Presented in honor of lliam R. Laughlin, D. 0. by 'lliamR. Laughlin COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA WILLIAM ROSS LAUGHLIN M.S. - D.O. Los ANGELES. CALIFORNIA The ^Praftice and Applied Therapeutics of OSTEOPATHY By HAZ CHARLES HAZZARD, Ph. B., D. O. Author of "Principles of Osteopathy," Former Profes- sor of the Principles of Osteopathy and of the Practice of^Osteopathy, Superintendent of Clinics, American School of Oste- opathy, Kirksville, Missouri. (Third Revised Edition.) KIRKSVILLE JOURNAL PRINTING CO. 1905. \A>JJ 7V V Copyright by CHARLES HAZZARD 1905. PRACTICE OF OSTEOPATHY. Preface to the Third Edition. Since the publication of the second edition of this work, the growth and progress of Osteopathy have been marked, and it has been the aim of the author to have these pages reflect those virile characteristics of the Science. He has made an earnest endeavor to add to his previous work as much as possible that would be of value to the profession. The work has been rewritten in many parts, and much new matter has been added throughout, considerably enlarging the volume. The same considerations that before led to the omission from these pages of the facts of pathology, symptomatology, etc., which the student finds useful in his studies, but which are so available from other sources, were still deemed sufficient. But the continued demand for a compact work upon this subject, of moderate price, and devoted exclusively to osteopathic considera- tions seems to warrant the bringing out of this further edition. CHARLES HAZZARD, New York City, Nov 18, 1905 "Go little book, "Bearing an honored name, " 'Till everywhere that you have went, "They're glad that you have came." (BILL NYE OR SHAKESPEARE.) PRACTICE OF OSTEOPATHY. Preface to the Second Edition. In preparing the second edition for press, much care has been taken to make the work a complete text-book upon the subject of Practice of Osteopathy, and to make it thoroughly osteopathic throughout. It is obviously unnecessary to include- in such a work ma- terial so easily available in the many standard texts of medical practice. It is better that the student should, so far as neces- sary, refer to them for the symptomatology, pathology, etc., of the diseases he studies, rather than to fill these pages with a repeti- tion of what has been so well written elsewhere. Thus the author is left free to devote these pages exclusively to the osteopathic aspects of disease. Collaterally with this work one may use any standard medical practice, as was done in the American School in the course in which the matter presented in this volume was delivered as a course of lectures. The second edition is thoroughly revised and much en- larged. To Part I have been added various points of use in examination and diagnosis from an osteopathic point of view. To Part II have been added several hundred new case reports. These reports have been added to the subjects which were con- sidered in the first edition, and have likewise been added to the work in the consideration of the many diseases not discussed in the first edition. By the use of these many CASE REPORTS there is established a foundation of actual fact and experience for this work. Theory is of value, and is assigned its proper place here, but the facts shown in the case-reports have been demonstrated by the actual work of Osteopaths in all parts of the field, whence these reports are drawn. They give to the practitioner the value of others' experience. Much care has been given to the analysis of LESIONS presented by reports, and to the pointing out of the lesions which may be expected as the CAUSES of disease. 6 PRACTICE OF OSTEOPATHY. Under the head of ANATOMICAL RELATIONS are considered the anatomical and physiological reasons why various given lesions may derange function and cause disease. These points have involved much careful research, and the author feels that they will be found of value to student and practitioner alike. The TREATMENT of each disease is discussed at some length. Much thought must be devoted by the successful practitioner to his method of handling his case. In each case the various points of treatment applicable are pointed out. Part I is re- ferred to in these sections as a key to Part II. In this way specific treatments are indicated. CHARLES HAZZARD. Kirksville, Mo., June 1, 1901. PRACTICE OF OSTEOPATHY. PART I GENERAL METHODS. CHAPTER I. EXAMINATION OF THE SPINE. Inspection, percussion and palpation are the physical meth- ods employed by the examiner. Of these the latter is most important. Attention must be given to the position of the pa- tient, changing it as required for the best detection of the various lesions for which examination is being made. For example, lateral deviations of vertebrae and departures from normal cur- vature of the spine are best detected while the patient is sitting. Points of separation between spinous processes, thickening of posterior spinal ligaments, rigidity of the spine, etc., are most readily made out while the patient is lying upon the side. The back must be bared in examination. For ladies, a loose gown buttoned down the front and back may be convenient- ly used. By the methods mentioned above the examiner searches for certain definite legions, as follows: INSPECTION reveals the color of the skin; rashes, which may indicate disease; the presence of curvature or other deformity; unequal muscular development, or change of contour from what- ever cause; scars, wounds, stains, and excoriations, leading to inquiry regarding accident, injury, operation, or the use of poul- tice; injected blood-vessels; tumors, enlargement of parts, etc. Inspection may be made with the patient sitting. In any examination, care must be taken not to so place the patient as to cause his position to mask the lesion. An un- natural posture may be to him natural by reason of his condit- ion. If now an attempt be made to cause him to assume the usually natural position, the result may be to obscure that which would be a clew to his disability. Close inspection should be made of a patient's habitual posture, gait, etc., as a preliminary step. One often gains thus valuable clews to his condition. 8 PRACTICE OF OSTEOPATHY. Inspection often reveals inequalities of waist-lines and hips. A waist-line deeper cut on one side, usually accompanied by a higher or larger contour of the corresponding hip, is a frequent indication of a swerved spine. PALPATION is our most important method of examination, the trained touch revealing to the Osteopath most of the lesions which he regards as the causes of disease. . With the patient sitting slightly bent forward, the arms folded loosely or the hands resting lightly on the knees, the ex- aminer stands behind the patient and passes his two index fingers, or the index and second fingers of the examining hand, care- fully down the opposite sides of the vertebral spines. He notes: I. Single vertebra or groups of vertebrae which may be deviated laterally from normal position. In such case there is usually, though not always, tenderness in the tissues upon the side of deviation, owing to the irritation by the process. In order not to mistake a bent spinous process for a lateral lesion of the vertebra, all such apparent lesions should be further tested by feeling out the transverse processes of the vertebra in question. Dr. Still uses these more than the spinous processes in identifying lateral lesions. If the spinous process is merely bent the transverse processes have not changed their relations to the surrounding tissues. Lateral deviation of one or more vertebrae causes the trans- verse processes to rotate slightly backward on one side and for- ward on the other. This alters the depth of the furrow running along the spine on either side of the spinous processes. Pressure of the examining finger carefully into those furrows at the point of lesion will show that the furrow on one side is deeper, and on the other side shallower, than normal. Such observation of transverse processes and furrows will obviate error over bent spinous processes. II. Lateral swerving or sagging of any portion of the spine. III. Any exaggeration, deviation from, or lessening of the normal curves of the spine. The most common of these are a flattening of the spine anteriorly at the dorsal curve between the shoulders, and a flattening of the spine posteriorly at the PRACTICE OF OSTEOPATHY. 9 lumbar curve, these two lesions together causing the so-called " straight spine." IV: Sharp friction, made by passing the hand quickly down the spine, reddens the tips of the spinous processes so that one may then count them or note their alignment. V. The flat of the hand is passed down over the posterior .aspect of the sacrum and detects any flattening or bulging thereof. It is also passed over the posterior superior iliac spines, noting their degree of prominence and comparing them with each other relatively to the sacrum. VI. The cushions of the examining fingers are pressed deeply into the sacro-iliac spaces to detect any abnormal tension or tenderness in the superficial or deep tissues. VII. The index finger follows the course of the coccyx to its tip, noting any lateral, anterior, or posterior deviation. VIII. The index finger is carefully passed down the spine upon the spinous processes, pressure being made firmly upon each, to detect either anterior or posterior projection of vertebrae. IX. The temperature of the back is found by passing the palm of the hand evenly over it. Vaso-motor disturbances, resulting in lowered or increased temperature of certain areas, may be thus discovered. Frequently a cold area may be traced diagonally backward and upward along the course of the spinal nerves toward the seat of lesion. The patient is now placed upon his side in an easy posit- ion. The examiner stands at the front of the patient and con- tinues the examination. X. The cushion of the examining finger, which is held at right angles to the spinal column, is carefully pressed deeply into the space between each successive pair of spinous processes. It discovers any separation or approximation of processes, thus of vertebrae. Students often have difficulty in distinguishing a separa- tion of processes from an anterior displacement, the former be- ing often diagnosed as the latter condition. One may avoid such errors by remembering that the separation is rarely so great as the space left by a marked anterior displacement of a ver- tebrae. The latter condition is rare. In case of doubt count 10 PRACTICE OF OSTEOPATHY. the next two spinous processes above or below the point in quest- ion, and compare the space they occupy with the space occupied by the lesion and the spinous process next above or below it. The comparison will at once aid in determining the point. Points of anatomical weakness are frequently found at the junction of the twelfth dorsal with the first lumbar verte- bra, also at the junction of the fifth lumbar with the sacrum. The fifth lumbar is often prominent posteriorly, but is also- very apt to be luxated anteriorly or laterally. Separations occurring between the fifth and the sacrum are often mistakenly treated as anterior displacements of the fifth. Separations at this point are common. Marked tender- ness is usually present. XI. The examining hand is passed slowly along the spinaL column to note any general or local thickening and increased tension in the posterior spinal ligaments which results in par- tially obliterating the spaces between the spinous processes, and in producing the so-called "smooth spinal column." XII. The examining fingers are pressed firmly into the spinal muscles and moved transversely to the course of their fibres for the purpose of detecting any abnormal hardening or contracturlng of them. Contractures generally affect certain sets of fibres rather than the muscle as a whole. They may be situated in the superficial or in the deep muscles, and may be primary or secondary according as they are produced by di- rect or indirect lesion of the fibres. XIII. The body of the patient is braced against that of the practitioner, who places the fingers of both hands upon the under side of the row of spinous processes, (the patient lying on his side) and draws the spine forcibly toward him, noticing whether the spine be rigid, or too greatly relaxed. It must be borne in mind that bony lesions are not alone important. Ligamentous lesions are quite as much so, and though they are not so generally discernible as are the former, the student must not forget that following upon and conse- quent to bony lesion they may bring pressure upon important structures, may thus interfere with the functions of blood-vessels,, nerves, etc., and become a fruitful source of ill. PRACTICE OF OSTEOPATHY. 11. PERCUSSION, PRESSURE AND MOTION may be employed in the examination of the spine, and may sometimes reveal deep tenderness or pain in the tissues which has escaped notice by the other methods. Upon motion, certain sounds are heard in various parts of the column, due to the motion of parts upon each other. These seem to occur most frequently in the neck, between the articular processes, and in the lumbar region, between the bodies of the vertebrae, and between the articular processes. Motion between the heads of the ribs and the bodies of the ver- tebra? , and between the tubercles of the ribs and the transverse processes is frequent. They may occur anywhere along the spine and are of diag- nostic value in indicating relaxation of ligaments, interference with blood-supply, resulting in insufficient secretion of synovial fluid, or malposition of bony parts. A motion which tends to separate the members of a joint may produce a suction sound therein. A sharp, cracking or snapping sound may accompany the normal play of tendons. The "examiner should not overlook the results of lesions which in any way alter the equilibrium of the spinal column. When this occurs, the weight of the trunk no longer rests squarely upon the pelvis, but drives upon it at an angle, unequally con- tracting lumbar muscles and ligaments, tilting the pelvis, shorten- ing a limb, etc. Lumbago and sciatica often result from such conditions, as do, likewise, various neck lesions, and even spinal curvatures. CHAPTER II. TREATMENT OF THE SPINE. In this chapter it is proposed to outline the general method of procedure in spinal treatment. As no specific case or dis- ease is now under consideration, the student must bear in mind that the treatments described are general methods and that in any given case he would find it necessary to select and combine these different modes in a manner best calculated to enable him individuallv to reach the case. 12 PRACTICE OF OSTEOPATHY. As far as practicable the specific lesions mentioned in Chapter I will be considered, and treatments appropriate to their re- duction will be given. These treatments are all manipulative. They have as their object the righting of what is mechanically wrong. They are therefore mechanical of necessity, and are founded upon the necessities of the human mechanism when deranged. In treatment, the practitioner may have in view either or both of two objects. He works to right the spine itself, and to affect it alone, or he works upon the spine to affect some other part of the body pathologically connected with the part of the spine in question. I. The patient lies upon the ventral aspect of the body in as comfortable a position as possible. The head turns easily to one side, and the arms hang down loosely at the sides of the table. The practitioner must see that the patient thoroughly relaxes the muscles of the whole body. He now, standing at the side of the patient, uses the palms of the hands or the cushions of the fingers to thorqughly manipulate and relax all the spinal muscles. In treating the muscles upon the side toward him, he works from one end of the spinal column to the other, in a direction at right angles to the general direction of the muscular fibres. He treats the muscles of the opposite side by spreading them away from the spinous processes. In this way all contractures of the muscles are released, flabby muscles are toned, blood and nerve mechanisms are freed and upbuilt. This removing ' of contractures is sometimes a necessary preliminary step to the diagnosis of deeper lesions which may have been masked by them. II. The patient lies upon his side, the practitioner stands at the side of the table, in front of the patient; with one hand he grasps the uppermost arm of the patient just above the elbow; with the other hand he holds under the spinous processes of any portion of the spine under treatment. Now, using the arm as a lever, he pushes it downward and forward, at the same time springing the spine toward him. This treatment releases tension in all deep structures, re- stores free-play between bony parts, and removes pressure from PRACTICE OF OSTEOPATHY. 13 blood-vessels and nerves. It may be applied in all cases of curvature, sagging or swerving of a portion of the spine, lateral deviations of vertebra?, in separating or approximating verte- brae, etc. III. Practically the same effect may be obtained upon the lower portion of the spine as follows: with the patient still upon the side, his thighs and legs are flexed, and fixed by pressure of the abdomen of the practitioner against them. Both hands are now free and spring the spine strongly upward toward him, or to manipulate the muscles; or, IV. With the patient still lying upon his side, the practi- tioner leans over him, placing his forearms, one against the iliac crest and the other against the shoulder. He now with his forearms pushes these two points further apart, while with both hands he springs the middle portions of the spine toward him, or manipulates the muscles. It will be observed that the treatment described under II, III and IV above all may be used to thoroughly stretch any portion of the spine by laterally directed force. In this way deeper stretching of all spinal structures may be accomplished within the limits of safety than by stretching the spine as a whole by longitudinal traction. V. The latter is applied with the patient lying upon his back; the practitioner, standing at the head of the table, passes one hand beneath the occiput, the other beneath the chin, and draws toward him. The required degree of resistance is afforded by the weight of the patient or by an assistant holding the ankles. The neck must not be rotated during this forcible tension, and jerking must be avoided. VI. The principle of exaggeration of the lesion is one that may be applied to the treatment of many bony luxations. It consists in so manipulating the parts as to tend to further in- crease their malposition, and in then applying pressure to them in such a direction as to force them back toward normal position at the same time as the part in question is released from its con- dition of exaggeration. This motion releases tension, loosens adhesions, and gains 14 PRACTICE OF OSTEOPATHY. the benefit of the natural recoil of the structures from their ex- aggerated position. VII. With the patient prone and the practitioner kneeling upon the table at one side of the patient, or with a knee upon either side, direct pressure may be applied, from above down- ward, to all spinal parts. This position of relaxtion is favor- able for forcing vertebrae or the heads of ribs into place and for the stretching of the deep and anterior spinal ligaments. VIII. The patient lies across the table with the abdomen and anterior chest resting upon it, the arms and head hanging loosely down upon one side and the legs upon the other. The practitioner may stand at either side of the table (or kneel upon it,) and work for results as in VII, with the additional advantage that the arms, neck, or limbs may be manipulated at will in the course of the treatment. IX. The patient sits, the practitioner stands in front, slightly to one side facing backward from the patient. He passes the arm nearest the patient back of the neck, and slips his hand under the opposite axilla from in front. This bends the neck and upper spine forward and swings the opposite side of the thorax backward, thus rotating the spine. By using the free hand as a fixed point at various points along the spine, its suc- cessive portions may be thoroughly rotated and all of its struc- tures loosened. X. The patient sits; the practitioner stands behind, push- ing the head forward and to one side with one hand, while with the other he makes fixed points along the upper spine, upon the side from which the head has been forced. The head is now swung forward and to the side opposite its first position while the hand brings pressure upon the fixed points, one after the other. This motion makes use of the neck as a lever of the first class, the fulcrum being formed by the hand at the fixed point, with the lesion (weight) below, and the power (hand applied to the head) above. It is a method of "exaggeration of the lesion," and is especially useful for the reduction of lateral luxations in the upper part of the spine. X. (a) A variation from the above applies the same prin- ciples to lesions lower down in the spine. The patient sits; the PRACTICE OF OSTEOPATHY. 15 practitioner stands at one side and passes one arm in front of him, grasping his body securely, and rotating his trunk about fixed points made at any desired place along the spine by the application of the free hand to it. The cushion of the thumb of this hand is pressed firmly against one side of the spines of the vertebrae suffering from lesion, while the bent index finger is pressed against the other. XI. The patient sits and clasps his hands behind his neck; the practitioner stands close behind, passes his arms beneath the axillae and his palms behind the patient's wrists, which he' grasps in his hands. As the practitioner straightens his body and draws the patient back against his abdomen the neck and upper dorsal spine are bent forward, the scapulae travel back and up, and all of the ribs, except the first three or four pairs, which are sprung forward and downward, are drawn strongly backward and upward. This treatment thoroughly stretches most of the spinal ligaments, costo-spinal ligaments, muscles of the back of the neck, scapula?, and of the spine. It also brings tension upon most of the intervertebral, the costo-vertebral, the costo-sternal, acromio-clavicular and claviculo-sternal articulations. XII. With the patient sitting, the practitioner, standing behind, may place one knee beneath the patient's axilla, thus raising and fixing the shoulder and the ribs of one side of the thorax. This relieves the spine of the weight of these struc- tures and affords the practitioner two free hands with which he may manipulate the spine or opposite side of the thorax, using the neck and other arm of the patient as levers, if desired. XIII. The ligaments of the posterior lumbar and of the sacro-illac regions may be thoroughly relaxed by bending the body of the patient, who is sitting, far forward between his well- separated knees. XIV. The same object is accomplished with the patient supine, while the legs and thighs are both forcibly flexed to their limit. XV. To stretch the posterior scapular, rhomboid, and levator anguli scapulae muscles, the patient lies upon his back while the practitioner slips one hand beneath the shoulder and grasps 16 PRACTICE OF OSTEOPATHY. % the spinal edge of the scapula, which has been approximated as closely as possible to the spinal column. The other hand holds the arm of the patient just above the elbow, and the arm is. raised and pushed across the chest, the patient's hand being in this way forced across well into the opposite axilla. XVI. With the same position of the patient, the anterior scapular muscles may be reached by thrusting the fingers of one hand deeply beneath the spinal edge of the scapula, while the other hand grasps the point of the shoulder. Now the whole lateral half of the shoulder-girdle may be rotated, the first hand continually working deeper beneath the scapula. XVII. A thorough "breaking up" of the lower dorsal and lumbar regions of the spine is accomplished as follows: The patient lies prone; the practitioner stands at the side and passes one arm beneath the thighs of the patient, just above the knees which he raises just free of the table, moving them horizontally from side to side. At the same time his free hand is applied to the part of the spine in question, the thumb upon one side of the spinous processes, -the fingers upon the other. The thumb and fingers make lateral pressure upon the spine, alternating with, and in a contrary direction to, the movement of the limbs. This treatment loosens and separates the vertebrae, releases tension of muscles and ligaments, and upbuilds nerve and blood- action. XVIII. Dr. Still, in case of lateral spinal lesion, stands in front of the patient, who is sitting. He passes both arms around the body and clasps his hands over the point of lesion; "sinks" the spine down upon this point, bends the patient to- ward the side of deviation of the vertebra, then with the hand makes pressure upon the vertebra to force it back to place while he rotates the body toward the opposite side. Very many more treatments might be described, but enough general treatments have been given to reach all parts of the spine and to correct the lesions that are likely to be met with in practice. These treatments may be combined or may be taken as the basis of new ones which the practitioner may often find necessary to work out in order to reach some special lesion or to treat some special case. PRACTICE OF OSTEOPATHY. 17 In this portion of the text, the treatments can of necessity be described, and their application be given, only in a general way. They are outlines of methods of procedure, and the ap- plication of the principles embodied in them must be made to the specific lesion met with in a given case by the practitioner. The lesions described in Chapter I, such as lateral deviation of a vertebra or lateral swerving of a portion of the column; vertebrae separated or approximated; anterior or posterior lux- ations of vertebrae; the "smooth spine"; the loss of normal curva- ture; the rigid or relaxed spine, etc., may all be reduced by vari- ous applications of these treatments. Generally speaking, the results attained by the use of these treatments are, the relaxation of contractured muscles; the re- lease of tension in nerve, muscle, ligament or other fibrous struc- ture; the reduction of bony lesion; the removal of obstruction from, and the renewal of, blood and nerve-currents. XIX. The fifth lumbar vertebra, after luxation, may be restored in various ways. The posterior- displacement is the most frequent. In this case one may place the patient upon his side, flex the knees against one's abdomen, fix the fifth lumbar by holding beneath it with one hand, while the other, slipped beneath the thighs, rotates the weight of the lower part of the body about the fixed point. Recent dislocations may be ad- justed in this way without difficulty. In long standing cases, continued treatment is necessary, the work of relaxation of parts, etc., in preparation for its reduction, being performed in part by the application of principles already described. With the patient upon his back and the body below the fifth lumbar protruding over the foot of the table, the practit- ioner, standing between the limbs and holding one under each arm, places both hands beneath the pelvis, makes a fixed point at the fifth lumbar, and by th* 1 movement of his own body ro- tates the lower half of the patient's body about the fixed point. With the patient upon his back, the practitioner standing at one side, the clenched hand is placed beneath the body at one side of the fifth lumbar spine. The leg and thigh are now strongly flexed by the free hand, external circumduction of the thigh is made, and the weight of the body is thrown onto the 18 PRACTICE OF OSTEOPATHY. fixed point. In some cases this treatment is sufficient for re- placing the bone. In case the vertebra be anterior the above treatments may be applied for the purpose of loosening all the ligaments. Also the principle of exaggerating the lesion may be ap- plied by making a fixed point of the practitioner's knee at the fifth lumbar, the patient sitting. The patient's body is bent backward against the fixed point and then rotated forward. Also, with the patient sitting and the fifth lumbar fixed with one hand, the free arm grasps the body of the patient and ro- tates it about the fixed point. The bodies of the vertebrae may be thus warped or slightly moved upon each other, drawing the bone back to place. In many long-standing cases of bony lesion, the strength- ening of the surrounding muscles and ligaments must take place and be depended upon to hold the ground gained as the part is gradually, during a course of treatment, brought back toward its normal position. XX. In case the. sacrum be found to be anterior or posterior from its normal position, this is a matter partly relative to the position of the innominate bones, luxations of which will be discussed later. In cases of posterior protrusion, after relaxation of the sacro- iliac ligaments, pressure may be made with the knee directly upon the sacrum from behind, with the patient either sitting or lying upon his side. At the same time the pelvis and the upper parts of the body are drawn strongly backward. XXI. In restoring the coccyx to normal position both ex- ternal and rectal treatment may be necessary. In some cases external treatment alone will be sufficient. The sacro-coccy- geal articulation is generally quite pliable. In external treatment, attention must be first given to the relaxation of the mucles and fibrous tissues concerned. The bone may then be grasped and moved or sprung from either side toward the median line, may be forced anteriorly, or the finger may be gently inserted beneath its tip and may draw it back toward its natural posi- tion. Rectal treatment should not be given oftener than once a PRACTICE OF OSTEOPATHY. 19 week or ten days. The patient lies upon his side or bends, face downward, over a table. The index finger, anointed with vase- line or oil is inserted, palm down, into the rectum. It is then turned palm up, laid along the hollow of the coccyx, and swept from side to side, to free the action of blood-vessels and nerves. With the finger in the rectum and the thumb outside, the bone may be grasped and moved toward any position necessary. As a rule its restoration to a normal position is only gradually accomplished. CHAPTER III. EXAMINATION OF THE NECK. INSPECTION and PALPATION are the two physical methods used in examination of the neck. INSPECTION reveals scars due to wounds, and suggests a history of accident or operation. The general conformation of the neck should be noted. Upon the anterior aspect may be seen enlargement due to increase in the size of the tonsils or of the lymphatic glands; abnormal pulsations or engorgement of the blood-vessels; an enlarged thyroid gland. Upon the posterior aspect may be found enlargement of the muscles or thickening of the tissues. Frequently an inequal- ity of the tissues in and below the sub-occipital fossae, due to thickening or to bony lesion, occurs. This inequality often indicates the existence of a typical cervical condition of much importance to the Osteopath. So frequently does one meet this sort of a neck in practice, and of such importance are the various lesions present, that its ready recognition becomes necessary. Upon inspection, inequality is seen in the postero-lateral aspects of the neck. One side will be somewhat hollowed, and the other side full. In general ex- amination of the spine one takes such condition as an indication of slight curvature. Further examination show such to be the case in the neck. The tissues are usually found, upon palpation, to be tense and contract ured upon the full side. They are as a 20 PRACTICE OF OSTEOPATHY. rule tender. The tissues upon the hollow side may be in a sim- ilar condition, not usually so marked. Palpation further shows a swerving of the cervical vertebrae, convexity to the full side. All or several of the vertebrae are involved, thus causing an ex- tensive cervical lesion, capable of producing the various ills due to bony lesion of this region. This cervical condition is often found associated -with, and may sometimes be due to. a swerve in the spine below or an in- nominate lesion, changing the equilibrium of the spine and giving a one-sided tendency. Any unnatural position in which the head may be held should be noted. PALPATION is here, as elsewhere, the important method of examination. For convenience the anterior structures may be examined first. The patient lies upon his back, relaxing the neck as much as possible. This object may be aided by the practitioner, placing one hand upon the forehead and gently rolling the head from side to side, while with the other he lightly manipulates the muscjes of the neck. A. ANTERIOR STRUCTURES. I. The tonsil is located by pressure of the fingers just below the angle of the inferior maxillary bone. Any enlargement or tenderness of the organ is to be noted. This examination should be supplemented by inspection of the throat internally. In palpation of the tonsil externally one often feels an en- larged lymphatic gland below the angle of the jaw, accompanying the enlargement of the tonsil, for which it should not be mistaken. II. Tender points, . frequent in catarrhal conditions, are found by deep pressure behind the angles of the inferior max- illary bones. III. The hyoid bone is located by pressing all the soft tis- sues just below the jaw toward the median plane of the body. This causes a prominence of the greater cornu upon the opposite side of the throat, which may be easily detected by the index finger. The finger remains upon the cornu and pushes it back to- ward the first side, thus making prominent the greater cornu of PRACTICE OF OSTEOPATHY. 21 that side. With the index finger and thumb upon the cornua, the bone may be moved about and a diagnosis of its position be made. Contracted tissues may draw the bone upward, down- ward, or to^one side. IV. The hyoid musdes, superior and inferior, are now carefully palpated to discover contracture, hypertrophy, con- gestion or tenderness in them. In public speakers, singers,and others liable to throat disease the superior hyoid muscles are often in pathological condition. V. From the hyoid region, palpation is carried down over the thyroid and cricoid cartilages, noting whether their condi- tion be normal, arid is extended along the throat structures to the root of the neck. In this examination the parts are grasped between the thumb and fingers of the examining hand and are moved from side to side. At the same time, deep but gentle pressure is made at either side of the larynx and trachea in order to note any undue tenderness in the laryngeal nerves, as gener- ally revealed Jby an impulse upon the part of the patient to cough or swallow. Immobility or harshness of sound upon motion of these parts as above indicates abnormal tension in the related muscles and other tissues. VI. Enlargement or wasting of the thyroid gland or enlarge- ment of the cervical lymphatic glands must be noted. VII. The stern o-mastoid muscle is made prominent by causing the patient to turn his head to the opposite side. Pres- sure deep behind the anterior border of this muscle impinges upon the pneumogastric nerve. Tenderness in it upon pressure may accompany liver or stomach disease. Its superior laryngeal branch is located by pressure behind the greater cornu of the hyoid bone. Note whether the hyoid muscles are contractured in such a way as to draw this bone back upon the nerve. Its recurrent laryngeal branch may be impinged by pres- sure near the anterior border of the sterno-mastoid muscle at the level of the cricoid cartilage. This pressure irritates the larynx and causes the patient to cough when the nerve is ten- der, as in various throat affections. Note the condition of irrita- bility of the nerve. 22 PRACTICE OF OSTEOPATHY. VIII. The phrenic nerve arises from the third, fourth, and fifth cervical nerves, and may, at its points of origin, be pressed backward against the bony column. It may be reached also by deep pressure with the thumb or finger in the angle formed by the posterior edge of the sterno-mastoid muscle with the upper margin of the clavicle. This pressure must be directed from above diagonally downward and forward toward the sternum. IX. Pressure of the head directly downward upon the spinal column with rotation, will sometimes discover deep pain at points of lesion. X. With the patient lying on his back, turn h'.s head well to one side and to the other, noting any inequality in the degree to which it readily turns. Contracted muscles, luxated vertebrae, etc., often prevent its turning so far to one side as to the other. Occasionally motion is so restricted (e. g., in chronic mus- cular or articular rheumatism) that the head can be turned scarcely a fraction of an inch. XI. The posterior structures of the neck may be tested for abnormal tension by flexing the head upon the thorax, the patient upon his back. The examining finger should follow the ligamentum nuchse carefully up to its insertion at the skull, where deep soreness and contracture are sometimes found associated with headaches. XII. The palms of the hands may be passed evenly over the surface of the neck to examine for variations of tempera- ture. Hot or cold areas may be found. It is common to find an area of increased temperature at the base of the skull behind- XIII. The state of the blood-vessels should be noted. A strongly pulsating carotid artery is seen in aortic regurgitation and in some nervous diseases. A venous pulse in the jugular veins may accompany marked tricuspid regurgitation. Con- gested veins of neck, chest, and face, especially if unilateral, may indicate pressure of a thoracic aneurysm or tumor. Often one sees one external jugular vein much fuller than its fellow, due to narrowing of the space between clavicle and first rib. Hard, incompressible, or rigid, carotid arteries indicate arterio- sclerosis. They are commonly accompanied by rigidity and PRACTICE OF OSTEOPATHY. 23 tortuosity of the temporal arteries, and by cardiac hypertrophy and valvular lesion. B. POSTERIOR AND LATERAL STRUCTURES. I. With the patient sitting, the practitioner passes the ex- amining hand down along the back of the neck. Just below the occiput is a depression in which he may feel the upper end of the ligamentum nuchse and the inner borders of the trape- zius muscles. With the head bent slightly forward and the ex- amining fingers pressed deeply into this space abnormal tension of these structures may be noted. II. The second cervical spine is the first bony prominence felt below the occiput. The spines of the third, fourth and fifth are made out with difficulty, as they recede from the surface anteriorly. The next palpable spine is that of the sixth, the next of the seventh. The latter is prominent, but not so much so as the first dorsal, from which it must be carefully distin- guished. There are two ways to distinguish between them. The sixth cervical spine is first located. While not at all promi- nent it may easily be felt as a small point snugly resting upon the upper surface of the seventh. Commonly a careful exam- ination locates the sixth without difficulty, thus the seventh is known to be the next below, and is distinguished from the first dorsal. Anterior, posterior, or lateral deviations of the cervical verte- brae may be diagnosed by this examination of the spinous pro- cesses. III. Anterior dislocations of the upper three cervical ver- tebrae may be sometimes noted by examining for the. promi- nence caused by the body upon the posterior wall of the pharynx. This is done by passing the finger over these bodies. IV. The position of the atlas is examined as follows: The patient lies upon his back and the practitioner stands at the head of the table. The transverse processes are located by thrusting the palms of the examining fingers deeply into the space between the angle of the inferior maxillary bone and the tip of the mastoid process. A finger is placed upon each transverse 24 PRACTICE OF OSTEOPATHY. process, which is usually prominent. Normally these processes should be midway between the angle of the jaw and the tip of the mastoid process. If they are too far forward, too far back- ward, to one side, or if one be forward and the other backward, the diagnosis is readily made by comparison of the position of the processes relatively to the points mentioned, and the cor- responding displacement of the atlas is discovered. Occasionally the posterior tubercle of the atlas may be felt in the space between the second cervical spine and the skull. In palpating the transverse processes of the atlas, care should be taken to feel out their shape and contour fully. They vary ex- ceedingly in size within normal limits, being sometimes so large as to extend below and behind the mastoid processes. If the relations of the atlas with the axis be unchanged, while those of the atlas with the skull are altered, we must re- gard the head as being displaced upon the atlas. V. Lateral deviations of vertebrae in the neck are best found by examining the articular processes. The head, with the patient lying upon his back, is turned to one side, making prominent the row of articular processes upon the opposite side. The second cervical spine is now readily located by its prominence behind, and the finger traces from it around to the articular process of the second, lying at about the same level, but slightly above. A finger is held upon this pro- cess and the head is turned to the opposite side. The other artic- ular process of the second is then located in the samp way. They are now compared while moving the head slightly from side to side, and lateral deviations or tenderness in the tissues are easily made out. With these two points fixed, the head may be gently turned from side to side, and the examining fingers travel down over the successive articular processes, careful examination being made of the position of each. VI. Deep pressure may be made from the anterior surface of the neck back upon the anterior aspect of the transverse pro- cesses and diagnosis of anterior luxation be made. VII. Crepitus and abnormal mobility of bony parts indi- cate fracture. VIII. The patient lies on his back, and the practitioner PRACTICE OF OSTEOPATHY. 25 stands at one side of the head, turns the head slightly to one side and passes the examining hand transversely to the course of the muscle fibers, noting any contractures of the muscles, superficial or deep. IX. He then stands at the head of the table and examines both sides of the neck at the same time, a hand upon each side, carefully comparing both sides with especial reference to any abnormality either of bone or of other tissue. X. Careful examination should be made for thickening of the tissues of the neck just below the occuput. Sometimes these tissues may be felt like a thick transverse band across the back of the neck just below the skull. Such a lesion is usually an in- indication of intense congestive headaches. XI. The scaleni muscles are made prominent upon one side by drawing the head to the opposite side. They are normally hard to the touch, and care should be taken in the diagnosis of contracture. Tenderness is often found upon pressure, as in cases of rheumatism. Their contracture often results in drawing the first two ribs upward out of place. XII. The brachial plexus of nerves emerges from between the scalenus anticus and the scalenus medius muscles, below the level of the fifth cervical vertebra. The head is inclined to the side to relax these muscles, and deep pressure is made at this point to impinge the plexus. Tenderness is thus revealed. This plexus may be readily traced downard behind the clavicle, and along the inner side of the arm. XIII. Tender areas are often found upon pressure in the sub-occipital fossae. They are due to irritation of the great and small occipital and great auricular nerves. It is through manip- ulation of these nerves largely that effects are gotten upon the superior cervical ganglia and upon the medulla. They are lo- cated at a point about two inches from the middle of the post- erior margin of the mastoid process, in a line at right angles thereto extending toward the median plane of the neck pos- teriorly. These nerves, when firmly pressed, carry a sensation of pain to the top of the head and over it to the brow. XIV. The superior cervical ganglion lies in front of the 26 PRACTICE OF OSTEOPATHY. transverse processes of the second and third cervical vertebrae, and may be reached by direct pressure through the tissues. The method of locating the transverse process of the second "cervical has been given under V of this chapter. Deep pressure from the anterior aspect of the neck may press this ganglion back against these processes. This ganglion lies in front of the rectus capitis anticus muscle, which is penetrated by its branches connecting it with the first four cervical nerves. The middle cervical ganglion, lying in front of the trans- verse processes of the sixth and seventh cervical vertebrae, may be likewise reached. This ganglion has branches connecting it with the fifth and sixth cervical nerves The lower cervical ganglion lies in front of the first costo- vertebral articulation, and is connected with the seventh and eighth cervical nerves. The transverse process of the seventh cervical vertebra is readily located by deep lateral pressure at the outer third of the supra-clavicular fossa. Lesions of the atlas and axis are by far the most important occurring in this region of the body, and account for many ser- ious diseases of the head and its parts, such as blindness, insanity, etc. The lesions of the neck hold an important relation also to diseases in other parts of the body. Comparatively little treatment is given directly to the head and its parts. These are treated largely through the removal of lesion in the neck. Hence the importance of most thorough and careful attention to its examination. The value of gently moving a part while under examination in order to relax tissues, to insinuate the examining fingers more deeply into them, and to develop the latent lesion through in- vestigation of its relations to its neighboring parts during move- ment must not be overlooked. CHAPTER TV. TREATMENT OF THE NECK. Treatment of the neck, as of other parts is, in its specific application, always removal of lesion. The following general PRACTICE OF OSTEOPATHY. 27 description of methods of work in treating the neck is for the purpose of laying before the student in a simple manner the general principles involved in our work. Later specific appli- cation of these general principles and methods will be made. I. With the patient upon his back, the guiding hand is laid upon his forehead and the head is rolled gently from side to side a few times to aid in relaxing the muscles. The fingers of the operating hand are laid, palm down, upon the muscles of the throat on the side opposite to the practitioner. As the head is moved away from the practitioner, these muscles are loosened through the shortening of that side of the neck. At the same time, the operating hand draws these muscles toward the median plane of the neck. The head may be now moved from side to side, Avhile the fingers upon one side of the throat and the thumb upon the other manipulate the tissues. All the tissues of the anterior aspect of the throat may be included in this treatment, contracture and tension at any given point being thus removed. The treatments must be gentle in order that sensitive necks may not be irritated. The operating hand must not be rubbed over the tissues, but they must be moved by the motion of the hand. Holding or pressing gently but continuously against a con- tracture, while the head is being slowly moved about, will re- lieve the tension and remove the lesion. II. The ligaments of the temporo-maxillary articulations, and the muscles and blood-vessels below the inferior maxillary bone may be relieved of tension, and be restored to free action, by springing the mouth open against resistance; The patient lies upon his back and the practitioner stands at the head of the table, placing the palms of his thumbs -upon the malar prominences, and the palms of the fingers beneath the jaw. The patient is now directed to open the mouth widely and then to gradually close it. Resistance is made by the operat- ing hands to the first motion, and the fingers press the superior hyoid muscles downward and forward toward the median plane of the neck during the second motion. The ligaments of the temporo-maxillary articulations may be sprung by thrusting a finger deeply into each glenoid fossa 28 PRACTICE OP OSTEOPATHY. after the patient has opened his mouth, holding them there while the mouth is shut. It is necessary to avoid hard pressure here. III. The hyoid bone may be held between the thurhb and finger and be moved vertically and laterally, stretching the hyoid muscles. IV. Pressure may be in some measure applied to the pneu- mogastric, glosso-pharyngeal and spinal-accessory nerves by deeply pressing the finger upward and inward behind the angle of the jaw, in the direction of the jugular foramen. The pneumogastric nerve may be manipulated by deep pres- sure behind the anterior border of the stern o-mastoid muscle. These three nerves are also influenced by manipulation upon their closely related nerves, the sub-occipital, great occipi- tal, small occipital, and great auricular, reached in the sub- occipital fossae as above described. V. Pressure upon the phrenic nerve may be applied at the points described in Capter III. VI. The sterno-mastoid muscle may be manipulated, fol- lowing the method described for treatment of muscles of the throat under I of this chapter. The muscle upon one side may be stretched by turning the head toward that side and slightly upward, thus increasing the distance between the mastoid process and the sterno-clavicular origin of the muscle. VII. The lateral and posterior muscles of the neck may all be treated in a manner similar to that described under I of this chapter. The practitioner may also stand at the head of the table, and with the palms of the hands upon each side and the back of the neck, gently grasp handsfull of the muscles, manipu- lating them thoroughly while slowly moving the head in all directions. Pressure and manipulation, together with motion, all gently and patiently applied, will relax the most obstinate contracture, loosen all deep fibrous structures, free blood-ves- sels and nerves, and prepare the way for what is usually the real object of the treatment, the reduction of bony lesions. VIII. With the patient supine, the head is pushed as far as may be easily done without resistance, first to one side and PRACTICE OF OSTEOPATHY. 29 then to the other, and it is noticed whether it turns as far to one side as to the opposite side. Inequality between the two sides indicates lesion usually upon the side toward which the head turns least easily. After relaxation of the tissues, turning the head to its limit toward each side will sometimes aid in the reduction of bony lesion, especially with the aid of pressure applied to force the part into its place. IX. (1) In lesion of the atlas the patient lies supine and the practitioner, standing at the head of the table, holds the head between the hands, with a thumb or finger upon each transverse process. The head is now moved in a direction to exaggerate the lesion, and with traction, rotation, and pressure upon the processes, the atlas is forced toward its position. (2) The operator may stand at the side of the head, one hand upon the forehead and the other pressed firmly just below the skull, in the region of the lateral arch of the atlas, on the opposite side. Exaggeration of the lesion, rotation, .and strong pressure aid in replacing the part. (3) The patient sits and the practitioner, standing in front, places one knee beneath the chin, while the hands grasp the sides and back of the head, and the fingers are firmly pressed upon the lateral arch of the atlas upon each side. Exaggeration of the lesion, traction, pressure, and rotation are now applied as before. The chin is slightly raised and drawn forward by motion of the knee beneath it. The head is rocked upon the atlas gently, the requisite pressure being made upon the lateral arches to press the bone back to its position. (4) The patient sits and an arm is passed about his head, the bend of the elbow coming beneath the occipital protuber- ance and the hand beneath the chin. The head is now forci- bly raised with the idea of moving it upon the spine in the de- sired direction, while the free hand makes pressure upon the spine or neck in the direction necessary to aid in reposition. (5) Dr. Still uses the following movement in setting the atlas. He stands in front of the patient, who is sitting, and clasps his hands behind the neck, just below the skull, pressing the pisiform bones firmly 'against the lateral arches of the atlas. 30 PRACTICE OF OSTEOPATHY. Now the proper movement is made to rotate the head to the affected side, "sinking" it down upon the spine, and to press the atlas into place. (6) With the patient lying upon his back, the practitioner stands at the head of the table, holds the head between his hands, presses his fingers against the lateral arches of the atlas, while the head is slightly raised from the table and supported by pressure from his own body, pressing it down upon the spine. Now the proper movement is made to exaggerate the defect, rotate the head, and press the atlas into place. These various treatments may be applied to any of the usual lesions of the atlas. The same principles may be applied to the different malpositions of any of the cervical vertebrae. Generally patience and time are necessary to the gradual res- toration of the bones to place. Much attention must be given to the thorough and gradual loosening of all parts in preparation for replacement. X. The axis is generally displaced laterally. The tissues upon its transverse and articular processes are quite tender and contractures are found in the muscles about it. Exaggeration of lesion, rotation and pressure usually restore it to place. XI. The scaleni muscles may be stretched by pressing the head down toward the side in question, pressing the fingers be- hind the clavicle upon the first rib to force and hold it down, while the head is now drawn to the opposite side. XII. Thorough loosening of all cervical tissues may be accomplished by a somewhat "spiral" treatment. The patient lies on his back, the guiding hand is placed upon the forehead, and the other hand is slipped beneath the neck and grasps it. The head and neck are now raised slightly, the head being ro- tated in one direction, while, as far as possible, exactly the op- posite motion is given the neck. The hand travels up and down the neck treating its different portions alike. XIII. Flexing the head strongly upon the thorax stretches the ligamentum nuchse and posterior tissues of the neck. PRACTICE OF OSTEOPATHY. 31 CHAPTER V. OSTEOPATHIC POINTS CONCERNING THE HEAD AND ITS PARTS. As stated, the chief lesions affecting the head and its parts occur in the neck, and have already been described. More detailed points in examination and treatment of these important structures will be considered in lectures upon their specific dis- eases in the second part of this work. The present chapter will embrace only general osteopathic points. INSPECTION AND PALPATION are the methods of examina- tion. By the former one notes the size and shape of the skull, the complexion, expression, eyes, etc. By palpation he notes the presence of tumors or other growths, open fontanelles, etc. A. THE EYE. Those lesions most frequently affecting these organs occur at the atlas and axis, and along the cervical and upper dorsal regions as low as the fifth dorsal vertebra. I. The conjunctiva lining the lids may be examined. The lower lid is drawn out and down, pressure being made at the same time below it, causing it to become prominent. The upper lid is turned back by grasping the edge slightly toward the outer canthus and raising the lid, while at the same time pressure is made upon it from above near the inner canthus. This inverts the tarsal cartilage and exposes the membrane. If while this lid is turned back the lower one is also treated as above, both together stand out more prominently and may be observed together. Granulations appear as minute white or pale red elevations. II. With the patient supine, direct pressure is made, with the palms of the fingers, upon the eye-balls, pressing them di- rectly back into the orbits. This impinges nerves, blood-vessels, muscles and all the orbital structures. It presses excess of blood from the vessels, and tones the muscles, nerves and the struc- tures of the intra-ocular mechanism. III. Tapping upon the eyeball has much the same effect. It is performed by placing the palms of one or two fingers over the closed eye, and lightly tapping them with the index finger. 32 PRACTICE OF OSTEOPATHY. Toning of the nerves, of the ball and its structures, and of the optic nerve is thus accomplished. IV. Granulations are crushed by squeezing them beween the finger and thumb, the finger being inserted beneath the lid. V. In pterygia, the small blood-vessels formed upon and^ in the corneal conjunctiva as feeders, may be broken up by draw- ing the back portion of the edge of the finger-nail across them. Care must be taken not to wound the conjunctiva. VI. In strabismus the weakened or tensed muscle may be treated by pressing the fingers into the orbit about the eyeball. B. THE FIFTH NERVE. This nerve is reached at various points about the head, as it sends many branches out over the head and face. Its treat- ment is especially important in headaches, neuralgias, diseases of the eye, nose, etc., for the reason that it carries vaso-motor and trophic fibres to these parts. I. Its supra-orbital branch may be traced from the supra- orbital foramen out over the forehead to the temple. It forms an angle of about fifty degrees with the superciliary ridge. It may be felt under the skin like a fine whip-cord, and it may be manipulated along its course by passing the fingers transversely across it. Often one nerve is more plainly felt, and often one is more tender, than its fellow. Though not invariably so, it is often noticed that the nerve which is seemingly slightly enlarged and more plainly felt is the one in abnormal condition. II. The infra-orbital and mental branches may be manip- ulated at their respective foramina. By clinching the fingers beneath the malar process several branches of the former may be impinged. The tissues over the foramina and along the courses of all of these different branches should be thoroughly relaxed to re- move irritation. III. A supra-trachlear branch is located slightly to the outer side of the mid-line of the forehead, a lachrymal branch about the middle of the upper eyelid, a temporal branch external to the outer canthus of the eye, an infra-trochlear branch upon the nose opposite the inner canthus, and a nasal branch at the lower third of the side of the nose. PRACTICE OF OSTEOPATHY. 33 All are subcutaneous and are readily manipulated after knowing where to locate them. THE EAR. With the EAR, as with the eye, lesion of the atlas, axis, or upper cervical region is the most usual cause of disease. The auricle should be drawn up and back in order that the external canal may be inspected for the presence of growths, boils, foreign objects, discharges, etc. Attention should be given to the condition of the cerumen. It is sometimes seen to be dry and flaky, indicating poor circu- lation and imperfect secretion. Or it may be abundant, forming a plug, which gathers in the deeper part of the canal and obscures the drum, generally, but not always, impairing or quite obstruct- ing the hearing in that ear. If it presses upon the drum it is apt to cause vertigo, or a sense of congestion in the head. In some cases the cerumen will be found to be entirely or almost, lacking, in one or both ears. This commonly indicates greatly impaired local circulation, due to cervical lesions, poor general health, or both. In many cases treatment has restored the normal secretion of wax. Itching and extreme tenderness of the canal are sometimes noted. The head-mirror and ear-speculum should be employed in the examination of the deeper parts of the canal, and of the tym- panum. Sometimes a plug of cerumen can be detected by this means only. By the use of these instruments the student should become familiar with the appearance of the normal drum. A good text- book, with its illustrated plates, showing the appearance of- the various abnormal conditions of the drum, is a valuable aid to this study. The patient should be instructed to close the mouth, hold the nostrils shut, and blow. This will reveal whether or not the Eustachian tubes are open, by the presence, or lack, of the crack- ling sound and sensation of fulness in the ears as the air is forced against the inside of the drum. When this act is performed, a perforation of the drum is 34 PRACTICE OF OSTEOPATHY. betrayed by the whistling of the air through the aperture, or by the gushing through it of secretions or pus from the middle ear. Impaired hearing may be due to fault in the outer, middle or inner ear, auditory nerve, or brain center. A watch is a very handy and delicate instrument to employ in testing the hearing. This should be done in a quiet room. First the watch should be held quite close to the ear, and gradually removed from it, to test the distance at which the ear may catch the ticking. Both ears should be tested in this way. The less acute power of one ear is often thus discovered. Sometimes the watch may not be heard to tick unless pressed close against the auricle. The ear which stands this simple test is sound, as to its hearing power, throughout the auditory mechanism. If the ear fails to hear the ticking when the watch is held near or against the auricle, the watch should then be held rather firmly against the upper part of the mastoid process, just behind the auricle. If now the hearing fails, the trouble lies, probably, in the inner ear, but may be located in either the auditory nerve or in the brain center. As a matter of fact, the causes of deafness lie, for the most part in the middle or inner ear, or in the Eus- tachian tube, being rarely referable to the auditory nerve proper or to the center. Deafness due to causes affecting nerve or center may be distinguished from strictly aural deafness in a simple way. In the former case the ticking can be heard only faintly or not at all whether the watch be held away from the ear or be brought near to it or pressed against the auricle or the mastoid. But in the latter the watch may be heard more dis- tinctly when it is held against the mastoid, since' by bone con- duction the sound is carried to the nerve. Sometimes the test is applied by having the watch held be- tween the teeth. If the Eustachian tube is occluded the sound is heard less distinctly upon the affected side. But if the ob- struction is in the middle ear, as from thickening of the tissues and rigidity of the ossicles, the sound may be heard more dis- tinctly upon the affected side (through conduction). Some- times, also, this occurs when there are impactions of cerumen against the membrana tympani. Tinnitus Aurium, or "ringing of the ears," consists of a PRACTICE OF OSTEOPATHY. 35 variety of subjective sounds due to nervous disease, anemia, catarrhal conditions, and various other causes. Generally speak- ing, the dull, throbbing or buzzing noises are due to obstructed circulation in the ear, especially in the fine capillary network spread upon the drum. This commonly results from colds and catarrhal affections. This class can often be bettered. On the other hand, ringing, screeching, or whistling Aoises commonly denote some affection of the nerves of the auditory apparatus, as is sometimes seen resulting from lagrippe. These cases are usually difficult to help much. Of the discharges from the ear, pus and blood are the most significant, and their source should be carefully sought. Treatment of the ear is discussed under the heading of Dis- eases of the Ear. THE NOSE. In the examination of the nose its external aspect should be noted. Deformities from operation, violence, or disease are common. The nose often indicates chronic catarrh by being bent somewhat to one side, following ulceration of bones or cartilages, or surgery. A peculiar "club-shaped" nose, with a large, rounded end is sometimes seen in the scrofulous. A red, or livid nose, with enlarged and injected vessels, is a common indication of bibulous habits, and this member some- times becomes grossly hypertrophied and deformed by excessive indulgence in alcoholic beverages. Redness of the nose very often results from congestion due to chronic valvular heart-dis- ease, from congestion of the liver, or from tight-lacing in women. The internal examination should be made by use of a con- venient dilator, head-mirror and speculum. The examiner should note the condition of the mucous membrane for redness or inflammation or for paleness and atrophy as in chronic catarrh. The character of the secretions and discharges should be noted, and, if abnormal, their source or cause carefully sought. Very offensive mucous discharges and pus indicate advanced catarrhal conditions, and may result from ulceration in the tissues of the nose or from abscess or ulceration in the frontal sinus or antrum. 36 PRACTICE OF OSTEOPATHY. Bleeding is usually from the membrane and due to local irritation, or from congestion of the vessels of the head, causing rupture of small vessels. After violence one should consider the probability of fracture of the base of the skull as a source of bleeding. Foreign bodies ; growths, such as polypi and adenoids; "spurs" of bone, due to hypertrophy resulting from catarrh; enlargement of the middle or inferior turbinated bones ; or a deflected septum may be found. The NOSE, apart from neck treatment, is sometimes treated by local manipulation. I. Manipulating and loosening all the tissues along the sides of the nose affects the blood-supply of its mucous mem- brane through branches of the fifth nerve. It will also operate to free the channel of the nasal duct. II. With the patient supine, the palm of the hand is placed upon the forehead, the other hand is laid upon the first, and the practitioner, bending over the head of the table, brings his weight .upon the patient's forehead. This pressure is continued several seconds and repeated a few times. It frees the nostrils and in acute colds frequently at once restores freedom of breathing through the nose. The affect is probably gotten by the pressure affecting the branches of the fifth nerve upon the forehead.lt is greatly in- creased by first applying momentary pressure, with the thumbs, to the internal jugular veins, which are thus dilated back to the capillaries by the pent-up blood, after which they carry away more blood, relieving the congested head and mucous membrane of the nose. III. In colds and catarrh, pain in the frontal sinus may be relieved by tapping with the knuckles upon the frontal bone over the sinus. The MOUTH and THROAT are sometimes treated internally by sweeping the palm of the index finger from the mid-line of the posterior portion of the hard palate outward and downward over the soft palate, pillars of the fauces, and tonsils. The uvula may also be touched. The nerves and blood-vessels of this region are thus toned. PRACTICE OF OSTEOPATHY. 37 The Uvula, being thus treated by digital application, elonga- ations of it are overcome through restoring tone to its muscles and vessels. It is usually elongated by conditions which con- gest it and the surrounding tissues, and the elongation is due to the loss of tone thus induced in the azygos uvulae muscles. This condition is often the cause of a little hacking cough in children. THE TEMPORO-MAXILLARY ARTICULATIONS are examined. Inequality in their action is discovered by standing behind the head of the patient, who is lying supine. The mouth is opened and closed, and deviation of the mid-line of the chin from the median plane of the body noted. Deviation of this nature in- dicates luxation of one of the articulations, the jaw usually de- viating away from the side of the lesion, though often toward it, by reason of tightened condition of the articulation on the affected side. I. The ligaments of the articulation may first be loosened as described under II of Chapter IV. Pressure upon the op- posite jaw while the patient is closing the mouth will bring the condyle back into place, II. Sometimes it is necessary to place a small cork or piece of wood between the posterior molar teeth upon the affected side. Pressure is now made beneath the chin, tending to close the mouth, and the jaw is slipped into place. The corks may be in- serted at the same time between the molars of both sides in case of bilateral luxation. Treatment I, may be alternately applied in such case. Opening the mouth against resistance (II, Chap. IV), man- ipulation of the throat to free the action of the carotid arteries, and treatment of the superior cervical region (XIII, Chap. Ill) are, together with removal of specific lesions, the chief metkods of treatment in diseases of the eye, ear, nose and throat. They produce affects by building up the blood-supply. Treatment along the mid-line of the skull, from the nasion to the occipital protuberance, thence outward along the sides of the head, affects the circulation in the longitudinal and lat- eral sinuses through connected nerves and veins. It also affects the sensory nerves of the scalp, they congregating about the vertex. 