disease, by hip-joint disease, by a dislocated hip, or by an overlapping of thigh or leg bones from fracture.

Standing erect will, of course, be a valuable help, for standing with the weight on one foot will tend to make the hip on that side more prominent. But generally the reason why one favors a certain side is because the other side is weaker; a weak back, a slipped innominatum, or an injured leg are common causes. There are many cases where the skirts will have to be considerably altered after the hips have been made symmetrical.

Pendulous Abdomen

The =pendulous abdomen= is another defect that is all too common. A great many people have prominent abdomens because they do not stand properly, but a pendulous or prominent abdomen is not necessarily synonymous with a stout abdomen. They attempt to stand erect by drawing the shoulders back and extending the abdomen. If they would hold the head erect and the chin in, with the shoulders back and the chest forward, and draw the abdomen inward and upward, their figures and physiques would undergo shortly a wonderful transformation. These directions also apply to pregnant women. Drawing the abdomen upward and inward will at first require considerable effort. It certainly will not be an involuntary act for the first few days.

The sagging of the abdomen not only causes an unsightly appearance but results in great relaxation of the abdominal muscles, interferes with digestive functions, displaces the pelvic organs, and weakens the action of the lungs and heart.

The laxity of the abdominal muscles allows the abdominal organs—the intestines, stomach, kidneys, etc.—to displace downward. This tends to indigestion, constipation, inactivity of the liver, etc., and causes a score of reflex symptoms. The organs become simply weakened from a lack of proper tone. This is a frequent cause of nervous prostration. Also it is one of the common causes of prolapsed and displaced pelvic organs, because the abdominal organs sag down upon them and the pelvic organs thus receive the brunt of the gravitative effect. Internal local treatment of the pelvic organs can only be a makeshift in these cases. The lungs and heart are weakened because the abdominal organs are dragging on the chest, the lungs can not aerate the blood freely owing to the abdominal weight and to the blood being obstructed in passing from the abdominal organs through the liver to the heart and lungs. The heart is handicapped in its work through lessened chest capacity and obstructed circulation. Just “suck” up the abdominal organs and see how much easier it is to expand the chest and to breathe.

There are other causes for a pendulous abdomen, such as a weakened spinal nerve supply to the abdominal muscles and organs. The weakened nerve supply may cause a loss of tone to the abdominal organs themselves, so that certain organs, as the stomach and intestines, become dilated and prolapsed; to the ligaments, and to the tissues and organs as a whole so that they become gravitated.

Through childbirth muscular fibres of the abdominal walls often rupture, leaving scars and a relaxed condition. Actual ruptures, hernia, of the abdominal muscles occur and cause a pendulous abdomen. Then there are cases of obesity where the pendulous abdomen is a symptom.

Much can be done with all of these conditions through osteopathic work; the patient must also help himself. The center of gravity of the body must be changed, and kept changed; correct posture and a constant effort will accomplish considerable. The “setting up” military exercises are excellent. Even in some cases of obesity the abdominal prominence can be markedly lessened by careful exercising and keeping the abdomen drawn in so that the abdominal muscles, the diaphragm, and the chest may be strengthened. For the relaxed, flabby abdomen, self manipulation of the weak muscles when lying on the back will materially aid.

Postural Curvatures of the Spinal Column

Undoubtedly, the great percentage of postural defects, or slumped states, are dependent, directly or indirectly, upon weaknesses in the spinal column. As was seen, round shoulders, the prominent hip, or the pendulous abdomen, are often initiated by spinal deviations and deformities, so naturally spinal column curvatures are a most fruitful source of direct defects of posture.

It is somewhat uncommon to find an anatomically true spinal column, although this does not preclude that one’s posture is defective, for often through pride and effort one may consciously overcome a defective posture.

It is the purpose here to offer a few suggestions relative to the development of a greater symmetry of the body. Nearly every one is more or less interested in physical exercises and development. And especially to those of sedentary habits do means and methods of exercise appeal. Curiously enough, in a way, nearly every layman looks upon defects in posture, symmetry and stature as an effect arising from lack of, or improper, exercise. He seems to be imbued with the idea that the body in most instances is practically permanent in construction and when irregularities in figure occur certain exercises will correct the defect. Thus have individuals been prone to look upon osteopathy as a method of passive exercises. Osteopaths should believe most thoroughly in exercising, personal hygiene, etc., but the idea of osteopathic manipulation is primarily one of anatomical reconstruction, and not muscular development alone. The work of the osteopath is to readjust or to re-mold the body framework and the many tissues that clothe it so that normality of function may predominate. The manipulation is not routinism but mechanical rebuilding of the tissues so that perfect freedom of vital forces may be forthcoming.

The spinal column presents the most frequent as well as many extremely interesting phases for re-correcting work. The number of abnormalities as to contour to which it is subject are many and varied. Emphasis should be placed upon possible congenital abnormalities and developmental defects as sources of certain derangements. Any variation or combination of variations with the normal or physiological curves constitutes an abnormality or pathological curve. And as a consequence defective posture, unless thoroughly compensated, is readily initiated. Not only may the normal curves be exaggerated, lessened, eliminated or reversed, but lateral and rotary curvatures are of frequent occurrence.

Curvatures involving the cervical region to the extent of producing noticeable defects of posture are principally lateral deviations of several vertebræ. Wry-neck is probably the most noticeable disturbance. The head and neck being drawn and slightly twisted to one side is a defect that is both noticeable and painful. Another common source of postural affection is an exaggerated forward curving of the neck vertebræ. This produces a stooped appearance of the neck.

The dorsal vertebræ are often curved backward too far. This produces roundness with too decided a fullness of the upper back and shoulders. The chest may be somewhat flattened as a secondary effect but not necessarily so. Neither are the shoulders what may be termed “round shoulders,” still such a condition may occur, for “round shoulders” are more often caused by a backward swerve of the column at the waist line. There is often a shortening of the anterior structures which pull the point of the shoulders forward. Forcing them backward will aid in correcting the fault. The dorsal vertebræ may be forward from what is termed a “straight” spine; this results in an exaggerated “braced” back position. Then lateral curvatures of the dorsal spine are common, which in time may develop into a rotary curvature; that is, the vertebræ are actually rotated on their axes. Lateral curvatures of the dorsal spine are slow and difficult to correct, for the ribs complicate matters very materially. Then, also, the vertebræ are apt to be deformed.

Curvatures of the lumbar spine, whether posterior, lateral or anterior, are common. Both dorsal and lumbar curvatures, as any one can readily see, are extremely common sources of postural defects. Erect positions of the body are maintained through the support of the dorsal and lumbar vertebræ. Stooped shoulders, one shoulder lower than its fellow, sitting humped over, sitting on the sacrum instead of squarely on the buttocks, the prominent hip, standing first on one foot and then on the other in order to rest the back, and the many allied variations of incorrect postures are largely dependent on the condition of the lumbar and dorsal spines.

It is not to be supposed that the above defects are the only ailments and disturbances that spinal curvatures cause, for, indeed, the defective posture may be by far a minor consideration. Disorders of body functions and affection of organic life itself are very often traced to the malaligned vertebræ.

The =causes= of spinal curvatures are many, but without question one of the most common causes is mechanical wrenching or twisting of the column from falls, jars, etc. Often the strain or sprain of the sections are readjusted through the inherent powers of the body, but there is a point where vis medicatrix naturae requires extraneous help to correct the perversion; and, naturally, such aid, by virtue of the cause of the disturbance, should be physical force mechanically applied. Other causes of spinal curvatures are contractions of muscles on one side of the column or paralysis of the muscles on one side; in either instance, muscular action is greater on one side than the other, which easily results in a curvature. This imbalance of muscular tension, whether due to the above or other sources such as overfatigue or various deleterious habits, is a prolific source of lesions. And among still other causes may be noted, bone diseases of the spinal column, compensatory deformities, and constitutional weakening and irritating diseases. Also, some occupations predispose to certain curvatures.

One can readily see that the =treatment= which is directed specifically to the cause of the vertebral deviation would be the most scientific. This is just what osteopathic work implies, direct readjustment of the sections at fault—not exercises, or routine stretching, or braces; although these latter methods may in some cases have their place as secondary aids. Of course exercises are usually physiological and may be employed, in many instances, as an auxiliary. Care should be taken to eradicate infectious foci when present.

Where curvatures are extreme, complicating and deforming the ribs, and absorbing the bodies of the vertebræ so they become wedge-shaped, and resulting from abscesses, no one can expect within reason to absolutely correct the posture. Some aggressive work can be accomplished, but a perfect symmetry will not be forthcoming. It may be well to emphasize again that where the ribs are involved the osteopath is not contending with the deformity of the spinal column alone, but in addition the entire transverse area of the body. (See also Spinal Curvatures).

=Conclusion.=—In concluding this rapid survey of a number of postural defects the principal lesson to be drawn is not one of developing the physique and thus perfecting a better posture, so much as curtailing and eliminating insidious beginnings of disease. These little ailments and deformities, of which postural defects may be the most noticeable, are so often the inception of more serious disorders. The anatomical structure being maladjusted, -aligned, or -positioned, easily and readily leads to consequences that require much time and patience to overcome.

Poise of body represents much to every one. Poise or correct posture coupled with careful and methodical exercise and correct breathing are material aids in constructive development, as well as in eliminating disease, for not alone may abdominal, pelvic and thoracic integrity be benefited, but the upper respiratory tract may be toned.

The most important goal that osteopathic science and art is striving for is that of a fully developed and rounded out prophylaxis or preventive treatment. When the public realizes that the proverbial ounce of prevention is an established medical reality then it can truly be said our science has reached its ultimate good. To those who are familiar with osteopathic theory, facts, and development, it is an open secret that this school holds the key to successful preventive treatment. The time is rapidly approaching when the actual lessening of diseases will be an established fact. Then will be the universal practice of the layman going periodically to his osteopath to see if there are any small or insidious beginnings of disorder or disease.

Not only must the many deleterious habits and errors of the daily regimen be corrected, but after environmental, physiological and structural adjustment, in so far as possible, has been attained, a daily regimen to maintain the normal should be instituted.

FOOTNOTES:

[43] Journal American Osteopathic Association, Jan. 1916.

[44] Osteopathic Physician, Nov. 1919.

PROLAPSED ORGANS

Prolapse of various organs or tissues are among the very common ailments that afflict all classes. Prolapse of the stomach, a kidney, the uterus, or the rectum is a familiar term to every one. But this condition may also rest with the intestines, the liver, an ovary, or even the heart.

Outside of injuries, congenital weaknesses, and so-termed surgical disorders, there are commonly two constant forces predisposing to prolapsed organs, viz: gravitation and weakened innervation; the one, of course, is a constant factor in either health or ill health, the other is dependent upon acquirement. Here the latter, or acquired nervous weakness, will especially demand our attention.

Where tissues are torn or lacerated, or congenital malformations are present, or tissues are weakened from ulceration and with a resultant scar tissue, or certain tumors are present, the disorder must be amenable largely to surgical measures if at all.

The perpendicular position of the body favors a decided gravitation of the abdominal and pelvic organs. This gravitative effect being a constant one, many methods, both surgical and mechanical, have been devised to hold in approximate and relative position certain organs and tissues that may be prolapsed. But it is well known that outside of a certain few instances where surgical measures are clearly indicated the prevalent use of braces, bandages, supports and the like are usually poor makeshifts.

The one great feature in these cases is that tonicity to organs and supporting muscles and tissues is more or less impaired. The tissue atony may vary from mere weakness to actual tearing and separating of the fibres. The indications in the cases about to be described are to stimulate a lowered nerve supply and to increase a lessened blood supply; if this can be accomplished, supporting muscles, ligaments and other tissues will be able to restore the prolapsed organs to normal positions, thus improving functions and eliminating disease symptoms.

In discussing the prolapse of the following organs, perhaps it should be noted here that all of the abdominal organs may be prolapsed as a whole. The intestines, stomach, liver, kidneys, etc., may actually prolapse together. This is more apt to occur in persons whose abdominal walls are thin and flabby. In women pregnancy is a common cause. When the abdominal organs have gravitated, the pelvic organs, also, are very likely to be disturbed and displaced; in fact, the pelvic organs are frequently disordered this way.

Prolapse and Dilatation of the Stomach

Dilatation of the stomach is a much more common and serious affection than prolapse of the stomach, although usually the two are associated. Prolapse, or ptosis, of the stomach means simply a downward displacement of the organ. This is apt to take place in those cases where all of the abdominal organs have gravitated. There is invariably some dilatation of the organ as well.

Weakness of the abdominal walls and of the supports of the stomach constitute the principal =causes= of the prolapse. Spinal deviations that impinge or obstruct the nerve strands (or obstruct the blood and lymph supply to these strands) to the supporting stomach tissues is the most frequent cause of the ailment. General debilitating diseases, as anemia, cancer, etc., are indirect causes of weakened organs with consequent displacements.

In dilatation of the stomach the condition may be either acute or chronic. The former is found where immense amounts of food or drink have been introduced.

One of the principal causes of chronic dilatation is some obstruction to the opening from the stomach into the intestine, so that the stomach contents do not pass readily into the bowel. This leads to chronic disturbances of the stomach walls, and the food remaining in the stomach somewhat indefinitely weights down and stretches the walls of the stomach. The obstruction may be a tumor, or some stricture or adhesion from scar tissue resulting from ulceration or inflammation. The treatment of these cases comes within the province of surgical interference rather than other methods.

The second important cause of chronic dilatation is muscular weakness of the walls from poor nerve supply. This is a common cause and osteopathy is very successful in curing these cases. The splanchnic nerves are below normal, usually from a slight lateral or posterior spinal curvature. The nerve force to the walls of the stomach not being normal causes atony of the muscles and dilatation results. This nervo-muscular atony, also, results from a chronic catarrh, or from a general nutritional disorder as tuberculosis or anemia. The treatment of the former would imply direct correction of nerve and blood supply with attention to diet; the latter can be cured only through relieving the nutritional disorder of which the stomach condition is a symptom.

Dilatation of the stomach is most common in people of middle age or older. The disease is usually easily diagnosed. The symptoms may not be indicative of the trouble beyond showing that the stomach is disturbed. Indigestion, uneasiness, and nausea are common. Vomiting of large quantities of material from the stomach is likely to occur. The patient is generally emaciated, the skin is dry, the bowels constipated, and the urine scanty.

The =diagnosis=, as a rule, is not hard to make. Through the media of inspection, palpation and percussion, the careful osteopath will have little trouble to determine the size of the stomach. Kemp’s[45] distinction between gastroptosia and dilatation of the stomach is as follows: “In dilatation the lesser curvature retains its relation to the diaphragm. The distance between the lesser and the greater curvature is increased, but the lesser curvature still maintains its relation to the diaphragm, with the exception that the pyloric end may extend farther over and somewhat farther down.” Another instructive point relative to diagnosis the above authors make is the importance of the splashing sound. Owing to the fact that the stomach in health closes concentrically about its contents and thus adapts itself to the volume of ingesta, no splashing sound can be elicited. Three different degrees of relaxation are diagnosticated as follows: “Splashing sound, which can be elicited only during the normal period of digestion, means simple atony; splashing sound produced after the legitimate time of digestion has expired means motor insufficiency; and splashing sound produced in the morning, after the night’s fasting, before liquid or food has been introduced, may mean stagnation, dilatation of the stomach, as understood by most writers.” (For a more complete outline see Dilatation of the Stomach. The object of this section is to present an outline of prolapsed organs as a whole, and to refer especially to the effectiveness of osteopathic treatment in this condition).

This is a disease where osteopathy has been particularly successful in not only relieving distressing symptoms, but in actually curing the disorder. This refers to the nervo-muscular atony type, for where there is obstruction due to stricture or tumor of the pylorus, resulting in stomach dilatation, the treatment, from the very nature of things, must be largely surgical. Stomachs that have been dilated and prolapsed several inches have been entirely restored to function and organic integrity. To =cure= these cases is a matter of stimulating nerve control and blood supply to the stomach tissues, and, often of greater importance, removing spinal impingements to the stomach nerve fibers, thus allowing nature to fully assert herself. In reality, outside of so-termed surgical cases and other cases where the stomach dilatation is merely a symptom of general nutritional disorder, the primary treatment, by far, is the spinal one. Treatment over the stomach is a decidedly beneficial treatment; it aids materially in toning both abdominal and stomach muscles; still this is mostly a secondary treatment.

Dieting is essential. Careful dieting lessens the tendency to catarrhal inflammation and reduces the work of the stomach to a minimum. Still, nourishing food is necessary and the dieting can easily be carried to an extreme. Liquids should not be taken freely. Fatty and starchy foods should be eliminated. Give the patient food at short intervals. Various nutritious meats are excellent.

In dilatation, and also general abdominal relaxation, daily abdominal treatments may be indicated. If the relaxation is pronounced, keeping the patient in bed with thorough spinal treatment two or three times a week, daily abdominal treatment, having the patient exercise abdominal parietes by drawing the walls in and up, upper thoracic breathing, and frequent feeding will accomplish comparatively quick results. The progress of each case depends very materially upon the general health, the physical status of other tissues, constitution, inheritance, environment, age, etc. Some cases will yield in two or three months, others will require two or three years in order to obtain the greatest possible benefit.

The Prolapsed Kidney

A =prolapsed kidney= is often termed a floating kidney, or movable kidney, or dislocated kidney. It is of common occurrence, especially in thin persons. Some authorities state that one woman out of every four has a floating kidney. It is more common in women than in men, and among the working class than other classes.

The condition is usually an acquired one, following severe strains from lifting, falls, injuries, etc. It is claimed by some that a floating kidney arises from congenitally weakened and relaxed tissues about the kidney, that is, the tissues that keep the kidney normally at anchorage. Thus a congenital looseness of the kidney would easily be a predisposing cause whence mechanical violence, repeated pregnancies, an enlarged liver, or tight lacing would act as an exciting cause. Undoubtedly in some instances there is a congenital predisposition, the peritoneal fold attaching the kidney to the spine being loose and the capsule of fat retaining the kidney being scanty, but osteopathic experience has amply demonstrated that the tissues anchoring the kidney may in many case become atonied and relaxed from lower dorsal spinal lesions. Rarely is a case presented to an osteopath that does not exhibit two apparently characteristic causative features, viz: spinal irregularity in the lower dorsal spine, and constriction of the zone about the waist, i. e., dropping and constricting of the floating ribs. Furthermore, correction of these lesions will almost invariably lessen the mobility of the palpable kidney.

The =symptoms= of a floating kidney are many and variable. The kidney may be slightly movable or it may be so loose that one can easily grasp it through the walls of the abdomen. Most of the symptoms are of a nervous reflex nature. Indigestion, which is likely to be very persistent, flatulency, heart palpitation, painful menstruation, irritable bladder, etc., are the most common symptoms. Still, blueness, depression and morbidness are frequently present. The most distressing direct disturbance is the feeling of weight in the abdomen, especially on standing, running or lifting. Sometimes the ureter becomes twisted and severe pain, colic and even collapse occurs. (Dietl’s crisis.)

The =diagnosis= of a dislocated kidney is not a particularly difficult matter. A little experience coupled with a delicate sense of touch will usually readily detect abnormal mobility of the kidney. A point to always remember is that the kidney normally descends about one-half an inch with each inspiration. Care should be taken not to mistake a floating kidney for a movable spleen, although this is not likely, as the shape of the spleen is different.

The =treatment= of a movable kidney under osteopathic measures is usually successful. In the first place a number of cases require but little attention, simply toning up the general health, and especially directing attention to the abdominal walls and organs. There are a number of cases where the kidney prolapse is incidental to general abdominal laxness and weakness. In more severe cases, treating the spine, raising the floating ribs, carefully manipulating over the abdomen, keeping the bowels open, and lessening liver congestion should it arise, will suffice; in fact, will remedy a good percentage of the cases. With others, a well fitting, medium width, elastic bandage with pad underneath will be beneficial. In these cases the patient should be taught how to treat the abdominal organs, to manipulate the abdominal walls, and to replace the prolapsed kidney; particularly after going to bed this can be done successfully by the patient and will prove a decided help in obstinate cases.

=Surgical measures= for fixing the kidney should seldom be resorted to. If the patient will live a careful life, avoid unduly straining himself, keep the bowels normal, and have the anatomical lesions corrected, he will come very near being entirely relieved, if not absolutely. Surgical measures are not always a success. Surgeons are not operating for this disorder so often as in past years. (See Movable Kidney—Diseases of the Kidney.)

Liver Prolapse

This is commonly termed a =floating liver=. There is prolapse of the organ as well as its being abnormally movable. It is not of frequent occurrence; women suffer from it much oftener than men.

Normally, the liver is partially held in place, in the concavity of the diaphragm, by a number of peritoneal folds. The attachment of these ligaments is to the spine and the diaphragm; their principal function is to prevent extended lateral movements. Of greater importance in supporting the liver in a normal position is the integrity of the abdominal walls, and the position of the stomach and intestines. If the abdominal walls are of normal tone the liver is very apt to be in correct position. And the rest of the abdominal organs, especially intestines and stomach, act as a cushion support. Often when the liver is displaced the remaining abdominal organs are, also, out of normal position and relation to each other; in fact, general prolapse of the abdominal viscera is a frequent cause of liver prolapse. An additional support of the liver is a certain cohesion of the liver and diaphragm, and the elastic traction of the lungs.

Foremost among the =causes= that predispose to inelastic and atonied abdominal walls are spinal irregularities, deviations, and curvatures, which impinge nerve force and obstruct blood supply. These same lesions weaken ligamentous supports of the liver and lessen tonicity of the other abdominal organs, so that local or general displacements are readily forthcoming. Strains, injuries, frequent pregnancies, etc., also act as causes that weaken the supports of abdominal tissues and organs. In a word it is very often the pendulous abdomen that is the immediate cause of a floating liver.

It is very rare to find the liver displaced to the lower region of the abdomen. The ptosis is usually somewhat slight. The organ generally rotates on descent, the right lobe being the lowest portion, owing to the attachment of a ligament, the ligamentum teres, to the umbilicus. Probably in some cases there is a congenital tendency to relaxation of the ligaments, and, thus violent exertions and atonic and flabby abdominal walls and diaphragm are secondary but important factors.

The principal =symptom= of a floating liver is a tumor in the right side, which may be low down. Palpation will usually determine this. Then the abdominal walls are flabby. Pain and bearing down of the right side are common. There is apt to be considerable indigestion. Various reflex symptoms are often present. The floating liver will seem larger than normal, as the liver is below the costal arch and much of it can be felt. Percussion will be of value in determining the extent of the disorder.

Much can be accomplished by =treatment=, especially where the displacement is of a lesser degree. Correcting the spinal lesions, toning up the abdominal walls and diaphragm, and replacing the displaced organs will be extremely effectual. The abdominal bandage may be of service. Certainly abdominal exercises will be beneficial.

A point to remember is, stimulation over the abdomen beneath the right costal arch will cause the liver to contract and retract. This is of considerable osteopathic note. The liver will often recede at least a half an inch. This is a liver reflex (Abrams).

Prolapsed Intestines

=Prolapse= of the =bowels=, as a whole, or, more frequent still, of a part, is undoubtedly the most common form of organ prolapse. The intestines are so situated that they readily feel the effect of gravitative influences, of atonic and anemic states, and of weaknesses and disorders of other abdominal organs.

Spinal irregularities come first as potent =causes= of bowel prolapse. The spinal nerves to the supports of the intestines, to the muscular coats of the intestines, and to the abdominal walls, are obstructed in their normal activity, and consequently those tissues to which these nerves are distributed are affected. Wasting diseases, as anemia, consumption, cancer and the like predispose to intestinal atony.

The severe mechanical wrenches, strains, frequent pregnancies, tight lacing, heavy skirts, large abdominal tumors, obesity, cause more or less general or local weakness.

The pendulous abdomen, from wrong or careless posture, and exclusive of other causes, is a common source of general bowel displacement. This form of disorder, besides being unsightly, favors abdominal stoutness. There are a number of instances where simply voluntarily holding or “sucking” the abdomen into place, until it becomes strong enough to support itself, has reduced one’s weight by five, ten or fifteen pounds. These were cases where most of the adipose tissue was about the abdomen. Thus exercising and toning the abdominal organs by keeping them in normal position rectified a dormant blood and lymph circulation, which was followed by absorption of the abdominal stoutness.

Congenital weaknesses are to be considered in many cases. The muscular ligaments may not be developed, the mesenteric attachments may be too long, and various other abnormalities may result from congenital disturbances.

Of particular local interest to the osteopath, outside of the bowels dislocating as a whole, are: first, the hepatic flexure; second, the ileo-cecal region; third, the sigmoid flexure; fourth, the rectum; and fifth, hernias. Each of these sections are of separate interest and will be considered presently.

The =symptoms= are extremely variable. Constipation, a feeling of discomfort in the bowels, nervousness, depression, lassitude and anemia are frequent. Colicky pains in the intestines, indigestion, hysteria at times, are also among the symptoms. In reality a great variety of symptoms may be present. The patient is likely to be emaciated. In some cases exhaustion is marked.

=Diagnosis=, as a rule, is not a difficult matter. The various neurasthenic symptoms in a lean patient with constipation, indigestion, and stomach and intestinal distress would lead one to suspect intestinal displacement. The outline or contour of the abdomen will often reveal the character of the trouble. The atonic, thin and relaxed walls of the abdomen may readily give view of the displaced organs. Then careful examination by palpation and percussion will help very materially in the diagnosis. Radiographic examination is a decidedly helpful diagnostic method.

The =hepatic flexure= is frequently prolapsed. The bowel (colon) ascends from below upward to beneath the costal arch and then angles sharply into the transverse colon, which extends directly across the abdomen to the left side. The ligaments that support this flexure are apt to become weakened or stretched and allow a descent of this section of the bowel, which is followed by constipation, indigestion, etc. The ligament especially involved is the colo-hepatic ligament. The =duodenum= may require attention. This can be raised by getting beneath it where the organ descends alongside of the ascending colon. The effect of treatment is to release tension of the duodeno-hepatic ligament which is closely associated with the portal vein, hepatic artery and bile-duct.

The =ileo-cecal region= is an area that readily becomes congested and catarrhally inflamed, especially from constipation or impaction at this point. The section often becomes atonic and prolapsed with resultant clogging of fecal matter. Owing to the close proximity of the vermiform appendix, appendicitis frequently results from the above condition. The osteopath can do much in these cases of appendicitis. Lesions are invariably found in the lumbar vertebræ or the floating ribs are depressed.

The =sigmoid flexure= is also frequently prolapsed. The fecal mass often becomes impacted here, owing to a settling or prolapse of this part. In some cases the prolapse is so marked that it extends to the rectum below and drags on the splenic flexure above.

Lumbar and innominate lesions are the usual causes, although, it seems in a number of instances, that relaxed walls of the abdomen cause a “contraction of the diaphragm resulting in kidney displacement and followed by intestinal prolapse.” The vertebral lesions, probably, first weaken the muscular coat of the bowel, then, second, the bowel supports (other than its own inherent tonicity) and the abdominal walls.

Prolapse of the =rectum= is of such separate importance that it will be but partly outlined here. As stated above, a source of rectal displacement arises from the section of the bowel above settling downward and ultimately causing invagination of one or more coats of the rectum. Dislocation of the coccyx is a potent cause of rectal disorders. Lumbar lesions, especially twists between the fourth and fifth, and fifth and sacrum are common causes of rectal weaknesses. Slips of the innominata are other causes of prolapse.

Osteopathy has had marked success in these cases. Cures may result from a single treatment to readjust the coccygeal displacement or temporarily relieve excessive physiological activity by dilating the rectal sphincter, or the treatment may demand a number of months’ work in correcting general abdominal prolapse. Raising the sigmoid is effectual.

A =hernia= is “the protrusion of a loop or knuckle of an organ or tissue through an abdominal opening.” Two of the common hernias of the intestines are inguinal and femoral. These conditions are most often acquired from severe straining, so that a loop of the bowel protrudes through a weakened and stretched area of the abdominal walls, though there is reason to suspect that congenital defects are often predisposing factors.

Mention of the hernia is here made because, in a way, it is a form of bowel prolapse; that is, a limited form, and osteopathy contains certain possibilities for a successful treatment. Hernia has always been looked upon as purely a surgical disorder; i. e., remediable by surgical measures only. Where a truss has failed to give relief surgery has been resorted to. This is true in most instances, but where the hernia is in the incipiency careful abdominal exercises (this should be carried out with great care, for severe exercise may produce a hernia or increase one already existing), massage to the tissues about the hernia, attention to the bowels, and spinal stimulation corresponding to the weakened tissue, and avoidance of strains may strengthen the tissues materially about the hernia.

Occasionally a loop of the intestine will prolapse into the cul-de-sac back of the uterus. A heavy dragging pain low down in the center of the abdomen and constipation or complete obstruction are the pronounced symptoms. Careful lifting of the loop of bowel by pressure within the vagina and traction from above with a hand outside, with the patient, on her back, with buttocks elevated, gives speedy relief.

The =treatment= of the prolapsed bowels represents those measures that will replace and keep in position the displaced organs. Naturally, the spinal and abdominal treatment comes first; this strengthens intestinal ligaments, tones intestinal muscles, and contracts the abdominal parietes, and at the same time the bowels are regulated, digestion and nutrition improved, and the general health built up. In some cases abdominal supporters will be of value. In a number of instances attention to chest mobility and diaphragm tonicity will be of value. Right living, which is represented by proper diet, sufficient outdoor exercise and regular habits, is invaluable.

The really specific treatment is to correct spinal, rib and innominate deviations and abnormalities. But direct local work will be, in many instances, necessary. General abdominal manipulation is good, but this should be supplemented by careful local treatment. The hepatic flexure requires a direct stimulating and replacing treatment. The ileo-cecal section should be raised, stimulated and emptied of the fecal mass. Direct upward manipulation of the sigmoid flexure in the left iliac fossa and of the splenic flexure beneath the left costal arch is extremely efficacious. Care must be taken not to bruise the parts. Getting beneath the prolapsed area and gently and intelligently raising the bowel so that it is emptied, toned up, and vascular congestion relieved, are the indications. This requires careful work and the necessity of gentleness can not be emphasized too much. Still in all of this treatment we should never forget the absolutely essential spinal readjustment.

Rectal prolapse requires lacol internal treatment, external tissue correction, especially of the coccyx, an innominatum or the lumbar spine, and, of much importance, deep, careful and thorough work over the sigmoid section.

Cases of bowel prolapse are every day experiences with the osteopath. The osteopathic treatment is of great value in these and a successful issue is very often the result. Cases of pendulous abdomen, of obstinate constipation, of chronic indigestion, of many nutritional disorders, of feeling pain, weight or dragging, locally or generally, in the abdomen, are very apt to be in persons suffering from prolapsed intestines.

A number of cases of bowel prolapse are associated with general prolapse of abdominal organs; that is, displacement of the stomach, kidneys, liver, spleen, etc. This general condition is termed enteroptosis or Glenard’s disease. It usually requires several months to treat it successfully. These patients are neurasthenic, malnourished, and often hysteriacs. The symptoms from which they suffer are innumerable. Mechanical weaknesses, lowered vitality, poor innervation and blood supply, and auto-intoxication are causative factors.

The Prolapsed Uterus

=Prolapse= of the =uterus= is of common occurrence. The prolapse may be incomplete or complete; the latter when the organ is presented to the external world. Of special interest are those affections exclusive of surgical cases. Ptosis of the abdominal organs upon the pelvic organs is a common cause of uterine prolapse. The abdominal prolapse crowds uterine space, congests the uterus, weakens the ligaments, and drives the uterus downward as a wedge.

Lumbar spinal curvatures are frequent causes of prolapse, as well as other displacements of the uterus. In this region vasomotor nerves to the pelvic organs make their exit, and, consequently congestions, inflammations, and weaknesses of supports are results. Also, slips of the innominata disturb the pelvic circulatory balance. Weakness of the uterine support from below, the vaginal walls and perineum, most often arises from lacerations at childbirth. Still, the vaginal walls may become relaxed through other causes. Tumors and extreme congestions are causes of prolapse. Heavy lifting is quite a frequent source of uterine displacements. Osteopathy is very successful in uterine prolapses; that is, any displacement of the uterus not of a surgical character. Correction of the external causes comes first. Then local treatment to replace, tone, and relieve congestion, and break up adhesions is necessary. The external treatment is usually the primary treatment. Local work is not always necessary. Lacerations and other surgical indications, of course, require surgery.

Ovarian Displacements

The ovaries may be prolapsed, the left much oftener than the right. When prolapsed, it drops backward, downward and inward.

Ovarian congestion, tumor, retroverted or retroflexed uterus, tubal disease, and pregnancy are among the principal causes. Back of these congestions, tumors and uterine displacements, are the osteopathic causes, particularly spinal and rib lesions from the ninth dorsal downward. Specific lesions at the ninth and tenth dorsals and corresponding ribs, affecting directly ovarian tissues, and lumbar and innominate lesions and abdominal prolapse disturbing uterine and tubal tissues, are the most frequent osteopathic causes. A retroverted or retroflexed uterus is often found. Uterine displacements bear down upon the ovary and cause its descent, and also disturb ovarian circulation.

As has been stated, the left ovary is more apt to be displaced than the right. This is owing to the absence of a valve in the ovarian vein on the left side, and also, this vein opens at a right angle into the renal vein; this anatomical feature easily leads to passive congestion of the ovary, and thus to diseases of the organ. Then the rectum is on the left side and large fecal masses are apt to crowd against the ovary, which tends to its displacement.

Thus it is readily seen that osteopathic treatment is very applicable to ovarian displacement unless the indications are surgical. A more or less constant burning or sharp pain in the ovarian region, with probably some feeling of weight, profuse and painful menstruation, depression, irritability, etc., are =diagnostic=. However, a local examination will reveal the status of the ovarian position and congestion.

The same =treatment= as in other organ prolapse is indicated: toning weakened tissues, relieving congestions, replacing organ, with careful attention to the bowels and the general health. There are no tissue disorders of any part of the body wherein osteopathy is more thoroughly indicated and the results more generally satisfactory than in prolapse. And especially should it be remembered that in prolapse of various organs many vague intestinal and pelvic disorders and even ureteral and bladder disturbances may be traced to bowel dislocations and excessive kidney mobility in which osteopathic measures are often successful.

=Conclusion.=—The purpose of this section on Prolapsed Organs has been to supplement the various articles on Dilatation of the Stomach, Movable Kidney, etc., with an outline that may include relaxation of a part or of the whole of the abdominal viscera. The physician is all too prone to simply note the most offending or conspicuously disturbed organ instead of carefully analyzing all the features, great and trivial, that may be either apparent or marked. A general relaxation of the abdominal and pelvic organs may be found, and a nearly complete restoration take place under treatment, but still a lacerated perineum may have to be repaired before a cure is completed. Or it may be in a general abdominal ptosis that a floating kidney will resist all measures for restoration, short of surgery, and before much improvement can be obtained the kidney will have to be stitched into place. An enlarged liver may crowd the kidney out of place or a transverse colon may prolapse and drag on contiguous tissues and still the annoying symptoms be referred elsewhere. Then the primal point of general relaxation may not be in one organ, but there may be a simultaneous displacement of several.

The thorax itself may be distorted from various diseases so that the chest is narrowed, the diaphragm displaced with consequent descension of the abdominal organs, and from the latter a displacement of the pelvic.

“Far down displacement, marked changes of form, and real disfigurements of the stomach are found in some cases of kyphosis and scolio-kyphosis.”[46] The osteopath will not only find this true in some cases, but in many cases, although he recognizes as causative factors injuries to the spine causing curvatures and postural defects as prolific sources of abdominal relaxation.

“Glenard’s whole theory of splanchnoptosia is based on the relaxation of the suspensory ligaments of the intestines, especially that of the transverse colon; and Stiller, the discoverer of the floating tenth rib, says that splanchnoptosia is a descent of the atonic stomach, of the colon (especially the transverse portion), of the kidney (the right or both kidneys), exceptionally of the liver or the spleen. A descent which has been developed mostly in tender age, in consequence of general relaxation, especially of the peritoneal suspensory ligaments in individuals with congenital general dyspeptic neurasthenia, tender muscles, lean habit, and slender bone structure, manifested in a higher degree by a floating tenth rib.” Stiller observed that when there is a floating tenth rib there is a displaced stomach and a floating kidney, although it is not found in every case, but never missing if the case is pronounced. The tenth ribs in these cases have only a ligamentous fastening and are as freely movable as the eleventh and twelfth.

That abdominal relaxation plays a very important part in many diseases of the abdominal and pelvic organs, in cardiac and pulmonary affections, disturbs the circulation in the legs, and is the source of many reflex affections no one can gainsay. The osteopath should always pay particular attention to tonic condition of the abdominal viscera, for relaxation of the suspensory tissues and walls, and atony and sluggishness of the organs are frequently paramount etiological factors. And the osteopathic treatment is the remedy par excellence.

FOOTNOTES:

[45] Rose and Kemp—Atonia Gastricia.

[46] Rose and Kemp—Atonia Gastricia.

SKIN DISEASES

Various skin diseases have been treated osteopathically with varying success. So much depends upon the cause of the disturbance and its removal, in skin diseases, that the cure does not rest so much with the mere treatment, as with the necessary skill in locating the disturbing factor. One has to be continually on his guard to locate external irritations and disorders of the digestive and genito-urinary tracts. A great deal depends upon the avoidance of external influences; eating nutritious food and having an unobstructed circulation. The leading object of osteopathic treatment is to free the circulation and thus promote a healthy and unobstructed flow of blood; in no other class of diseases is this more essential than in skin diseases. After the removal of cutaneous irritations and the correction of internal disorders, the cure of the case depends upon the removal of constrictions to the cutaneous blood-vessels. The osteopath corrects the lesions found, relaxes the muscles thoroughly and stimulates the circulation to the parts involved, and promotes a healthy activity of all the excretory organs. When the upper part of the body is affected, lesions are generally found at the atlas and axis, and when the lower part of the body is affected, lesions at the fifth lumbar are of common occurrence, although lesions may be located at various points corresponding with the seat of disturbance. The constant use of hot baths will be found a helpful measure in many skin diseases. But use of soap must be considered as too much alkali will neutralize the oil of the skin and cause undue dryness, but bran may be substituted to advantage. Cleanliness is necessary but the result sought is, also, flushing the cutaneous vessels. There are many cases where a specific vertebral lesion will cause, through the peripheral nerves, a cutaneous irritation with intense itching and discomfort. This, in turn, produces an exudate with or without a crust and a condition results which is not amenable to any local or constitutional treatment but an adjustment of the lesion will in most cases bring immediate relief. Application of this principle will aid greatly in treatment of any skin disease. In no disturbance of health is it more necessary to find the cause than in skin disease and once found to apply specific treatment.

=Eczema= is frequently met in osteopathic practice. It is the most common form of skin disease, comprising nearly one-third of all these disorders. For a differential diagnosis of the several varieties the student is referred to special texts. It is well to remember that the same underlying causes may be basic to the various forms, for several varieties may occur at the same time or one variety pass into another, though commonly one form is more prevalent. The limbs, face and genitalia are the most common sites, though the eruption may occur on various parts of the body.

=Etiology= includes a number of factors, constitutional and local. Dietetic errors, indigestion and faulty elimination comprise the principal underlying causes, often manifested through absorption of toxins and leucomains. In fact any disorder of the abdominal viscera, organic or functional, may be a predisposing factor, likewise various disorders of the pelvis, tuberculosis, diabetes, anemia, etc. should be considered. So-called gouty and rheumatic tendencies may be the constitutional basis.

The many osteopathic lesions play a very important role in lowering not only systemic resistance but of local tissue as well. This feature can not be over-emphasized.

Then local irritants, mechanical, chemical and thermal, are not to be neglected. These are usually of secondary importance. Micro-organisms are probably a complicating factor after the lowered resistance has been established. Vasomotor neurosis, through constitutional defects, toxins and the very significant osteopathic lesion, is probably an essential part of the pathogenesis.

=Treatment= is usually successful if the various etiologic factors are eradicated. Early treatment is very important. If the disorder is of more than local significance change the entire daily regimen of the patient. Diet, outdoor exercise and sufficient sleep should be definitely regulated. A certain amount of general treatment to improve digestion, assimilation and elimination is imperative. An unbalanced diet and over eating must be corrected. In certain moist types, eliminating fatty foods will be helpful, while in dry forms the starches and sugars should be reduced.

If there is an underlying disease this should be remedied if possible. Particular attention should be paid to constipation.

Common sense in diet, rest, change of environment and free elimination, coupled with due attention to the osteopathic lesions, will cure the vast majority of cases. The greatest difficulty arises where there is some underlying disease. The parts should be protected against irritation such as dirt, cold, soap, and too much water. Meddlesome local treatment is to be guarded against. A simple application is boric acid, rice-flour or cornstarch, or where there is much itching add carbolic acid to the saturated solution of boric acid. Substitute bran for soap for cleansing purposes.

=Herpes Simplex=, fever-blister, or “cold sore” comprise two principal varieties: =herpes facialis= and =herpes genitalis=. The first occurs upon or near the lips, face, neck or ears. When the herpes is on the tongue or the mucous membrane within the mouth it is commonly termed “canker sores.”

Herpes genitalis is located on the prepuce, glans penis or farther back upon the penis. In the female the labia majora and minora and vestibule are the usual locations. Lack of cleanliness, sexual excitement and adherent prepuce are causative factors, though predisposing factors such as faulty circulation and disturbed innervation are to be considered.

In “cold sores” there is often some gastro-intestinal disturbance, especially intestinal stasis, cold in the head and other infections that supply toxins which irritate the nerves. No doubt there are underlying osteopathic lesions that lower the local nerve resistance or block the impulses such as vertebral and inferior maxillary lesions. The predisposing disturbance is probably due to the Gasserian ganglion.

Cold winds and excessive exposure to the sun’s rays will effect the tissues over the mental and infraorbital foramina, tensing the muscles and irritating the nerves at these points. On palpation they will be found sensitive. Frequent rotary motion by tip of finger over foramina will open them and allow congestion to drain.

=Herpes Zoster=, or shingles, is an acute inflammatory disease characterized by groups of small vesicles, usually along the course of the intercostal nerves on one side of the body. Before the vesicles appear there is more or less severe neuralgia. The eruption is unilateral, very rarely bilateral. The nearby lymphatics are usually enlarged.

Though the intercostal nerves are the ones most frequently involved, still the lumbar, thigh, trifacial and other cutaneous nerves may be affected.

The most common lesion is an inflammation of the posterior spinal ganglion which usually involves the fibers of the entire nerve. Inflammation of the nerve outside of the ganglion will cause the disorder. Toxins from various infectious sources are often exciting causes. Vertebral and rib lesions are always found; and where the Gasserian ganglion is involved lesions of the inferior maxilla and upper cervical vertebræ are predisposing factors. Thus osteopathic lesions from traumatism, cold and wet, and imbalance of muscular tension are important. Exudates, tumors, pleuritic and pulmonary affections are to be considered as possible sources.

=Treatment.=—Adjust vertebral lesions and carefully raise and separate ribs if intercostals are affected. Look after vertebral origin of any other nerve or nerves if otherwise. Local application of talcum or starch or boric acid will generally be sufficient.

=Urticaria=, hives or nettle rash is a common affection often due to some derangement of the digestive tract. This may be a mechanical irritation or of a toxic nature. Every one is familiar with the various foods that are apt to cause the hives, shell fish, strawberries, cheese, pork, oatmeal, mushrooms, etc.

The irritation may be a reflex one from the visceral disturbance; also, there may be irritation of the pelvic organs that would give rise to the trouble. It is well known that certain drugs will produce urticarial eruptions. There are cases where the irritation is simply local due to the nettle, mosquito bites and wasp stings.

In chronic cases intestinal stasis, nervous exhaustion and nephritic diseases are important.

No doubt osteopathic lesions frequently determine the location of the wheals. These lesions affect the innervation and thus establish a basis for the reflex vasomotor effect. This is in the nature of spasm of the cutaneous vessels quickly followed by dilatation with exudation of serum. The irritant probably acts on the walls of the blood vessels.

=Treatment= consists of thoroughly emptying the bowels by warm water enema, correcting the diet, toning the viscera and adjusting the osteopathic lesions. Thorough attention to the patient’s environment, daily habits and occupation are of value. Warm soda baths will relieve the itching.

=Acne= is a common skin disorder that is characterized by an inflammation of the sebaceous glands of the nature of papules, tubercles or pustules. The face, shoulders, chest and back are the regions usually involved. It generally, appears about puberty. Blackheads is the starting point; these are accompanied with greasy skin and dust, and influenced by micro-organisms and more or less intestinal disorder.

The general or systemic health no doubt affects the local disorder, as in many skin diseases; for various intestinal derangements as indigestion, constipation, etc.; pelvic and menstrual irregularities; general ill health; anemia, etc. affect circulatory, glandular and nervous integrity. Any disturbance of normal elimination is important.

The =treatment= consists of careful attention to the general health and to the local innervation of the face or region involved. Measures that tone the bodily organs such as outdoor life, regular habits, plenty of sleep and correct diet are important. In some cases the X-ray is of value.

ANIMAL PARASITES

Tape Worms

=Varieties.=—Taenia solium; taenia saginata; bothriocephalus latus.

The larvæ of tape-worms are introduced into the intestinal canal by food and drink. The parasite reaches adult growth in the intestines. The larval forms are then found again in the muscles and solid organs.

=Taenia Solium.=—This is derived from the hog, and is the most common form in this country. When mature it is from two to four yards in length. The head is small, about the size of a pin, and provided with four cup-like suckers surrounded by a double row of hooklets, hence it is called the armed tape-worm. The head is fastened to the body by a thread-like neck, and following the neck, the body occurs in segments. The sexual organs, both male and female, occur in the center of the broad surface of the segment. The segments are about one millimeter in length and seven or eight millimeters in breadth. There are thousands of ova in each mature segment. The worm attains its growth in about twelve to fifteen weeks, after which time the segments are shed and passed. For further development the ova must gain entrance to the stomach of a pig or of man, and passing from the stomach they may reach the muscles and organs and develop into larvæ or cysticerci.

=Taenia Saginata.=—This is derived from beef, and is much longer and larger than the taenia solium. It is from five to six yards in length; the head is over two millimeters in breadth, is square shaped, and has four large sucking discs, without hooklets; hence it is called the unarmed tape-worm, in contra-distinction to the hooked variety. The segments are thicker and the ova larger, and they are passed and ingested in the same manner as the taenia solium.

=Bothriocephalus Latus.=—This is found especially in Europe and is very long, measuring from eight to ten yards; it is derived from fish, is not provided with hooklets, but has two lateral grooves. The segments are short and wide, the sexual organs being on the narrow side of the segment.

=Etiology.=—Unhealthy condition of the stomach and intestines is the predisposing, and uncleanliness an important, factor in the occurrence of tape-worm. Those eating imperfectly cooked beef, pork, fish or other meats, and those handling fresh meats, are liable to be affected with tape-worm.

When the ovum is taken into the stomach the capsule is dissolved and the embryo passes into the small intestines, fastening itself into the mucous membrane, by its hooklets and suckers and grooves.

=Symptoms.=—Tape-worms occur in the human being at all ages. Oftentimes symptoms are absent, the expulsion of segments being noticed and thus the worms accidentally discovered. The tape-worm is seldom dangerous, but if a worm is known to exist it is always a source of considerable anxiety on the part of the patient. Severe anemia may result and be wrongly diagnosed.

There are dyspeptic symptoms, colicky pains, nausea and occasionally diarrhea. The appetite is variable, sometimes ravenous. This condition is followed by loss of flesh and various reflex phenomena, as vertigo, headache, convulsions, palpitation, choreic movements, itching of the nose and anus, paralysis, and rarely, insanity. In addition to these symptoms there may be a wrinkled countenance, sensation of a cold stream winding itself toward the back immediately after a meal, pain in various parts of the body and ringing in the ears. The decisive diagnostic symptom is to find segments of the worm in the stools.

=Diagnosis.=—Discovery of the ova or segments in the passages of the bowels is the only proof of the presence of a tape-worm.

=Prognosis.=—Favorable in all cases.

=Treatment.=—Prophylactic treatment is necessary. Meats should be thoroughly cooked so that the larvæ will be destroyed; and all segments of tape-worms passed in the stools should be burned—by no means should they be thrown outside or in the water-closet.

The immediate expulsion of a tape-worm is not a necessity. First of all the mode of living, and then the general state of health should be corrected. Tape-worms invariably result from a general state of unhealthiness, and with improved health and corrected digestive processes the worms cannot exist, and in a short time will be expelled. Expulsion of the head is necessary before the case will be cured, for if the head is not expelled new segments will continue to grow.

Stimulating the liver to increase the amount of bile, and increasing the activity of the digestive glands of the stomach and intestines, by a thorough treatment of the splanchnic region and direct treatment over the abdomen, will usually be sufficient for the cure of intestinal parasites. The treatment will probably have to be repeated several times, in order that the intestines may regain a healthy tone, so that the parasite will not find favorable conditions for its existence within the intestines, and that the bile may be secreted in sufficient quantities to dislodge the worm.

Hahnemann claimed, “that during a period of comparative health tape-worms do not inhabit the intestines proper, but rather the remnants of food and fecal matter contained in the intestines, living quietly as in a world of their own without the least inconvenience to the patient and finding their sustenance in the contents of the bowels. During this state they do not come in contact with intestinal walls, and remain harmless. But when from any cause a person is attacked by an acute disease the contents of the bowels become offensive to the parasite, which in its writhing and distress touches and irritates the sensitive intestinal lining, thus increasing the complaints of the patient considerably by a peculiar kind of cramp-like colic. (In similar manner the human foetus in the womb becomes restless, twists its body and moves whenever the mother is sick, but floats quietly in the liquor amnii, without distressing her while she is well.)” This but harmonizes with the osteopathic theory and practice with regard to tape-worm, that there is an unhealthy condition of the intestines which predisposes to the affection, and consequently the cure must be a correction of such a disordered state.

During the treatment, if a light diet of milk and broths is given, it will favor an earlier removal of the parasite, by helping to remove the mucus in which the head is embedded. If this fails extract of male fern is suggested.

Ascaris Lumbricoides (Round Worm)

This is the most common parasite, and is found principally in children; it is also found in cattle and hogs. It is of a yellowish brown color and in form resembles earth worms. The worm is cylindrical, pointed at both ends; the female is from seven to twelve inches in length, and the male from four to eight inches. They are probably introduced into the stomach by food and drink. They occupy the upper part of the small intestine, and are usually one or two in number, though they may be numerous. Occasionally they migrate into the stomach and are ejected by vomiting, or into the trachea and produce suffocation, or into the larynx or Eustachian tube, or they may pass downward to the anus, or into the bile ducts.

=Symptoms.=—Oftentimes symptoms are absent. There may be dyspepsia, colicky pains, mucous stools, meteorism, vertigo, fretfulness, voracious appetite, anemia, sallow complexion, headache, chorea and convulsions. Other symptoms may be present, as grinding of the teeth and itching of the nose and anus. Obstruction of the bowels has occurred. If a worm enters the bile duct obstructive jaundice occurs. A decisive diagnosis can be given only when the worm is seen.

=Treatment.=—Particular attention should be paid the liver, for it is here that we must seek the natural remedy in the form of bile, in order to eject and cleanse the system from nematodes.

Modes of improper living should be corrected; cleanliness is essential, and there should be attention to the general health of the patient. Thorough correction of all defects of the spinal column in the region of the splanchnics, and careful direct treatment of the bowels is indicated. The child may be put to bed and fasted twenty-four hours, then the liver strongly stimulated to increase flow of bile.

If the above treatment is not successful oil of wormwood may be employed.

Oxyuris Vermicularis

(Thread-worm; Pin-worm)

This small parasite, commonly seen in children, is from three to five millimeters long in the male and about twenty millimeters in the female, is blunt at one end and sharp at the other, and occupies the colon and rectum. They are probably introduced into the intestines in the ova, by uncooked fruits and vegetables, or by the dirty hands of mothers and nurses of the infants. They vary greatly in number; migrate to the rectum where they deposit their eggs, and are often discharged in the feces, where they appear like pieces of ordinary white thread.

=Symptoms.=—Loss of appetite, anemia, restlessness and irritability are marked. The itching becomes intolerable when the worms come down in the rectum to the anus and within the folds about the anal orifice. In the female the worms may wander into the vagina where they become particularly distressing, and thus may produce excessive sexual excitement and cause nymphomania and masturbation.

=Treatment.=—Cleanliness of the most scrupulous kind should be demanded in every instance. Injections of cold salt water (repeated for at least ten days) and other agents within the rectum will destroy the eggs as soon as they are deposited, besides relieving the terrible itching. In obstinate cases use quassia decoction.

Attention to the general health of the patient and great care of the intestines and other digestive organs are absolutely necessary. The spinal treatment to the intestines and other digestive organs, as well as thorough direct treatment over the abdomen, is indicated.

Uncinariasis

(European hook-worm disease; Miner’s anemia; Ankylostomiasis; Hook-worm disease)

This disease results from infection by the hook-worm of any of the various types. In Europe it is found in Italy, Belgium, Germany, France and Switzerland. In America it seems to be of Africo-Asiatic origin but was first discovered in the Southern states and abounds chiefly in Texas, Florida, Georgia, North and South Carolina as well as in the West Indies. Infection comes from unprotected feces that are allowed to be spread where the feet or hands may come in contact as it is without doubt that the contagion occurs through the skin. One authority states that hook-worm is rarely found except in cases where ground itch has occurred within a period of eight years. Negroes harbor the parasite and transmit it but seem immune to its effects while the poorer whites are afflicted to a large degree. The worms are carried from some abrasion of the skin, by the blood to the heart and lungs, thence to the pharynx and swallowed, thence to the duodenum and jejunum where they attach themselves to the lining walls. Here they not only feed upon the blood but develop a toxin. The female worm is about twice the size of the male, 10 to 18 mm. as against 6 to 11 mm. and there is slight difference between the old and new world varieties. The head is provided with four hook shaped teeth which form the attachment to the intestine and it is very secure.

=Diagnosis.=—For years the languid, dull, expressionless, lack-luster of eye and general unambitious characteristics of the inhabitants of the great sand belt of the United States attracted attention and was attributed to laziness but the discovery of the hook-worm explained the cause. Children are stunted in mind and body and have a muddy, dirty white complexion.

At the beginning there must be a very considerable colony of the parasites to cause symptoms but as the disease advances there is a distention of the abdomen from enlargement of the spleen and liver and from flatulency. There is palpitation, shortness of breath, cardiac bruits from the severe anemia while edema of the feet and legs is rather common. The blood shows a severe secondary anemia with its coagulation time much increased. Leucocytosis is not common; hemoglobin is from one-tenth to one-half normal with erythrocytes about half normal.

=Treatment.=—The removal of the worms with the least possible harm to the body is indicated. Thymol is a poison which is not absorbed by the body, when carefully given, and which is very toxic to the parasite. The dose varies from eight grains for a child under five years of age, to forty-five for an adult. Thymol is soluble in fats and in alcohol, so that for a day or so before the thymol is given, and from one to four days after, no fats or alcohol should be taken. The best way to avoid poisoning by thymol is to give the patient charcoal, then no fats or alcohol is permitted until the treatment is completed. When the stools become black, the thymol is given on an empty stomach. A purgative is given a few hours later. Enemas should be used very freely in order to facilitate the removal of the injured or poisoned worms. Another dose of charcoal is given, and when the stools are black again, the patient may return to his ordinary diet. The denial of fats to the person so thoroughly accustomed to bacon three times a day is a factor met with difficulty in dealing with patients of the ordinary class with the disease. (Clinical Osteopathy.)