38 PRACTICE OF OSTEOPATHY. CHAPTER VI. EXAMINATION OF THE THORAX. From an Osteopathic point of view, and not at present considering the contents of the thoracic cavity, the examina- tion of the thorax consists mainly in discovering, by palpa- tion and inspection, whether its bony structures are all in posit- ion. Ligamentous and muscular lesions, also lesions of blood- vessels, nerves, and centers are closely associated with bony lesions. The relations of the thorax to the spine as a whole and to its own contained viscera cause its lesions to be among the most important ones found in the body. Lesion of the spine, especially of its thoracic portion, often seriously affects the. thorax proper. INSPECTION reveals change in the general conformation of the thorax. It is made with relation to the spine, and effects of spinal irregularities are considered. Flattening or promi- nence of the ribs, either in portions of the thorax or affecting it as a whole; restriction or increase in the movements of the thorax, upon one or both sides; color of the skin, eruptions, scars, etc., are all noted. Change in the general conformation of the thorax is sig- nificant of the presence of many lesions. Often a single glance assures the examiner of the presence of many lesions which are closely related, and which, as experience teaches, are all in a train of abnormalities, so that he is practically sure from the be- ginning that he will find present certain various lesions. A weakened condition of the spine, allowing of lateral swerving of its vertebrae or of changes in its normal curves is apt to be found causing a weakness of the costo-vertebral ligaments. The ribs are therefore not held in their proper relation to the spine, the whole thorax is weakened, and the ribs sag downward, narrow- ing the antero-posterior diameter of the chest, or otherwise dis- torting it. The foundation is thus laid for the various diseases of heart, lungs, etc. The angles of the ribs are approximated and become prominent along the postero-lateral aspects of the PRACTICE OF OSTEOPATHY. 39 chest, or "stand out in rings under the shoulders," as Dr. Still says. This narrows the thorax so that a lateral view of it shows the axillary and infra-axillary regions narrowed, and the examining hand swept down along the angles finds the lateral span of the chest much decreased. The two sides may differ. The ilio- costal spaces are narrowed, sometimes to the extent of oblitera- tion. In case of a lateral swerve of the spine the ribs upon the convex side are found to be more oblique, and their inter-spaces are narrowed or obliterated. At the same time the whole thorax may be altered in shape as above described. The patient may sit, lie, or stand during inspection, as most convenient. PALPATION, the more important method, proceeds in con- junction with further inspection, and is used in the detection of the various special lesions to be described. I. With the patient standing or sitting, the palms of the hands are passed evenly over the anterior and posterior aspects of the chest, comparing side with side; region with region. The temperature is also noted. II. The precordial region is examined for any protrusion or retraction of the thoracic wall, significant with relation to heart- disease. III. Each lateral half of the chest is examined for change or lessening of its antero-posterior diameter, considering the direction of the component ribs as well. Lessening of this di- ameter, and a tendency of the ribs to greater obliquity in direction, reveals a flattened side or sides of the chest. This shows spinal lesion generally, also disturbed ligaments, blood-vessels, nerves, etc., of all related parts. In this case the whole side is dropped down and the ilio-costal space is lessened. People with such lesions are always poor breathers because of the extra effort required of weakened muscles to raise the dis- arranged ribs. They therefore suffer, in addition to the results of specific lesion, from the various evils of congestion and im- perfect oxygenation consequent upon poor rib, chest, and lung action. IV. The same lesion may affect a portion of the thorax. 40 PRACTICE OF OSTEOPATHY. Often a flattening of the ribs posteriorly beneath the scapula is found. Protrusions or retractions of one area of the chest generally correspond with the reverse condition in the corresponding an- terior or posterior area. This is not true in case of slipping of the ribs downward. V. Marked depressions in the supra or infra-clavicular re- gions are significant in the diagnosis of tuberculosis of the lungs. VI. With the patient lying on his side, the palm of the hand is swept along the lateral and postero-lateral aspects of the chest, from the shoulder downwards. Changes in the position of the ribs individually, or in the conformation of the side of the thorax in question are thus readily made out, mainly by detection of changes in the angles of the ribs from normal. The STERNUM must be examined. I. It may be as a whole, protruded or retracted, following a change in the general shape of the thorax. II. Luxation between the first and second parts, anteriorly or posteriorly, may occur. III. The ensiform may be displaced laterally. THE CLAVICLE AND CORACOID. The latter is located as the first bony prominence at the outer end of the infra-clavicular fossa. Its relation to the clavicle is to be noted, also the condition of the tissues attaching to it. The clavicle may be luxated at either its sternal or acro- mial articulation. The sternal end may be upward, anteriorly or posteriorly from its normal position. The acromial end may be displaced downward toward the coracoid or upward upon the acromion process. Sometimes the bone is tilted so that one's fingers may be thrust for behind its upper edge. These lesions are generally easily detected by inspection and palpation. The examination of the sternal end is often facilitated by having the patient lie flat upon his back, then pressing the tip of the examin- ing finger down deeply upon the sterno-clavicular junction, at the same time comparing it with its fellow, which should be felt out by the other hand. Very slight depressions or elevations may be thus detected, as may also tenderness. PRACTICE OF OSTEOPATHY. 41 Dr. Still points out that in diseases of the throat the ster- nal end of the clavicle is often found displaced backwards against the pneumogastric nerve, irritating it and causing the disease. LUXATION OF RIBS. One of the main objects of examination of the thorax is to locate misplaced ribs. Departures from normal conforma- tion of spine are at once indications of lesion of the several ribs. Hence, following the general examination as outlined above, each rib in particular must be scrutinized. Landmarks for the location of the various ribs should be employed. I. Ribs are frequently separated or approximated beyond normal limits. These conditions are discovered by placing the patient upon his side and following the successive intercostal spaces with the tip or side of the examining finger. In the latter lesion the tissues are tender along the course of the intercostal space, due to irritation of the sensory branches of the intercostal nerves. II. The same examination would reveal rotation of a rib upon its horizontal axis. In such case the intercostal space is unequally widened or narrowed. As a rule the twisting is about the head as a fixed point, and the lower margin of the rib is turned out prominently. Then the intercostal space next below is narrowed anteriorly and widened posteriorly. The anterior end is tended downward, luxating the costo-chondral and the chondro- sternal articulations, as it deranges the costal cartilage. The reverse rotation of the rib may take place, making prominent the upper edge, throwing the anterior end upward, etc. III. By various lesions of the ribs, the cartilages are twisted, distorted or torn loose. In such case tender points are found upon pressure at the costo-chondal or chondro-sternal articulations. The cartilage may be bulged forward by protrusion of the rib, causing a prom- inent tender point. It may be retracted, causing a slight de- pression. With the patient lying supine, the examining fingers may be carefully passed over the successive pairs of cartilages and these lesions be noted. 42 PRACTICE OF OSTEOPATHY. IV. The heads of ribs are often luxated, and may sometimes be easily felt near the transverse process of the adjacent vertebra. This lesion is most readily found by carefully feeling along the shaft of the rib upward toward its head, using deep pressure. It may be impossible to trace the shaft by touch where it is covered by the thick erector spinae muscles. In such case it is easy to follow the direction of the rib up to the spine. Deep palpation may reveal the head to be prominent, depressed, or sore. The FIRST RIB is located by deep pressure behind the mid- dle or inner one third of the clavicle. If the latter has been found in situ, comparison with it may be made to determine whether the rib be up or down. By deep pressure the rib may be traced well back toward its head, which is masked by the lateral cervical muscles. Pressure may be brought upon the head at the level of the seventh cervical spine, one and one-half inch laterally there- from. This pressure is deeply in the tissues over the region of the head of the rib. The latter is, not always easily felt by touch, but may often be definitely felt out. Sometimes the head of the first rib is separated from and drawn outward away from its spinal articulation, when it may be easily felt. This sometimes occurs in cases of exophthalmic goitre. Dr. A. T. Still points out that lesions of the first rib often cause goitre. A more reliable method for definitely locating the head of the first rib is as follows: Find the tip of the transverse process of the seventh cervical vertebra, (XIV, Chap. 3) and make firm downward pressure just in front of it. As the head of the first rib lies anterior to the transverse process of the first dorsal ver- tebra, the first bony part felt under this pressure is the first rib in the region of its head. The sternal end of the rib is located just below the clavi- culo-sternal articulation. Its cartilage and shaft may be traced well outward an inch or more before disappearing beneath the clavicle. In case it be luxated upward, the cartilage is retracted, leaving a flat area or a depression at the cartilage. If downward, a protrusion of the cartilage at the edge of the sternum is usual. In either case the cartilage and the tissues about the rib are sen- sitive to pressure. PRACTICE OF OSTEOPATHY. 4cf The first and second intercostal spaces are wider than the others. The SECOND RIB is located opposite the junction of the first and second parts of the sternum. Prominence or depression of its cartilage, and tenderness in the tissues about it are caused in the same way as in the case of the first. Its head is located and pressure brought upon its region at a point one and one-half inches external to the first dorsal spine, upon a level with the superior angle of the scapula. THE ELEVENTH AND TWELFTH RIBS are more frequently luxated downwards because of their anterior ends being un- supported and because of traction upon the latter by the quad- ratus lumborum muscle. Their free ends are readily located except when irritation from them, or other cause, has irritated the overlying muscles, causing hypertrophy or contracture. In such case they must be located from the tenth rib. The free end of the eleventh lies well forward, thus distin- guishing it from the twelfth. They may be so displaced downward as to be almost ver- tical; may overlap the iliac crest, or may be luxated upwards, the free end of the twelfth lying beneath the eleventh, or that of the eleventh beneath the tenth. Frequently a luxated rib guides one to a spinal lesion. Displaced ribs cause disease by mechanical interference with internal viscera, by irritation of surroundirg soft tissues, by dragging ligaments, impinging nerves, or occluding blood- vessels. One must remember that in probably most cases of displacement of a rib there is lesion at its head affecting the re- lated spinal nerves. CHAPTER VII. TREATMENT OF THORACIC LESIONS. The thoracic portion of the spinal column is anatomically a part of the thorax, but has already been discussed under an- other head. Osteopathic treatment of the chorax is directed generally 44 PRACTICE OF OSTEOPATHY. to the restoration of the ribs and other bony portions to cor- rect mechanical relations. It includes with this, work upon ligamentous, cartilaginous, and muscular lesions, which are usually secondary to bony lesion. Thus while osteopathic treat- ment of the thorax consists largely in the putting of ribs into proper position, this work is always done with an eye to those other lesions, and effects all surrounding tissues; muscles and ligaments; nerves and vessels; centers and viscera. Thoracic is inseparable from spinal work, owing to the in- timate anatomical relations of these parts. There are various ways of setting ribs. Many of them rest upon the principle that the head of the rib, being but slightly movable, is the fixed point; that pressure upon the angles tends to move them about this fixed point; and that this pressure may be guided and aided by elevation of the arm or rotation of the shoulder, bringing traction upon the pectoral and latissimus dorsi muscles, etc., which are attached to the ribs. In some treatments, the sternal end is made the fixed point and the parts are manipulated accordingly; in some, both ends of the rib are fixed, etc. Exaggeration of lesion, fixing of a fulcrum, traction upon attached tissues, and rotation of related parts are principles applied to the work. I. With the patient sitting upon the side of the table, the practitioner, standing in front, passes an arm about the body of the patient, extending his hand past the spine behind, and pressing with the fingers upon the angles of the ribs of the fur- ther side. With the other hand he raises the patient's arm of the side in question, in front of the body and high over the head, rotating it downward and backward. This brings traction upon the pectoral muscles and soft tissues of the whole anterior aspect of the side of the chest, elevates the entire side, and effects par- ticularly the ribs upon the angles of which pressure is made. Care must be taken to maintain this pressure until the end of the move- ment of the arm. This motion may be repeated, the pressing hand traveling down the back to each successive rib in need of treatment. PRACTICE OF OSTEOPATHY. 45 This treatment elevates all the ribs and tones all connected muscles, ligaments,' vessels, nerves, etc. II. The patient sits upon the stool; the practitioner stands behind, and, resting one foot upon the stool, makes a fixed point of his knee at the angle of the rib under treatment. One hand holds beneath the lower edge of the ribs, in front, while the other elevates and rotates the arm as in I, or the first hand may press down upon the upper edge of the rib, in front, while the arm is drawn from in front downwards to the side of the body, and backwards. In these ways the ribs may be forced downward or upward. III. With the patient sitting or lying upon his side, the rib is thrown into action by the patient's taking a full breath. The operating hands are applied, one at either end of the rib in question, and advantage is taken of the relaxation of tissues and the motion of the rib which take place as the patient expels the breath. The whole rib is manipulated at this time toward its normal position. This treatment is aided in some cases by pushing the rib still further from its normal position before an attempt is made to restore it to place. In this way the principle of exaggeration of the lesion is called into play. IV. Treatment II may be applied with the patient lying upon his side instead of sitting. Here the practitioner stands behind, rests one foot upon the table, bending his limb so as to bring the flat of his knee against the angle of the rib. The treatment then proceeds as in II. The arm may be rotated either forward and up, or downward and back, pressure being made at either margin or at the sternal end of the rib as desired. This treatment allows the practitioner more latitude than does II. Great caution must be exercised in any application of the knee to the chest, either anteriorly or posteriorly. Active work with it should be avoided, use being made of it only as a fixed point. V. A fixed point may be made of the flat of the knee at the sternal end of the rib; the arm of the patient upon the same side is manipulated for traction as before, while the other operating hand is passed over the patient's opposite shoulder and applied 46 PRACTICE OF OSTEOPATHY. to the spinal region of the rib. This treatment is applicable to luxations of the heads of ribs. The patient is sitting. VI. With the patient supine, the practitioner stands at one side and reaches across the patient to manipulate the ribs of the opposite side. One hand is slipped beneath the back and ap- plied as a fixed point to the angles of any ribs in question; with the other hand the patient's arm is rotated as before for traction. VII. With the patient lying prone, the practitioner, stand- ing at one side, reaches across the body and makes a fixed poin't of his elbow upon the angle of the rib. At the same time the hand of the same arm grasps the patient's forearm upon that side drawing it back and up. Thus, while the rib is in action the pressure of the elbow forces the head into place. VIII. With the patient lying prone, pressure with the oper- ating hands may be brought vertically downward upon heads or angles of ribs, springing them into place. IX. With the patient lying supine, the practitioner stands a,t the side of the table and raises the patient's arm of the same side to a level with the shoulder. With the arm thus horizontal, traction is made upon it, away from the body, and in such a direction as to bring longitudinal tension upon the costal cartil- ages. The other hand manipulates the cartilage to reduce an}' twist or anterior prominence of it. X. With the patient sitting, the practitioner stands facing him, making pressure with one hand upon the sternal end of the rib in question. The other arm is passed about the patient's body, and the hand locates and brings pressure upon the head of the same rib. With both ends of the rib thus fixed, the mo- tion of the practitioner's body is used to rotate the patient's trunk about these fixed points, at the same time manipulation is directed to the restoration of the rib to position. It may be said that, as a rule, the setting of a rib requires time and patience, though in many cases this may be accom- plished at once. It is rarely the performance of a set motion that does this work. On the contrary, the practitioner, with his hands in position and the parts under his control as described in any particular treatment, must continue his efforts, with vary- ing traction, pressure, rotation, etc. Movements of the pa- PRACTICE OF OSTEOPATHY. 47 tient's whole trunk, bending, turning, raising the parts, etc., may all contribute to the gradual relaxation and yielding of the parts to the persistent, well-directed, and carefully judged efforts of the Osteopath. In the case of the FIRST AND SECOND RIBS many of the gen- eral principles and treatments, as already described, may be applied. Special methods, however, are generally necessary to replace them. As already stated, these ribs are usually lux- ated upwards, but may, as well, be displaced downwards. I. UPWARD DISPLACEMENTS. (1) The scaleni muscles are first relaxed and stretched (Chap. IV, div. XI), the head is now bent toward the shoulder of the affected side, and pressure is brought directly downward upon the upper margin, the sternal or spinal end of either or both ribs (Chap. VI). In this way, either rib may be lowered as a whole or at either end. (2) With the patient lying upon his back, the practitioner stands at the head of the table; presses the palm of the thumb down upon the upper margin of the first rib; with the other hand he raises the arm of the patient upon the side in question, and pushes it across the chest at the level of the shoulder, thus re- laxing the tissues at the side of the neck, and elevating the clavicle so that the thumb may be thrust more deeply behind it. Pres- sure may be applied anywhere along the upper margin of the rib, lowering it to its normal position. (3) A most effective treatment is shown by Dr. Still. For example if the lesion be to the right rib, the patient is to sit side- wise upon the table. The practitioner sits beside him, at his left, passing his right arm under the left axilla and placing his right fingers on the upper aspect of the rib. His left hand is pressed against the patient's head. First the patient's head is. drawn toward the practitioner while his body is pushed slightly away. This swerves the spinal column and throws the luxated rib up higher, exaggerating the lesion. Now the head is pushed well away from the practitioner, while the body is drawn to him, with accompanying strong pressure of the right hand downward upon the shaft of the first rib, which is thus replaced. 48 PRACTICE OF OSTEOPATHY. II. DOWNWARD DISPLACEMENTS. (1) With the patient sitting, the practitioner stands be- hind and brings pressure with his fingers upon the inferior mar- gin of the first or second rib. At the same time the head is bent to the opposite side, bringing traction upon the rib through the scaleni muscles, and rotated backward. This rotation tends to bring more traction upon the anterior end through the scalenus anticus (in case of the first rib.) The treatment may be used to elevate either rib. (2) The treatment as described under II and IV of this chapter may be used. (3) With the patient sitting and the practitioner standing in front, pressure may be made by the fingers below the region of the heads of the first and second rib, (see Cap. VI), while the head is bent to the opposite side and rotated forward. This rotation tends to bring more traction upon the posterior ends of the first and second ribs through increased traction respectively of the scalenus medius and scalenus posticus muscles. (4) In case of anterior protrusion of the cartilages (see Chap. VI), pressure may be brought upon them while treatment (I) above is being given. Or the patient's arm is raised to the level of his shoulder and drawn backwards, bringing traction upon the cartilages, while pressure is applied to them. The first two ribs may be separated, as follows: The pa- tient lies supine and a hand is slipped beneath his shoulder, bent to form a fulcrum beneath the two ribs; the patient's arm is grasped at the elbow, raised, and bent strongly across the anterior chest at the level of the shoulder. This tends to drive the two ribs sternum-ward, and to separate them anteriorly owing to the intercostal space being wider at its anterior end than at the other. THE ELEVENTH AND TWELFTH RIBS. A. DOWNWARD DISPLACEMENTS. A preliminary step must be taken in the relaxation of all muscles and tissues about the ribs, especially of the quadrati PRACTICE OF OSTEOPATHY. 49 lumborum muscles. This is easily accomplished by manipu- lation of the tissues. A special method of stretching the quad- rati is as follows: The patient lies upon his side and the prac- titioner stands in front. He grasps the arm of the patient and draws it diagonally forward, at the level of the shoulder, in a direction away from the pelvis. At the same time his other hand makes pressure upon the anterior iliac crest in a direc- tion diagonally backward, i. e., in a direction exactly the op- posite from that in which the arm is drawn. This stretches the muscles diagonally and rotates the lumbar portion of the spine, The motion is now reversed by standing in front of the pelvis, grasping the crest of the ilium, and drawing it diagonally forward in a direction away from the shoulder. At the same time the other hand holds the bent arm rigid at the side and pushes it in a direction opposite from that of the traction applied to the pelvis. This motion gives the opposite diagonal stretch to the quadratus lumborum, and rotates the lumbar region of the spine. The eleventh or twelfth rib itself is readily manipulated upward or downward by taking advantage of three points; (1) The head usually remains a fixed point, (2) Pressure made upon the outer aspect of the rib in the region of its angle (or turn in case of the twelfth, which lacks the angle) may be so directed as to move or rotate the rib upward or downward about the fixed point, (3) The free end may be readily moved upward or down- ward by the pressure of a finger, and this pressure, combined with pressure in the opposite direction applied at the angle, readi- ly rotates the rib about its horizontal axis. One hand easily spans the rib, leaving the other hand free to manipulate the body and aid the operation. The thumb is pressed against the free end of the rib and forces it upward or downward, while the fingers of the same hand bring pressure in the opposite direction at the angle of the rib. In this way the rib is rotated about the head as a fixed point and may be raised or lowered as desired. I. With the patient lying upon his side, his knees flexed and supported against the abdomen of the practitioner, the operating hand manipulates the rib as above described, forcing 50 PRACTICE OF OSTEOPATHY. it upward. At the same time the free arm has grasped the semi-flexed limbs, raised them slightly to rotate the pelvis and lower lumbar spine, and thrusts them downward in extension to stretch the soft tissues and aid in increasing the distance be- tween ribs and pelvis. II. This movement may be varied, grasping the limbs in the same way and drawing them and the pelvis over the side of the table, rotating them downward about the edge of the table, extending the limbs and rotating them upward and onto the table. The rib is manipulated as in I. This is a strong treatment, and applies great force to the rib. III. With the patient sitting, a hand is applied to each end of the rib. The patient takes a full breath to throw the rib into activity; pressure is so applied as to exaggerate the lesion, and the rib is finally pressed upward to its normal position as the patient exhales. IV. The patient lies upon his side; one operating hand grasps the ilio-costal tissues and draws them diagonally down- ward and forward in the direction in which the rib points. The other hand is placed upon the angle of the rib and pushes it in the same direction. In this way the tissues are stretched and the lesion exaggerated. The motion is finished by an upward turn of the hands, the former pressing the end of the rib upward, the latter forcing the shaft of the rib upward. B. UPWARD DISPLACEMENTS. In these cases the anterior ends of the ribs are upward under the rib above. All tissues are first relaxed as before, and the free end is located by deep pressure beneath the ribs and tissues. The rib may be manipulated as before described. Treatments I, II and III may be applied equally as well to the reduction of upward displacements; the appropriate pres- sure being made to force the rib downward. The STERNUM, if PROTRUDED or RETRACTED as a whole, is restored to normal through the general shaping of the thorax l&y methods already described. The ensiform appendix, being cartilaginous, is usually easily sprung by pressure and trained toward its normal position. PRACTICE OF OSTEOPATHY. 51 In case of luxation between the first and second parts of the sternum, traction is brought upon the first part through the deep .cervical tissues and the sterno-mastoid muscle of either side by rotation of the head backward and to one side. At the same time pressure is made upon the prominent end of the first or second part, reducing it. The CLAVICLE may be restored from any of its usual mal- positions as follows: The patient lies supine and the practi- tioner stands at the head of the table, slightly to one side, the fingers of the operating hand are pressed, palm up, behind the clavicle, the tissues being relaxed by slightly raising the shoulder. The free hand now grasps the arm of the patient just above the elbow and pushes the bent arm across the chest, up over the face, above the head, and rotates it down to the side again. This motion has raised the clavicle and allowed the fingers to be pressed deeply behind it. They may be applied particularly to the sternal end. The elevation of the shoulder has widened the anterior end of the costo-clavicular space and allowed the fingers to be brought well forward toward the sternal end. As the arm is now rotated outward, the increase of distance between the sternal and acromial attachments of the bone draws it down hard upon the fingers between it and the rib, forcing it upward from either an anterior or posterior downward dislocation. In case the sternal end has been dislocated upward on the sternum, the motion would have been the same, except that during the outward rotation of the arm, pressure would have been made above the sternal end to force it downward. In case the acromial end had been downward or upward the same motion would be applied, with the operating hand di- rected to that end of the bone. During the outward rotation of the arm the bone would be grasped between the fingers behind and the thumb in front and moved upward or downward from its displacement. Here, as in case of the ribs, it is less probable that the per- formance of a single set motion would accomplish the work than that insistent, though not violent, traction, pressure, rotation, etc., according to the manner of the described treatment, would secure the result. 52 PRACTICE OF OSTEOPATHY. The posterior margin of the clavicle may be tipped up- ward, so that the space between its outer end and the scapula is widened. The tissues at this point are then tender. The condition may be remedied by the proper application of the above treatment for reduction of displacement of the acromial end. CHAPTER VIII. GENERAL OSTEOPATHIC POINTS IN REGARD TO THE ABDOMEN AND ITS PARTS. Many of the specific lesions affecting thfe abdomen and its contained viscera occur in the spine and thorax and are of kinds already described. Much of the treatment for diseases of these parts is upon such lesions. The subject of examination and treatment of the various organs will be considered more in de- tail in relation to their specific diseases. The aim of this chapter is to give general methods of examination and general osteopathic points concerning these' parts. POSITION: The patient lies supine; the thighs are flexed and the feet rest upon the table; the head and chest are slightly elevated by the inclined head of the table. In this position the abdominal muscles are relaxed. The sides of the body are dis- posed alike to avoid unequal tension upon the tissues. Inspection, palpation, percussion and auscultation are the physical methods employed. INSPECTION reveals enlargement due to gas or fluid, tumor, muscular contraction, etc.; color; distended or retracted walls: restricted or increased motion; pulsation or engorgement of blood-vessels, etc. PALPATION reveals change in temperature: tumors, super- ficial or deep, fluid or solid; tenseness or flabbiness of the ab- dominal walls; enlargements and displacements of organs, etc. Pulsations, also, are to be noted. A marked pulsation of the abdominal aorta is common in nervous people, but generally indicates liver, stomach, or intestinal congestions. PRACTICE OF OSTEOPATHY. 53 Deep palpation of the abdomen in thin persons readily reaches the bodies of the lumbar vertebrse, rising quite prominently under the touch. They should not be mistaken for tumor. The examiner should grasp the abdominal walls in the fingers and raise them up away from the abdominal viscera, thus en- abling him to tell whether tender places, growths, etc., lie in or beneath these walls. PERCUSSION reveals the limits of organs, presence of tu- mors, fluids or gases, etc. AUSCULTATION reveals the gurgling of gases, fetal sounds, lubrication of the bowel, etc. I. A general treatment of the abdomen is sometimes nec- essary for general relaxation of the abdominal walls, often as a preliminary step toward further examination. With the pa- tient in position as above, the practitioner stands at the side of the table and with the palm of the hand manipulates the tissues to relax them. Care should be taken to avoid pressure with the tips of the fingers or other rude work which causes the tissues to contract. The hand should be warm and the manipulation gentle but thorough. II. Direct manipulation, including pressure and various movements, is often made upon the various abdominal organs. Specific directions for the treatment of any given organ are re- served until diseases of these organs are considered. But, speak- ing in general of abdominal manipulation as one of the methods in the repertoire of the Osteopath, care must be taken to make clear the difference between such manipulation and massage. Here the mode of motion is relatively insignificant. The manip- ulation is not for the general effect following a thorough abdominal massage, but is corrective ; directed to the specific end of restoring to proper mechanical relations an organ or organs definitely ascertained to be in need of mechanical adjustment. Here, as elsewhere in the body, this work removes pressure from, or in- terference with, blood-vessels and nerves. For example, osteo- pathic treatment of the colon is not made for general manipula- tive effect, but is directed to raising and straightening a sigmoid too much bent or folded. Thus it removes a mechanical ob- 54 PRACTICE OF OSTEOPATHY. struction to bowel action, but also lets free pelvic circulation and nerve-action impeded by such a condition. Or, manipulation of the colon raises from its unnatural po- sition the gut which has prolapsed and become wedged down among the pelvic viscera, where it has destroyed harmony of the functions. Osteopathic manipulation in this way is specific and corrective, based upon mechanical principles, and is applied by a practitioner who knows what causes such abdominal condi- tions and how to correct them. III. With the patient in position as above, or standing or sitting bent well forward, the fingers are inserted deeply be- neath the viscera in each iliac fossa. They are now drawn di- rectly upward, raising all the pelvic and abdominal viscera, freeing the action of the femoral and pelvic vessels and nerves. In case the patient has bent forward he straightens the body again at the time the viscera are raised. IV. With the patient lying upon the right side, the prac- titioner stands behind the pelvis and presses the fingers deeply into the iliac fossa upon the side of the sigmoid nearest the median plane of the body. He now raises the sigmoid flexure upward and slightly outward over the flaring inner surface of the ilium. This raises the gut from the pelvis, relieves kinking, and frees the circulation of the part. The movement may be repeated for the caecum. The knee-chest position is very important and effective in all conditions requiring the elevation of pelvic and abdominal viscera. The patient gets upon his knees, and, turning his head to one side, lays the upper part of the chest upon the table (still remaining on his knees.) While he is in this position manipula- tions are made to draw abdominal and pelvic contents down away from the pelvis. Gravitation aids this process. V. With the patient in the dorsal position, the practitioner stands at the side and places the palms of the hands over the false ribs and cartilages, one on either side, heel out and fingers directed toward toward the median plane of the body. Pres- sure is now made evenly upon the sides, springing the ribs and cartilages down upon the viscera beneath. As the pressure is directed inward the ribs are forced toward the mid-line and pressed PRACTICE OF OSTEOPATHY. 55 down u'pon the viscera. Repeating this motion at intervals of a few seconds thoroughly tones the nerve-plexuses and blood- flow of the upper abdominal viscera. VI. Deep pressure is made upon the solar plexus as follows: The patient lies supine, the practitioner stands at the side and lays the palmar surface of the distal phalanges of one hand over the pit of the stomach, at the level of the tips of the seventh and eighth ribs. Pressure with the second hand upon the first is gradually applied, the hand sinking deeper into the tissues until very deep pressure has been made. The plexus may now be manipulated by a slight circular movement of the hand. This treatment tones the action of the solar plexus, etc. It should be gently and gradually applied, but the pressure must be considerable. VII. Deep pressure as above at any point will cause a purely nervous pain to lessen or disappear, while it increases a pain due to inflammation. VIII. Displaced ribs sometimes mechanically depress vis- cera, and must then be replaced by methods already described. IX. The fundus of the gall-bladder is reached by deep pressure beneath the tip of the ninth rib on the right side. Thence the course of the bile duct to the duodenum is somewhat in the shape of a reversed "S," opening into the duodenum from one to two inches below the umbilicus. Manipulation aids in empty- ing the bladder and in passing gall-stones along the duct. Abdominal treatment is generally in conjunction with treatment upon the specific lesion occurring in the spine, thorax, etc. It must be given carefully, as there are many diseases, e. g., typhoid, in which rough abdominal treatment might cause seri- ous injury. It is directed to a specific end and restores mechani- cal relations of parts, frees nerve and blood-mechanisms, removes muscular contracture, etc. 56 PRACTICE OF OSTEOPATHY. CHAPTER IX. EXAMINATION AND TREATMENT OF LESIONS OF THE PELVIS. The importance of pelvic lesion can scarcely be overestimated on account of its relations to the spine above, to its contained viscera, and to the lower portions of the body. This chapter does not deal with diseases of the pelvic organs, but with bony and ligamentous lesions of the pelvis which are so significant, from the osteopathic standpoint, as causes of disease in the pelvic viscera, in the limbs, or in the body above. A. LESIONS AFFECTING THE PELVIS AS A WHOLE: I. EXAMINATION. The examiner must not neglect to ex- amine the spine in relation to pelvic lesion, as malpositions of this structure are almost sure to destroy spinal equilibrium and thus to affect spinal relations, sometimes to a serious extent The most common of such results is swerving or curvature of the spine in response to the efforts of nature to adapt the spine to a crooked pelvis. The pelvis as a whole may be tipped forward or backward; may be turned to either side ; or may be tilted, throwing one crest up and the other downward. These malpositions may be com- bined in various ways. The general symptoms of such trouble are pelvic diseases, female disorders, backache, neck lesion, sciatica, lameness or paralysis of the lower limbs, etc. In case of lesion of the whole pelvis, the point of movement upon the spine is usually the lumbo-sacral articulation, but the fifth lumbar vertebra may be carried with the pelvis, or the yielding point may include the whole lumbar region. INSPECTION AND PALPATION aid each other in the examina- tion. (1) Both superior posterior iliac spines are found equally too prominent in case of backward luxation of the pelvis, or (2) They are alike found to have receded anteriorly in for- ward luxation, or (3) One is prominent and the other has receded anteriorly in twisting of the pelvis sidewise, or (4) One stands higher than the other in case of tilting of PRACTICE OF OSTEOPATHY. 57 the pelvis laterally. In the latter case, comparision shows in- equality in the length of the limbs, and tenderness is often found in the tissues upon the iliac crest of the low side owing to greater tension upon them. At the same time the waist line is deepened upon the high side and filled out upon the low side. Examination and comparison of the posterior superior spines is best made upon the bared back, with the patient sit- ting sidewise upon the table. The practitioner sits upon a low stool directly behind the patient, placing a hand upon each spine, examining and comparing them carefully. Care must be taken that careless posture of the patient does not cause an apparent inequality, or, on the other hand, that an assumed position does not mask the lesion. With the patient sitting or lying on the side, careful pal- pation is made of the superficial and deep soft tissues in the sacro-iliac and posterior sacral regions. These are commonly .sensitive to pressure, but are always tensed, congested and strained over the sacro-iliac articulation and the posterior sacral foramina. These ligamentous lesions alone cause much ill by obstructing nerve-action. The hand is also passed along the crests of the ilia, making deep pressure in the tissues, to discover tenderness in them. Tilting of the pelvis may be ascertained by having the pa- tient hold the tape between his teeth in the mid-line of the body, from which point measurement is made to the inner malleolus of the tibia on each side. Tilting of the pelvis cannot be ascer- tained by measurements unless a fixed point above the pelvis is used as the starting point. II. TREATMENT. In the treatment of all the lesions above described, a pre- liminary step may usually be made with advantage by thor- ough relaxation of the soft tissues in the sacro-iliac regions as already described. (Chap. II, divs. Ill, XIII, XIV, XIX.) All the lesions described may be treated with the patient sitting upon the stool, his pelvis fixed by an assistant, who stands in front or behind and grasps the iliac crests, one with each hand. (1) For backward tipping, the assistant stands in front and 58 PRACTICE OF OSTEOPATHY. draws the pelvis forward, while the practitioner stands behind r grasps the patient beneath the axillae, and raises and draws the trunk backward. His work is aided by pressure of his knee against the sacrum. During this treatment, slight rotation of the body from one side to the other during the lifting process helps the reduction of the lesion. (2) For tilting upward on one side or for turning to either side, this same treatment may be applied -with variations to suit the condition. (3) For tipping forward, the assistant stands behind and draws the pelvis backward, while the practitioner manipulates the trunk from in front, in a similar manner as before, grad- ually working and drawing it forward. (4) For tipping forward, the patient may lie upon his side, the practitioner stands behind the pelvis, making a fixed point with one palm against the lower portions of the innominates and sacrum. He now draws backward, with the other hand, upon the uppermost iliac crest and anterior superior spine. The patient lies upon the other side and the motion is repeated. (5) For tipping backward, the patient lies upon his side, the practitioner stands behind and presses the flat of his knee against the upper portion of the sacrum. He now grasps the uppermost limb with one hand, the uppermost shoulder with the other, and draws the body backward, while forcing the pelvis carefully forward. (6) For tilting upward of the pelvis, one may adapt to the reduction of this lesion the treatment described in Chap. VII, A, Downward Displacements of Lower Ribs, for the stretching of the quadrati lumborum muscles. (7) For turning of the pelvis to one side, one may adapt to the reduction of this lesion the treatment as described in Chap. II, div. XVIII, third treatment. B. LESIONS AFFECTING PARTS OF THE PELVIS. We deal here chiefly with lesions of the innominate bones. They are more frequent than lesions of the pelvis as a whole, and are relatively more important. The general indications of innominate lesion, which would lead one to examine for such displacement, are back-ache, sciatica, . PRACTICE OF OSTEOPATHY. 59 pain or lameness in the limbs, limping or unequal gait, pelvic disease, female disorders, etc. The lesions of the innominate commonly met with are: I. The innominate displaced forward or backward. II. The innominate displaced upward or downward. III. Combinations of the above, which are the rule. It is rare that the simple lesion I or II is found. Frequently the displacement is downward and backward at the same time, lentgh- ening the leg. This lesion is, on the whole, the most common but the opposite luxation, forward and upward, is frequent. Generally if the lesion is backward, it is at the same time down- ward; if it is forward, it is at the same time upward. In the latter case, the leg is shortened. Yet it cannot be stated as the invariable rule that the backward lesion is combined with the downward one, and that the upward and forward positions always combine. The luxation may be back and up, or vice-versa. Yet, whatever the combined lesion be, a lengthened limb indi- cates a downward displacement of the innominate, while a short- ejied limb shows the reverse. There are numerous points upon the lateral articular surface of the sacrum, any one of which may act as the fixed point about which ,the innominate bone may rotate. This fixed point may be termed the axis of rotation, and its location determines how the innominate rotates, and whether the leg be lengthened or shortened as a result of the lesion. Thus, if the axis of rotation be located upon the upper and anterior part of the auricular sur- face of the sacrum, the innominate may rotate forward, while at the same time the posterior superior spine is thrown upward and the leg is lengthened. The reason why the downward lesion usually complicates the backward one is found in the beveled edge of the sacrum where it articulates with the ilium. This bevel is wedge-shaped with its broad end up. Moreover, its posterior margin is longer, and rises higher than its anterior edge. Thus the beveled auri- cular surface of the sacrum, which bone is broader in front and tilts forward so that the posterior margin of its base stands higher, directs the ilium either downward and backward, or upward and 60 PRACTICE OF OSTEOPATHY. forward, according to the direction of the forces causing the lesion IV. Each innominate may suffer from lesion at the same time, which ma}- be alike upon both sides, or different. EXAMINATION: PALPATION, aided by INSPECTION, is used in the examination. I. The length of the limbs is compared, and is one of the first and most reliable methods of examining for lesion of the innom- inate. The patient is laid upon his back; care is taken that he shall lie perfectly straight; the limbs are flexed and rotated to relax muscles and ligaments, and to prevent any unnatural tension in these structures from causing merely apparent differ- ence in length. The limbs are now drawn down and compared at the heels. It is best to have the patient keep the shoes on, but care must be taken to notice that the heels of the shoes do not differ in thickness, and that they are pushed back snugly against the patient's heel. This examination is for confirmation only, and while it is a clear indication, that one innominate is luxated, further ex- amination is necessary to determine whether one leg is too long, or the other too short, or both. II. Tenderness in the sacro-iliac ligaments upon deep pres- sure, and tenderness in the tissues along the crest of the ilium indi- cate that the lesion is upon the side upon which such tenderness occurs. The sacro-iliac ligaments are found tensed upon the side of lesion. While this tenderness and tension will usually indicate uni- lateral lesion, it is not an invariable sign, as the strain thrown upon the opposite side often causes like effects. Tenderness at the pubic symphysis is often present in these cases. III. The position of the posterior superior iliac spines is the best indication of lesion, receding anteriorly, prominent poster- iorly, up, or down, down and back, forward and up. etc., indi- cating the corresponding malposition in the bone. Comparison of the spine of the luxated bone with that of the normal bone is made. This examination must be made upon the bared back with the patient sitting. The practitioner sits directly behind PRACTICE OF OSTEOPATHY. 61 i the patient, palpation of both spines alike is made at the same time, one hand upon each. This facilitates comparison. IV. The waist-line is frequently changed in each case. Usually that upon the side of lesion is deeper through the pa- tient's favoring that side; bending toward it. For the same reason the muscles about the hip, pelvis and lower spine upon the opposite side may be hypertrophied. V. The spine adjacent to the pelvis must be examined for curvature, swerving to one side, hypertrophy or tension of tissues, etc., secondary to pelvic lesion. VI. Measurements may be made from the mid-line of the teeth to the inner malleolus of each tibia. TREATMENT: Preliminary relaxation of all surrounding tissues is first done by methods already described. I. BACKWARD LUXATIONS and their combinations: a. Patient lies upon his back; the practitioner stands at the side and places the clenched hand as a fixed point beneath the posterior superior spine of the luxated bone; the knee is flexed against the thorax and is rotated outward strongly enough to raise the weight of the patient and throw it upon the clenched hand. In this way the weight of the body is made to force the bone forward. b. The patient lies upon his side; the practitioner stands in front of the pelvis, slips one hand between the thighs and grasps the tuberosity of the ischium, the other hand is upon the pos- terior crest. He now draws forward upon the latter point while he pushes backward upon the tuberosity. By pulling forward on the tuberosity and pushing backward on the crest, the an- terior displacement of the bone may be set. Commonly one alternately pushes and pulls to thoroughly loosen the bone, ending by the appropriate motion to set it. c. Patient lies upon his sound side; the practitioner stands behind the pelvis, making pressure with his hand upon the upper back part of the innominate, while at the same time he draws the uppermost thigh backward. This forces the bone forward. II. FORWARD LUXATIONS and their combinations. a. The patient lies on his side, lesion uppermost; the practi- tioner stands behind the sacrum and places his hand or the flat 62 PRACTICE OF OSTEOPATHY. surface of his knee against the lower part of the sacrum, while he draws backward upon the anterior spine and crest of the lux- ated innominate. b. See "b" above. III. UPWARD LESION. a. The patient sits upon a stool and an assistant stands in front and fixes the pelvis by firm pressure downward upon the crests of the ilia. The practitioner stands behind, grasps the patient's trunk beneath the axillae, and lifts, turns and springs the whole trunk away from the side of lesion. This same motion may be applied to forcing the body down toward the side of lesion in downward luxations. b. For reducing the upward lesion one may adopt the treat- ment described in chapter VII, A, for the stretching of the quad- ratus lumborum muscle. For downward luxation see "a" above. The SACRUM and COCCYX have already been discussed. (Chap. I, divs. V, VI, VII; Chap. II divs. XIX, XX) Anterior or posterior, upward or downward luxation of the sacrum may be overcome by combinations of the treatments described for the sacrum and for the innominate. Spinal treatment must be given in conjunction with pelvic treatment as the case may require. C. GENERAL POINTS CONCERNING THE PELVIS. The pudic nerve and artery may be located where they cross the spine of the ischium, and be reached by deep 'pressure. The patient lies upon his side, the practitioner stands in front and bends the uppermost thigh backward to loosen the muscles and tissues. Pressure is made down upon the spine at a point between the middle and lower third of a line drawn from the posterior superior spine of the ilium to the outer side of the tuber ischii. The gluteal arteries may be impinged in the same way by deep pressure at a point between the upper and middle thirds of a line drawn from the posterior superior spine of the ilium to the outer side of the great trochanter when the thigh has been rotated forward. PRACTICE OF OSTEOPATHY. 63 Deep manipulation may be made over the course of the iliac blood-vessels, beginning at a point about two inches below the umbilicus and thence diagonally outward to the point where the femoral vessel leaves the pelvis beneath Poupart's ligament. The internal iliac artery runs diagonally downward into the pelvis from about the mid-point of the line of the first manipu- lation. The spermatic or ovarian vessels may be manipulated by deep pressure along a line beginning at the level of the umbil- icus, one inch external thereto, and running down to enter the pelvis at a point one and one-half inches internal to the anterior superior spine of the ilium. In case of these vessels one aids the venous flow by cen- tripetal progress along the lines defined. As an aid in relieving or restoring blood-flow in various pelvic diseases the treatments are of value. The hypogastric plexus is reached by deep pressure at a point about two inches below the umbilicus. The plexus lies between the common iliac arteries, just below the bifurcation of the aorta. The pelvic plexuses are reached a little lower and outward from the mid-line, where they lie deep in the pelvis each side of the rectum. D. OSTEOPATHIC WORK PER RECTUM. The index finger is generally used in rectal work as its use is less interfered with by the knuckles. Proper precautions for cleanliness and to guard against infection must be employed. The patient lies upon the right side or stands bent over a table. The examining finger, lubricated with vaseline or soap-suds is inserted, palm down, into the rectum. It notes mal-position of sacrum or coccyx; weakness, folding or prolapsing of the rectal walls; whether the grasp of the external sphincter is nor- mal; enlargement of the prostate gland in the male; protrusion of the cervix or fundus of the uterus against the rectum in the female; the presence of tumor or other growth; haemorrhoids, protruding or internal. The prostate gland lies below the anterior wall of the rec- 64 PRACTICE OF OSTEOPATHY. turn and is felt in that position about one one-half inches from the anus. Either lateral lobe, or the central lobe may be enlarged. In the latter case, stricture of the urethra is threatened, as the gland surrounds its first part. TREATMENT: In prolapsed and weakened walls the finger should smooth out the walls and press them upward as far as possible. This aids reposition, tones nerves and blood-force, and helps to establish normal tone in the muscular walls. A weakened sphincter is much stimulated by the simple insertion of the finger. It may be dilated by introducing two or three fingers held in wedge-shape, spreading them apart upon withdrawal. For an enlarged prostate gland, the finger makes pressure upon it and is swept laterally over it to aid in freeing the blood- flow from it. Care must be taken not to irritate it. Its surround- ing tissues should be well relaxed. In haemorrhoids, all the surrounding tissues are gently manipulated for relaxation and to remove interference with free circulation, after which pressure is made directly upon the distended vessels to empty them of blood, and to gently force them back into place if external. (See " Haemorrhoids. ") Rectal treatments should not usually be given oftener than once a week or ten days. Great care should always be exercised to cause as little irritation as may be. As a rule these treatments are but secondary to the removal of pelvic or spinal lesion. E. OSTEOPATHIC WORK PER VAGINAM. The examination is made with the index finger for the same reasons as in the case of rectal treatment. The same pre- cautions as to cleanliness, etc., should be observed. As a rule local treatment is secondary to that done upon spinal or pelvic lesion, which is usually the real cause of those conditions which require local treatment. It is proposed here to review this subject only in a gen- eral way, giving the main points in connection with the exam- ination and treatment of this region as a part of the body, leaving detailed consideration to the portions of the course dealing with the specific diseases of these organs. PRACTICE OF OSTEOPATHY. 65 I. LOCAL EXAMINATION: The patient on her back or on her side, preferably in the Sims position. * In the latter case the practitioner stands behind. The index finger anointed with vaseline is introduced, passing from the region of the fourchette forward. The guiding hand is placed upon the abdomen (bi- manual palpation) and by deep pressure may aid in locating the organ and in diagnosing its position. External pressure over the region of the broad ligaments will sometimes reveal tenderness in them in cases of prolapsus uteri. In case the ten- derness is unilateral it is usually in the ligament suffering from the most tension because of the organ having fallen toward the opposite side. The examining finger should first note the condition of the vaginal walls, which may be weak and flabby, or prolapsed and contorted by the malposition of the uterus. The presence of enlargement or tumor of surrounding organs is to be noticed. At the upper extremity of the vaginal canal is felt the cervix protruding into the canal. The external os uteri opens transversely at the lower end of the cervix. In women who have borne children the external os inclines to be circular, but by careful examination the trans- verse axis may be distinguished. This is made more certain by the shape of the cervix, which is somewhat flattened antero- posteriorly. By these two points, the transverseness of the os and the position of the cervix, the diagnosis of the position of the uterus is greatly aided. If the transverse os (or the longer transverse diameter of the cervix) has assumed an oblique di- rection in the pelvis, it indicates a corresponding turn in the position of the organ. This turning to one side is usually com- bined with the prolapsus or version of the organ in one direction or another. , If the cervix points forward and upward, the fundus has gone down and back, and may be against the rectum. In such case the fundus is often felt through the posterior vaginal wall. Or the uterus may have turned in falling backward, so that the fundus lies down toward either sacro-iliac region. If the cervix points backward and upward, it indicates that the fundus has descended anteriorly upon the bladder. It may often be felt 66 PRACTICE OF OSTEOPATHY. through the anterior vaginal wall. There are all degrees of prolapsus, and malposition. Some may be so slight that the cervix and fundus have deviated but little from normal position. By noting the direction of the os, the direction of the cervix, and (if possible) the position of the fundus, no difficulty is usually experienced in discovering the form of malposition from which the patient is suffering. The different forms of flexion are more difficult, but may be made out by the relative position of the cervix and fundus. For example, if the cervix remains near normal position while the fundus is found backward, retroflexion is diagnosed. In these cases, retroflexion, anteflexion, etc., the uterus is bent over on itself. The examining finger detects the bend hi the organ by finding itself in the space between fundus and cervix. Adhesions are noted by the fixity of the uterus in malposi- tion; its resistance to pressure directed toward its normal posi- tion, or to positions assumed by the patient to aid in replacing it . II. LOCAL TREATMENT: The patient may lie upon the back, upon the sid0 gr. to a pint), or a weak solu- tion of mercuric chlorid (1:50,000 or 100,000) are recommended. For septic cases, a saturated solution of boric acid may be used. ENURESIS, (Incontinence of Urine). DEFINITION: Inability to retain the urine. A neurosis due to sacral or lumbar lesion which so affects the motor nerve mechanism of the bladder as to result in lack of control. LESIONS AND ANATOMICAL RELATIONS: The lesions usually occur in the lower lumbar and sacral regions. They have been discussed in the beginning of the chapter on renal diseases (see ante). Frequently some single lesion, as of the 2nd or 5th lum- bar, is found, the removal of which cures the case at once. A common lesion is weakness and posterior position of the whole lumbar spine. Quite often lower dorsal lesion is found. An- terior lesion of the 5th lumbar is a frequent cause. As the vesical plexus supplies the muscular coats of the bladder, and as it is in connection, through the pelvic 'plexuses, with both the lumbar and sacral nerves, lesions of these por- tions of the spine may readily affect the motor activities of the bladder. This becomes more evident in the light of the fact that the motor fibres of the circular muscles and sphincter of the bladder are derived from the lumbar portion of the sympathetic namely, from the llth and 12th dorsal and the 1st and 2nd lum- bar spinal nerves connecting with the sympathetic by way of 228 PRACTICE OF OSTEOPATHY. the aortic plexus, the inferior mesenteric ganglion, the hypogas- tric and pelvic plexuses. On the other hand, the 2nd, 3rd, and 4th sacral nerves furnish the chief motor supply to the longitu- dinal muscle fibres of the bladder. (Quain). The American Text-Book of Physiology states that stimulation of the sacral nerves (1st, 2nd, 3rd and 4th) causes a reflex contraction of the bladder. It is evident that lumbar and spinal lesion may di- rectly affect this nerve-supply. The lesion involving the sphinc- teric center of the bladder; the paralytic incontinence; the imperfect vesical innervation and paresis of the walls from over distention; the spasmodic incontinence due to over action of the compressor muscle of the bladder, may all arise from spinal les- ion as described occurring at certain or various points in the lumbar and sacral regions. This lesion may cause a stoppage of nerve-supply, resulting in a paralytic condition, or in an irri- tation of the bladder. The anatomical relation between lesion and disease is clear in this case. The PROGNOSIS is good. Very many cases have been suc- cessfully treated. Generally quick results are attained. Treat- ment causes immediate lessening of the trouble. Cure is the rule. TREATMENT: The relation of lesion to disease is so close in this disease that the first step is to remove the lesion. This may be all the treatment necessary. A thorough stimulation of the lumbar and sacral region affects the nerve-connections explained above and tones the motor mechanism of the bladder. Spasmodic conditions call for thorough inhibition of these re- gions. Corrective spinal work restores normal conditions and allows Nature to attend to the result. Abdominal treatment over the hypogastric plexus and over the internal liiac vessels aids the case. When the condition is due to a prostrating dis- ease the treatment must be directed as well to the upbuilding of the system. A prolapsed uterus must be replaced, and other irritating causes removed. Among the latter may be intestinal worms, an elongated prepuce, etc. Circumcision is advisable in the latter case. In neurotic children treatment must be given to the general nervous syste. Enjoin regularity of habits in children, and regulate diet and drink, especially for the latter PRACTICE OP OSTEOPATHY. 229 part of the day. Avoid late play; all worry, and excitement. The child should sleep in a cool room, under light covers. The hips may be elevated a little. Keep the rectum empty. RENAL DROPSY. DEFINITION: This is "an abnormal accumulation of watery fluid transuded from the blood-vessels into the cellular tissues and lymph-spaces." "A toxemic edema" (Butler). It is a common occurrence in acute and chronic nephritis and in other form of kidney diseas3. The lesions are those causing the primary disease of the kidneys. The prognosis is good, the condition yielding quickly to treatment. The kidneys become very active under treatment and throw off the accumulated fluid from the system. In case 3, under "Diseases of the Urinary System," great dropsical swell- ing of the body from feet to middle of the back was quickly over- come by treatment. Under the subject "Ascites" is reported a case in which enormous quantities of the fluid were passed from the system by the kidneys which were kept well stimulated. The TREATMENT is for the removal of lesion and the cure of the primary disease of the kidneys. The organs must, them- selves, be kept thoroughly stimulated by treatments described in "Congestion of the Kidneys," q. v. The heart should be kept thoroughly stimulated to overcome its weakness, a feature quite important in these cases. This treatment aids in overcoming the venous stasis present in the whole system. Any special dis- ease of the heart present should be given due attention. It is apt to be dilated as well as weak. Any lesion affecting the heart should be removed. An important effect is gotten upon the heart by the thorough treatment to the kidneys, thus' lessening the vascular tension in the system due to the kidney disease. (See Dilatation of the Heart, for treatment). It is thought that the accumulation of fluid in the tissues is due to the relaxation and loss of elasticity in them. This prevents the forcing of the lymph into circulation, and allows the fluid to infiltrate the tissues. For this condition a thorough gen- eral spinal and muscular treatment is necessary to increase the activity of the circulation, and to add tone to vessels and tissues. 230 PRACTICE OF OSTEOPATHY. DISEASES OF THE HEART AND CIRCULATORY SYSTEM. As in considering the diseases of the urinary system, a num- ber of cases are here noted for their value in showing various facts in regard to the practice upon cases of this class. The}- show either important lesion, the removal of which cured the disease; quickness of results gained by osteopathic treatment in serious or long standing cases, unrelieved by other methods of treat- ment; and something of the variety and range of the practice in these cases. These reports as far as they go, are typical of the practice. They are not, however, presented as model case re- ports, nor as representing the whole field of practice in diseases of this class. (1) Fatty degeneration of the heart. 'The patient was too weak to walk ; the action of the heart was very weak ; arrhyth- mia was present; great dropsy of the lower limbs prevailed. The patient could sleep only by kneeling over a couch with the chest supported by pillows. This position relieved irritation from the lesion. Lesion was marked; there was great contracture of the muscles from the atlas to the 6th dorsal, especially marked in the upper dorsal region. The patient was very round shouldered. These causes brought about a drawing together of the sternal' ends of the ribs, and lessened the cavity of the chest, allowing of less room for the heart's action. For two weeks the patient was treated daily, and could then lie down to sleep. After one month he could walk a quarter of a mile to the office for treatment and return unaided. At the end of a three month course of treatment he returned home to work, and was well two years later. (2) A case of palpitation of the heart, with goitre, uterine disease, etc., presented contracture of the spinal muscles. The clavicles were both down and backward at the sternal end; there was lesion of the first right rib and of the second left rib; also a general dropping of the ribs which narrowed the chest cavity. Lesion affected the 1st and 2nd lumbar, and the pelvis was tilted. In six months all lesions were corrected, and the case showed marked improvement. (3) Palpitation of one years standing, attending physical or mental exertion. Subluxation of the fifth rib was discovered. PRACTICE OF OSTEOPATHY. 231 It was removed in one treatment, and the patient suffered no further trouble. (4) Palpitation and a complication of diseases; lesion found at the atlas and in the upper dorsal spine. No palpitation oc- curred after the third treatment. (5) Great palpitation of the heart, due to marked spinal curvature in the upper dorsal and cervical regions, came upon the patient frequently. Such an attack was usually treated medically with digitalis and kept the patient in bed for several days. Osteopathic treatment always relieved the patient of such an attack in a few minutes, and the patient could go about her usual duties. It was a common occurrence in this case to slow the heart-beat as much as twenty beats per minute, this effect not being transient, but lasting for several days. (6) Arrhythmia and a general bad condition of the health; lesion of the 4th left rib; slight lateral lesion of the fifth lumbar vertebra. The latter was probably responsible for uterine trouble present, which may have influenced the heart. After two months treatment the heart beat was almost normal. (7) Arrhythmia, in which the patient was very weak. The left 5th w r as down upon the 6th and slightly inward. The cer- vical and upper thoracic spinal muscles were very much con- tracted. The treatment was directed to raising the rib and re- laxing the contractured muscles, and resulted in regulating the heart-beat in six weeks. (8) Functional weakness; sinking spells occurred upon any exertion, as in climbing stairs. The left thorax was found depressed; the left clavicle was displaced downward at its sternal end, while it was up and forward at its acromial end. All the ribs were crowded together. Relief followed the first treatment, and the case was cured in five weeks. (9) Functional weakness of the heart, due to a downward displacement of the right fifth rib affecting the intercostal nerve. The case was cured in two months. (10) Impeded heart-action, resulting from a fall causing spinal injury and nervous shock. The marked lesion was found at the atlas. (11) Valvular disease of 12 years standing in a lady aged 40. 