=Prophylaxis.=—After treatment it is imperative to prevent reinfection and to do that the most rigorous sanitary measures must be instituted. All feces must be disposed of and habits of cleanliness in defecation insisted upon while negroes, who harbor the worm without showing symptoms, must be looked after as well as the actual victims. Care of the feet is important and shoes should be worn in infected regions and all abrasions of the skin protected. Drinking water must be uncontaminated which presents a problem as wells and springs are usually unprotected. Absolute and persistent cleanliness is the answer to the question of prevention.

Trichiniasis

Trichiniasis is a name given to a disease produced by the embryos of the trichina spiralis. In the adult condition the trichina spiralis lives in the small intestines. The embryos migrate into the muscles where they finally become encapsulated. Man is infected by eating insufficiently cooked pork containing the encapsulated worm, which is set free during the digestive process. About the third day they attain their full growth and become sexually mature. Each one discharges large numbers of embryos. As soon as born the young brood is carried away from the bowel and invade the muscles through various channels—principally by means of the blood stream and along the connective tissue routes. The female trichina may bring forth several broods of embryos in succession. In nine or ten days after infection the first brood reaches its destination. They attain to maturity in about two weeks after entering the muscular tissue. In this process an interstitial myositis is excited and a fibrous capsule is formed in four to six weeks. The capsule gradually becomes thicker and finally calcareous infiltration may take place.

Thorough cooking destroys the parasite. The disease is most frequent among the Germans who eat raw ham and sausages.

=Symptoms.=—These are sometimes absent, especially when only a few are eaten. If large numbers have been ingested, gastro-intestinal symptoms develop in the course of a few days. Vomiting, diarrhea, and pain in the abdomen may be present.

In from one to two weeks muscular symptoms develop. There is fever, muscular pain, especially during motion, and the muscles are stiff, tense and sometimes swollen. When the respiratory muscles are involved dyspnea is produced, which may prove fatal. Eosinophilia is a helpful diagnostic point. Edema, especially of the face, is an important symptom. Profuse sweats, itching and tingling of the skin have been observed.

=Diagnosis.=—Epidemics of this disease are more easily diagnosed than an isolated case. Among the Germans, if cases of apparent typhoid fever occur after a picnic or other feasting occasion, where raw ham or sausages have been indulged in, this disease should be suspected. Examination of the stools and of the muscles will be of aid. The worms may be discovered in the pork, a portion of which has been eaten by the patient.

=Prognosis.=—This depends upon the number of worms ingested. The prognosis should always be guarded. Early, marked diarrhea is favorable.

=Treatment.=—Prophylactic treatment is of great importance in trichiniasis. Inspection of the meat supply, is doing much to prevent trichiniasis; although the most practical way to prevent the disease is to thoroughly cook all pork and sausages. The central portions of the meat should be well cooked.

In the feeding of hogs care should be taken that they do not receive any offal, but only milk, grain, vegetables, etc.

When a person is infected with trichiniasis, thorough and prompt evacuation of the bowels should be performed at once, so that the embryos will not have time to pass into the muscles, but will be ejected from the body. This should be followed by a thorough and persistent treatment for several days of the liver and intestines; treat both the liver and intestines directly and through the spine. The object of this treatment is to render all the digestive juices active, so that they may dislodge the animal parasite, and to prevent their passing into the muscles. Also keep the bowels active for several days.

When the larval parasites have entered the muscles, a treatment cannot be applied to affect them directly, but the health of the body should be maintained if possible, and the severer symptoms, as the muscular pains, weakness and insomnia combated. Thorough manipulation, massage and hot baths will be of special aid in relieving the stiffness and weakness of the muscles.

Filaria

(Filaria Sanguinis-Hominis)

There are two varieties. One is a thread-like worm with tapering, blunt ends, appearing in the blood at night, hence called =nocturna=, while the other is of slightly different form, appearing in the blood only by day and is called =diurna=.

The mosquito is the communicating host of the parasite. During the night, or should the patient sleep during the day, the =nocturna= appears in the peripheral circulation, while during the other interval they are probably in the other vessels, particularly the lungs.

After the mosquito has taken blood from an affected patient it requires from six to seven days for the metamorphosis of the minute filaria which are then lodged in the probosis of the mosquito and introduced into the blood of the next victim. The adult parasite is from three to four inches long and the thickness of a coarse hair, with clear sexual distinction.

=Pathologically= there are no distinct lesions, as the parent worm must establish one. Lymphatic engorgement may result from plugging of the thoracic duct or of a large lymphatic with consequent engorgement which may develop symptoms in the inguinal glands, pelvic and lumbar lymphatic trunks. As these varicosities develop rupture may occur; if into the genito-urinary tract chyluria or chylocele may result, or if in the abdominal cavity chylous ascites.

Lymphangitis follows a lymph stasis, which later results in =elephantiasis=. (Barbadoes leg.)

=Symptoms.=—Elephantiasis affects the legs, but the arms rarely; the labia of the female and scrotum of the male; occasionally the breasts and other parts of the body. Fever is present on account of the lymphangitis, accompanied by rigors and delirium and there is marked local inflammation. The attack terminates in a pronounced sweat. In deeper parts there is deep seated pain and signs of sepsis, while abscesses may develop over the inflamed area.

The varicose inguinal glands are doughy, soft and painless, with both sides affected alike. The scrotum is affected by the extension, and at times the testes.

=Treatment= is surgical, as the tumors must be removed. Unless the female worm is also removed this is, however, only palliative.

Methylene blue is said to be destructive to the filaria and it is practically harmless to the human body. The only treatment is one that will aid in building up the general health.

HEMORRHAGES

Nasal Hemorrhage

(Nose bleed; Epistaxis)

=Osteopathic Etiology= and =Pathology=.—Traumatism, such as picking the nose, blows, and surgical operations; straining when coughing; nasal tumors and ulcerations; lesions of the atlas, or any lesion of the upper cervical vertebræ, that would interfere with the vasomotor distribution to the nose and cause local congestion or weakness of the blood vessels; obstructions to the general circulation; irregularities or suppression of the menstrual flow may result in nose bleed, as a vicarious menstruation; suppression of a habitual hemorrhoidal discharge.

=Pathologically= the great frequency of nasal hemorrhage is due to the great vascularity of the nasal mucous membrane. Usually in cases of spontaneous origin, bleeding is from the region of the septal artery. Spontaneous bleeding may also occur from posterior hypertrophies or adenoid vegetations. The blood flowing downward into the fauces, is expectorated in such cases, and may be mistaken for a hemorrhage from the lungs.

=Treatment.=—The position of the individual is important. He should assume a sitting posture, or as nearly so as possible. Holding the nostrils tightly, or plugging them with a piece of cotton, will favor the formation and retention of a clot, so that the hemorrhage may be controlled. Pressure upon the carotid artery, or upon the facial artery at the angle of the inferior maxilla, will slow the blood current and favor the formation of a clot, also pressure on the sides of the bridge of the nose may influence it. Correcting any lesions that may exist in the superior cervical region, as derangement of the vertebræ or contracted muscles, will remove obstructions or irritations to the vasomotor system of the affected region, and thus equalize the vascular system. Holding the arms above the head, and the application of ice to the nose are of aid in some cases. Also, injection of cold or hot water into the nostrils. In serious and obstinate cases, where other methods fail, a plugging of the anterior and posterior nares should be resorted to, using absorbent cotton or gauze.

Broncho-pulmonary Hemorrhage

(Hemoptysis)

=Osteopathic Etiology= and =Pathology=.—Pulmonary congestion; croupous pneumonia; tuberculosis; hemorrhagic infarction; ulcers of the larynx, trachea or bronchi; gangrene of the lung; fibrinous bronchitis, carcinoma of the lung; lesions of the ribs or vertebræ from the second to the seventh dorsal inclusive, may cause diseases of the bronchial tubes or lungs, that result in hemoptysis, or the hemorrhage may be caused directly by extreme congestion resulting from the disordered vasomotor nerves; diseases of the heart, such as mitral disease, causing pulmonary congestion; aneurism of the branches of the pulmonary artery; vicarious menstruation from deranged menstrual functions; diseases of the vessel walls, or blood, as scurvy, anemia, hemophilia, etc.

=Pathologically= in many cases, the lesions are microscopic, consisting of ruptured capillaries. In other cases larger vessels may be ruptured, or are the seat of erosion. Many other lesions may be observed. After death the bronchial mucosa is occasionally found inflamed and the lung tissues paler than normal.

=Diagnosis.=—A differential diagnosis must be made between epistaxis, hemoptysis and hematemesis.

In =epistaxis= the blood may flow from the posterior nares into the pharynx; it causes coughing and a discharge of the blood may occur the same as in hemoptysis. A careful examination of the nasal region alone can determine the source of the bleeding.

In =hemoptysis= the history of the case as to pulmonary or cardiac diseases is to be considered. There is a feeling of weight and of uneasiness in the chest. A salty taste and a tickling of the throat precedes the bleeding. The blood is ejected by coughing and is bright red, frothy, very little coagula, and is alkaline in reaction.

In =hematemesis= the history would indicate disease of the stomach, spleen, liver or heart. Uneasiness, and occasionally nausea and faintness, precedes the bleeding. The blood is ejected by vomiting, and is dark, clotted or fluid, mixed with food, and is of acid reaction. In a few instances the blood due to hemoptysis may be swallowed, and vomited.

=Treatment.=—In all these cases of hemoptysis the patient should be placed in bed and absolute rest demanded. An attempt should at once be made to correct any lesion that may be found influencing the cause of the bleeding. Correcting lesions to the vasomotor nerves of the lungs and bronchial tubes, and equalizing the disturbed vascular area, may be sufficient in a number of cases. These lesions will be found principally in the upper dorsal region. In some cases, perhaps, there is an impairment of the trophic nerves by the same lesions, thus interfering with the tone of the vessel walls and pulmonary tissues. The diet should be light, nutritious and non-stimulating. The use of hot drinks is to be avoided. The rapidity of the heart’s action should be reduced. This is best performed by thorough treatment of the dorsal spinal nerves of the left side over the heart, and by inhibition in the suboccipital region. The ice-bag to the precordia is also helpful. Iced drinks and the eating of ice is of aid. Stimulation of the systemic circulation will be of value in helping to relieve the pulmonary congestion, although the two systems are somewhat independent of each other. Also, hot foot baths and the evacuation of the bowels may be of additional value. In cases due to organic disease of the heart, the mind and body should receive absolute rest, so that the diseased areas may be strengthened as much as possible; besides a tonic treatment for the heart’s action is necessary.

After the hemorrhage has subsided care should be taken that bleeding does not occur again. All irritations of the respiratory tract should be avoided. A stimulating diet, tobacco and alcohol should be avoided. Nutritious food and a moderate amount of exercise is indicated.

Hemorrhage of the Stomach

(Hematemesis)

=Osteopathic Etiology.=—Injuries to the stomach; local diseases, as congestion, ulcers and cancer; vicarious menstruation; a mechanical obstruction to the portal circulation; spinal lesions to the vasomotor nerves of the stomach; alterations in the blood; perforation of the stomach walls, involving a blood vessel; disease of some neighboring organ.

=Diagnosis.=—A careful examination of the case and of the blood ejected will be necessary to determine the nature of the cause. The differential diagnosis as to the source of the blood, whether from the stomach or lungs, was given under hemoptysis.

=Treatment.=—Correction of any lesions that may influence the blood pressure in the region of the stomach, is the first requisite. Treatment of the splanchnics has the greatest influence upon the vasomotor nerves to the stomach. Treatment of the vagi nerves and of the fourth and fifth dorsals, will quiet the violent movements of the stomach, and thus aid in controlling the hemorrhage. Stimulation of the cervical sympathetics and heat applied to the feet will tend to equalize the vascular system, and thus lessen the gastric congestion. The application of a broad flat ice-bag over the stomach will be of great value. Keep the patient quiet in bed. Surgical interference may be necessary.

Intestinal Hemorrhage

=Osteopathic Etiology.=—An obstructed circulation of the blood through the venaporta, as in diseases of the heart, lungs and liver; lesions of the vertebræ deranging spinal nerves to the intestinal blood supply; injuries caused by corroding or cutting substances; mechanical injuries to the intestines; degeneration or erosions of the blood-vessels from ulcers of the intestines, as from typhoid fever, typhus, dysentery, etc.; disordered menstrual or hemorrhoidal discharges.

=Diagnosis.=—The locality of the intestines affected can be approximately determined by an examination of the discharged blood. When the blood comes from the upper part of the intestines, it is generally dark and mixed with the intestinal contents, which gives it a tarry appearance. It is generally red and fluid when it comes from the lower portion of the bowels. If from the stomach, the blood is thoroughly mixed with fecal matter. Throwing the passage into water, the water is colored red when it contains blood, and if the contents contain bile the water is colored green or yellow. Also, noting the areas of contracted muscles, as in intestinal colic, will aid in the regional diagnosis.

=Treatment.=—Absolute rest in all cases is necessary, the patient remaining as quiet as possible. Food, in severe cases, should not be given for ten or twelve hours. The bed-pan should be used in caring for the evacuations. Correction of the lesions along the spinal region, chiefly of the lower dorsal and lumbar regions, that are impeding the innervation to the intestines, should be attended to at once. This treatment tends to relieve any hyperemic condition of the intestinal mucosa and influences the whole vasomotor area of the mesentery. Direct treatment of the abdomen in a few cases is of great value to relieve obstructed and contracted vessels in the mesentery, but in certain pathological conditions, e. g., typhoid fever, leave the abdomen alone. Treatment (inhibition) along the spinal column from the sixth dorsal to the coccyx is helpful in all cases to quiet the peristalsis of the intestines. In severe cases cold drinks, eating of ice and an ice pack to the abdomen are of aid. In a few instances surgical measures will be necessary.

Hematuria

=Osteopathic Etiology.=—Congestion and acute inflammation of the kidneys, exacerbations of pyelitis, renal calculi, chronic nephritis, traumatism, tuberculosis, etc.; affections of the urinary tract, as calculi or lacerations of the ureter; calculi, cystitis, ulcerations, etc., of the bladder; calculi, gonorrhoea, parasites, etc., of the urethra; general diseases, chiefly the acute specific fevers and blood diseases; blows, wounds and traumatic influences, external to the kidneys; lesions of the renal splanchnics.

=Diagnosis= of the locality of the hemorrhage in the urinary tract: In hemorrhage from the =kidney= the blood is thoroughly mixed with the urine, giving a uniform color. Blood casts and leucocytes are present. In hemorrhage from the =ureters= the blood is usually molded in clots which conform to the shape of the ureter. The clots appear like small dark worms. In hemorrhage from the =bladder= the blood is not thoroughly mixed with the urine and large clots form upon standing. In hemorrhage from the =urethra= the blood often discharges without micturition. When urine is passed the blood precedes the passage of urine.

=Treatment.=—Rest is essential. A correction of the lesions to the renal splanchnics is necessary to control the congestion and inflammation of the kidneys. When the ureters, bladder or urethra is involved, attention must be given to the condition of the spinal column below the renal splanchnics. In all cases the inhibitory treatment to the lower spinal column and ice to the loins are of value. If surgery is indicated, do not delay operation.

Uterine Hemorrhage

Most of the causes of uterine hemorrhage come under the subject of obstetrics; others under menorrhagia and metrorrhagia. Such will be found in obstetrical and gynecological works.

=Treatment.=—The patient should assume the dorsal position with the buttocks raised. If any displacement of the uterus is present or if there is any foreign material in the uterus, usually such should be corrected or removed at once. Stimulation of the clitoris is a most effectual means to control uterine hemorrhage; it contracts the circular fibres of the uterus. Stimulation of the uterus directly through the vagina, and over the abdomen, and stimulation of the upper wall of the vagina, will aid in contracting the uterus. A quick, unexpected pull of the hair on the mons veneris will have the effect of closing the capillaries by shock to the nervous control (Dr. Still). Before closing the os, however, it is well to know that there is no irritating foreign material within the body of the uterus. Correction of obstructions of the vasomotor nerves of the uterus through the splanchnic and lumbar region is important. Compression of the abdominal aorta, and vaginal injections of hot water may be of aid, as will also a hot water bag at the lumbar region and ice water bag over symphysis. In severe cases inversion of the body, if it can be done with safety, may be performed. Packing the vagina is a method resorted to occasionally in severe cases.

Hiccoughs

Occasionally there is a case of hiccoughs that has been continuous for hours or even days and that all efforts have failed to stop. They are caused by an irritation to the peripheral distribution of the phrenic nerve from some gastric disturbance or a local irritant acting upon the center in the medulla. It may follow fright or great emotion and be associated in persistent form in rheumatism, typhoid fever and other febrile diseases. It follows abdominal operations at times and is very distressing. When occurring in elderly people with pneumonia and in peritonitis with distention it usually marks the end. The same may be said in case of carcinoma of the stomach and bowels.

=Treatment.=—Go first to the origin of the phrenic nerve at the third, fourth and fifth cervical and, if there is a lesion as there will probably be, adjust it and note results. This will be sufficient in many cases. Failing, bring direct pressure on the nerve just above the clavicle and anterior to the sternomastoid muscle and release the scaleni muscles. After this examine and treat at the fifth and twelfth dorsals. Correct any lesions but best results will be had from inhibition at these points. Another method is to stand beside the patient and insert the fingers of both hands under the costal end of the ribs and lightly pull. Firm pressure over the solar plexus with flat of the hand is sometimes beneficial. In hysterical cases, drawing out the tongue will often be effective and it has been suggested that standing the patient on the head will stop them in short order. Tickling the nose to produce violent sneezing is an ancient remedy. Some one of these will cure the case, as osteopathy has never failed so far as recorded.

The stomach should be emptied of all irritating matter to prevent recurrence.

VARICOSE VEINS

In varicose veins there is a dilatation of the calibre of the veins and their valves are insufficient. The walls are irregularly thinned, lengthened and tortuous.

=Osteopathic Etiology= and =Pathology=.—The =internal saphenous= is the vein most frequently affected, although any vein throughout the body may become varicose. Commonly, varicose veins occur in the lower extremities and occasionally in the arms.

The =valvular insufficiency= is caused by stretching of the wall of the vein, thus separating the thin, free edges and leaving an interspace that allows regurgitation of the blood. The valves becoming insufficient, the column of blood in the veins has no support against gravity, and being interrupted in its course does not flow normally into collateral channels. The walls of the veins become thin, as does also the adjacent skin, thus increasing the danger of a rupture, either external or subcutaneous.

Varicose veins are most frequently found in females, following uterine enlargements. The condition may be due to any obstruction or constriction that prevents the free return of blood from the veins, such as dislocations of the hip, either slight or complete, dislocations of innominata, contractions of adductor magnus muscle affecting femoral vein, prolapse of diaphragm obstructing vena cava, tissue constrictions about the saphenous opening, garters, and, in fact, anything that might impede the free venous flow. The tendency to varicose veins increases as age advances, and many cases are found among people of middle life who have been accustomed to standing a great deal. Injuries to the pelvis, thigh or leg, lessening the nutrition to the leg, or injuries to the nerves, as vertebral dislocations in the lower dorsal or lumbar regions (the fourth lumbar especially) may be causes of varicose veins. Pregnancy or tumors in the abdomen or pelvis, causing pressure upon the iliac veins, are occasionally causes. Distention of the sigmoid flexure, causing pressure upon the left iliac vein, or distention of the cecum; pressing upon the right iliac vein, are fruitful sources, as are also diseases of the heart and lungs. Varicose veins of the upper extremities are due to occupations requiring overuse of the arms.

=Complications.=—Varicocele, hemorrhoids, labial varix in the female, varix over pubes, ulceration and eczema due to disturbances of nutrition, edema and thrombus.

=Symptoms.=—=Lower Extremities.=—Cramping pains in the limbs upon rising. Fullness and heaviness of the limbs. Inspection may reveal superficial varicose veins near the saphenous opening, upon the external thigh, in the popliteal space, upon the external leg or behind the ankles. Edema and congestion of the foot and ankles occur in a few cases. Pain is quite a prominent symptom, due to pressure upon the nerve fibres. Eczema and itching are due to disturbed innervation and blood supply to the skin. Ulceration may occur, due to the bursting of a vein.

=Upper Extremities.=—Before the varicosity appears there is usually pain or a feeling as of a sprain in the involved region of the arm. The pain is usually confined to a muscle or group of muscles.

=Treatment.=—The majority of cases are due to disorders about the pelvis, hip or thigh, and the treatment resolves itself into the removal of these obstructions or constrictions. Occasionally cases are caused by partial dislocations of the hip joint, which can be easily overlooked during a hurried examination. The slipping of an innominatum is an important factor. Rest in a recumbent position, attention to the general health, and especial attention to the bowels and liver, are essential in acute attacks. Occasionally the heart and lungs are at fault. Treatment twice per week should consist of removing any of the numerous causes of the condition, and spinal treatment as well; then the leg should receive special attention. Remember, thrombi may form and the vein must, under no circumstances, be touched in the treatment. Begin by carefully rotating the leg to stretch contracted tissue about the saphenous opening, then separate the tendons of the popliteal space and follow the course of the vein to the abdomen and relax tissue about it. Keep patient off the feet as much as possible and elevate the leg when sitting.

In rupture of varicose veins the hemorrhage can be arrested by elevating the limb and applying pressure with the fingers, above and below the wound, until a compress and bandage can be applied. The support of the varicose veins by elastic stockings will ease the pain and prevent edema in many cases, but, as a rule, it is a direct hindrance to the circulation on account of the necessity of having the stocking fit closely. Surgical operations are rarely indicated.

Phlebitis

(Phlegmasia alba dolens; milk leg)

An inflammation of a vein. In the condition described here it is a puerperal septic inflammation of the femoral vein. About the third week after confinement there is a swelling of the leg with or without redness. Great pain accompanies the condition and the temperature gradually rises to 102°-3°. As understood by osteopaths, this is the result of a partial closing of the saphenous opening during parturition so that the venous flow is partly stopped.

=Treatment= consists in carefully rotating the leg at the hip so that the fascia lata is spread, opening the lumen of the vein so the congestion will drain out. There will, also, probably be found innominate or lumbar lesions which must be adjusted with the result that almost immediate relief is given as a rule.

Chronic Phlebitis

The chronic form shows considerable inflammation along the line of the vein marked by tenderness, edema and thickening of tissue. The entire leg may be more or less involved through circulatory injury. In these cases will be found definite innominate lesions of a primary type or the distortion is superinduced by lumbar lesions. A few cases are quickly cleared up through adjustment that is readily secured. However, in others, there being considerable thickening of the sacro-iliac articulating tissues, some time may be required to get complete adjustment and consequent restoration of femoral circulation. In addition to this, careful abduction, flexion, hyperextension and circumduction is indicated. This last technique should be executed with great care and with due regard to pathology. If Dr. Still’s emphatic command were followed, that all maternity patients should have both legs rotated and innominates inspected, there would be no phlebitis cases, acute or chronic.

THE RECTUM

To treat the rectum intelligently and thoroughly, requires special knowledge on the part of the osteopath. A speculum should be used in many cases when making an examination, and all abnormal conditions carefully inspected with the eye; although much can usually be noted by the examination with the finger alone. The best position in which to give an examination and treatment is to have the patient on the side, with thighs flexed upon the abdomen. In a few cases the patient may lean over an operating table.

The =objects= of =rectal treatment= are many—to relieve hemorrhoids, etc., of the mucous membrane; to correct a dislocated coccyx; to treat an enlarged prostate gland; to replace a prolapsed rectum; to tone the lower bowel in cases of constipation; to give reflex stimuli to the heart and lungs, in cases of fainting, paroxysms, etc.; to relieve severe pains in the rectum at the time of the menstrual period, and to relieve congestion, inflammation, contracted tissues, etc., of local sources; to relax spasms in croup, and to remove tension to the nervous system in some forms of insomnia. In fact, so many diseases are affected by reflex irritations from the rectum that its examination is a necessity in many cases. The phrase “when in doubt treat the rectum” was coined by a progressive student and there is an element of truth in it. Surgical assistance to treatment will be considered under hemorrhoids.

The principal need of osteopathic internal rectal treatment, is: (1) To relax all contracted and constricted fibres about the walls of the rectum and between the sacrum and coccyx. (2) To correct a dislocated coccyx. (3) To dilate the sphincters thoroughly, in order to relieve irritations about the sphincters, and to stimulate the sympathetic nerves.

Work through the rectum to treat an enlarged prostate gland, to correct a displaced uterus, and to make a more thorough examination of the uterine tissues, the Fallopian tubes and the ovaries, is a frequent occurrence.

In giving =local treatment=, cleanse the fingers and oil the index finger; then, after introducing it into the rectum relax the contracted tissues by an upward sweeping motion on all sides. This treatment relieves all obstructions to vessels and nerves caused by contracted fibres, and tones the rectal walls. In prolapsed sigmoid, causing obstructive constipation, the finger can be used to separate the folds of mucous membrane and open the lumen of the bowel. Frequently there will be enough tone to the muscular coat so that the irritation will set up slight peristalsis and cause the bowel to draw up to a considerable degree. In children where there is much straining at the stool, the sigmoid will often be found down and by using the little finger the same results can be accomplished and much relief given.

To =dilate= and =stretch= the sphincters thoroughly a speculum or dilator should be used under anesthesia; still, considerable can be done by one or two fingers. The sphincter should be thoroughly stretched in all directions, care being taken when an instrument is used that too much force is not applied. Secure as much voluntary relaxation of the sphincter as possible. Inhibition at 2d and 3d sacral will aid. This treatment is of aid in cases of hemorrhoids and prolapse of the rectum, in constipation due to the loss of tonicity of the lower bowels, in tightness of the sphincters, in pain of the rectum, and in stimulating the heart and lungs. In cases of a prolapsed rectum, due to irritation about the sphincters, causing tenesmus, this treatment is of special value, as it gives the sphincter a physiological rest. Frequency of treatment per rectum must depend entirely on the patient and disease. It can be given daily in many cases and is frequently so indicated in acute hemorrhoids, prostatic troubles, etc.

According to Quain, the sensory nerves to the rectum are from the second, third and fourth sacrals. Some of the motor fibres of the circular muscles of the rectum are from the lower dorsal and upper two lumbar nerves; these pass by the aortic plexus to the inferior mesenteric ganglion. Associated with these fibres, are the inhibitory fibres of the longitudinal muscles of the rectum. The sacral nerves contain motor fibres to the longitudinal muscles, and inhibitory fibres to the circular muscles of the rectum. In all cases of rectal trouble, the lower dorsal and upper lumbar vertebræ may be found deranged, and thus interfere with the rectal nerves. Relaxation of the sacral muscles over the sacral foramina has a marked effect in relieving =tenesmus=. In dysentery, where there is a constant desire to defecate, a thorough upward relaxation of the sacral muscles will give great relief.

=Proctitis= or inflammation of the rectum is not an uncommon disorder. The disease has been divided into acute, chronic, gonorrheal, dysenteric, and diphtheritic. Foreign bodies, impacted feces, cold, purgatives, prolapse of the sigmoid, and lumbar, coccygeal and innominate lesions are the most important causative factors. The =acute= form is more frequently found in older people. The =symptoms= are tenesmus, frequent evacuations of blood and mucus (possibly pus), prolapse of the mucous membrane, feeling of fullness, and radiating pains. The gonorrheal, diphtheritic and dysenteric forms are of rare occurrence, with the exception that the dysenteric may be somewhat frequent. The =treatment= is to remove all local irritations, cleanse the bowels, and put the patient in bed. All irritating foods are to be prohibited. Use milk, soups, beef juice, soft boiled eggs and similar foods. Correct all osteopathic lesions; especially will inhibition over the sacral foramina relieve the tenesmus. Cold water in the rectum and applied to the anus will be beneficial. If abscesses occur, employ surgical measures.

=Prolapse= of the =rectum= is another common rectal disorder. Acute cases are especially found in children, due to straining at stool. The sacrum is more straight, and thus violent straining, coughing, etc., the more readily produces prolapse. Prolapse of the mucous membrane is the most common, although all of the rectal coats may be involved. Prolapse of the upper part of the rectum into the lower or invagination is frequently met with by osteopaths. The sigmoid may prolapse and also affect the rectum. The =treatment= is to return the mass, using an anesthetic if necessary. If it is not retained, place straps across the buttocks. Then with attention to lesions that may be disturbing and weakening the rectal walls, and thorough local toning treatment, the prognosis should be favorable. In high rectal prolapse local attention is necessary as well as deep treatment through the abdominal walls to the sigmoid and upper rectum. The use of Cole’s irrigator for high enema will replace and elevate both the upper rectum and sigmoid and greatly aid in a cure. Regularity of habits and proper food are essentials.

Hemorrhoids

=Definition.=—A dilated or varicose condition of the plexus of veins lying in the submucous tissue of the lower part of the rectum. The dilatation of these hemorrhoidal veins may extend into the adjoining subcutaneous tissues and mucous membrane, and the perirectal plexus and adjoining venous plexuses of the bladder, uterus, vagina and sacral canal may become involved.

=Osteopathic Etiology= and =Pathology=.—The chief predisposing cause of piles is man’s erect position and the absence of valves in the hemorrhoidal veins. Thus a retardation or stagnation of the portal vein would cause a backward movement of the entire column. It is evident that such a downward pressure of the blood in the portal system would dilate and extend the blood vessels, to the very capillaries in the rectal region.

This retardation may arise from several causes: obstruction of the portal vein, from diseases of the liver; diseases of the heart; obstruction or destruction of the capillaries of the lungs; pressure from a gravid uterus, tumor, etc.; a general loss of tonicity of the abdominal walls, as in persons who take but little exercise; the excessive use of wine, tea and coffee; injuries to the spinal column, especially in the lumbar, sacral and coccygeal regions; a dislocation of an innominate bone; lifting; constipation; straining at stool; carelessness of the calls of nature, etc. Catarrh of the bowels may cause a congestion of the mucous membrane and consequently piles. Hereditary influence may be a factor in a few cases.

Hemorrhoids are divided into two classes, =external= and =internal=. An =external pile= is one that arises from the margin of the anus outside of the external sphincter muscle. It differs from the internal pile from the fact that it is always composed either of skin or hypertrophied connective tissue, forming a mere cutaneous tag, or else it is composed of a small cutaneous vein enlarged by a clot of blood. The =internal hemorrhoids= are composed mostly of enlarged veins and are connected by hypertrophied connective tissue. They have a free arterial supply and are covered by the mucous membrane of the rectum. They are due, usually, to an affection of the middle hemorrhoidal blood supply, thereby being a part of the visceral vascular system. Internal hemorrhoids, when protruding, can be returned within the rectum, while the external ones cannot. The venous turgescence varies in size from a pea to a walnut. They may be single or may surround the entire anal opening like a bunch of grapes.

Repeated attacks of engorgement of the veins involved, will in time change the mucous membrane or the submucous tissue, and cause catarrhal swelling of the mucous membrane, or hyperplasia of the connective tissue. At first the hemorrhoid is usually a blood tumor, but in chronic cases it is oftentimes made up largely of connective tissue. Owing to pressure of the varicose veins, atrophy of the mucous and submucous tissue may occur. The white or slimy hemorrhoids occur when these roughened parts of the mucous membrane become inflamed and thickened, resulting in suppuration.

=Symptoms.=—The symptoms are quite diagnostic and need not be mistaken. Besides the appearance of tumors, there may be constipation, pain during stools, indigestion, headache and pain in the back. Hemorrhages frequently occur, and if suddenly checked, as by cold, other disturbances may occur, as congestion of the head, lungs, stomach, liver, kidneys, etc., which may result in hemorrhages from these organs. Fissures of the anus, contraction of the rectal sphincters and prolapse of the rectum may occur. Occasionally in old people there is a varicose state of the veins of the neck of the bladder, and in females, of the uterus and vagina, which causes hemorrhages of these organs. The communicating plexus of the spinal canal may be affected, causing weight, numbness and pain, so as to simulate a lesion of the cord. The patient may have a hypochondriacal disposition and be disinclined to work, especially at mental labor.

=Prognosis.=—Depends upon the predisposing and immediate causes, but a large majority of cases can be cured.

=Treatment.=—A thorough examination of the patient should be made, not only to ascertain the extent of the local trouble, but to understand thoroughly the general health of the sufferer, especially the state of the heart, lungs and liver.

Many cases of hemorrhoids are caused by lesions in the lumbar and sacral regions, and especially dislocations of the coccyx (usually anterior) and the innominata. Correcting these lesions will oftentimes cure the hemorrhoidal disorder. Simple dilatation of the rectum once a week, in addition to other treatment, is of great aid in curing hemorrhoids, not a few of the cases being cured by dilatation alone. It relaxes the tissues about the tumefied vessels. Treatment is rarely necessary above the second lumbar, (unless there is more or less of a constitutional disorder) as the superior hemorrhoidal blood vessel of the inferior mesenteric is given off about opposite the second lumbar.

In cases where the abdominal walls have become relaxed, a treatment should be given to strengthen the abdominal muscles and viscera. Particular attention should be given the liver. Treatment should be given over the abdominal muscles directly, and also to the spinal nerves of the same region. The diet should be strictly regulated and the bowels kept loose, and stimulants, indigestible food, full meals and too much meat should be avoided. Injection of cold water before stools is a good prophylactic, and applications of cold water to the protruding pile will be of some help in relieving the congestion. A squatting position during defecation will relieve considerable strain.

=Hemorrhoids= in the =acute state=, within twelve or twenty-four hours from the engorgement, yield quickly to treatment. The local technique is to relax the tissues about the tumor, especially above and along the line of the vein, then with pressure at its base carefully force out the engorged blood. Follow this up by another treatment the next day and continue until normal. The vein wall, not being permanently stretched, will contract and if the irritating cause is found, there is little danger of return. Remember, in a case like this, the danger of embolism and be sure a clot has not formed. Cases of hemorrhage at stool, during or immediately following evacuation, when not from a bleeding pile, may be of considerable quantity and the source difficult to locate. It may be due to ulcerations or easily ruptured capillaries of the mucosa, but the cause will in many cases be found in the innominata and a reduction of the lesion give relief.

=Rectal conditions=, associated with piles, and =requiring surgery= after treatment has failed, are: =hemorrhoids=, which are of such long standing as to become organized tissue, (these will keep up continual irritation and cannot be absorbed); =saccules= or pocket, formed by folds of mucous membrane catching and holding particles of feces, gradually enlarging and ending with considerable reflex symptoms; =fistulae=, complete or incomplete, may frequently be healed by adjusting coccygeal or innominate lesions, but are apt to recur from the tract not being clean in the center or bottom; =abscesses= in or about the anus or rectum are usually traced to coccygeal, innominate, or local interference to circulation; =fissure=, complete dilatation under anesthesia to insure physiological rest of parts, is probably the best treatment. It is suggested that a fissure may be healed by making surgically clean, touching with iodine and coating with collodium. =Papillae= are small, hard black-capped papules in the lower rectum, each one involving a nerve terminal and causing much distress. All these conditions give rise to much discomfort and with surgical assistance can be cured without much trouble. It is not necessary to make them a major operation and do uncalled-for things. The less surgery about the rectal sphincter the better.

=Care= of the =anus= and =rectum= after operation or successful treatment is a factor in preventing return. First, there should be soluble, non-irritating stools, which do not tend to bring about prolapse from straining. Diet and regularity contribute to this. Second, absolute cleanliness. This can only be obtained by following the stool with an enema of four or five ounces of cool water and immediately passing it. It will bring forth a considerable quantity of feces which would otherwise have been retained for another twenty-four hours. This procedure following, as it does, the stool does not in any way interfere with the normal function or create a habit. The anus should then be thoroughly washed in cool water and as thoroughly dried. Dusting with borated talcum powder, starch, etc., will prevent chafing.

GENITO-URINARY

THE PROSTATE GLAND

This gland is subject to several painful and annoying diseases, controlling, as it does, the flow of urine and exerting such a profound influence over the sexual functions. The nerves to the prostate pass between the gland and the levator ani muscle, and the secretory branches are from the sacral nerves, while Quain gives the sensory as from the tenth, eleventh (twelfth) dorsal, first, second and third sacral and fifth lumbar. Lesions affecting the prostate are occasionally found at the tenth and eleventh dorsal and fifth lumbar, while the innominate lesions are common causes of trouble. These should be corrected, if present, and local treatment given to the gland. “Massage of the prostate,” says Lydston,[47] “properly performed, is one of the most valuable advances in genito-urinary therapeutics that has been developed in many years.” Osteopathic technique is to place the patient on the side, knees flexed, and standing in front insert the index finger. Care must be used not to bruise the gland and it must be touched lightly when sensitive. Relax tissue about the gland, and, then, from the median line with an outward movement, massage the surface of each lobe. This influences the blood and nerve supply, while the pressure will tend to relieve congestion. Length of treatment, as well as frequency, depends entirely upon conditions. Do not make the mistake of treating the perineum instead of the gland and do not gouge it with the finger. Remember it is sensitive tissue.

=Hypertrophy= is most commonly met with in practice, as twenty per cent of men past middle life are said to be afflicted. It is probably not a sequence of old age, but due to chronic, congestive and inflammatory conditions. Anything which would produce these conditions—spinal lesions, excessive venery, masturbation, or other more innocent causes—would in time bring about enlargement. As the length of catheter life is estimated at six years it is of great importance that the condition be early recognized, for in advanced stages surgery is the last resort. In early stages the prognosis is good, either for a cure or to stop further enlargement, while many enlarged ones at the catheter stage have been greatly benefited or cured. Treatment of the gland once per week is usually enough, but in older cases can be given semi-weekly. Look well to nerve and blood supply.

=Acute Prostatitis= is a serious and painful inflammation, causing urinary retention usually. It results from trauma, horseback riding, over exertion, gonorrhea and its maltreatment, etc. Lower dorsal and lumbar lesions are frequent. This condition must be closely watched. Inhibition of the sacral nerves will help control pain and stop any spasm of the sphincter. Cold applications to the gland externally at the perineum will aid in reducing inflammation. Local treatment should at first be given to the adjacent tissues as the gland will be very sensitive. Later direct massage will be of great benefit.

=Chronic Prostatitis= may follow an acute attack or it may originate as a chronic or subacute affection. Frequent micturition and dull pain, referred to the perineum and rectum, with the local examination, make diagnosis sure. The spinal lesions should be corrected and the gland massaged. This will induce absorption, by squeezing out the inflammatory products and do much toward preventing future hypertrophy. “Massage is done by the finger. The patient is placed in the knee-elbow position and massage employed for four minutes daily. The value of massage in chronic prostatitis is very great, but should be employed with much caution and never in cases of suppuration.”[48]

=Prostatorrhea= is often taken for spermatorrhea and any irritation of anterior sacral nerves would cause undue activity to the secretory nerves to the gland. This is easily determined.

=The Seminal Vesicles= can be reached just above the prostate, and if inflamed and tender or if engorged by inspissated seminal fluid, local treatment will be of benefit. Frequent massage, daily in some cases, to the gland and treatment to the sympathetic nerves above the trigone of the bladder, to the nerve fibres passing along the spermatic cord, and to the arteries directly, will be of the greatest aid in impotency.

In =Chronic Gonorrhea=, where the gonococcus has found lodgement in and about the gland, it can be more readily dislodged by massage than by any other form of treatment.

=Retention of urine= from nervous excitement or other minor causes, can often be overcome by local massage of the prostate.

=Spastic stricture= can usually be cured by work about the prostate and its innervation.

Varicocele

A varicose enlargement of the veins of the spermatic cord, epididymis and testicle. In varicocele the pampiniform plexus is usually enlarged, but all the veins of the cord may be involved. The swelling gets smaller under compression or in a horizontal position and enlarges again on standing erect. It is almost invariably found on the left side, and the testicle on the affected side is generally smaller and softer than its fellow.

The predisposing =causes= are a longer and tortuous spermatic vein on the left side; the absence of support of the veins from surrounding muscles; the imperfect valves; the entry of the left spermatic vein into the renal vein at a right angle, instead of at an acute angle like the right vein; the more liability of compression of the left spermatic vein by accumulation of feces in the sigmoid flexure; the lack of normal exercise of the sexual functions in young, unmarried adults. Lesions in lower dorsal and upper lumbar affect the condition; the eleventh dorsal particularly. A lesion at the second lumbar may cause neuralgia of the testicle with engorgement of the vein.

The exciting causes are straining during stool, heavy lifting, excessive sexual indulgence or anything that would determine more blood to the testicles. Varicocele is similar to the varicose state of the hemorrhoidal veins and may have like causes.

The =diagnosis= is easily made. The feeling of the veins between the fingers like a convolution of earth worms; dull, aching, dragging sensation, and possibly prostration, weakness and dejectedness of spirits, are characteristic symptoms. “The condition is devoid of danger, except that it often begets morbid fears on the part of the patient, usually the result of suggestion.”[49]

The =treatment= consists of regulation of the bowels, removal of such predisposing and exciting causes as may be found, treatment of the vessels along the spermatic cord, and treatment to the lower dorsal and lumbar regions. In severe cases a suspensory bandage will give temporary relief. Surgical interference may be necessary in some cases in order to effect a cure.

Impotency

Results from treatment in these conditions are particularly gratifying and offer a great field of activity in this day of sensational medical advertising. This condition can well be classed under four heads, Exhaustive, Traumatic, Psychic and Organic.

=Exhaustive Impotency= is the result of functional abuse, masturbation in early life, excessive venery, coupled with intemperate use of alcohol and improper diet without sufficient sleep. It can be symptomatic in neurasthenia. There is at first irritation of the spinal centers, which causes exaggerated sexual activity, and later this is followed by complete or partial loss of function. The first step is for a radical reform in habits; regulation of the bowels, as they will likely be constipated; direction of the mind into wholesome channels, and then skillfully directed spinal treatment. Where there has been masturbation, look well for sources of irritation to the parts; a long foreskin or adherent prepuce indicates surgical aid, or there may be a lesion at the sacrals involving the nervi erigentes or, of greater importance, the pudic nerve. The innominatum can be at fault in this. The lower dorsal, ribs and upper lumbar are of importance. Kraft-Ebing says: “Conditions of absolute impotency are, however, rare, and are caused =only= by severe vertebral and nervous diseases.” Nerve irritation undoubtedly is the cause of sexual perversion (outside of heredity and malformation) so their relief is as necessary to bring about reform of habits as to effect a cure. Where the general health is affected constitutional treatment should follow. Motschutkovsky uses suspension in treating these cases with good results. The effect is to separate the vertebræ, freeing spinal nerve and blood channels. The prostate will probably be found in an irritated, sensitive condition, as well as the seminal vesicles. Treat as outlined under the prostate gland. Ligation of the dorsal vein of the penis is recommended by some authorities as tending to aid turgescence of the organ. Prognosis is so dependent on how well the patient follows directions, age, environment and general condition that it is hard to give, but as a rule is rather favorable.

=Traumatic Impotency= is a strictly osteopathic classification, for the reason that sexual weakness is often traced to lesions resulting from remote injuries. These injuries may be to the spine, ribs or sacrum. The lower spine may be impacted from a fall or the result of long continued riding on rough streets or the railway. This inhibits the nerve supply to the extent of often seriously impairing the sexual functions. If the cord is injured to any extent the results are more serious. Treatment in these cases has given uniformly good results. It will always be due to a specific lesion, so the examination must be thorough.

=Psychic Impotency= is the form most frequently met with and generally the most difficult to cure, yet it should not be if the patient’s confidence can be secured, for in many cases sexual power is but slightly impaired, but owing to the suggestions given by the medical advertisers the victim diagnoses his own case as hopeless. “It is not uncommon that virility returns with the peace of mind.”[50] Observe all the procedure given and then inspire hope where it can be honestly given, and if the patient is progressing favorably, other things being equal, advise early marriage under strict rules of conduct. If already married, conjugal relations should be most carefully investigated and the wife taken into your confidence. Her cooperation in correcting very possible errors in sexual matters, as well as sympathetic aid in easing the patient’s anxiety and chagrin, will be invaluable. Nothing but the frankest understanding between all parties is permissible and the osteopath must be in absolute control.

=Organic Impotency= is the result of a cortical injury or disease. The latter is the most common, as it follows tabes dorsalis, paralysis affecting the lumbar cord, some cases of diabetes, etc. Also, any congenital malformations or absence of all or part of the organs. Prognosis in these cases is bad, as cure is seldom possible.

In no other class of cases will honesty, tact and good judgment count for so much or the rewards be greater.

FOOTNOTES:

[47] Twentieth Century Practice of Medicine, Vol. XXI.

[48] C. Kruger, Munch Med. Woch.

[49] Deaver’s Surgical Anatomy, Vol. II, p. 652.

[50] Vecki, Sexual Impotence.

HEAT STROKE

(Heat Exhaustion: Sunstroke)

An affection produced by exposure to excessive heat. Two varieties are recognized; heat exhaustion and thermic fever.

=Heat Exhaustion.=—This is caused by prolonged exposure to high temperatures, combined with physical exertion. Fatigue, overeating, alcoholic drinking, and poor sanitation predispose. This may occur without exposure to the direct rays of the sun, the heat being artificial, or in mid-summer, in close, confined rooms the same result will be produced. There is vasomotor paralysis, the surface of the body is usually cool, the temperature may be as low as 95 degrees F., while the pulse is small and rapid.

=Sunstroke= or =Thermic Fever=.—This is usually caused by prolonged work under the direct rays of the sun in a humid, very hot and sultry atmosphere. This is caused by the action of the heat upon the heart centers producing a paralysis of those centers.

=Pathologically=, rigor mortis develops early and is marked. Putrefactive changes appear early, owing to the high temperature of the cadaver. The various organs are deeply congested, the venous engorgement is extreme in the cerebrum. There is rigid contraction of the left ventricle; while the right is dilated and filled with blood. The blood is fluid and dark. Parenchymatous changes take place in the liver and kidneys.

In heat exhaustion with lowered temperature there is a paralysis of the vasomotor center in the medulla, and the heat is dissipated more rapidly than it is produced. In thermic fever the heat regulating centers become paralyzed by the action of the excessive temperature and more heat is produced, and less dissipated than normal.

=Symptoms.=—=Heat Exhaustion.=—This may occur gradually or suddenly with a severe attack of faintness, pallor, dizziness, headache, cold perspiration and sometimes blindness as the first symptoms. Consciousness is rarely entirely lost. In severe cases there is more permanent collapse. The pulse is rapid and feeble and there is great restlessness and delirium. Under prompt treatment mild cases may recover in a few hours, while in extreme cases death may occur almost at once from heart failure.

=Thermic Fever.=—In some cases the patient is struck down, becomes quickly unconscious, and may die within an hour, or death may be almost instantaneous. In other cases there is pain in the head, oppression, dizziness, nausea, vomiting and sometimes diarrhea or frequent micturition. Soon unconsciousness sets in, the face is flushed, the eyes injected, the breathing labored and there is a temperature of from 105° to 110° F. The pulse is full and rapid, the skin hot and dry and the pupils are contracted. There is usually complete relaxation of the muscles, and in some cases there is twitching and jactitation. Epileptiform convulsions are rare. In fatal cases the coma deepens, the pulse becomes feeble, rapid and irregular, the breathing hurried and shallow and death occurs in a few hours. Favorable cases are indicated by a fall in the temperature and by the return of consciousness. In these cases recovery may be complete. In some cases the patient may never be able to stand even moderate degrees of temperature, which often produce excitement, headache and pain in the cervical region. Failure of the memory, and the loss of power to concentrate the mind are sometimes sequelæ. Meningitis, epilepsy and insanity are also sequelæ.

=Diagnosis.=—This presents little difficulty. The history and circumstances preceding the attack are very important in making the diagnosis. The diagnosis between heat exhaustion and sunstroke fever is readily made. In heat exhaustion the temperature is =lowered=, the pulse is feeble, consciousness is rarely completely lost; in sunstroke fever the temperature is extremely =high=, there is usually complete unconsciousness, and the pulse is full and rapid.

=Prognosis.=—This should be guarded, depending upon the severity of the case.

=Treatment.=—In cases of =heat exhaustion= remove the patient to a shady place and apply water to the face, chest and spine. Thoroughly treat the upper cervical region, in order to control the impaired vasomotor centers and nerves. If the temperature is below normal a hot bath should be given. Keep the heart and lungs stimulated.

In =sunstroke=, place the patient in a recumbent position and loosen all constricted clothing, and stimulate the heart’s action. The high fever is to be met promptly. Place the patient in a bath of water, to which add ice freely. The patient may also be rubbed with ice, and ice water enemata may be employed. The muscles of the neck will be found contracted, probably due to cerebral hyperemia. A thorough relaxation of these muscles will be of great aid in equalizing the vascular system. It is a good plan to thoroughly relax all the muscles along the spinal column for the same purpose. When the temperature nears normal the baths should be stopped. After the temperature has been reduced place the patient upon a cot with ice to the head. The cervical treatment should be repeated as often as necessary. The diet of the patient should be liquid for a few days. Plenty of water and stimulation of the kidneys and bowels will be found beneficial. The sequelæ are to be treated according to the condition. Much can be done for the sequelæ of heat exhaustion and sunstroke. Lesions will be found corresponding to the regions involved. Deep contracted muscles are common.

DEPARTMENT OF OPHTHALMOLOGY

By C. C. REID

It is the desire to make this discussion on the eye the most useful possible to the whole profession. Let it be plainly understood that there is no effort to cover every phase of eye pathology but to elaborate eye diseases and therapeutics strictly from the standpoint of osteopathy. There are many very elaborate and extensive text books and even encyclopediæ written on the eye by the medical profession. The world of ophthalmic literature is extensive and profound. Just so are the elaborations on the general field of medicine. Such things as hereditary influences, congenital deformities, amblyopias, albinism, coloboma and the field of ophthalmic surgery does not concern us at the present time in an osteopathic text book. This department is dedicated to a scientific development of ophthalmic therapeutics along osteopathic lines of thought. Some things in the therapeutics of the eye concern all schools alike. For instance, proper cleanliness and antiseptic precautions in regard to the eye, dietetics, hygiene and the care of the general health. The same anatomy and many of the same methods of examination and diagnosis obtain in all schools. It is the intention to go into the opthhalmic therapeutic field in these discussions where osteopathy has a different outlook with a definite distinct reform to offer in the viewpoint of the anatomy, methods of diagnosis and the system of treatment.

How to Examine an Eye

It has been said that one should be a good general man in order to be a competent specialist. This is especially true in regard to ophthalmic therapeutics. Many systemic diseases have eye symptoms and pathology. The same blood and lymph that nourishes and bathes different parts of the body, also circulates in the structures of the eye. In the examination of the eye, heredity, occupation and environment are to be taken into consideration. Osteopathic lesions may exist from falls, strains, twists, blows, colds and exposure and impair the integrity of the metabolic processes of the eye through the nerve connections and blood supply and lay the foundation for a great variety of eye diseases. With these lesions existing about the neck and upper dorsal, it is only required to have some insignificant local irritant to start symptoms and cause pathology apparently out of all proportion to the etiology. It is important then that one understand the nerve centers and reflexes and the osteopathic logic underlying these conditions or else he must frequently work without a satisfactory explanation of the etiology and consequently be more or less unscientific in his treatment.

The eye examination should consist of the case history, the family history, inspection, osteopathic examination, especially from the fourth dorsal vertebra to the occiput and especial examination of the eye by inspection and other methods.

=1. The Case History.=—Thoroughness of the doctor, or the lack of it, will be readily displayed at this point. Every little thing, as far as possible, that has a bearing on the case should be observed and uncovered in the case history. The physician should want to know every fact that helps him to better understand his case. Patience in hearing the history will often be of great assistance. It gives light on the physical and mental condition of the patient. Much can be gained by being careful and attentive. Notice carefully what he emphasizes and what he thinks is the most important. Inquire in regard to headaches, nervous symptoms, previous eye trouble and past illnesses. Get a venereal history if present, as many eye diseases are complicated or caused by syphilis or gonorrhea.

=2. The Family History.=—Inquire as to blindness in the family and about the age it occurred, if any. Get a venereal history if possible.

=3. Inspection.=—Much inspection can go on while the history is being taken. Observe the countenance, whether there is strabismus or frowning due to eye strain, photophobia as suggested by the effort to avoid the light; note symmetry. Look closely at the lashes, lids, conjunctiva, cornea and iris. Note any scales or crusts on the lids at the root of the lashes. Turn the lids for further inspection. Note the size and relation of the eyes. Exophthalmos may be due to an enlarged globe in high myopia, to Graves’ disease, orbital tumor and paralysis of the extrinsic muscles, or staphyloma. In blepharospasm there may be a corneal ulcer or a rupture of the eyeball. An exact examination must be made at the first visit in order for a diagnosis to institute the best treatment possible. Study the conjunctival sac for congestions, hypertrophy, swelling, tumors, foreign bodies, trachoma bodies and secretions. In all forms of conjunctivitis the congestion is most marked in the fornix and decreases toward the sclerocorneal junction. In iritis and cyclitis there is a circumcorneal injection, a pink or red color radiating from the cornea. Note any corneal pathology in the way of ulcers or abrasions and foreign bodies. Compare the tension of the eyes.

=4. The Osteopathic Examination of the Eye.=—This heading is put here in order to show what osteopathy has to offer that is distinct as belonging to our system and not practiced by any other school. Osteopathic research so far has shown that osteopathic science has much to offer on etiology and diagnosis and treatment in eye diseases. The case history, family history and inspection should require but a few minutes but they are essential to a proper examination and may aid us in what to expect osteopathically. Weak nerves will cause asthenopia. A broken arch, an innominate lesion or a slipped axis may cause weak nerves. The osteopathic eye examination then should consider the whole mechanism of the body. In case glasses are being worn for asthenopia they may readily be made unnecessary by osteopathic treatment in the correction of the lesions and building up the system. Some time ago some parents sent their daughter to me to have her eyes fitted for glasses. They stated that she had been to different doctors and opticians and no one had ever given satisfaction. They said she was all right every other way if her eyes were properly fitted with glasses. They did not want her examined or treated otherwise because she would be well every other way with correct glasses. Her vision was right eye 5-20, left eye 5-15 or about one fourth vision in each eye. A plus .87 diopter sphere combined with a plus 3 diopter cylinder in axis 90 gave her perfectly normal 5-5 vision in each eye. This gave her perfect satisfaction until she started to school in September, a couple of months later. Before the end of the first month she was having trouble with her eyes and was again sent to me by her parents. Her vision was reduced to 6-15 in each eye with her glasses on. She wondered and no doubt the parents did, if it was not another case of a misfit in glasses similar to all her previous experiences. This time I insisted upon a thorough physical examination against all protest. The following lesions were discovered: the left innominate was up and back or tilted posteriorly, first lumbar anterior and to the right, sixth and first dorsals to the right. The case was not refracted again. I took particular care the first time and I was quite sure the refractive error was corrected. It was all explained to the parents and regular osteopathic treatment was begun. In less than a month practically every lesion was corrected, her vision returned to normal and she also was cured of an annoying backache with which she had been bothered for years. Her nerves were depleted a great deal. She got benefit in ways that she had not dreamed of. This approach to the eye is not considered by physicians in general, even the oculists. I have had about ten special courses in medical colleges and hospitals on the eye, ear, nose and throat, and I have never heard anything mentioned that would indicate any ideas of the logic involved in this case. Surely osteopathy has much to offer in eye troubles that is new and unique. The osteopathic examination of the eye then should begin with the feet, going then to the innominates, lumbar, dorsal, ribs and cervical regions. Oculists are too prone to rely upon crutches (glasses) in the treatment of asthenopia.