232 PRACTICE OF OSTEOPATHY. Marked edema of limbs and abdomen were present. She was suf- fering also from bronchial asthma. Lesions were contracture of lower cervical and upper dorsal muscles; the upper ribs were all drawn tight tgoether, under treatment the asthma and dropsy were cured, and the whole general health was made better than for years. (12) Valvular lesion following acute rheumatism, in a young man of 23. There was a twist in the spine at the 2nd dorsal and at the 5th dorsal. Great benefit was gotten under the treatment. (13) Enlargement of the heart, mitral and aortic incom- petence, and regurgitation ; showed lesion in forward displacement of the atlas, lesion of the left clavicle and upper two or three left ribs. Three treatments produced much improvement, one months treatment corrected the arrhythmia, and constant improvement went on under treatment. (14) Angina pectoris after lagrippe; spinal muscles con- tractured; the 3rd to 5th ribs displaced downward. (15) Angina pectoris showing lesion of the 2nd to 5th left ribs. The left arm could not be raised above the head without extreme pain. Under treatment the pains became gradually less severe, until they had practically ceased at the end of two months. (16) Angina pectoris, caused by downward displacement of the left clavicle, and cured by its correction. (17) Varicose veins and milk leg of fifteen years standing. The tissues surrounding Hunter's canal and the saphenous open- ing were tense, and the lumbar vertebrae were anterior. An operation had been advised, but the case had been practically cured under osteopathic treatment at the time of the report. (18) Varicose veins of eight years standing. Three varicose ulcers were discharging when treatment began. Innominate lesion was discovered. The case was cured in five weeks. (19) Varicose veins, for which operation had been made without success. The patient was compelled to sit with the limb elevated, and had been thus for five months. The physicians found they could do nothing more, and recommended continued elevation. One month of osteopathic treatment cured the case. (20) Varicose veins of two years standing. Severe and PRACTICE OF OSTEOPATHY. 233 continuous pain in the limb prevented sleep. The muscles over the sacrum and the lower lumbar vertebrae were rigid. In one month of treatment the case showed great improvement. (21) Varicose ulcers of ten years standing in a man of 55. The ulcers extended from the middle of each leg down upon the foot. The case was cured in three months by opening the venous return from the limb. (22) Disturbed circulation, in which the superficial cap- illaries of one side of the body were flushed, reddening the skin, while the other half of the body was pale. The line of demarkation between the halves of the body was very prominent. This trouble had come upon the patient as the direct result of a hard bicycle ride. Lesion was found at the fifth lumbar, and its cor- rection cured the case. (23) Disturbed circulation. The patient had accidentally received a hard blow upon the head, and intense pain developed upon one side of the head. She was unable to turn her head without turning the whole body. If she lay upon the injured side great pain followed. This condition was of five years stand- ing. Examination showed a strong contraction of the deep muscles of the neck, which set up irritation of the local sympa- thetic, affecting the vaso-constrictor fibres of the side of the head in question, causing over-contraction of the vessels, setting up the pain. Treatment was directed entirely to the contractured muscles, and in five weeks time overcame the trouble entirely. (24) Circumscribed ecchymosis upon the left wrist, about the diameter of a five cent piece, due to no bruise or injury to the tissues directly. The spot was drak, nearly black, and was allompanied by slight numbness in the forearm. The lesion was a slight elevation of the first left rib. The condition seemed to be a vaso-motor effect from pressure upon the brachial plexus or by interference with the spinal sympathetic connections. Reduc- tion of the lesion was accomplished at one treatment and had an immediate effect upon the ecchymosis. The area began at once to grow lighter in color, and in ten minutes had materially changed. In six hours it had disappeared. (25) General Dropsy, ascites being quite marked, in a lady of 38, and of 2^ years standing. Lesions occurred' as a pos- 234 PRACTICE OF OSTEOPATHY. terior condition of the third dorsal, and a separation between the fifth lumbar and the sacrum. The spinal muscles were all very tender. The case was cured. The treatment was almost en- tirely upon the lesions, with some general spinal, cervical and thoracic treatment combined. LESIONS: In seeking the lesion and in giving the treatment in cardiac diseases, certain centers, prominently connected with the normal activities and pathological manifestations of the heart, must be specially examined for lesion. These centers, given be- low, do not always relate to specific anatomical or physiological centers of the texts, but in some cases refer to bony points be- come prominent in osteopathic work as locations of lesion or of places where treatment produces special results. These are: the first rib (heart failure); corpora striata; 1st, 2nd, 3rd, 4th, 5th. dorsal vertebrae ; 2nd to 4th dorsal (valves of the heart) ; 3rd and 4th cervical (rhythm of the heart); superior cervical ganglion (a sympathetic center) ; upper four or five dorsal nerves, especially the 2nd and 3rd (accelerator center); medulla (general circula- tory). General vaso-motor centers which, with the special vaso- motor innervation of a given viscus, suffer from lesion in circu- latory disturbances: superior cervical ganglion; 2nd dorsal, 5th lumbar, for general superficial capillary circulation. The lesions usually present in cardiac diseases are: (1) of the atlas and axis; (2) the cervical region generally, both mus- cular and bony lesion. Lesions of the atlas, axis and cervical region affect the superior cervical ganglion and the other sympa- thetic supply of the heart. (3) Lesions of the clavicle are found, as are those, (4) of the 1st rib, (5) of the 2nd rib, (6) of the upper six ribs, especially on the left side, (7) of the upper five dorsal vertebrae, (8) as a change in the general shape of the thorax, (9) of the fifth left rib in particular, (10) of the diaphragm, i. e., of the lower six ribs, any or all of them, and of certain portions of the spine. Rib lesions are of prime importance in such diseases. They seem to be relatively more frequent than other sorts, perhaps for the reason that they affect the heart often mechanically, through alteration of the chest cavity, as well as by interference with its. PRACTICE OP OSTEOPATHY. 235 nerve-connections. As to kind, the rib lesion is as important as any other lesion, while as to frequency it is of greater importance Many of the rib lesions are of the 4th and 5th ribs, either or both, and usually of the left side. Lesions of the 6th rib, significant with relation to the apex, also occur. As a matter of fact, le- sions of these two are the most important of the rib lesions. They may affect both nerve-connections and mechanical relations of the heart. The fact that the apex beat (falling at the fifth inter- space) may be interfered with, easily deranging the whole rhythm of the organ, may account in part for the frequency with which such lesion causes cardiac disease. In numerous cases the 1st and 2nd rib present lesion, usually on the left side. While these lesions are not so generally the cause of heart disease, they are frequent and important lesions in these cases. Their main effect is through disturbance of the nerve-connections. The first rib may derange circulation through the sub-clavian vessels, as may the clavicle. In some cases lesion of the clavicle occurs. While not frequent, these lesions may be the cause of serious trouble. Spinal lesions, including both muscular and bony, are of the greatest importance when it is considered that rib lesion con- tributes to them by disturbance of the spinal nerve-connections. They act by producing derangement of the important nerve- connections in the upper dorsal region. From this point of view, bony and muscular lesions in the cervical region become signif- icant. While not so frequently the sole cause of heart disease, they yet often occur and derange the important sympathetic connections of the heart and this region. Lesions of the atlas, axis, or of any of the first three or four cervical vertebrae, also of the rectus capitis anticus major muscle, may affect the superior cervical ganglion as well as other cervical sympathetics. It may be noted that practically all of the above lesions affect the heart, in w r hole or in part, through its nerve-connec- tions. This seems to be the most important avenue over w-hich abnormal influences travel from lesion to heart. By working directly upon nerve distribution to the heart, irrespective of le- sion, important changes are readily made in its activities. Physi- ologically this organ is markedly affected by nervous influences. It seems that a viscus whose nervous equilibrium is so readily 236 PRACTICE OF OSTEOPATHY. disturbed or influenced, should be peculiarly susceptible to the influence of lesions to its regulative mechanism. Such lesions as Osteopathy considers, affecting this mechanism directly as they do, must be the true cause of many pathological states. Their removal is therefore a rational means of cure. The diaphragmatic lesion is of some importance in heart diseases, as mentioned above. It is frequently associated with a narrowed thorax, by reason of increased obliquity of the ribs, as well as of various other lesions of them. These lesions prevent free rib action, meaning also, practically, free thoracic play, free diaphragmmatic play, and free circulation. The various lesions which impede the free play of these parts must unfavorably affect circulation. In the cases of varicose veins reported, the importance of lumbar, sacral, and innominate lesion becomes apparent, also of the stoppage of venous return. Lesions of the tissues about the saphenous opening, and along Hunter's canal, are important in this connection. Two cases of vascular disturbance showed lesion of the cervical region and of the 5th lumbar vertebra, it being noticeable that each came at a place at which it could af- fect the center for superficial circulation. (Superior cervical and 5th lumbar). In periods from one or a few treatments to three months results are attained in long standing or serious cases that well demonstrate the superiority of osteopathic therapeutics. In one case the pulse was reduced from 140 to 110 at the first treatment, and was kept down and constantly improved thereafter. In case 4 it is pointed out that the pulse could be slowed as much as twenty beats per minute. Considering the fact that a cardiac medicine that reduces the heart beat one per minute is a success- ful one, it is readily seen that osteopathic control of the heart is most successful. The ANATOMICAL RELATIONS between the lesion and the heart-disease are made clear by the following facts. In view of them it seems that the science of Osteopathy, by its methods of diagnosis, arrives at the real cause of the disease. This is true also with reference to diseases in general. The pneumogastric nerves and the sympathetics are the PRACTICE OF OSTEOPATHY. 237 cardiac nerves. The pneumogastric is the heart inhibitor, and its center has been definitely located in the medulla. It is a well-known osteopathic fact that lesion in the superior cervical region, acting through the superior cervical ganglion, may dis- turb the centers contained in the medulla. In such case the heart may be affected by disturbance of the center of cardiac inhibition. Special details of the action of the vagus in inhibiting the heart have been observed. Strong stimulation of the nerve lengthens both systole and diastole, i. e., slows the beat. It also lessens the force of contraction, and causes the heart to beat not only more slowly, but more weakly. At the same time this stim- ulation results in the heart handling less blood, as the output and the input of the ventricle are both diminished. The ventricular tonus is diminished, and the heart dilates further by vagus stim- ulation, while at the same time the walls of the ventricle have been found to be softer. Osteopathic lesion to the vagi is a demonstrated fact. In view of the above functions of these nerves, it becomes at once apparent that lesion to them might cause serious disturbance. An irritative lesion, keeping up stimulation of the nerve, would per- manently slow the beat, lessen cardiac force, retard circulation, and possibly lead to dilated and flaccid heart. On the other hand, should the lesion be of a nature to cut off or to inhibit to a degree the vagal impulse normally retarding the heart within limits, the accelerator sympathetics would be left free to run the heart too fast. In either case the removal of the lesion to the pneumogastric would be of prime importance in curing the con- dition. Aside from removal of lesion, osteopathic treatment of the vagi has been demonstrated to influence heart action. The after effect of vagus stimulation Gaskell notes to be increased force of cardiac contraction. This is an indication that upon re- moval of lesion Nature would make special effort to repair the former deficiency of function. As it is known that section of the vagus is followed by atrophy of the cardiac muscle, it would be possible that serious lesion might approximate such a result. The vagus supplies the heart by its upper and lower cervical and thoracic cardiac branches, which join with the sympathetic 238 PRACTICE OF OSTEOPATHY. and go to the cardiac plexus. It also has connection with the superior cervical ganglion. As this nerve is known to be amenable to osteopathic treatment at many points, likewise susceptible of lesion at various places, as at the atlas, axis, and upper dorsal via its sympathetic connections, along the sterno-mastoid muscle and at the clavicle, its importance in relation to the cause and cure of heart disease is apparent. The cardiac depressor nerve, whose presence has been dem- onstrated in man, as well as in various other mammals, retards heart action in a manner different from that of the vagus. Its stimulative impulses come from the heart and act upon its sym- pathetic connections with the splanchnics to produce a reflex vaso-dilatation in the abdominal vessels. They dilate and re- ceive a large amount of blood from the general system, the gen- eral blood pressure is lessened, arterial tension falls, and the heart is thus quieted. It is thus apparent that a bony lesion in the splanchnic area might affect the spinal connections of the splanchnics, pro- ducing an inhibitor effect that would likewise dilate the abdom- inal vessels, and slow the heart by a process similar to that by which the heart depressor nerves function. On the other hand, lesion in the splanchnic area might be of a nature to irritate or over-stimulate the sympathetic connec- tions, thus causing a constriction of the abdominal vessels, and combating the normal dilator tendency of the depressor nerve, thus preventing the heart from being retarded in its beat to a normal degree. Hence splanchnic lesion may result in abnormal slowness or rapidity of the heart, and this condition may lead to other cardiac disease. These facts may explain Avhy we so frequently meet digestive disturbances and the like in heart disease. A further fact becomes evident. The practical Osteopath makes much use of the splanchnic and abdominal areas in his work upon cardiac and circulatory disturbances. By inhibiting the splanchnics, and by an inhibitive or relaxing treatment over the abdomen, he dilates the vast area of abdominal vessels and calls the blood from other parts of the body. Reflexly the gen- eral blood-pressure is lessened, arterial tension is decreased and PRACTICE OF OSTEOPATHY. 239 the heart is quieted. On the other hand, stimulative treatment to splanchnics and abdomen will, by the opposite effect, increase arterial tension and strengthen cardiac action. An important avenue to the heart is through the cervical sympathetic ganglia, each of which sends a cardiac branch to the cardiac plexus. Between these branches, the branches of the vagus, and the thoracic sympathetic there are numerous points of communication. Each ganglion is so situated and so connected with the spinal nerves that it is susceptible to lesions. The upper ganglion lies in front of the second and third cervical vertebrae and communicates with the upper four cervical nerves. It may suffer from lesion of the upper three vertebrae. Its branch- es of communication with the 3rd and 4th cervical nerves often pierce the rectus capitis anticus major muscle, on the sheath of which the ganglion lies. Contracture of this muscle may act as lesion to them. The middle ganglion lies in front of the 6th and 7th cervical vertebras and connects with the 5th and 6th cervical nerves. The lower ganglion lies in front of the 1st costo-verte- bral articulation, and connects with the 7th and 8th cervical nerves. They are susceptible to lesion respectively of the 5th, 6th, and 7th cervical vertebrae and the 1st rib. All three are liable to muscular lesion in cardiac disease. The accelerator or augmentor nerves of the heart are sym- pathetic. They are antagonistic to the vagi. That they are liable to suffer from spinal lesion is at once apparent from their anatomical relations. They are derived from the upper four or five dorsal nerves, especially from the 2nd and 3rd. They join the sympathetic at the middle and lower cervical, perhaps also first thoracic, ganglia. (Quain). The most important treat- ments for cardiac stimulation or inhibition are made in the upper dorsal region, at the origin of these nerves, by stimulation or inhibition of them. Important heart lesions occur in the upper dorsal region (spine or rib) and probably affect the heart through these connections. The connection of these ganglia with the middle and inferior cervical ganglia lends the latter added im- portance in these matters. When these accelerators are stimulated, they increase the frequency of the heart-beat from 7 to 70 per cent, but a long 240 PRACTICE OF OSTEOPATHY. stimulation produces no greater acceleration than a short one. This marked increase in the pulse is quickly apparent under os- teopathic stimulation of the accelerators. Further results of stimulating them are an increased force of the ventricular beat, the ventricles are more completely filled by the auricles and their volume is increased. The strength and volume of the auricular contractions are also increased. Hence our treatment both quickens and invigorates the heart muscle, and the organ conse- quently handles more blood at a beat. Lesions of the lower cervical, upper dorsal, or upper thoracic (rib) region might be of such a nature as to maintain continual stimulation of the accelerators, lead to permanently quickened and strengthened heart-beat, and produce such an affect as hyper_ trophy of the heart. Or the lesion might cut off or lessen the accelerator impulse, leading to abnormally slow heart-beat, lack of strength of heart action, etc. Hence the importance of cor- recting lesion in these regions. Jacobson (in Hilton's "Rest and Pain") points out that the cardiac plexus through the aortic plexus, is connected with the 4th, 5th and 6th. spinal nerves. This fact may in part ex- plain the importance of lesion of the 4th and 5th ribs in heart disease. The 1st, 2nd and 3id spinal nerves, through the sym- pathetic, supply sensory fibres to the heart. (Quain). The above facts explain why secondary lesion as contractured muscles may occur along the upper dorsal spine as far as the 6th in cardiac disease. The cardiac plexus is made up of the cardiac branches of the vagus and from the cervical ganglia, whose functions and rela- tions to cardiac disease were pointed out above. This plexus suffers from lesion of those nerves, and is the medium through which lesion acts upon the heart. The right and left coronary plexuses, derived from the cardiac, supply the coronary arteries. Lesion to them, through the cardiac, would influence nutrition and circulation in the heart substance. The intercostal nerves may become important paths of transmission of the effects of lesion to the heart. It is well known that rib lesions are among the most frequent causes of heart- disease. Possibly much of their influence is by irritation to the PRACTICE OF OSTEOPATHY. 241 intercostal nerves. These nerves are the anterior primary branches of the spinal nerves, and the ramus communicans from each thoracic sympathetic ganglion passes directly to the intercostal nerve corresponding. As shown above, the heart is in connec- tion with the upper six dorsal nerves through its sympathetic sppply. The upper four or five give origin to the accelerators. The 1st, 2nd and 3rd contribute sensory branches to the heart. The 4th, 5th and 6th connect -with the cardiac plexus through the aortic. Hence, on account of this direct connection between heart and the anterior primary divisions of the upper six dorsal nerves the immediate effect of lesion in this portion of the thorax might be upon the heart. Hence the importance of luxated ribs, sore and contractured intercostal muscles, a narrowed chest and changed shape of the thorax. These facts emphasize the im- portance of free thoracic play in the maintenance of the health of the thoracic viscera. A general changed shape of the thorax may have its bear- ing upon the etiology of cardiac trouble in other ways. The total intercostal circulation represents a considerable portion of the general circulation. If this whole circulation be obstructed, as may occur in those conditions in which a general alteration in the shape of the thorax has produced narrowing of the inter- costal spaces, the heart must be put to greater exertion to force the blood through this area of obstructed vessels. Furthermore, such a condition of narrowed thorax is just the one pointed out as the cause of lesion to the diaphragm, which obstructs the flow of blood through the aorta and still further embarrasses the heart. Take these obstructions to intercostal and aortic circulation in conjunction with rib lesions to intercostal nerves, a frequent^oc- currence, and it could hardly result otherwise than that cardiac derangement must follow. The phrenic nerve innervates both heart and diaphragm. Lesion to it may affect this organ, or treatment of it may aid in cardiac cases. It is joined by branches from the middle or lower cervical sympathetic ganglia and from the thoracic sym- pathetic, both of which are connected with the heart innerva- tion. It perforates the diaphragm and joins the abdominal sym- pathetic. It supplies the right pericardium, the right auricle, 16 242 PRACTICE OF OSTEOPATHY. and the inferior vena cava. Perhaps it, a motor nerve, co-ordi- nates the activities of heart and diaphragm, so closely related in function. Its inhibition is our common method of relaxing the diaphragm in hiccough. Its inhibition would be important in securing a lax or quiet diaphragm, so desirable in the treatment of certain forms of cardiac diseases, the more so as it may likely be suffering from the irritation of the disease affecting the heart or its coverings. Clavicular lesion may affect the subclavian vessels, dam back the flow of blood through the artery, or, by preventing the return flow through the vein, cause the periodic loss of a heart- beat through insufficient filling of the organ. The intimate relations between the cardiac nerves and the general nervous system is seen in the fact that stimulation of the sciatic increases the force and frequency of the heart-beat. These facts are of value hi treatment for the general circulation. PERICARDITIS. Under osteopathic treatment the prognosis for cure is good in the dry or plastic form and in that with serous effusion. In the purulent form, and in chronic adhesive pericarditis the prog- nosis must be unfavorable, though much might be done to bene- fit the patient's condition. The LESIONS affect the blood-supply by derangement of the spinal sympathetics. Irritative rib lesions, bringing pressure directly upon the heart, cause the disease by mechanical irrita- tion of the pericardium. This is especially likely to occur in lesion to the fourth and fifth left ribs, they occurring at the site of apex beat, where the greater range of motion is more likely to be interfered with by narrowing of the thoracic cavity or by inward displacement of these ribs. Lesions to the subclavian vein at the first rib or clavicle, and to the anterior intercostal vessels, preventing venous drainage of the pericardium, may predispose to the condition. A narrowed thorax and a deranged diaphragm may, by pressure or traction upon the pericardium, allow special causes to set up irritation and inflammation in the structure. These various lesions may lay the foundation for the disease, some special active cause producing it directly. Thus PRACTICE OF OSTEOPATHY. 243 spinal and other lesion to the cardiac nerves weakens the tissues and lays them liable to the effect of such disorders as rheumatism, gout, scarlatina, influenza, etc., secondarily to which pericarditis occurs. In such cases also attention must be given to the lesion accountable for the primary disease. In the TREATMENT the patient must be kept at rest in the recumbent position to aid in slowing the beat of the heart. This object is directly accomplished by stimulation of the vagus and inhibition of the accelerators. The former is treated by manip- ulation along its course behind the sterno-mastoid muscle. In- hibition of the accelerators is applied along the spine from the 6th cervical to the 5th dorsal. With the patient lying upon his back the left arm is raised and held well above and behind the head, while steady pressure is applied along the upper dorsal region as far down as the fifth vertebra. ' The lesion must be removed. The ribs may be carefully raised to free the venous circulation through the internal mam- mary veins, which drain the anterior intercostal veins. This aids in allaying the inflammation, as does also the inhibitive abdominal treatment by drawing the blood to the abdomen. The latter operation is assisted by inhibition along the splanch- nics at the spine. Calling the blood to the abdomen not only aids in allaying the inflammation, but may' slow the heart by decreasing arterial tension. As this reflex dilatation of the ab- dominal veins is a result the same as that produced by the heart depressor nerve in functioning to quiet the heart, it is supposable that treatment given to dilate these vessels produces a result similar to that resulting from depressor nerve action. As all the ribs are carefully raised to expand the thorax and give freedom to the heart, the various intercostal . muscles should be gently manipulated and relaxed. On account of the close connection pointed out above between the intercostal nerves and the sympathetics connected with the heart, it is probable that reflex sensations are transmitted from the dis- eased cardiac apparatus to the intercostal nerves, leading to a contractured condition of the intercostal muscles generally. The phrenic nerves should be inhibited to relax the dia- phragm (and pericardium (?) which it supplies). This treat- 244 PRACTICE OF OSTEOPATHY. ment is the more important in pericarditis, as the diaphragm is probably irritated by the inflammation in the pericardium directly contiguous to it. Irritation would mean contracture. This relaxation of the diaphragm would aid in quieting the heart and in relieving the whole local condition. The desirability of securing a lax state of diaphragm and pericardium in the treat- ment of pericarditis is suggested by Hilton. The pain about the heart is lessened by the whole treat- ment. Direct treatment may be made for it by inhibition of the 1st, 2nd, and 3rd dorsal nerves (sensory to the heart), and the 4th, 5th, and 6th dorsal nerves, which apparently convey sensory impressions from the heart. The dyspnea is relieved by the allaying of the inflammation, quieting the heart, and raising of all the ribs. Effusion is pre- vented or resorbed by keeping up free circulation, especially after the acute stage for the latter object. If necessary, the ice- bag may be applied to the precordial region to allay the inflam- mation. Its use may become necessary in the intervals between treatment. The diet should be of milk and broths during the acute stage. Later ,it should be light. Treatment should be given daily. More than one treatment per diem may be necessary, especially attention to various phases. Treatment for the various forms of pericarditis would be upon the same plan, with due attention to the manifestations of each condition. In the chronic form it would be proper to keep the heart well stimulated, to increase its nutrition. The patient should take plenty of rest lying down to avoid hyper- trophy of the heart. For the plastic form and for that with serous effusion,' the treatment is as above described. In the latter, during the stage of effusion one must carefully watch the heart to prevent collapse. When the pulse becomes weak, and cyanosis is present, the heart and lungs should both be stimu- lated. In the purulent form the treatment should be applied as above, but this condition calls for surgical treatment. The pericardial sac should be drained. HYDROPERICARDIUM is a condition in which a serous fluid transudate occupies the pericardial sac. but no inflammatory condition is present. It is commonly associated with renal or PRACTICE OF OSTEOPATHY. 245 cardiac dropsy, and its treatment is that indicated for them, q. v. PNEUMOPERICARDIUM calls for palliative treatment similar to that described for pericarditis with effusion. The heart should be kept stimulated against collapse. The case calls for surgical treatment. PALPITATION. DEFINITION: A paroxysmal rapidity of heart-action, per- ceptible to the patient, and usually accompanied by increased force, disturbed rhythm, precordial distress, anxiety, and dyspnea. This condition is caused by special lesion, usually a bony one, that interferes with the nerve-mechanism or with the heart mechanically. This, and the so-called neuroses of the heart, are, from the osteopathic standpoint, neuroses mainly because of their being caused by disturbed nerve-mechanism of the organ. This is no more nor less true in such diseases than in the general diseases of the heart. LESIONS AND ANATOMICAL RELATIONS have been discussed in a general way above. An examination of the several cases of palpitation reported at the beginning of the chapter shows a wide range of lesion, namely, from the atlas to the last rib, when considering as a lesion producing this condition those changes in the shape of the thorax and those lesions of the lower six ribs responsible for lesion of the diaphragm embarrassing the heart. These lesions may act by disturbing the nerve-connec- tions of the heart, by occluding certain vascular areas or single vessels, or by direct mechanical pressure upon the heart. Le- sions of the clavicle and first rib are frequent, and they, by dam- ming back the blood in the sub-clavian artery, may cause periods of labored beat of the heart to force it through. Or by lessening venous flow from the sub-clavian vein such lesion ma"y cause a paroxysm of rapid beating of the heart in the endeavor to fill itself. Cervical and upper dorsal lesions, curvatures of the upper spine, lesions of the upper five ribs, and general contracture of the spinal muscles may all act as irritant upon the accelerator sympathetics, noted as rising from the upper four or five dorsal nerves and passing to the middle and lower cervical sympathetic ganglia. Stimulation of these accelerators thus caused could 246 PRACTICE OF OSTEOPATHY. produce the rapid beating of the heart found in palpitation. This class of lesion is most frequent in these cases. Atlas lesion may affect the heart through the superior cer- vical ganglion and its upper cardiac branch. But through this ganglion such lesion is able to affect the inhibitory center in the medulla, or it may affect the vagus itself by way of its sympathetic connections with the ganglion mentioned. The result is over- activity of the inhibitor function of the vagus, and the rapid beat thus allowed as the result of unapposed activity of the accelerator. This style of lesion is not a frequent cause of palpitation. It may be argued that as bony lesions are by nature con- tinuous, the paroxysmal rapidity of the heart in palpitation could not be thus caused, that the effect of this continuous lesion must itself be continuous as opposed to paroxysmal. Such is not the case, however. The lesion may not be so excessive in degree as to keep up continual irritation. Its irritation may become active only in certain motions or postures of the affected parts. It may be the neuropathic basis weakening the nerve tissues and laying the heart liable to the effects of special emotions, stimu- lants, .etc. The lesion might even, per se, be of a nature to cause continuous irritation and yet its effects not be continually ap- parent as rapid heart-beat on account of the natural variation in the activity of the accelerator centers and in the condition of the nervous system. Luxation of the fifth left rib mechanically irritates the heart and causes palpitation. Occuring as it does at the site of the apex-beat, it is just as likely a cause of palpitation as is the pressure from a stomach dilated with gas. Displacement of this rib and of the 4th is a common cause of palpitation. Rib lesions in general are quite apt to be found in cases in which palpitation is brought on by slight muscular exertion. The movable rib, being luxated, is readily thrown into an exaggerated condition of lesion upon muscular effort. Cases are continually met in which some special form of muscular activity, perhaps necessitated by the patient's occupation, has first caused the displacement and has then become the repeatedly-acting cause of the various attacks of palpitation which have followed. A frequent and serious cause of heart disease in general, PRACTICE OF OSTEOPATHY. 247 at? well as of palpitation in particular, is found in a general down- ward luxation of the ribs resulting in a narrowed thorax. Such a condition becomes a three-fold lesion. Looked at as the cause of palpitation it acts: (1) By partially occluding the calibre of the arteries in the total intercostal area, aggregating a considerable vascular total. (2) By causing lesion to the diaphragm of a nature allowing it to constrict the aorta. As a result of all this arterial obstruction the heart labors (palpitation) to force the blood along its accustomed channels. (3) By irritation to the intercostal nerves in the narrowed intercostal spaces. The upper six of these nerves, as above explained, are in direct sympathetic connection w r ith the heart and convey to it the irritation engen- dered in the intercostal spaces, causing it to palpitate. It will be noted that chronic heart sufferers are very often the possessors of flat chests and narrowed thoraxes. Dyspepsia, flatulence and diseased abdominal organs often reflexly set up palpitation. It may be that both effects are the results of a common lesion, i. e., one to the splanchnic nerves (abdominally or spmally). It has been explained that the de- pressor nerve of the heart acts reflexly through the splanchnics to produce vaso-dilatation in the great abdominal vascular area, "bleeding the patient into his own venis," and to cause a fall of blood-pressure, with a quieting of the heart. On the other hand, splanchnic lesion may set up intense vaso-constriction in this area, oppose the circulation of the blood in this way, and cause the labored beat or palpitation of the heart to force the blood through. The common cause assigned for palpitation, such as a strong emotion, the use of tea, coffee, tobacco, and alcohol; reflex dis- turbances from the ovaries, uterus, and other pelvic organs, etc., seem to be but incidental. There must be some cause determining the effects of these agents upon the heart. Otherwise it is hard to explain why these things effect one patient's heart and not that of another. The real cause weakening the heart and allow- ing these incidental causes to disturb it lies in the anatomical weak point affecting the organ or its connections. A multitude of cases cured by replacement of a displaced rib, or the like, leads to the conclusion that these so-called causes had little to do with 248 PRACTICE OF OSTEOPATHY. the real cause ; as of case 6 above, in which three weeks treatment cured palpitation of many years standing, and rendered the patient immune to the effects of coffee and tobacco, which before he could not use. In cases where the palpitation is purely secondary, as in anemia, from the changed state of the blood, and in acute infectious diseases, from the irritation of toxic substances circulating in the blood, the lesions belong to the primary disease. The PROGNOSIS is good. The most marked and long stand- ing cases have yielded readily to treatment. The case is gen- erally relieved at once and soon cured. The TREATMENT of the time of attack must look at once to quieting the nerve irritation that is causing the trouble. (1) Often the immediate removal of the lesion is practicable and is the sole treatment necessary. (2) Inhibition of the accelerators in the manner described in detail in the previous pages is the most efficient method of at once relieving the palpitation. Considerable pressure may be applied to the accelerator area of the spine, the left arm mean- while being strongly held above the head (see Pericarditis). Steady pressure at each point along these nerves for several min- utes is necessary. During this treatment one hand is slipped beneath the "patient, the arm may be held down above the head against the table by the pressure of the practitioner's trunk against it, while with his hand he relaxes the intercostal tissues all about the precordial region. This is to release contractions in the in- tercostal muscles set up by the irritation carried from the cardiac plexus to the upper intercostal nerves, with which it is closely connected. (3) Stimulation of the pneumogastric nerves in the neck aids inhibition of the heart-action (IV, Chap. IV). "Pressure upon the vagus in the neck, or pressure upon special points in the abdominal parieties, (the ovarian region in particular) some- times arrests the attack promptly" (Anders). (4) Stimulation of the abdominal sympathetics, by a quick treatment, will aid in inhibiting the heart beat. A better method, however, is to dilate the vast abdominal vascular system by the deep, inhibitive abdominal treatment. This drains the blood \ PHACTICE OF OSTEOPATHY. 249 into the abdomen, decreases general arterial tension, and quiets the heart. It is the exact process by which the depressor nerve quiets the heart, and may possibly cause it to function. Strong inhibition of the spinal splanchnics aids- this process. (5) All the ribs should be carefully elevated to allow free play to respiration and heart. The dyspnea is a reflex from the disturbed heart. It is relieved by this treatment, and by the re- lieving of the heart. (6) Other sources of irritation, as anemia, pelvic disease, etc., call for special treatment. (7) Upon the attack the patient should be laid upon his back at once, and the clothing about the neck and chest should be loosened. Treatment (2) should be at once applied. In case of necessity during the practitioner's absence, an ice-bag applied to the precordial region is a good domestic remedy. The patient may swallow bits of ice or drink plentifully of cold water. Hot and somewhat stimulating drinks are recommended. If the attacks are frequent or persistent the treatment must be often given. In treatment to prevent the recurrence of at- tacks a course of treatment may be carried out along the lines laid down. Special attention would naturally be given the le- gion. t Heart action and circulation would be built up, etc. At- tention should be given to the diet, as certain articles of diet may cause palpitation. An overloaded stomach should be relieved by vomiting. TACHYCARDIA, BRACHYCARDIA AND ARRHYTHMIA. The first is a rapid beating of the heart in paroxysms of variable duration, unaccompanied by any marked subjective sensations. The second is an abnormal slowness of the heart, temporary or permanent. The third is irregular beating of the heart, the irregularity being manifest in volume, force or time, .alone, or in various combinations, presenting various peculiarities. The lesion and its mode of causing disease, described for palpitation, are essentially the same for these three manifesta- tions of disturbance to the cardiac mechanism. The treatment, also, would proceed along the same general lines there laid down, being varied" to suit the requirements of the disease and of the 250 PRACTICE OF OSTEOPATHY. individual case. As a matter of fact the lesions found as the actual causes of these different diseases are practically the same in kind, affect the same areas, nerve connections, and vascular relations, but differ in degree, in concentration upon a particular region, e. g., chiefly upon the accelerators in the upper region to produce tachycardia, and therefore in the particular manifesta- tion or results of their presence. It is natural that those lesions producing palpitation should be greater in degree and more continuous and severe in action, thus producing tachycardia; that upper dorsal lesion should so excessively affect the accelerators as to permanently inhibit their activity to a degree great enough to cause brachycardia, or that the periodic or irregular manifestations of the effects of such lesion should produce arrhythmia. The latter is generally a feature of ordinary palpitation. In the same way arterial, venous, or other nerve lesion might become the cause of either disease. In other words, a purely osteopathic classification of diseases would regard these conditions as essentially the same, both as to lesion and as to general manner 'of treatment. One must bear ip. mind the fact that these conditions are frequently simply symptomatic, as, for example, the arrhythmia resulting fiom reflexes from kidneys, lungs, liver or stomach, or from the toxic effects of tea, coffee, tobacco, alcohol, or drugs. But they may also be due to cardiac changes in the ganglia, or in the walls, such as simple dilatation, fatty degeneration, or sclerosis. The fact that tachycardia is looked upon as being a mani- festation of paralysis of the pneumogastric or stimulation of the sympathetic is significant from the osteopathic viewpoint. The prognosis for these conditions is ordinarily good. The results attained are very satisfactory and cases are often readily cured. The fact that they are frequently symptomatic of other disease, or secondary thereto, makes the prognosis and treat- ment depend upon the primary condition. When, as is often the case, they are found to depend upon specific removable lesion the progress is good. It is not good when organic heart disease is present. The treatment for these conditions must be primarily the PRACTICE OF OSTEOPATHY. 251 removal of lesion or irritating cause, or the treatment of the pri- mary disease to which either may be secondary or symptomatic. All causes of reflex irritation, and the abuse of tea, coffee, and alcohol, etc., must be looked to. That for tachycardia and arrhythmia is practically that for palpitation. The treatment for brachycardia is mainly stimulation of the accelerators. In the treatment of brachycardia or the tachycardia following acute infectious diseases, e. g., typhoid fever, the excertory organs must be stimulated to free the system of poison, and the centers controlling the activities of the heart must be built up, as they have been invaded by the poison of the disease. In brachy- cardia the heart and lungs must be kept stimulated against the occurrence of syncope or physical prostration. Treatment in the intervals may be directed to upbuliding the general health , mechanical correction of the body, etc. Proper physical train-' ing to strengthen the heart muscle is valuable in all cases, and is practically all that is necessary in some cases. IRRITABLE HEART is another neurosis, and is to be regarded in the same light as the above conditions. It will be found to depend upon practically the same lesions, and readily yields to the treatment. Thorough general treatment for the nervous system should be added to that given the heart. The digestive disturbances, constipation, etc., yield readily to the treatment for those conditions. The cardiac uneasiness is overcome by keeping the ribs raised, and by inhibition of the heart's action. The patient should avoid stimulants and overexertion. ANGINA PECTORIS. DEFINITION: Paroxysms of violent pain in the pecordial region, extending to the neck, back and arms, and accompanied by a sense of impending death. It is said to be largely symp- tomatic. The lesions presented in the above cases were mainly to the left ribs over the heart. One case showed lesion to the left clavicle, affecting the subclavian circulation. Another case is reported with the lesion as a spreading of the sixth and seventh left ribs anteriorly. Lesions to the ribs over the heart are very' common in this disease. The upper dorsal spine is often affected. 252 PRACTICE OF OSTEOPATHY. The nature of the pain of angina pectoris is not well understood. Upper dorsal lesion may irritate the sensory nerves of the heart. (1st, 2nd, and 3rd dorsal.) The irritation of the lesion upon the heart may result in a neurosis of the sensory branches of the vagi. Other lesion to the vagi through their sympathetic connections may cause it. Some writers advance the theory that an aortitis is present and causes it. A deranged nerve-mechanism as the result of spinal, rib and other lesion, seems sufficient,from an osteo- pathic point of view, to cause this disturbance. The fact that it is usually associated with some form of organic heart lesion, arterio-sclerosis, etc., is not contrary to the idea that bony le- sion is at bottom the cause of the whole bad condition. The prognosis must be guarded because of the frequent presence of organic heart disease in cases manifesting angina pectoris. The prognosis for relief is good, and cases are often entirely cured. The treatment consists mainly in relieving the pain. This may be best accomplished by raising the left lower ribs in the region of the heart, especially in case of lesion here, by adopting the motion described for inhibition of the accelerators, bringing pressure over the upper three spinal nerves (cardiac sensory) at the same time, and also relaxing the tissues of the pecordial region, with additional inhibition of the pneumogastric nerves. Spinal inhibition may be carried down along the spine as low as the 6th dorsal nerve. Inhibition should be made upon the local nerves of the parts to which the pain has radiated, as to the brachial plexus, the cervical and spinal nerves, etc. A general course of treatment, should be given to strengthen the patient's general health, to correct heart action, and to re- move all lesions. In this way much may be done to prevent the recurrence of the attacks. The patient should lead a quiet life free from physical, mental and emotional extremes. Rest of mind and of body, and a good diet, are helpful. In case of emergency use of the ice-bag, or of hot applications over the heart may be useful. ENDOCARDITIS AND MYOCARDITIS. These are inflammations of the endocardium and of the PRACTICE OF OSTEOPATHY. 253 heart muscle, attended by various pathological and degenera- tive changes in the part attacked. The extent to which the path- ological changes go in most of these cases renders a cure hope- less. All forms of these diseases are apt to produce serious val- vular lesions. Aside from simple acute endocarditis, death is imminent in most of these cases, yet much may be done in in- dividual cases to alleviate conditions and to prolong life. The LESIONS AND ANATOMICAL RELATIONS as pointed out at the opening of the chapter apply here. It is seldom that myocarditis or any of the several forms of endocarditis seems to occur idiopathically. How far the actual causes of these diseases may be shown, from the accumulation of osteopathic data, to be specific osteopathic lesions to the heart remains to the future to decide. The accepted cause of these conditions generally is the irritation of the organ by the poisonous products of disease. Acute articular rheumatism is made accountable for 40 per cent of simple acute endocarditis. Rheumatism, ma- laria, scarlet fever, pulmonary tuberculosis, syphilis, gout, poison- ing, etc., are looked upon as the primary diseases in which poison- ous products are generated and cause endocarditis or myocardi- tis as a secondary condition. Various other causes are assigned. While poison in the system is admitted by the Osteopath to be sufficient cause of disease, it seems likely that specific le- sion to the cardiac apparatus has much to do in weakening the heart and laying it liable to the invasion of these diseases. Cir- culation to the substance of the heart is under control of the coronary plexus, derived from the cardiac plexus. Lesion to the latter through its spinal connections may affect the former and disturb the nutrition of the organ. The same result may be produced by lesion to the pneumogastrics, said to contain vaso- motor fibres to the heart and to have charge of trophic condition. It is obvious that the usual cardiac lesions may predispose the heart to these diseases. The direct irritation of the left ribs upon the heart, when they are displaced, may directly cause pericarditis and myocarditis. As medical etiology lays most of these cases to the action of bacteria, it is reasonable to conclude that direct lesion to the heart deteriorates the vitality of its tissues and allows them to gain a foothold. 254 PRACTICE OF OSTEOPATHY. This conclusion is strengthened by the fact that endocarditis sometimes follows chronic wasting diseases, such as diabetes and gleet. The fact that chronic endocarditis may be due to mechan- ical influences, may be caused by heavy muscular effort, strain- ing, etc., and the further fact that myocarditis is ascribed by Anders to injuries of the antero-lateral thoracic region emphasizes the idea that mechanical lesions regarded as important by the Osteopath may directly cause these conditions. The PROGNOSIS for simple acute endocarditis is good. It de- pends some upon the primary disease. The prognosis for chronic and ulcerative endocarditis and for myocarditis is grave. If specific lesion is found and may be removed, perhaps much may be done for the case generally speaking, much may be done in all of these cases to limit the disease and to prolong life. Chronic endocarditis has been cured. The TREATMENT is practically that described for pericard- itis, q. v. Knowledge of the nerve and blood-supply and of lesions gives one the key to the situation. The lesion and all cause of irritation must be removed, and the patient, in the acute stages, is kept in bed' to keep the heart quiet. Inhibition of the accelerators and stimulation of the vagi is done as directed. The ribs are raised to give the best freedom, and the abdominal treatment may be applied to draw the blood away from the heart and aid in keeping it quiet. Strict attention must be given the primary disease. In those generating toxins in the system the bowels, kidneys and liver are stimulated to excrete the poisons. In the chronic forms the heart and its connected nerves may be carefully stimulated to increase its tone and nutrition. The vegetation in acute endocarditis may be absorbed. Prophylactic treatment in rheumatism and in those dis- eases leading to these conditions consists in keeping the heart well stimulated, and in maintaining free action of kidneys and bowels to excrete the poison. In acute endocarditis the precordial pain and dyspnea, if present, are relieved by carefully elevating the ribs in the region of the heart by elevating the arm and holding it up behind the head. While the arm is held in this position the intercostal PRACTICE OF OSTEOPATHY. 255 tissues about this region should be manipulated and relaxed' The upper dorsal spinal region should be inhibited, from the 1st to the 6th dorsal. This treatment would likewise quiet palpitation. The heart should be carefully sustained and kept gently stimulated, especially if it show indications of failing. In ulcerative endocarditis the whole progress of the case must be carefully watched. If it accompany a septic disease, especial attention must be given that condition, and the chief indication is to keep the poison freely excreted from the sys- tem. Local symptoms of this form of endocarditis, if present, are similar to those for which the treatment has been described in the acute form. Gastro-intestinal disturbance, vomiting and diarrhoea, calls for such treatment as has been described for these conditions. The local circulation to eyes and kidneys should be kept active to prevent retinal and renal hemorrhages, evident as hematuria and dimness of vision. Kidneys must be stimulated to increase the urine, which may become scanty and contain albumen. A general spinal and cervical treatment is necessary to quiet the general nervous system and to relieve headache, delerium, somnolence or coma, which may appear. Chronic endocarditis necessitates such treatment as is de- scribed for valvular lesions, q. v. Myocarditis should be treated as are endocarditis and per- icarditis, conditions which it frequently accompanies as a com- plication. It is necessary to keep the heart quiet. Enforce ab- solute rest, and attend to the general nutrition. FATTY DEGENERATION OF THE HEART. DEFINITION: A condition in which the fitoes of the cardiac muscle are converted into fat. LESIONS such as have been pointed out affecting the heart may be present. The fact that this condition is often second- ary to cardiac hypertrophy, q. v., would lead one to work for such lesions as cause it. These lesions act in various ways to cause the heart to overwork and hypertrophy, either by over- stimulation of the accelerators, obstruction to the arterial cir- culation, by causing valvular lesion, etc. After hypertrophy 256 PRACTICE OF OSTEOPATHY. when the centers and parts concerned become exhausted, fatty degeneration occurs. It is pointed out by Anders that lesions to the coronary arteries are the most significant causes of fatty degeneration. Narrow- ing of the lumen of those vessels must result in defective nutri- tion of the cardiac muscle, and fatty degeneration follows. It was pointed out above, in considering the general anatomical relations of lesion to heart disease, that these coronary arteries are regulated in their calibre and activities by the coronary plex- uses, right and left, which are derived from the cardiac plexus. Hence it is seen that lesions to the vagus and to the sympathetic nerves of the heart, acting through the cardiac and coronary plexus, could so influence these vessels as to narrow their lumen, and cause mal-nutrition of the heart leading to degeneration. Where the condition is due to a cachetic condition of the system, as in phthysical and anemic conditions, and when it is secondary to some severe acute disease, lesion must be expected according to the primary disease. The PROGNOSIS must be guarded. Sudden death may en- sue. Yet, on the other hand, much may be done to strengthen the heart and build up its substance. The TREATMENT must be according to the requirements of the individual case. In each case the special cause of the condi- dition should be found out and treated. The lesion must be cor- rected. Special attention should be given the dilatation. It may be treated as described for that condition. The heart should be continuously but judiciously stimulated, because of the weak- ness of the heart. This should be by stimulation to the accelera- tors in the uppe* dorsal region, and to the sympathetics in the neck. This increases the strength of the beat and the tone of the heart muscle. By the same process, and by removal of lesion, the functions of the coronary plexuses are corrected, free circu- lation to the heart muscle is brought about, and it is better nour- ished. The palpitation, dyspnea, small and irregular pulse, and cool extremities are due to the cardiac dilatation, and are bene- fited by treatment of that condition. Raising the ribs and stim- ulating the heart will be helpful for these symptoms. PRACTICE OP OSTEOPATHY. 257 Pseudo-apoplectic attacks may occur, and should be promptly met. The patient should be placed upon his back with the head a little raised. The heart should be well stimulated, and this treatment should be extended the whole length of the spine. The cervical tissues should be relaxed, and strong inhibition should be made in the sub-occipital fossae for several minutes. Next the splanchnics should be inhibited as well as the solar plexus, and the treatment should be given, as described before, to call the blood to the abdominal vessels. By this procedure systemic circulation is rendered active, the blood is called from the head, and is distributed throughout the vascular system. For cardiac asthma treat as in ordinary asthma. The ribs should be occasionally elevated, and the lungs should be kept well stimulated, to overcome breathlessness and the Cheyne- Stokes breathing which tends to appear. Agina pectoris may be treated as directed for that condition. In anemic and cachetic conditions responsible for the fatty degeneration, the oxygen-carrying power of the blood should be increased by a thorough course of general treatment devoted to the upbuilding of the general health. The spleen, bowels, kid- neys, liver and gastro-intestinal tract should receive special stimulating treatment. The patient should be kept upon a carefully regulated diet. Light exercise invigorates the heart. FATTY OVERGROWTH, or fatty infiltration, is a condition in which an abnormal amount of fat is deposited in the auriculo- ventricular groove, beneath the visceral layer of the pericardium and even between the muscle fibers of the heart. The disease is apt to occur in the obese, and in those who over-eat, or who lead sedentary lives. Such LESIONS as before mentioned may be present, inter- fering with the nerve mechanism of the heart and disposing it to this condition, or causing the primary disease to which this is secondary. The PROGNOIS is good for cure. The TREATMENT consists in removal of lesion and in due at- tention to the primary disease. The heart should be kept well stimulated as it may suffer weakness by reason of atrophy of its 258 PRACTICE OF OSTEOPATHY. fibers and the liver. It tends to be dilated, and may then be treated as described for dilatation of the heart. This treatment overcomes the resultant vertigo, syncope, dyspnea, cyanosis, palpitation, each gf which may be especially treated as before indicated, as may also the asthma and bronchitis which are apt to occur. In obese persons it is well to keep the pancreas and the liver stimulated. (See Obesity). This will aid in preventing the deposition of fat. Also one should administer thorough general treatment, with the same object in view. Careful and contin- uous stimulation of the heart ni creases the tone of its muscle and the strength of its beat. Exercise helps this. In these conditions much may be accomplished by diet and exercise. A special method is followed. It consists in, (1) lim- iting the supply of fluids allowed the patient, (2) enforcing a proteid diet, (3) taking as much exercise of a special kind as will l>e tolerated by the condition of the heart. The fluids are limited to 36 oz. in twenty-four hours. The diet consists of coffee, tea, or water; a little bread; game, veal, or beef; salad, vegetables, fruit and eggs. The exercise is walking up graduated inclines, to invigorate the heart muscle. This is well accomplished by walk- ing up hills, varying, from mild inclines, gradually, to steeper ones. VALVULAR DISEASES. The prognosis in cases of this kind is not generally favor- able. As a rule, valvular disease is incurable. Yet some cases may be cured, and a fair number have been cured by osteopathic treatment. In cases not curable, much may be done to better the patient's condition, and prolong his life, Cases caused by simple dilatation or diminished contractile power may be cured. Also when occurring in simple acute endocarditis the prognosis for cure is good. LESIONS: In many cases of valvular lesion, in the left heart especially, the lesions present would be as described for endo- carditis, to which disease these may be secondary. In tricuspid insufficiency due to obstructed pulmonary circuit, lesion to the lung, as ascribed in the chapter on lung diseases, may cause the valvular trouble. In aortic stenosis from increased tension in the aorta, the PRACTICE OF OSTEOPATHY. 259. condition may be due to lesion to the diaphragm as explained, impeding circulation through the aorta. The same result may follow extensive arterial obstruction, as of all the intercostals. the sub-clavians, the abdominals, etc., as explained under An- atomical Relations at the opening of this chapter. Aortic valvu- lar lesions following heavy muscular strains, etc., may be due to the presence of some one of the various lesions described as affect- ing the heart, which forms a predisposing cause. Lesions to the vagus and to the sympathetic supply of the heart may lead to lack of tone and diminished contractile power (see general anatomi- cal relations) which sometimes causes valvular disease. General lesions to the cardiac mechanism, as of upper vertebrae, ribs, diaphragm, vagi and sympathetics, doubtless weaken the heart and act as predisposing causes to the valvular lesion which so frequently follows other disease. The TREATMENT in ordinary cases would be to sustain the heart and to maintain compensation. It should look to the removal of any lesion, or of any obstruction to the blood-current, especially in tricuspid insufficiency caused by obstructed pul- monary circulation, and in aortic stenosis due to increased tension in the aorta. Diaphragmatic lesion or important arterial ob- struction may be present. In the obstructed pulmonary circu- lation the lungs should be kept stimulated and any lesion to the lung should be removed. In all cases the whole general circula- tion must be kept free and well stimulated, in order to aid the heart to carry out its work, thus relieving it of much labor. In cases in athletes, or due to heavy muscular strain, one should suspect the presence of definite spinal or rib lesion due to such activities. The primary disease which may be causing the trouble calls for treatment according to its kind. In diminished con- tractile power or dilatation of the left ventricle causing mitral insufficiency, the accelerators, should be stimulated, as this in- creases cardiac tonus and strength of beat, and contracts the heart. In such cases lesion should be suspected to the vagus, as lesion to this nerve may diminish ventricular tonus, dilate the heart, and weaken its walls. In all such cases the patient should lead a quiet life, free from excitement or exertion. He should be much out of doors, 260 PRACTICE OF OSTEOPATHY. and live upon a light nutritious diet. He should avoid straining at stool, the use of alcohol, tobacco, etc. Bathing is recommended, with exception of Turkish baths. HYPERTROPHY OF THE HEART. In these conditions the prognosis is fair. Much may be done to maintain the patient in a state of comfortable health, preventing dilatation. Cases may sometimes be cured by os- teopathic therapeutics. The prognosis depends upon that for the condition producing the hypertrophy. In such forms of valvular diseases as are curable it may be cured. In cases due to exopthalmic goitre it may be curable. Such LESIONS as before described in cardiac disease may affect the nerve connections, etc., of the cardiac mechanism, and cause or predispose to the condition. A common cause is obstruction to the circulation through the small arteries. In the light of such fact, lesions before pointed out, causing ob- structed pulmonary circulation, obstructed aorta, intercostals, subclavians, abdominals, etc., are important. As the heart hypertrophies in valvular disease frequently, lesions would have to be sought according to primary conditions. Lesion to the sympathetics, as in exophthalmic goitre, causing hypertrophy are important. Lesion to vagi and ac- celerators, resulting in over-activity of the heart, may cause hyper- trophy. When such simple causes as the use of alcohol, coffee, tobacco, etc., and lead poisoning, etc., are alleged, one is bound to suspect one of the ordinary lesions present as the real cause allow- ing the heart to be affected by such agents. The TREATMENT looks to the lesion, obstruction to the blood- flow, etc. It is directed to the primary disease when the hyper- trophy, as is the rule, is a secondary condition. The circula- tion through the lungs should be kept free. The patient should remain quiet. Attention should be given the sympathetics to slow the beat as much as possible. The patient should lead a quiet life, free from excitement. His diet should be chosen with care, and he should particularly avoid overeating, alcohol, coffee, etc. PRACTICE OF OSTEOPATHY. 261 DILATATION OF THE HEART. DEFINITION: There may be simple dilatation of a cavity, causing increase in its size and thinning of its walls. The dilata- tion may be accompanied with hypertrophy, in which there is increase in both the size of the cavity and in the thickness of the muscular wall. As to CAUSES, the lesions as discussed would be sufficient. No specific lesion has been pointed out for this condition. Le- sions to the cardiac mechanism weaken the heart and thus are especially apt to predispose to dilatation. Under such conditions over-exertion and great physical strain would be more likely to cause dilatation of the right ventricle. As the vagus nerve has been shown to have a trophic influence upon the heart walls, also an influence upon their dilatation, lack of tone, and a softened condition of them, lesion to it would have an important part in the production of dilatation. Obstructed circulation, and any cause producing increased intra-cardiac pressure may result in dilatation. This is seen in mitral diseases. Osteopathic lesion causing obstruction to the intercostals, abdominals, pulmonary circulation, etc., as before discussed, may become the direct cause of dilatation of the heart. The PROGNOSIS is not good. It depends upon that for the primary condition often, as in valvular diseases where the prog- nosis is bad. When due to specific removable lesion the prog- nosis may become favorable. The TREATMENT consists in righting of mechanical relations and removal of lesion. Ostruction to the circulation must be relieved, and heart and lungs must be kept well stimulated to empty the chambers of the heart of the clotted blood that is retained in them. Stimulation of the accelerators aids the pro- cess by steadying and strengthening the heart beat, contracting it and adding tone. When secondary to acute infectious disease, valvular dis- ease, etc., the primary condition must be treated. The dropsy and dyspepsia present depend upon the bad circulation and are treated in the usual ways. Stimulation of the lungs and raising the ribs relieve the dyspnea. Stimulation to the kidneys in- 262 PRACTICE OF OSTEOPATHY. creases the flow of urine, which has been lessened, and aids in overcoming the dropsy. In the acute form the patient should rest in bed. In the chronic form he should avoid fatigue. General directions for the care of the patient are as before given. CARDIAC DROPSY should be treated upon the same plan as renal dropsy, q. v. The kidneys should be kept thoroughly stim- ulated to quicken their excretory action and to thus relieve vascu- lar tension. The heart and general circulation should be kept gently stimulated in order to lessen venous stasis, to help out cardiac compensation, and to force the lymph into the circulation. ARTERIO-SCLEROSIS calls chiefly for a general palliative course of treatment, equalizing and aiding general circulation, and attending to the special disease or cause that is responsible for the condition. As the lack of elasticity in the blood vessels interferes with the propulsion of blood through them, the heart should be kept well stimulated, and general circulation should be aided by a general spinal and muscu-lar treatment. To this may be added the abdominal treatment, and the treatment which regularly elevates and depresses the ribs, thus aspirating the ven- ous blood and toning general circulation. This treatment also meets the important indication of increasing the blood-supply to the viscera, as it has been lessened. Keeping the heart well stimulated maintains the balance of the cardio-vascular forces, and this, with the aid given the general circulation by the above treatment, renders less necessary the hypertrophy of the left ventricle, that is, limits the progress of such hypertrophy. By this plan of procedure, myocardial degenerations and dilatation of the left ventricle, common in the latter stages, as well as the dilatation of the aorta often present, are rendered less probable. Palpitation, dyspnea, angina, and precordial constriction are treated as before directed. The cerebral type calls for cervical treatment to lemove any obstruction to the circulation, and to aid the blood-flow to the brain. Raising the clavicles, opening the mouth against resistance, working along the course of the carotids, etc., may all be useful. The special effects in this type, such as tinnitus, PRACTICE OF OSTEOPATHY. 