It is easy for the osteopath to conceive how lesions of the upper dorsal and cervical regions may occur and disturb the nerve and blood supply to the eye. This is why asthenopia appears so frequently with ordinary use of the eyes, even without abuse or refractive errors.

The Lumbar Region

The lumbar region should be carefully examined, especially for any curvature which might cause a disturbance of the equilibrium above. Compensatory curves or individual lesions would be the result with a consequent interference with the integrity of the nervous reflexes to the eye.

The Dorsal Region

The same may be said of the dorsal region as of the lumbar in regard to curvatures. There is one individual lesion in this region that very frequently exists with eye troubles, i. e., the 2nd dorsal vertebra lateral. Any of the upper four dorsals in lesion may be a causative factor in predisposing to disease of the eye but it has been my observation that the 2nd is involved most often. In severe headaches due to eye strain from refractive error, a good diagnostic symptom is tenderness and contraction at the 2nd dorsal even when there is no subluxation.

The Cervical Region

This region should have particular care in search for individual lesions. It is quite easy to pass over some small cervical lesion that may be causing serious disturbance, especially if the neck happens to be fleshy. I have corrected cervical lesions and stopped twitching of the eyelids (orbicularis palpebrarum) and other muscles about the face.

The first case I ever saw was twenty-two years ago when I was a junior at Kirksville. Dr. F. P. Millard, now of Toronto, was a room mate of mine. He was constantly annoyed by a twitching of an eyelid. I did not find any lesion for it. We went one day to see Dr. Still at his home and told him of our difficulty. He said without examination that the 3rd cervical was in lesion. There was a senior student present whom the “Old Doctor” directed how to use the proper technique. There was a sharp pop, the vertebra evidently went into right relation, the twitching stopped. I understand the patient has had very little trouble since.

Injuries, exposure and strains to the spine may have antedated an innominate lesion and caused weak joints, muscular and ligamentous tension, local inflammations and partial immobilization of joints. All this would have its modifying effects upon the manifestation of secondary lesions from the innominate abnormality. This makes the study of the bony relations very complex and the effect upon the numerous blood vessels, nerves and other soft tissues still more complicated.

The Ciliospinal Center

Following osteopathic examination and giving proper importance to lesions below the fourth dorsal vertebra, we must remember a special significance to be attached to lesions of the =upper dorsal= in relation to the eye.

Almost any author on nervous diseases or diagnosis will discuss this center. Many of us have it not sufficiently impressed, hence I repeat some known relations. The =ciliospinal= center consists of a nuclear group of cells in the lateral horn of the last cervical and two upper dorsal segments of the spinal cord. From this nucleus fibers pass to the anterior division of the eighth cervical and first and second dorsal nerves and become the white rami communicantes which are efferent in their function. These fibers pass to the =inferior cervical sympathetic ganglion=, thence upward with the sympathetic trunk through the =middle= and =superior cervical sympathetic ganglia=, along the carotid plexus to the vessels of the face and eye, to the glands of that region, to the unstriped muscular fibers of the levator palpebræ superioris and to the =dilator pupillae muscle=.

Any strong feeling or emotion (which of course is perceived and interpreted by the brain cortex) will cause a dilatation of the pupil of the eye. The cervical sympathetic being cut, dilatation does not take place. The rami of the cervical, first and second dorsal cut, the phenomenon stops. It is evident the ciliospinal center is under the influence of a center or centers in the brain. Bing says “There is even an idiomotor mydriasis, which may be brought about by a very vivid mental conception of darkness.”

It has been noted that paralyzing lesions of the cervical sympathetic, of the last cervical and two upper dorsal segments of the cord, and of the anterior roots and rami communicantes of the same, will result in myosis.

The efferent rami are also vasomotor, secretory and trophic. It must necessarily follow that congestive and inflammatory conditions, secretory perversion of the lachrymal, Meibomian, Zeissian and perspiratory glands, and disturbance of the normal nutrition of any of the orbital tissues may result from lesions of the lower cervical and upper dorsal vertebræ.

Osteopathically we know that such a lesion may not be sufficient to be paralytic in its effect, but stimulatory. In this case we may note a pupil habitually too wide and more or less photophobia from a superabundance of light. The unstriped muscle fibers in the levator palpebræ superioris may be unduly contracted making an appearance of a slightly bulging eyeball when it is only a wide open eye.

One who has eye strain from a refractive error, overuse of the eyes, or unbalanced muscles will as a rule have tenderness at some spot in the region of the =ciliospinal= center. A mechanical lesion at that part of the spine may or may not exist in such conditions, but I believe the soreness is there every time. This is one of the diagnostic points in differentiating =headache= of eye strain from other conditions.

White rami are only in the dorsal region and to the second lumbar and from the second, third and fourth sacral. It has been noted that lesions of the cervical vertebræ do not have as profound an effect upon the eyes as do lesions of the first three dorsal vertebræ. The plausible explanation of that is that the cervical vertebræ have no white rami from their corresponding nerves in the bulbo-spino-sympathetic-ciliary arc as have the upper dorsal.

From all the foregoing statements one can readily contemplate the intricate complexity of our osteopathic problems in relation to the eye. Combine this logic of the lesions outlined and the ramifications of the structures with their normal and perverted functions and combine it with contributing causes, such as infection, exposure, irritants, etc., and amidst the great diversity we reduce much miscellaneous, unclassified material to a degree of simplicity. Many otherwise unexplainable conditions become reasonably clear.

Dr. Louisa Burns under “The Experimental Demonstration of Osteopathic Centers” has this to say:

“Somatic Reflexes”

“In the first series of experiments, the electrodes were placed upon the nasal mucous membrane of animals under anesthesia. The muscles near the third thoracic vertebra were at once strongly contracted....

“The electrodes were then placed upon the conjunctivæ. The muscles near the second vertebra were then contracted. There were also slight and inconstant contractions of the cervical muscles....

“The electrodes were placed upon the eye ball. The muscular contractions were sometimes noted near the second thoracic vertebra, but the reaction was not constant. The cervical muscles were scarcely contracted at all.

“The electrodes were placed upon the outer surface of the eye lids. The facial muscles were contracted very quickly and forcibly, but no contraction of the muscles of the upper dorsal region were noted....

“The =superior cervical ganglion= was exposed to view, and the electrodes placed upon it. The pupils became greatly dilated, the conjunctivæ became lighter in color, and the mucous membranes of the nose and throat were also lightened....

“The =Gasserian ganglion= was exposed to view. The ganglion was stimulated directly. The upper thoracic muscles were very strongly contracted, and the blood vessels in the area of the distribution of the fifth nerve were immediately and strongly contracted. Some of the sympathetic fibers are carried by way of the fifth nerve. In order to exclude the effect of the direct stimulation of these fibers, the fifth nerve was cut, and the central end was stimulated by the electrodes. The muscles of the upper thoracic region were contracted, as before. The vessels in the area of distribution of the fifth nerve were contracted after latent period of a minute or so....

“The stimulation of the central end of the cut fifth nerve caused strong muscular contractions in the upper thoracic region, and also constriction of the vessels in the area of distribution of the fifth. Direct stimulation of the superior cervical ganglion produced effects identical with those produced before the mutilation.

“The spinal cord was cut above and below the superior cervical ganglion. This cut was made from behind, and the sympathetic chain was uninjured. The effects noted after both operations were the same, and can be described as one.

“The stimulation of any cranial structure failed to cause reflex contraction of the muscles in the upper dorsal or the cervical region.

“Stimulation of the cranial structures did not produce any vascular changes except those which might be referred to the direct effects of the electricity upon the vessel walls.

“Direct stimulation of the =superior cervical ganglion= produced the effects noted before mutilation.

“Therefore the cervical portion of the spinal cord is an essential element of the reflex arc by way of which sensory impulses from the cranial structures are able to affect the condition of the upper dorsal muscles, and also in the path by which these impulses are able to affect the size of the blood vessels of the cranial structures themselves....

“Mechanical stimulation of the tissues near the second thoracic spine was followed by a contraction of the blood vessels of the cranial mucous membranes and the conjunctivæ, by a dilatation of the pupils, and an increased secretion of saliva. These effects were practically invariable....

“The superior cervical ganglion was subjected to mechanical stimulation by the manipulation of the tissues over it. In animals, this maneuver was followed by dilatation of the pupils and by a contraction of the cranial vessels, which was soon followed, if the stimulation continued, by a dilatation which was rather persistent.

“After the =extirpation= of the =Gasserian ganglion= without the injury of the sympathetic nerves, the mechanical stimulation of the tissues near the second and third thoracic vertebræ caused the same vaso-constriction and =pupilo-dilation= as was observed in the animal before mutilation.

“After the destruction of the cervical portion of the sympathetic chain, and after the extirpation of the Gasserian ganglion in most animals, the mechanical stimulation of the tissues in the upper dorsal region did not produce any perceptible effects....

“Mechanical stimulation of the tissues near the second and third thoracic spines caused dilatation of the pupils and contraction of the vessels of the cranial mucous membranes.

“Inhibition, or the maintenance of an artificial lesion, caused dilatation of the vessels of the nasal mucous membranes and of the conjunctivæ. The eye ball was also somewhat congested. The pupils were dilated in this case also.”

The Nose and Throat in Eye Trouble

An examination of the eye would not be complete without a careful inspection of the =nose and throat=. The same nerve and blood supply that go to the eye is tied up so definitely with the nose and throat that when there are lesions of the nose and throat the eye is often affected secondarily. Just recently a case of =dacryocystitis= came into my office. After I had carefully examined her eye, spine, nose and throat, she informed me that she had been to three eye specialists before and not one of them had ever looked at her nose and throat, not to mention the spine. She had cervical and dorsal lesions, and =diseased tonsils=. The =inferior turbinate= on the side of the dacryocystitis was curled out so that it lay against the external wall of the nose almost if not altogether blocking the entrance of the =lacrymal duct= to the inferior meatus. This was evidently the predisposing cause of her dacryocystitis.

In =neuralgia= of the eye, =blepharitis=, =obscure pain=, =conjunctivitis= and often deeper troubles you will find a bad condition of the =nasopharynx=, such as adenoids, vegetations, pus pockets, adhesions in the fossa of Rosenmuller, contraction of the soft palate, disturbed relations of the septum and turbinates, sinus trouble, poor drainage, exostoses and polyps. In eye disease all these things should be discovered if they are present, in order to get best results and in order to make a careful diagnosis.

Examination of the Eye by Special Methods

The first thing after the family history, personal history, inspection of the eye and the osteopathic examination, is to find out how well the patient can see. To test the acuteness of vision certain test letters are used. Snellen’s Test Letters are good. The normal eye can read 3-8 inch letters at twenty feet. The test letters on the cards usually range in size to be read at 10, 15, 20, 30, 40, 50, 70, 100 and 200 feet. The most desirable distance is 20 feet. If at the distance of twenty feet he reads the 3-8 inch letters his acuteness of vision would be marked 20-20 or normal. Always use the distance between patient and chart as the numerator of the fraction and the number above the letters which he reads as the denominator. If he is twenty feet away, the numerator remains twenty and the denominator changes according to the line of letters seen on the test cards thus: 20-15, 20-30, 20-70, or 20-200 may express the vision. If the patient could not see the 200 feet letters at 20 feet he must be brought nearer, say 10 feet, for him to see the large letters; his vision would be 10-200. These fractions representing the acuteness of vision may be expressed in meters. Some charts have letters numbered that way.

If the vision is good enough for small objects to be clear, the near point should be taken. This would show the amount of accommodation of the eye. This is expressed in diopters.

A =diopter= is the unit of measurement of the =refractive= power of lenses. =Lenses= are numbered by their refractive power in diopters. A lens that has a curvature that will refract parallel rays of light and bring them to a focus at one meter distance is said to be a one diopter lens. This unit of measurement for the refractive power of lenses was proposed by Nagel in 1866. It soon became quite generally used.

The focal distance of a lens decreases as the strength of a lens increases. One diopter lens (written 1 D) has a focus of one meter (1 M) or 100 cm distance. A 2 D lens has a focal distance of ½ M or 50 cm. A 4 D lens has 25 cm focal distance and a ½ D lens has 100 cm ÷ ½ = 200 cm distance or 2 M. Trial cases have in them lenses varying in strength from .12 D or .25 D to 20 D of the spheric form. We will not discuss the trial case here.

Accommodation in the Eye

=Accommodation= in the eye is the ability of the eye to vary its focal point. When the normal eye (emmetropic) is at rest its focal point is at infinity so far as parallel rays are concerned. This is called the far-point or the “=punctum remotum=” (P. R.).

When the eye looks at letters twenty feet away it scarcely accommodates at all to get a focus, or so little that it may be disregarded in ordinary practice. Now if one brings fine print close to the eye he will find a point so close that it becomes indistinct. This point is the near-point of focus or the =“punctum proximum”= (P. P.). The range of accommodation is the difference between the refractive power of the eye when it is at rest and when the accommodation is exerted to the utmost, the difference between the P. R. and the P. P.

If one must accommodate one diopter to get a focus at one meter or forty inches distance, at thirteen inches or reading distance one must accommodate at least 3 D in order to see the letters clearly. If 3 D were the total of his accommodation he could not read at that distance but a few minutes; because the accommodation could not be held at its maximum for long at a time. Eye strain with its train of symptoms would result. Hence it is quite important to find the near-point or punctum proximum in order to judge in regard to eye strain in an emmetropic eye. If there is a refractive error, allowance for it must be made accordingly.

As a person gets older the accommodation in the eye becomes less and less until at 45 years of age he can only use 4 to 5 D of accommodation. This is so close to the amount required for reading that he has some eye strain. He begins to hold his paper farther away from him so he requires less accommodation. This condition we call “old sight” or =presbyopia.= An emmetropic eye at forty-five to fifty years of age requires a plus glass to make up for some accommodation in reading.

Frequently there are latent disturbances of equilibrium of the extrinsic muscles of the eye. This is =heterophoria.= If it is a latent convergence it is =esophoria=; if a latent divergence it is =exophoria=. The latter is more frequent. Hyper- and hypophoria are used for upward or downward tendencies. Normal muscular balance is =orthophoria=.

Cause the patient to fix on an object about thirteen inches away with both eyes; push a sheet of paper in front of one eye and watch behind the paper, the eye thus covered. If heterophoria exists the eye will move slightly from its point of fixation since it no longer sees the object. In orthophoria it will remain fixed as long as the other eye sees the object; the innervation to the different muscles is properly distributed.

A Maddox rod found in any complete trial case may be placed before one eye. Have the patient fix on a candle flame, say twenty feet away. The flame appears drawn out into a luminous line. This line can not be fused with the candle flame as the other eye sees it if there is heterophoria. The amount and kind of disturbance is somewhat indicated by the distance and direction of the luminous line and the flame. The exact amount can be measured by the use of a prism that will cause them to fuse.

Next the patient should be taken to the dark room and a careful inspection of the anterior segment of the eye should be made with oblique illumination. First use the unaided eye, then use a lens that magnifies. The 20 D plus lens from your trial case will suffice for the magnification. Note the transparency or lack of it in the cornea and crystalline lens; the depth of the anterior chamber and the appearance of the pupil and iris. Now we are ready for the ophthalmoscopic examination.

=The Ophthalmoscope.=—This is an instrument that commands great respect. Any one who is interested in eye troubles must have and use the ophthalmoscope if he expects to be efficient in diagnosis, upon which, of course, intelligent treatment must forever depend. One must try and try again in order to become proficient in the use of the ophthalmoscope.

A Schematic Eye is of great assistance to a beginner who does not have clinics or patients on whom to practice. Such an eye with full directions can be obtained at almost any optical goods store. It will make the study of ophthalmoscopy easy and interesting. The pupil can be regulated to any size and the eye can be made short (hyperopic), long (myopic) or normal (emmetropic) for study.

The efficient use of the ophthalmoscope makes the diagnosis of internal diseases of the eye as easy as the diagnosis of external diseases of the eye. Only some rare conditions will puzzle, and that is true of any part of the anatomy.

The ophthalmoscope is a simple instrument; its chief function is to illuminate the interior of the eye. The value of ophthalmoscopic findings depends on their correct interpretation by the examiner.

The ophthalmoscope has a mirror to reflect the light into the eye. It has two discs on which are mounted convex (plus) and concave (minus) lenses. The larger disc has seven plus and eight minus lenses. To these may be added the lenses in the smaller disc making many combinations.

A drop of a 2% solution of cocaine or homatropine may be used as a mydriatic where one can not otherwise see clearly the fundus. If no mydriatic is used a somewhat weak illumination should be employed in order not to arouse the accommodation to much activity and make the pupil small. If there is any opacity in the media a strong illumination should be used. The room should be dark; the darker the better.

There are two methods of using the ophthalmoscope. The =indirect= and the =direct= methods. One is more useful at one time and the other at another time. By the indirect method we view the whole field of the fundus more readily but less in detail. With the ophthalmoscope before his eye the examiner’s face is twelve to fifteen inches from that of the patient. When the “=red reflex=” of the eye is seen a plus 13 or 16 D lens is interposed near the patient’s eye. This magnifies the field. The image is inverted. As a rule it is best seen with a +4 D lens in the aperture of the ophthalmoscope.

This method is especially more satisfactory in high degrees of myopia and astigmatism. The =optic disc= is the objective point. One may see a retinal vessel first; this should be followed to its emergence from the disc. From this point view all parts of the fundus by having the patient look in different directions. This is better by the indirect method than for the examiner to vary his position.

The direct method of ophthalmoscopy is better for detail work and in all cases except high degrees of myopia and astigmatism. It is also better in determining errors of refraction. The patient looks straight across the room. For a beginner it may be essential to dilate the pupil, hence the schematic eye as suggested.

If the examiner has a refractive error, he should wear his own glasses or correct by throwing in front of his eye proper lenses in the ophthalmoscope. Face the patient and sit on the side of the eye to be examined. Use left eye to examine the patient’s left eye and right eye for the patient’s right. Examiner and patient keep both eyes open. The examiner may not be able to suppress the image of his other eye and may have to close it part of the time. Catch the “red reflex” some 15 to 18 inches away and move close to the patient’s eye. The “red reflex” color varies with the error of refraction, the transparency of the media, the degree of pigmentation and the size of the pupil. A blood clot will make it redder, some exudates will make it gray or yellow.

The examiner may approach as close as half an inch from the eye to be examined. Find the optic disc and examine all points of the fundus from it. Rotate in glasses to correct the patient’s refractive error if he has any. The strongest plus glass with which the fine retinal vessels can be clearly seen will represent the =hyperopia= of the eye. This is true only if the examiner’s accommodation is at rest. The weakest minus glass with which the fine retinal vessels can be clearly seen represents the =myopia=.

=A Normal Fundus.=—The color of the fundus is due to the blood vessels of the retina and choroid and the connective tissue of the choroid and sclera. Variation is due to the pigment. In the albino it is light pink. In the negro it is dark reddish. There are all gradations between the two.

The =optic disc= is the end of the optic nerve as it comes into the eye; it is circular in shape, pink in color, and sharply defined. It is about 1-16th of an inch in diameter; about 15° to the nasal side of the pole of the eye and slightly above the horizontal. There may be a dark =choroidal ring= around the disc or part way around. There may also be a white ring caused by the sclera. As a rule there is a depression in the center of the disc out of which the retinal vessels emerge and spread out over the fundus.

The =fovea centralis= or point of clearest vision is located two and a half disc diameters to the temporal side of the disc. Around this is a circular area of light yellow, the =macula lutea=.

The subject of ophthalmoscopy has been touched upon somewhat in detail because of its great importance to the general practitioner. Every osteopathic physician should know the ophthalmoscope well enough to recognize the ordinary lesions inside the eye. When we take up pathological conditions of the eye we will have occasion frequently to refer to the ophthalmoscopic appearance. Without the use of this instrument all of our clinical field research on internal diseases of the eye is valueless. Many have told me they have cured cataract with osteopathic treatment, some say they have cured specific neuroretinitis with no sequelæ, others testify to opacities and blindness from various causes. Invariably we ask if they used the ophthalmoscope in their diagnosis and with it watched the progress of the case. Almost invariably the answer is “no, it looked like it,” “the symptoms indicated it,” or “Dr. so and so, an oculist diagnosed it as such.” Fellow Osteopaths! we can not base our claims on this kind of data. With a little study and practice the ophthalmoscope can be mastered. Not till then can we get reliable statistics on internal diseases of the eye in our case reports. Osteopathy has much to reveal to us in this field and for the sake of the science and our patients we appeal to every one to do the work here set forth.

Diseases of the Eye

OSTEOPATHIC MANIPULATION FOR EYE DISEASES

A general correction of lesions should be made in order to give perfect alignment and equilibrium. Lesions that affect the nerve and blood supply will be found from the fourth thoracic to the occiput; more often at the occiput, atlas and axis in the cervical region and the second and third thoracic in the dorsal region including the ribs.

Correction of these lesions must have specific attention in every case of eye disease that shows any tendency to chronicity or in repeated eye disease and exacerbations.

A thorough upper spinal treatment to insure good mobility of all joints and establish freedom of fluids and forces is recommended.

The =nose=, throat and =sinuses= should be examined for pathology. If the tonsils and pharynx are not normal the cotted index finger should be introduced into the mouth until the anterior pillar of the fauces is reached. A mouth gag may or may not be used. Massage the tonsil through the anterior pillar then move to the top and press down on the tonsil with a pumping motion. Repeat this from below the tonsil and posteriorly. Slip the finger under the soft palate and stretch it thoroughly. Clean out any adhesions and vegetations in the vault of the nasopharynx and fossa of Rosenmuller. Stretch the pillars of the fauces by pressing down on each side at the root of the tongue.

If the sinuses are diseased they should be drained. If the nose is diseased and has abundance of secretion, first use irrigation for cleanliness.

Manipulation in the nose will be of great benefit in some eye diseases as pathology there frequently has an important bearing on diseases of the eye. The nose is often too narrow and contracted. The first inch of the nose is muscular and cartilaginous; it is of even more importance to dilate the nose in contractured conditions than it is the sphincters at the lower end of the rectum. The great benefit derived from rectal dilatation has been recognized for years.

In dilating the contracted nose a wide blade nasal speculum may be used. The cotted and oiled little finger may be used where it is properly adapted in size. The dilating can be done with practically no pain and no damage to membranes or other tissues. It should not be extended beyond the cartilaginous and muscular part. Manipulation of the turbinates and tissue further back may be done if needed, by the use of instruments. The Edwards turbinate adjuster instrument (Aloe Co., St. Louis) or the Ruddy Nasal Third Finger (Sharp and Smith, Chicago) are the best instruments so far devised for this operation.

A thorough stretching of the =eyelids=, manipulation of the =eye ball= and the points of the fifth nerve are indicated in many diseases.

The lids may be stretched by pulling them from side to side. The cotted forefinger well oiled (sterile vaseline) may be slipped into the conjunctival sac back of either lid and with the thumb on the outside the lid may be massaged or stretched in any direction. The points of the fifth nerve may readily be influenced at their respective exits about the orbit. The eye ball and deeper contents of the orbit can be profoundly treated by pressing the finger into the orbit above, below and at the sides of the bulb and pushing it in all directions as far as possible. The Ruddy eye finger instrument was devised for this deep manipulation of the orbital and bulbar structures. It is of high value. One finger may be laid on the closed eye and with a tapping motion with the other hand a vibration or oscillation of the orbital structures may be had. This is a useful treatment.

The wise selection and skillful use of these various methods of treatment for the eye will solve most of our difficulties.

This short survey of osteopathic methods will aid us in the more specific discussions to follow.

Neuralgia

A considerable number of people seem to be subject to attacks of pain in one or both eyes. These attacks of pain come at varying intervals; in some cases several times a day, in others as far apart as one or two weeks. The pain will suddenly start almost without warning and with very little provocation, and last from one to twenty-four hours. It is very severe and the patient frequently thinks something terrible is wrong. Something terrible is wrong so far as his comfort is concerned. But in these cases to which I am referring there is no organic trouble with the eye. The patient does not need glasses. There is no sign of inflammation. Vision is not disturbed. Local examination of the eye with the ophthalmoscope reveals that the fundus of the eye is normal. There is no symptom connected with the eye except pain, occasionally accompanied by a slight redness. I have had several cases in my own practice and my attention has been directed to cases of other physicians.

These cases differ from tic douloureux in that there is no muscular spasm. In fact, motor nerves do not seem to be involved. The involvement seems to be largely in the =fifth cranial nerve=, usually the supraorbital, or other smaller branches of the ophthalmic division of the fifth cranial. Sometimes we note slight dilatation of the pupil with more or less congestion. This would indicate an involvement of the sympathetic branch to the eye.

The lesions discovered in these cases have been a subluxation of the occiput upon the atlas or an upper cervical lesion and frequently some involvement at the second dorsal. There has been noted also trouble in the nasopharynx such as contractures of the muscles of the soft palate and adhesions in the fossa of Rosenmuller.

Misplacements of the uterus have also been found in some cases.

Treatment

Nearly all these cases are curable with from one week to six weeks treatment. Of course the treatment must be intelligently directed after a correct diagnosis as to the cause. The cause can usually be removed. One case to which my attention has been directed was that of a woman about forty years of age who had very severe pains. With all the local treatment of the eye and otherwise she got practically no results until she had replacement of the uterus, which brought immediate relief. Other cases have no trouble on that kind but have lesions of the cervical region and on correction of these lesions the neuralgia disappears. Other cases have had the nasopharynx cleaned out by the finger operation and the stretching of the soft palate which relieved the neuralgia immediately or in a few days. Numbers of cases have been to medical physicians and had various eye remedies administered locally with no permanent benefit. Of course the treatment was administered at the wrong place.

The ramifications of the sympathetic and fifth cranial nerves are so complex and far-reaching that we must keep in mind that one or more of many causes for the trouble may exist and be quite remote from the seat of the pain.

Diseases of the Eyelids

Occasional factors are bee stings or insect bites, which completely occlude the palpebral fissure. We may have some palpebral edema from lid abscesses, chalazion, hordeolum, dacryocystitis, panophthalmia and so forth. In =hemorrhagia subdermalis= there is so much spongy tissue beneath the skin about the eye that the blood extends easily and far. The red tint will soon change to a reddish blue and then become dark, what is known as a black eye (ecchymosis). This frequently results from a blow. The skin is sharply attached around the orbital margin by tense connective tissue so the area of the hemorrhage is limited to the region of the orbit. There may be spontaneous rupture of some of the vessels by hard sneezing or coughing, especially in young children. In older people it may indicate a fragile condition of the vessels, arteriosclerosis or some trouble with the kidneys. The diagnosis of the eye condition is not difficult but the cause of the hemorrhage in that region might be investigated further. Local treatment is of some value in these conditions. They may be soothed by cold compresses. In bee stings and insect bites use an alkaline compress. Manipulation about the eye and osteopathic treatment of the neck with a view to directing a better circulation to that region will aid much.

Herpes Zoster Ophthalmia

This affection of the supraorbital branch of the fifth cranial nerve may extend to the eyelids. It may not go beyond the stage of blistering and redness with some edema. However, it is possible for it to become gangrenous and even extend to the conjunctiva and cornea. I had one case of herpes zoster gangrenosa of this region. There were several gangrenous spots as large as a dime on the forehead and extending down in the region of the eyelid. The process extended to some extent on the cornea and in healing left a condition of irregular astigmatism.