263 syncope, headache, vertigo and the like, are remedied by cor- rected circulation. They may be treated in the usual ways. Likewise lungs and kidneys should be vigorously treated to prevent their involvement, and the circulation to the extremities should be kept active to prevent starvation of the tissues and resulting gangrene. Much may be done to retard the progress of the disease by correcting any habit that favors the disease, such as the use of alcohol, excessive eating and drinking, muscular over-strain, etc. The diet should be light and non-stimulating. Rheumatism, gout, syphilis, Bright 's disease, mitral dis- ease, emphysema, and other diseases which predispose to arterio- sclerosis, should be carefully looked after. ANEURYSMS. The treatment of arieurysms must be largely palliative. Under favorable conditions the danger to life from the aneu- rysm may be greatly lessened, and the contents of the sac may be clotted, practically curing the case. The treatment must be with great care. Any considerable handling of the patient, in the way of strong treatments, must be avoided on account of the danger of rupture of the aneurysm. It is probable that various lesions, affecting vaso-motor and trophic nerves, weaken the vessels, and lay them liable to aneurysm by action of various causes, such as sudden great strain from physical exertion, arterio-sclerosis, etc. It is likely that spinal and rib lesions, acting upon the innervation of the thoracic aorta, and often combined with lesion to the diaphrgam which allows it to obstruct the aorta, may be the causesof weakness and strain upon this vessel that result in aneurysm. With the Osteopath, as with other physicians, the object of treatment must be to decrease arterial tension, produce clotting of the blood in the sac, and favor contraction of the walls of the sac. It is necessary for the patient to remain entirely quiet upon his back, thus diminishing the number of heart beats, as well as their strength, and at the same time the pressure of the blood in the sac. A most valuable aid in this process is a large amount of 264 PRACTICE OF OSTEOPATHY. inhibiting treatment applied to the accelerator innervation of the heart. (2nd to 5th dorsal and lower cervical). As the patient lies upon his back, the operating hand may be slipped beneath the shoulder and inhibition be applied. The free hand may press the shoulder down upon the inhibiting fingers. If the left arm be raised above the head to aid in this treatment, it should be done slowly and cautiously. This treatment diminishes force and frequency of the heart beat. It is also of the greatest importance to decrease arterial tension by further inhibitive treatment applied to the superior cervical region to affect the general vaso-motor center in the medulla. To this should be added the treatment for dilating the abdominal vessels and calling the blood to them.by inhibition of the splanchnic area of the spine and by the inhibitive, relaxing treatment to solar plexus and abdomen, as before described. This treatment locally upon the abdomen cannot be applied in .case of abdominal aneurysm, but the remainder of the treatment may be safely used. Any lesion or source of obstruction to the vessels, partic- ularly to the aorta*, should be removed. The diaphragm, if prolapsed, should be raised, and it should be sustained by a belt about the lower costal region. The palpitation of the heart may be quieted by the inhibition applied to the accelerators; the dysp- nea by very cautious and gentle elevation of the ribs; the pain by inhibition of the local nerve-supply of the part affected; other symptoms, according to their kind, may be met by the usual osteopathic procedures. While most of these symptoms are due to pressure from the aneurysm, the treatment is employed to relieve and to make the patient comfortable. The methods employed to reduce blood-pressure, etc., also favor contraction of the sac. Tufnell's treatment by absolute rest in the recumbent po- sition, and a restricted, dry diet is highly recommended. The dietary consists of 2 oz. of bread and butter and 2 oz. of milk for breakfast; 2 or 3 oz. of meat and 3 or 4 oz. of milk or claret for dinner; 2 oz. of bread and 2 oz. of milk for supper. This regimen must be persisted in for several months, in order to bring about sufficient diminution of the blood-volume. PRACTICE, OF OSTEOPATHY. 265 / ' Surgical methods are often necessary for the reduction of aneurysm. The patient should avoid stimulating diet and drink, and should avoid excitement. VARICOSE VEINS, (ANEURYSM OF VEINS). DEFINITION: This is a condition in which the veins be- come enlarged, elongated, tortuous, and distended with blood It may occur in various parts of the body, and is, generally speak- ing, due to obstruction to the blood-flow from the veins, by le- sions of various kinds. The term "varicose veins" is applied especially to this condition in the lower extremities, in which the internal saphenous suffers most often. The LESIONS are bony, muscular, tendinous, etc., or pressure from adjacent organs or growths, obstructing the venous flow. The course of the vessel, its surrounding anatomical parts, and sources of its innervation, must be carefully examined for sources of obstruction, the simple removal of which constitutes the effic- ient treatment in these cases. In the case of the internal saphenous vein there are numer- ous lesions which may act to obstruct the flow of blood. One of the most common of these is tension or thickening of the tis- sues about the saphenous opening, impeding the out-flow from the vein. Sometimes relaxed abdominal walls, or ptosis of the abdominal viscera, may cause pressure upon the femoral vein where is passes beneath Poupart's ligament. A displaced or pregnant uterus, or a loaded caecum or sigmoid, may bring pres- sure upon the iliac veins, and cause varicoses in the ex- tremities. It is also possible for a prolapsed diaphragm, com- pressing the azygos veins and obstructing the ascending vena cava to produce a like result. The vaso-motor innervation to the lower limbs is from the lower dorsal, lumbar, and sacral sympathetic ganglia, and lesion to lower dorsal vertebrae, lower ribs, lumbar vertebrae, innomi- nate bones, sacrum, or pelvis may act through the connected nerves to weaken the vaso-motor state of the arteries of the lower limbs, cause weakness of the circulation, and allow such causes as excessive standing to cause varicoses. Dislocations of 266 PRACTICE OF OSTEOPATHY. the hip, partial or total, tense the tissues and muscles, obstruct- ing venous return, and causing this condition. When the condition is due to pressure from tumors in the abdomen or pelvis, heart or lung disease, ascites, etc., the lesion must be sought according to such primary condition. The PROGNOSIS is good. Very severe and long standing cases can be cured. Osteopathic treatment has cured very many cases in which the enlarged veins had reached a large size. Ulcers and eczema resulting from varicose veins heal up after the cir- culation is restored. The TREATMENT is directed at once to the removal of the obstruction. In case of obstruction at the saphenous opening one may employ such a treatment as described in Chap. X. The intestines should be raised from the femoral vein (III, IV, Chap. VIII); the prolapsed uterus should be replaced ( Chap. IX, E) ; the abdominal walls should be strengthened by local treatment and by treatment to the spine; and in like manner tumors, a constipate^ bowel, ascites, diseases of heart or lungs, etc., should be treated as necessary according to directions given for those various conditions. Tight garters should not be worn. Lesion to lower ribs, spine, pelvis, etc., should be corrected. Special treatment is given in these cases to stimulate the vaso- motor innervation of the limbs to aid in keeping the circulation active. Likewise, a muscular treatment of the limbs, with flexion, circumduction, etc., and thorough abdominal treatment, reaching the iliac veins, the ascending cava. the portal circula- tion, etc., would be found helpful. The liver should be kept free, and the bowels as well. Care must be taken in the treatment that the thinned walls of the veins do not rupture and cause serious hemorrhage. In case of varicose ulcers, and of eczema, the part should be kept clean, and a healing dressing may be applied, but the parts must not be kept irritated by too frequent washing. Ulcers and eczema heal when the circulation is made free. Thrombi may form in the varicosed veins, and care must be taken to absorb them, not to break them down, on account of the danger of embolism. Bandages, silk stockings, etc.. are gradually removed, and PRACTICE OF OSTEOPATHY, 267 the vessels and circulation are strengthened to take care of them- selves. Elevation of the limb and recumbency help. DISEASES OF THE NERVOUS SYSTEM. CHOREA. (St. Vitus Dance). DEFINITION: A disease of the nervous system character- ized by involuntary contraction of muscle groups, accompanied by weakness, and often by slight mental derangement, due to spinal lesions interfering with motor function of brain or cord. CASES: (1) A case in a young girl, of three or four months standing; very severe; had lost all control of hands and feet r and of speech; could take only liquid food. It was thought she could not live. Lesions were found at the atlas and 4th dorsal vertebrae. The case was cured. (2) In a boy of nine, chorea followed vaccination. Le- sion was found at the atlas and at the 2nd to 4th dorsal verte- brae. Case cured in five weeks. (3) A case in a child of eleven, of nine months standing. Very severe; no sleep for six nights; power of articulation was lost. Six weeks of treatment showed great improvement. (4) A girl of ten; marked lesion of the atlas, and of the 3rd and 4th cervical vertebra?; the 2nd to 6th dorsal vertebrae were irregular and lateral; 5th lumbar posterior; cured in four rnonths. (5) Case of two years standing in a boy of twelve; right hand useless and carried in a sling; lesion at 1st and 3rd dorsal. Under treatment he became able to write well in one month. The case was cured. (6) A case of two years standing in a girl of thirteen. She had grown continually worse under usual treatment. The atlas was found displaced to the left, and upon its being replaced at the second treatment the jerking of the muscles began to grow less at once. The case was cured and the child, previously under- sized, grew rapidly thereafter. (7) The patient was a girl of thirteen; confined to the bed; arms and limbs drawn and useless; she could not sleep, or speak intelligently. Bony lesions were found in the cerivcal and lower 268 PRACTICE OF OSTEOPATHY. dorsal regions, and all the spinal muscles were contractured. The case, of three months standing, was cured in one month. (8) A case of acute chorea, in a girl of 7, a pupil in the pub- lic school. Lesions were: 2nd dorsal lateral, 6th dorsal pos- terior, slight curvature to the left in the dorsal region, muscles in cervical region contractured. Inhibition at the sub-occipital region controlled the twitching of the muscles at once. The case was cured. (9) A case in a girl of 10, which had been gradually coming on for six months. Atlas and axis were luxated to the right; 1st and 8th dorsal vertebra deviaed laterally; 5th and 6th ribs drawn together. Overstudy at school was the direct exciting cause. She was cured in 2^ months. (10) Huntingdon's Chorea. A case of hereditary chorea is reported, which was without a doubt a true case of Hunting- don's chorea. The father and mother had both been sufferers from chorea; the very marked affection of many muscle groups was present; the child was very dull, and had been regarded as having lost her mind. The condition was confirmed, chronic, and hereditary. The I 2nd and 3rd dorsal vertebrae were anterior. The case was cured. LESIONS AND ANATOMICAL RELATIONS: The lesions in these cases are found in the majority in the upper dorsal and cervical regions. Eight of the above cases described lesion and are illustrative of the facts generally observed in such cases. All showed lesion in the cervical or upper dorsal region, one or both. Neck lesion is important in these cases. Six of the above showed cervical lesion, five of the six being atlas lesions. The fact that atlas lesions alone may cause the disease is illustrated by case (6) . The fact that the upper dorsal lesion alone may cause it is illustrated by case (5). But fre- quently, as in four of those reported, combined lesion of the cervical and upper dorsal regions occur. The upper dorsal lesion is perhaps the most important one. Six of the above showed lesion somewhere in the upper six dorsal vertebras. The spinal area from the atlas to the 6th dorsal may be regarded as the important locality for lesions producing chorea. They may occur lower or affect the ribs as well as vertebrae. PRACTICE OF OSTEOPATHY. 269 These lesions high" up in the spine may involve the cord and brain, in a similar manner but lesser degree, as in paralytic affections of the whole body. The frequent occurrence of high lesion explains the usual general effect of the disease upon the whole body, including the upper and lower limbs, and suggests the idea that the cord, brain, or both are involved by the lesion, The authors state the pathology of this condition is obscure no constant lesions being found. Probably, as McConnell ob- serves, this is due to the fact that spinal lesion may often involve simply nerve-fibers. Some writers hold the disease to be a func- tional brain disturbance affecting the centers controlling the motor apparatus. From this point of view cervical and atlas lesion have important bearing, as they may influence brain cen- ters by interference with blood-supply to the brain through direct impingement upon the vertebral arteries and by disturbance of the cervical sympathetics. Upper dorsal lesions aid this effect by sympathetic disturbance. From this viewpoint either atlas, other cervical, or upper dorsal lesion alone could cause the dis- ease. It is worthy of note that the upper dorsal lesion (1st to 6th) falls upon a portion of the cord richer, perhaps, than any other in sympathetic centers. The cilio-spinal center, vaso-motors to face and mouth, pupillo-dilator fibers, motor fibers to involun- tary muscles of the orbit, vaso-motors to the lungs, accelerators to the heart, etc., all occur within this spinal area. This dis- turbance to the sympathetic may have much to do in unbalanc- ing the nervous system in such cases. This lesion could a]so effect spinal fibers by impingement, or the nutrition of the cord through sympathetic disturbance of its blood-supply. On the whole the likely pathology in this disease is that there is cord lesion or brain lesion due to mechanical irritation or to cut off nutrition. These various lesions weaken the portions of the nerve-system involved, and lay it liable to the action of such reflex causes as irritation due to parasites, eye-strain, nasal disease, sexual disorders, etc., or to such causes as over-study, shock, worry, strain, etc. The PROGNOSIS is good. It is rare that the treatment fails to cure or greatly relieve the case. Cure in a short time is the 270 PRACTICE OF OSTEOPATHY. rule, even in serious and long standing cases. The TREATMENT consists mainly in removal of lesion as the real cause. In some cases this is the sole treatment necessary. Ordinarily it is necessary to carry the patient through a course of treatment. All causes of irritation or nerve-strain should be removed. Such are intestinal worms, causes of worry, etc., as noted above. An important measure in these cases is the treatment upon the neck and spine for the general nervous sys- tem. The neck treatment reaches the sympathetic system, the medulla, the circulation to the brain, and influences the whole nervous system. It consists of the removal of lesion, relaxation of tissues, inhibition or stimulation of the cervical nerves and centers, etc. The spinal treatment is upon the same plan. It should be carried down along the spine. These treatments quickly relieve nervous tension and quiet the nervous system. They correct the circulation to the brain and central nervous system, increasing their nutrition, and stopping the muscular twitching characteristic of these conditions. Inhibition of the superior cervical ganglion may also aid in stopping the twitch- ing. An important treatment is the removal of contracture of the muscles all along the spine, common in these cases. At- tention must be given to the patient's general health. The heart is often very fast and should be slowed in the way already described. The kidneys should be stimulated and general meta- bolism in the body looked to, to increase too light specific gravity of the urine. The bowels must be kept regular. A thorough general treatment should be given to the mus- cular system, especially to those muscle groups involved in the disease. This includes flexion and circumduction of limbs and arms, etc. In some cases inhibition of the cervical sympathetic will cause the muscular twitching to cease at once. It has been accomplished by pressure between the 3rd and 4th cervical ver- tebrae. In the hygienic treatment of the case all causes of nerve- strain, over-work mentally, excessive physical exertion, etc., must be removed. Muscular exertion may lead to heart involve- ment, especially as cervical and upper dorsal lesion favor such PRACTICE OF OSTEOPATHY. 271 conditions. The diet should be light and nutritious. Fruits and vegetables may be taken, but meats and highly seasoned foods should be avoided. Sponging of the back, chest and neck with cold water is useful. The various CHOREIFORM AFFECTIONS, such as the spasmodic tics, habit chorea, laryngeal tic, choreic wry-neck, facial tic, jumping disease, etc., also rhythmic or hysteric chorea, fibrillary chorea, athetosis, and various other forms, are met in the same way. A number of such cases have been cured. Huntingdon's chorea, a hereditary disease with progressive dementia, is a very grave disease. EPILEPSY. DEFINITION: A disease in which there is loss of conscious- ness, with or without convulsions. From the osteopathic point of view it is caused by lesions interfering with the nutrition of cord or brain, or irritating the motor nerve strands running to the peripheral motor structures, or exciting connected nerves. CASES: (1) A case showing lesions at 7th and llth dorsal vertebrae. Under the treatment the attacks were much decreased in frequency not having appeared for a considerable period. (2) A case of more than one year's standing in a girl of thirteen; three to twelve attacks daily; lesions in upper cervical spine, posterior curvature from 6th dorsal to lower lumbar, marked lesions occurring at the 6th dorsal and at the 5th lumbar; all spinal muscles very rigid. Improvement began at once upon treatment, and the case was cured in three months. (3) A case of fifteen years standing in a man of thirty. No attacks occurred after the first treatment, and the case was cured in four months. No recurrence of attacks nineteen months later. (4) Daily attacks in a boy of eighteen, apparently due to a nervous stomach disease. The latter was cured in three months, and no further attack had occurred six months afterward. (5) A case of fourteen years duration in a lady of eighty was cured in two treatments. No attack occurred after the first treatment. The report was made two and a half years after the cure, no further attack having occurred. 272 PRACTICE OF OSTEOPATHY. (6) In a boy of twelve, monthly spells of two days dura- tion occurred, during which he would have from three to five spasms. The 3rd cervical vertebra was found turned far to the right. Under a three months course of treatment he had not had the last two monthly spells. (7) A case of petit mal in a young man of thirty. Lesions at the atlas, which was to the right and turned with the right transverse process backward, and at the axis, displaced to the left. Case still under treatment. (8) A case of petit mal due to lesion of the atlas to the right and back, and of the 2nd cervical to the left. (9) A case in a woman of 31. The atlas was slipped to the left; 4th cervical much to the left, and 3rd to the right; 1st, 2nd, 6th, 7th and 8th dorsal posterior; marked separation between 5th lumbar and sacrum; left ribs considerably down. A his- tory of severe falls during childhood was noted. The disease was over 23 years standing. The lesion at the 3rd cervical seemed the greatest source of irritation. When its condition was exaggerated it caused an attack. Immediate benefit was given by the treat- ment, but the case did not remain under treatment until. cured. When first seen the patient was in a series of attacks lasting two to three days. The attacks began at once to be less frequent and were two months or more apart when treatment ceased. (10) A case of six years standing in a woman of 22, the at- tacks coming on first after a fall down stairs, in which the side was hurt. Lesion was found as downward luxation of the left 12th rib, and prolapsus or contraction of the diaphragm. The treatment was to the removal of lesion and to equalize circula- tion. Benefit came by the first treatment, and the case was cured in three months. (11) A case of nine years standing in a woman of 32. The attacks were at first nocturnal, later coming on in the daytime. Lesion was a right lateral condition of the atlas, with marked contracture of the deep and superficial muscles along the spine. The condition was at once benefited, and a cure was gotten in three months of treatment. The lesion of atlas was bettered at the first treatment, giving relief. During an attack the patient PRACTICE OF OSTEOPATHY. 273 was brought out of it in five minutes by strong pressure over the solar plexus. (12) A case of epileptiform seizures in a woman of 20, of three years standing. The atlas was to the right; the spine was posterior from the 12th dorsal to sacrum; the spinal muscles and the tissues were contractured. The uterus was anteflexed. Under treatment the case was much benefited. The attacks were rendered much lighter and much less frequent. (13) In a case of epilepsy in a boy, removal of lesion to the coccyx cured a case after all other means had failed. LESIONS AND ANATOMICAL RELATIONS: It seems that le- sion along the neck and spine anywhere may cause epilepsy. Dr. A. T. Still is credited with the statement that there is usually lesion between the 2nd and 3rd cervical vertebrae. He also ascribes epilepsy to lesion causing prolapse of the diaphragm, and obstruction to the arterial and venous blood, and of the lymph, in the vessels perforating it. In this way the products of digest- ion are retained and decompose, the patient suffering from auto- intoxication. Lesions in the above cases occurred at the atlas, cervical region, and from the middle dorsal down to the last lumbar. McConnell states that lesions occur often in the splanchnic area and to the ribs, especially in the spinal region between the 4th and 8th dorsal vertebrae, also that the prominent lesions occur in the neck from the 3rd to 7th vertebra. He notes a case caused by displacement of the right 5th rib. An attack could be caused by irritation of this lesion, or be relieved at once by replacing the rib. The neck lesions seem, on the whole, to be the most im- portant. Neck and spinal lesion may act by obstructing the blood-supply to brain or cord. They may affect the cord di- rectly by mechanical irritation, or may affect brain, cord, or nervous system generally through the sympathetics. In this way they may bring about those morbid conditions of the cord, brain and meninges said to cause the disease. While the path- ology of epilepsy is unknown, it yet appears that osteopathic lesion may account for many of the various conditions assigned as causes. Such lesions, disturbing the sympathetic system > 274 PRACTICE OF OSTEOPATHY. may act as does peripheral irritation from dentition, worms, cicatrices, adherent prepuce, etc. Various of these lesions may directly irritate peripheral nerve structures. As traumatism is assigned as a cause, osteopathic lesion, as cause or effect of trau- matic conditions, may be the real cause. According to Gray, the best accepted modern theory of the cause of epilepsy is that it is due to direct or indirect excitation of the cortex or of nerve-strands leading from the cortex to the the perpheral structures; that there is a peculiar condition of the motor tract which runs from the motor convolutions to the peripheral motor structures and muscles. He states that we are ignorant of the nature of this molecular condition; that muscles can be convulsed only by direct excitation of the muscle itself, or of the motor tract leading from the muscle up to the motor convolu- tions; but that some varieties of epilepsy are evidently due to an excitation that extends into this motor tract from some part of the nervous system beyond it. It would seem clear that osteo- pathic lesion may irritate these motor tracts somewhere in their course, as by direct pressure of luxated spinal vertebrae, etc., or that in a multitude of ways it may produce excitation in some other part of the nervous system from which it extends to the motor tract. As nerve irritation by lesion is the important point in osteopathic etiology generally, being well supported by num- erous instances in which its removal has cured the disease, it is a reasonable conclusion that the various bony lesions found in epilepsy are causing it by excitation of the sort mentioned. This point is likewise supported by the fact that removal of such le- sion has often cured epilepsy. The PROGNOSIS is fair in the ordinary case, a fair number of the cases coming under osteopathic treatment being cured entirely. A large percentage not cured are benefited. There seems to be but little difference in the prognosis in favor of petit mal. In Jacksonian Epilepsy the prognosis is not good. TREATMENT: At the time of attack but little can be done for the patient. If the patient can be reached at the aura the attack may be prevented by pushing the patient's head strongly back against a hand applying deep pressure in the sub-occipital fossse. This treatment seems to arouse reflex stimulation or to PRACTICE OF OSTEOPATHY. 275 equalize blood-flow to the brain by effect upon the superior cer- vical ganglion and medulla. Anders states that constriction of the limb in which the aura occurs, forcibly moving the patient's head, placing snuff to the patient's nose, applying ice to his spine, etc., will sometimes prevent the attack. McConnell calls attention to the fact that in cases where the exciting factor seems to be in the intestine and there is reverse peristalsis of the intestines, causing a re- version of the nerve current in the vagi, thorough rapid abdom- inal treatment will normalize peristalsis and aid in preventing an impending attack. Stimulation of the solar plexus may lessen the attack by calling the blood to the intestines and thus reducing pressure in the cranium. At the time of the attack the patient must be prevented from having serious falls, if possible. The clothing about the neck should be loosened so that it may not restrict circulation. Some object should be slipped between the teeth to prevent the patient biting his tongue. Small objects that may fall into the windpipe should not be used for this purpose. A general course of treatment is depended upon to prevent recurrence of attacks and to cure the case. This consists in the removal of lesion, whatever it may be, and all causes of reflex irritation mentioned above. It is especially important to re- move lesion acting to irritate the motor fibers of the central nervous system, in view of the fact pointed out above that such excitation is probably the most efficient cause of epilepsy. Treat- ment should be given to correct blood-flow to and from the brain, including such treatments as opening the mouth, against resist- ance, treatments along the course of the carotids, elevation of the clavicles, treatment of the cervical sympathetics, etc. At- tention should be given to upbuilding the general health, and to keeping bowels and stomach in good condition. All causes of worry or nerve-strain should be avoided and the patient should lead an out-door life. The food should be light and easily di- gested, consisting of some meat, fruit, vegetables, cereals, etc. Cold sponge baths are recommended. 276 PRACTICE OF OSTEOPATHY. MIGRAINE, (Hemicrania, Sick Headache) AND OTHER FORMS OF HEADACHE (Cephalagia). DEFINITION: Migraine is "a neurosis characterized by severe attacks of headache, often paroxysmal and more or less periodic, with or without nausea and vomiting." It is of ob- scure pathology; there seems to be nothing to connect it with lesion, and from an osteopathic point of view it is generally found to be due to cervical bony lesions. Headache is the general term used to describe pain in the head. It may be either symptomatic or idiopathic, the latter being generally chronic and due to specific bony lesion, usually in the cervical vertebrae. A large class of the latter come under osteopathic treatment, generally in a very bad condition after having suffered far beyond the power of drugs to cure. These may almost be considered as suffering from a hitherto undes- cribed form of headache, depending upon a specific lesion, often the result of accident, and usually immediately relieved and cured upon removal of the lesion. The form embraces many of the kinds of headache generally described under one or other of the usual classifications. CASES: (1) Extremely severe frontal headache in a man of thirty-two, since boyhood. He had taken every known remedy without avail. Lesions were found in muscular contractions on the right side of the neck; the dorsal spine was. anterior in its upper half; the llth dorsal vertebra was luxated to the left, the 2nd and 5th lumbar vertebrae were prominent; the sacrum was tilted forward and the left innominate was slipped, lengthening the limb. The lesions were corrected and the case cured. (2) Migraine in a man of thirty, since his sixteenth year. when he fell from a wagon. Lesion existed at the 3rd cervical vertebra and at the atlas. The case was relieved at once and cured. (3) In a boy of twelve a very severe headache was caused by a fall on his head from a bar in the gymnasium. The atlas was found displaced laterally, and the case was cured. (4) In a chronic case of occipital headache persisting for years, no ordinary remedy would affect the condition. The PRACTICE OF OSTEOPATHY. 277 atlas was found slipped and the muscles about it very much contracted and tender. Relief was given at one treatment, and the case was cured. (5) A man of forty-five, troubled for many years by occipital headache, mostly upon the left side. Lesion was found at the atlas, impinging upon a cervical nerve. Cure was accomplished in two months. (6) In a lady of thirty there was constant occipito-frontal headache. The eyes were weak and painful; the glasses had been changed six times in one year. The muscles of neck and shoulders were found much contracted, the atlas was luxated to the right and painful upon pressure. But one severe headache occurred during one month's treatment, and the eyes were much improved. In two months the glasses were laid aside and the headache was cured. (7) Headache, with blind spells, in a woman of forty-one; the 1st and 2nd cervical vertebra? were approximated and sore; the muscles of the upper cervical region very tense; headache constant; 1st to 8th dorsal vertebra were flattened anteriorly; llth dorsal to 3rd lumbar posterior. The patient had suffered a sunstroke, and had had two or three attacks monthly since. (8) Congestive headache in a man of thirty-seven, of twelve years standing. Violent attacks occurred daily, and every known remedy had been used in vain. The sole lesion was a depressed clavicle interfering with the venous flow from the head. Two treatments restored the bone to place and cured the case. (9) Chronic headache of four years standing, caused by a fall upon the back of the head, which rendered the neck partly stiff. There was contracture of the tissues over the spinous process of the axis, which was displaced to the right. After four treatments the pain had disappeared. (10) A lady had for many years suffered from agonizing headache, so severe at times as to render her unconscious. For some months the head had not ceased aching, day or night. Lesion was found as slight luxation of the 3rd and 4th dorsal vertebrae, and there was a well marked lesion at the llth and 12th dorsal. The headache disappeared during one month of treatment, with no return after several months. 278 PRACTICE OF OSTEOPATHY. (11) A case in which a woman suffered from intense head- aches, there being also feeling of oppression at the base of the skull. The axis was lateral and anterior. The case was cured by adjustment of lesions. (12) A case of migraine, with chronic dysentery of five years standing, in a man of 33. Lesion was a posterior condi- tion of spine from llth dorsal to 3rd lumbar. The treatment was directed to removal of lesion, curing the case. (13) Migraine of five years standing in a boy of 16. The 3rd cervical and 4th dorsal vertebras were lateral to the right. Treatment was directed to removal of lesion, diet and exercise also being attended to. The case was benefited by one treat- ment, and apparently cured by three treatments. The course of treatment being continued once a week for two months. One continually meets cases of severe chronic headache re- sulting from the use of drugs. LESIONS: Migraine, with other forms, shows the usual lesions. Lesions found to produce it are of the atlas; 2nd and and 3rd cervical, upper dorsal; 8th, 9th and 10th dorsal; 7th and 8th ribs. When headache is symptomatic purely, lesion depends upon the primary disease, but specific lesion is often present and de- termines the effect in the head. Atlas, axis, cervical, and, to some extent, spinal lesions are the important ones producing headache. They result in chronic, idiopathic headaches. Often these may develop into insanity. Lesions act by disturbing sympathetic relations, reflexly causing the headaches, just as may be the case in reflex head- ache from uterine prolapsus. They all act by stoppage of blood- flow. This may occur in several ways. The vertebral arteries may be occluded by pressure from the displaced cervical vertebra ; the clavicle may hinder venous flow in the external and internal jugulars, the sympathetic irritation may set up vaso-motor reflexes and prevent proper circulation. A lesion may cause headache by direct pressure of the luxated vertebra upon a nerve- fibre. A very common place for this to occur is at the atlas which impinges branches of the suboccipital nerve sent to supply the occipito-atlantal articulation. The same thing is apt to PRACTICE OF OSTEOPATHY. 279 occur at any of the upper three cervical vertebrae, the correspond- ing nerves sending branches to supply sensation to the scalp. Contraction of tissues over branches of the fifth nerve, or at their foramia of exit may cause headache. Reflex or direct irritation of the fifth nerve may cause it. Lesion in the splanchnic area is often responsible for mi- graine. The kinds of pain in headache aid in diagnosing the variety. Dana notes the fact that a pulsating or throbbing pain occurs in headache due to vaso-motor disturbance, as in migraine; a dull, heavy pain in toxic or dyspeptic forms; a constrictive, squeezing, or pressing pain in neurotic or neurasthenic cases; a hot, burning, or sore pain in rheumatic or anemic headache; a sharp, boring pain in hysteric, epileptic, or neurotic forms. The pain is usually found to be localized in or referred to the peripheral ends of the fifth nerve, they supplying the antero- lateral parts of the scalp and the dura mater with sentation. Hence treatment is directed to the branches of the fifth nerve upon the face and scalp. The chief local treatment in occipital headache is made to the upper four cervical nerves, as their branches are here involved. The PROGNOSIS is good in all forms of headache, even in migraine. The most long standing and severe cases yield readily to treatment, even when all other remedies have failed, The TREATMENT described will apply to any of the numer- ous kinds of headache described, though special portions of the treatment laid down may apply to any given case as sufficient for it. The treatment must be adapted to the case, each one needing a special study of its features to enable one to discover the cause and apply the proper treatment. The treatment suc- cessful in one case may not apply to another. The lesion must be removed, and this often constitutes the sole treatment necessary. All causes of irritation must be removed, such as eye strain, sympathetic disturbance, uterine or stomach disease, etc. Ordinarily the first step is the relax- ation of contractured muscles in the neck and upper .dorsal re- gion. These muscular contractures may often be used as guides to locate bony lesion. Sometimes one small contractured fibre 280 PRACTICE OF OSTEOPATHY. will lead the examiner to the seat of bony subluxation, if care- fully followed. This relieves irritation to nerves, frees circula- tion and prepares for the replacing of a displaced vertebra. At- tention should be given to freeing all points of venous flow from the head. Treatment may be made in the course of the veins across the forehead to the outer canthus of the eye and down toward the angle of the jaw, along the jugular veins, raising the clavicle and relaxing all the tissues. Inhibition along the back and sides of the neck in the re- gion of the upper four vertebrae, and in the sub-occipital fossae, quiets the upper four cervical nerves and aids in restoring equal- ity of circulation through affect upon the superior cervical gang- lion. Often pressure made as follows is sufficient: in the mid- line of the neck, just below the occiput ; below the ears, upon and below the transverse processes of the atlas; along the upper dor- sal region at the upper three or four vertebrae. These treat- ments quiet cerebro-spinal nerves and correct vaso-motion. Treatment should be made upon the face over the points of the fifth nerve (Chap. V, B). Relax tissues over the nerves and at the foramina. Manipulation to relax the tissues all along the course of the longitudinal sinus, from nasion to occipital pro- tuberance, and thence laterally toward the mastoid processes, over the course of the lateral sinuses, aids in freeing the circula- tion in them. As this treatment is carried over the vertex the terminals of the various sensory nerves of the scalp are affected and quieted. Deep pressure over the solar plexus, and inhibitive abdom- inal treatment, aid in relieving the headache sometimes by quiet- ing the reflexes and calling the blood away from the head. Exciting causes should be avoided. It is well in such cases as need it to give attention to regulating the condition of stomach and bowels. Cold applied to the forehead and temples, and heat applied to the base of the skull and the extremities, aid in relief. LOCOMOTOR ATAXIA AND SPASTIC PARAPLEGIA. DEFINITION: Locomotor Ataxia, or Tabes Dorsalis. is a disease characterized by sclerosis of the posterior columns of PRACTICE OF OSTEOPATHY. 281 the cord, loss of cooidination in the muscles of the limbs, absence of the patellar reflex, lightning pains in the limbs, and the Argyll Robertson pupil, which reacts to accommodation but not to light. CASES: (1) In a woman of thirty-two, lesions were found at the atlas and upper lumbar region. Under treatment she regained control of the bladder and bowels, became able to walk well, and the progress of the disease had apparently been termi- nated. (2) In a man of twenty-nine, the lesion was a complex curvature of the spine. It was lateral to the right from the 5th dorsal to the 2nd lumbar, and posterior in the lower lumbar region, being so marked that the left lower ribs came within the iliac fossa, while the right ones descended over the hip. The whole thorax was misshaped. The right limb was atrophied to one-half its original size. After eight months treatment the patient could walk thirty-five blocks without a cane; his general health was good and the disease was showing raid improvement. (3) A case in a young man of twenty, in which there was marked scoliosis of the dorsal spine, involving the thorax, some improvement in the locomotor ataxia was gained urider treat- ment. (4) A case in a man of thirty-five showed spinal lesion in the dorsal spine between the shoulders, the vertebrae being irreg- ular and posterior. Under continued treatment his walking was much improved, visceral crises were prevented, the control of the bladder and rectum were regained, and the pains in the lower limbs were done away. (5) A case presented spinal lesion in the form of a too great anterior sweep of the lumbar region of the spine. (6) Locomotor Ataxia of a severe form, of four years dura- tion. The eyes had become so bad that patient could not read, and could scarcely distinguish light from dark. Lesion was found at the 1st and 2nd cervical, 4th and 5th dorsal, posterior condi- tion of the lower dorsal and upper lumbar spine, and lateral les- ion at the 5th lumbar. Gradual improvement took place under treatment, a considerable gain having been made at the time of the report. 282 PRACTICE OF OSTEOPATHY. SPASTIC PARAPLEGIA (Spastic Spinal Paralysis) is a cord disease with loss of muscular power, exaggerated patellar re- flexes, a peculiar gait, and precipitate micturition. It is a pri- mary sclerosis of the cord. CASE: A middle-aged man, after injury to the spine in a mine accident, was affected with complete motor and sensory paraplegia. Operation for supposed fracture of the 7th dorsal vertebra removed pressure and restored sensation for the greater part. Spastic paraplegia developed. The lesions were found to be a posterior 7th dorsal vertebra; 8th, 9th and 10th posterior and toward the left. Considerable improvement was made under treatment. LESIONS in both of these diseases are found at various places along the spine. In spastic paraplegia they are generally in the lower dorsal, lumbar and sacral regions. In locomotor ataxia spinal curvature is often found as the cause. Derangement of the thoracic vertebrae in the region be- tween the shoulders often causes it. Atlas, cervical, and lum- bar lesions are often found. Dr. Still points out lesion of the sacrum as the cause 'of locomotor ataxia. The PROGNOSIS in neither disease is promising as to cure. Most cases are benefited, some to a marked extent. Locomotor ataxia is more frequently met with and, on the whole, more suc- cessfully treated. The progress of the disease is often checked; control of bladder and rectum are established ; the power of walk- ing, even after complete loss in some cases, is restored. These These cases are generally benefited, but sometimes do not yield to treatment. In cases of spastic paraplegia the sum-total of results is not so great. The walking is often improved, and pre- cipitate micturition is bettered. The sclerotic changes in the cord in these diseases render them incurable, even after removal of specific lesion, yet the sclerotic process is doubtless often checked by the removal of lesion and the attendant treatment. A few cases of both diseases, in early stages and resulting from injury, are reported cured. The TREATMENT of locomotor ataxia consists in the removal of lesion and general spinal treatment. The removal of lesion PRACTICE OF OSTEOPATHY. 283 is insufficient. The thorough spinal treatment must be made to influence spinal nerve connections, the central distribution of the sympathetics, and the blood-circulation about and to the spine. This treatment should be given especially from the mid- dle dorsal down, as the degenerative changes in the cord and meninges begin in the lower part. If the ataxic condition has not yet appeared in the arms, and cerebral symptoms have not developed the indications are especially for treatment to the lower spine. Treatment to the upper spinal and cervical regions should be given, however, at any stage, to limit or prevent the spread of the pathological cord changes in these regions. The nerve-supply to the limbs, upper and lower, as well as the limbs themselves, should be treated. Care must be taken in this matter, as the tendency of the long bones to fracture is marked in locomotor ataxia. The arthropathies, if present, call for special treatment to the joint involved, and its nerve and blood- supply. As the knee-joints are most frequently attacked, the treatment to the lower limbs wll serve to lessen the danger of their occurrence. The spinal treatment should include spring- ing the spine, and various other methods of separating the verte- brae from each other, increasing circulation about them and keeping up their nutritive integrity, as the articular surfaces and interarticular fibro-cartilages are liable respectively to absorption and atrophy. Abdominal treatment should be maintained to prevent visceral crises, most common about the stomach. Treatment should be upon the abdominal nerve-plexuses and blood-circu- lation. The stomach and bowels may thus be kept in good con- dition. Lumbar and sacral treatment, together with treatment to the internal iliac blood-vessels from the abdominal aspect, aid in restoring the sphincters of bladder and rectum to good con- ditions. In case of necessity the cathseter should be used to empty the bladder. To relieve the lightning pains in the limbs strong inhibition should be made upon the anterior crural nerve in Scarpa's triangle; upon the great sciatic at the back of the thigh between the tuberosity and the great trochanter, slightly nearer the latter; and upon the lumbar and sacral portions of the spine. 284 PRACTICE OF OSTEOPATHY. The treatment of spastic paraplegia proceeds upon the same lines as the general treatment for locomotor ataxia, including removal of lesion, thorough general spinal treatment, and treat- ment of the lower limbs. The spasticity in the latter sometimes hinders treatment, but may be overcome by inhibition of the -anterior crural and sciatic as above. Other forms, such as Secondary Spastic Paralysis, in which the symptoms are not so well marked; Congenital Spastic Par- aplegia, usually due to injury at birth; Ataxic paraplegia, com- bining spastic and ataxic features, retaining the reflexes; and the Combined System Sclerosis, Disseminated Sclerosis, etc. are approached in the same manner for discovery of lesions and treat- ment. PARALYSIS AGITANS. (PARKINSON'S DISEASE. SHAKING PALSY). DEFINITION: A chronic disease, in which there is tremor, peculiar character of speech and gait, and progressive loss of muscular power. The LESIONS found in this disease usually occur in the cer- vical and upper dorsal region, and among the upper ribs. These lesions, being present, doubtless determine the victim of the dis- ease. It occurs in those whose central nervous system is thus weakened and laid liable to the action of such secondary causes as exhausting illness, mental strain, worry, traumatism, etc. The latter may directly result in such lesions. The fact that the pathology of the disease is obscure, it being by many regarded as a functional disturbance, and the further fact that the causes are not well known, lends color to the theory that such lesions as are recognized by Osteopathy, being always such as are not sought for by the regular practitioner, are the real causes of the condi- tion. They occur high in the spine, at a point where, acting upon the central nervous system, they could produce the effect in the whole body, as noted in the tremor of both upper and lower limbs, as well as of the head sometimes. The PROGNOSIS : There is a reasonable expectation of limiting the progress of the disease and bettering the patient's general condi- PRACTICE OF OSTEOPATHY. 285 tion. The fact that there is no pathological change in the cord, and that the disease is probably functional, leaves ground for hope that very much benefit, perhaps cure, can be attained under osteopathic treatment. A number of cases have been cured. The practitioner must bear in mind that it is a feature of the disease for the patient to sometimes be better, and he must not too strongly encourage the patient when such a period oc- curs, without reason to expect the permanence of such gain. The TREATMENT consists in removal of lesion; the thor- ough relaxation of all spinal and cervical muscles, particularly apt to be set and hardened about the neck and shoulders; and a most thorough general spinal treatment. Particular attention should be paid to the condition of the nerve-plexuses supplying the upper and lower limbs. These, and the circulation to the limbs, should be strongly stimulated. The general health is usually good, but it is not amiss to keep bowels, kidneys and liver stimulated. Light exercise and baths are good for the case. OCCUPATION NEUROSES. DEFINITION: A neurosis due to constant use of certain groups of muscles in occupations which necessitate delicate movements, resulting in cramp, spasm, paralysis, tremor, or neuralgia, and due to specific lesion to the nerves supplying the affected groups of muscles. The very numerous varieties of this disease, various forms of musician's cramp, telegrapher's seamstress', driver's, milker's, cigar-maker's, etc., are all manifestations, more or less severe r of obstruction to the nerves supplying the parts involved. These obstructions generally act upon the nerve-supply of the upper limbs, but in a few varieties, as in ballet-dancers and tailors, those of the lower limbs may be involved. CASES: Numerous cases of telegrapher's, writer's and pianist's paralysis are known and recalled in this connection, although the data as to lesions, etc., are not now available. These cases were generally cured. The following cases are typical. (1) A marked case of telegrapher's paralysis, of three years standing. For two years the hands had been almost useless, "286 PRACTICE OF OSTEOPATHY. and the patient could not distinguish by touch between an ink- stand and a pencil, sensation and motion were both much im- paired. The lesions were found in the 1st, 2nd, and 3rd right ribs being close together; the clavicle down upon the right first rib, and the cervical origin of the brachial plexus covered with much contractured muscles. After one months treatment the patient could write his name. In six weeks he could distinguish between coins by touch, and in three months the case was cured. (2) Pianist's paralysis, showing lesions in the upper dorsal spine. (3) Pianist's paralysis, showing lesions in the cervical and upper dorsal regions of the spine, depression of both clavicles, and contracture of muscles in the posterior cervical, upper dor- sal and shoulder regions. (4) Penman's paralysis in a man of 35, of three years stand- ing. The 3rd cervical to the 5th dorsal region of the spine was lateral to the right. The case was cured in two months by cor- rection of lesion and treatment of the circulation to the arm. (5) Pianist's cramp in a woman of 25. There was a slip of the sternal end of the clavjcle, and slight deviation of the 3rd, 4th. and 5th cervical vertebrae. The condition was of three years duration. The case was benefited after second treatment, and was cured in one month. This case had been diagnosed as "tuberculosis of the bone, " and amputation had been advised. The LESIONS in these cases are doubtless often directly due to the occupation. Case (1) above is a good illustration of the result of an occupation requiring the elevation of the right shoulder resulting in drawing together, the upper three ribs, and in approx- imating the clavicle and first rib in such a manner as to bring pressure upon the brachial plexus. A faulty posture, involving bad position of the shoulder, neck and upper spine, is quite as likely to result in bony lesions in these parts as is faulty posture to result in spinal curvature. In a certain number of cases the lesions are likely present in the spine and other parts, and determine an early break-down in the anatomical parts concerned in the occupation, from over- use. Over-use of an arm, as in writing, no doubt plays its part in wearing out the nerve-mechanism, but the fact that many PRACTICE OF OSTEOPATHY. 287 young people suffering from an occupation neurosis are found to have these lesions, while many other persons labor assiduously for years at the same occupations without disability indicates that the lesions behind the excessive use is the real cause of the trouble. Use of the arm is really excessive only in proportion as the parts do not recuperate after use. The lesion to nerve-sup- ply prevents proper recuperation, and the arm wears out because of the presence of lesion. In pianist's spinal disease is often found to be due to sit- ting for hours at the instrument. It may as reasonably cause spinal lesions of a nature to result in the neurosis of the arms. That central, i. e., spinal, lesion is present is indicated by the fact that in penman who learn to write with the left hand after an attack of paralysis in the right the disease usually soon makes its appearance in that member also. In pianist's the trouble is generally from spinal lesion. Lesions may occur high in the cervical region, but such is not likely to be the case. Lesions from the origin of the brachial plexus to the sixth dorsal vertebra are met with. Most com- monly the lesion lies between the fifth cervical and fourth dorsal, favoring a position still lower in the cervical and about the upper three or four dorsal. Lesion of the clavicle and upper two ribs, especially upon the right side, are very common. It is readily seen from the nature of the causes producing lesion that the ribs below the upper two may be involved. Ribs and vertebrae as low as the 5th or 6th may be luxated and cause the trouble. Vaso-motor, secretory and trophic affections occur in the affected member. Vaso-motors to the arms are found as low as the first thoracic ganglion, or lower. The connection of the intercostal nerves with the sympathetic system may explain why rib lesions this low may cause the trouble. The first and second intercostal nerves are connected with the brachial plexus. They are often impinged by the corresponding ribs in these troubles. McConnell calls attention to the fact that slight luxations of shoulder and elbow-joints may cause this disease. In such case the affect would probably be through lesion to the articular branches sup- plied from the brachial plexus. While Dana states that this condition is "a neurosis having 288 PRACTICE OF OSTEOPATHY. no appreciable anatomical basis," it seems from the results gotten by the removal of lesion that Osteopathy discovers the real anatomical cause of the disease. The PROGNOSIS is good. Even the worst cases are cured. Cure is the rule, though some cases may be intractable. TREATMENT: The removal of lesion as the direct cause, as in displacement of the clavicle onto the brachial plexus, is often the only treatment necessary. The nerve and blood-sup- ply of the affected part should be kept free by treatment upon them, and by relaxation of all contractured muscles and hardened tissues. The arms should be stretched and treated as described in Chap. X. The brachial plexus may be stimulated on the inner side of the arm just below the axilla, and in the neck be- hind the clavicle. Treatment should be carried up along the plexus to the spine. The elbow and shoulder joints should be sprung and adjusted if necessary. (Chap. X.) It may be necessary to have the patient rest from his occu- pation during the treatment, particularlyi at first for a few weeks. This matter depends upon conditions. Some cases have been cured while the customary work is continued. In some cases it is well to give a general treatment to the nervous system, as nervous symptoms may appear. Vertigo and insomnia are some- times present, doubtless due to the upper spinal lesions affect- ing the blood-circulation to the brain. Local work should be carried over the brachial artery, and over the fore-arm and hand. This increases local circulation and does away with the local congestion and secretory disturb- ance found in the affected members. It may be useful for the patient to develop the arms by systematic gymnastics. The various mechanical appliances used to lessen the work upon the affected muscle groups and to call into play other and larger groups, may be useful if the patient finds it necessary to continue his occupation. Sleeves that interfere with free motion of the hand in writing, cuffs that bind the wrist, constricting bands that may be used as sleeve supporters, and any agency limiting mo- tion and circulation must be avoided. Systematic gymnastics of the hand and arm are helpful in developing proper circulation, also in upbuilding neglected muscles. PRACTICE OP OSTEOPATHY. 289 The pain frequently present in arms and shoulders may be quieted by inhibition of the plexus arid its spinal origin, but gen- erally yields to the general process of relaxing muscles, etc. NEURASTHENIA. (Nervous Prostration.) DEFINITION: "A functional disease of the nervous system, characterized by mental and bodily weakness." It is not a psychosis. There is functional exhaustion and irritatability of the nerve centers. (1) In a woman of thirty-two, neurasthenia developed after confinement and sickness. Symptoms of the disease were all very well marked. Lesions were found in a displacement of the third cervical vertebra to the right, general depression of the ribs, separation of the llth and 12th dorsal yertebrae, a posterior luxation of the fifth lumbar vertebra, and contracture of the lumbar muscles. The neurasthenia was apparently reflex from uterine disease. Two weeks daily treatment re-established men- struation, which had been suppressed for some time. Under one months treatment all the symptoms had disappeared. (2) A case of neurasthenia in a lady of sixty, following over- work and runaway accident. The whole spine and body was hyperesthetic, the spinal tissues, from occiput to sacrum, were exceedingly tense. Treatment was beneficial from the first. One years treatment produced great improvement. (3) In a lady of fifty, with uterine disease, lesions were found in a posterior luxation of the atlas and depression of all the ribs, narrowing the thorax. The patient was benefited. (4) Traumatic neurasthenia developed after the patient was thrown from a buggy. Lesion was found in a slip at the fourth lumbar and marked lateral luxation of the tenth dorsal vertebra. The spinal lesion was corrected in three weeks, but no improvement occurred in the patient's general condition until ten weeks treatment had been taken. After two weeks further treatment the case was well. (5) Nervous exhaustion in a man who had been suffering from kidney disease. The whole spine was rigid, with its muscles and ligaments all tense. Pus and phosphates appeared in the 290 PRACTICE OF OSTEOPATHY. urine. During 3^ months treatment the patient gained 12 lbs v the urine cleared, and the case was cured. (6) Nervous prostration of four years standing in a woman of 42. Many minor lesions occurred along the spine, especially the 3rd and 4th cervical vertebrae were lateral, the 6th cervical posterior, a general posterior condition of the dorsal region, the 4th and 5th lumbar lateral, the coccyx anterior, the left innom- inate up and back. There was a prolapsed uterus, dysmenorrhoea, enlarged liver and spleen. The case was cured in three months. The LESIONS found in neurasthenia are general spinal le- sions. Different cases present different lesions, and no typical lesion may be described for all cases. Yet perhaps a majority of these cases show a depression of all of the ribs, narrowing the thorax and often causing enteropsis. Floating kidney and en- teroptosis are well known as causes of neurasthenia. There is no doubt that many cases of neurasthenia apparently thus caused are really due to bad spinal condition and flattening of the thorax through depression of all the ribs. These extensive lesions affect cerebro-spinal system directly, also the sympathetic system, thus causing the neurasthenia and the enteroptosis. Often the lesion in these cases is such as produce disease in some organ, secondary to which neurasthenia is developed. This is well illustrated in these lower spinal lesions producing uterine disease, from which neurasthenia is reflexly caused. Thus a variety of lesions may be found in neurasthenia, dif- ferent cases presenting different lesions. Each case demands an individual study. For the production of neurasthenia there is necessary merely a lesion producing an irritation upon the nerve system, reflexly or directly, allowing a leakage of nerve-force, and determining the victim of neurasthenia from overwork, worry, uterine disease, naso-pharyngeal disease, the use of coffee, aico- hol, etc. The different varieties of neurasthenia may be caused by the predominance of lesion, e. g., the cerebral type by upper dorsal and cervical lesions, the gastric by splanchnic lesions, the lithemic by lower dorsal and upper lumbar lesions, etc. Influenza, a common cause of this disease, is a malady particularly noted by osteopathy as producing serious spinal lesions, mostly in the PRACTICE OF OSTEOPATHY. 291 shape of contracted muscles and tenseness of the other tissues, but sometimes actual bony lesions by drawing parts out of place through contracture of attached tissues. Lesion thus produced may cause neurasthenia. It is common as the result of trauma- tism, such as caused by railway accidents, bony lesions thus being produced as irritants to nerves. The PROGNOSIS for cure is good. Those cases that have not yielded to any of the usual modes of treatment often readily yield to osteopathic treatment. The best of results may be ex- pected in the worst cases. Cases are often quickly cured if gotten in the early stages. The average case demands a somewhat long course of treatment, varying from a few months to a year or more. The TREATMENT must be adapted to the case in hand after a special study of its peculiarities and requirements. The re- moval of every source of reflex irritation is neccessary, but these sources must be studied out in each individual case, The le- sions present should be removed, but the case is not always at once benefited thereby, as a course qf treatment is generally neces- sary to recuperate the exhausted nerve-centers. Consequently a most systematic and thorough course of treatment must be devoted to this end. The various spinal treatments as described, for relaxation of all spinal tissues, springing the vertebrae apart for freedom of circulation and stimulation of the spinal nerve- system and the circulation thereto, are -given to increase nutri- tion of the nervous system and upbuild the exhausted centers. This spinal treatment affects the sympathetic system markedly. Cervical treatment is also important in this connection. Good results are usually at once apparent in relief of nerve-tension, reduction of irritability, and correction of function. Special manifestations of the condition, as heada'che, in- somnia, vertigo, etc., call for cervical treatment particularly. Bowels, kidneys, liver, etc., must be carefully looked after to re- lieve constipation, lithemia, anorexia and other such symptoms usually present. A thorough general treatment of the whole body is not amiss in these cases. The patient must be kept free from excitement and from all causes of drain upon the nervous vitality. The diet should 292 PRACTICE OF OSTEOPATHY. be light and nutritious. The use of cold sponge or shower baths ; etc.. will aid him to preserve a cheerful state of mind. Some cases may be treated daily with advantage, in the beginning of treatment. Later, the treatments may be decreased in number to three or two per week. HYSTERIA. This is a condition frequently met and treated osteopath- ically. One needs to be continually upon guard against its sim- ulation of other conditions, being equally careful not to over- look other diseases because of a hurried diagnosis of hysteria. Being a functional disease of the nervous system, and a psychosis, it is frequently found to depend upon some spinal bony lesion acting as the cause disturbing the nervous equilibrium. The lesion varies. One cannot expect a certain kind of lesion in these cases, but generally finds some actual derangement which is, at bottom, responsible for the altered nerve-conditions, making it possible for a neurotic disposition, infectious fevers, poisons of various kinds, emotional disturbances, mental or physical strain, and other causes to result in hysterical attacks. Dr. Still calls attention to the fact that in hysteria the lower ribs are often displaced downward, and the colon is prolapsed in the pelvis. He raises the ribs, draws up the intestine and corrects the circulation to the genitals. Correction of lesion removes the primary cause of irrita- tion to the nervous system, perhaps cures a certain disease to which the hysteria is secondary, and this is an important step in the radical cure of the condition. The PROGNOSIS for cure is good. The treatment relieves nervous tension and quiets the overwrought system at once. In the TREATMENT considerable tact must be used. The primary treatment embraces the removal of all lesions and causes of irritation. A course of treatment for the general ner- vous system must be carried through. The general treatment as described for upbuilding the nervous system in neurasthenia would be applicable here. During an hysterical attack the practitioner must use great firmness, but not violence, with the patient. He must gain PRACTICE OF OSTEOPATHY. 293 mental and moral control, and while applying a general relax- ing and inhibitive spinal and cervical treatment to relieve nerve- tension and to quiet the nervous system, by a strong show of authority compel the patient to cease various motions, unbend a clenched hand, stop incoherent talking, etc. Sometimes a dash of cold water upon the face or abdomen, or pressure over the ovaries will end the attack. All sympathetic friends must be dismissed from the room, and moral suasion, with isolation of the patient, be tried. The practitioner must gain the patient's confidence. Hysterical joints, hysterical pains, contractures, eye-symptoms, paralysis, etc., call for no special treatment; all disappear upon regulation of the mental condition and upbuilding of the general nervous system. Many chronic cases, as in bed-ridden hysterics, must be carried through a course of education in performing simple mo- tions and acts which they thought beyond their power. The patient should lead a regular life, and her mind should be kept occupied by some engrossing occupation. Judicious management of the case, authority over the pa- tient, and a careful general treatment for the health of the body and particularly of the nervous system, will be successful in the majority of cases. INSOMNIA. DEFINITION: 'Incomplete, disturbed, or lacking sleep. A condition frequently idiopathic and caused by specific lesions, usually bony. Idiapathic insomnia embraces many forms gen- erally looked upon as symptomatic or secondary. Many really symptomatic or secondary cases are noted, especially in nervous diseases, the primary condition itself being usually found to de- pend, at bottom, upon bony lesion. CASES: Very numerous cases are met and treated osteo- pathically. The following cases illustratrate various points in connection with such cases: (1) Insomnia, nervousness and complication of troubles. Sleep could not be induced by the most powerful soporifics. Le- sion was found among the cervical and upper dorsal vertebrae. The case was cured in two months treatment. 294 PKACTICE OF OSTEOPATHY. (2) Insomnia and general nervousness, pronounced in- curable. The patient had had no good nights sleep in fiveyears> and had become a nervous wreck. Lesion was found in the shape of contractured condition of all the cervical muscles. (3) A case of several years standing, in which the lesion affected the atlas, which was displaced a little to the right, was cured by the correction of the lesion in six treatments. (4) A case of insomnia as an accompaniment of neuras- thenia, in which the patient had depended upon soporifics for a number of years, slept well after the second or third treatment. The use of artificial aid to sleep was necessary but at rare inter- vals thereafter. The case was practically cured at the time of report. (5) A case of insomnia of some years standing, due to cer- vical and upper dorsal lesions, cured in six months treatment. (6) A case of three years standing, in which the heart-beat had become very irregular from the resulting nervousness. Four treatments corrected the heart beat, and the case had been prac- tically cured, at the, time of report. (7) A case of insomnia with constipation and amenorrhcea. in a woman of 22, of thirteen months standing. The atlas was to the left; the posterior cervical tissues were all thick and tense, especially upon the left ; the seventh dorsal spine was rather irreg- ular. The pelvis was twisted, with apparent lengthening of the right limb. The treatment at once benefited the case, and it was cured in 4 months. (8) A case of paroxysmal sleep, or narcolepsy, presenting lesion in the form of a luxation of the second cervical vertebra toward the right. The case was not observed under treatment. (9) A case of narcolepsy due to cervical lesions successfully treated. (10) A case of protracted sleep, in which the patient fell asleep on April 26, 1902, and slept for 3 months, with but few periods of awakening. The lesion was found between the skull and the atlas, causing, probably, passive congestion. Correc- tion of the lesion cured the case, after all other means had failed. LESIONS AND ANATOMICAL RELATIONS: The lesions, both in insomnia and in the various other disorders of sleep are gen- PRACTICE OF OSTEOPATHY. 