=Treatment.=—The prognosis in herpes zoster is always favorable under osteopathic treatment. Lesions of the cervical region will almost invariably be found interfering with the sympathetic connections of the fifth cranial nerve causing the trophic disturbance to the region. Osteopathic treatment applied to these conditions will always hasten normalization. The affected part might be kept covered with some soothing lotion to keep the skin soft.

Hordeolum

This is commonly known as a =sty=. It is due to suppuration of the =glands of Zeiss=. It is a harmless affection but causes pain and inconvenience.

=Diagnosis.=—Swelling and pain with a small inflammed nodule in the palpebral margin is quite diagnostic.

=Treatment.=—The circulation is obstructed in this region. The effort should be made to open the circulation before pus has formed. This can frequently be done and the hordeolum aborted by carefully picking up the eyelid and rolling the nodule between the fingers. This will cause some pain but if it is kept up for a moment or two about every hour through the day with an occasional thorough treatment of the neck the sty will usually be aborted. If pus forms it should be opened as soon as it points and then the squeezing and rolling process may be employed again, which will aid rapidly in the freeing of the circulation.

Chalazion

This is a =Meibomian cyst= in the eyelid. It shows as a circumscribed swelling on the inner side of the lid. It frequently becomes large enough to produce some deformity of the lid. A chalazion is movable on the tarsal cartilage. It is a chronic condition and the cyst may become as large as a bean. There may be more than one in the same lid.

=Treatment.=—When a chalazion is small and not of long standing it can frequently be cured by osteopathic treatment. Introduce the finger into the conjunctival sac under the lid, and with the thumb externally, grasp the chalazion between the finger and thumb; roll it thoroughly. Squeeze and massage it two or three times a week for awhile. This, combined with a thorough treatment of the neck, will result in a cure. If at the end of six weeks the condition has not disappeared surgery should be resorted to.

Blepharitis

This is an inflammation of the eyelid. It is either =acute= or =chronic= according to the cause. Acute blepharitis may be due to heat or injury. Chronic blepharitis affects the glands of the lid causing a perversion of the secretions. There is usually the formation of crusts and scales. This condition is known as =blepharitis sicca=. In some cases infection will form little pustules at the roots of the cilia. There is soreness and aching. There may be photophobia. The nasal region may be involved. Osseous lesions of the cervical region are usually present. Refractive errors frequently exist in these cases. Occupation or environment may expose to dust or wind sufficient to keep up the irritation.

=Treatment.=—Change environment. See that there is thorough cleanliness of the lid. Rub or pick away all scales. Use a bland ointment. Correct any cervical or upper dorsal lesions.

Ptosis

This is =congenital= or =acquired=. In congenital ptosis operation seems to be the only treatment. Acquired ptosis is amenable to treatment frequently. The cause is some lesion interfering with the passage of proper nerve force to the levator muscle of the lid. The lesion may be at the origin of the third nerve, at the cortical nucleus in the sigmoid gyrus or in the trunk of the third nerve, or a lesion of the muscle itself. Tumor, trauma, syphilis, sclerosis, hemorrhage, gout or rheumatism, or anything that will produce a peripheral neuritis are causative factors. Lesions of the cervical and upper dorsal by reflecting back upon the nerve centers may produce a ptosis.

=Treatment.=—Remedial measures according to indications. Cases due to osteopathic lesions as indicated will usually yield readily to treatment. Where there are other factors treatment must be varied accordingly.

Trichiasis

This is a condition in which part or all of the eye lashes turn inward and touch the eye ball, due to cicatricial contractions in the conjunctiva and tarsus. Many of the cilia are so small in these conditions that it is very difficult to see them. A loupe or a magnifying glass must be used in order to discover them.

=Dystrichiasis= is a condition where the cilia come in irregularly growing in all directions, some of them turning in toward the eye ball and causing irritation.

=Treatment.=—An epilatory should be used to extract all of the wild hairs. Care should be taken to get out the finest ones as they will frequently cause irritation if not removed.

Entropion and Ectropion

=Entropion= is a turning in of the eyelid and =ectropion= is a turning out. These conditions may be spasmodic and temporary. Entropion is more often due to cicatricial contraction in old blepharitis or trachoma conditions. In some cases the condition may be corrected by the use of strips of adhesive plaster. In cicatricial conditions operation is the rule. Spasmodic ectropion may be corrected sometimes by curing the conjunctivitis. Bandaging may be resorted to. In paralytic ectropion osteopathic treatment may serve to produce a complete cure. Operative procedure should be a last resort.

Diseases of the Lachrymal Apparatus Dacryocystitis

=Dacryocystitis= is an inflammation of the lacrymal sac. It is due to some lesion in the nose, malposition of the inferior turbinate or a poor blood and nerve supply to the lacrymal region as determined by cervical lesions. The sac becomes infected and we have a =dacryocystoblennorrhea.= Pus and tears are regurgitated into the eye through the puncta. There is irritation and the conjunctiva may become infected at any time, also the cornea. It is a dangerous and annoying affection.

=Treatment.=—Osteopathic measures have something to offer along this line. The medical idea seems to be completely surgical in recent years. The first and only thing to be done surgically is to obliterate the sac or dissect it out and curette the nasal duct, completely destroying the apparatus. Lancing does not affect a cure. By treating for a good nerve and blood supply to that region, the irrigation of the nose and a thorough squeezing of the sac each time with a view to forcing the solution in the sac down through the nasal duct into the nose, a cure may be effected in many cases. If these cases can be gotten before infection has taken place, in the state of epiphora or the backing up of the tears into the eye, thorough treatment along the lines just indicated will in nearly all cases result in a cure.

Boric acid solution should be used to wash out the sac when pus is present. The attempt should be made to force it into the nose. Probing properly done is of value in many cases. These cases should be followed up with great care.

Treat the neck thoroughly and spring the inferior maxilla.

Diseases of the Conjunctiva Conjunctivitis

The conjunctiva is a mucous membrane that coats the posterior surface of the eyelids and the anterior surface of the eyeball. It forms a sac, which is slit open in front in the line of the palpebral fissure.

The conjunctiva consists of three parts (1) the conjunctiva tarsi, the part on the lids; (2) the conjunctiva bulbi, the part on the eyeball, and (3) the conjunctiva fornicis, the part connecting the first and second; it is the retrotarsal fold or the region of transition, often called the fornix. The first part can be seen by everting the lids. It is adherent to the tarsus. It is covered with a laminated cylindrical epithelium. The membrane contains an abundance of lymphocytes similar to adenoid tissue. This increases with every inflammation of the conjunctiva. This is why =chronic conjunctivitis= often results in thickened lids.

The =blood supply= of the conjunctiva of the lids is from the muscular branches of the ophthalmic artery. The =nerve supply= is from the ophthalmic division of the 5th cranial and the sympathetic.

The bulbar conjunctiva continues over the cornea. It is covered with layers of pavement epithelium. Its blood supply comes from the posterior conjunctival vessels about the retrotarsal fold, and the anterior ciliary arteries which accompany the tendons of recti muscles; these two systems anastomose in the conjunctiva. Conjunctival injection or congestion shows a superficial net work of larger or smaller vessels that move with the conjunctiva. The color is scarlet or brick red. Ciliary injection occurs as a rose-red or pale violet zone around the cornea, spoken of as peri-or circumcorneal injection. It does not move with the conjunctiva and occurs more with diseases of the cornea, iris and ciliary body.

In the =etiology of conjunctivitis= a great variety of germs are considered by different writers. Collins and Mayo give a report of “germs found in normal conjunctiva.”

Bacillus Xerosis in 94% of normal conjunctivæ; Staphylococcus Albus in 79%; Pneumococcus in 9%; Diplobacillus in 6%; Staphylococcus Aureus in 6%; Streptococcus in 5%.

If this be true, and I do not doubt their statement, we are practically compelled to say that these germs at least are only secondary in the etiology of conjunctivitis. Just at this point osteopathy comes with its flood of light and makes it easily explainable why some conjunctivæ become inflamed while others do not, when all have germs present. The lesion disturbing the integrity of blood supply and nerve force to the eye is the primary cause while the presence of germs may be the aggravating cause. The lesion prepares the soil in which the germs thrive sufficiently to become an irritant. There are all gradations of this soil preparation. The more fertile the field (i. e. the more profound the effect of the lesion) the more virulent germ life may become; the resistance is proportionately less.

=Conjunctivitis= is =classified= for convenience in study, diagnosis and treatment as follows:

(1) Catarrhal, (a) acute, (b) chronic, (c) follicular; (2) gonorrhoeal; (3) ophthalmia neonatorum; (4) trachoma; (5) diphtheritic; (6) eczematosa (phlyctenulosa); (7) vernalis; (8) tubercular; (9) traumatic. This is the clinical classification after Fuch.

Treatment of Conjunctivitis

In order to give the best care in these cases it is quite essential that both the primary and secondary causes be given attention. Some good =germicide= or =antiseptic= is to be used with intelligence. This is in harmony with the great principles of antisepsis and cleanliness taught by osteopathy from its inception. The use of the microscope in the =bacteriology= of conjunctivitis aids in more definite diagnosis and the selection of a proper germicide. For the Koch-Weeks bacillus, the pneumococcus and the influenza bacillus silver nitrate 1% or a 25% solution of argyrol is used; for the diplo bacillus (Morax-Axenfeld) zinc sulphate 1 gr. to the ounce is almost a specific.

A good way to prepare the zinc prescription would be:

Boracic acid and water oz. 1.

Zinc sulphate gr. 1.

The boric acid and water of course being a saturated solution. Apply one drop to each eye about four times a day. If one can not have the use of the microscope to make specific the diagnosis, the zinc solution may be alternated with the argyrol as the germicide. Ice cold applications are good in many of these cases.

Catarrhal Conjunctivitis

=Acute=.—mostly affects the conjunctiva of the lids in the light form. If severe it invades the bulbar conjunctiva. There is redness and swelling and increased secretion which dries at night upon the edges of the lids and glues them together. The eyes are better in the morning and worse toward evening. =Corneal ulcers= and =iritis= may arise as complications. Chronic inflammation may result.

=Etiology.=—Textbooks on the eye give =bacteria= as the chief cause; some scarcely mention anything else. After discussing how the bacteria get there and multiply, they usually bring in some statement to indicate that in many cases no bacteria can be found in the secretions from the conjunctiva. These latter are unaccounted for in the etiology.

=Catarrhal conjunctivitis= is non-specific in its origin.

The great science of osteopathy will fill in the missing links to works otherwise very exhaustive on the eye.

If the cause is due only to a passing irritant as dust, smoke, pollen or wind the disturbance may vary from hyperemia only, to a severe attack of conjunctivitis. Fuch says the majority of cases are produced by bacteria, but THAT IN NOT A FEW CASES OF CONJUNCTIVAL CATARRH THE EXAMINATION OF THE SECRETIONS FOR BACTERIA PROVES NEGATIVE. He also says that the usual course of the disease is from eight to fourteen days, but NOT INFREQUENTLY THERE REMAINS A CONDITION OF CHRONIC CATARRH PROTRACTED OVER A LONG TIME; THAT NOT INFREQUENTLY THE NORMAL CONJUNCTIVAL SAC CONTAINS PATHOGENIC GERMS.

Some authors divide the =etiology= into (1) specific, (2) non-specific. The first they account for by irritants due to dust, heat, smoke, metal, pollen, cold, wind, glare of light, eye strain from overwork of the eyes, ametropia and chronic alcoholism. The second they account for by germ life, most often the Morax-Axenfeld diplobacillus or the Koch-Weeks bacillus, the latter germ being found in the so-called “pink-eye.” It is contagious. This is one condition for which the zinc sulphate (½% to 2% solution) is almost a specific.

No doubt the irritants and the bacteria mentioned, with others, do cause much of our catarrhal conjunctivitis and that one who fails to consider properly the local conditions in practice will be sadly lacking in best results.

On the other hand many cases, treated for local conditions only by very competent men who used the best antiseptics and germicides, have very indifferent results. The acute condition would continue and gradually become chronic. From observation, study and experience there are causes aside from local irritants, ametropia, bacteria, syphilis, rheumatism or measles. There is some disturbance to the integrity of the =spinociliary sympathetic arc=. In many cases of eye disease note lesion and tenderness at the upper dorsal, the removal of which will cause improvement of the eyes. Many cases of eye strain can be relieved by correction of the first, second or third dorsal, and the use of glasses made unnecessary.

Irritation of the eye will cause more or less tension of the muscles at the second and third dorsal, and stimulation of the tissues near the second and third dorsal spines will cause dilatation of the pupils and contraction of vessels of the cranial mucous membranes; which means vasomotor, secretory and trophic disturbances.

It follows then that an =osteopathic lesion= at the second or third dorsal will cause or tend to cause disease of the eye. There may be all gradations in the effect produced, the lighter being mere tendency, while again it may be enough to set up profound vasomotor, secretory and trophic changes in and about the eye. The first effect of the lesion may be stimulatory, and later, inhibitory. The normal resistance of the eye would be lowered and naturally, local irritants, bacteria and ametropia would have a more profound effect. This will explain how one can develop conjunctivitis in the absence of a local irritant with no bacteria present, and no eye strain.

All of these causes, or any number of them, may be acting together, and each more virulent because of the influence of the other.

=Lesions= of the =occipito-atlantal= joint or any of the cervical articulations may cause eye disturbance. There are no efferent ramicommunicantes in that region and the course of the physical disturbance must be greater in proportion to the eye trouble produced, than at the upper dorsal. It is important however to make a close examination of the entire cervical region in eye trouble.

What has been said on the osteopathic causes of acute catarrhal conjunctivitis applies with equal force to chronic and =follicular concatarrhal conjunctivitis.=

What has been said on the osteopathic causes of =acute= catarrhal conjunctivitis applies with even greater force to the =chronic= form. The great variety of local irritants may account for acute conjunctivitis, and does in most instances; but in chronic conjunctivitis local irritants are more often secondary or incidental while the osteopathic lesion with its effect upon the =bulbo-spino-sympathetic= ciliary arc is the =fundamental= cause. Of course some continuous local irritant, e. g., an uncorrected refractive error, excessive light, heat, dust or germ life in the environment may cause a chronic conjunctivitis. Other causes may be retracted lids (lagophthalmus) leaving the eyeballs too prominently exposed; turning in of the cilia (entropion, trichiasis or dystrichiasis) which impinge upon and irritate the bulbar conjunctiva. =Chronic blepharitis= may spread to the palpebral conjunctiva and then the bulbar. Foreign bodies in the eye, or infarction of Meibomian glands may be causes. The diplobacillus (Morax-Axenfeld) is the most common germ in chronic catarrhal conjunctivitis.

=Symptoms and Course.=—In mild cases the redness is only moderate. The conjunctiva is smooth and not swollen. Old cases have hypertrophy with thickening. There was a small girl who came into the office recently who had the conjunctiva of the lids decidedly swollen with some hypertrophy. Her eyes were glued shut with pus every morning. Pus pockets were forming along the follicles of the cilia and on the direct edge of the lid. Her troubles started a year ago and got gradually worse. A few osteopathic treatments were given during three months (she was irregular in coming) and argyrol, 20%, used locally. All pus and debris were cleared off the lids and conjunctiva each time. The swelling all left and the thickening became inconsiderable; the eyes looked almost clear. On pressure there was tenderness at the right side of the second dorsal. No mechanical lesion was apparent there but in treatment that region was thoroughly loosened.

The subjective symptoms are usually worse at night; pain, heaviness of the lids; feeling of a foreign body in the eye; burning; itching and dryness in many cases.

This condition is one of the most frequent of eye diseases in adults; may be senile catarrh in advanced age. It is frequently complicated with blepharitis, ectropion, epiphora and ulcerations of the cornea.

=Treatment.=—The osteopathic treatment depends on the findings in the osteopathic examination. No case of chronic catarrhal conjunctivitis should be treated without a thorough examination of the whole spinal, rib and innominate mechanism. Careful and detailed adjustment should be made of any lesions that might disturb the ciliary arc, the other nerve connections, the blood supply or the body equilibrium.

This does not mean that local treatment of the eye should be neglected in any way. Any measure that will aid in getting rid of local pathology as quickly as possible should be ours. Where there is abundant secretion, silver nitrate 1% to 2% solution put on the conjunctiva with a brush when the lids are turned, or argyrol 20% to 25% dropped into the eye are among the best antiseptics for local use. If the diplobacillus is present zinc sulphate ½% solution is indicated.

The nose, nasopharynx and pharynx should never be overlooked in this disease.

Follicular Conjunctivitis

=Follicular conjunctivitis= is of catarrhal origin. It is characterized by the presence of follicles. There may be only a few or a great many. If numerous they are often in rows on the palpebral conjunctiva. Microscopically they show as circumscribed masses of adenoid tissue. In this they resemble the granules of =trachoma=. Sometimes cases persist for years with little or no inflammatory symptoms. On account of the follicles this disease is frequently confused with trachoma.

We have heard numbers of well meaning conscientious osteopathic physicians testify to curing cases of trachoma with a short course of osteopathic treatment with no pathology remaining. We are absolute believers in the effectiveness of osteopathic treatment and want to give it full credit for doing all it will; but here we want to enter a plea to the profession that we need more discrimination and definiteness in our diagnosis. Technique is being emphasized and we say Amen! It is proper for us to be thoroughly competent in technique but diagnosis should be made just as emphatic because scientific technique depends upon diagnosis for each individual case.

=Differentiation= of follicular conjunctivitis from trachoma.

=Follicular conjunctivitis= occurs (1) chiefly in the young; (2) the follicles are smaller, more sharply limited, project more above the conjunctiva, are often in rows, and oval in shape; (3) the disease clears up with no bad after effects often without any treatment and the tendency is to ultimately get well; (4) it never leads to shrinking of the conjunctiva, to pannus or other destructive sequelæ; (5) it can arise without contagion and is not considered contagious although, like trachoma, it does attack large numbers of people who are confined in a small place.

=Trachoma.=—(1) It seldom occurs in children; (2) the follicles are larger, do not have sharp outlines, are less prominent under the conjunctiva, are round in shape and never in rows; (3) tends to lead to more or less pathology and seldom recovers spontaneously; (4) scar tissue becomes a product of the inflammation in the conjunctiva and leads to shrinking of the conjunctiva, causing in turn entropion and trichiasis. Pannus is the sure result of unarrested cases as there is a tendency to infection of the cornea from the infected conjunctiva moving over it and remaining in contact; (5) trachoma has been proved to be contagious. Trachoma bodies which are considered the infective agent have been isolated.

The use of atropine in some instances will cause a follicular catarrh which clears up on stopping the use of the poison.

Parinauds “Infectious conjunctivitis” has granulations but almost always occurs in only one eye and is accompanied with constitutional symptoms.

=Treatment of Follicular Conjunctivitis.=—The treatment should be directed against the inflammation. The trophicity of the nerve terminals to the conjunctiva may be altered by osteopathic lesions.

Suggestions under chronic catarrhal conjunctivitis apply here. If there is no inflammation the follicles tend to disappear, leaving no trace of pathology, hence a few osteopathic treatments of the lids and the cervical region will hasten normalization.

Gonorrheal Conjunctivitis

This disease is sometimes called =purulent ophthalmia= or =acute blennorrhea=, It is caused from an infection of the conjunctival sac with the gonococcus of Neisser. Contact with soiled fingers or linen may transfer the germ.

=Symptoms.=—Within 12-48 hours after inoculation the first symptoms of redness and irritation occur. This is soon followed by much swelling and tension of the lids and chemosis of the conjunctiva. There is much pain and a copious discharge of pus coming from beneath the lids. At first the pus is yellow or yellowish green.

Later the symptoms begin to subside; there is less tenseness and heat; the lids can be more readily everted and the discharge ceases after 6 or 8 weeks. The puckered conjunctiva becomes rough and granular.

In these cases the =prognosis= is always grave; more so than in ophthalmia neonatorum. The eye is almost always marred in some way. One of the great dangers is involvement and destruction of the cornea. If the cornea becomes hazy soon after symptoms begin it is not a good omen. =Ulcers= will likely form and then there is a tendency to puncture the cornea. In mild cases the cornea may escape without injury. In severe cases it is likely to ulcerate. If it perforates, the anterior chamber is emptied and the iris prolapses into the perforation; adhesions take place and there is healing with reformation partially of the anterior chamber. An adherent leucoma is the result with practical loss of vision. There may be a bulging of the cornea known as anterior staphyloma. The iris and ciliary body may become involved, causing iritis and cyclitis, or the whole inner structures may be affected making a =panophthalmitis= with =atrophy= of the eyeball.

The cornea is affected by the infective material direct or the nutrient vessels to the cornea at the limbus may be obstructed by the extreme swelling and pressure.

=Complications= of arthritis, rhinitis, septicemia and endocarditis may arise. If there is none of these, at least there is a general debilitated condition which needs attention.

=Treatment.=—The treatment should be =local= and =constitutional=, The diagnosis should be made quickly from the history, symptoms microscopically, and local cleansing begun at once and followed diligently. Excessive discharge should be wiped away with cotton. The conjunctival sac should be thoroughly irrigated every hour or oftener if necessary to keep it clean. This is to be done day and night. A saturated solution of boric acid may be used, or corrosive sublimate one grain to the pint, or permanganate of potassium solution 1-5000. The irrigation should be followed by the free use of argyrol 25%. This procedure will keep the eye clean and be the means often of saving the cornea from destruction and the eye from blindness.

If there should be ulceration of the cornea a drop of atropine ½% should be used in the eye often enough to keep the pupil dilated and the ciliary body at rest.

Osteopathic physicians no less than other physicians should not neglect this local, careful, persistent, antiseptic cleansing of the eye in such cases. The osteopathist can do more. He is not limited to antisepsis even in this kind of work, however important it might be. The unaffected eye should be carefully protected. Buller’s shield should be used.

The osteopath should give thorough treatments to the neck and the fifth nerve.

Supporting treatment to the system according to indications should be given e. g., bowels, kidneys, nerves, muscles, joints as in constipation, nephritis, neurosis, rheumatism, arthritis, endocarditis, septicemia, rhinitis etc.

Ophthalmia Neonatorum

This is an =acute purulent conjunctivitis= in the new-born. Neonatorum comes from a junction of the Greek word Neos—new, to the Latin word natus—born; new-born. This disease is the bugbear to the obstetrician. He must always be on the lookout for it and act promptly in order to save sight. Every general practician should make a careful study of this disease if he expects to treat children.

Sixty to seventy percent of conjunctivitis neonatorum is due to the infection with the gonococcus of Neisser. It usually comes from a gonorrheal discharge from the genitals of the mother. The nurse or anyone who handles the baby might be the agent in the transmission of the infection.

The disease is not always of gonorrheal origin. Some cases are due to the pneumococcus, streptococcus, diplobacillus or one variety of staphylococci.

Thus there are two varieties or types of ophthalmia neonatorum; a severe type which is =gonorrheal= or specific and a mild type which is non-specific.

In some states there is a law which requires the use of silver nitrate in the eyes of all babies at birth. Every baby’s eyes should be thoroughly washed at birth, with boric acid and where there is the least suspicion of gonorrhea silver nitrate 1% or argyrol 25% should be used. A routine use of one of the silver salts would be good practice.

=Symptoms.=—Gonorrheal cases begin usually the third day after birth, non-gonorrheal, on the fifth or sixth day. Both eyes are usually involved, one worse than the other. The lids swell much. There is chemosis of the conjunctiva which may put the cornea in a pit. The discharge is abundant. It is yellow or greenish yellow.

The disease gradually declines and the discharge ceases in six to eight weeks. The conjunctiva is thickened and looks granular. May be some cicatricial changes.

The chief danger is to the cornea, more so if it becomes hazy the first two days. Corneal lesions seldom occur in non-specific forms.

If the cornea is involved perforation is likely, with a general inflammation of the eyeball (panophthalmitis) followed by atrophy (phthisis bulbi).

Complications such as rhinitis, meningitis, endocarditis and general septicemia may occur.

=Diagnosis= is made from the onset, character, symptoms and course with the use of the microscope.

=Prognosis.=—Delayed or improper treatment in these cases will likely be fatal to sight as sloughing of the cornea will occur. With prompt and proper care the prognosis is favorable.

=Treatment.=—Mild cases (non-specific) are treated in the same manner as simple conjunctivitis. In severe cases (specific) clean the eye carefully and apply cold compresses of gauze 15 to 20 minutes at a time every hour or two. Keep the gauze on a block of ice and change every few minutes. If the cornea is involved heat may prove more satisfactory. There must be constant removal of the discharge. Wipe away the excess and irrigate freely with boric acid at least every hour day and night and more often if necessary. After each washing use a solution of argyrol 25%. Once a day silver nitrate 1% solution may be used and washed out with a salt solution.

If the cornea should ulcerate the treatment need not be altered.

The attendants should be carefully instructed as to the importance of the care and the contagious nature of the pus.

Antisepsis and cleanliness here is more essential, effective and exclusive than in any other disease of the eye. Wisdom in the use of antiseptics is a strong point in the armamentarium of every progressive osteopath.

Trachoma

This disease is known as =granular lids= or =granular conjunctivitis=. Although the germ has not been discovered, we know this is an infectious disease. A roughness and hypertrophy of the conjunctiva develops. There is development of follicles or granulations. Later these products are absorbed and cicatrization of the tissues follows.

=Cause.=—Trachoma is found most common in Egypt and Arabia. It spreads easily in crowded institutions. It is in many instances a mixed infection with the Morax-Axenfeld bacillus, Koch-Weeks bacillus and the gonococcus.

=“Trachoma bodies”= have been discovered which are claimed by some to be a causative factor in the disease. These small bodies are not found in all cases however.

Spinal lesions of the cervical and upper four thoracic vertebræ will disturb the blood and nerve supply to the eye which will predispose to the disease should some of the virus or germs of trachoma be present. In practically all these cases there is tenderness if not an actual twist at the second and third thoracic.

=Symptoms.=—A small boy came to our clinics complaining that his left eye was smaller than the right. No inflammation or swelling was prominent. The eye looked normal except slightly smaller than the right. On turning the lid granules in the fornix of that eye were readily noticed. Trachoma had a good start. The tissues were so hypertrophied in that region that the eye could not be opened quite as wide as the other one, hence the impression that that eyeball was smaller. The granulation often develops so insidiously that the victim may have the disease for months before he realizes he has a bad eye. When symptoms appear there may be photophobia, lachrymation, gluing of the lids from a scanty secretion, pain, and blurring of vision. The granules are gray, translucent and roundish under the conjunctiva.

Hypertrophy increases to a certain height when cicatrization and contraction begin. The duration may be years. The more the hypertrophy the longer the duration and the greater the contraction. (Note here that treatment should be directed toward combatting the hypertrophy by establishing circulation).

=Sequelæ.= I merely mention the sequelæ here: pannus, ulceration of the cornea, trichiasis, dystrichiasis, entropion, ectropion, symblepharon, xerosis, corneal opacities. For the explanation, pathology and treatment of these sequelæ not covered in this treatise, see any good works on diseases of the eye as Weeks, Fuchs or De Schweinitz.

=Treatment of Trachoma.=—In reporting cases of trachoma treated and cured by osteopathy we should be sure of our diagnosis.

The treatment is antiseptic, hydrotherapeutical, osteopathic and operative. A saturated solution of boric acid should be used. Argyrol 20% is good if there is much secretion. Nitrate of silver 2% and copper sulphate are still used in some cases to advantage as claimed by some physicians. The osteopath should count on careful cleanliness.

Hot compresses over the eyes are often very agreeable.

Operations are often performed for trachoma. The granules are rolled out with Knapp’s roller forceps, and other methods.

=Grattage= is practiced with some wonderful results. It is done as follows: Get some fine sand paper and cut it in strips about one-half inch wide by three or four inches long. Put it in alcohol in a vessel for ten to fifteen minutes. Pour off all the alcohol except a few drops that will cling to the vessel by capillary attraction. Touch a match to the residue. This will burn just enough to make the sand paper absolutely sterile without burning the latter. Put the patient under somnoform. Use a small artery forceps to grasp the edge of the eyelid, roll the lid back over the artery forceps to expose all granulations clear to the fornix. Use a protector to the eyeball. Now with the sandpaper quickly scrape or curette away all of the trachoma bodies and granulations. Repeat the process on the other eye if it is involved. Wash out well with a saturated solution of boric acid and bandage the eyes for a few hours. This will cause considerable swelling and inflammation. Use cold applications and keep the eyes disinfected. I have seen some very good results from this method.

=Osteopathic.=—Following the sand paper operation a thorough treatment of the cervical and upper dorsal region would add considerably to the rapidity of the patient’s recovery and sense of well being. General tonic treatment is of special benefit in nearly all trachoma cases as they are subnormal in their general health.

One form of technique which has been used by myself and others to advantage in these cases is as follows: Sterilize the fingers carefully, lubricate with vaseline or K. Y. the forefinger of the right hand. With the left hand raise the upper lid and introduce the forefinger of the right hand with the thumb above. Catching the lid between the thumb and finger squeeze and massage the whole structure clear to the fornix as thoroughly as possible. Repeat the process on the other eye.

A technique used by Dr. Edwards of St. Louis is as follows: After sterilizing and lubricating the forefinger lift the lid and introduce the finger as far as possible into the orbit pushing the fornix back into the orbit. This stretches all the tissues around the fornix, opening up a better conjunctival and palpebral circulation. The ciliary vessels and nerves are stretched and stimulated. It is rather surprising to one who has not tried it, how far the finger can be introduced into the orbit.

One set of nerves that should be especially studied and considered in trachomatous conditions is the cere-brobulbo-spino-sympathetic-ciliary arc. This has already been elaborated. All spinal lesions should be carefully diagnosed and corrected.

Dr. T. J. Ruddy’s third finger eye instrument is very useful in these conditions in restoring normal circulation about the orbit.

See that the nose and throat are normal.

Phlyctenular Conjunctivitis

By some this disease is considered an =eczema= of the conjunctiva. This will at least enable us to get an idea of the conjunctival pathology. What is said of phlyctenular conjunctivitis applies largely to its corresponding disease of the =cornea-phlyctenular keratitis=. Scrofulous ophthalmia is applied by some because so many of these phlyctenular patients have =scrofula=. Herpes conjunctivæ is used as a name because of the small blisters or blebs that form in the beginning stage. Little red eminences develop near the limbus (sclerocorneal junction). They are cone shaped, slightly elevated about the surrounding tissue. There may be one or several, usually not more than one or two. After a few days the cone breaks and on top appears a small gray ulcer. There is further breaking down and the cone disappears leaving an ulcer on level with the conjunctiva. Vessels are congested about it. There may often be noted an area of small vessels, fan like in shape, running from the outer region of the conjunctiva to the ulcer or phlyctenule.

=Etiology.=—This is a disease of frequent occurrence in children, mostly among the poor classes. Such things as eczema, dirt, adenoids, scrofula, rhinitis, malnutrition, abuse of tea and coffee and exanthematous disease are mentioned by oculists as causes. I have no doubt any or all these conditions predispose to phlyctenular conjunctivitis.

De Schweinitz in “Diseases of the Eye,” 1916 edition, p. 242, says: “The exact cause of ocular lesions, or phlyctenular eruption, has not been determined.”

I have met Dr. De Schweinitz and heard him lecture on the eye. I consider him one of the best eye specialists in the country. His experience and study with the eye dates over many years and his book has gone through eight editions. He is professor of ophthalmology in the University of Pennsylvania; Ophthalmic Surgeon to the Philadelphia Polyclinic Hospital, the Philadelphia General Hospital etc., etc.

His opinion represents the summary of the investigation of the ophthalmic profession the world over and through all the past down to the present time. “The cause of phlyctenular conjunctivitis is not known.”

=Bacteriology.=—At times in the ulcers have been found the staphylococcus pyogenes aureus and albus. They are also found in a normal conjunctival sac. They could not with logic be taken as a causative factor; at least they would be only secondary.

If oculists and other students of the eye all had a good deep osteopathic vision to throw light upon these problems many causative factors would take on a new meaning. Such supposed causes as have been mentioned, e. g. eczema, adenoids, rhinitis and malnutrition may easily be secondary to the osteopathic lesions. Micro-organisms may be enabled to act because of trophic and circulatory disturbances to the conjunctiva through disturbed nerve connections from lesions in the cervical and upper dorsal regions. Herpes zoster is purely a trophic nerve disturbance manifestation on the skin as blebs or blisters with more or less neuritis. Any lesion that would affect the integrity of the function of the fifth cranial nerve might easily manifest itself as herpes of the conjunctiva.

We believe the osteopathic lesion is primary and fundamental in the causation of most of our phlyctenular conjunctivitis. Of course insanitation, scrofulous diathesis and the exanthemata play their role. A good diagnostician should figure out the relative importance. The history, onset and examination will usually eliminate these conditions.

=Symptoms.=—Lachrymation, photophobia, blepharospasm and injected vessels are the chief symptoms. There is pain as well as fear of light. The child fights examination.

The attack subsides in ten to fourteen days unless there is multiplicity of blebs. Some patients have repeated attacks for months or years. Many of these cases in medical clinics keep coming for months with repeated attacks. Never leave out careful osteopathic treatment.

=Prognosis.=—This is favorable for a final cure. If there should be multiple blebs and frequent recurrence and the cornea is invaded, the prognosis is not good for perfect sight. The pathology goes deep enough to affect Bowman’s membrane of the cornea disturbing the substantia propria. This causes a macular condition of the cornea which impairs sight.

=Therapy.=—Diet should be bland; the eyes should be protected from irritants; yellow oxide ointment should be used in the eye once a day or 10% argyrol. The ointment is preferred. Moist warm compresses on the eye are comforting. A boric acid wash in almost all conjunctival trouble is good. If there is much irritation giving a suspicion of iris involvement a drop of atropine ½% should be used. The general regimes of living should be regulated.

Osteopathic treatment should be directed toward building up the general health and correcting all lesions, especially that may have a specific bearing on the eye trouble. Such lesions will be found more often at the first, second and third thoracic, but may be anywhere from there to the occiput.

Vernal Conjunctivitis

This disease is known by many as =vernal catarrh= or =spring catarrh= of the conjunctiva. It is a chronic inflammation which sets up changes in the conjunctiva and tarsus. This disease may be confused with trachoma unless one observes closely. There are broad flat papillæ on the conjunctiva. These papillæ may readily be taken for granulations. They are larger than the granules in trachoma. They somewhat resemble the arrangement of cobble stones. The conjunctiva has a bluish-white filmy appearance called by some, milky shimmer.

The disease was thought at first to appear only in the spring, hence the name vernal. Many cases continue through the year with exacerbations in the spring. It occurs more often in boys. Both eyes are attacked. It may heal and leave no trace. It may last from four to twenty years.

=Causes.=—Almost all works on the eye say the cause is not known. De Schweinitz says, “Definite information in regard to the cause of this disease is lacking.” There may be a micro-organism which has not been discovered.

I wish to call the attention of the osteopathic profession to the great fact that there are numbers of diseases of the eye as well as of other parts of the body about which the medical profession are entirely “at sea.” This gives valuable ground for scientific research by our profession.

My experience with this disease is not sufficient for me to speak with any positiveness or finality as to its cause. The altered trophic parts and the very chronic condition existing leads me to the firm belief that we will ultimately find the cause as a mechanical lesion affecting the trigeminal or sympathetic (or both) nerve connections. Glare of light and local irritants act only as secondary causes. Nasal disease may be associated and act as a cause.

=Symptoms.=—There is photophobia, some mucus, slight pericorneal injection, redness of the conjunctiva of both the bulb and lids; that of the lids is thickened and of dull pale color due to sub-epithelial hyaline thickening. The fact that there is no pannus, and flat granulations and recurrence with spring, marks it from trachoma.

=Prognosis.=—Under medical treatment it is unfavorable; may last twenty years. Slight opacity of the cornea may develop.

=Treatment.=—The eyes should be protected with dark glasses. Cold compresses give some relief. Boric acid is good as a wash. Yellow oxide of mercury ointment may be of service as an antiseptic and alternative. If nasal disease exists, it, of course, should be treated according to indications. Fundamentally the lesions in the spine in the cervical and upper dorsal regions should be specifically corrected. When enough cases of vernal catarrh have been observed and treated osteopathically much light and benefit will be brought to bear upon this obscure and intractable disease of the conjunctiva.

Diseases of the Cornea

Anatomy

The cornea with the sclera forms the outer coat or tunic of the eye ball. The cornea is in front and forms one-sixth of the envelope. It is a segment of a smaller globe than that of the sclera. It is about 12 mm. horizontally and 11 mm. in the vertical diameter. Its thickest part is at its junction with the sclera where it is about 1 mm. This junction is called the limbus. The cornea is inserted into and rests on the sclera like a watch crystal. The fibers of the cornea pass continuously into the sclera, however. The normal cornea is transparent. Most morbid changes of the cornea cause a diminution in this transparency. In old age a narrow gray line near the corneal margin makes its appearance. This is known as the =arcus senilis=. There is a little strip of perfectly clear cornea between the arcus senilis and the limbus.

The cornea has five layers. These layers should be noted with care, as in wounds of the eye, foreign bodies in the cornea and ulcerations, the results depend much upon which layers are affected.

1. The =anterior epithelium= consists of pavement cells of several layers. This layer of the cornea may be damaged or scratched off in large patches and still it will heal readily leaving no trace of the injury.

2. The =anterior elastic lamina= or =Bowman’s membrane= is very thin and homogeneous; it is just beneath the epithelial layer and forms a resisting sheath to prevent damage to the next layer.

3. The =stroma= or =substantia propria=. This layer composes about nine-tenths of the cornea. It is composed of minute connective tissue fibers between which lie some stroma cells or corneal corpuscles. Some of these cells are fixed while others are motile. The motile ones are the white blood-corpuscles which move about in the lymph passages of the stroma. They increase in any irritation of the cornea.

4. =Descemet’s membrane.= This is a tough homogeneous hyaloid membrane back of the stroma. When the stroma is diseased and breaks down Descemet’s membrane may be sufficient to prevent a puncture of the cornea.

5. The =Endothelial layer= is a single layer of flattened cells which coat the posterior surface of Descemet’s membrane.

The margin of the cornea is in relation with three membranes, the conjunctiva, the sclera and the uvea (iris and ciliary body). In a disease of the cornea, a conjunctivitis, an iritis or a cyclitis is easily started.

The cornea contains no vessels. It is nourished by imbibition. At the limbus there is a rich network of marginal loops supplied by the anterior ciliary vessels. From these loops the blood plasma passes into the stroma of the cornea.

The nerves of the cornea come from the ciliary nerves and the nerves of the bulbar conjunctiva. These are from the trigeminus and the sympathetic. The nerves extend numerously in the stroma passing forward through Bowman’s membrane into the epithelial layer. This makes the cornea very sensitive to the touch.

Examination of the Cornea

Note the size and form. Both may be modified by morbid processes. Note the surface with regard to curvature, evenness and smoothness. In =keratoconus= the curvature is greatly increased. Noting the reflex images in the cornea and comparing these with those of a normal cornea will show any variation in curvature. Also any =unevenness of the surface= may be noted by the irregularity or distortion of the images. Uneven spots on the cornea may be =depressions or elevations= from loss of substance; =wrinkles or collapse= from lowered tension.

If the smoothness or polish of the cornea is lost it looks like glass that has been breathed upon or greased. It is lusterless and dull.

Note also the transparency of the cornea and determine the form, extent and density of the opacity; whether it is diffuse or in spots; in the deep or superficial layers. A magnifying glass should be used in the study of opacities. According to the density of the opacity of the cornea it is known as a =nebula= or a =nebulous opacity=, a =macula= or a =leucoma.= The nebula is the least noticeable and the leucoma is the densest opacity. A leucoma is a condition of complete opacity. The cornea looks white.

Defects in the corneal epithelium may be made to show clearly by the use of a 2% solution of fluorescein which stains them green.

Note the sensitiveness of the cornea by touching it with the end of a thread, a little cotton or a shred of paper. The sensitiveness is diminished or lost in glaucoma and some other diseases.

Diseases of the Cornea

Almost all diseases of the cornea have some form or degree of inflammation. =Keratitis= is the word generally used for inflammation of the cornea. In order to aid clearness in discussion there are various subdivisions of keratitis made by different writers. Suppurative and non-suppurative are the principal types. In =suppurative keratitis= there is always some destruction of corneal tissue which on healing leaves an opacity with partial loss of vision. Germs gain entrance into the tissues usually from the exterior and some form of ulceration results.

The following classification is taken from Fuchs:

=Suppurative Keratitis.=—(1) Ulcer of the cornea; (2) Serpiginous ulcer; (3) Keratomalacia or Xerosis; (4) Keratitis neuroparalytica.

=Non-suppurative Keratitis.=—(A) SUPERFICIAL: (1) Pannus, or keratitis with blood vessels; (2) Phlyctenular, or keratitis with vesicles. (B) DEEP: (1) Parenchymatous or interstitial.

In keratitis there is first an infiltration or the increase of cells in the substantia propria or the parenchyma of the cornea. This is the exudate of the inflammation. It causes the cornea to look more or less dull or cloudy. The disease may clear up at this point or go on to suppuration. If it clears up it is known as =resorption=. If the lamellæ of the substantia propria are not destroyed by the process, resorption takes place with no loss of substance. The exudate disappears and there is perfect transparency of the cornea again. There may be slight damage of the stroma preventing perfect transparency. Resorption of the exudate may not be quite complete which may become partly organized and left permanently fixed in the cornea. Cases resorbing without destruction of the stroma are forms of the non-suppurative keratitis group.

If the stroma breaks, suppuration occurs. This is the second stage and is associated with a localized destruction of the cornea. These cases are known as =suppurative keratitis= or =ulceration of the cornea=. The disintegration begins in the most anterior layers of the cornea. A slight depression in the cornea can be noticed. The infiltration is all about the ulcer, getting less as it is more remote from it. If the floor and walls of the ulcer are foul with the infiltrate it is known as a =progressive= ulcer. =Sloughing= may continue to spread the ulcer.

If the cloudiness around it disappears and the ulcer acquires a smooth transparent base and edges it is known as a =retrogressive= or clean ulcer.

The disintegrated areas of the cornea may be replaced by newly formed tissue. This is the third stage or that of =cicatrization=. This new tissue is connective tissue. It is opaque, leaving a permanent opacity.

=Stages of keratitis=:

=Suppurative.=—(1) Infiltration; (2) Suppuration and (3) Cicatrization or Reparation. The suppuration is progressive or retrogressive.

=Non-suppurative.=—(1) Infiltration; (2) Resorption.

In the diagnosis of a keratitis one should look at it very carefully. A loupe which has thick plus sphere lenses will magnify the field and may be of great assistance in observing closely the condition.

If the cornea is clouded and dull the trouble is recent and if there is no loss of substance it is an infiltrate (first stage). If there is loss of substance it is a progressive ulcer (second stage.)

If the surface is lustrous but cloudy the trouble is an old one and if there is loss of substance it is a retrogressive ulcer; if no loss of substance it is a cicatrix.

Frequently blood vessels grow in from the margin in ulcerations of the cornea. This is usually a process of healing of the corneal ulcer. The advent of the blood vessels is favorable. After healing the blood vessels gradually disappear. They never entirely disappear from large cicatrices.

In some cases new vessels accompany the inflammatory process and like the exudate are a part of the clinical picture of the disease as in parenchymatous or interstitial keratitis. Pannus also has vessels. They are not in the cornea but are in new tissue deposited upon it.

=Symptoms appearing in keratitis=:

1. =Ciliary injection= or a red area encircling the cornea. If the keratitis is severe there will be considerable inflammation of the conjunctiva which may hide to some extent the ciliary injection.

2. =Iritis or iridocyclitis= may set in. The iris and ciliary body are in such intimate relation with the cornea that these structures are very subject to involvement in any severe keratitis. With iritis would come danger of =synechiae= or adherence of the iris to the anterior surface of the lens.

3. =Hypopyon.=—In suppurative keratitis there is some exudate into the anterior chamber of the eye. This exudate drops to the bottom of the chamber and looks like pus had gathered in the bottom of the aqueous. This condition is called hypopyon.

4. Other symptoms which are frequently prominent are =diminished vision=, =pain=, =photophobia=, excessive =lachrymation= and =blepharospasm=. Edema of the lids and conjunctiva may occur.

Intelligent treatment of keratitis of course is based upon the exact conditions present. Great care in diagnosis and treatment should be exercised.

Ulcer of the Cornea

Inflammation of the cornea sets in from some cause. There is an infiltrate into the substantia propria. A spot becomes cloudy and the surface over it becomes dull; at this point the epithelium breaks down or exfoliates and the loss of substance in the parenchyma is the beginning of an ulcer.

=Cause.=—The cause may be constitutional or local. The causes usually thought of from the medical standpoint may be noted in such books as “Diseases of the Eye” by De Schweinitz or Weeks. I wish especially to call attention to the fact that there is frequently a primary and underlying cause of corneal ulcers not mentioned in any medical texts, i. e. the osteopathic lesion. By this I mean more than the spinal lesion although the subluxation lesions that result from the occiput to the fourth dorsal are of most importance. Any tension or change of tissue in the cervical region that may interfere with perfect freedom of circulation of blood to the tracts and centers in the cord, is to be considered. The osteopath of course should take into consideration all causes primary and secondary and govern himself accordingly.

=Symptoms and Course.=—There is a gray area surrounding the ulcer at first, also the floor is grayish in color. In this condition it is known as a =progressive= ulcer or a =foul= or =unclean= ulcer. This cloudiness or gray area may increase in size and the ulcer keep spreading, or it may go deeper even to perforation of the cornea.

Some ulcers advance or spread on one side and heal on the opposite side so that they creep along on the cornea—these are the so-called =serpiginous ulcers=.

With corneal ulcers there is irritation, pain, photophobia and increased lachrymation. There is usually some ciliary injection which is an indication of involvement of the iris and ciliary body. If iritis occurs there is contraction of the pupil with slow reaction. =Hypopyon= may develop. With iritis and the exudate there is likely to be adhesions between the iris and the lens known as posterior synechia.

A few corneal ulcers are asthenic and do not have irritative symptoms and yet are dangerous.

When the ulcer begins to heal it is called =retrogressive=. Dead tissue is cast off; other tissue becomes transparent from resorption. We have a =clean= ulcer. Symptoms disappear and cicatrization begins. Vessels extend to the ulcers and soon it is leveled up with the corneal surface. Cicatrization may leave it slightly below the corneal level or above it.

If there should be perforation of the cornea from the ulcer there may be =complications=, e. g. keratocele, loss of aqueous, dislocation and expulsion of the lens, intra-ocular hemorrhage, flattening of the cornea, fistula of the cornea, glaucoma, intra-ocular suppuration, prolapse of the iris into the opening, etc. These complications and sequelæ that occur occasionally will not be considered here.

After healing is complete by cicatrization there is opacity of the cornea in proportion to the depth and size of the ulcer. In months and years of time there is some clearing of the opacity so that small superficial opacities may become invisible.

=Treatment of Corneal Ulcers.=—Most ulcers of the cornea are quite amenable to proper treatment and the prognosis is favorable. Neglect or wrong treatment is very dangerous. The treatment is local and constitutional. Often the ulcer is kept going by unwholesome constitutional conditions.

=Local Treatment.=—This varies according to the stage of the ulcer, whether progressive or retrogressive. In a progressive or foul ulcer if due to trauma any foreign bodies should be removed. If the ulcer is a result of pathology of the conjunctiva it is of primary importance to treat the conjunctival condition.

In mild cases of ulcer a dressing over the eye with atropine ½% to keep the pupil dilated is sufficient local treatment. The bandage protects the eye from bright light and other environment and the atropine puts the iris and ciliary body at rest preventing complications and giving nature her best chance to work.

If the ulcer is rapidly progressive, warm compresses an hour or two a day are good; iodoform sprinkled on the ulcer or actual cautery may be used. In the retrogressive stage (clean ulcer) healing has begun and we desire to get as near as possible a resistant transparent cicatrix. Yellow oxide ointment is useful at this stage.

=Osteopathic.=—The local measures just mentioned are not incompatible with osteopathic theory or practice. They are merely adjunctive in getting nature’s reaction toward normalization, as also are hot and cold applications. Osteopathy comes in now in a most important and fundamental way with the constitutional and specific lesion treatment. The =bulbo-spino-sympathetic-ciliary arc= has been mentioned and explained. Through this important nerve connection with the eye, profound and wholesome effects on the eye may be gotten by osteopathic treatment. Frequently lesions of the occiput, cervicals and upper dorsals will affect the integrity of the ocular structures through disturbances of nerve and blood supply.

The stomach, bowels, liver and kidneys should be carefully noted in corneal ulcers. Poor circulation, indigestion, constipation and auto-intoxication may have an important bearing on the recovery of the ulcer.

Xerosis or Keratomalacia

This is a disease of the eye in children due to insufficient nutrition of the cornea. Hereditary influences, depleting diseases and lesions affecting the trophic nerves to the eye are causes.

=Treatment= consists of building up the nourishment of the child, correction of lesions and careful dieting. Hot applications to the palpebral region helps to bring the blood supply to the eye for local effects.

Keratitis Neuroparalytica

This disease is due to a paralysis of the 5th cranial nerve. The cornea becomes slightly cloudy. The epithelium gradually sloughs away. An ulcer may or may not form. Pain and lachrymation are absent because of paralysis of the trigeminus. There is usually ciliary injection.

=Treatment.=—The most important treatment for this unfortunate condition is manipulation to restore the integrity of the 5th cranial nerve and the blood supply to the eye. Cervical, spinal, nasal, nasopharynx treatment should be given. Spring the inferior maxilla.

A drop of atropine (1%) should be used locally because of the ciliary injection. Warm compresses used locally will help. The healing usually leaves some opacity of the cornea. Keep the eye bandaged to protect the cornea.

Pannus

This form of keratitis is superficial and is characterized by the formation of blood vessels in the cornea. It is caused by some irritative influence. Most often it is a complication of trachoma.

If the irritation can be removed the vascularity gradually recedes, leaving a clear cornea unless the deeper structures of the cornea have been involved.

Phlyctenular Keratitis

This disease is an involvement of the cornea with an eczematous process similar to phlyctenular conjunctivitis. There is more likely to be ciliary injection and iritis, in which case atropine should be used. The treatment is the same otherwise as for phlyctenular conjunctivitis.

Parenchymatous or Interstitial Keratitis

This is shown by a diffuse inflammatory infiltration of the substantia propria of the cornea. Part or whole of the cornea of one or both eyes may be involved. Very fine blood vessels may invade the deep structures of the cornea.

=Cause.=—Syphilis, tuberculosis, rheumatism, diabetes and rachitis are systemic diseases found back of this trouble.

=Symptoms.=—Irritation, lachrymation, photophobia with ciliary injection are the chief symptoms.

=Treatment= must be local and constitutional.

Locally atropine should be used. Dark glasses should be worn or the patient must be kept in a dark room. Treatment to the trigeminal nerve and tissues of the orbit should be given.

Constitutional treatment should be spinal with the idea of arousing all the forces of the body to greater activity. Careful dieting should be followed according to indications.

The infiltration and blood vessels will ultimately disappear. Sometimes enough may remain to cloud the vision.

Diseases of the Iris and Ciliary Body

The iris and ciliary body have the same blood and nerve supply. That is, they are supplied by the same set of vessels and nerves. For this reason it is practically impossible to have an iritis absolutely independent of a cyclitis or some inflammation of the ciliary body. If the iris is the primary seat of the trouble there are certain symptoms that may indicate such a state. However, when we are treating the iris or diagnosing conditions of the iris we must remember that the ciliary body is very likely more or less involved and may be the primary seat of the trouble.

In =iritis= there are some symptoms which are caused from the hyperemic condition of the eye, such as a slight change in color. The pupil becomes rather inactive, there is some ciliary injection with photophobia, lacrymation and pain. In case of an exudate in the iris there may be thickening, and the exudate in the anterior chamber of the eye will form a =hypopyon=. Sometimes the small vessels will break and there will be a little bleeding which will be mixed with the debris in the bottom of the anterior chamber. This is known as hyphemia. There are likely to be adhesions between the iris and the anterior capsule of the lens known as posterior =synechia=. The pupil is more or less irregular. If atropine is dropped into the eye to dilate the pupil, parts of the edge of the pupil will be adhered while the other parts dilate making it very irregular.

In case of cyclitis there is an exudate from the ciliary body into the posterior chamber. This may cause a total adherence of the iris to the crystalline lens. With the ophthalmoscope, opacities in the vitreous may be noticed. These are exudates. The tension of the eye is liable to increase a little at first but as the exudates absorb there is more or less softening. Vision is low. Also in cyclitis there is ciliary injection, photophobia, lacrymation and pain, similar to that of iritis. Pressure on the eye ball will reveal a very tender condition around the sclerocorneal junction or over the area of ciliary injection.

The causes of iritis, cyclitis or iridocyclitis frequently are systemic conditions and infection such as syphilis, rheumatism, gonorrhea, tuberculosis, infectious diseases and metabolic changes, it may be of traumatic origin or sympathetic. Fuchs says “There are many cases of iritis for which no cause can be discovered and therefore which cannot be placed under these causes.” We agree with him and advance the theory of cervical and upper dorsal lesions or trouble in the sinuses, nose, nasopharynx or throat. No doubt osteopathy can throw some important light on the causes of diseases of the iris and ciliary body. The nose and throat should be examined in all these cases.

=Treatment.=—Atropine must be used in the sore eye to put the iris and ciliary body at rest and dilate the pupil to draw it back from the lens so that adhesions may not form. Warm compresses will give much comfort. Sweating should be brought about. All fluid should be reduced to a minimum. Diet should be very moderate and the bowels kept unusually free. The eye should be protected by dark goggles. Thorough treatment of the neck and upper dorsal region with attention to the nose and throat should be given. Constitutional treatment should be given according to the indications mentioned under causes. If annular synechia or total posterior synechia form or there is atrophy of the eyeball operative work may be needed. Also for injuries, tumors, anomalies and so forth of the iris see the latest medical works on this subject.

Diseases of the Choroid

The =choroid= is the vascular tunic of the eye. With the iris and ciliary body it forms the =uvea=. The iris and ciliary body are rich in nerve terminals and when inflamed; pain is a prominent symptom. The choroid has no sensory nerve terminals. When it is involved alone; pain is not present however severe the pathology. Embryologically Descemet’s membrane is a part of the uvea. When the uveal tract is diseased we frequently note symptoms of a descemetitis as a turbidity of the anterior chamber and spots on Descemet’s membrane. When one part of the uvea is inflamed the tendency is to pass to the other parts because of the intimate blood supply.

Choroiditis

There are many forms of choroiditis given by writers according to the clinical picture and the pathology.

=Symptoms.=—No pain is experienced unless there are complications. Vision is altered in some degree. The use of the ophthalmoscope may reveal opacities in the vitreous. Pigmentation spots and exudation may be noted in the fundus. In disseminated choroiditis spots of exudate appear in the fundus which go on to atrophy, leaving irregular circular light patches.

=Treatment.=—In all forms of choroiditis careful diagnosis of constitutional conditions should be made and treatment given according to indications.

Nasopharynx and orbital treatment as outlined under manipulation for diseases of the eye should be given.