295 erally found in the atlas and cervical and upper dorsal regions. All such cases, perhaps constituting a majority of all cases of these diseases, should be regarded from the osteopathic point of view as idiopathic insomnia, dependent upon specific lesion interfering with circulation to the brain. Lesions to the atlas and second cervical vertebra are very common causes, and le- sions usually occur within the cervical region or among the upper five dorsal vertebrae. Lesions to clavicle and to corresponding ribs may be present. It will be observed that from the occiput to 5th dorsal all these lesions fall within an area particularly rich in sympathetic and vaso-motor centers for the head, as before pointed out. Atlas and axis lesion acting upon the superior cervical ganglion, medulla, or cervical sympathetic, and other cervical and the upper dorsal lesions acting upon the sympathetic nerves supplying vaso-motor control to the blood vessels of neck and head, disturb circulation to the brain and cause the insomnia. . Direct pressure of the cervical vertebrae upon the vertebral arteries may contribute to, or produce, the same result. It is probable that in many cases of insomnia there is an anemic state of the brain caused by the interference of such le- sions with the sympathetics or by direct pressure upon the arteries. The insomnia in various diseases of the heart and arteries, in general anemia, and in Bright's disease, is said to be due to an anemic condition of the brain. On the other hand it is doubtless true that there is in many cases a sluggish or impeded cerebral circulation as a result of the disturbance of sympathetic vaso- motors, impeded venous return, etc., caused by these lesions. In neurasthenic insomnia, it is said, there is loss of vaso-motor tone in the cerebral vessels. The use of various mechanical rem- edies is based upon the idea of calling the blood from the head to the skin or abdominal organs, i. -e., a hot foot-bath, eating a light lunch, etc. In some cases the symptoms indicate the necessity of in- creasing or decreasing the amount of blood in the cerebral ves- sels, and these results may be readily attained by the appropriate treatment. But, from the nature of the case, removal of lesion and the restoration of free circulation result in restoring normal quiet to the nerve mechanism and normal flow of the blood in 296 PRACTICE OF OSTEOPATHY. the vessels, characteristic of the normal body which enjoys health- ful sleep. Such a result is the most rational object of the treat- ment. When insomnia is symptomatic or secondary, lesions must be sought according to the primary condition. In some cases of disturbed vaso-motor conditions of the brain, lesion is found in the form of much thickened, tensed, and overgrown tissues at the base of the skull, above and about the spine of the axis, extending laterally toward the mastoid process. With this condition there frequently exists an approximation of the second cervical spine to the occiput. The PROGNOSIS in insomnia is good. No class of cases pre- sent more striking results in the shape of cure of the most long- standing and intractable cases. It is a frequent occurrence that a case of some years standing is made to sleep naturally after a single or few treatments. Not all cases thus easily yield to treatment. Often great patience and persistence are necessary to secure good results. The TREATMENT calls for the removal of lesion primarily, and of any cause of irritation to the nervous system. The treat- ment as described in detail for headache, q. v., is applicable here. It embraces inhibition of the superior cervical ganglion and of all the cervical vaso-motors, including the middle and inferior cervical ganglia and the upper dorsal centers, deep pressure be- neath the ears and beneath the occiput. All the cervical muscles and other tissues should be thoroughly relaxed. A general spinal treatment, in nervous cases, at once relieves nerve-tension and irritation, and materially aids in producing sleep. It is some- times well to add to this a general body treatment as an aid in equalizing circulation and toning up the nervous system. All points of cervical circulation should be attended to. The treat- ment begun over forehead and face may be continued down over the neck, opening the mouth against resistance, stimulating the carotid arteries and jugular veins, raising the clavicles, and even the upper few ribs, and thus entirely freeing the circulation to and from the head. In cases of congestion of the cerebral vessels the inhibitive PRACTICE OF OSTEOPATHY. 297 abdominal treatment should be used to draw the blood away from the head to the abdominal vessels. In anemic cases one should add treatment to liver, kidneys, stomach, bowels and spleen. The heart and lungs should be stimulated. In insomnia due to auto-intoxication, as in lithemia, uremia, malaria, etc., one should look particularly to the excre- tions. Various domestic remedies may prove useful in simple cases, such as a warm general bath, a hot foot-bath, a cold douche down the spine, exercise and light massage, sleeping in cold rooms, avoidance of late meals, and the avoidance of mental work sev- eral hours before retiring. The various perversions of sleep, such as dreams, and night- mare, sommolentia, or incomplete sleep, somnambulism, morbid drowsiness, narcolepsy, catalepsy and prolonged sleep, would all be approached and treated upon the same lines as laid down for insomnia. PARALYSIS. The various formes of paralysis come, with much frequency, under osteopathic treatment. Paralysis of every part of the body and from various causes, is successfully treated. The following cases are illustrative. CASES: (1) Paraplegia in a young lady, caused by a fall of eighteen feet. The lower half of the body, and the lower limbs were paralyzed; control of the bladder was lost; within a certain period of five months she had passed twenty-eight calculi about the size of peas, never before the accident having had any urinary trouble. Lesions as follows: Marked pos- terior and slight lateral curvature of the spine, involving the lower and upper lumbar regions.; the coccyx was bent and twisted; the right innominate bone was luxated backward. The condition was of nine and one-half months standing. After the first treat- ment she was able to sleep without the customary opiate. During the second weeks treatment she began to gain control of the blad- der, and the bowels acted naturally. The urine became normal at this time. During the course of the treatment an ulcer upon the right foot healed. A course of two months treatment had almost cured the patient at the time of reporting the case. 298 PRACTICE OF OSTEOPATHY. (2) Paraplegia in a man, due to an injury in a runaway accident in which he was thrown, striking the lower dorsal and lumbar regions of the spine. After two weeks he gradually be- gan to lose the use of his limbs, and in seven months he was con- fined to a chair, soon becoming unable to move a muscle of either limb. Lesions were as follows: 9th, 10th and llth dorsal ver- tebrae backward sufficiently to simulate the posterior angular projection in Pott's disease; a marked contraction of the mus- cles of the right side of the spine to the same side as the contrac- ture and limited by its extent; great tension and slight lesion at the junction of the fifth lumbar vertebra with the sacrum ; a bind- ing together of all the spinal vertebras by an apparant contrac- ture of the ligaments. After a few r treatments motion returned, and the patient was able to go about upon crutches. The case had been almost cured after a course of five weeks treatment. (3) Complete paralysis of the body below the waist, and of the lower limbs, caused by spinal curvature. The case was en- tirely cured, sensation, motion, and function of abdominal and pelvic organs being restored. (4) Lack of free use of the feet due to a paralytic stroke six years before. A disarticulation among the tarsal bones w r as discovered, and its removal practically cured the case. (5) Paraplegia, paitial, was cured by correction of lesion of the sixth dorsal vertebra. (6) General paralysis in a case which gradually for six years lost the use of all the voluntary muscles, the eyes were crossed and nearly blind, bowels and bladder were involved. The case was cured by adjusting lesion between the atlas and occiput, the latter being displaced anteriorly upon the former. (7) Infantile paralysis involving the left lower limb. The case was in a child two years old. A sacro-iliac lesion was found as the cause, and was treated. The child could move the limb slightly after the first treatment, and after the sixth treatment perfect use was restored. (8) A case of paralysis was found presenting lesions at the occipito-atlantal and lumbo-sacral articulations, and from the sixth to the tenth dorsal vertebrae. There was a history of ex- posure, alcoholism, sexual excess and great physical strain. PRACTICE OF OSTEOPATHY. 299 Correction of the lesions effected a cure in five months. (9) A case of paraplegia in a man of fifty-five, due to injury in a railroad wreck. Both innominate bones were found dis- placed anteriorly, and lesions were involving the whole lumbar and lower dorsal regions of the spine. The paralysis of the limbs was total. After three treatments the patient could walk with crutches. After two weeks treatment the patient could walk without crutch or cane, being as well as ever, excepting some weakness of the spine. (10) Paraplegia, involving the bowels, in a lady of fifty- three, and of fifteen years standing. Sensation was lacking in the limbs, and there was very little motion. In less than one months treatment sensation and motion were both perfectly restored, and the bowels were acting naturally. (11) Paralysis following a stroke. The cervical muscles were found contractured. Their correction was accomplished in five weeks, and none of the paralytic condition remained. (12) Paralysis affecting the fingers and thumbs of both hands in a boy of fourteen The only lesion was contracture of the muscles along the lower cervical and upper dorsal regions of the spine. There was also some atrophy of the muscles over the brachial plexus and the axillary artery. Five months treat- ment restored the thumbs and first two fingers to nearly normal condition, the condition of the other fingers was much improved, and the hands could be used considerably. (13) Paralysis and muscular atrophy of both arms in a boy six years of age. The condition followed an attack of malaria. The condition spread to involve both lower limbs. Spinal le- sions were found preventing circulation to the cord. The child began at once to improve under the treatment. After the third treat- ment he could move his fingers. In two weeks he could use his hands well enough to feed himself. In one month he was prac- tically cured. (14) Disseminated subacute cervical and lumbar myelitis in a boy of seven, following the swallowing of two pins. Severe illness at once followed, and in the fifth week the pins were lo- cated by the X-ray on the left side about the level of the third cervical vertebra. They were later ejected, he becoming imme- 300 PRACTICE OF OSTEOPATHY. diately totally paralyzed. For two weeks it was thought he could not live. After about seven weeks the case came under osteo- pathic treatment. The tissues of the entire cervical region were badly swollen and intensely painful, and this condition was found along the whole spine. Control of the bowels and bladder was lost, and the muscles of both upper and lower limbs were atrophied. After the first treatment the patient slep soundly for the first time in two weeks. After about four months treatment the case was practically cured. (15) Monoplegia attacking the right lower limb of a girl of six, paralyzed since the age of ten as the result of spinal men- ingitis. No bony lesion was found, but the treatment was di- rected to increasing the circulation to the cord. The case was practically cured in three months treatment. (16) Paraplegia of eight months standing. The patient was bedridden. Lesion was found as a posterior condition of all the lumbar vertebrae and a slip of the last lumbar upon the sacrum. The case was cured in three months. (17) Bell's disease (facial paralysis), due to lesion at the second cervical vertebra, cured in three weeks. (18) Partial paralysis of the lower limbs, of four months standing, due to lesions at the sacro-iliac articulation and at the 5th dorsal vertebra, cured in two months. (19) Partial paralysis in a lower limb in a girl of six, since infancy, accompanied by under-development of the limb, was found to be due to a partial dislocation of the hip, and was cured in two months. (20) Paralysis, probably Progressive Spinal Muscular Atro- phy, in a woman of thirty-five, of fifteen years standing. The last two years had been spent in bed. Lesions were found at the 7th cervical and 1st dorsal vertebrae, which were anterior. The case was cured in ten months. (21) Paralysis of the fingers, affecting the last two, and partly the middle finger of the right hand. The patient was a lady of seventy-nine years of age. A fall upon the hand had occurred a short time previously. A slight lateral lesion of the first dorsal vertebra was found and corrected, curing the case in six weeks. PRACTICE OF OSTEOPATHY. 301 (22) Hemiparesis or Hemiplegia in a lady of sixty, of six weeks standing. The right side was affected. Lesion was found in the 3rd cervical and 5th lumbar vertebrae, the spinal muscles also being much contracted. The patient walked after the third treatment and was cured in six weeks. (23) Hemiplegia, partial, of the right side, following light- ning-stroke. A displacement of the atlas was found and righted at once, immediately curing the case. (24) Paralysis and Dysentery. The paralysis affected the lower limbs, and had been of seven years standing. Lesion was found as great tenderness at the lumbo-sacral joint, a slip for- ward of the 5th lumbar, luxation of the innominates, and a lateral swerve of the lumbar and lower dorsal region of the spine. A tremor of the head was present, the cervical muscles being very tense. After seven months treatment the lesions were about overcome and the patient was nearly well. (25) Paralysis affecting certain muscles of the throat, also affecting the speech. The lesion was found in a contracture holding the hyoid bone out of place. The patient was cured by relaxing the contracture. (26) Facial paralysis of more than one year standing, was cured in three weeks treatment. The lesion was found in a dis- placement of the second cervi-cal vertebra. (27) Facial paralysis caused by luxation of the atlas and axis to the left. There was also tension of the tissues at the base of the skull and on the left side of the neck. The case, still under treatment, was improving satisfactorily. (28) Facial paralysis was seen on the day following its first appearance. The lesion was marked muscular contraction at the angle of the jaw on the affected side. Treatment gave im- mediate relief, and the case had almost been cured in "ten treat- ments. (29) Progressive paralysis in a case, after two' falls causing serious illness. Motion in the lower limbs was lost, blindness ensued, and speech became unintelligible. There was formication in the hands and arms,and extreme pain along the spine,occurring in agonizing paroxysms. Lesions were found as a lateral dis- location of the third cervical vertebra, luxation of 7th and 8th 302 PRACTICE OF OSTEOPATHY. right ribs, and a posterior protrusion of the lumbar vertebrae. One treatment brought the first sleep possible in three days. Under treatment the spinal pain was relieved, vision was restored, and the patient had been practically cured at the time of the report. (30) Crutch paralysis in a man of sixty-five, causing loss of use of the left hand. A crutch had been used on the left side. The head of the second left rib was found displaced, and the head of the humerus was slightly dislocated anteriorly. After eleven treatments the patient was well. (31) Myotonia Congenita (Thomsen's Disease) in a man, of ten years standing. Lesion of spinal vertebrae was removed, curing the case. (32) Hemiplegia in a child twenty months old, of ten months standing. Lesion was found at the atlas, which was immediately replaced, and rapid improvement followed. In three weeks the child could walk, and recovery was almost perfect. (33) Brachial Neuritis of five months standing, causing severe pain in arms and shoulders, and partial paralysis of the hands. Lesions were found in luxation of the 2nd, 3rd and4th right ribs, and the 2nd left rib, with irregularities of the lower cervical and upper dorsal vertebrae. One treatment greatly relieved the pain; three treatments enabled the patient to close his hands and snap his fingers; and in three months treatment the case was entirely cured. (34) Partial paralysis of one hand, loss of memory, and at times inability to articulate. Lesion was found at the 2nd cervical vertebra. The case was cured by one months treat- ment. LESIONS: The facts of these cases are typical, and illustrate much that is seen in the practice upon this class of cases. They point prominently to importance of anatomical lesion of the kind most regarded by osteopathy, as the cause of paralytic dis- eases. The necessity of the removal of such lesion in curing the condition is obvious. These facts clearly indicate the great po- tency of actual bony lesion, derangement of a bony part, in caus- ing paralysis. They illustrate also what experience shows to be a fact, that displacement of spinal vertebrae occurs as the real cause of a majority of the cases of paralysis. Rib lesions PRACTICE OF OSTEOPATHY. 303 sometimes occur, but do not seem to be important as causes of such disease. The finding of a partial dislocation of a hip as the cause of paralysis in a limb is a fine point of osteopathic diagnosis. These lesions are occasionally found and are of prime importance. They are almost invariably overlooked in the usual line of prac- tice. Their reduction is the sole and immediate remedy of the monoplegia. In a few cases both hips have been found thus luxated causing apparent paraplegia. Contractured muscles are no doubt generally secondary lesions. But with some frequency they have been found as the sole discoverable cause of paralysis, and their removal has re- sulted in cure. Innominate lesion is found to be of the greatest importance in causing paralysis of the lower extremities. The coccyx le- sion does not seem to be important in this connection. The atlas lesion is perhaps the most important single lesion, notwithstand- ing the fact that it does not with great frequency occur as the sole cause of a paralytic condition. Occurring at a part of the spine where the bones are small and the contained portion of the cord large, it is particularly likely to impinge upon the medulla and cause paralytic effects in the whole body below, upon one side of the body, or in the head and its parts. As shown above, le- sions of the atlas occurred in five of these cases. It was present in two of these cases suffering paralysis of both upper and lower limbs. In one of these cases, in which also there was blindness and crossing of the eyes, it was the sole lesion. This circum- stance is well illustrative of the importance of the atlas lesion. In two cases it was the sole lesion causing hemiplegia. It was present with lesion of the axis in a case of facial paralysis. A glance at the summary of the lesions will show the very general range of these bony lesions. Atlas, axis, cervical,upper dorsal, middle dorsal, lower dorsal, lumbar, innominate, coccyx, hip, rib and shoulder lesions' were found. It seems that any movable part along the spine, or in relation with the various nerve- plexuses concerned in the various paralysis, may become mis- placed and become a factor in producing a paralytic condition. Yet there is a great deal of constancy of lesion. It tends as much toward the specific in this class of cases as in any. Generally 304 PRACTICE OF OSTEOPATHY. in paraplegia, monoplegia or paralysis of the two upper limbs the lesion is local at a place where it may affect the origin of the nerves concerned in the innervation of 'the parts involved. All of these seven cases of paraplegia show this in low lesion along the spine. All the six cases of monoplegia show it in local le- sions to the origin of the plexuses involved. It often happens that in cases of paralysis involving the upper and lower limbs, one or both, there is a high lesion affect- ing the upper and a low lesion affecting the lower members. Yet a single lesion high up more frequently perhaps causes the trouble in the upper and lower limbs. Lesions of the fifth lumbar and of the innominates are frequent in paralysis and in hemiparaplegias. These are important lesions. An inspection of the lesions reported in seven of the above paraplegia cases show that the lower dorsal and upper lumbar region is a favorite place for lesions in such cases; that spinal curvatures may cause the condition; that fifth lumbar and in- nominate lesions are much in evidence. In case of general paralysis involving upper and lower limbs it is noted that atlas 1 lesion alone may be the cause; that often there are both upper and lower lesions, respectively affecting upper and lower limbs; and t-hat contractured muscles and causes obstructing circulation to the cord may be sufficient. The monoplegias show much constancy of lesion to the origin of the plexuses. The hip-joint, shoulder-joint, and sacro- iliac lesion all attract attention. The hemiplegias seem more apt to show single high lesion, as of the atlas, but both high and low spinal lesions may be present. Dr. Still says that in hem- iplegia the atlas is often back and to the left. The facial paralysis shows specific bony lesions. In three of the four cases the 2nd cervical vertebra is involved. In one of these three the atlas is also at fault. In a fourth case there was merely contracture of muscles occurring over the course of the trunk of the nerve where it crosses the ramus of the jaw. In these cases, bony lesions if present, are expected to occur among the upper three cervical vertebrae. ANATOMICAL RELATION'S: The close relation between the esion and the disease is shown by several facts. The early de- PRACTICE OF OSTEOPATHY. 305 velopment of paralysis after accident giving origin to those le- sions found upon examination to exist at important points in- dicates the correctness of the osteopathic idea that such lesions are the direct causes. The further fact that recovery is depend- ent upon the removal of- such lesions, that it actually is accom- plished by their removal, also shows the close relation of lesion to paralytic disease. Finally the Osteopath's experience directs him to expect bony lesion at certain spinal areas, according to nerve-distribution from the spine to affected parts. In all these cases we speak of lesion significant to the Osteopath only. The various lesions, bony and otherwise, act in several ways to cause the paralytic effect that follows their presence. In the first place, a misplaced vertebra or bony part, or a contractured muscle, may brine direct pressure upon a nerve, a fibre, or a plexus, cutting off its function and causing paralysis in its area of dis- tribution. In one case pressure of the first dorsal vertebra upon the last cervical and first dorsal nerves, one or both, which make up the ulnar nerve, resulted in paralysis in the ulnar distribution in the hand, affecting the little finger, ring-finger, and in part the middle finger. The same conclusion is indicated in the case in which contracture of the hyoid muscles drew the bone against the pneumogastric nerve, causing paralysis of the laryngeal muscles, affecting deglutition and speech. The same evidence of direct pressure upon nerves is seen in another case where the muscles contracted over the trunk of the facial nerve; in another where the head of the humerus impinged the brachial plexus; in another where the sacro-iliac lesion affected the sacral nerves. In all of these cases quick results following the removal of pressure show that the effect of the lesion must have been directly upon the nerves involved by pressure. In such cases the result is seen to be directly upon the pan supplied by the impinged nerves, it is uncomplicated by results in other parts of the body, and is manifested in a circumscribed area, namely, in the muscle groups supplied by the nerve or nerves in question. In diagnosis a practical point is to expect lesion of a kind exerting direct pressure in case presenting gen- eral features as described above. The lesion is known at once 20 306 PRACTICE OF OSTEOPATHY. to be located some where in the path or at the origin of the nerves involved. On the other hand, a certain class of lesion is found in par- alytic disease by lesion to the cord. The effect to the cord may be through direct pressure upon it, or in- other ways. An example of such conditions is seen in a case in which lesion of the 2nd cer- vical vertebra caused partial paralysis in one hand, loss of mem- ory, and at times inability to articulate. There was evident involvement of brain and cord, and the lesion was too high to affect the brachial plexus by direct pressure. In such case there is possibility of the lesion affecting the cord either by direct pressure or by interference with the sympathetic or cord-nutri- tion. The supposition of direct pressure is supported by the fact that removal of the lesion cured the case in one month. In another case, formication in the upper and paralysis in the lower limbs, blindness, unintelligible speech, and paroxysms of spinal pain, clearly indicate involvement of cord and brain. The lesion of the 3rd cervical vertebra was too high to affect the brachial plexus by direct pressure; the lesion to the lumbar ver- tebra likewise could not have pressed directly upon the nerve- supply to the lower limbs. Yet the paralytic condition in lower limbs, referable to the posterior displacement or protrusion of the lumbar vertebrge, favors the theory of direct pressure upon the cord, since such paralysis of the lower limbs is known to follow actual lesion to the lumbar segments of the spinal cord. In one case the hemiplegia resulted from lesion at the atlas, and was cured by its removal. The fact that the child could walk in three weeks after treatment began, and the highness of the lesion, both favor the idea that there was pressure upon the cord. In a case where there was paralysis of the voluntary mus- cles, crossed eyes, and partial blindness, the lesion was again at the atlas (occipito-atlantal) and the same reasoning would ap- ply. So in another case, paraplegia following lesion of the 6th vertebra. It must be noted that in all these cases the results are quite unlike those in the first group considered. The results, instead of being direct upon nerve or plexus, are indirect; they are also complicated with effects in more than one part of the body, and PRACTICE OF OSTEOPATHY. 307 are not circumscribed by being limited to one muscle group. It is an indication in diagnosis to expect such cord lesions in cases showing this style of effects from lesion. In some cases the lesions no doubt do shut off nutrition to the cord or brain. It is seen in cases where cervical bony lesion results in atrophy of the optic nerve, causing blindness through interference with its nutrition. In another case lesions were described as being present and preventing circulation to the cord. Treatment with the idea of restoring this circulation resulted in quick benefit and cure. In another case, the lasting effects of the meningitis upon the cord were overcome by building up cir- culation to it. Quickness of results in many cases indicates functional derangement from pressure of the lesion, which being removed leads to immediate restoration of function. On the other hand a course of treatment must look to regeneration of nerves and of ganglion cells in many cases where degeneration has taken place in these tissues because of the effect of the lesion. In hip cases, the under-development accompanying the paralysis is often due to pressure upon blood-vessels as well as upon nerves. The pressure is from the displaced bone and the contractures of tissues. There is a class of cases of paralysis in which fever has been the antecedent factor, as in cases in which paralysis of a limb follows typhoid fever. The paralysis of the vocal-cords, for ex- ample, following diphtheria, is often seen. Other diseases, febrile or not in character, in which there is much auto-intoxica- tion, may be followed by similar sequelae. In these cases, the poison generated in the system affects nerve-centers, or nerves direct, producing the paralysis.- Such sequelae are much more likely to occur in cases in which strong medication has been a feature of the treatment, since the emunc- tories, already occupied with all the poison they can eliminate, are called upon to handle in addition that introduced into the system in the form of drugs. Such sequelae are not so likely to occur in cases treated by osteopathic therapeutics. In the cases in which such sequelae occur, the locus of the 308 PRACTICE OF OSTEOPATHY. paralysis is probably determined by lesions which are present and affecting certain centers or nerves, laying them liable to such effects of autointoxication. It is evident, also, that in cases in which certain of the emunctories are weakened by lesion, such lesion may become responsible for the sequelae through having lessened the function of these eliminative organs. This class of cases is well handled, usually, if not of too long standing. The PROGNOSIS in paralytic cases is very favorable. A large percentage of the cases is entirely cured. Few cases are neither benefited nor cured. The apparent greatness of the lesion bears no proportionate relation to the degree of the effect. A small or very limited lesion often causes the most serious par- alysis. Many cases are slow and difficult. Some cannot be cured. The length of standing of the case should not determine the prognosis. Recent cases may be the most difficult to cure. Many of the most long standing and worst cas2s aro quickly ben- efited and cured. The prognosis is good, even after "strokes," and often where there is blood-clot on thj brain. TREATMENT: The bony lesion must ba 1*3 moved. This is often the most necessary treatment. But most cases require a course of treatment to regenerate, through the blood-supply, the nerves and centers effected. This necessitates insuring a good quality of blood, and in many such cases the important first step consists in sufficient treatment to bowels, stomach, liver and kidneys to improve the general health and expel all impurities from the blood. The general spinal and cervical treatment should be ap- plied to tone the general nervous system and to increase the circulation and nutrition of it. This is accomplished by relax- ation of all the spinal tissues, separation of the spinal vertebra? to allow free circulation, and stimulation of the central distribu- tion of the sympathetic having control of circulation to the spine. In case of blood-clot upon the brain the treatment is to increase cervical circulation to absorb it. This can be accom- plished in cases where the clot has not had time to become or- ganized or encysted. After cerebral hemorrhage, treatment PRACTICE OF OSTEOPATHY. 309 should keep this object constantly in mind. But in many old cases of hemiplegia after cerebral apoplexy, where doubtless the clot has become organized, much benefit can be given by the treatment. Local treatment is made upon the paralyzed limb or part to soften contractures, build up circulation, increase nutrition of the tissues, and to tone the local nerve-mechanism. Lesions as described in this chapter will be found in most of the various diseases of brain and spinal cord. The same prin- ciples and methods of treatment, varied to suit the case, may be applied to them. For example, in CEREBRAL HEMORRHAGE, OR CEREBRAL APOPLEXY, strong inhibition is made at once upon the sub-oc- cipital regions to dilate the blood-vessels and to aid in reducing the congestion. This object is aided in a most important manner by the general cervical, spinal and abdominal treatment, re- laxing all tissues and calling the blood to these parts away from the head. These treatments should be relaxing and inhibitive in nature as before described. The head should be kept raised to aid in drawing the blood from it. In the intervals in treat- ment the ice-bag may be applied to the spine. The patient should remain quietly in bed and be fed upon a liquid diet. After the acute stage the treatment should be carried on to remove the blood-clot from the brain and to overcome the hemiplegia. The former is accomplished by the usual cervical treatments to increase circulation to the brain; the latter by such treatments as described in detail above for cases of paralysis. The clot may, if taken in time, be completely removed, and the patient should be treated twice or several times daily. Later he may be treated daily or three times a week. INFANTILE PARALYSIS, in children up to three or four years of age, is often caused by disorders of the digestive tract, as in teething or after catching cold or in bowel complaint. In such cases cerebral congestion and spasms are prone to occur, and during the spasm a vessel is burst in the brain, with resulting hemorrhage and clot. In some of these cases the congestion, hemorrhage, clot, and inflammation occur in the cord, causing ACUTE ANTERIOR POLIO- 310 PRACTICE OF OSTEOPATHY. MYELITIS. Such cases do well under treatment in these acute conditions, and the resulting Infantile Paralysis, if seen early, or if not of long standing, will often yield well to a persistent course. In cases of HEMORRHAGE INTO THE .SPINAL MEMBRANES, HEMORRHAGE INTO THE SPINAL CORD, and HEMORRHAGE INTO THE MEDULLA and PONS the treatment is upon quite the same lines as for cerebral hemorrhage. In the first two conditions the patient should be kept lying upon his side or face, not upon his back, to favor the drainage of the blood. In the various forms of SPINAL MENINGITIS, often met in our practice, good prognosis is the rule. Cases are made to re- cover entirely, all paralysis or lingering stiffness of the muscles being overcome. The treatment in the acute form is the general spinal, cervical, and abdominal, to control the circulation of the cord and call the blood away from it. The rigidity of the muscles is overcome by manipulation and by careful, inhibitive spinal treatment. Bowels and kidneys must be kept active by treat- ment, to aid in removing toxic products from the system. It may be necessary to use a catheter on account of the paralysis of the sphincter of the bladder. In the intervals of treatment ice-bags may be applied along the spine. A course of treatment should be carried on to insure complete resorption of the in- flammatory products from about the cord, and to prevent or overcome any paralytic sequel to the condition. The same plan of treatment will apply to CHRONIC SPINAL MENINGITIS, and to the various forms of PACHYMENINGITIS and LEPTOMENGITIS. Further special treatment is to be applied according to the needs of the individual case, and according to the manifestations of the disease. In MYELITIS the same general plan of treatment should be adopted to gain vaso-motor control and lessen the inflamma- tory process in the cord. Diagnosis should be made of the por- tions of the cord affected, and treatment should be applied here particularly to absorb the extra vasted blood and do away with the danger of softening or degeneration of the cord following. The patient should be kept quiet, and attention be given to any special manifestation in the case requiring alleviation. Care PRACTICE OF OSTEOPATHY. 311 must be taken in the manipulation to avoid all irritation of the skin on account of the liability to bed-sores. Rigidity and spasm in the affected muscles may be overcome by inhibitive manipu- lation of them, and by inhibition of the nerves. Guard against renal and pulmonary complications by keeping the lungs and kidneys well stimulated. A course of treatment must follow to guard against or overcome paralysis. The prognosis is good in the acute case. A chronic case may be cured, or much may be done for its benefit. In CHRONIC MYELITIS, DISSEMINATED MYELITIS, and ACUTE ANTERIOR POLIO-MYELITIS, (see above) the same line of treat- ment is to be followed, with attention to special manifestations of the disease in each case. In meningitis, myelitis, apoplexy, etc., various spinal and cervical lesions occur, of the kinds pointed out in the general consideration of the subject of paralysis. ACUTE ASCENDING PARALYSIS, or Landry's Paralysis should be treated according to the directions given for the general treat- ment of paralysis. The spinal treatment must be particularly thorough, and heart and lungs should be kept well stimulated. The practitioner must be constantly upon his guard, as the dis- ease runs a very quick course, and may soon terminate in death. SYRINGOMYELIA should be treated as the ordinary case of chronic paralysis. PROGRESSIVE BULBAR PARALYSIS, or Labioglossopharyn- geal paralysis, needs treatment mostly in the cervical and upper dorsal regions, in order to remove lesion and to stimulate the circulation to the brain to prevent the atrophy of the roots of the various cranial nerves involved in the condition. The general health should be attended to. The treatment should^ include thorough spinal work as the cord tends to be involved, and pro- gressive muscular atrophy may appear. CEREBRAL ANEURYSMS are to be treated as are other aneurysms, q. v. HYDROCEPHALUS calls for treatment to maintain the gen- eral health, and for cervical and spinal treatment to correct cir- culation to and from the brain. 312 PRACTICE OF OSTEOPATHY. CEREBRAL PALSIES OF CHILDHOOD. (Infantile Paralysis.) Under this head are included hemiplegia, the birth palsies, and paraplegia. The various forms of infantile paralysis (see above) come frequently under osteopathic treatment. Ordi- narily good success is had in curing them, or in materially bene- fiting conditions. Many require a long and patient course of treatment. Some are soon cured. In the paraplegias much is done to help out the retarded downward development of the motor pathway. It is upon account of the necessity of develop- ing this part of the cord that so many of these paraplegic cases are slow to be cured, yet these cases have often been cured. In a few such cases slight luxations or dislocations of the hip- joint have been found as the cause of the condition. In the majority of these cases of infantile paralysis, lesions of the cervical vertebrae, especially of atlas, axis, and upper ver- tebrae, is found. It" is doubtless due to difficult labor, the use of forceps, or rough handling in delivery. Some cases are doubt- less due to menigeal hemorrhage resulting from such causes. Lesion may be present in the upper dorsal spine, The TREATMENT is practically that described for the gen- eral case of paralysis. Correction of lesion is, of course, the indispensable part of the treatment. Its removal frequently at once results in cure, with but little additional treatment. The thorough general spinal and abdominal etc., treatment described for paralysis, q. v., should be applied to these cases. A long course of such treatment is the rule. The cervical treat- ment, and the treatment usually given to increase cerebral cir- culation should be given, both for the purpose of absorbing a possible clot upon the brain, and to help on the retarded brain- development. Some of these cases are probably due to polio- encephalitis, congenital encephalitis, or meningo-encephalitis. They are therefore chronic cases by the time they come under our treatment, and call for the ordinary treatment given chronic paraplegia, hemiplegia, etc. It is seen to be absolutely necessary PRACTICE OF OSTEOPATHY. 313 to devote much treatment to increasing spinal and cerebral cir- culation, as before described, for the purpose of repairing the tissue changes that have taken place, in the form of sclerosis, vessel changes, etc. Spastic cases should be treated as directed for spastic par- aplegia. Prophylactic treatment should be given to avoid such se- quelae as epilepsy, choreic affections, tremors, athetosis, etc. Generally speaking, these cases should receive very careful systematic training to develop and control the muscles. In such cases as are affected by general convulsions or spasms of certain muscle groups, one may employ, to control such man- ifestations, hot baths (with mustard), enemata, etc. INFANTILE CONVULSIONS. (ECLAMPSIA.) Various kinds of convulsive attacks occur in children, some- times soon after birth, generally later. They may be due to much the same style of lesion as noted for infantile paralysis. Cervical lesion is common, leading to congestive conditions of the brain, cord, and meninges, and causing the convulsions. A far more common cause is lesion to that portion of the spine concerned in innervation of the gastro-intestinal tract. Gastro-intestinal irritation and debility result, and cause the condition. An overloaded stomach, intestinal parasites, denti- tion, phimosis, and other sources of irritation may be expected. The condition is frequently secondary to rickets, infectious dis- eases, etc. The PROGNOSIS in the ordinary case of convulsions in a child is good. It must be guarded in many cases. The TREATMENT at the time of the seizure must be to re- lax the spasms of the muscles, and to draw the blood away from brain and cord, equalizing circulation. Strong inhibition at the superior cervical region is the first step. The inhibition may be carried on down along the spine. It is usually best given with the patient lying on the side, while the spine is sprung and held at various points, relaxing the tissues and inhibiting the nerves. Sometimes the convulsion is at once relieved by continued strong 314 PRACTICE OF OSTEOPATHY. inhibition at the superior cervical, splanchnic, and lower lumbar regions. This treatment acts by reaching, at these several places, the important vaso-motors in the spinal system. Warm baths are effective in checking convulsions, also one may make cold applications to the head. Further aid is given to equalizing the circulation by the re- laxing, inhibitive abdominal treatment before described. Attention must at once be given to the bony lesion, either re-adjusting it or relaxing the bony parts and tissues about it, in order to relieve the irritation from this source. All sources of reflex irritation are to be sought out and removed. Especial attention must be given to gastro-intestinal affections so often present. They are to be treated, according to their kind, as directed in the chapter on diseases of this region, In cases of an overloaded stomach the child should be caused to vomit. In enteritis an enema will afford immediate relief. Later the general health should be attended to. Lesions should be removed, and a thorough course of spinal treatment should be gone through. ANGIONEUROTIC ' EDEMA, or acute circumscribed edema, is a condition in which there is localized' edema in the skin or mucous membranes. It is to be treated by removal of obstruc- tion to the nerves supplying the part involved, and to the venous and lymphatic drainage of the part. The heart and general circulation should be stimulated. The condition of the nervous system must be looked after, as nervous disturbances in the pa- tient favor the occurrence of the edema. He should be quiet, and the general spinal and cervical treatment should be used. Gastro-intestinal disorder may be present and should be looked to. ERYTHROMELGIA, or red neuralgia, "is a chronic disease in which a part of the body usually one or more extremities suffers with pain, flushing, and local fever, made far worse if the parts hang down. 5 ' (Weir Mitchell). CASE: T. F., aet. 47, farmer, affected with erythromelalgia in both lower limbs. The feet were both affected, but the trouble never progressed above the ankles. They suffered from erupt- ions, fever, redness, distended veins, and great pain. The symp- toms were aggravated when the patient stood, or let the limbs PRACTICE OF OSTEOPATHY. 315 hang down. Elevation of them afforded relief. Lesion was found in posterior condition of the lumbar vertebra, and of both innominate bones. The case was observed for some eight months. It had been practically cured at the time of this report. It is induced by exposure, rheumatism, a nervous temper- ament, occupations which require standing, abuse of alcohol, and traumatism. One finds lesions affecting the origin of the nerve-supply of the parts affected, or interfering with the cir- culation, thus weakening the parts and laying them liable to the action of the various exciting causes of the diseases. It should be treated as are neuralgia and sciatica, q. v. Ice cold applications afford relief, and rest with the limb placed in the horizontal position is recommended. Headache, dizzi- ness, palpitation of the heart, and fainting, if present, should be treated as before directed. Tonic treatment to the nervous system fortifies against the prominent tendency of the condition to recur. MENIERE'S DISEASE, or aural vertigo, is a disease of the labyrinth accompanied by vertigo, deafness, noises in the ear r vomiting, etc., usually occurring in the elderly. The lesions are such as are found in the great majority of ear cases, namely ; of the atlas, axis, and upper cervical vertebrae particularly. These may weaken the nerve-supply and circu- lation to the ears, and lay the patient liable to such direct ex- citing causes as exposure, gout, congestion, syphilis, irritation due to gastric disturbance, etc. The TREATMENT is directed to the removal of lesion, and to the direct exciting cause or disease. The main treatment, locally, should be cervical, and of the sort described in ear dis- eases. (See lesions, treatment, and anatomical relations in Dis- eases of the Ear). Treatment should be directed especially to the prevention of deafness. Cases may fully recover. Symptoms at the time of attack may be treated as necessary. Counter-irritation over the mastoid process is recommended. 316 PRACTICE OF OSTEOPATHY. DISEASES OF THE MUSCLES. MYOTONIA CONGENITA, or Thomson's disease, "is character- ized by prolonged contraction of the muscles concerned in vol- untary movements when brought into action." This disease is said to be the rarest in medicine, and medical texts say that the disease cannot be cured, while practically nothing can be done by treatment. One case has come under osteopathic treatment, and was cured. It had been examined by numerous physicians and had been under the care of a celebrated neurologist, who had made special mention of the case as a typical one of Thorn- sen's disease. The case was cured merely by removal of spinal lesion, and by general spinal treatment. (See the "Journal of Osteopathy," Feby. 1899, p. 439). The lesions were of the 6th, llth, and 12th dorsal vertebrae .and of the 1st, 2nd, 3rd, and 5th lumbar. A report of the case 10 months after the cure showed the patient still entirely well. The various forms of IDIOPATHIC MUSCULAR ATROPHY and HYPERTROPHY; pseudohypertrophic muscular paralysis, the ju- venile form of progressive muscular atrophy, and the facioscapulo- humeral form, all call for general spinal and muscular treatment. The central nervous sytem is held to be normal, as in the case of myotonia congenita, and the disease is said to effect the muscles alone. Yet, in myotonia congenita removal of spinal lesion and spinal treatment cured the case. It seems at least that treatment to the spinal system of nerves, as well as spinal lesion to them has a marked effect upon these idiopathic muscular conditions. Flexion, extension, rotation, etc., of the lirnbs and parts constitutes the muscular treatment for them. Symptomatic treatment may be added as necessary. NEURALGIA. CASES: (1) Severe facial neuralgia of two weeks standing, with inflammatory eruption upon the affected side, the right, and inflammation of the right eye. The usual treatments had been tried for two weeks without avail. The lesion was a marked displacement of the atlas to the left. It was corrected and the case was cured in one treatment. PRACTICE OF OSTEOPATHY. 317 (2) Facial neuralgia affecting the right side of the face and head, especially the forehead over the right eye. The lesion was luxation of the atlas to the left. The case was cured in one treat- ment. (3) Facial neuralgia of two years standing was greatly re- lieved by one treatment and was cured in six weeks, the patient gaining twenty-two pounds during that time. (4) Facial neuralgia and pains between the shoulders. The lesions were contraction of cervical muscles and lateral lux- ation of the fourth and fifth dorsal vertebrae. Four treatments cured the case. (5) Brachial neuralgia, involving the left arm and the left side as low as the fifth rib. The pain was intense, and the case was of more than two years standing. The arm was wasted and the pain continuous. Lesions were a lateral luxation of the second dorsal vertebra, and contraction of the muscles of the upper spinal region as low as the sixth dorsal vertebra, drawing together the upper five ribs on the left side and causing inter- costal neuralgia in this region. In two weeks the pain was over- come and the arm began to develop. The case was cured. (6) Brachial neuralgia of more than one years standing. The pain affected the right arm and rendered it almost useless. The lesion was of the right first rib, pressing upon the brachial plexus. At the third treatment the rib was set and the pain ceased. (7) Cervico-brachial neuralgia in the right arm, shoulder, and chest, due to lateral luxation of the 5th cervical and third dorsal vertebrae and muscular contractures of the cervical and left intercostal muscles. The case was practically cured in four months. (8) Intercostal neuralgia of several years standing, cured in less than one month. Spinal and rib lesion corrected. (9) Intercostal neuralgia due to heavy lifting, so severe that the patient was unable to sit erect without great pain. Le- ' sion was depression of the 3rd and 4th ribs on both sides. Im- mediate relief followed treatment, and the case was cured in four weeks. (10) Intercostal neuralgia of ten years standing, causing 318 PRACTICE OF OSTEOPATHY. an intense pain in the left side, extending to the abdomen. Le- sion was a luxation of the 8th left rib, and the case was cured by replacing it. (11) Spinal neuralgia of a number of years standing, due to lesion of the 4th dorsal vertebra. The case was cured in two months. (12) Neuralgia in the head, of eight years standing, lasting continually thirty-six hours during each' menstrual period. Le- sion was at the atlas, with muscular contractions in the lower dorsal and lumbar region. The case was cured in one month. (13) Neuralgia of the stomach of three years standing, the attacks coming on after each meal. At the time of exami- nation so serious had the condition become that the patient had not taken solid food for more than two weeks. Lesion was a lateral twist of the spine between the 6th and 7th dorsal verte- brae. Improvement followed one treatment, and the case was cured in about one year. i (14) Ulnar neuralgia, accompanied by swelling of the arm and of the ulnar side of forearm, hand, and third and fourth fingers. The trouble* was of two years duration, spinal lesion was found at the origin of the brachial plexus, and a contraction of the muscles in the upper dorsal region. After four treatments there was no further pain, and the case was dismissed cured in one month. (15) Neuralgia in the third finger of the right hand, of sev- eral years standing. Lesion was at the third cervical vertebra, which was corrected in a few treatments, removing the condit- ion. (16) Tic Douloureux of twelve years standing. The pain would occur spasmodically in the infar-orbital terminals of the fifth nerve, at intervals of from three to ten minutes. Lesion was found in a displaced atlas, which was corrected in six weeks, curing the case. DEFINITION: "Neuralgia is a pain in the course of a nerve unaccompanied by structural changes." It is due to irritation, direct or indirect, of the nerve. Often this irritation is from pressure of a displaced bony part or of contractured tissues. The LESIONS found causing this condition ?.re usually bony, PRACTICE OF OSTEOPATHY. 319 and these act by pressing directly upon a nerve or by affecting centers or sympathetic connections. In case 6 above, the brachial neuralgia was due to direct pressure of the first rib upon the brachial plexus of nerves. In case 1 or 2 it is evident that le- sion of the atlas was too low to affect the nerve involved, the fifth cranial, by direct pressure. Here the effect may have been upon the medulla, thus affecting the center in which certain roots of origin of the fifth arise, but more probably the effect was upon the nerve through its numerous sympathetic conec- tions in the upper part of the cervical region, as pointed out in the discussion of the fifth-nerve in diseases of the eye, q. v. In intercostal neuralgia the pressure is usually directly upon the nerve by a displaced rib, but may be due to vertebral lesion. The commonest bony lesion in neuralgia is a luxated ver- tebra, such a cause having been known to produce neuralgia in any part of the body. (See cases 1, 5, 7, 11, 13.) It is probable that in such cases the vertebra brings direct pressure upon the nerve as it emerges from the spinal canal. Any bony part in the body in relation to nerves may be- come displaced and impinge upon the adjacent nerve, causing neuralgia. Frequently the cause of irritation is pressure of con- tractured tissues upon the nerve. This occurs at the foramina. The tissues at and about the foramen become congested or con- tractured, pressing upon the nerve. These contractures may occur along the spine, as in case 4. Contractures of the inter- costal muscles may draw the ribs together, irritate the nerves and cause the neuralgia. Contractures are often the direct irritating cause in cases of neuralgia due to exposure, traumatism, etc. The lesion may be one causing a primary disease, as rheu- matism, gout, or specific infectious disease, allowing of the gen- eration of poisons in the systems, which affect the nerves by cir- culating in the blood. In Tic DOULOUREUX the lesion is usually at the atlas, but often is found among the other upper cervical vertebrae. Con- tracture of the cervical muscles and of the tissues about the foramina are often the causes. In CERVICO-OCCIPITAL neuralgia the lesions are usually among the upper four cervical vertebrae. 320 PRACTICE OF OSTEOPATHY. In INTERCOSTAL neuralgia occur lesions of vertebrae at the origin of the nerves affected, or of the ribs, and of the spinal and intercostal muscles. MASTODYNIA, or neuralgia of the breast, occurring generally in women, is due to similar lesions as intercostal neuralgia. Com- monly one finds rib lesion in the region affected. LUMBO-ABDOMINAL neuralgia, marked by pain in the lum- bar region, hypogastrium, buttocks, or genitals, is caused by lesion in the lower dorsal and lumbar spine. CERVICO-BRACHIAL neuralgia is due to lesion of the lower cervical vertebrae, of the first rib, clavicle, and of the upper dor- sal vertebrae. It may be caused by vertebral lesion anywhere from the atlas to the sixth dorsal. Neuralgia in the LOWER LIMBS is due to lumbar, sacral or innominate lesions. VISCERAL NEURALGIA, as of stomach or intestines, is caused by vertebral lesion of the corresponding spinal region. COCCYGODYNIA is caused by displacement of the coccyx, but may also be due to sacral, lumbar, or innominate lesion, leading to interference with the nerves by pressure, con- tracture of tissues, etc. Neuralgia in the FEET, in addition to spinal and pelvic lesion, is often due to lesion of the small bones of the feet. This is the case in MORTON'S PAINFUL TOE, META- TAESALGIA, etc., in which subluxaticns among metatarsals or phalanges cause pressure on the nerve. These conditions often occur in heavy persons who arc much on the feet. Often in such persons lithaemic, or gouty, or rheumatic diatheses are present, and contributing to the condition. Treatment must consider the whole condition. Sometimes the lesion is difficult of permanent and quick adjustment, owing to the weight of the person, who is more or less about. Under such conditions a well-placed pad of felt affords great relief, as a temporary measure. It should be about 1 inch, by 2 or 3 inches, by ^4 inch. FLAT-FEET sometimes give great trouble in the same manner, in the same class of cases, namely lithaemic, etc. Not only may the feet be painful and troublesome, but in some cases the pain may not be in the foot, but in the ankles or shins, perhaps well up toward the knee. The PROGNOSIS is good in all kinds of neuralgia. Cases of PRACTICE OF OSTEOPATHY. 321 long standing often yield at once. A few treatments, or a single treatment commonly, at once relieve the pain. Permanent cure is usually accomplished. The TREATMENT is simple. Often the removal of lesion is sufficient to. entirely cure the condition. The lesion should always be removed as soon as possible. Likewise any cause of irritation must be removed, as an ulcerated tooth, a cicatrix, a growth in the nose, etc. Constitutional conditions giving rise to neuralgic states must be met according to the case. Relaxation of all contractured muscles must be accom- plished. The manipulation is carried over the course of the af- fected nerve, relaxing the tissues about it. The pain of the disease does not prevent this local treatment. Inhibition of the pain is accomplished, not by pressure, but by light manipulation. The main treatment is usually upon a lesion at the origin of the affected nerve, or in its path. The above method of treatment is applied to any special variety of the disease. Tic Douloureux often yields at once to light manipulation over the course of the affected branches upon' the face. (Chap. V. B.) SCIATICA. Sciatica is a disease in which Osteopathy has secured par- ticularly brilliant results. Great numbers of cases have been cured, many of them having tried previously every known means of treatment. The PROGNOSIS is good. Usually immediate relief is given upon the first treatment. Often the case is soon cured, though many cases call for a patient continuance of the treatment. The LESIONS are almost always of such a nature as to bring irritation upon the nerve, either by direct pressure upon the nerve, or upon certain fibres contributing to it. Derangement of its blood-supply may play a part in producing the condition. The common lesions are bony ones along the lumbar and sacral regions. Lesions of the 4th and 5th lumbar vertebrae, lesions of the first and second sacral nerves by contracture of the tissues about them, innominate displacement, slipping of the sacro-iliac joint and derangement of its ligaments, displacement 21 322 PRACTICE OF OSTEOPATHY. of the sacrum, and derangement of the coccyx, are all important forms of lesion producing sciatica. These lesions impinge the fibres. Some may directly press upon the nerve. A frequent cause of sciatica is contracture of the pyriformis muscle upon the trunk of the sciatic nerve. The tissues about the sciatic notch may be contractured and irritate it. It is said that lesion along the cord, anywhere from the 2nd dorsal down, may cause sciatica. McConnell states that downward displace- ment of the llth or 12th rib may cause it. The TREATMENT is simple. It calls for the immediate re- moval of the source of pressure or irritation by correction of lesion. A general relaxation of the tissues about the nerve and about its connections is done, due attention being given to re- laxation of ligaments, as at the sacro-iliac articulation. This relaxation of the tissues should be carried along the femoral vessels, often thus relieving the condition in an im- portant manner. The tissues along the course of the nerve, at the sciatic notch, at the back of the thigh, and behind the knee should be relaxed also. Strong internal circumduction is used to relax the pyriformis muscle. The sciatic nerve should be well stretched by one of the methods described. (Chap. X.) Other forms of neuritis call for treatment upon similar lines to those followed in the treatment of sciatica. A LOCALIZED NEURITIS commonly shows obstructive le- sion to the nerves supplying the part. Such lesion is often the direct source of irritation causing the neuritis. In some cases it weakens the local nerve mechanism. In BRACHIAL NEURITIS, a common lesion is pressure of the first rib or clavicle upon the brachial plexus. Vertebral lesion in the cervical and upper dorsal region (4th cervical to 2nd dorsal) is often the cause. Lesions of the upper three ribs. irritating the upper two intercostal, which join the brachial plexus, may be causative factors. One finds also slight slips at the shoulder or elbow joint, contracture of the cervical muscles and other tissues, and contracture of the tissues along the course of the plexus and the cords formed from it. PRACTICE OF OSTEOPATHY. 323 MULTIPLE NEURITIS is almost always due to the toxic ef- fects of alcohol. The TREATMENT in neuritis is especially to remove the source of irritation to the nerves. In localized or brachial neur- itis this is usually at once accomplished by removal of bony or muscular lesion. This source of irritation must be sought from the origin of the nerves supplying the part involved out along the course of them. Relaxation of muscles along these nerves is usually of considerable benefit. Movements should be used to stretch the nerves affected. In these ways the circulation to the nerve is corrected, and the inflammation is reduced. Any toxic condition of the system should be carefully treated. If the neuritis occurs after gout, diphtheria, influenza, etc., atten- tion must be given to purifying the blood, and to excreting the poison from the system by way of the kidneys, liver, bowels, and skin. These remarks apply especially to multiple neuritis. If it be due to excessive use of alcoh'ol, abstinence should be en- forced. In such cases treatment must be given the whole spinal system, and the general health must be looked to. INSANITY. CASES: (1) Farmer, injured while at work, later became insane. Treatment by the usual methods did not avail and preparations were made to take him to an asylum. He had been insane for some months, when the osteopathic examination was made. Four men were required to hold the patient during the examination, so violent had he become. Lesion was found as a marked displacement of the third cervical vertebra to the right. It was set at once, and the patient immediately fell asleep, sleep- ing for twelve hours and awaking rational. In a few days the patient was well. (2) A young lady, violently insane for six years. Lesion was found as a slightly misplaced atlas, which was corrected at one treatment. The symptoms of insanity all disappeared in a few days. There was history of a fall six years previous to the development of the insanity, and it was thought that the luxa- tion of the atlas was 'caused then. (3) A young woman of twenty-four, insane and confined 324 PRACTICE OF OSTEOPATHY. in an asylum for eight months. Lesion existed in the form of a double lateral curvature in the lumbo-dorsal region; 5th lum- bar vertebra posterior;. 4th dorsal markedly posterior; 3rd and 5th dorsal anterior; 7th and 8th right ribs pressing upon the liver; innominates, one forward and the other back, one limb being 1 inch longer than the other. Treatment directed to the cor- rection of these lesions caused immediate benefit, and the pa- tient was apparently well after two weeks treatment. (4) In a lady of twenty, insanity of two months standing. There was a history of attacks of marked cerebral congestion. At times she became violent. The lesions were great tender- ness and tension in the cervical region above the 4th vertebra, but no bony lesion; tenderness at the 5th lumbar vertebra and over the left ovary. Dysmenorrhoea was present. After the first treatment she slept for eleven hours, and awoke sane for the first time in eight months. After three weeks treatment the patient was well. (5) A boy acted in an insane manner after a fall upon his head from a window. A cervical vertebra was found luxated, and one treatment sufficed to cure the case. (6) A lady of thirty-eight, who had been a chronic sufferer from rheumatism, had become insane ten years previously to treatment. At the time of becoming insane the menses had ceased. She had been in an asylum for six months, growing continually worse. She was much excited and suffered hal- lucinations. The lesions were such as pertained to the rheumatic condition; general muscular contracture, joints somewhat stiff- ened, tenderness over the kidneys, feeble pulse, and subnormal temperature. One month of treatment showed great improve- ment; after two months the menses were re-established and the mind was nearly normal. Recovery was complete. (7) Insanity in a man followed injury in a runaway accident. Lesion existed as anterior displacement of the atlas and a twist. of the second and third vertebrae, one being turned forward and the other backward. There was also contraction and soreness of the posterior cervical muscles. Continued pain existed at the top of the head, there was an eruption upon the face, and a PRACTICE OF OSTEOPATHY. 325 marked abnormal pulsation of the abdominal aorta. Treatment soon cured the case. (8) Insanity of three weeks standing in a lady, in whose case the cause was found to be an anteversion of the uterus. A fact that had been quite overlooked in her long course of medical treatment. Osteopathic treatment was given this condition, and the drugs were discontinued. In two weeks the patient became rational, and in seven weeks was entirely cured. The cases are illustrative of osteopathic practice in insanity, numerous cases of which come under treatment. As a rule bony lesions are found. Sometimes lesion exists in the form of merely muscular contracture in the cervical region. The LESIONS are generally in the cervical region. Five of the above eight cases presented such lesion. Atlas lesion is frequent. In some cases are general spinal lesions leading to effects upon the nervous sys- tem. Often marked lesion is found in the dorsal region. Mc- Connell notes the occurrence in insanity of middle dorsal, renal splanchnic, and rib lesions. The latter occur among the middle ribs on the right side. Case 3 above shows such lesions. Lesions act by interfering w r ith cerebral circulation, prob- ably in some cases by pressure upon the cord, and also by affect- ing the nervous system and setting up reflexes. On the whole but little can be said definitely in regard to the pathology of in- sanity from the osteopathic point of view. That lesions exist as the cause of such conditions, and that their removal cures, and alone can cure them, cannot be doubted from the facts. But just how lesion is acting to cause derangement of the mental functions is not known. It is noticeable that quick results usually follow treatment, as in the eight cases above. Often the patient falls at once into a deep and lasting sleep. These facts- indicate some marked and immediate relief to the brain. It seems as if some great pressure had been taken off the brain, leaving the mind free and Nature unopposed in her work of repair. This is doubtless literally true in those cases of insanity attended by cerebral congestion, in which the impeded circulation is at once restored to normal tension by removal of that which impedes the venous flow from the head. When the lesion is cervical it is altogether likely that its action upon the brain is by deranging 326 PRACTICE OF OSTEOPATHY. the cerebral circulation, either by direct pressure upon the ver- tebral arteries by a displaced vertebra, by irritation to cervical sympathetics and the vaso-motor center in the medulla, or by a combination of these two. In this way may be set up either hyperemia or anemia of the brain. For example, pressure upon the vertebral arteries and irritation to the vaso-motors causing vaso-constriction might co-operate to cause marked anemia of the brain. On the other hand, impeded venous return and in- creased arterial tension in this region might result from lesion and cause cerebral hyperemia. Many cases of insanity are met in which there is hyperemia, as in cases 4 and 7. That hyperemia and anemia are important in relation to insanity is shown by the statement of Kellogg that "insanity from circulatory disorders of the brain arises chiefly in intense hyperemic and anemic forms." That osteopathic lesion pro- foundly affects cerebral circulation is evidenced by many facts in the treatment of various diseases. The importance of these circulatory disturbances is further indicated by Kellogg 's state- ment that vascular degenerations deprive the brain of its cus- tomary blood-supply and also prevent elimination of the waste products of cellular activity. It is evident that the lesion shut- ting off the arterial supply or preventing free circulation in the brain cquld act as could vascular degeneration in producing the effects mentioned. Kellogg says it is freely admitted that there is a previous link in the chain of events leading to insanity from such causes as he mentions above. This link the Osteopath sup- plies by noting these important bony and other lesions, without the removal of which these cases fail to be cured. It is likely that the atlas lesion, so often found in insanity, acts chiefly by deranging the circulation through its close rela- tions to the superior cervical ganglion and the medulla. It does not seem that this and other cervical bony lesion cause direct pressure upon the cord, as in such case one would expect par- alysis in the body below, yet it is not impossible that it may press directly upon the cord, getting its effect upon the brain through ascending tracts. The general spinal, vertebral and rib lesions mentioned may affect the general nervous system, as is known to be a fact PRACTICE OF OSTEOPATHY. 327 from a study of nervous diseases, (see Paralysis) in this way leading to nervous diseases, reflex and otherwise, which are at the basis of insanity. "All the (various influences) acting in the production of general diseases of the nervous system are those fundamentally involved in the causation of insanity." (Kellogg.) The splanchnic, right rib, and renal lesions noted by osteopathy as present in insanity cases may cause insanity through derangement of kidneys, liver and gastro-intestinal tract. The fact is noted by writers upon insanity that kidney diseases, notably Bright's disease, and gastro-intestinal condi- tions, as gastric and intestinal catarrh, are sometimes closely associated with the causation of insanity. Likewise liver dis- ease is well known to be closely connected with insanity, gall- stones and icterus being common in insanity. These visceral diseases, as well as some nervous diseases, seem to be related to insanity through the vaso-motor reflexes they arouse. Kellogg says, "vaso-motor disorders essentially constitute the connecting link in the causation of insanity by visceral affections and periph- eral nervous diseases. The vaso-motor center in the medulla is under the reflex control not alone of the cerebral cortex, but of the entire peripheral distribution of the sensory nervous sys^ tern, so that not only emotional stimuli, but peripheral irritations, may affect circulatory changes and variations in the blood-pres- sure which stand in proximate relation to mental disorder. ' ' It is a well demonstrated fact that osteopathic lesion causes not only the visceral diseases, but likewise marked vaso-motor disorders, etc., apparently so closely related to these brain con- ditions. In view of these various facts it seems that the Osteopath has in insanity a broad field for his labors. Nor would he be confined to that class of cases in which the traumatic effects of lesions due to violent accident and the like are the causes of in- sanity. But as it is evident that the various lesions, bony and otherwise, that he finds may become fundamental to the causa- tion of insanity through producing visceral, nervous, and vaso- motor disorders, his field in insanity must be as broad as the disease. The PROGNOSIS is good. The most brilliant and quickest results are often attained. A large percentage of the cases treated 328 PRACTICE OF OSTEOPATHY. are cured. It is needless to say that many cannot be cured. The TREATMENT looks to the removal of lesion, and of all causes of irritation, reflex, emotional and otherwise. The whole nervous system should be upbuilt by general spinal and cervical treatment. One of the main objects is to correct cerebral circu- lation. A congested condition is treated as in congestive head- ache or apoplexy, q. v. The abdominal inhibition may be em- ployed. The general health is looked to, kidneys, liver, stomach, bowels, pelvic viscera, heart and lungs are all regulated in case of affection in them. The patient should lead a quiet, regular life. DISEASES OF THE EYE. CASES: (1) Impaired vision in a boy of seventeen, who had been wearing glasses over three years. Severe headache and inability to read followed removal of them. Lesion was found as lateral luxation of the atlas and third ceivical verte- bra. After three weeks treatment the glasses were removed, and at the end of two months the eyes were completely cured. The report was made six months later, the eyes still being well. (2) A case in which weakness of the eyes and rheumatic pains in the shoulder were caused by lesion in the form of close- ness of the second and third cervical vertebrse. After one treat- ment the glasses were laid aside and the pain in the shoulder was gone. The trouble, caused by a fall in a gymnasium, affect- ed but one eye and one side of the body, a nervous twitching of the muscles being present. (3) A young lady had suffered with weak eyes for two years. The eyes would be very painful if the glasses were laid aside even for five minutes. Lesion was of the 2nd dorsal vertebra, lateral to the left. After five treatments the glasses were dis- carded. (4) In a lady of forty, weakness of the eyes, accompanied by great pain in the eye-balls and at the base of the brain. Le- sion existed at the atlas and third cervical vertebra. Constipa- tion and uterine prolapsus were present, with characteristic le- sions. After one month the eyes were almost well. Photopho- bia was a feature of the case. PRACTICE OF OSTEOPATHY. 329 I (5) In a case of weak eyes, with pain in the neck, occipital headache, and a complication of troubles, lesions were found as anterior luxation of 3rd, 4th, and 5th cervical vertebrae, the 5th being sore. The whole spinal column was stiff and stooped for- ward. (6) In a case of weak eyes in a young man of twenty, of two months standing, the patient was unable to read, the balls were injected and painful, and the lids were inflamed. The atlas and :axis were too close. (7) In a lady of thirty-two, weakness of the eyes and chronic hoarseness had existed for twenty-two years. The left cervical muscles were very sore, there was a separation between the atlas and axis, and the 5th cervical vertebra was sore. The right tear duct was closed. (8) In a case of weakness of the eyes, coupled with indi- gestion, jaundice and hemorrhoids, the 7th to llth dorsal verte- bra were posterior; coccyx anterior; and innominate forward. (9) Extreme weakness of the eyes, together with female disease. A few minutes use of the eyes caused violent head- .ache. Lesions were at the atlas and in a tilting of an innominate bone. The case was cured by removal of the lesions. (10) Eye trouble in a boy of thirteen, not benefited by glasses. Patient was very nervous. The atlas was slipped for- ward. The lesion was corrected and the case was cured in six weeks. (11) A case of pterygium due to granulated lids of sixteen years duration. The left pupil was covered by the growth, and the right one was nearly so. The case was cured by the adjust- ment of cervical lesion. (12) Pterygium over each eye due to lesion of -the atlas. Under treatment gradual correction of the lesion was accompanied by gradual absorption of the growth. (13) Partial blindness and strabismus, associated with general paralysis, due to a forward slip of the head upon the atlas. 'The case was cured in two months. (14) A case of blindness from optic-nerve atrophy, due to .a fall from a swing, resulting in lesion of the atlas and several 330 PRACTICE OF OSTEOPATHY. cervical and upper dorsal vertebrae. The disease was of twenty- three years standing. It was cured by two years treatment. (15) Blindness of one eye, and almost total loss of sight in the other, of about a years duration, was cured in two weeks by cor- rection of lesion of the atlas, which was displaced to the right, and of one of the first ribs, which was luxated upwards. (16) Partial blindness, the patient being unable to read or to recognize a person ten feet away. The trouble was due to starvation of the optic nerve from lesion of the upper cervical vertebra. In four months the patient had been cured. (17) Blindness, almost total, in a man of sixty, due to a fall when he was a child. Lesion was found as luxation of a cervical vertebra. The treatment so benefited the eye that it could see to read coarse print. (18) Total blindness in the left eye for more than two years, due to lesion of the atlas. The pupil was much dilated. After one treatment sight was partly restored, and at the end of a month of treatment the case was nearly entirely well. (19) Total blindness with paralysis of lower limbs, formica- tion of upper limbs, etc. Lesion was found in lateral luxation of the third cervical vertebra, of the 7th and 8th right ribs, and posterior protrusion of the lumbar vertebrae. Soon vision was partly restored, but with diplopia. Slight pressure upon the seventh cervical vertebra would at once restore perfect vision. When pressure was removed diplopia again occurred. L r nder the treatment the sight was entirely restored. Speech had been lacking, but was restored, and the paralysis was cured. (20) In a young man of twenty, diplopia of two years dura- tion had followed a severe attack of measles. The 3rd cervical vertebra was displaced anteriorly and the tissues about it were sore. Tenderness existed also at the 5th and 6th cervical verte- brae. The first dorsal was posterior, the 2nd to 6th flattened, the 8th to 12th weak, with a separation between the 12th dorsal and 1st lumbar, and the 1st to 4th lumbar vertebras were pos- terior. The case was cured in one month. There had been supposed hemorrhagic retinitis. (21) A case of strabismus due to lesion of the 2nd dorsal vertebra was cured by correction of the lesion. During the PRACTICE OF OSTEOPATHY. 331 course of treatment, after the eyes had first become straight- ened, pressure upon the second dorsal vertebra would cross them again. (22) A case of strabismus, unilateral, convergent, due to a fall in a runaway accident. The atlas was displaced to the right; 4th and 5th cervical vertebrae anterior. The case was improving under treatment. (23) Kerito-conjunctivitis, in the left eye, of four years standing. There was opacity of the upper two-thirds of the cornea, with marked vascularization, inflammation and granula- tion of the eyelids, and injection of the sclerotic. The atlas was luxated to the left, the fifth and sixth cervical vertebrae were anterior and to the left, and the upper dorsal vertebrae were pos- terior. Under the treatment the case was almost cured in less than two months. (24) In a man of thirty-seven, glaucoma was present, and total blindness of the left eye was predicted by the oculist. The patient was a neurasthenic, probably of the cerebral type, pain in the head and eye being extreme. The eye-trouble was over- come and the patient's general condition much improved by three months treatment. No special lesions were found. (25) Partial blindness, in which the blindness was limited to a circular portion of each eye. Lesion was found as a luxa- tion of the atlas to the right and backwards. The case is still under treatment. (26) A case in which the tear-duct was closed. It had been growing worse under the usual form of treatment for two years. The eye was much inflamed. Relief was experienced at the first treatment, after the second the duct was permanently opened, and the inflammation about the eye gradually disap- peared. The case was well a year later. (27) Eye-strairi, causing constant headache, due to a luxated atlas. Glasses gave no relief. The headache did not recur after the first treatment, and the eyes were well after seven treatments. The case had been of but two or three months standing. (28) Astigmatism in a girl of ten. Lesion was found at the 2nd dorsal. Treatment was directed to correction of this 332 PRACTICE OF OSTEOPATHY. lesion and to stimulation of the ocular blood and nerve-supply. The case was soon cured. (29) In astigmatism for which the patient had worn spec- tacles for nine years, lesion was found in anterior luxation of the atlas and a twist of the inferior maxillary bone. The glasses were permanently discarded after one treatment, and the case was soon entirely cured. These reports illustrate very well the general lesions found in diseases of the eye. The most important lesions occur among the vertebrae of the cervical and upper dorsal region. Muscular lesions are often found in this region, and are of considerable importance. The whole cervical region is frequently involved, or any one or several of the vertebra may be luxated. Perhaps the more important lesions are of the atlas, axis, and 3rd cervical vertebra. The 4th and 5th are also important. Other bony lesions occurring in these cases, and of import- ance in eye troubles generally, are luxation of the inferior max- illary bone and of the first rib, sometimes also of the clavicle. There is a form, of neck lesion that often plays a part in the production of eye disease, as well as of other forms of head and neck trouble. It involves the whole cervical region, often causing a lateral swerve of the cervical spine. The cervical tissues are contractured or hypertrophied upon one side more prominently than upon the other. The condition is often evident upon simple inspection from immediately behind. The fullness upon one side of the neck, and generally a corresponding depression in the tissues on the opposite side, are readily seen. In some cases the condition is better appreciated upon palpation. The fingers are readily pressed more deeply into the tissues upon one side of the posterior cervical aspect than upon the other. Contrac- ture of the muscles may be felt here on both sides. If the verte- brae are traced down the mid-line of the back of the neck, a lateral swerve is often evident. In other cases the bony lesions are more evident by examination of each vertebra with the patient lying upon his back. Dr. A. T. Still calls attention to the fact that contracture of the cervical muscles opposite the 4th vertebra are common .in eye-diseases, and that pressure here causes pain in the eye. PRACTICE OF OSTEOPATHY. 333 A case is reported in which pressure between the 2nd and 3rd dorsal vertebrae upon the right side revealed tenderness at that point and also caused pain in the eye. Without question cervical bony lesion is the most important one with which the Osteopath deals in eye-diseases. Upper dorsal lesion may be muscular, but is usually bony. It involves chiefly the upper four or five vertebrae, but may ex- extend as low as the 6th or 7th. The lesions of the 1st, 2nd and 3rd dorsal vertebras are the most important here. A common abnormality of the anatomical parts here is a "hump" or prom- inent cushion of flesh covering the spinous processes of the upper two or three dorsal vertebrae. There is often conjoined with this condition a marked prominence of the first dorsal spine from above, as if the cervical spine had been moved a little anteriorly upon the first dorsal. This cushion is a common condition in eye troubles of various sorts, and is sometimes connected with heart-trouble. Among lesions of this region may be mentioned lesion of the upper ribs on either side as low as the sixth, sometimes thought to have bearing upon nutritional disturbances of the eyes. We are perhaps not in a position as yet to point out that special kinds or locations of lesion result in specific diseases of the eye. Cases involving deficiency somewhere in the optic tract seem to favor lesion in the upper cervical region. In the above reports, 19 cases in which probably the intrinsic appara- tus of the special sense of sight was involved, such as weakness, impaired vision, blindness, etc., show lesion chiefly in the upper cervical region. All but 2 cases show cervical lesion, 13 of them being entirely in the cervical region; 11 at the atlas; 8 at the axis, third, or both; also the 4th, 5th and 7th were involved. The most important lesions occurred about atlas, axis and third. Cases in which there is nutritional disturbance, as in con- junctivitis, keratitis, glaucoma, cataract, and closure of the tear-duct, also cases in which there is structural change, such as astigmatism, pterygium, etc., probably due to lack of nutrition, present atlas, general cervical, inferior maxillary, and upper dorsal lesion. Compilations of data, by which proof of these 334 . PRACTICE OF OSTEOPATHY. might be made, are lacking. Yet it seems that nutritional dis- turbances, involving in some way chiefly the fifth nerve, would be found tending more toward the upper dorsal region, for the anatomical reason that this nerve has important connections with the upper dorsal nerves and cord. Motor disturbances, such as diplopia, strabismus, eye- strain, etc., show less of high cervical lesion and more from about the third cervical down to the upper dorsal. In this connection it is recalled that diplopia has been caused by pressure at the 7th cervical, and strabismus by pressure at the 2nd dorsal. This phase of the subject, inquiry how far specific lesion re- sults in certain forms of eye disease, presents a good field for research. It is evident that at present we cannot more than indicate probabilities. ANATOMICAL RELATIONS: There are good anatomical rea- sons why lesion in the upper dorsal and cervical regions causes eye disease. These portions of the spine are particularly rich in nerve connections with the eye. These lesions act by dis- turbing blood, nerve, or lymphatic-supply of the eye. The blood- supply suffers sometimes by direct impingement, as of vertebrae upon the vertebral arteries, or by derangement of the vaso-motor control by lesion to the nerves. The lymphatics suffer by direct impingement, as by clavicular lesion damming back the lymphatic- drainage from the head. The lesion affecting the eye does so chiefly, however, by disturbance of the numerous important nerve- connections met in the upper dorsal and cervical regions. Experience has taught the Osteopath that bony lesion in those regions causes most eye-diseases and that its removal cures them. The superior cervical ganglion, well known to suffer by lesion of atlas, axis, or 3rd cervical, sends its ascending branch to join the carotid and cavernous plexuses, thence to help form a secondary plexus about the ophthalmic arteries and to con- tribute branches to the minute plexus of the sympathetic within the eye-ball itself. Thus is established a direct path of com- munication between the upper cervical lesion and the eye. The ciliary ganglion lies at the back of the orbit, between the trunk of the optic nerve and the external rectus muscle. PRACTICE OF OSTEOPATHY. In this situation it is readily impinged by that treatment that presses the eyeball back into the orbit. With this ganglion are connected the 3rd, 5th, and sympathetic nerves, it thus becom- ing, through the functions of these nerves, a sensory, motor, and sympathetic center for the eye-ball. Neck lesion, as will be shown, may effect either or all of these nerve-connections, in this way deranging the function of the ganglion with regard to the eye. The third cranial nerve innervates all the voluntary mus- cles of the -eye except the external rectus and the superior ob- lique. It is, further, the nerve which contracts the pupil by sup- plying the sphincter function of the iris. This function is shown by the American Text-Book of Physiology to have its center in the superior cervical ganglion, where it could be affected in le- sion of the upper cervical region, causing disturbance of accom- modation in the eye. Neck lesions are know r n to cause strabis- mus and diplopia (cases 19 and 21), showing disturbance by such lesion of the function of the 3rd nerve. (Also of the 4th and 6th). The anatomical relations in strabismus caused by lesion at the 2nd dorsal, and in diplopia by lesion at the 7th cervical, are not well understood. The local treatment of the ciliary ganglion is important in these motor disturbances. Fibers antagonistic to the ciliary function of the third nerve, being dilators of the pupil, are found rising in the third ventricle, whence they pass through the medulla and cervical cord to the anterior roots of the upper dorsal nerves and to the first thoracic ganglion of the sympathetic. From these points they reach the eye via the cervical sympathetic cord, ophthalmic division of the fifth, and its nasal and long ciliary branches. These facts indicate the importance of upper cervical, gen- eral cervical, and upper dorsal lesion in the causation of lack of accommodation, eye-strain, and similar troubles. The latter sympathetic connection indicates the so-called cilio-spinal center at the 4th cervical to 4th dorsal. Quain states that these pupillo-dilator fibers pass from the 1st, 2nd and 3rd nerves, sometimes also from the^Tth and 8th cervical. In addition to the above, motor fibers to involuntary mus- cles of the orbit and eye-lids pass from the upper four or five dorsal nerves. Also retinal fibers leave the sympathetic at the 336 PRACTICE OF OSTEOPATHY. superior cervical ganglion, pass to the Gasserian ganglion of the fifth, thence through its branches to the eye. It is shown that, acting through these fibers, stimulation of the cervical sympa- thetic causes constriction of the retinal arteries, while stimula- tion of the thoracic sympathetic causes dilatation of them. These facts indicate the importance of cervical and upper dorsal lesion in vaso-motor disturbances in the retina, as in retinitis. The fact that many of these sympathetics, as pointed out, pass to the eye via the fifth nerve shows the intimate relation between the superior cervical ganglion, the cervical and upper dor- sal sympathetic, and the fifth nerve, consequently the potency of cervical and upper dorsal lesion to affect the fifth nerve. This nerve sends its sensory ophthalmic division to join with the sympathetic from the cavernous plexus. It has trophic and vaso- motor fibers to the eyeball and its appendages. Green states that section of the fifth nerve is followed by keratitis and ulcera- tion. It has charge of the nutrition of the eye-ball, supplying also the lachrymal glands, conjunctiva, skin of the lids and ad- jacent parts of the face. *Nutritive disturbances of the eyes, such as keratitis, conjunctivitis, retinitis, cataract, glaucoma, pterygium, etc., must be referred to lesion affecting the fifth nerve. Likewise optic nerve atrophy, and other effects due to insufficient nutrition, would result from lesion affecting the fifth. Slips of the inferior maxillary articulation are thought to impinge fibers of the fifth nerve, (articular branches from the auriculo-temporal nerve) and to cause certain eye troubles, (case 33.) A review of these various connections shows that cervical and upper dorsal lesion may affect: 1. The superior cervical ganglion and its sympathetic con- nection with the local sympathetic plexus of the eye-ball. 2. The various cervical nerves, and through them the gang- lion and the other cervical sympathetics. 3. The pupillo-constrictor center in the superior cervical ganglion. 4. The pupillo-dilator center in the same ganglion and at at the lower cervical and upper three dorsal nerves. 5. The motor fibers from the upper four or five dorsal nerves PRACTICE OF OSTEOPATHY. ' 337 to the involuntary muscles of orbit and eyelids. 6. The fifth nerve by its connections with the superior cer- vical ganglion and cervical sympathetic. 7. Constrictors of the retinal arteries in the cervical sym- pathic. 8. Dilators of the same in the thoracic sympathetic, and both of these at the superior cervical ganglion. It is noticeable that all of these eight connections, except perhaps No. 5, may be reached at the superior cervical ganglion. This explains the special importance of lesion to atlas, axis and 3rd cervical, before pointed out as most frequent in eye diseases. These upper cervical lesions affect this ganglion. From the variety of functions represented in these various fibers congrega- ted in the superior cervical ganglion we must conclude that lesion of the atlas, axis, or third, ' etc., affecting this ganglion, would cause a variety of diseases of the eye. Lesions causing stomach, kidney, and pelvic diseases may secondarily become the cause of disturbances in the eye. The relation here is probably entirely reflex. Perhaps also in these conditions alteration of blood-pressure is a disturbing factor. It seems that cervical lesion causing obstruction of the tear-duct, as well as manipulation upon the nose along its course to open it, affect the mucous membrane lining it, through the distribution of the fifth nerve. Clavicular and first rib lesion, obstructing the lymphatic drainage of the eye by obstructing the flow from the deep cer- vical lymphatics into the thoracic or right lymphatic duct, may affect the metabolism of the eye. It has been thought that le- sion affecting the female breast may react, upon the eye reflexly. The PROGNOSIS in eye-diseases is, generally speaking, good. Marked results, even to cure of blindness of many years stand- ing, have been acquired. Very often suprisingly quick results have been attained. An examination of the case reports at the opening of this chapter will show that in twenty-four of the thirty-three various cases reported a cure was affected. Quick results, either as cure or benefit, were attained in seventeen cases. The 'cases met by the Osteopath are frequently of long standing *For important functions of the fifth nerve see "Principles of Osteopathy." 1 o., . , 338 PRACTICE OF OSTEOPATHY. and in bad condition. In many cases these results were gotten after specialists had failed. All cases cannot be cured. Many are subjects for the specialist. The TREATMENT of eye-diseases is necessarily almost en- tirely upon the neck, as it has been shown that the lesions in these cases occur here. The removal of the these various lesions is already understood from discussions in the previous pages. The treatment looks, in general, to the establishment of per- fect circulation, and the regulation of the nerve-mechanism. The general neck treatment, as applied in cases of insomnia, headache, apoplexy, etc., q. v., given with a specific object in view, would be the method employed (see also Chap. Ill and IV). In many cases the simple removal of lesion is the only treat- ment required. Often this treatment and the general neck treat- ment may be supplemented by local treatment upon the eye, and about it, reaching its nerve-mechanism and blood circula- tion directly. (See Chap. V, A. and B) This work includes treatment to the fifth nerve as the one being in charge of the nutri- tion and circulation of the eye. This nerve is particularly re- garded in all nutritive diseases, such as keratitis, and in all in- flammatory, hyperemic or anemic conditions, such as conjunc- tivitis, etc. In conjunctivitis the local irritant, if one be present, must be removed. Treatment should not be made upon the eye in these cases, but about it. The chief treatment is in the neck, especially upon the superior cervical ganglion. In granular conjunctivitis the same treatment is made. The granulations must be broken down. (Chap. V). After this the correction of the circulation by the cervical treatment prevents their further growth. In keratitis treatment proceeds as in conjunctivitis. In both conditions the fifth nerve must be especially treated. The removal of lesion and the correction of blood-flow are the essential points in these and all similar cases. "In pterygium especial treatment is made to cut off the "feeders" (V. Chap. V.) After this operation they are absorbed by the corrected circulation by means of the neck-work. In some cases removal of neck lesion is followed by absorption of the PRACTICE OF OSTEOPATHY. 339 growth, as in case 15. Sometimes light manipulation over the closed lids aids the absorption. The same remarks apply to pannus. In diplopia, ptosis, strabismus, and other motor troubles, lesion must be sought as the cause of the muscular palsy, tension, etc. Treatment is applied to the lesion and to the affected nerve. These troubles sometimes yield to the correction of cervical le- sion alone. The muscles may be treated directly as in VI. Chap. V. In cataract the treatment looks to the absorption of the cataract through increased circulation. Cervical treatment, removal of lesion, and local treatment about the eye and upon the fifth nerve, all as before described, have successfully accomp- lished a cure in these cases. In such cases, Dr. Still says that the crystalline lens is disarranged. He holds one fingerc lose against one side of the eye-ball, with the lid closed, and thumps this finger with the index finger of the other hand, to jar the ball and straighten the lens. In the various optic nerve troubles, also, the treatments "are used to affect the nerve through its blood-supply. Nu- merous cases of blindness from optic-nerve atrophy have been cured in this way. The optic nerve be may stimulated by tap- ping or pressure upon the eye-ball. (II, III, Chap. V.) Ret- initis likewise yields to this treatment. In conjugate deviation, both eyes turning strongly to one or other side, the lesion, usually cervical, affects the third and sixth nerves, supplying respectively the internal rectus and the external rectus of the eye-ball. The treatment is local and cervical. DISEASES OF THE EAR. CASES: (1) Deafness of two years duration in a lady of forty-two, caused by displacement of atlas to the right, tighten- ing muscles and ligaments around the ear and lower jaw. Ten- derness was extreme in the cervical region. Dry catarrh was present. There was lesion of the 2nd cervical vertebra. The patient had been injured in a railroad wreck, being confined to 240 PRACTICE OF OSTEOPATHY. bed. She could not hear a clock strike in the room, nor the playing of a piano. After three treatments the patient could hear the clock strike. After five weeks treatment the hearing was completely restored. (2) Deafness in a young boy, due to lesion of the atlas. The deafness was complete in one ear, and almost so in the other. After one months treatment he could hear conversation spoken in an ordinary tone. (3) In a boy of fourteen, a continuous discharge from the right ear, of ten years standing. Lesion of the atlas and axis, luxated to the right, and contraction of the tissues. The case was cured in nine treatments. (4) In a boy of eleven, partial deafness in, and continual discharge from, one ear. The lesion was a slip of the atlas. The case was cured in one months treatment. (5) In a young lady, an abscess in one ear had been dis- charging for several months. After one treatment there was no further discharge, and after four treatments the trouble had disappeared. (6) In a young lady, partial deafness of some years stand- ing, continually growing worse. Several members of her family are afflicted in the same way. An ear specialist had pronounced her case hopeless. Lesions were luxation of the 2nd and 3rd cervical vertebrae; thickened tissues at the base of the skull; irregularity of the upper dorsal vertebrae. The entire treatment was directed to the head, neck, and upper dorsal region, with the result that after one months treatment the patient could hear a watch tick at double the distance that she could upon beginning treatment. (7) A case of growing deafness, of some years standing, in a gentleman who had given up his profession upon this account. Lesion was found at the atlas, which was turned backward and to the left. Upon its adjustment the hearing was much im- proved. (8) Complete deafness in the left ear, and partial deafi in the right ear, complicated with facial neuralgia, of about 20 years standing. The atlas was posterior and to the left. In two months treatment great improvement was made. PRACTICE OF OSTEOPATHY. 341 (9) A case of intense earache of years standing. The atlas was displaced slightly to the right. This was adjusted at the first treatment, and no earache appeared after that. The LESION in ear diseases, as illustrated by the above cases, is almost as a rule in the atlas and axis. The 3rd cervical and other cervicals may be affected, but in the vast majority of cases the atlas and axis, one or both, are affected. It is more often at the atlas than elsewhere. A luxation of the temporo-max- illary articulation, impinging probably the articular fibres of the auriculo-temporal branch of the inferior-maxillary division ^of the fifth nerve, and contractured tissues about the upper cer- vical region and the angle of the jaw, may act as lesions in these diseases. The fifth nerve supplies the external auditory canal by its auriculo-temporal branches, the upper one of which sends a branch to the tympanum. Also the vidian of the fifth sends nasal branches to the membranes of the end of the Eustachian tube. The internal throat treatment, given to affect this tube, does so by stimulating these fibres, thus freeing the secretions in this portion of the Eustachian tube. Reasoning by analogy, doubtless the secretory, trophic, and vaso-motor functions of the fifth nerve with relation to the eye and other parts of the head and face are extended to the ear, secretion of cerumen and cir- culation about the ear being to some extent under control of the fifth. Experience connects lesions of this nerve with ear-dis- eases. It has been shown that the nerve suffers from lesion of the upper cervical region, such as occur in ear-troubles (see Dis- eases of the Eye). The treatment of this nerve, so important in nasal catarrh and other inflammatory affections of the eye, nose, and parts of the head, is important likewise in these catarrhal, inflammatory, and other circulatory troubles, so commonly com- plicated with the diseases of the ear. Vaso-constrictor fibers for the ear are contained in the cer- vical sympathetic. They constitute another pathway for the effect of cervical lesion to reach the ear. Likewise the atlas and axis lesion may affect the blood-supply of the ear through the iiH'd'ulla, \vhich suffers from these lesions. It is possible that vaso-motors for the head exist in the upper dorsal nerves, though 342 PRACTICE OF OSTEOPATHY. upper dorsal lesion is rare in ear trouble. It is likely that much of the effect of cervical lesion upon the ears is gotten through the vaso-motors and other sympathetics. The pneumogastric nerve has an auricular branch, and is in close connection with the fifth in relation to the ear, as well as with the cervical sympathetic. The petrosal ganglion of the glosso-pharyngeal is related to upper cervical lesion by sending a branch to the superior cervical ganglion. Its tympanic branch passes from this ganglion and contributes fibers to the mucous lining of the middle ear, and to the mastoid cells. It sends branches to unite with the sympathetic and form a plexus on the carotid artery in the carotid canal. Thus is this nerve connected both with neck lesions and with the blood-supply to the ear. The facial nerve, well known to be influenced by lesions of the atlas and axis, as seen in facial paralysis, has direct communica- tion with the auditory nerve and with the auricular branch of the pneumogastric. The various simple methods described in the texts on this subject will aid one to determine the location of the trouble in the external, middle, or internal ear. The disease may be seated in the auditory nerve or in the brain, in such case being as di- rectly connected with cervical lesion, before shown to affect the brain and cranial nerves. Examination of the ear is given in detail in Part I. TREATMENT: An ear syringe may be used in the ordinary ways to cleanse the ear of secretions, discharges, foreign objects, insects, etc. Care must be used with the syringe. It should have an olivary tip to prevent introducing it so far as to touch the drum. If a piston syringe be employed, care must be taken not to press the piston in too quickly, as it may inject the fluid with sufficient force to injure or perforate the drum. It is best to use an ordinary fountain syringe, with an appropriate tip. and hung up not more than a foot or eighteen inches above the level of the patient's head, in order to have a gentle flow. For antisepsis, to insure cleanliness when there are discharges from the ear, one may use a warm solution of boracic acid, sat- urated, or containing from one to two teaspoonfulls of the powder to a pint of water. PRACTICE OF OSTEOPATHY. 343 When there is a firm plug of cerumen in the canal, it is well to first soften it by dropping a few drops of sweet oil into the canal, and allowing it to remain over night after having plugged the meatus with a little absorbent cotton. After the softening process, a good deal of the wax may be carefully removed with a spatula, but it is not always advisable to attempt to remove it all in this way, as the canal may be sensitive or the drum may be irritated. The remnants may always be safely and easily re- moved by gentle syringing. Considerable water may be used if necessary. When insects get into the ear they should be first drowned with a little water or sweet-oil, then removed by syringing. The removal of bony lesion and the cervical treatment as before described are the main osteopathic treatments applied in ear diseases. The presence of the original cause of these dis- eases in the form of neck lesion necessitates practically the whole treatment being cervical. There is no local ear treatment, ex- cept as in common methods in vogue in use of syringe, etc. Outside of removal of lesion, an almost specific treatment for eye and ear is that of opening the mouth against resistance (Chap. IV, Div. I, II, VII), and the neck treatment, with the object of increasing circulation through the carotid arteries. Due attention is given to the cervical sympathetics and vaso- motors in this connection. A valuable local treatment of the ear in cases where the drum, or local circulation, or normal secretions, etc., are affected, is as follows: The tragus is pressed rather firmly into the external meatus, and then quickly released, the operation being repeated about once per second. Or the finger may be moistened and introduced into the meatus, being worked in and out like a piston". These treatments create a local suction and pressure which stimulates circulation and all the local tissues, stretches and massages the drum, and helps to soften and relax it in cases of retraction due to catarrhal processes, etc. In cases of retraction of the drum it is sometimes helpful to frequently introduce a little sweet oil- into the canal to aid in softening it. Such treatments also aid in loosening the ossicles in catarrhal deafness, thus rendering 344 PRACTICE OF OSTEOPATHY. them more susceptible to vibrations of sound. These treatments will materially aid in improving the hearing in some cases. A similar effect is gotten, also, by inflating the ear drum in the familar manner of holding nostrils and mouth closed and blowing. This should be judiciously practiced by the patient in all cases of retraction of the drum in catarrhal deafness, in order to keep the drum and ossicles relaxed and able to vibrate, but this must not be done to excess for fear of eventually leading to hyper- trophy of the drum. A few inflations, once or twice per day, are enough. The drum may also be inflated by the practitioner, who spreads a clean handkerchief over the ear and applies his lips close over the meatus and blows. It is probable that by these means, and more especially by the latter, subluxations of the ossicles may be reduced, restoring or aiding the hearing. There are on record some cases in which a few such inflations have greatly increased the power of hearing, probably because thereby luxated ossicles have been articulated. The throbbing, buzzing or humming sounds that occur in the ear with catarrha"! affections, etc., can sometimes be stopped by use of the above measures. Perforations of the drum generally readily heal up, as do incisions by the knife, but not always. These perforations may not be in* the drum proper, but at the notch of Rivinius, which is covered with skin and will quickly heal. The internal throat treatment may be used, the finger be- ing directed about the opening of the Eustachian tube to stim- ulate the local points of the fifth nerve, the mucous membranes, and thus the secretions. This aids in freeing the tube, an ob- ject that is well accomplished by the aid of the external throat treatment upon the carotids, etc. In catarrhal affections of the ear the treatment is as described for nasal catarrh. In earache the treatment embraces the repair of lesion, inhibition of the upper cervical nerves, and inhibition about the mastoid process, below the ear, in front of the ear, etc. PRACTICE OF OSTEOPATHY. 345 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. GOITRE; EXOPHTHALMIC GOITRE. CASES: (1) In a lady of twenty-five, a bilateral, vascular goitre of about three months standing, growing rapidly, causing con- siderable dyspnea and discomfort. The treatment consisted merely of stretching the muscles and ligaments attached to the sternal end of the clavicle, raising it, and depressing the first rib. Marked improvement followed the treatment at once. Two months later the enlargement and .other symptoms had disap- peared. (2) Exophthalmic goitre and nervous prostration of one months standing. The trouble followed nervous strain and over- work. The goitre was as large as a hen's egg, and the usual symptoms of exophthalmic goitre were present. The case yielded rapidly to treatment and at the end of two weeks the goitre had disappeared and the eyes were normal. In one month the patient had recovered from the goitre and nervous prostration, and had gained twenty pounds in weight. (3) In a boy of fourteen, a goitre of two years standing. Lesion existed as lowering of the right clavicle and muscular contracture in the lower cervical and upper dorsal region. One treatment a week for twelve weeks cured the case. (4) A case of goitre treated by raising the clavicles, relax- ing the tissues surrounding the gland. After one month there was a perceptible change, after two months the growth had begun to get smaller and after three months the condition was cured. (5) In a lady of thirty-four, a large exophthalmic goitre with all the usual symptoms marked. The' general system was in bad condition. Lesion was luxation of the fourth cervical vertebra; the spine was irregular. The case was cured in six months. (6) In a lady, a goitre of one years standing. No bony lesions were found. After one months treatment the diameter of the neck had been decreased one and one-half inches. (7) Exophthalmic goitre of eight months standing in a woman of 26. Lesions were: 3rd and 4th cervical vertebrae posterior, 7th cervical lateral to the left; 3rd, 4th and 5th dorsal 346 PRACTICE OF OSTEOPATHY. posterior; subluxation of 4th rib on the left side. Benefit was noted after the 2nd treatment, and the case was cured in four months. (8) Dr. Still mentions a case of vassular goitre in which he raised the clavicles and caused the goitre to entirely drain away in 45 minutes. DEFINITION: Goitre is denned as "chronic hypertrophy or hyperplasia of a portion or the whole of the thyroid gland. It is of obscure origin, involving one or more of the structural tissues, and is subject to various degenerative changes." The so-called simple goitre is met in various forms: simple hypertrophic, follicular, fibrous, vascular, cystic, degenerative, etc. The}- are frequently met and treated osteopathically. Exophthalmic goitre (Graves' or Basedow's disease) is quite a different condition. It is defined as, "a chronic neurasthenic neurosis characterized by rapid heart-beat, enlarged thyroid. protrusion of the eye-balls, and various neurasthenic or vas<>- motor symptoms." Osteopathy simply regards goitre as an enlargement of the thyroid gland due to a specific, usually bony, lesion which interferes with the proper blood and lymph circulation of that body. This leads to congestion, engorgement, and hypertrophy. In some cases, especially in exophthalmic goitre, the lesion may act chiefly upon the innervation of the gland, producing the various phenomena marking the disease. The LESIONS bear, in conformity with the above view, a close anatomical relation to the disease. They are generally bony lesions of the cervical and upper thoracic regions, consist-' ing in displacements of middle and lower cervical vertebrae, of the clavicle, or of the first rib. Yet various muscular, and other tissue, contractures are often found as the lesions in the case. These commonly occur together with bony lesion, but may be independent of such. They occur mostly in the anterior region of the neck, involving the infra-hyoid muscles and the soft tissues down to the root of the neck. The scaleni muscles are often in- volved. The posterior cervical and upper dorsal muscles are sometimes found contractured and acting as lesion. The chief bony lesions in simple goitre are of the clavicle PRACTICE OF OSTEOPATHY'. 347 and first rib, while in exophthalmic goitre lesions of the cervical vertebrae are more frequent. Dr. Still points out that in goitre the heads of the first ribs will often be found to be displaced up- ward and outward, away from the spinal column. Yet either form of lesion may occur in either case. The clavicle and rib lesion, and the contracturing of the anterior cervical tissues act specifically by obstructing arterial, venous, and lymphatic cur- rents to and from the gland. The inferior thyroid artery arises from the thyroid axis, which, lying behind the clavicle and scalenus anticus muscle may suffer pressure from them when abnormal in position. The superior thyroid artery is related to the infra-hyoid muscles, and may suffer from their contracture. But the interferences of these lesions with the lymphatic and venous drainage of the gland are doubtless most potent in causing goitre. The lymphatics of the gland are large and numerous, emptying upon the right into the lymphatic duct, upon the left into the thoracic duct, both avenues of lymphatic drainage, therefore, lying where derangement of clavicle or of first rib may obstruct them. Just as clavicular and first rib lesion has been known to obstruct lymphatic drainage of the breast and result in so-called cancer, the same kind of lesion may prevent lymphatic drainage and cause goitrous enlargement of the thyroid. In a like manner the venous return becomes abridged. The superior and middle thyroid veins are in relation to the in- ferior hyoid muscles, and suffer pressure from their contracture. They both empty into the internal jugular vein which may be obstructed by clavicular lesion. The chief venous flow is through the three or four large inferior thyroid veins, and it may be im- pinged by clavicular and anterior cervical lesion. This view of lesion is well supported by the fact that simple goitres often rapidly disappear, after treatment restoring clavicle and first rib to position, relaxing anterior cervical tissues, and re-estab- lishing perfect circulation of all fluids to and from the thyroid. This has been observed in some cases, probably of vascular goitre, by Dr. Still, in which the facts strikingly illustrate the correctness of the osteopathic etiology. In these cases he saw, in a few r hours, a great reduction in the volume of the gland follow removal of 348 PRACTICE OF OSTEOPATHY. such obstructions to the vessels. The glands seemed to have been rapidly emptied and the goitre drained away by the re- newed drainage. The nerve-supply of the thyroid gland is from the middle and inferior cervical ganglia of the sympathetic. Consequently various vertebral lesions are found, especially in exophthalmic goitre. Such lesions have been found from the 2nd to the 7th cervical vertebra. In discussing diseases of the eye and of the heart, the connections of the cervical sympathetic mechanism with both of these organs has been pointed out. The lesions oc- curring thus to the innervation of the thyroid, cervical lesions, are likewise closely related anatomically to the innervation of eye and heart, accounting in part for the related disturbance of these organs in exophthalmic goitre. This disease has been regarded by medical writers as due to disturbed innervation of the gland, or to an affection of the sympathetic nerves. It has been sometimes thought that the seat of the disease is in the medulla, and that the disturbance of the thyroid function causes the gland to throw into the blood substances that irritate the nerves and cause the various neuras- thenic symptoms accompanying the condition. It is readily seen that cervical lesion may disturb the innervation of the organ, set up the sympathetic disturbance, and derange the function of the thyroid. This disturbance of the sympathetic innervation is further evident in the vascular condition of the gland, its arteries being dilated, and in the paralysis of the orbital vessels, whicll become distended with blood and cause the exophthalmos. Dana explains all symptoms upon the theory of vaso-motor and cardio-motor paresis, a result that may readily be due to the operation of cervical lesion upon the sympathetic. The PROGNOSIS is good in all cases. It is to be noted that according to Anders the prognosis in goitre (simple) is but guard- edly favorable as to life, but unfavorable as to cure, while but few cases of exophthalmic goitre are expected to be cured. Yet under osteopathic treatment very numerous cases of both kinds have been cured. A cure is often effected, even in long standing cases which have tried all the known remedies. The prognosis is most favorable in younger and shorter PRACTICE OF OSTEOPATHY. 349 cases, and in those in which the gland is soft. Under treatment, signs of softening in a part of the gland are indications of pro- gress. In the vascular and parenchymatous forms the progress is good. The former promise the most for quick results. In the hard, fibrous forms, and in those in which degeneration of the tissues, or calcareous infiltration has taken place, the prognosis is not favorable. Some cases of goitre yield quickly; some are very slow. From one to three months treatment, or much longer, is usually necessary. The TREATMENT looks at once to the removal of lesion, and to the free opening of lymphatic and venous drainage. All the cervical muscles must be relaxed. This direction applies to the deep anterior cervical and the hyoid muscles, as well as to the tissues about the gland. Pressure is made downward over the goitre, out about its edges, and along the course of the veins draining it. All the tissues about the root of the neck anteriorly, and about clavicles and first ribs, must be relaxed. The ribs and clavicles should be separated, elevating the latter and depressing the former. Close attention should be given to all the cervical verte- bral articulations, seeing that they are perfectly adjusted. In exophthalmic goitre one must look particularly to the cervical sympathetics, toning them to overcome the vaso-motor paresis. Inhibitory cardiac and local eye treatment may be applied as before directed. A moderate pressure of the eye-ball back into its orbit -aids in emptying the blood from the distended vessels. For a similar reason pressure upon the gland, in ex- ophthalmic and in vascular forms of goitre, is good measure. In the former kind one should look well to the constitutional condit- ion and to that of the general nervous system. ANEMIA. DEFINITION: A condition in which there is a diminution either in the quantity of blood or in one of its constituents. The Anemias are divided into: I. Primary (simple, chloro- tic, and pernicious) ; II. Secondary (symptomatic) ; III. Leu- cocytosis; IV. Leucocythemia. PRACTICE OF OSTEOPATHY. The lesions noted in anemia are merely of the general spinal form. Cases of primary and secondary anemia come, with fair frequency, under our treatment. They are almost without ex- ception successfully treated. The TREATMENT in all the anemias is practically the same, varying in different cases according to the manifestations and needs of the case. In all forms the general plan of treatment is to remove such lesions as may be found present and to give special attention to the renovation of the general health by thorough general spinal treatments, designed to increase heart- action, tone the circulation, increase nutrition, and thus to im- prove the quality of the blood. In SIMPLE OR BENIGN ANEMIA (Primary), the treatment embraces removal of lesion and the thorough general treatment above described. Special treatment should be given the spleen. The liver, kidneys, skin and bowels should be kept active. In this way the quality of the blood is improved, and nutrition of the tissues is increased. The heart should be kept well stimulated in order to over- come palpitation. This treatment also aids in overcoming the dyspnea, which should be further treated by lower costal treat- ment to stimulate the diaphragm and by raising the ribs and stimulating the lung area of the spine (2nd to 7th dorsal) . Head- a,che should be treated in the usual way. It is quite necessary to look after the hygienic conditions under which the patient lives. Diet, drink, and manner of life need attention. In CHLOROSIS or "green sickness" one must follow the general plan of treatment outlined above. This condition is character- ized especially by a deficiency of hemoglobin in the red corpuscles, and iron is the specific drug remedy employed. There is a ques- tion whether the iron thus administered is absorbed by the blood. The osteopathic idea is to normalize the organic functions of the body and to build good blood by increasing glandular activity in the body. This excretes impurities and enables the blood to secure from the food the elements, especially iron, that are lack- ing in it. The heart must be kept well stimulated, as the cardiac mus- cle is often softened, and the organ may be dilated. Special PRACTICE OF OSTEOPATHY. 351 attention must be given to disorders of menstruation. The dis- ease often dates from a period of scanty menstruation, and while amenorrhoea is said not to be a cause of the condition, it is quite necessary to overcome it, if present, in the process of restoring health. The treatment must also be directed to a regulation of the bowels, as toxemia due to the absorption of poison from retained fecal matter has much to do in causing chlorosis, it is held by some. Attention should be given to hygienic conditions. Pure air, plenty of nutritious food, good sleep, etc., are necessary. Moderate exercise and hot baths are recommended. Nervous, circulatory, gastro-intestinal, and general symp- toms may be met according to the needs of the case. PROGRESSIVE PERNICIOUS ANEMIA requires much care in treatment, as it is considered a dangerous condition. However, under osteopathic treatment it seems to be readily cured. A thorough general spinal, muscular and abdominal treatment is necessary to overcome the anemic condition of most of the or- gans and tissues. The general treatment above described should be assiduously applied. In the course of it heart, liver, kidneys, and gastro-intestinal tract should be well treated, as they show a tendency to fatty degeneration. Increase of general circulation overcomes the tendency to ecchymosis in skin and mucous mem- branes. Particular attention must be given to the spinal treatment, spinal circulation should be kept active to guard against sclerosis of the posterior and lateral colums of the cord, to which are due the various paralytic symptoms which are likely to occur. SECONDARY ANEMIAS are purely symptomatic. They in- dicate some disease or abnormal process in the body, and may at the same time be complicated with one of the primary anemias. They occur; (1) after hemorrhage, as from bursting of an aneurysm epistaxis, piles, menorrhagia, etc. ; (2) in inanition, as from esoph- ageal carcinoma, chronic gastritis, etc.; (3) from excessive a I hum in ions discharges, as in B right's disease, lactation, exten- sive suppuration, dysentery, etc.; (4) from the action of toxic agents, as in poisoning from lead, mercury, arsenic, phosphorus, or in acute or chronic infectious diseases. 352 PRACTICE OF OSTEOPATHY. The prognosis depends upon that for the primary condition. The TREATMENT must be according to the cause. After hemorrhage, rest and nutritious diet are required. The primary disease in each case must be treated. Hygienic treatment, plenty of fresh air, good food, sunshine, rest, and later, light exercise, necessary. In toxic cases the excretories must be kept stimu- lated to eliminate the poisons from the system. LEUCOCYTOSIS is "a temporary increase in the number of polymorphoneuclear leucocytes in the blood, though rarely in the mononeuclear elements." It may be continuous. It is often a physiologic condition, as soon after birth, during pregnancy, after meals, after exercise, after massage and baths, etc. It is frequently a pathologic condition, being secondary to disease, as acute inflammations and acute infectious febrile dis- eases. Being reparative and protective in nature, a natural pro- cess, it calls for no treatment. Treatment should be directed to the primary disease. LEUCOCYTHE.MIA, or leukemia, is a blood disease in which there is marked and persistent increase of the number of leu- cocytes in the blood. It is said to be due to lesion to the spleen, bone-marrow, and lymphatic glands. The spleen and lymphatic glands are enlarged. The prognosis is not favorable. The TREATMENT should be upon the general lines before laid down. The gastro-intestinal symptoms; shortness of breath; edema of ankles, face and hands, etc., occur as in the anemias. Treatment should include the liver, which is found to be enlarged, and the kidneys should be kept stimulated, as the leucocytes collect in them, as in the liver. MYXEDEMA. This is a condition in which there is a peculiar disorder rf the general nutrition of the system, due to atrophy and loss of function of the thyroid gland. There is a myxomatous change of the sub-cutaneous tissues, and a cretinoid cachexia. PRACTICE OF OSTEOPATHY. 353 The condition appears as, (1) True Myxedema, (2) Spo- radic Cretinism, or (3) Operative Myxedema. But few cases have been treated Osteopathically. Re- sults are not satisfactory. McConnell states that serious lesions of the cervical vertebrae have been found in these cases. The TREATMENT must necessarily be a general one to in- crease general nutrition, and to thus aid in overcoming the con- dition of malnutrition of the system. The disease is regarded as being of tropho-neurotic origin. It is supposed that the in- ternal secretion of the active thyroid gland aids in maintaining the normal metabolism of the body, consequently it is of great importance in these cases to remove lesion to the gland, restore nerve and blood-supply to it, arid thus regenerate its activities. In case of congenital absence or removal of the gland it is obvious that nothing could be done except to maintain the gen- eral health by the treatment, and overcome in that way, if pos- sible, the effects of the lack of thyroidin. It seems that in these cases thyroid feeding, a treatment regarded as specific, would be necessary. In case of atrophy of the gland an attempt should be made to upbuild it by local work on circulation and nerve-supply. Cervical treatment should be added, to increase circulation to the brain, and the kidneys should be kept active to overcome the tendency for sugar and albumin to appear in the urine. The local treatment should be upon and about the gland, coupled with a cervical and upper thoracic treatment, as de- scribed for goitre, q. v. CONSTITUTIONAL DISEASES. RHEUMATISM. CASES: (1) *Inflammatory rheumatism, off and on, for sixteen years. The effect was general, but the body below the waist was worse, hip and lower limbs being very bad. Le- sion occurred at the 4th lumbar vertebra. The inflammation began to subside with the first treatment. The patient, con- fined to the bed, was able to sit up in one week, and was cured. *-For convenience Acute Rheumatic Fever is considered here instead of with the Infectious Diseases. 23 354 PRACTICE OF OSTEOPATHY. (2) Muscular rheumatism, in the form of torticollis, follow- ing malarial fever. The condition was of one months standing. It improved from the first treatment, and was cured in three weeks. (3) Muscular rheumatism in the shoulder, the patient hav- ing been unable to raise her hand to her head for seven months. The first rib was found partly dislocated at its head. The arm could be raised to the head after one treatment, and the case was cured in one month. (4) Acute articular rheumatism in a lady of eighty-three, of three months standing. Lesions occurred in the upper dorsal and lumbar regions of the spine. The hips and khees were af- fected. One months treatment had greatly improved the case. (5) Articular rheumatism affecting the foot, of six years standing, and due to an upward dislocation of the tarsal end of the first metatarsal bone. The case was cured by reducing the dislocation. (6) Chronic rheumatism of eight months standing. The patient was unable to raise his hand to his head or to dress him- self. After one treatment he could do both, and the case was practically cured by four treatments. Lesions were found at the third cervical vertebra, 1st to 4th dorsal, and 4th lumbar. (7) Lumbago, in occasional attacks, one of which had been brought on by bicycling. Lesion was found in a lateral luxa- tion of the 4th lumbar vertebra. The case was relieved by one treatment, and was cured in three treatments. (8) Lumbago, brought on by a muscular strain, showed lesions at the lumbo-sacral and sacro-iliac articulations. The ease was cured in a few treatments. LESIONS: In the three forms, Acute Articular Rheuma- tism, or Rheumatic Fever, or Inflammatory RehumatismjChronic, or Chronic Articular Rheumatism; and Muscular Rheumatism, various bony and muscular lesions are found. In rheumatic fever special bony lesions may be lacking. Often spinal le- sions affecting liver and kidneys are found, and muscular contractures may be present' as lesion. Bony lesions are apt to occur at the origin of the nerves supplying the affected points. Contractured tissues due to climatic effects are common. PRACTICE OF OSTEOPATHY. In practically all forms of rheumatism, lithsemia, uric acid, gout, and the allied conditions, the real foundation of the trouble lies in lesions which interfere with metabolism. The commonest of these are found in the splanchnic area of the spine, interfering chiefly with the functions of the digestive tract and of the liver. Probably the great majority of these cases originate in this way.' Often some other particular lesion determines the point at which the disease makes its chief at- tack. In Muscular and Chronic Rheumatism specific lesion is much more definite than in Rheumatic Fever. Local bony le- sions play an important part in the production of muscular rheu- matism, as do also muscular contractures. Both may be due to physical strains. Contractures may likewise be due to ex- posure to inclement weather, etc. It is common in muscular rheumatism of shoulders and arms to find luxation of the lower cervical and upper dorsal vertebrae, one or several, together with contractures in the fibres of the trapezius muscles in these regions. So in rheumatism of special muscle groups, bony lesion is quite generally found at the origin of the nerves supplying them. This is equally true for chronic articular rheumatism. For example, in those very numerous cases in which the joints of- the lower limbs are affected, it is almost the rule to find lumbar or innominate lesions obstruct- ing the nerve-supply to the limbs. In rheumatic affections .of special localities as, for ex- ample, the wrist, ankle, etc., it is common to find a local bony part out of place, as carpal, tarsal, or metatarsal bone. In lum- bago there is almost invariably luxation of lumbar vertebrae, irritating the nerve-fibres supplying the muscle-bundles of the erectors spinae. The contracturing of tissues as the result of chronic rheu- matism is often sufficient to draw a joint out of place, as in case of the hip- joint. Lesions in rheumatism act by deranging blood and nerve- supply, locally or generally. In inflammatory rheumatism the effect is a constitutional one, acting upon the system through lesions which derange the functions of liver and kidneys; also 356 PRACTICE OF OSTEOPATHY. of the central nervous system. Yet this condition is often a good deal like "catching cold," and presents, therefore, no con- stant lesion. In the other forms of rheumatism, such as Rheumatic Tor- ticollis, affecting the sterno-mastoid and other muscles; Lum- bago, affecting the lumbo-dorsal fascia, erectors spinse and smaller lumbar muscles; Cephalodynia, attacking the occipito- frontalis and temporal muscles, and the galea capitis; Dorso- dyiiia, of the muscles of the upper part of the back and shoulders; and Pleurodynia, of the nbro-muscular structures of the chest, local derangement of nerve and blood-supply is the result of the lesion. This lesion may be present at the exact locality of the effect, or in the course or at the origin of the nerves supplying the part. In the case of muscular rheumatism particularly, the fact that the pathology in indefinite, that no structural changes occur in the muscles, and that many authors regard it as neuralgia, well supports the osteopathic theory that it is due to bony or muscular lesions irritating the nerve-supply of the muscles affected. This effect is especially well shown in that form of muscular rheumatism known as Lumbago, in which ver- tebral lesion, irritating the local nerve-fibres, is regarded as the cause, osteopathically, As a matter of fact, one meets numer- ous cases diagnosed as either rheumatism or neuralgia, or to which these terms are applied interchangeably. From an osteo- pathic point of view it makes but little difference which view of the case is taken. The essential fact is lesion irritating nerve- supply, its removal being the necessary therapeutic measure. The PROGNOSIS, in all forms of rheumatism, is good. Even the so-called incurable chronic rheumatism is often cured. The prognosis is especially good in inflammatory and muscular rheu- matism. In such cases one expects to give relief at one treat- ment. Quick cures are often made in them. In chronic cases the progress is slow because of the deformity, the deposit in the joint, and the thickening of the local tissues. Many of these cases are incurable but may be benefited. Up to a certain point the deposits may be absorbed, the deformity overcome, and the joint be put in good condition. It is the rule, however, that the enlargement or deformity of the joint cannot be much relieved, PRACTICE OF OSTEOPATHY. 357 though the progress of the disease may be stayed. The TREATMENT of these cases must be persistent, but not severe. In inflammatory rheumatism the extreme pain, which cannot tolerate the slightest jarring of the floor, or movement of the bed-clothes, must be considered. Yet it does not prevent treatment of the case. Delicacy of manipulation enables one to soon overcome the patient's fear and to manipulate the joints at will. The beneficial effect of this treatment becomes at once apparent in reduction of the pain and inflammation. Cases should not be treated too often or too long at a time. In these cases, especially in rheumatic fever, special at- tention must be given to stimulating the activities of kidneys, liver, digestive system, and skin, to remove poisons from the system and to improve the condition of the blood. Often the treatment is at first confined to these parts, so important is it to gain control of their functions. A general spinal treatment is necessary in rheumatic fever, for constitutional effects. A close watch must be kept upon the general health, and lungs and heart must be kept well stimu- lated. Careful stimulation of the heart will prevent the disease reaching that part. It is particularly necessary to provide against the heart being affected. The circulation to the joint, muscle, or part affected must be kept free. This is accomplished by work along its vessels, by removal of bony lesion and muscular contracture, but especially by springing the bones of the joint so as to separate them and allow of free circulation of the blood to the membranes. It is in this way that the deposits are removed and the membranes restored to normal condition. In acute inflammation of a joint, also, its blood-supply must be kept free and itself be lightly manipulated, to take down the inflammation. In muscular rheumatism the muscles, should be stretched and manipulated gently to stimulate the metabolism of the local tissues, aiding them to throw off the poisonous substances sup- posed to collect in them. In any case the nerve-supply of the part must be treated from its origin, and the lesion be removed. 358 PRACTICE OF OSTEOPATHY. In lumbago the affected muscles must .be relaxed, and the lesion be reduced. It is readily affected. The patient may sit upon a stool, while the practitioner stands in front and passes the arm about the body, clasping either side of the spine well down toward the sacrum. He now raises and slightly rotates the trunk, first to one side, then to the other, relaxing the mus- cles, separating the vertebra 1 , and releasing the nerve-fibers from impingement. By these means, in most cases, a subluxated lower dorsal or lumbar vertebra, the most usual cause of the trouble, is set back into place, and the cause is removed. In Inflammatory rheumatism one should look after the hy- giene of the sick chamber. Cold baths and sponging with tepid water are allowable for the fever, but are not usually necessary under the osteopathic treatment. The patient should be be- tween blankets, which absorb the perspiration and prevent chill. The joint should be well protected by being wrapped in some soft, warm material, such as cotton. The diet should be light and nutritious. Chronic cases should be protected from toil, exposure, etc. The treatment for the special forms of rheumatism men- tioned is upon the same lines. GONORRHEAL ARTHRITIS, while not properly regarded as a rheumatism, may yet be considered in the same category of treat- ment. Specific bony lesion is commonly found at the affected joint or at the origin of its nerve-supply, weakening the joint, and laying it liable to invasion by the poison of the disease. Knee and ankle joints are most frequently affected. The PROGNOSIS, while guarded, is favorable for a cure. There is not the destruction of the joint as in chronic articular rheumatism, and to a certain extent the condition is more sure of entire recovery. Yet the progress of the case is apt to be slow, and one must be upon his guard against relapses. The TREATMENT of the joint is practically the same as that described for articular rheumatism, combining with it treatment for the primary disease, looking particularly to the excretion of the poison from the system via bowels, liver, kidneys, and skin. PRACTICE OF OSTEOPATHY. 