Rest and protect the eyes. Secure free elimination.

Panophthalmitis

By injury or otherwise pathogenic germs are introduced into the eye. The trouble begins as a =suppurative choroiditis= and rapidly spreads to all the eye structures. The vitreous chamber becomes filled with pus.

=Symptoms.=—Pain is severe and sight is lost early. The conjunctiva and lids are much swollen. There is a mucopurulent discharge. The cornea becomes gray and may slough. In about two weeks the inflammation subsides and the globe passes into atrophy.

=Treatment.=—Elimination must be thorough. Spinal treatment for keeping up strength. Cervical, upper dorsal and nasopharynx treatment for the eye. Moist hot compresses to the eye. Operation, incision for drainage, or evisceration may have to be performed.

Sympathetic Ophthalmia

The other eye may become inflamed by the process from the panophthalmitis passing around through the circulation or the continuous structures. All symptoms of a general inflammation appear and vision gradually diminishes.

=Treatment.=—In panophthalmitis of one eye always watch the other eye closely. If it becomes irritable or shows any signs of being affected the diseased eye should be promptly removed, especially if vision is lost in that eye. If no irritation occurs, continued conservative treatment of the panophthalmitis may result in a subsidence of the disease without the well eye becoming affected.

Sympathetic inflammation rarely develops earlier than a month after injury to the exciting eye. Sooner than that or even a few minutes after injury there may be some signs of sympathetic irritation and the symptoms continue with no evidence except a slight circumcorneal injection. It should be treated like iritis. A thorough toning of the system by spinal treatment should be given. Order a limited diet. Secure free elimination.

Glaucoma

Glaucoma is essentially an increase in the intra-ocular pressure. All other symptoms of the trouble may be traced to this condition.

In =Primary Glaucoma= the increase in pressure sets in without any discoverable antecedent disease of the eye.

In =Secondary Glaucoma= the increase in pressure is due to some other disease of the eye. It is a symptom, a complication or accessory and is confined to the eye diseased.

Primary glaucoma affects both eyes, but not always at the same time. Fuchs says primary glaucoma constitutes about 1% of all eye diseases. It is often mistaken for iritis or iridocyclitis and treated with atropine which is contraindicated. It may be regarded as beginning cataract and time lost in expecting it to become ripe. These delays and wrong treatment have caused much blindness.

Palpation with the finger or the use of the tonometer may readily detect any increase in tension. A correct diagnosis must be made early and proper treatment instituted if vision is to be saved.

=Primary glaucoma= may or may not have signs of inflammation. If the tension rises suddenly inflammatory symptoms develop (acute) while if the increase in tension develops gradually these symptoms are lacking (simple).

=Acute primary glaucoma—Symptoms.=—First stage, rise in tension, vision obscured, sees a colored ring around lights, cornea dull, pupil dilated and sluggish, some ciliary injection. The attack may clear up for a day or for weeks. Gradually the symptoms become permanent after repeated attacks. Second stage, when the attack comes there is much pain, visual power fails rapidly, may be edema of the lids and chemosis of the conjunctiva, all symptoms become much exaggerated, the cornea becomes cloudy. After a violent attack the vision is more or less permanently damaged. Third stage, after many attacks the optic nerve becomes excavated and atrophy takes place.

Simple Primary Glaucoma

=Symptoms.=—Tension comes gradually; no inflammatory signs; pupil somewhat dilated and sluggish, the cornea may look slightly smoky. With the ophthalmoscope a cupped disc may be noted. There is gradual diminution of sight, which begins by contraction of the field.

There are many theories advanced as to the cause of intra-ocular tension in glaucoma. (Fuchs, Weeks, De Schweinitz).

=Treatment.=—Eserine is used instead of atropine. The object is to contract the pupil and draw it away from the side wall of the eye ball so the sinus (Schlemm’s canal) and the pectinate ligament (the filtering angle) may become free. The good effect of this is more marked in inflammatory glaucoma. In simple primary glaucoma miotics do little good.

Reports from osteopathic treatment of this condition have been favorable in a number of cases. Careful manipulation of the structures of the orbit with the finger or with Dr. Ruddy’s third finger eye instrument is good in restoring better circulation of the lymph and blood. Special attention to the venous drainage should be given. Treat the points of the fifth nerve, the nasopharynx and cervical region, spring the jaw. Treat second dorsal.

Have the patient avoid strong emotions or excitement. Keep the bowels free and use only a very bland diet.

Iridectomy is considered the best operation in glaucoma.

In the treatment of secondary glaucoma the other diseases or complications must be considered in conjunction with the foregoing treatment.

Diseases of the Lens

Opacities or Cataract

=Symptoms.=—Beginning opacities can best be recognized with the ophthalmoscope. Advance opacities can be seen at a glance with the naked eye.

Vision is disturbed according to degree and location of the opacity. If the opacity is in the center of the lens and the periphery is transparent they see better when the pupil is dilated. When the opacities are in the periphery of the lens they see better by day. Muscæ volitantes and polyopia are present until increasing opacity closes up all clear areas shutting out these visual perversions.

There are many clinical varieties of cataracts which may be studied in works on ophthalmology.

=Causes.=—Some interference with the nutrition of the lens accounts for the condition. Heredity is supposed to play a part in some cataracts. Rickets, convulsions, traumatism, old age, some drugs (ergot), inflammation of iris, ciliary body and choroid are given as causes. Cervical and upper dorsal lesions and disease of the throat, nasopharynx and nose will interfere with perfect circulation and drainage of the orbit, and may well have much to do with many idiopathic cataracts.

=Treatment.=—Many cases have been reported cured by osteopathic measures. Correct lesions and treat to establish free nerve force and circulation of blood and lymph to the orbit. Manipulation of the orbital tissues and mild vibration of the bulb are measures of value. More hope may be held in symptomatic, toxic, secondary and progressive cataracts. The process may be stopped and in many cases there is hope of a clearing.

Diseases of the Retina

The retina lines the back part of the eye ball. It comes forward to the ora serrata. It consists of ten layers which have been demonstrated microscopically. One layer of it passes over the ciliary body and back part of the iris to the pupil. The fibers of the optic nerve spread out over the retina. The point of entrance of the optic nerve is the papilla. It is to the inner side of the posterior pole of the eye. The retinal vessels emanate there. The macula lutea is the yellow sensitive spot at the posterior pole of the eye. The fovea is the center of the macula. The rods and cones constitute the external layer of the retina. This layer is the light perceiving stratum. For vision to be perfect all the other layers must be perfectly transparent. The visual purple is a chemical substance in the rods that gives the retina a purplish-red color. The light shining into the eye forms images which are converted into nervous stimuli by chemical action of the visual purple and by physical changes and fibrillations in the rods and cones.

Retinitis

=Symptoms.=—The ophthalmoscope must be used in diagnosis. There is at first cloudiness of the retina; the outlines of the papilla become indistinct. We may note light patches of exudates. The vessels are more tortuous and often there are hemorrhagic spots. Opacities in the vitreous due to the exudate may be seen. Vision is disturbed in proportion to the inflammation. Weeks or months are required for recovery. Atrophy may set in and cause blindness.

=Cause.=—Many general diseases are found back of this trouble, e. g. albuminuria, diabetes, leukemia, syphilis, gout and arteriosclerosis. Idiopathic cases occur with none of these diseases present, which gives a field for osteopathic research.

=Treatment= should be directed against the general disease when present. For local effects treatment should be given to all the centers and localities that affect the trophism, nerve supply and circulation to the eye. Protect the eye by dark glass or confinement to a dark room and complete rest. Keep the bowels free and produce diaphoresis.

Optic Neuritis

This disease when manifest in the eye ball is called papillitis. If back of the bulb it is =retrobulbar neuritis=.

=Symptoms of papillitis.=—Pupils are dilated and sight diminishes. The color of the papilla is altered to a white, reddish or gray and may show extravasation of blood. The papilla is swollen (choked disc), the arteries are thin and the veins are engorged. It takes months for the inflammation to clear. Atrophy is likely to occur.

=Causes.=—Brain diseases are the most frequent cause, e. g. tumors. Syphilis, febrile diseases, nutritive disturbances, lead poisoning, heredity and growths in the orbit are cited as causes.

=Symptoms of Retrobulbar Neuritis.=—There is little or no change in the papilla. The diagnosis must be made mostly from the way the vision is affected. The rule is a central scotoma in the field of vision. The first colors to disappear are red and green. In the acute form there is quick disturbance of vision. The eye looks normal outside and shows practically no change inside.

=Cause.=—Toxemia, cold, influenza; nasal, nasopharyngeal and sinus disease (ethmoids), and infectious diseases are causes. Idiopathic inflammation of the optic nerve is noted by most oculists. Here the profound effects of spinal lesions upon the eye adds some important light.

=Treatment of Papillitis and Retrobulbar Neuritis.=—In each individual case the treatment requires consideration of the causal factor. There may be required constitutional treatment in many cases. In others the cause may be found in the nose, nasopharynx, or spine. Effort should be made to remove the lesion in each case. Diaphoresis will aid in acute stages.

Atrophy of the Optic Nerve

There are many causes for this condition such as optic neuritis, meningitis, acute infectious diseases, locomotor ataxia, arteriosclerosis, nasal disease, syphilis, traumatism, alcoholism, exposure, embolism of the central retinal artery, diabetes and poisoning. Diagnosis must determine the original cause.

=Treatment.=—I have mentioned conditions in the nose as frequently accounting for various eye troubles. If these atrophies of the optic nerve can be gotten early, many of them will be influenced very favorably by osteopathic treatment. Spinal treatment to direct the circulation to the area of the orbit at the base of the brain is beneficial. Regulation of the patient’s diet, habits, methods of living and so forth is important. Excessive mental strain, excessive sexual intercourse and stresses of every kind should be prohibited. Special treatment should then be given according to the causal factors entering into the case.

Eye Strain and Its Reflexes

For the subject of refraction and refractive errors such as the different forms of hypermetropia, myopia and astigmatism the reader is referred to the many excellent works on ophthalmology which cover these subjects quite thoroughly. They are only used here in the relation to eye strain and its reflexes. The osteopathic logic here given should be combined with a reading of the refractive errors in such works as Fuchs, Weeks, De Schweinitz and others.

Asthenopia

=Eye strain, weak sight or asthenopia= embraces the group of symptoms dependent upon fatigue of the ciliary muscles or of the extraocular muscles.

There are three varieties of asthenopia. (1) Retinal or nervous, (2) muscular and (3) accommodative.

The symptoms are headache—frontal, fronto-temporal or fronto-occipital. It may extend into the neck between the shoulders. Eye balls may be tender, diplopia at times, may be photophobia, lachrymation, congestion of the eye, itching and burning of the lids.

=Accommodative Asthenopia.=—In this form the ciliary muscle is fatigued. The cause is usually overuse of the eye when hyperopia and astigmatism exist; sometimes in myopia or presbyopia.

=Treatment.=—In this form the treatment is the proper fitting of glasses and improvement of the general health.

=Muscular Asthenopia= is due to tiring of the extraocular muscles, usually the internal rectus. This may result in a phoria or a non-paralytic squint.

Ametropia may exist but asthenopia may come even in emmetropia due to overuse of the eye.

=Treatment.=—Correct ametropia if present, with glasses. Exercise the weakened muscle. Correct the nerve supply to the weak muscle. Treat cervical and upper dorsal. Manipulate tissues of the orbit. Spring the jaw. Correct any nose and throat pathology.

=Nervous, Neurasthenic or Reflex Asthenopia.=—The cause is supposed to be some functional disorder, more often found in females. May be due to too dim or too bright light, overuse of the eyes. Hysteria may follow ametropia.

=Treatment.=—Often the treatment is troublesome and the case is very obstinate according to old school methods. Rest, hygiene, general health and habits are looked after. The cause must be found or the treatment cannot be specific.

These are the different forms of eye strain as ordinarily classified. Now as we study the reflex symptoms from these and attempt to trace out the reflexes from an osteopathic point of view, we may find some more definite causes of these conditions and consequently some methods of treatment not found in standard text books might naturally suggest themselves.

Reflex symptoms that have been traced to eye strain by ophthalmologists are as follows:

Constipation, indigestion, heartburn, nausea, vomiting, nervous attacks, fear of impending calamity, irritability, despondency, insomnia, restless sleep, epilepsy, nervous twitchings and enuresis. All these symptoms have been seen to disappear after eye strain was corrected. There is no absolute way of proving that all these symptoms have existed because of eye strain. The existence and disappearance of some of them at the time of treatment for eye strain may be a coincidence. It is evident that eye strain in varying degrees may produce a train of symptoms similar to many above mentioned.

A patient, nervous, anxious, uneasy, and despondent, constipated, and having some indigestion, showed on examination contractures and tenderness at the third dorsal. It was found he was suffering from eye strain from overuse of glasses that were too strong for him. The eyes were refitted. He was wearing a

(R)+4.50 D. S. = +.50 cyl. Ax. 180. (L)+4.50 D. S. = +.50 cyl. Ax. 90 for close work and a (R)+2.00 D. S. = +.50 cyl. Ax. 180 (L)+2.50 D. S. = +.25 cyl. Ax. 90 for distance. The new glasses were—Reading— (R)+3.00 D. S. = +.25 cyl. Ax. 180 (L)+3.00 D. S. = +.25 cyl. Ax. 180 Distance: (R) + 1.50 D. S. = +.25 cyl. Ax. 180 (L) + 1.50 D. S. = +.25 cyl. Ax. 180

He was fitted two years previously. At that time the stronger glasses were correct. Eyes change more or less constantly, especially between the ages thirty-five to fifty-five years. When glasses are fitted, a weak ciliary muscle after a rest may become stronger and allow weaker glasses to be worn.

If a young person is fitted for myopia, in a few years he may discard his glasses as presbyopia develops. A person fitted correctly, who has a strong ciliary muscle may not be able for awhile to see as well with the glasses as without them. After they are worn awhile the ciliary muscle will cease its efforts to accommodate so much and the glasses give the desired effect. In some cases the doctor’s reputation to fit glasses properly may suffer at the hands of such people who sometimes refuse to take glasses, or after getting them refuse to wear them.

In the case of the man just mentioned a refitting quieted the nervous symptoms—he became more cheerful and ceased to worry. Indigestion and constipation improved. The soreness and contractures were overcome in a few treatments.

Now let us ask the question, why is it that eye strain will cause nausea and vomiting? Also why will indigestion affect the eyes by causing “spools” in the vision?

A little osteopathic logic, based as it always is or should be, upon anatomy and physiology, may throw some light on this subject. No doubt every one of us has demonstrated many times clinically that indigestion from overeating will cause soreness and contractures at the third and fourth dorsal, the nerve center in the spine for the stomach.

The reflexes between the viscera and the eye are complex and difficult to follow. In giving the probable course of the nerve reflexes from the optic nerve to the third nerve Dr. Louisa Burns suggests the following: “The nerve elements of the retina start the impulse; it passes over that portion of the optic nerves which enter the anterior quadrigeminates, the cells of the quadrigeminates where the impulses are coordinated, then by axons of these cells to the lateral or viscero-motor nucleus of the third nerve, thence to the cells of the ciliary ganglion, and by the non-medulated (sympathetic) fibers of these, the short ciliary nerves to the non-striated muscles concerned, viz: the ciliary muscle, some fibers of the levator palpebral and the sphincter of the iris.”

The third nerve arises in the floor of the aqueduct of Sylvius from two nuclei; a lateral nucleus which is a viscero-motor group of nerve cells, and a central nucleus or a somato-motor group of cells. The somato-motor nucleus supplies all the extrinsic muscles of the eye except the external rectus and superior oblique which are supplied by the sixth and fourth respectively. The nasal branch of the ophthalmic division of the 5th sends fibers to the ciliary muscle. Association fibers connect the nuclei of the 3rd, 4th, 6th and 7th. The evidence is in favor of the 10th or pneumogastric having such association fibers.

We noted four places in the brain to which the optic tracts go before the radiations reached the center of sight in the occipital lobe. If we cannot follow all the reflexes through the brain and cord at least with the facts we have it is not difficult to imagine abnormal impulses coming over the third nerve from a straining of the ciliary nucleus, thence over viscero-motor fibers in the lateral horn of the cord, over the white ramicommunicantes, through the sympathetic ganglia, over the splanchnics to the stomach, producing abnormal peristalsis, nausea and vomiting. In turn we would have the somato-motor nerves to the muscles affected as before described, contraction and congestion of muscles of the spine.

When we have patients consult us and describe a train of symptoms like nausea, vomiting, nervousness, frontal and occipital headache, we should have eye strain in mind and inquire for lachrymation, photophobia, itching and burning lids and congestion of the eye. Any of these things should make us think of testing for ametropia in its various refractive errors, as well as a careful spinal and a nose and throat examination. General physical and laboratory diagnosis should not be neglected.

References

Fuchs’s Text Book of Ophthalmology, Duane.

Headaches and Eye Disorders of Nasal Origin, Sluder.

External Diseases of the Eye, Greeff.

Vol. III Practical Medicine Series: The Eye, Ear, Nose and Throat by Casey A. Wood, Albert H. Andrews, Geo. E. Shambaugh.

Diseases of the Eye, Weeks.

Diseases of the Eye, Ear, Nose and Throat, Posy and Wright.

Diseases of the Eye, De Schweinitz.

Diseases of the Eye, May.

Text Book of Ophthalmology, Roemer and Foster.

Diseases of the Eye, Jackson.

Ophthalmic Surgery, Meller.

DISEASES OF THE EAR, NOSE AND THROAT

By J. DEASON

Diseases of the Ear

=Methods and Technic of Examination.=—The external ear may be examined by direct inspection with or without the aid of artificial light. The external auditory meatus may be examined by means of a simple conical ear speculum and reflected light from a head mirror. This method requires considerable practice but efficiency can and should be attained because it can be used under all conditions and therefore is a reliable method.

The Holmes electric auroscope which we use and recommend for examining the meatus and ear drum, is very efficient but like other electrical equipment is not always dependable. There are many electrical equipments for examining the ear, but so far I have found none other than the one above mentioned that is worth space in an instrument cabinet.

To examine the meatus, grasp the pinna and draw it firmly upward and backward. This tends to straighten the canal so that the aural speculum may be inserted well into the external canal. It must be remembered that the auditory canal is always sensitive and while there is really little danger of doing any harm by exercising ordinary care, the patient is always afraid of being hurt and one can accomplish better results by practicing careful technic.

If the electric auroscope is used, the eye should be placed very close to the lens and every part of the canal, walls and drum membrane carefully examined. The Holmes auroscope has a small tube and bulb, pressure upon which will vary the air pressure in the meatus and cause the drum to move. This must be done very carefully because in very thin, atrophic membranes there is some danger of rupturing the drum.

Diseases of the Auditory Meatus

=Inspissated Cerumen=, or hardened ear wax is one of the most common affections of the meatus. The cause in some cases can be traced to lesions of the mandible, but in many cases the cause is unknown.

=Treatment.=—Protect the clothing by means of a towel or rubber neck piece. By means of a soft rubber ear syringe, wash the canal thoroughly by forcing warm soap solution into it. I prefer concentrated liquid castile soap (any good soap will do) diluted about one to four in water as warm as the patient can bear it. The soap solution is contained in a pus bowl held tightly against the neck under the ear. There is little danger of using too much force with the soft rubber syringe.

In most cases the hardened cerumen will be dislodged by the syringing only. If this cannot be done, it may be well to discontinue the treatment until the following day. The solvent action of the soap solution will further reduce the hardened mass and it usually can be removed by syringing the following day. This method is preferable in many cases because patients dislike the pain which usually accompanies the use of a curet.

The dull loop curet is the most efficient and safest instrument for removing hardened cerumen that the syringe may fail to dislodge. This instrument must be used with great care because the membranes, long protected by the covering of cerumen are hypersensitive and bleed easily.

After removing the cerumen, the canal should be thoroughly dried and lubricated with some non-irritating lubricant. It is also well to place a small pledget of absorbent cotton into the external opening to protect the sensitive membranes from the cold, air and dust.

In drying the canal I prefer to use a small aluminum applicator, twisting a small piece of absorbent cotton on the end in such a way as to cover the tip well, thus making any injury from its use impossible.

Atrophic Meatus

Sensitive or itching ears as the patient commonly describes it, is a very common disease caused by any atrophic condition of the membranes of the auditory meati and frequently found in common with auditory or other cranial nerve deficiency or degeneration. The direct cause of the irritation is the collection of particles of dry cerumen.

=Treatment.=—The local treatment consists of syringing with warm (118° to 120°F) soap solution until all of the scaly cerumen has been removed. The canal is then dried and lubricated as described above. Several such treatments may be required after which I prefer the use of the continuous irrigating ear cup, using salt mixture instead of the soap. The same salt mixture as is recommended for nose and throat irrigation is satisfactory. After such irrigations the application of phenol-glycerine (10% phenol in glycerine) seems to be an efficient treatment.

The local treatment must, of course, be accompanied by corrective treatment to the mandible and upper cervicals.

Furunculosis

There are three acute affections of the ear which may usually be diagnosed from their points of tenderness or pain. Pain upon moving the lobe or pinna indicates furunculosis. Pain on pressure posterior to the angle of the jaw or externally in front of the ear indicates middle ear infection and pain on pressure over the mastoid region suggests mastoiditis.

Probably the most common of the painful diseases of the external meatus is furunculosis, which is a subcutaneous infection of the lining membrane of the meatus. The point of swelling may usually be seen but in some cases the entire canal is closed.

=Treatment.=—In all cases of occluded pus, drainage must be obtained, but in the early stages of furunculosis, it is not always possible to determine the place of “pointing” or the most desirable point to lance. As soon as the place of “pointing” can be located it is advisable to lance deeply by means of a curved paracentesis knife. The parts are thoroughly cleansed and anesthetized by applying phenol and neutralizing with alcohol. The external parts are first painted with alcohol to prevent “burning” from any phenol which may be dropped upon them. A small cotton applicator is used, applying the concentrated solution of phenol or the crystals (using only a small amount of phenol) to the affected parts and immediately neutralizing with alcohol. Care must be observed not to apply any phenol to the drum membrane and the operator must be sure that the action of the carbolic acid is completely neutralized by a liberal application of alcohol.

The knife blade is placed beyond the furuncle, its curved point turned outward and quickly drawn forward through the furuncle, cutting deeply. The canal is then packed with a pledget of cotton dipped into phenol-glycerine.

If the place of pointing cannot be seen, palliative treatment may be applied by thoroughly cleaning the meatus, drying and applying a phenol-glycerine pack. Heat may be applied by means of a therapeutic lamp. Any electric light bulb or the dry electric pack will do. The external parts are well lubricated with paraffin oil and the heat applied continuously or intermittently until the pain is relieved.

Infection of the Meatus

Infections of the meatus are frequently secondary to, or accompanied by furunculosis. The treatment, therefore, is similar to that of furunculosis.

Always try to locate the point of infection, lance or curet, apply phenol or other chemical germicide, neutralize, dry and pack with phenol-glycerine. After the point of infection has been thoroughly drained, cleanliness and protection from dust or further infection is all that is necessary.

In all cases of infection of the external meatus, suspect middle ear abscess as a cause. There may be a pin-point opening through the drum, from which the infection has originated and is being maintained.

=Otomycosis= or fungus infection of the auditory meatus is rare. It usually resembles other infections symptomatically, but often without pus. A microscopic examination will serve to diagnose the condition.

The treatment consists of thorough cleansing, drying and the free application of alcohol. Alcohol is dropped into the ear until the canal is full and a pledget of cotton applied to retain it. Usually two or three applications are sufficient to effect a cure.

=Eczema= of the auricle and meatus is of two types, the squamous or scaly form and the sclerotic form. Both forms are chronic and may be readily diagnosed by the appearance.

=Treatment.=—Some cases are very difficult to cure but we have had excellent results with the following treatment: Careful adjustment of cervical and mandibular lesions; thorough treatment of any local infections of head or neck; direct application of phenol-glycerine, local cleanliness and protection from irritation.

Diseases of the Middle Ear

Clinically the middle ear consists of the tympanic cavity and its contents, the Eustachian tube and the mastoid cells.

Acute Suppurative Otitis Media

Acute infections of the middle ear result from acute nasopharyngeal affections such as colds, influenza, measles, mumps, whooping cough, etc. Bathing in contaminated water often results in infection to the middle ear through the Eustachian tube.

=Diagnosis.=—Earache, pain on pressure under the angle of the jaw and sudden deafness are the symptoms. (There are also the common febrile symptoms.) The chief physical signs are: redness and bulging of drum membrane, and contraction and tenderness of upper cervical muscles.

=Treatment.=—If the patient is seen before the drum has ruptured it is seldom necessary to lance the drum if the proper treatment is given promptly.

Drainage must be obtained and maintained by catheter aspiration through the tube irrigation of the nasopharyngeal cavity, irrigation of the meatus by means of the continuous ear irrigator and application of dry heat over the affected part. Heat is best applied by means of a therapeutic lamp. (Any lamp with reflector that will furnish proper heat is efficient as there is no virtue in colored light.) The skin surface over the ear, side of face and mastoid region is first well lubricated with some mineral oil to prevent blistering and the heat is applied either constantly or intermittently. A pledget of absorbent cotton dipped into phenol-glycerine is placed in the meatus and forced loosely against the drum. This should be removed every few hours and a fresh pledget put in.

The neck and upper dorsal muscles should be kept relaxed and adjustive treatment given frequently.

Under this treatment the pain should be relieved and the bulging of the drum should disappear in from two to twelve hours. If this is not accomplished or if the condition grows worse, the drum should be lanced. See some text on otology for technique. In my experience, very few cases have required paracentesis.

It must be remembered that treatment should be continued regularly and for some time after the pain and other symptoms have been relieved or a recurrence is probable. Patients should have daily treatment until the physician is sure that no complication or recurrence is likely to result.

If the patient is not seen until after the drum has ruptured, the same treatment may be applied except the irrigation or syringing of the meatus. This, in case of ruptured drum, may force pus into the mastoid cells resulting in mastoiditis. Instead of syringing, the auditory meatus is cleaned by means of a cotton applicator or by aspirating with a catheter. At all times drainage through the meatus must be maintained until the drum begins to heal.

Acute Mastoiditis

Acute mastoiditis results from acute or chronic otitis media. In some cases the otitis media may have been only a mild attack.

=Diagnosis.=—There is no one symptom that is positively diagnostic but a number of signs and symptoms must be considered as follows:

1. Always suspect mastoid complications in acute otitis media and watch for this complication daily. Most cases have some mastoid inflammation.

2. Pain or swelling over mastoid. Pain may not be present, but usually is, sometimes radiating over temples and eye on affected side.

3. Tenderness on pressure not always present. May be very marked. Tenderness extending to tip or above ear means extension of infection. If persistent tenderness over tips with marked swelling and discoloration—operation is indicated.

4. Swelling, not always present, but sometimes very marked. If extreme swelling and bluish discoloration—usually means operation.

5. Temperature varies from normal to 104° or 105° F. Temperature of more than one or two degrees means systemic absorption and suggests surgical drainage. Streptococcus or staphylococcus infections cause higher temperatures and require drainage earlier than other infections.

6. Transillumination not positive, but of some value. Like X-ray, usually shows dark, because of inflammation, but must rely upon symptoms, as above.

7. =Microscopic.=—Stain for pus, bacteria and bone debris. Hematoxylin stain shows dark bone particles if there is bone disintegration.

8. =Blood Count.=—If absorption, there will be some variation in proportions of leucocytes. Any high leucocytosis shows systemic absorption and the natural attempt to overcome the infection.

=Non-Surgical Treatment.=—1. Drainage must be maintained from middle ear through tube or drum or both. Catheter aspiration through tube. Sometimes gentle inflation to clear the tube, followed by aspiration is effective.

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