359 ARTHRITIS DEFORMANS (Rheumatoid Arthritis.) DEFINITION: A chronic disease of the joints, in which destructive and proliferative changes occur in the tissues of the joint. While not a rheumatism, it is regarded osteopathically from much the same point of view as are the various forms of this disease. The lesions found are of the same style as those for articular rheumatism, occurring at the spinal origin, or in the course, of the nerves supplying the affected joints. The small joints of the hands or feet, sometimes the large joints, are affected. Every joint in the body may finally become involved. The PROGNOSIS is fair, but the case will require a long course of treatment. The progress of the disease can be entirely stopped, the function of the joints can be almost entirely restored, and they can be much reduced in size, pain can be stopped, and the general health can be kept good. The deformities that have taken place in the joints cannot be removed. Most satisfactory results have been attained under osteo- pathic treatment. The TREATMENT is practically that outlined for articular rheumatism. It must be persistent in order to repair the marked changes that have taken place in the tissues of the joint. It is of prime importance to increase the suffering nutrition of the joint, and to this end lesion must be removed from blood and nerve-supply, and they must be kept actively stimulated. The bones of the joint should be spread apart as in rheumatism, to enable the blood to circulate freely throughout the joint. A certain amount of local treatment about the joint is necessary to aid this process, as well as to affect the muscles and other ap- pendages of the joint, which are suffering atrophy. Treatment should begin at the spinal origin of the nerves of the part affected. A thorough course of muscular treatment for the limb involved should be carried out. Hygiene and diet should be considered. Plenty of meat and vegetables are allowed. Exposure to wet and cold must be avoided, and bathing is recommended. 360 PRACTICE OF OSTEOPATHY. GOUT (Podagra.) DEFINITION: A constitutional disease, in which there is arthritis of the small joints, and deposits of urates of soda about them. LESIONS, as commonly found, affect the joint locally, its innervation, or the kidneys. One or more such lesions may be present in any case. It is common to find a slight derange- ment of one of the joints of the great toe, or of the part affected. McConnell notes lesion of the astragalus. These cases generally present the characteristic lesions of the kidney areas, weakening the organs, and laying the system liable to an accumulation of urates by means of sedentary habit, overeating, abuse of alco- hol, etc. The PROGNOSIS is good. Immediate relief is given during the attack. The pain is quieted. Recovery will be complete if the treatment is followed long enough. The TREATMENT looks at once to the removal of bony le- sion above described. It is quite necessary to adjust the bones of the joint involved. This may be carefully undertaken even during an acute attack. The intense pain may be relieved by careful manipulation of the joint itself and by opening the cir- culation about it. This takes down the inflammation. In this stage, treatment should begin at the spinal origin of the nerves of the part involved and be carried down the limb to the joint. The limb should receive a general muscular treatment. The joint should be carefully stretched. In case of the great toe, it may be submitted to tension and to slight motion from side to side. In urgent cases hot applications to the affected joint may be made. It may be wrapped in cotton woop and be kept ele- vated during the intervals of treatment. During the acute stage the patient should be kept upon a diet of milk, farinaceous food, and plenty of water. Fever if persent, should be treated as described for fevers. The bowels should be kept well opened. It is necessary to give most thorough treatment to the kidneys to eliminate the urates from the system. The blood- supply to the joint should be kept under treatment to cause ab- sorption of the deposits of urates in and about it. PRACTICE OF OSTEOPATHY. 361 The joint should be well protected from the cold, and the patient should be guarded against exposure, while at the same time the heart, stomach, brain, etc., and the general spinal sys- tem, should be kept well stimulated in order to avoid the grave complication known as retrocedent gout, in which the arthritic symptoms are transferred to an internal organ. The diet of the gouty patient is a matter of considerable importance. It should be restricted in quantity, and should be taken at regular hours. Succulent vegetables (cabbage, salads, string-beans;) farinacea (rice, hominy, etc.); fruits, ex- cept bananas, tomatoes and strawberries; fats, in the form of butter; and stale bread may be used. Meats are to be restricted; oysters, fish, and fowl may be taken. All alcoholic beverages must be refused. Plenty of water and alkaline mineral waters .are good. Bathing and exercise should be regularly employed. LITHEMIA (Irregular gout; American gout) is a condition the pathology of which is much like that of gout, but the joints .are not very much involved. There is an excess of urates in the blood. The kidneys are involved, suffering from lesion, and .are unable to keep the blood free of these poisons The PROGNOSIS is good. The condition yields readily to treatment. Cases may be entirely cured. The TREATMENT is a most thorough and corrective one for the kidneys. They must be kept active in order to free the system of the urates. A general spinal treatment, with atten- tion to bowels, liver, stomach, etc., is necessary to increase the nutrition of the body, and to cause it to take up more of the excess of nutriment. On the other hand, the diet must be strictly limited. A diet of cereals and fruit is particularly good, meat being entirely omitted. Alcohol, tea, coffee, and tobacco are best not taken. Sweets, fats, butter and cheese are hot to be taken. The patient should drink plenty of water. The liver should be kept well treated to avoid hemorrhoids and biliousness. The general spinal and special treatment for nervous and digestive systems aid in keeping the patient free from many annoying symptoms. Further symptomatic treat- ment may be given as necessary. 362 PRACTICE OF OSTEOPATHY. OBESITY. (Polysarcia, Lipomatosis Universalis.) DEFINITION: A condition due to an increase of fat in the tissues of the body, sufficiently great to impair functions, and showing lesion to the lymphatic system, liver, pancreas, etc. CASES: (1) A case of obesity in which there was marked pathological condition of liver and kidneys. Treatment was directed particularly to these organs,and a strict diet was enforced. In ten days the patient began to improve, and at the end of two weeks found that he had lost ten pounds. After one month the treatment was discontinued, as the patient left the city tem- porarily. Returning later he reported a loss of twenty-five pounds and the enjoyment of better health than for a long time, (2) A second case, treated upon the same plan, lost 37 pounds in two months, and the health improved. (3) A case of obesity reduced 23 pounds in five months treatment. Numerous cases have been successfully treated. The LESIONS in these cases are largely spinal vertebral ones affecting the innervation of the lymphatic system, of the liver, and of the pancreas Dr. Still points out spinal lesion to the full length of the thoracic duct, acting through the various spinal sympathetic connections, splanchnics, etc. He mentions es- pecially lesion at the 4th dorsal, which he calls a center for nutri- tion, and at the 7th cervical, opposite which the duct ends. He has called attention to lesion in the upper dorsal region, just below the cervical, giving rise to the growth of a fleshy cushion, a condition of affairs that seems to influence the lymphatic sys- tem and cause a deposition of fat. He also works high in the cervical region, opposite the transverse processes of the vertebrae, for nerves controlling the calibre of the duct. Lesion at the 1st and 2nd ribs, and at the clavicle, are found in some cases. They may cause pressure upon, and obstruction of, the thoracic and right lymphatic ducts where they empty into the innominate veins. Obstructive lesions to the nerves controlling the lymphatics or to the lymphatics directly, prevent the proper flow of the lymphatic fluid containing the saponified and emulsified fat ah- PRACTICE OF OSTEOPATHY. 363 sorbed by the lacteals. Thus the fat is not freely enough poured into the circulation and passed to the lungs to be oxidized, there and in the arterial blood, and as a result the fat is deposited in the tissues of the body. Lack of oxidization of the fats is a well known cause of obesity. Splanchnic spinal lesion is also a factor in such conditions. It acts probably in more than one way. In the first place it may aid in disturbing the nerve-control of the thoracic duct and receptaculum. But it probably also affects the activities of pancreas and liver. Lower rib lesion could do the same thing. *The pancreatic fluid and the bile, chiefly the former, emul- sify and saponify the fats, preparing them for absorption into the lymph capillary of the lacteal, whence they are carried into the thoracic duct, and to the circulation to the lungs for oxidiza- tion. Deficiency of these secretions would thus prevent the proper preparation of the fats for absorption and further elabor- tion. The American Text Book of Physiology states that the bile acids stimulate the epithelial cells to a greater activity in the absorption of fats. As the fats are not properly prepared by the action of the pancreatic and liver secretions, it seems probable that they are absorbed into the circulation directly from the intestine, and, not being in a state for oxidization, are carried through the portal circulation and deposited in the tis- sues. Of course much of the fat is passed from the intestine with the fecal matter. Thus excess of fats and starches in the diet is deposited as adipose tissue. The PROGNOSIS is fair in cases of obesity. If the fat is solid and healthy, and the general health good it is difficult, to reduce the fat except by careful dieting and exercise. But if the fat is soft and flabby, it may be greatly reduced by proper treatment. Many cases have been treated successfully osteopathically. The TREATMENT must be directed to the correction of the lesions described. It is essential to keep normal the functions of liver and pancreas. They should be treated by local abdominal work, and by the removal of lesion. If the cushion of flesh ap- *Phila. Jour. Osteopathy, Nov. '99. p. 6. 364 PRACTICE OF OSTEOPATHY. pears in the upper dorsal region it should be treated by direct manipulation, causing it to be gradually absorbed. All sources of obstruction to the lymphatics and to their irmervation must be removed. The heart should be kept stimulated, on account of its ten- dency to weakness and fatty degeneration. The breathlessness often present should be treated by raising the ribs as in asthma. Kidneys must be kept active, and be stimulated against nephritis, which is apt to come on late in the disease. A thorough general spinal and muscular treatment, includ- ing limbs, abdomen, chest, etc., aids in the oxidization of the fat in the tissues. A course of exercise may be prescribed with the same object. It should not be too severe in patients with weak hearts and vascular systems. Lungs and stomach should be kept treated. The latter is apt to be dilated, and to suffer from gastritis. The lungs are likely to suffer enlargement and fatty infiltration. A strict diet should be enforced in these cases. This is an essential part of the treatment of them. The amount of food should be small. Starches, fats, and sweets are to be excluded. The amount, of water allowed is small, and alcoholic drinks are forbidden. It is well to follow some prescribed dietary such as Oertel's, Ebstein's, or Banting's. Severe exercises must not be prescribed in cases in which heart and vessels are not perfectly sound. RICKETS (Rachitis). DEFINITION: A constitutional disease of children, in which there is marked nutritive change in bones and cartilages, result- ing in defoimities. It is a general nutritive disturbance, and there are no con- stant bony lesions. Improper hygiene and nutrition are the causal factors. Osteopathic treatment has been successful in the handling of these cases. The progress of the disease may be limited, further deformity is prevented, but deformities once confirmed cannot be corrected. Beginning deformities may be corrected. The TREATMENT is mainly such a change in the diet as to PRACTICE OF OSTEOPATHY. 365 supply the elements lacking in the nutrition of the body. In case the babe cannot be properly nourished by the mother's milk, cow's milk diluted is found to be the most satisfactory sub- stitute. Barley water is also recommended. The feeding should not be too frequent nor excessive in amount. Older children are allowed light meats % vegetables and fruit. The hygienic treatment is quite as important. Plenty of fresh air and sunshine, and daily bathing are very helpful. The child should not be allowed to lie much in one position. This should be frequently changed. It should be kept from walking until danger of deformity is past. With this treatment the value of proper osteopathic treat- ment cannot be overestimated. Its effects in increasing gen- eral nutrition of the body are well demonstrated. A thorough, but careful, general spinal treatment should be given. This reaches the general nervous system and affects function through- out the body. It also aids in overcoming the nervous symptoms manifest in the case. The liver, spleen, and kidneys should be treated, as they may be involved. The bowels should be kept free. A general muscular, abdominal and cervical treatment should be added to the general spinal treatment. Impaired nutrition of certain muscles may lead to a semblance of paralysis. These muscles should be well treated to build them up. If the bony parts are yet soft much may be done to restore shape of the parts. A curvature of the spine may be entirely cured. Treatment should be directed to shaping of the parts undergoing deformity. DIABETES MELLITUS AND DIABETES INSIPIDUS. CASES: (1) Diabetes Mellitus in a man of thirty-four. The disease was well established by urinalysis and the charac- teristic symptoms. The patient was a great sufferer from pain in the lower dorsal and lumbar regions, and showed bony lesions at the 12th dorsal, second and fifth lumbar vertebrae. He was discharged cured after months treatment, and has since passed the medical examination for life insurance, being pronounced a good risk. 366 PRACTICE OF OSTEOPATHY. (2) Diabetes Mellitus in a young man of nineteen , who had been given up to die. He was passing nine pints per day of urine of a sp. gr. of 1054. In one week it was reduced to 1048, and four pints per day. He gained strength daily, and was practically cured at the time of report. (3) Diabetes Mellitus in a lady of fifty-six. The patient had lost eighty pounds in six months, and* her symptoms were very marked. The case was expected to die. Lesions were found in the upper cervical vertebrae, also of the 2nd and 3rd dorsal, and lower dorsal and upper lumbar veitebrse. The sp. gr. of the urine was 1043, sugar 4 per cent, and quantity from 10 to 18 pints per diem. Improvement was continuous from the first, and in five months the case was cured. (4) Diabetes Mellitus in a lady of fifty-six. She passed about 200 ounces of urine each day, containing a large percentage of sugar. Lesion: A depression of the right ribs over the region of the liver. The case showed marked improvement under the treatment. In four -months the general symptoms were much improved, and the quantity of sugar was less than half as much as at first. (5) Diabetes Mellitus, in which lesions were found in the lower dorsal and lumbar region. Also in the cervical region and at the atlas. Marked improvement took place under treatment, but the treatment was discontinued before a cure was affected. (6) Diabetes Mellitus showing lesion in the lower dorsal and lumbar regions. The treatment was continued for four months, and the case was completely cured, the patient passing a medical examination for life insurance. (7) Diabetes Mellitus in a man fifty-one years of age. Le- sions was a posterior condition of the spine from the sixth dorsal to the second lumbar vertebra. At the time of report one months treatment had been taken, and improvement was made. (8) Diabetes Mellitus showing lesion in the cervical and lower dorsal regions. The urine contained two per cent of sugar. Complete cure was made. LESIONS causing diabetes are usually bony lesions along the spine from the middle dorsal to the lower lumbar region. McConnell notes the fact that in a number of cases there was PRACTICE OF OSTEOPATHY. H67 a posterior swerve of the spine form the middle dorsal to the upper lumbar region. Sacral lesion has been noted in these cases, some showing a slip of the ilium, some lesion of the fifth lumbar. Cervical lesion, chiefly in the upper cervical region is sometimes found in diabetes mellitus. Sometimes a rib lesion, as in case 4, occurs in the region of the liver or of the splanchnics. Lesions of the dorsal and upper lumbar region involve the in nervation of these organs, derangement of which is thought to be most closely associated with diabetes. Through their effects upon the splanchnics and solar plexus, they derange the func- tions of the liver, pancreas, and intestines, all thought to be im- plicated in this condition. It is well established that pancreatic disease is usually closely associated with diabetes; that a gly- colytic ferment secreted by this gland is necessary to normal metabolism. This being disturbed results in sugar in the urine. Such a result is doubtless affected by such lesions as above, in- terfering with the innervation of the organ by way of the solar and splenic plexuses. It has already been shown how closely are such lesions as- sociated with derangement of the liver innervation, the glyco- genic function of the organ being disturbed in diabetes. It may be that these lesions likewise aid the condition by deranging the activities of the intestinal villi. According to Pavy's view of diabetes, a disturbance in the functions of the cells of the intestinal villi is the essential feature in the causation of diabetes. Lesion to the vaso-motor innervation of the portal vessels, arising from the 5th to 9th dorsal may have something to do with such a disturbance. Lesion to the upper region may aid this effect. The influence of the general nervous system in diabetes is well known, but not well understood. It is shown that lesions to the medulla, cord and sympathetic system cause diabetes. The various spinal and cervical bony lesions doubtless could do the mischief resulting in diabetes, as it has been shown frequently that these lesions may injure cord, medulla, or sympathetic system, as in paralysis, etc. In this connection one sees the importance of upper cervical lesions, which affect the medulla. 368 PRACTICE OF OSTEOPATHY. Here, in the floor of the fourth ventricle, lies the so-called diabetic center. It is a point, puncture at which results in diabetes. The effect is doubtless gotten through the vagi nerves, whose origin is from this point. With regard to this fact, also to the well known participation of the vagi in liver functions, it seems that cervical and spinal lesion, affecting the vagi through their sympathetic cervical connections, or through their connections with the solar plexus, may in this way produce a part of the effect of lesion in diabetes. PROGNOSIS: Although diabetes mellitus is a grave, and, by ordinary methods, an incurable disease, the outcome under osteopathic treatment is usually more encouraging. A fair percentage of cures has been shown, there being no room for doubting the facts in such cases. In accounts of twenty-six cases gathered by Dr. C. W. Proctor, thirteen improved con- tinually under the treatment; seven were entirely cured; others were yet under treatment. It may be well said that in such cases our prognosis for re- covery is fair, and for benefit is good. The TREATMENT ,is mainly, as far as the specific treatment is concerned, upon that portion of the spine most affected with lesion, namely along the splanchnic and lumbar regions. It is of course necessary to remove the lesion as soon as possible. Treatment at the above mentioned regions is particularly for restoring the normal functions of pancreas, liver and small in- testine. As the heart, kidneys, lungs and spleen undergo patholog- ical changes, it is necessary to give special attention to their condition, according to methods before given. The skin and general excretory system must be stimulated to aid in excreting the sugar from the blood. The bowels must be treated for the constipation which is usually present. A thorough general systemic treatment is given for the purpose of affecting the various organs involved in the disease, stimulating and increasing the general nutrition of the body which is much affected, and upbuilding the general nervous system. It is necessary to give close attention to the diet and reg- PRACTICE OF OSTEOPATHY. 369 imen of the patient. Carbohydrates must be excluded from the diet as thoroughly as possible, no sugars nor starches being allowed in any form. Meats, fish, poultry, eggs, and green veg- etables which do not contain starch (string-beans, lettuce, water- cress, spinach, young onions, tomatoes, olives, celery) are allowed. So, likewise, are milk, cream, butter, and cheese. The patient should drink plenty of water, especially such alkaline mineral waters as Vichy, Carlsbad, etc. He should take light exercise, but should avoid fatigue, particularly inimical to his weakened condition. For the same reason, while warm and steam baths are recommended, they should not be prolonged for fear of a weakening effect. In DIABETES INSIPIDUS the lesions are usually found in the lower splanchnic area, affecting the kidneys. Some cases show lesion of the superior cervical vertebrae. In the latter case the effect may be upon the medulla, or upon the sympathetic sys- tem. There is a point in the floor of the fourth ventricle, punc- ture at which causes diabetes insipidus. These various bony lesions may cause it by affecting the cord, since it is known that injuries to the cerebro-spinal axis result in the disease. Anders regards the condition as a vaso- motor neurosis, usually of central, sometimes of reflex origin. It is also thought to be due to a vaso-motor relaxation of the kid- neys. It is readily seen that spinal lesion to the renal splanchnic could result in this vaso-motor neurosis and give rise to the dis- ease. The PROGNOSIS is good under osteopathic treatment, al- though the condition is regarded as incurable. A fair number of cases are cured. The TREATMENT is mainly local for the kidneys, by removal of lesion at the splanchnic areas arid by the various special ways of affecting the kidneys as pointed out in considering diseases of the kidneys. Some general treatment for the nervous system may be necessary. 370 PRACTICE OF OSTEOPATHY. INFECTIOUS DISEASES. DIPHTHERIA. Numerous cases have been treated successfully by osteo- pathy. The LESIONS usually found in such cases are muscular and bony lesions in the neck. Dr. Still regards the important cause a contraction of the tissues of the throat and neck, includ- ing the scaleni muscles, drawing the first rib backward under the clavicle and thus disturbing its articulation with the first dorsal vertebra. These contractions about the throat interfere \rith the venous circulation through the pharyngeal and internal jugular veins, favoring a congested or eatarrhal condition of the mucous membranes of the throat, and leading to diphtheria. It is well known that catarrhal conditions predispose to the Bony lesions and muscular contractures in the cervical region interfere with the innervation of the muscles and mucous membrane of the throat. The sympathetic innervation is from the superior cervical ganglion. This distribution unites with fibres from the pneuinogastrie. glosso-pharyngeal and external laryngeal nerves, forming the pharvngeal plexus. Hence upper cervical lesion may. by affecting the superior cervical ganglion, derange the sympathetic vaso-motor supply of the pharvngeal mucous membranes and lead to the dise.-i- The PROGNOSIS is good. The case is usually readily cured. In the TRRATMKNT the main idea is to keep open the circu- lation to the throat and to thus prevent the formation of the membrane, or to prevent its further growth. A thorough re- laxation of the muscles and anterior tissues of the neck must be maintained. The tissues at the root of the neck, and about the clavicle and first rib must also l>e kept free and loose. The clavicle should be raised. The first rib should be pressed down- ward and forward, working at its central articulation to correct the position of its head. By the process of these treatments the venous and lymphatic drainage from about the throat is open. This regulates the vaso-motor disturbance of the mem- branes, tends to loosen the membranes already formed, and. by PRACTICE OF OSTEOPATHY. 371 preventing further exudation, stops the further growth of the membrane. The splanchnics, liver, kidneys and bowels should be treated twice daily, to keep free the excretion of poison from the system, and to aid nutrition, to keep up the strength of the system. Cervical bony lesion should be removed, and treatment should be given to the vagi, superior cervical ganglion, and cer- vical sympathetic^, to correct circulation and aid in gaining vaso-motor control. The internal throat treatment should be given to aid in gaining the same end. Proper precautions should be taken to protect the finger so that the child may not wound it with his teeth. The finger is inserted and swept down over soft and hard palate, fauces and tonsils, to relieve the local inflammation by starting the circulation. In laryngeal diphtheria an external treatment about the larynx and down along the trachea is good. (Chap. III. A. V.) Laryngeal intubation should be done in case of threatened suf- focation. A general systemic treatment should be carefully given to build up the strength. The heart and lungs should be care- fully stimulated to avoid complications in them. The case should be carefully looked after for some time, to strengthen the heart and to overcome the weakness of the throat. The general treatment aids in preventing paralysis, par- ticularly apt to occur about the throat, sometimes in other parts of the body. The patient should be isolated and the usual antiseptic precautions should be practiced. The patient should be kept upon a liquid diet. Milk, ice cream, broths, and the like are used. CROUP. (Spasmodic Croup, Catarrhal Croup, or Laryngi.smus Strid- utafl.) Jn.ii \rno.N : This is a disease peculiar to children and h-ld to be chiefly of nervous origin, but it is often a.--o<-iat<-d with acute catarrhal laryngitis. It is associated with paroxys- 372 PRACTICE OF OSTEOPATHY. mal coughing, difficulty of breathing, and attacks of threatened suffocation. Numerous cases have been successfully treated by osteo- pathy. The LESIONS of greatest importance in croup involve con- tracturing of the muscles and tissues of the throat, irritating the pneumogastric nerves, and their recurrent and superior laryngeal branches. These contractures likewise prevent proper circu- lation to and from the larynx, and favor the catarrhal condition in this way. The irritation of the pneumogastrics and their branches is accountable for the spasmodic condition of the larynx during the paroxysms. Dr. Still regards as important sacral and lower spinal bony lesions in croup. He a,lso finds a contracture of the omohyoid muscle, drawing the hybid bone down and back upon the superior laryngeal nerve, irritating it, and causing the spasm. In croup, as in other throat diseases, he finds that the contracture of the cervical tissues and scaleni muscles draws the first rib back under the clavicle, draws it upward, and deranges its articulation with the first dorsal vertebra. This condition is important in shutting off venous and lymphatic drainage from the larynx, and favors the inflammation of the mucous membrane. Various contractures of the posterior cervical muscles, as well as those bony lesions common in laryngitis, as of atlas, axis, and 3rd cervical vertebra, are sometimes present, acting to dis- turb sympathetic innervation, vagi, and circulation. One, must, however, chiefly regard those contractures and bony lesions about the throat and neck anteriorly. Arising from exposure, cold, etc., they become the chief cause of croup. The PROGNOSIS is good. Immediate relief is given by the treatment. The spasm, stridulous breathing, and threatened suffocation are overcome at once by the treatment during the attack. The chief TREATMENT is to at once relax all the anterior cervical tissues, to free the circulation and to relieve the irrita- tion to the superior and recurrent laryngeal nerves. The treat- ment should begin well up beneath the inferior maxillary bone. being made especially about the hyoid bone and muscles and PRACTICE OF OSTEOPATHY. 373 should be carried down along the throat and trachea. The hyoid bone should be grasped and manipulated laterally, forward, and upward, relaxing the omohyoid and other muscles. (Chap. Ill, A, III, Chap. IV, III.) The process of freeing the circulation is materially aided by working along the course of the carotid arteries and internal jugular veins, raising the clavicle, and relaxing the surrounding tissues. Treatment may be made close along the larynx and trachea. .(Chap. Ill, A. V.) This is helpful during the spasm. Inhibition may be made upon the superior laryngeal nerve by pressure immediately below and behind the greater cornua of the hyoid bone, and upon the recurrent laryngeal at the inner side of the sterno-mastoid muscle at the level of the cricoid car- tilage. This is likewise useful during the spasm. Anders notes the fact that sometimes the epiglottis becomes wedged into the rima glottidis, and must be helped out by the use of the index finger. The spasm may be lessened by manipulation about the region of the diaphragm, relaxing it, and by treatment of the phrenic nerves in the neck. (Chap. Ill, A. VIII.) Due attention must be given to the tissues and bony lesions of the posterior cervical region. All sources of reflex irritation, as intestinal parasites, den- tition, indigestion, etc., must be looked after. The child should not be allowed to over-eat or drink. In spasmodic croup the attack is sometimes relieved by easing an overloaded stomach. Tickling the fauces with the finger will cause the vomiting. Cold applications may be used over the throat and chest. A warm bath is a convenient means to break up a spasm. WHOOPING-COUGH. (PERTUSSIS.) DEFINITION: An acute, highly contagious disease, occurring chiefly in children, and characterized by a catarrhal inflammation of the mucous membrane of the respiratory tract, and by a pecu- liar spasmodic cough ending in a whooping inspiration. 374 PRACTICE OF OSTEOPATHY. Its true nature is not known, but that theory that regards it as a lesion of the phrenic, pneumogastric, sympathetic, or recurrent laryngeal nerve, or perhaps of the medulla, best ac- cords with the osteopathic view of the etiology. The PROGNOSIS is good. The case may be aborted if taken early, but if the disease is well started but little more than allevia- tion can be accomplished. The case is safely carried through, and the danger of complication is minimized. The LESIONS: In whooping-cough, as in croup, the con- traction of the omohyoid muscle, drawing the hyoid bone against the pneumogastric nerve, is important, as is also the contrac- turing of the cervical tissues drawing the first rib back, and dis- turbing its central articulation. Cervical bony lesions are found at the upper, middle, and lower cervical vertebra?, and bony lesions are also found about the first and second dorsal vertebrae, the first rib and clavicle. The upper cervical lesion affects sympathetics and vagi in ways before pointed out. The middle cervical lesion affects phrenics and diaphragm, sometimes important in this condition. The contractures of 'throat tissues, lesion of clavicle and first rib retard venous and lymphatic drainage, and lead to catarrhal conditions, well known to be of much importance in producing the condition. The mucous membranes are thus weakened and laid liable to the action of the specific infection. Lesions of the upper dorsal vertebrae and of the upper two or three ribs may derange the sympathetic connections of the laryngeal innervation. The TREATMENT is much the same as in croup. The prime point is to free the circulation about the larynx and whole re- spiratory tract, as there is a catarrhal condition of the whole tract. This object involves the relaxation of all the anterior cervical tissues, treatment of the hyoid bone, and relaxation of the omo-hyoid, raising the clavicle, etc. All bony lesions of the cervical, upper dorsal, and upper thoracic region must be over- come, together with existing contractures, in order to remove all sources of irritation to the laryngeal innervation. The ways in which these lesions act, and the method of their removal has before been sufficiently explained. PRACTICE OF OSTEOPATHY. 375 For the cough, treatment should be made down along larynx and trachea, and about the angle of the jaw. Dr. Still mentions, also, treatment to the phrenic nerves and diaphragm to relieve the condition. The lungs may be stimulated, and all the upper ribs be raised, to ease respiration. The lungs, heart, kidneys, and gen- eral system must be carefully looked after and thoroughly treated to avoid the complications and sequelae that may arise in the form of broncho-pneumonia, pleurisy, pericarditis, acute nephritis. "Jacob Sobel gives the results of his own experience with the paroxysms of whooping cough treated by pulling the lower jaw downward and forward. Pulling the lower jaw downward and forward controls the paroxysms of whooping cough in most instances and most of the time. The method is usually more successful in older children than in younger ones and infants. In cases without a whoop the expiratory spasm with its asphyxia is generally overcome, and in those with a whoop the later is prevented. It is as successful as any single drug, or even more so. Mothers should be instructed in its use, so that attacks, especially at night, might be arrested. The manipulation is harmless and painless. Its only centra-indication is the presence of food in the mouth or oesophagus. Patients thus treated are less likely to suffer from complications and sequelae than those treated only medicinally. It is advisable to try this method in other spasmodic coughs and laryngeal spasms." (N. Y. Med- ical Record.) It is probable that by drawing the jaw down and forward the suprahyoid muscles pull upon the hyoid bone, stretching all the hyoid muscles, and releasing pressure from off the superior laryngeal nerve, which passes just behind the greater oornu, thus relieving the irritation of the nerve and the consequent spasm in the muscles, especially the crico-thyroid. IXFLUEN7A. (LAGRIPPE EPIDEMIC CATARRHAL FEVER.) CASES: (1) Four cases in one family restored to usual health within a week. (2) Four cases cured in four or five treatments, no bad re- sults following the disease. 376 PRACTICE OF OSTEOPATHY. (3) Lagrippe, attacking the throat and complicated with a severe tonsillitis, was cured by several treatments. (4) A severe attack of lagrippe cured in four days by treat- ment directed to bowels, kidneys, and splanchnic nerves. (5) A list of thirty-five cases, one of which had been cured by one treatment, and the remaining cases cured by several treatments, none requiring over four. (6) A report of a number of cases of lagrippe, all with marked symptoms. In every case the patient was able to be up in from one to three days. No complications nor sequelae arose. (7) A lady of seventy-one had been confined to her bed for two weeks with lagrippe and rheumatism. After seven treat- ments she was about, the lagrippe being cured and the rheuma- tism much improved. (8) A case of lagrippe cured in four treatments. LESIONS: While no specific bony lesion has yet been men- tioned as occurring in Influenza, there is yet a specific condition of lesion doubtless closely associated with the invasion of the disease into the system. This condition is a general contrac- turing of the spinal muscles, most marked in the upper dorsal and cervical regions, but affecting the whole spinal system. This may be regarded as the specific lesion in influenza. Dr. Still regards it as shutting down upon the whole vascular and nerve system of the body, through the constricting effect of these contractures upon the spinal nervous system through its pos- terior distribution. The result is a sluggish condition of all the vital fluids, lymphatic, blood and nerve. While it is doubtless true that the bacillus of Pfeifer is the infecting agent, it yet remains to account for the sudden invasion of the system by this germ, since it is known that the germs of disease cannot attack healthy tissues and that a body in perfect health is immune. In this connection it is significant that debilitated persons fall the easiest victims to the malady. In a majority of such individuals it is doubtless true that various osteopathic lesions already exist and so weaken the system in one way or another as to lay it liable to the invasion of the germ. Just so, the general muscular contracture found as the char- PRACTICE OF OSTEOPATHY. 377 .acteristic lesion in lagrippe, acts upon the vital forces of the sys- tem to debilitate them and lay the body liable to invasion. This theory would appear entirely reasonable in the light of the fact that Pepper thinks it likely that the germ exists everywhere, but depends upon certain extraordinary atmospheric or telluric conditions for occasion to break out into virulence. It is quite reasonable to hold that some special set of circumstances, it may even be these same extraordinary atmospheric conditions, re- :sults in these spinal contractures which, occurring coincidentally with the periods of virulence of the germ, allow of the invasion of the system. Lagrippe is most frequent in bad weather, and it may be that then exposure to cold may set up these contractures. While it is true that the authorities hold the disease to be entirely in- dependent of climate and season, it is yet true that a person may '"catch cold", at any time and place, these contractures being well known to result. It is probable that the presence of various lesions, bony and otherwise, in the body, determines the disease to a special part of the system, resulting in the peculiar manifestation of the disease which distinguishes it as the abdominal type, the cere- bral type, the thoracic type, etc. Probably, too, such lesions are responsible for the various complications and sequelae which constitute so marked a feature of the attack, as affections of lungs, heart and nervous system. The PROGNOSIS under osteopathic treatment is particu- larly good, one or a few treatments being usually all necessary in uncomplicated cases. When the case is taken in time com- plications do not ensue. If present they are usually readily overcome by the treatment. It is a well known fact that the mortality in influenza is due chiefly to its complications, consequently not the least satisfactory result of osteopathic treatment is in overcoming danger of these. The distressing sequelae, especially affecting lungs, nervous system, and eyes and ears, do not occur. The TREATMENT indicated is a thorough general one, as -for a bad cold, including particularly the complete relaxation of all the spinal tissues, thus restoring the equilibrium of the 378 PRACTICE OF OSTEOPATHY. vascular and nervous system. This object accomplished, a long step toward recovery has been taken. During this process occasion is taken to strongly stimulate heart and lungs, regulating circulation, sweeping out congestions, inducing perspiration and lessening fever, and sustaining these organs themselves against the effects the disease is likely to pro- duce in them. This treatment embodies raising the clavicle and ribs, work over the chest anteriorly, stimulation of the vaso- motor and accelerator innervation in the upper dorsal region, etc., all described in considering the diseases of heart and lungs. The liver, kidneys, bowels and fascia are likewise kept well stimulated. It is well, especially in the iheumatoid type, to carry the relaxing treatment over all parts of the body, flexing and rotating the thighs, working about the shoulders, upper limbs, neck. etc. This overcomes the distressing general aching and soreness in the muscles. Careful abdominal treatment is called for, particularly if the disease shows a tendency to settle in that region. Work upon the liver, bowels, solar and hypogastric plexuses, and splanchnics in the usual way will meet these requirements. The general spinal and cervical treatment both aids the general effect and provides against affection of the central nervous system, brain, and organs of special sense. The general health must be carefully guarded, the patient must be kept from exposure, be prevented from going out too soon, and be kept upon a light nutritious diet. This should be largely fluid in case the patient is confined any length of time to his bed. The fe^ffcr, headache, pains in the eye-balls, and other man- ifestations of the disease are treated specially in the usual ways. MALARIA. Malaria is a disease which, although due to the activities of a specific germ, the hematozoon of Leveran, yet presents marked bony lesions, which account for the manifestations of the germ within the system. The LESIONS are mostly in the splanchnic area, disturbing PRACTICE OF OSTEOPATHY. 379 the sympathetic and vaso-motor innervation of liver, spleen and kidneys. McConnell notes lesion as a marked lateral deviation at the 9th and 1th dorsal vertebrae, and a resulting downward luxation of the 10th rib, also lesion of the 9th to llth dorsal ver- tebrse or in the corresponding ribs. Dr. Still points out lesion at the first lumbar, at the sacrum, at the splanchnics, and in the cervical region. These various bony lesions must produce a marked effect upon the sympathetic system, resulting in vaso-motor disturb- ance. The PROGNOSIS is good. Dr. Still says that he never needs to give a patient a second treatment. Usually a few treatments overcome the difficulty, and quick results are often shown. Yet it often happens that but slow progress is made. Complica- tions, however, are prohibited by the treatment. Marked re- lief is at once given during the paroxysm. The TREATMENT is directed particularly to the splanchnic area, and to opening of the abdominal blood-supply. By the splanchnic and abdominal treatment, liver, kidneys, spleen, and bowels are kept in an active state. This is the chief object of the treatment. Treatment is given at any time, during or between the par- oxysms. The specific treatment employed by Dr. Still in cases of malaria is as follows: With the patient sitting facing him, he passes his arms beneath the axillae and grasps the spine with both hands, one on either side of the spinous process, at the fourth dorsal vertebra. He now draws the patient's body to- ward him, though not moving the patient from his position on the chair, thus stretching the spine and bringing pressure upon the 4th vertebra. He closes this manoeuver by twisting or ro- tating the trunk slightly, first to one side and then to the other, all the time continuing the pressure at the vertebra. This simple process is repeated at the 12th dorsal for the renal splanchnic. In this way the splanchnic and renal splanchnics are stimulated. He concludes the treatment by momentarily bringing pres- sure with his thumbs down upon the femoral arteries. The time of this pressure is merely long enough to allow one heart- 380 PRACTICE OF OSTEOPATHY. teat to elapse. His idea is that this momentary damming back of the femoral currents upon the heart causes it to give a sudden strong beat to overcome the resistance, rousing it to activity and stimulating the system. A general spinal, cervical, and stimulative treatment to heart and lungs may be given for the chill. This overcomes the intense vaso-motor constriction of the surface of the body, collateral with an inward congestion, and equalizes the circula- tion. The abdominal treatment aids this process. This general treatment likewise aids in taking down the fever. The more specific treatment may be given as indicated, in the cervical region, upon the chief vaso-motors, and vaso- motor center of the medulla, via the superior cervical ganglion. No specific treatment is called for to allay the sweating, .as this is itself a relief to the patient's condition. The general method of treatment described may be properly applied during this stage or during the intermission. TYPHOID FEVER. CASES: (1) A 'case taken in the usual way" and presenting the usual symptoms. The fever was 103 degrees at 4 p. m., when the osteopath was called. The next morning the fever was below 102 degrees, rising that evening to 103.5 degrees. On the succeeding evening it was again 103.5 degrees, but this was the highest point reached. Thereafter, instead of the temperature remaining about 104 degrees for two w r eeks, as is typical, the gradual decent began immediately and in two weeks the patient was well. As early as five days after treatment began most of the symptoms had disappeared. (2) This case when first seen, had a pulse of 102, a tem- perature of 105 degrees, and all the usual symptoms marked, even delirium being present, and the stools and urine passing involuntarily. He had been ill with the fever for two weeks. Gradual decent of the temperature began immediately upon treatment. It became normal seventeen days after treatment began. The symptoms began to abate with the fever, all but the weakness having disappeared in twelve days. (3) A case seen on the day after it had taken to bed, with PRACTICE OF OSTEOPATHY. 381 a temperature of 101 degrees. In two days the symptoms began to abate. On the fourtli day the fever had risen to 104 degrees, falling, then rising on the seventh day to 104 degrees again. After this there was a gradual descent, until on the evening of the twenty-fifth day the temperature was normal. The usual per- iod of high temperature had thus been prevented. (4) In a girl of nine, who had suffered from typhoid fever, the lingering effects of the disease, suffered from five years before, were very marked. The difficulty took the form of acute at- tacks commencing with pain in the eyes, followed by intense headache and delirium, and a rash upon the skin. As the rash disappeared, swelling and pain in the joints would follow. These attacks would recur about every two weeks. The child was emaciated and suffered from involuntary micturition. She had been under skilled medical care, and the case had attracted such attention that it was discussed before a convention of physicians in Denver. Being treated osteopathically during an attack, she recovered at this time without the usual swelling and rheumatic symptoms. After two months treatment the case was discharged cured. The only bony lesion was a lateral luxation of the third cervical vertebra, but all of the spinal muscles were intensely contractured. These few cases are quite typical of the many treated. LESIONS: Dr. Still describes, as the charactesistic "ty- phoid spine," a posterior prominence of the lower lumbar region, caused by a backward displacement of the 3rd, 4th, and 5th lumbar vertebrae. He holds that the result produced by these lesions is a paralysis of the lymphatic supply of the bowels, by pressure upon the spinal nerves at their exit from the interverte- bral foramina. Thus is produced the essential typhoid- condi- tion of the small intestine characteristic of the disease. He notes also lesions along the upper dorsal region, at which point he makes treatment upon the lungs, correcting the activ- ities of the lymphatics system, thus, as he says, making water to put out the fire of the fever. In general the lesions found in typhoid fever are rib, ver- tebral and muscular lesions affecting the splanchnic and him- 382 PRACTICE OF OSTEOPATHY. bar regions of the spine, irritating spinal nerves, and through them disturbing the sympathetic, vaso-motor, and lymphatic supply of the small intestines. As before pointed out in detail (see diseases of stomach and intestines), these portions of the spine suffering from lesion give origin to the visceral nerves of the intestines. The vaso- motor supply of the abdominal vessels, according to Quain,- is from the splanchnic and lumbar portion of the cord. These include the vaso-motors of the jejunum and ileum, the seat of ulceration in the disease. Pathologically, the process in the first two stages of typhoid, infiltration and necrosis of the patches, is regarded as a vaso- motor disturbance. The first stage is an intense inflammation, involving to a greater or less degree the whole mucosa. The second stage is the result of an obstructed circulation to the parts of the intestine involved. In view of these facts it is evident that successful therapeutic measures must gain vaso-niotor control. It is an indication to the Osteopath that he must do spinal work upon the vaso-motor area supplying the bowels, re- moving the lesion 'that is obstructing the natural play of the forces necessary to health. The PROGNOSIS is good, yet one must not forget to be upon his guard, constantly, against the complicatiQns and intercurrent maladies that so often carry off the typhoid patient. Under osteopathic treatment, however, complications and sequelse are quite prevented. Indeed, much fine osteopathic work has been done upon paralytic and various other forms of the sequelse fol- lowing an attack of typhoid fever. If taken within a week or ten days the course can be usually aborted to a marked degree. Often cases gotten early have had their course terminated within a few days. Bad cases, taken under treatment after so late as the fourteenth day, commonly at once show marked improvement. The characteristic course of the temperature is entirely changed. It is usual to notice, no matter in what stage the case may be when it comes under the treatment, that the temperature begins at once to gradually decline. When the case is taken PRACTICE OF OSTEOPATHY. 383 before the second week, the usual period of high temperature i? prevented. TREATMENT: The main object of the treatment, as pointed out, is to gain vaso-motor control of the intestinal blood-supply, and to restore intestinal lymphatics to normal activity. Con- sequently the main treatment in these cases is spinal. It must be devoted particularly to the correction of the mal-positions of the 3rd, 4th and 5th lumbar as described above, and to the removal of any spinal, muscular, rib, or vertebral lesion present. Most of the treatment in these cases must be done upon the spine, leaving the abdomen almost entirely free from manipula- tion. All the spinal muscles should be relaxed, this, with a careful cervical treatment, quieting the nervous system, and relieving the jerking of the subsultus tendinum. This treatment is care- fully made while the patient is lying upon one side. The patient must not be moved into various positions any more than can be avoided. It is important to avoid fatiguing him. Lungs and heart should be kept gently stimulated by work in the usual place in the upper dorsal. This aids in keeping up the patient's strength and in preventing complicating diseases of these organs. Treatment at the renal splanchnics should be given to keep the kidneys active. The main treatment being along the splanchnic and lumbar regions, these portions of the spine are treated by careful relax- ation of all contractures, by gently springing the spine for the relaxation of ligaments and for the freedom of the nerves, and in removing the bony lesions mentioned. The correction of the lesion to 3rd, 4th and 5th lumbar controls the diarrhoea. It may be treated in the usual way. The spleen and liver are reached by spinal work at their in- nervation. The abdominal treatment is almost nil. Any manipula- tion made here should be with extreme gentleness. It is best to confine this treatment to the iliac regions, raising the intes- tines slightly, with the idea of straightening them in the iliac fossse. (IV. Chap. VIII.) The fever is treated by work at the superior cervical ganglion 384 PRACTICE OF OSTEOPATHY. in the usual way, thus regulating the systemic circulation by affecting the general vaso-motor center in the medulla. The treatment to the heart and lungs aids this process by equalizing the circulation, as does also the general spinal work and the treatment given along the spine for intestinal circulation specific- ally. The heart beat should be slowed by inhibition at the 2nd to 5th dorsal, on the left. In case of rapid beating of the heart, persisting sometimes for a long period, Dr. Hildreth finds that correction of the left 5th rib gives relief. The hiccough is treated in the usual way. In case of hemorrhage the patient should be kept perfectly quiet, have no solid food, and an ice-bag should be applied over the caecum. The foot of the bed should be elevated. Inhibition of peristalsis should be done by work from the 9th dorsal down along the lumbar region. In case of perforation, hot applications, or the ice-bag, are applied to the abdomen to relieve the patient. The usual precautions should be taken for the hygiene of the sick room, the disinfection of the linen, the sterilizing of the stools and urine, and general cleanliness. The patient's body, a part at a time, should be sponged with tepid water daily. The Brand system of baths is much usejl at the present day. In regard to diet the usual observance of "a strictly liquid diet is followed. Some are using light, easily digested food the first week or ten days, until danger of perforation has arrived. The claim is made that the patient's strength is in this way much better preserved. It would be safe for an Osteopath to carry a case through on such a diet providing he got it early enough to prevent the danger of perforation. After first taken the patient should not be allowed to get up from his bed. A bed-pan and urinal should be used. During convalescence the patient's condition should be carefully watched. The return to a hearty diet should be grad- ual in spite of his great appetite. After a liquid diet the semi- solid food should not be allowed until the temperature has been normal a week. PRACTICE OF OSTEOPATHY. 385 ERYSIPELAS. (St. Anthony's Fire, "The Rose.") Erysipelas is a disease frequently treated and cured osteo- pathically. The PROGNOSIS is good. The LESIONS are various forms of obstruction to the cir- culation of the part affected. The lesion may be bony, or a contracture of muscles or other tissues. It may directly press upon veins and lymphatic vessels, preventing the proper drain- age of the part, or it may derange the vaso-motor innervation and the sympathetic innervation of the lymphatics. For ex- ample, a case of erysipelas in a lower limb was cured by turning the head of the femur well in the socket, and in raising the ab- dominal viscera up from the region of the crural arch, where they were pressing upon the blood-vessels and preventing drainage from the limb through femoral vein and lymphatics. By thus relaxing the tissues and removing direct impingement from the vessels, the blood-flow was restored and the case was cured. Another case in which the eruption appeared upon the face, was cured by springing the temporo-maxillary articulation with the assistance of corks placed between the molar teeth, as one would set a dislocated jaw. In this way various tissues about the jaw may have been relaxed, or impingement, of the fibers of the fifth nerve removed, restoring circulation. The most usual lesions in erysipelas are found preventing the circulation from the head, as the face is the part most fre- quently attacked. Lesions of cervical vertebrae and muscles affect the vaso-motors and sympathetics regulating the blood and lymphatic circulation of the face, and lead to inflammation by obstructing these fluids, the specific germ being present and attacking the part thus rendered liable to its action. Clavicle and first rib lesions may directly obstruct the jugular veins and the cervical lymphatics, leading to the same result. McConnell notes lesion of the 2nd, 3rd, 4th and 5th dorsal vertebrae, and of corresponding ribs and surrounding muscles, causing erysipelas in the face, by disturbing sympathetic inner- vation. The TREATMENT is simple, calling for removal of lesion and 25 386 PRACTICE OF OSTEOPATHY. re-establishment of venous and lymphatic drainage of the affected part. This involves relaxation of muscles and other tissues, restoration of bony parts to position, freeing of nerve connec- tions, etc., as already pointed out, according to the part affected. It is not necessary to manipulate the inflamed part. As erysipelas is a dermatitis, the need of gaining vaso-motor control is apparent. The special treatment of the neck to affect free circulation to and from the head and face has been sufficiently discussed in the treatment of diphtheria and of the eruptive fevers. A general spinal treatment must be given to strengthen the general nervous system against the various nervous com- plications and sequelae that may arise, such as delirium, coma, subsultus tendinum, etc. Bowels must be kept free, and liver and kidneys kept active to get rid of the poison of the disease which is deranging the constitutional condition. The kidneys must be especially supported against albuminuria and uremia. Among the hygienic measures and domestic remedies rec- ommended are isolation of the patient, drinking plenty of cold water, cold spongings of the part, or applications of iced cloths, and the application of collodion over the eruption. Carbolized vaseline may be used to anoint the affected part. The diet is important. The patient should be liberally fed on a light, nutritious diet. Anders states that liberal feeding of the patient is of greater service to the patient than any of the recognized forms of medicinal treatment, and the lack of atten- tion to the diet during the primary attacks tends to increase the frequency of relapse. MEASLES. (MORBILLI, RUBEOLA). Very numerous cases have been successfully treated The PROGNOSIS is good. The danger of complications and sequlee is minimized, as these cases recover quickly and thor- oughly under the treatment. While it is held that measles, once started, must run its course, yet the period of convalescence is shortened and the child is about earlier without danger of complications. PRACTICE OP OSTEOPATHY. 387 LESIONS: Dr. Still describes in this disease a general ."con- gestion of the lymphatic drainage of the skin becoming evident as a cutaneous rash. This general congestion is due to spinal muscular contractures all along the spine, irritating the spinal distribution of nerves, and through them deranging sympathetic vaso-motor and lymphatic nerve-supply. This general congestion of the spinal muscles appears as lesion in muscles. The clavicle may be found with its sternal end displaced backward against the vagus nerve, causing the cough, and aiding to cause the catarrhal condition of the bronchi. Upper rib lesions may be found, their correction relieving the cough. Weakened children, especially those presenting upper spinal arid thoracic rib lesions, are apt to become victims of pul- monary tuberculosis after measles. The clavicle and first rib lesion, as well as various cervical bony lesions and muscular con- tractures, probably account for complications and sequela in eye, ear, nose and throat. These effects come largely through obstructed lymphatic drainage from the neck, a fact well illus- trated by the marked enlargement of the cervical lymph glands as a complication or sequel of the disease. In the TREATMENT the first step, especially if the rash has not developed, is a thorough stimulation of the cutaneous sys- tem, including a general spinal treatment, with particular at- tention to atlas and axis, for effect upon the vaso-motor center in the medulla; upon the second dorsal and fifth lumbar, cutan- eous centers. In tardy cases one such treatment suffices to bring out the rash abundantly, a desirable result, since upon its ap- pearance the headache and fever disappear, and the patient feels better. This treatment would include a general relaxation of the spinal muscles, correcting the lymphatic obstruction. An important effect of the general spinal and cervical treat- ment, together with some special treatment to heart and lungs, is to correct the general circulation, calling away from all the viscera the abnormal amount of blood retained in them as a con- gestion, in this disease. For this purpose there should be added treatment of the splanchnics, solar plexus," liver, kidneys, and abdominal circulation generally. 388 PRACTICE OF OSTEOPATHY. The usual treatment of the throat, internal and external; of the neck; of clavicle and first rib; of the upper anterior chest, raising the ribs, and working in the anterior intercostal spaces against the costal cartilages; and of the face and nose, should be given to overcome the catarrhal condition of the respiratory tract, just as a cold and a bronchitis are treated. The lungs should be kept well supported by the treatment, to avoid the danger of bronchitis and pneumonia. Likewise kidneys, eye, ear, nose, and throat should be guarded against effects in them. The cough is relieved by relaxing the throat tissues, treat- ment along the larvnx and trachea, correction of first rib and clavicle, and raising of the upper ribs. The patient should remain in bed until desquamation is well along, should be in a darkened room for the sake of the eyes, and should be kept upon a light diet of milk, bread, light soups, etc. The general spinal treatment, and treatment of the cutane- ous system and centers, will aid in allaying the itching of the skin. For this purpose, also a daily warm bath may be given. RUBELLA. (FRENCH OR GERMAN MEASLES.) VARICELLA. (CHICKENPOX.) To these conditions we may apply the same general remarks concerning lesions and treatment, osteopathically, as made in considering measles. The very mild symptoms accompanying these conditions call for but little treatment aside from the general constitutional one, pointed out in detail in measles. These points of treatment may be applied as necessary. Due attention must be given to avoid exposure, the clan- gers of complications, etc. In rubella the enlargement of the cervical lymphatics calls for attention in the manner pointed out. The slight fever and catarrhal symptoms are readily overcome. In both conditions due attention must be given to the cervical PRACTICE OF OSTEOPATHY. 389 and general spinal treatment, and to the maintenance of the activities of the various viscera. Usually the spinal muscles are contractured, and must be relaxed. These contractures doubt- less affect the general lymphatic system by way of the spinal nerves. For example, in varicella the superficial lymph glands are sometimes visibly enlarged. In varicella the usual precaution of preventing the child's scratching off the scabs by putting mittens or bandages upon the hand and wrists,' and of painting the scab over with collo- dion may be observed. SCARLET FEVER. (SCARLATINA.) Numerous cases have been successfully treated osteopath- ically. The PROGNOSIS is good, but must be guarded in cases com- plicated with diphtheria. The experience is to bring these cases safely through the attack, free from complications and sequelae. The LESIONS are, in general, the same as described for the various acute, specific fevers. Contractured spinal and cer- vical muscles are noted. One must expect various bony lesions, accounting for the weakness of the special parts attacked by complications or sequelae, as for the kidneys, throat, and general nervous system by the usual bony lesions found present in dis- eases of these parts. The TREATMENT proceeds along the lines already laid down. In this case there is especial need of thorough constitutional treatment on account of the multiplicity of symptoms and the variety of organs sometimes affected. The general spinal treatment is given, relaxing muscles, stimulating the splanchnics, etc. Particular attention must be given to lesions affecting the kidneys, and to the thorough treatment of the innervation of them, throughout the course of the disease, for the purpose of avoiding the post-scarlatinal nephritis, so common a complication. For a like reason one must give especial attention to the treatment of the throat to avoid diphtheria. The cervical treatment must be carefully carried out. The marked enlargement of the lymphatic glands that sometimes 390 PRACTICE OF OSTEOPATHY. occurs may be avoided or controlled by the usual treatment. Relaxation of all the anterior and posterior muscles, etc., must be done. This treatment frees the lymphatic and blood-circu- lation through the neck, and keeps eye, ear, and throat in good condition. The heart must be kept well supported. The fever is treated in the usual way. When the patient's system is kept well sup- plied with moisture by allowing him a plentiful supply of cold water, daily treatment of the sub-maxillary salivary glands will aid in keeping the mouth and lips moist. The irritation of the skin may be relieved by the treatment indicated for that purpose in measles. Daily tepid sponging and warm bathing, as well as anointing of the skin with an animal fat or cocoa butter, are useful for this purpose. The patient should be isolated, the scales shed in desqua- mation should be carefully collected and burned, and the room should be disinfected, after convalescence. The diet should be light. Plenty of milk and alkaline water may be used. VARIOLA (Small-Pox.) It is at present impossible to say anything specific with regard to treatment of small-pox by osteopathic methods. It is doubtful whether the disease, in any marked form, has ever been treated osteopathically. Numerous light cases have been treated. It would have to be met upon the same general plan as other fevers, with particular attention to the special clinical manifestations of the disease. An Osteo- path should follow the same precautions with regard to isola- tion, disinfection, and antisepsis as are followed by any other physician. The usual osteopathic procedure would be followed in the treatment of muscular pains, vomiting, diarrhoea, convul- sions, etc. The ordinary method of preventing pitting by keep- ing the face washed with a carbolic or mercuric-chlorid solution and covered with clean cloths saturated with warm water, and of protecting the eyes by keeping them covered by cloths wet in a boric acid solution, and by darkening the room, could probably not be improved upon by the Osteopath. He should see that the patient is well bathed, that the diet is carefully regulated, and PRACTICE OF OSTEOPATHY. 391 should meet the various manifestations of the condition by the usual osteopathic methods. CEREBRO-SPINAL FEVER. (Epidemic Cerebro-Spinal Meningitis, Spotted Fever.) This condition has been successfully treated osteopathic- ally. It should be treated upon the plan followed in the other forms of meningitis, and also in the treatment of various fevers, as described. It is necessary to be especially persistent in the local treatment to the spine and cervical regions, on account of the marked effects of the disease upon the cord. Continual treat- ment in these regions is a most valuable aid in keeping the cir- culation equalized and in lessening the inflammatory processes going on about the cord. It should be mostly of a relaxing, inhibitive sort, with much direct inhibition in the superior cer- vical region and along the splanchnic and lumbar regions. The spinal column should be carefully sprung, held, and relaxed. The painful and contractured muscles along the neck and back (opisthotonos) must be continually and gently relaxed. This spinal treatment is aided by the abdominal treatment, as before described, given for the purpose of drawing the blood to this region, away from the cord. This whole process of treatment lessens the inflammatory process in the meninges, aids in absorb- ing the effused serum, and the fibrino-purulent exudate, and aborts the progress of the disease. It practically prevents the usual sequelse and complications met in this disease. In the course of the treatment due attention should be given to the adjustment of various spinal vertebral lesions usually present. The heads of the ribs and the deep tissues should be carefully examined for lesion. This part of the treatment is quite an important factor in gaining complete freedom of circu- lation, and complete removal of irritation. The remainder of the treatment is largely for the relief of the various manifestations of the condition. One should follow the directions before given for treatment of the fever, vomiting, constipation or diarrhoea, occipital headache, etc. For the sud- den violent pains one should use inhibition at various points along the spine and at the local plexuses and nerves. Sueh 392 PRACTICE OF OSTEOPATHY. treatment, well applied, together with the spinal treatment,, would reach the convulsions if they occur. It is well to give particular stimulating treatment to the kidneys, not only because the urine is scant and shows the usual febrile characters, but also because of the toxaemia due to the disease, and because of the tendency of nephritis to appear as a complication. Eyes, lungs, heart, and organs of special sense must be kept well treated to avoid danger of complications or sequels affect- ing them. The PROGNOSIS must be guarded, but under osteopathic treatment the best of results may be expected. DYSENTERY (Bloody Flux.) DEFINITION: An infectious disease, characterized by an inflammation of the large intestine, frequent mucous and bloody stools, tormina, tenesmus, prostration and other marked symp- tioms. It is due to specific spinal lesion. CASES: (1) Chronic dysentery of five years standing, in a man of thirty-thre'e. Lesions were a posterior condition from the llth dorsal to 3rd lumbar. The case was cured in one month of treatment. (2) A case of acute dysentery of two days standing. Ail the symptoms were marked. The case was much relieved by the first treatment, the bowels did not move until twenty-four hours after it. (3) A severe case of acute dysentery in a child. It was treated two days and the stools became normal. (4) A case of chronic dysentery of a severe nature, in a patient suffering with paraplegia. Lesions were an anterior condition of the 5th lumbar vertebra, a lateral swerve of the lower dorsal and lumbar region of the spine, and luxation of the innominate bones. The condition was cured in four months. The PROGNOSIS is good. Treatment is usually at once successful in relieving the condition. Many cases are cured in one or a few treatments, even though they are chronic. The worst forms of dysentery have been successfully treated after all other treatment had failed. Generally a course of treatment PRACTICE OF OSTEOPATHY. 393 is advisable in order to fully remove lesion and to restore the tis- sues of the bowel to their normal condition by a corrected circu- lation. The LESIONS and the TREATMENT are identical with those described for diarrhoaa. PARASITES. Patients suffering from the presence of the various animal parasites frequently come under treatment. The common round worm (Ascaris Lumbricoides) ; the pin-,thread-, or seat-worm (Oxyuris Vermicularis) ; the hematozoon of malaria (Hemato- aoon of Leveran) ; and the several forms of tape-worm (Tsenia Solium, T. Latum, T. Saginata) are successfully treated osteo- pathically. No particular lesion, of course, can be mentioned in this connection. Yet commonly in these cases the various rib, ver- tebral, and other lesions affecting the bowels are present. Their removal is related to the cure of the condition as a part of the treatment directed to securing good general health, and free action of liver and of bowels, all of which are quite important in the treatment of the case. CASES: (1) Pin- worm in a child of three years, of several months standing. No lesion was noted except a downward position of the lower ribs. Treatment was directed to raising the lower ribs, to stimulating the innervation of intestines and liver, and to direct manipulation of these organs. No local application at the anus, nor enema was required in this case. The child was cured by 10 treatments, passing forty-five worms. (2) A case of pin- worms in a child suffering with poor gen- eral health. The case was cured in two months. (3) A case of tape-worm in a woman suffering from bad general health. The liver was in bad condition. The treatment corrected spinal lesions and restored liver function and general health. A tape-worm was expelled. The case was well one year later. (4) A case of tape-worm which had not been helped by the usual medical treatment. The liver was inactive, and le- sion was found as a lateral swerve of the spine from the 4th to 3!)4 PRACTICE OF OSTEOPATHY. the 8th dorsal vertebra. The treatment was particularly to the liver and the spine. The worm was passed. TREATMENT in these cases is directed to the removal of spinal or other lesion; the restoration of a healthy condition of the bowel and general digestive apparatus; the stimulation of hepatic activity particularly, for the purpose of increasing the flow of bile, held to be effective in expelling the worm; and the upbuilding of the general health. This treatment applies to the general case. The treatment for malaria has been described elsewhere. Its success demonstrates the ability of osteopathic treatment to clear the blood of the protozoan parasite present in it. In cases of pin-worms it is necessary to keep the parts thor- oughly clean. The ova are killed by anointing the anus with lard. Injections of lard into the rectum will kill the worms. Enemata of cold water, plain, or with a little salt or soap added, may be used to free the rectum. The child's finger-nails should be kept trimmed and well cleaned to avoid transfer of the ova by accumulating under them. The rest of the treatment is as directed above. In case of round or tape-worms, it is w r ell to enforce a liquid, such as milk, diet for a day or two in order to weaken the worms and to leave them more accessible to the action of the bile. For tape-worm, the patient should then drink quantities of pumpkin- seed infusion, or eat a gruel made of mashed pumpkin-seed, con- tinuing several days if necessary, until the worm is passed. The prophylaxis includes the thorough cooking of the meat, especially of beef and pork, from which tape-worms are usually gotten. The trichina is found in pork, usually. The dejecta containing ova or segments of the worms should be burned. In all cases avoidance of impure drinking water is necessary. In cases of trichiniasis, if infection is suspected prompt and thorough treatment should be made as described, in order to get rid of the embryo young before they leave the intestine and invade the muscles. Later a course of treatment for the general health, and general muscular treatment should be given. This will reach the muscular pains, insomnia, and weakness. PRACTICE OF OSTEOPATHY. THE INTOXICATIONS. Various chronic cases of alcoholism, and opium, morphine, or cigarette habit have been cured under osteopathic treatment. CASES: (1) A young man of 35 came under treatment for "nervous prostration" due to chronic alcoholism. He was a nervous wreck; could not sleep nor digest his food; had palpita- tion of the heart; the lungs and kidneys were affected, and he suffered from frequent attacks of sick headache and constipa- tion. His left leg was varicosed. He suffered much from melan- cholia, and had unbearable craving for opium or whisky. He had taken the Keeley cure once, another cure twice, and another five times. After a course of treatment his general health was very much improved, and he had no desire whatever for an in- toxicant. (2) Chronic alcoholism in a man of 31. The patient had taken the Keeley cure three times, and had taken besides several other cures. He had become insane from the use of a drug, the use of which he had learned while under treatment of one of these cures. He had had delirium tremens eight times in three years. During all this time he had never lost the desire for whisky. He was a nervous wreck, ate but little, and could sleep only under the influence of drugs. At the time of beginning treatment he was using three quarts of whiskey a day. At the end of three weeks treatment he was using no stimulant, and his appetite for it was under control. At the end of the second month he was eating and sleeping naturally, and all desire for drink was gone. Four months later he was still well. (3) A woman addicted to the use of opium came under the treatment. Upon leaving off the drug she was attacked with great pain, which was relieved by the treatment. These pains were successfully relieved whenever they appeared, and continually grew less severe. Gradually the system was built up and the desire for the drug ceased. (4) In a case addicted to the cigarette habit for 12 years,, all desire for the article was removed by the treatment. (5) A man of about 33. who had long been a cigarette smoker. 396 PRACTICE .OF OSTEOPATHY. and whose nervous system had been wrecked by the habit, was cured by a course of osteopathic treatment. The TREATMENT in these conditions is practically the same. In opium, morphine, and cigarette habit the effects are the same, as the harm is done by the opium. From the use of either alcohol or opium the nervous sys- tem becomes undermined and comes to depend upon the stim- ulant. Gradually the nervous system is wrecked. In either case it is the object of the treatment to build up and restore tone to the nervous system, and to enable it to do without the accustomed stimulation of the drug. The style of treatment is & thorough general spinal and cervical one, which corrects the circulation to the brain and cord. In addition treatment is de- voted to buliding up the general health, and special treatment is given to the various symptoms and manifestations as neces- sary. In this way the system is strengthened and the nature! functions are restored. As strength is gained there is constantly less desire for the accustomed drug. The desire for it is quite taken away. In case of opium habit the principal anatomical changes in the tissues are due simply to malnutrition, consequently a gen- eral treatment to the circulation, nervous system, bowels, stomach, liver, etc., is the rational method of repairing the effects of the drug. The muscular cramps are treated by local and spinal inhibition; the insomnia is treated as before described. Pal- pitation, weakness, dyspnea, etc., are readily affected by keep- ing the heart stimulated, the ribs raised, etc. In the case of alcoholism the tissues are fat-infiltrated, de- generated, cirrhotic. congested or inflamed. Liver, kidneys, heart, lungs and stomach are quite likely to be affected by these processes. These effects in the various organs may be treated in ways described in considering the various diseases of them. It is obvious that a thorough and persistent course of treatment is necessary to correct local circulation and restore these tissues to normal. Delirium tremens should be treated as described for con- vulsions. A spinal and cervical treatment would be particularly PRACTICE OF OSTEOPATHY. 397 indicated. The insomnia yields to the treatment usually made for that condition. SUNSTROKE (Heat-Stroke; Insolation; Thermic Fever) and HEAT EXHAUSTION. These two conditions are due to exposure to high temper- ature. The former is brought on by exposure to the direct rays of the sun. The latter is contracted by persons working in close, confined places in high temperature. The state of the patient in one of these conditions is quite different from that in the other. In sunstroke there is very high temperature, 106 to 115 F., marked dyspnea, red or livid skin over the entire body, lack of perspiration generally, a full pulse, unconsciousness and coma. In heat exhaustion there is cold, clammy, and pallid sur- face of body; the temperature is normal or subnormal, occasion- ally slightly feverish; the pulse is full and small; consciousness is rarely lost. The TREATMENT differs some in these two conditions. Sunstroke is much the more serious condition. It must be treated promptly. The patient should be laid in the shade, the clothing should be loosened, and the applications of cold water to head, spine and surface of the body are made. Ice may be rubbed over the surface of the body, or the patient may be put in an ice-bath (ice in the water.) Ice water enemata may be used. After the temperature has been reduced the pa- tient should be given much the same treatment as described for apoplexy. It is especially important to relax all the cervical muscles, which are found to be much contracted. The spinal muscles should also be relaxed, and the abdominal treatment may be given to draw the blood away from the brain and cord. The patient should be kept quiet, and the heart should be inhi- bited. Cervical relaxation and inhibition should be continu- ously applied. Heat exhaustion calls for less treatment. Usually the patient soon recovers if removed to a shady spot, with the clothing loosened, and sprayed with cool water. The muscles of neck and spine should be first relaxed, and the whole spinal system, 398 PRACTICE OF OSTEOPATHY. heart, and lungs, should be thoroughly stimulated. In case the temperature be subnormal the patient should be placed in a warm bath. After-treatment for the spine, neck and general system prevents the sequelae that are so frequently the results of sun or heat-stroke, such as headaches, brain affections, intolerance of heat, etc. LIGHTNING STROKE. Several cases have been treated osteopathically of persons suffering from the effects of lightning-stroke. Paralytic affects are usually found. The case must be treated upon general principles, usually as a case of paralysis. As a rule marked ver- tebral lesions and contractions of cervical and spinal muscles are found resulting from the stroke. Good results are gained by treatment. DISLOCATIONS, DEFORMITIES, JOINT-AFFECTIONS, ETC. This class of troubles furnishes the Osteopath with very numerous cases. The marked success of osteopathy in curing spinal curvature; setting old dislocations; overcoming chronic pain, stiffness, etc., in joints; overcoming the various effects of injuries to any part of the body; curing synovitis, ankylosis, etc., makes this line of practice a very satisfactory one. The curing of spinal curvature without the use of braces or mechanical appliances; the removal' of plaster casts, jackets, splints, bandages, and all things of that kind, causing the natural resources of the parts to be depended on, is a novel and success- ful feature of Osteopathy. The setting of old dislocations is not much attempted by other lines of practice. Great success is met in this line. It is evident by a glance at the case reports that egregious blunders are repeatedly made by the most skilled physicians in many cases of this and similar sorts. "Tubercular joints, " "ruptured ligaments," "fractured bones," and various other serious con- ditions are often found by the Osteopath to be partial or complete dislocations, slips, strains, etc., which are curable. PRACTICE OF OSTEOPATHY. 399 CASES: A few typical cases of deformity, etc., in each of the various parts of the body subject to these conditions are here presented. Great numbers of these cases are upon record, but it will be sufficient to confine this list to a few examples. (1) A pronounced double lateral curvature, in a young lady, involving the whole dorsal region, with single vertebral lesions at 10th and llth dorsal, and 4th and 5th lumbar. The spine was very sensitive, but this condition was overcome by three or four treatments. After twelve treatments the patient, considerably benefited, went away upon a visit, remaining several months. Upon her return it was found that the curva- ture and spinal condition were materially improved. Seven more treatments cured the condition entirely. (2) Double lateral curvature of five years standing in a girl of twelve. The curvature was to the right from 3rd to 8th dorsal; to the left from the 9th dorsal to 3rd lumbar. The case was cured by four months treatment. (3) A posterior curvature in the dorsal region, in a young boy, general health was poor. After two weeks treatment the spinal brace was removed, and after two months treatment the curvature had entirely disappeared. (4) Pott's disease of eighteen years standing, in a young lady of twenty-eight It came on gradually after a fall at the age of eight, having developed to completeness in two years. Casts were worn for two and a half years, during which time two abscesses discharged, one just below the anterior superior spine on the left, the other hi the right limb just below the groin. For years the abscesses would alternately heal and break. The posterior angular projection involved the vertebrae from the 4th dorsal to the sacrum, the apex being at the 10th dorsal. She came under treatment at the age of twenty-eight. Both ab- scesses were discharging freely; after three months treatment a third abscess appeared, and the patient appeared to grow worse. After this she began to improve and the curvature began to yield. Two abscesses healed. Gradually the curvature was reduced until scarcely noticeable, and the 3rd abscess was nearly healed. The general health was perfect. The patient's height had been increased two and a half inches. 400 PRACTICE OF OSTEOPATHY. (5) A thyroid dislocation of the hip set in one treatment. (6) A dislocation of the hip of three years standing; the patient had been upon crutches ever since the accident pro- ducing the injury. The hip was set in three treatments, and the patient had no use for crutches thereafter. (7) A dislocation of the hip of four years standing in a case which had been thrown from a buggy. The femur had been fractured at the same time. The hip was set in three months treatment. (8) Tuberculosis of the hip and spine, so-called, in a girl of sixteen, of four years standing. The best physicians had pro- nounced it tuberculosis of the hip. The hip was found to be slightly dislocated downward and forward, and there was ver- tebral lesion of the 3rd and 4th lumbar. The hip was set and the case entirely cured hi four months. (9) A case diagnosed by the physician as hip-joint disease. The patient had been confined to his cot for ten months. A partial dislocation of the hip was found and set in three months treatment, curing the case. (10) Partial dislocation of hip and knee-joints. The pa- tient had worn a laced leather stocking from the ankle half-way to the thigh for eleven months. He walked with a crutch. The case had been diagnosed as "rupture of the internal lateral lig- ament of the knee" by two prominent Chicago physicians. The dislocations were set in nine treatments. (11) A case which had been diagnosed as a "complicated fracture of the neck of the femur," of five years standing. Spec- ialists had confirmed this diagnosis. The injured limb was three inches shorter than the other. Osteopathically the case was diagnosed as a dislocation and was cured. (12) Tuberculosis of the knee, so-called, in a boy. The joint was put in a cast. There was constant pain in it. A slip of the hip-joint was found, and its adjustment cured the case. (13) Torticollis due to contraction of the sterno-mastoid muscles. By four treatments the muscle was relaxed, and the condition was cured. (14) Torticollis of many years standing, caused by injury to the neck. The muscles were extremely rigid, and the cervical PRACTICE OF OSTEOPATHY. 401 vertebrse were badly curved and twisted. There was constant pain in head, neck, and eyes. The case was greatly relieved permanently by the treatment. (15) Injury of the knee and shoulder- joints in a bicycle accident. The knee condition had been diagnosed as rupture of the ligaments. By three weeks treatments the shoulder and knee were entirely cured. (16) Tubercular knee in a boy six years old. The knee was swollen, and the temperature was 103 F. The case was much benefited by three weeks treatment, and was well on the way to recovery. The 10th and llth dorsal, 1st, 2nd, 3rd, and 4th lumbar vertebrse were posterior. (17) A long standing pain in the shoulder, which had been examined and treated by eminent physicians both in Europe and America without relief. Lesion was found in crowding to- gether of the 2nd and 3rd dorsal vertebrae. After one treatment the patient suffered no further pain. (18) Partial dislocation of the head of the humerus, of some months standing, causing a painful condition which had been treated as rheumatism. The case was cured by setting the bone. (19) Fibrous ankylosis of the elbow-joint in a boy of five, due to being kept in splints too long after fracture of the humerus. The condition was of eight weeks standing. By the treatment use of joint was gradually perfectly restored. (20) Broken down arches of the feet in a man of twenty- eight, due to rheumatism which had settled in the ankles. The astragalus was markedly dislocated to the inner side. For two years the patient had worn braces to support the arch of the instep. By the treatment the bones were replaced and the arches were rebuilt into their natural condition. The case was cured in six weeks. TREATMENT OF DISLOCATIONS, DEFORMITIES, AND JOINT-AFFECTIONS. While the treatment of each of these conditions will be dis- cussed separately, some general remarks apply to them collec- tively. The marked success of Osteopathy in cases of this kind 402 PRACTICE OF OSTEOPATHY. is largely due, at bottom to an intimate knowledge of nerve and blood-supply of the affected part, patience and skill in manip- ulation, and the ability to relax, strengthen, or build up tissues, open a joint and direct the circulation to it, and in all respects to thoroughly prepare parts concerned to be returned to the normal state. In the recent case this preparatory treatment does not take long. In the chronic one, which represents a con- siderable majority of this class, this preparation may necessarily extend over many months. It is here that patience and skill play an important part. Often the preliminary work done in getting all parts ready to be restored to normal is the most im- portant and most distinctively osteopathic part of the process. When parts are once prepared, as for example in the setting of a hip, the final manceuver used to replace the bone in position is practically the same as a surgeon would use for the purpose. These remarks apply with almost equal force to both disloca- tions and deformities. Yet in the latter case the correction of position of bony parts is continually going on, pari passu with the process of the treatment. In case of joint-affections this process of treatment constitutes the whole course of procedure, yet it not infrequently occurs that the replacing of a slipped bony part is a portion or the whole of the treatment of a joint- affection. TREATMENT OF SPINAL CURVATURES AND OF POTT'S DIS- EASE: The treatment of the various forms of spinal curvature and of Pott's disease are upon much the same lines. In all, the preliminary work as described is of the utmost importance. It constitutes much of the course of treatment, but bony parts are drawn and pressed back into place all the while. Spinal curvatures are rarely painful, but when they are the first step in the treatment is to carefully relax all spinal tissues, deep and superficial; to increase or correct circulation in tluMn; and in these ways to gradually work out the soreness and to strengthen them. In any case of curvature this sort of treatment constitutes the first step in the procedure. To this end one may use any or all of the treatments described under I, II, III, IV, and V, in Chap. II. In this way the spine is gradually strengthened through- PRACTICE OP OSTEOPATHY. 403 out ; the muscles and ligaments are given greater strength to hold the ground gradually gained, now and later, in the form of the slow restoration of bony parts toward the normal position. Likewise, during this process of treatment, the interverte- bral discs, which have been altered in shape by pressure atrophy, are gradually freed of unequal pressure and are rebuilt into proper shape by properly distributed pressure and by the renewed blood- circulation. After a short preliminary treatment, or at once if the case allows, attention is directed to the replacement of bony parts. It is a good rule in spinal curvatures to begin at the lowest ver- tebra involved and make an attempt at each treatment to set it back into place. When this has been accomplished, and while it is going on. the next vertebra, then the next, and the next, and so on, is attempted. Much may be gained in this way. Suspension of the patient in the osteopathic swing, or in the special apparatus devised for the suspension of curvature patients, is a great help to the practitioner in the treatment. By this device the weight of the patient's body is used to help draw the bony parts back into place during the various special treatments employed for that purpose. In this way very rapid gain^ have been made in straightening the curve. Various special movements may be successfully applied to the reduction of the bony parts. The treatments described under VI. VII. VIII. IX. X. 'x(a). XI. XII. XVII. and XVIII, in Chap. II. may be used and combined as desired. This style of treatment should be combined all the time with that described as the first step in the process of treatment. The treatment must be most persistently and assiduously applied, the practi- tioner using a considerable degree of force to put parts back into place. But violence must be avoided. During the course of the treatment all spinal braces, jackets, casts, and artificial supports or corrective mechanisms of even- sort are laid aside, either gradually or at once as the patient may be able to do without them. In this way one gets rid of their irritating local effects and of their detrimental influence upon the general health, while at the same time the parts are taught to depend upon their own strength, a matter essential to a cure. 404 PRACTICE OF OSTEOPATHY. Due attention must be given to complications and to the general health. The practitioner must bear in mind the changed relations assumed by the ribs both with respect to each other and with respect to the vertebrae. Treatment must be^ applied during the^. course of treatment, to the adjusting of these ribs. The various special methods described in Chap. VII may be used. This method of treatment applies to SCOLIOSIS, LORDOSIS. KYPHOSIS, and their combinations. In case of POTT'S DISEASE the same general plan of treat- ment is followed. In case the destructive process in the bones and discs has ceased, and cure by deformity has followed by bony ankylosis of the vertebrae, one cannot straighten the spine, but much may be done to correct the general health. Yet, as in the case reported above (see case reports), it often happens that after years of deformity the spine has been materially straightened. In this disease the 'destructive processes can be quite stopped often, or greatly limited; general health is bettered, and pain is relieved. In these cases thorough attention to the general health is necessary. Also bowels, kidneys, liver, and skin must be kept well stimulated to aid in carrying off the septic products of the disease. In case of the appearance of abscess, it must be drained when it has come to a head. Such quantities of pus cannot be absorbed, and the abscess should not be allowed to break. After drainage the abscess may be entirely healed by the treatment. Various swerves in the spine, or departures from the nor- mal curves, are frequently met with. They are often called curvatures, but are not properly so regarded. Yet they may predispose to curvatures. They may be readily righted by the treatments given above. Pott's disease requires a long and patient course of treat- ment. This is often true of the ordinary curvatures, but very frequently a single month, or a few months, of treatment will show surprising results. The TREATMENT OF DEFORMITIES proceeds upon much the same general plan of treatment as described for curvatures. All the surrounding parts must be relaxed, strengthened and PRACTICE OF OSTEOPATHY. 40t5 prepared by a course of treatment directed to the complete restor- ation of circulation to the parts and tissues involved. When the preparation is completed the practitioner proceeds by ex- aggeration of lesions, traction, pressure, rotation, etc.. applied to the bony part to force it back into place. It often happens that in apparent deformity of a bony part, as of a joint, while pain and abnormal position and condition of the tissues is apparent at the joint, the real cause may be an ob- struction in the nerve and blood-supply of the joint somewhere above or at the spine. Thus apparent deformity of a knee has with much frequently been found to be due to a luxation of the hip-joint or of spinal vertebra-. A deformity, as an enlargement of a joint, may be not real but apparent by reason of atrophy of the surrounding tissues. Then the cause must be sought elsewhere for the wasting of the tissues. But the surrounding tissues often waste in cases of joint disease or deformity. It sometimes happens, as in the case of "hysterical joints" that there is no real diseased condition of the kind suspected. .Muscular and ligamentous deformities are often the results of some preceding or existing disease. In such cases treatment must be made accordingly. Locally one must direct treatment to the affected tissues te relax and restore them. On the other hand these muscular and soft tissue deform- ities are surprisingly often found to be due to a vertebral lesion, or other lesion, at the origin or in the course of the nerves supply- ing the part. In such case the treatment must embrace the re- moval of lesion as the real cause, and corrective work upon the deformed tissues. It sometimes happens in the treatment of these cases that the spinal lesion is treated to the exclusion of the local treatment upon the affected part, or that treatment is mistakenly directed to a spinal lesion not responsible for the con- dition. One will learn that he must judge of the relative import- ance of treatment directed to one situation or the other. Sometimes a minute luxation of a joint itself is the cause of the trouble. In cases of deformity due to deposits in and about joints, as in chronic rheumatism, the circulation is built up and kept stim- 406 PRACTICE OF OSTEOPATHY. ulated to absorb the deposit. In such cases it is necessary to adapt some motion to thoroughly stretching or spreading the joint in order that the renewed blood-supply may freely circu- late in the joint. Various special treatments applicable to the treatment of deformities will be found described in the general treatments for the upper and lower limbs. The TREATMENT OF DISLOCATIONS is fully described in Chap. X. Concerning the TREATMENT OF JOINT AFFECTIONS little need be added to what has been said in describing the treatment of deformities (see also the treatment of rheumatism.) Pain in a joint is often to be due to a spinal lesion or to a lesion in a re- lated joint. A very common occurrence is to discover the cause of a so-called tubercular knee, or of a swelling or synovitis of the knee-joint, in a luxation of the hip-joint. In all cases of joint affections one must look closely for lesion to nerves or vessels supplying the joint from the origin down, and remove it as the cause of the trouble. To this must be added local manipulation of the joint and its parts in order to correct proper circulation. Plaster casts and bandages are at once removed to aid in securing freedom of blood circulation. One must not forget that apparently very serious disease has often been found by osteopaths to depend upon a slight slip of the bones or cartilages of the joint affected. Treatment upon the principles laid down will usually suffice to slip these back into place. In strains, sprains, and inflammations of a joint one must free the local and the connected circulation to take down the inflammation. If applications are used, hot are better than cold. In chronic affections it is usually necessary to treat from the spine out to the joint in question, besides removing all bony lesions, adjusting all tissues, etc. Moderate use of a joint is usually advised, at discretion. The use builds up a natural condition. Cases of bony ankylosis are incurable without breaking. Llgamentous ankylosis may be cured. If any motion at all ex- PRACTICE OF OSTEOPATHY. 407 ists in a joint there is good reason for belief that it may be in- rrr;isod, possibly fully restored. DISEASES OF WOMEN. CASES: (1) Dysmenorrhcea and irregularity of menstrua- tion, with a complication of troubles in a young lady of t \vcnty- five. The lower dorsal and lumbar vertebrae were anterior. The case was cured in ten weeks, having gained 22 pounds. (2) Dysmenorrhoea in a married woman of 38. At each period she was confined to her bed, there being menorrhagia, headache, nausea, etc. The condition was of 12 years standing, since childbirth. The uterus was prolapsed and retroverted. The right innominate was posterior. The bone was replaced, the uterus put into correct position, and the case w r as discharged cured in two months. (3) Dysmenorrhoea of 3 years standing in a young lady of 21. Lesions were: 5th lumbar to the right, and surrounding tissues much contracted; 9th, 10th and llth dorsal vertebrae luxated and that portion of the spine rigid. Patient's general health was much affected. The case was cured by removal of lesion in two months. (4) Amenorrhcea. with a complication of troubles, in a woman of 22, of 13 months standing. The greatest gynecolo- gist in Cincinnati said the uterus was atrophied and she would never menstruate again. Lesions were: 7th dorsal spine to right and whole spine rather irregular; pelvis twisted with ap- parent lengthening of right limb. The case was benefited from the beginning of treatment and was cured in four months. Menses appeared in six weeks. (5) Amenorrho?a of 7 months standing in a case in which the period had been very irregular, often not occurring for three or four months. The general health was much affected. After two weeks treatment she was much better, and the menses ap- peared. Under the treatment the patient gainted rapidly in weight, the normal, period being re-established. (6) Amenorrhcea in a young woman, of over 8 months standing. Lesions were: 2nd lumbar posterior; 1st, 2nd and 3rd 408 PRACTICE OF OSTEOPATHY. dorsal lateral; 5th lumbar anterior. Treatment corrected the lesions and cured the case in three months, the patient having gained 12 pounds. (7) Amenorrhcea of more than a years standing in a young woman. Lesions: 4th and 5th lumbar anterior; luxation of 8th and 9th dorsal, and stricture of the os. Lesions were corrected and the os was relaxed by spinal work. Menstruation came on normally. (8) Menorrhagia and dysmenorrhoea. The menstrual flow started upon the least exercise. The curves of the spine were straightened, and there were many slight irregularities in it. The coccyx was lateral to the right and anterior. The case was first treated during period, and the flow ceased at once, not re- turning for four months, after which it was normal. (9) Uterine hemorrhage suddenly appearing with abdominal pains. The latter were intense and the hemorrhage profuse. One treatment entirely relieved the trouble. (10) Uterine hemorrhage, frequent and profuse, in a married woman who had previously undergone operation for the removal of uterine fibroid- tumors. The uterus was retroverted, the left innominate anterior, and the 2nd and 3rd lumbar vertebrae lux- ated. The hemorrhages ceased after the second treatment. (11) Metrorrhagia of 2 years standing. The right innom- inate was slipped upward, and its correction entirely cured the trouble. (12) Prolapsus of the uterus in a lady of 40, who had suffered with spinal trouble and dysmenorrhrea for 26 years. The pa- tient had been taking local treatment for uterine displacement and other trouble twice a week for two years. After three months of osteopathic treatment, in which time about five local treat- ments were given, the prolapsus, leucofrhcea, etc., were cured. Practically all the treatment was upon spinal lesion, the spine having been found swerved one and one-half inches laterally. It was corrected. (13) Prolapsus of the uterus, with retroversion, hi a woman of forty of sveral years standing. Lesion was a slight displace- ment of an innominate. The case was cured by local and spinal treatment. The lesion was corrected. PRACTICE OF OSTEOPATHY. 409 (14) Leucorrhcea in a married woman of thirty. Lesion: slight deviation of lower dorsal and lumbar vertebrae to the left. Upon correction of spinal lesion, in less than one month, the case was cured. (15) Leucorrhcea, congestion of the ovaries, and painful menstruation, of three years standing. The left innominate bone was luxated, and lesion also occurred at the 10th and llth dorsal vertebrae. The case was cured in four months. (16) Vaginal cyst in a woman of forty, following subin- volution and prolapsus of the uterus after child-birth three years previously. The cyst was about the size of a hickory nut, and had formed about four months previously to the time of exami- nation. Spinal lesion present was a separation between the nth lumbar and sacrum. Treatment consisted mainly in correction of spinal lesion. Local treatment was given to restore tonicity to the very lax vaginal walls, and to improve venous and lymphatic drainage. The cyst entirely disappeared by six weeks treatment. (17) Vaginal irritation due to lesion as a tilted ilium, which \vas removed and the case was cured. (18) Chronic hemorrhagic endometritis in a woman of fifty-seven, who had not walked for three years, and who, for eighteen months had been unable to sit up, as the slightest ex- ertion caused hemorrhage. The condition was of thirty years standing. Lesions: 3rd and 4th cervical vertebrae anterior, from ninth dorsal to sacrum decidedly posterior. Improvement Mas marked after one months* treatment, patient being able to walk about the house. The case was cured in three months. The patient was still well two years later. (19) Salpingitis in a married woman, multipara, who had previously suffered acute suppression of menses. The condi- tion became very acute, and operation was advised. The pa- tient was in great agony. At this point an Osteopath was called. Light spinal and local abdominal treatment relieved the pain in half an hour, and the patient slept for six hours, the first natural sleep in a number of days. She was awakened by fresh pain, caused by the natural discharge of about 1 pint of pus. Two or three light treatments were given before evening of the next day, and the soreness entirely disappeared. The patient was 410 PRACTICE OF OSTEOPATHY. able to be about that day. No return of trouble occurred. (20) Inflammation of the ovaries in a woman of twenty- six, of several years standing. For four years ordinary treat- ment had been tried. Operation was advised. Lesions: mus- cular contractures in the middle dorsal and lower lumbar regions, the whole spine being weak. The case was cured in two months. (21) Acute inflammation of the ovary in a woman of thirty- five. Lesions: 5th lumbar posterior, sacral muscles contracted and sensitive, muscular contractions in the region of the affected ovary. The case was treated twice daily for three days and was cured. (22) Ovarian colic in a case in which there had been acute attacks previously. A cold had contractured the muscles on the left side of the lower lumbar spine. The right innominate was displaced doward and forward. The patient was in great pain. Relief was immediate, and the case was cured in one treat- ment. (23) Climacteric, with dropsy and asthma, in a patient of fifty-two. For one year the patient had suffered with all the trying symptoms of the menopause. Lesions were found at the spinal connections of the cardiac, hepatic, renal, ovarian, uterine, and hypogastric plexuses. Improvement was immediate. No asthma appeared after the second treatment, the patient grew strong and was entirely cured in three months. (24) Phlegmasia Alba Dolens (Milk-leg) in a woman of twenty-three, of three weeks standing. There was innominate lesion, marked tenderness in the sacro-iliac region, and lesions at the 6th and 7th dorsal. The treatment was largely confined to the lesions, and the milk-leg symptoms disappeared in three treatments. The case was cured. When the case was taken under treatment the fever was 103, the leg was much swollen and very painful, confinement had occurred three weeks before. LESIONS AND ANATOMICAL RELATIONS. The lesions in cases of women's diseases are practically all found below the eighth dorsal. Considering the multiplicity of diseases it is interesting to note that they are almost without. PRACTICE OF OSTEOPATHY. 411 exception traced to actual spinal lesion at the centers controll- ing the pelvic viscera, or upon the closely related nerves. Le- sion is as near specific in this class of cases as in any. (Jenerally speaking, lesion may be expected anywhere among the lower three or four dorsal vertebra? and corresponding ribs, among the lumbar vertebra^, at the lumbo-sacral articulation, at the innominates, sacrum and coccyx. It is very common to find lesion at the 9th, 10th, or llth dorsal, affecting the center of blood-supply to the ovaries; at the 2nd lumbar, affecting the blood-supply to the uterus; and at the 4th and oth lumbar, at which point lesion is particularly apt to occur affecting the hypo- gastric plexus, and through it the pelvic viscera. Cases have been observed in which a displaced lower rib irritated an ovary and caused disease in it. The oth lumbar lesion is perhaps the most frequent one, it Ix ing at the same time a weak point ana- tomically, therefore particularly liable to lesion, and in important relation to the hypogastric plexus. Innominate lesion is perhaps the next most frequent. Its relation to the sacral nerves, which are so closely connected with the pelvic viscera, accounts for its importance. Such lesions as have been pointed out as the causes of enter- optosis and prolapse of the diaphragm become important causes of prolapsus of pelvic viscera by pressure from above, and by weakening the supports of these organs, also of congestive dis- turbances such as must follow in such a state of affairs. In female diseases one should look for lesion especially at the 5th lumbar, at the innominates, at the 2nd lumbar, and about the 9th, 10th. and llth dorsal. There is sometimes irri- tation of the internal pudic nerve where it emerges from the pelvis to cross the spine of the ischium. The ovarian vessels are frequently obstructed by enteroptosis, especially by ptosis of the transverse colon. In menstrual disorders lesions occur from the 10th dorsal to the 4th or oth sacral, and among the lower ribs. Painful menstruation is often found to be due to lesion at the 5th lumbar and at the innominates. The lesions as described are seen to be at points where they interfere with the nerve-connections and circulation of the pelvic 412 PRACTICE OF OSTEOPATHY. viscera. There are two groups of vaso-motor nerves for the genitalia, one in the lumbar region and the other in the sacral, as pointed out in the American Text-Book of Physiology. For the external genital organs vaso-motor fibres rise from the 2nd, 3rd, 4th, and 5th lumbar nerves, run forward in the white rami communicantes, and pass through the pelvic plexus and pudic nerve to reach the organs they supply. From the anterior roots of the sacral nerves rise vaso-motors which, when stimulated. dilate the vessels of the external genitals. Vaso-constrictors for the fallopian tubes, uterus, and vagina in the female, and for the vasa deferentia and vesiculae seminales in the male, are found in the sacral nerves. The 2nd, 3rd, 4th, and oth lumbar nerves send vaso-motor fibres to the internal, as well as to the external gen- itals. According to Quain's anatomy, it is probable that sensory nerves pass through the sympathetic, those supplying the ovary from the 10th dorsal; those supply the uterus (a) in contraction, from the llth and 12th dorsal and 1st lumbar, (b) os uteri, (1st), 2nd, 3rd, 4th sacral , (5th lumbar rarely.) It is seen that these points have been found as the seat of lesion in pelvic disorders. This sensory innervation is made practical use of in pelvic dis- orders. Often by preliminary inhibition along this spinal re- gion pain is quieted. Quain's' anatomy also notes motor fibres for the uterus passing into the sympathetic from the lower dorsal and upper one or two lumbar nerves, and reaching the. uterus via the aortic plexus, the inferior mesenteric ganglion, hypogastric and pelvic plexuses. Also motor fibres to the uterus descending from the lumbar region and terminating in the sacral ganglia. It is at once seen that lower dorsal and upper lumbar lesion is important, as it affects this distribution via the inferior mesenteric ganglion. The other lumbar lesions are also seen to be important. According to Foster's physiology, stimulation of the in- ferior mesenteric ganglion causes circular contractions of the uterus, with descent of the cervix and dilatation of the os. Stim- ulation of the sacral nerves contracts the longitudinal fibres, shortens the cervix, and closes the os. These various motor effects are used by the Osteopath in PRACTICE OF OSTEOPATHY. 413 both gynecology and obstetrics, for example, he stimulates the sacral nerves to contract the uterus and lessen hemorrhage, or he stimulates the upper lumbar to gain dilatation of the os. By treatment to the lumbar and sacral regions he regulates the blood-supply through the vaso-motor innervation described above. Inhibition of the clitoris is held to relax the circular fibres of the cervix and dilate the os. Inhibition at the 4th sacral nerve is used to relax the vagina. The TREATMENT of female disorders is eminently successful. It will be seen from the above description of lesions and of ana- tomical relations that osteopathy can gain control of the motor, vaso-motor, and nervous mechanisms of the liver. A knowl- edge of these, and proper treatment of them in a given case are all that is necessary. A study of the facts above in regard to nerve-supply, lesion, and case reports, will enable one to work out proper treatment for a given condition. In any case the removal of lesion as soon as possible is of the utmost importance. Frequently this is the only treatment necessary. Quite generally, the removal of lesion, together with a little spinal and abdominal treatment are found to be sufficient for complicated cases. In any painful case one must first make thorough spinal inhibition from the ninth dorsal to and including the sacral nerves. In this way all the sensory nerves noted above are reached. Often this preliminary treatment is used to great ad- vantage in allaying the local pain to such an extent as to allow of local or abdominal treatment which before could not be en- dured. The osteopathic method of examination and treatment of the uterus and vagina locally has been described in Part I. In cases of suppression of menses the treatment must look to the removal of the lesion obstructing the circulation. This must be expected particularly along the region described above as the location of the vaso-motors for ovaries, uterus, etc., i. e. r along the 5th to 12th dorsal, all the lumbar, and all the sacral region. Examination must also be made for pressure of an ab- dominal organ, such as the transverse colon, upon the ovarian 414 PRACTICE OF OSTEOPATHY. artery. In any case it is well to work carefully down along the course of this vessel, beginning a little above the level of the umbilicus and proceeding downward to the pelvis. Usually in these cases it is sufficient to give a thorough, strong, stimulating spinal treatment, from the 9th dorsal down to the sacrum. It is not advisable to include the sacral nerves in this treatment, as their stimulation contracts the uterus and closes the os. It is better to relax the tissues over them and to inhibit them. During the spinal stimulation all spinal parts and tissues should be carefully relaxed and sprung. This treatment in- cludes stimulation of the llth and 12th dorsal and 1st and 2nd lumbar, by way of which effect is gotten upon the connections of the inferior mesenteric ganglion, stimulation of which aids in dilating the os. One may also treat this ganglion directly by deep abdominal treatment over its site, it lying upon the inferior mesenteric artery a little below and externally from the umbilicus. Further treatment may be made down over the course of the common and internal iliac vessels, stimulating their flow. The clitoris should be inhibited, and the uterus should be replaced if prolapsed. Inhibition may be made upon the pudic nerve where it crosses the spine of the ischium. Sometimes dilatation of the cervix and os uteri aid the case. The same treatment applies to scant menses. In many of these cases the general health suffered severely. Particularly is one apt to find the lungs involved in cases of any length of standing. Careful attention must be given the lungs and the general health. Irregular menstruation is generally corrected by such a co'urse of treatment. In DYSMENORRHCEA the first step is to apply the strong spinal inhibition along the area of sensory innervation described above. Careful and moderately strong inhibition applied at successive points from the middle dorsal down, given in such a way that the spine is sprung and held at each point for two or three minutes, has the effect of relaxing the spinal tissues, re- lieving the irritation and gently starting the flow. Commonly a little trying will indicate a certain point in the spine at which PRACTICE OF OSTEOPATHY. 415 inhibition gives immediate relief. This point is different in the different cases. Dysmenorrhoea is generally relieved by a treatment which gently starts the menstrual flow. Quite commonly these cases are due to retarded circulation. Hence one must do gentle ab- dominal manipulation over the vessels and tissues concerned. It is also often advisable to give a light spinal stimulation, as above, with this purpose in view. A common cause of dysmenorrhoea is sudden stoppage of the flow by malposition of the uterus, leading to congestive ob- struction of the circulation. In such cases it is necessary to carefully replace the uterus. Local treatment must, however, be avoided at time of menstruation except in cases of the most urgent necessity. Often the treatment given, as described, gives instant relief. It is sometimes necessary to give a general spinal treatment to quiet the nervous system, as nervous disturbances may cause dysmenorrhoea. In cases due to cold a thorough general treat- ment, including stimulation of heart and lungs, may be added to the treatment outlined above. In these cases a hot tub bath or hot vaginal douches may be the only aid required. In menorrlwa, metrorrhagia and uterine hemorrhages often there is a specific lesion of the innominate present. The innom- inates should be adjusted, at the symphysis pubes as well as at the articulation with the sacrum. A special treatment recommended in these cases is to place the knee against the sacrum and pull backward upon both innominates. Obviously one must have in view the removal of the cause, whatever it is, and the stanching of the hemorrhages by the contraction of the blood-vessels. Often a quick, rather hard jerk, at the hairy covering of the mons veneris is sufficient to contract the vessels and stanch the flow. Quick and rather forcible stimulation of the round lig- aments where they cross the pubic arch, about an inch each side of the symphysis. will help. Stimulation of the clitoris and strong stimulation of the sacral nerves contract the uterus, cervix, and os, and are important means of stopping the flow. One should avoid stimulation of the lower dorsal and lumbar regions 416 PRACTICE OF OSTEOPATHY. of the spine. In some cases compression of the common and in- ternal iliac arteries is helpful. Deep pressure is to be made upon them and continued for considerable time. In some cases good results have been gotten in this way. Injections of very hot or of cold water are often useful. The patient should be on her back with the hips elevated. This quiets the heart and aids the venous drainage. Vicarious Menstruation yields to the treatment directed to re-establishing the normal menstrual function. It should at the time be treated as any hemorrhage, according to the place at which it appears. Prolapsus Uteri and the various displacements are consid- ered in Part I. In case of adhesions with prolapsus, it is the aim to gradually stretch and break them down by carefully stretch- ing the organ away from them. This may be generally accom- plished. It is done by local treatment. It is probable that this process is in part an absorption of the adhesive tissues by the renewed circulation, as in case of fibroid tumors, etc. To strengthen the ligaments to hold the organ in place, treatment must look to the removal of lesion, the spinal and ab- dominal stimulation of the blood-supply, and the strengthening of the perineum. Stimulation of the pudic nerve at the spine of ischium aids the latter object. In young girls stimulation of the round ligaments and external abdominal treatment to the iliac blood-supply, etc., is usually quite sufficient for a cure. In cases of Leucorrhoea the object is to correct circulation and prevent the abnormal secretions. The condition is usually due to obstruction of the vaginal circulation, and quite often occurs along the lower lumbar or sacral region. Its removal usually soon results in cure. Often the local circulation is im- peded by a prolapsed uterus, resulting in leucorrhcea. In such cases cure of the prolapsus is necessary. Lumbar and sacral stimulation, and abdominal treatment about the deep pelvic vessels aid in correcting the circulation. Cleanliness is essential. Hot vaginal douches are useful. In Congestive Disturbances of the Ovary and Ovaritis, correc- tion of the circulation is the main object. The abdomen is apt to be quite painful in the region of the ovaries, and it is necessary PRACTICE OF OSTEOPATHY. 417 first, often, to make spinal inhibition along the course of the sen- sory nerves. After this careful abdominal treatment may be given, relaxing all the local abdominal tissues and thus freeing the local circulation. The work should be carried up along the course of the ovarian vein, which accompanies the ovarian artery above described. A certain amount of spinal stimulation is useful in the correction of circulation. The treatment for the fallopian tubes is local and spinal of the kind described. In all cases of pelvic disorders it is well to see that the lower ribs are well raised, and that no obstruction to circulation from the lower abdomen occurs at the diaphragm. The treatments given to raise the abdominal' and pelvic viscera are also helpful. (Chap. VIII). For the treatment of ovarian and uterine tumors see "Tu- mors. ' ' For the Climacteric treatment is largely symptomatic, to relieve the headache, hot flashes, nervous disturbances, etc. A constitutional treatment is given, with special attention devoted to the spinal system, to strengthen the nervous system and to quiet nervousness. Local treatment to the uterus is not nec- essary unless local trouble exists. Care should be taken not to bring on the menstrual flow by hard treatment in the lumbar and sacral regions. In Phlegmasia Alba Dolens (Milk-leg) the treatment con- sists in the removal of lesion and the correction of circulation to the limb. The adjustment of innominate lesion, or of a lux- ation of the hip-joint, and the relaxation of the pelvic muscles may be all the treatment necessary. These causes act as ob- structions to the nerve and blood-supply and cause the trouble. The thigh should be flexed and rotated, and treatment may be given as for varicose veins, q. v., to aid in the venous return from the limb. OBSTETRICS. It is not the object here to deal with the conduct of a case of child-birth. That is left to special works upon the subject. It is sufficient, within the scope of this \vork, to give the special 418 PRACTICE OP OSTEOPATHY. osteopathic points in connection with obstetrical work. It is the common practice, during the early stage of labor, after the true pains have commenced, to hasten labor, if desir- able, by stimulation at the parturition center at the 2nd lum- bar. This increases circular contractions in the uterus, causes descent of the cervix, and dilatation of the os. It is usually best to rely upon the natural process of labor and very often this treatment is not used. Later one may aid the further dilatation of the os by inhi- bition of the clitoris. This is accomplished by pressure over the lower part of the pubic symphysis, between the labia. In- hibition of the round ligaments is also used for this purpose. For severe pains in the back, desensitize about the 5th lum- bar and relax the neighboring spinal tissues. If the bearing down pains do not come regularly and hard enough, one should give occasional firm stimulation in the re- gion of the second lumbar. As the head is descending the finger should be used to press back the edges of the os all around the head. Also, in case of folds in the vaginal walls, they should be kept smoothed out, and the walls should be pressed well up and outward all around. If these folds occur they cause great pain an-i headache. To prevent laceration of the perineum, both hands should be applied to the pelvis. One presses the tissues down over the pubic arch and inhibits the clitoris, while the other grasps the two tubers ischii and springs them toward each other, at the same time supporting the perineum. As the head is born the hand makes pressure against it, as required, to prevent its coming with too great force. When the afterbirth is ready for delivering, slight stimula- tion at the upper lumbar will aid it if necessary. If necessary, a quick pull at the mons veneris will aid in expelling it. A cough will sometimes be sufficient to start it. After it is born the hand should be placed upon the abdom- inal wall and support the uterus until it is well contracted and hard. Desensitize the clitoris to stop after pains. PRACTICE OF OSTEOPATHY. 419 It is well to flex and circumduct the limbs carefully, be- fore leaving a case, to see that there are no slips at the hip- joints or excessive contractures of muscles, which may lead to milk-leg. DISEASES OF THE MALE GENERATIVE ORGAXS. CASES: (1) Orchitis, in a young man, following muscular strain. Lesions: 4th lumbar posterior, 5th lumbar anterior, left iliac very painful. The left testacle was affected. The treatment at once gave relief. The lesion was corrected and the case was cured. (2) Orchitis due to lesion at the 10th and llth dorsal ver- tebrae. The patient was in intense pain and the testacle was greatly swollen. Relief was immediate, and cure as well, upon removal of lesion. (3) Edematous swelling of the prepuce in a boy. following accident in which the innominate bone was luxated. Its cor- rection cured the case. (4) Impotence; lack of power to secure erection in a man suffering from marked contracture and soreness of the lumbar muscles, due to being on the feet too much. One treatment re- laxed the muscles and overcame the difficulty. (5) Impotence and splenitis. Lesions: Oth. 10th, and llth left ribs depressed; posterior curvature in the dorso-lumbar region, prostate gland atrophied. The case was cured in four months. (6) Impotence in a man of fifty-one, of three to four months standing. Lesions: 4th and 5th lumbar turned to the right. 1st lumbar to the left. 4th dorsal vertebra to the right. The patient had tried medicine, electricity, and hydrotherapy with- out avail. He was cured by six weeks treatment. (7) Varicocele in a case which had tried medical treatment without success, and in which operation was recommended. It was entirely cured by osteopathy in five weeks. (8) Enlarged prostate gland in a man of seventy-eight, causing retention of urine and cystitis, for which he had been unsuccessfully treated for many years. Treatment reduced the gland, and the case entirely recovered. 420 PRACTICE OF OSTEOPATHY. (9) Enlarged prostate in a man of sixty-eight, who for several months had suffered with some retention of the urine. The prostate was reduced by a few treatments and the case was cured. (10) Prostatitis and stricture of the urethra in a man of forty. He had had an operation for the stricture, but it w r as unsuccessful. There was great pain upon urination, and Avrnk- ened sexual power. The case was entirely cured in two months. (11) Gonorrheal prostatitis in a young man. Operation had been unsuccessful. The prostate was enlarged and hard. It was reduced by treatment and the case was cured. LESIONS AND ANATOMICAL RELATIONS in diseases in the male generative organs occur in positions corresponding to le- sions pointed out in female pelvic diseases. These lesions occur from the 8th or 9th dorsal down, including the lumbar, lumbo- sacral, and innominate lesion. The lower lesions seem to be the more important ones. It is to be noted that vaso-motors for both external and internal genitals occur in the male in the same regions as de- scribed in female diseases, at the 2nd, 3rd, 4th and 5th lumbar and at the sacral nerves. The sympathetics convey to the prostate sensory fibres derived from the 10th, llth, (12th) dor- sal; 1st, 2nd, 3rd sacral, and 5th lumbar; and to the prostate from the 10th dorsal. (Quain). For the epididymis sensory fibres are derived from the llth and 12th dorsal and 1st lumbar. It is readily seen that the lesions usually found in male gen- erative diseases fall within these areas of innervation. TREATMENT: In all these cases it is necessary to bear in mind the anatomical relations of lesion to disease, and to see that such lesion is removed. In a good many of these conditions the removal of lesion is all that is required. After removal of the irritating cause, spinal and abdominal treatment of the kind described for female diseases is usually helpful. The treatment for the prostate has been described in Part I. In cases of prostatitis the treatment must be carefully applied locally, and it should be directed particularly to freeing the tis- sues about the gland. Great case is necessary not to irritate the structure. Abdominal and spinal treatment may be added. PRACTICE OF OSTEOPATHY. 421 For Orchitis the treatment is mainly in removal of lesion. This immediately relieves and usually cures the case. Spinal and abdominal treatment may be directed to the relaxation of tissues, relief of tension, and correction of circulation. The tissues about the inguinal canal should be kepi relaxed to main- tain free drainage from the testacle. Treatment should be carried well up along the spermatic vein, terminating on the left in the renal vein and on the right in the inferior vena cava at about the same level. The abdominal viscera may be raised to aid free circulation. The patient should remain quiet. If the case is severe he may lie upon his ba-ck with hips elevated. The irritating pressure of clothing, etc.. should be avoided. In case of Varieoeele the object of the treatment is to empty the over-distended veins, to strengthen the vessels, and to re- move the causes which obstruct the circulation. Lesion in the lower lumbar and sacral region is usually present and weakens the vaso-nv.)tor innervation of the parts. Allowing of sluggish circulation and venous engorgement. The lesion must be re- moved, and spinal treatment is made to strengthen the v a so- motor supply. The veins are stripped to empty them, and the manipulation is carried up over the spermatic vein to its con- nection with the renal vein. Care must be taken to see that the tissues about the inguinal canal do not obstruct the veins, also that pressure from the abdominal viscera i> entirely removed. To this end the bowels must be kept free and the abdominal contents should be raised as before directed. In some cases surgical interference may be necessary, yet on the other hand cases have been saved from operation by the treatment. Impotence and Spermatorrhoea have been very successfully treated. In some cases thorough relaxation and stimulation of the spinal musculature and nerves from the middle dorsal region down is the only treatment necessary. In other cases the removal of innominate lesion and the stimulation of the sacral nerves has been successful. It is well to have the patient lie on the side and then strong pressure is made with the knee in the sacro-iliac articulations, springing them freely. In these cases lesion at the region of the genito-spinal center 422 PRACTICE OF OSTEOPATHY. in the cord (1st and 2nd lumbar) is sometimes present and re- sponsible for the trouble. A good point of treatment is to stimulate the perineal nerve where it crosses the spine of the ischium. This strengthens the erector muscle of the penis. Enlargement of the prostate gland is sometimes closely associated with these conditions, and it should be reduced according to directions given above. All causes of reflex irritation, as from an elongated prepuce, constipation, nervousness, etc., must be removed. It is quite necessary in most cases to direct general treatment to the quiet- ing and strengthening of the nervous system. In these nervous cases it is well to place the patient upon a simple diet, with the avoidance of stimulants and excitement. Cold baths, exercise, and outdoor life are helpful. GONORRHCEA AND SYPHILIS. Some cases of syphilis and a number of cases of gonorrhoea have been treated osteopathically. Some success has been ap- parent in the treatment of syphilis, the patient at the time being considerably bettered or gaining, entire relief from the symptoms with which he was suffering. Extended observation of these cases, however, has not as yet become a matter of record. Gonorrhrea is usually readily cured without the usual se- quelse. The special treatment is to the blood-supply upon the lines laid down, with the idea of controlling the circulation and reducing the inflammation. Constitutional treatment is given, and liver, kidneys, and bowels are kept active to aid in getting rid of the poisons. TUMORS. CASES: (1) Ovarian tumor, upon which operation was advised, cured by two months treatment. (2) Uterine fibroid tumor, the patient having for sixteen years suffered intensely at period. Surgeons were about to operate upon the case, when it was decided to try osteopathy. After four treatments the period was passed without any dis- comfort. After three months treatment the tumor had disap- peared. PRACTICE OF OSTEOPATHY. 423 (3) Intestinal fibroid tumor. There was a history of con- stipation, and colicky pains for a number of weeks, constantly increasing in severity and frequency, and leading finally to spasms. The abdomen was much distended with feces and gas; the 10th, llth and 12th ribs were displaced downward. The tumor could be deeply palpated in the left side of the abdomen, at the level of the crest of the ilium. The colon was cleared with repeated enemas of water and oil. As the tumor still remained an operation was decided upon. But, before the day set. the tumor loosened under osteopathic treatment, and was passed from the rectum. It was in size lH by 1 ] 4 inches. It was examined by leading physicians who pronounced it fibroid tumor. (4) A tumor upon the back of the neck, due to a much en- larged sebaceous gland, had been growing for ten years. Treat- ment was directed to softening the contents of the gland until able to pass it through the duct, the passage being facilitated "by removal of the hair into the follicle of which the gland emptied. Under the treatment the tumor had been much reduced at the time of report. (5) A tumor of the brain, so-called, was a condition found to be due to a displacement of the atlas and a great contraction of the cervical muscles. The head was drawn backward, the giddiness, insomnia, and ocular disturbances were present. The condition seemed likely to lead to insanity, and leading physicians diagnosed it as a tumor upon the brain. Correction of the le- sion cured the case, and the diagnosis of cerebral tumor was shown to be wrong. (6) An abdominal tumor in a lady, the waist measuring 46^ inches, and increasing at the rate of one inch per week. Le- sion was found at the oth dorsal, also at the llth, and the left ribs were luxated. The tumor appeared to be as large as a cocoa- nut. At the end of one months treatment the growth had been stopped and the waist measurement was reduced one inch; at the end of 2 months, the waist was 31 ] ^ inches, and had reached nearly normal size. The treatment Avas continued for three months longer, and the case was discharged cured. (7) A tumor of the breat. about the size of a walnut, very 424 PRACTICE OF OSTEOPATHY. hard and involving the center and deep portion of the gland. Sharp pains radiated in all directions from the tumor, but mostly toward the axillary region. The condition was found to be an engorgement due to ob- structed vessels, with which the gland is richly supplied. The lesion was a twist of a clavicle, narrowing the space between the clavicle and first rib, and caused by using a crutch for a lame leg upon the same side as the lesion. Thus was caused an obstruc- tion to the lymphatic drainage of the breast, and the growth resulted. As a preliminary measure the limb was cured and the use of the crutch was dispensed with. The clavicle was righted and the growth began to be absorbed. The case was cured in seven weeks. (8) A tumor just external to the vaginal orifice, of four months standing. There was a fluid contained in the tumor, and it varied in size, becoming smaller after the patient had re- mained in a recumbent position for a few days. There was pro- lapsus of the uterus and lesion among the lumbar vertebrae. The case was cured in two months. (9) An ovarian tumor in a patient, from whom, two years previously, the left ovary and a tumor weighing twenty-five pounds had been removed. A few months later a tumor ap- peared upon the right ovary, and operation was advised. After a month and a half of treatment the tumor had disappeared. (10) Fibroid tumors of the uterus in a patient who had, four years previously, been injured in the left side by a vicious cow. The patient was suffering from heart and bowel troubles, and female diseases. Various spinal lesions were found. By four treatments the tumors were loosened and passed, there being several of them, varying in size from that of a hen's egg to that of a walnut. The PROGNOSIS, generally speaking, to benefit or cure various tumors by osteopathic treatment is good. Numerous cases have been saved by this means from the surgeon's knife. While many tumors cannot be cured, the treatment merits a trial in every case before operation be submitted to. The LESIONS are various bony, muscular, and other ob- structions to blood and lymph flow, or to nerve-supply. Some PRACTICE OF OSTEOPATHY. 425 lesions cause tumorous growths by direct irritation of the tis- sues. A frequent cfause of tumors is found in lesion to the lym- phatic drainage of a part, through direct pressure upon its lym- phatic vessels or by constrictor effect upon them by lesion to the vaso-motor and sympathetic nerve-supply. Tumors of the breast are very often due to such a cause. The common lesions in tumor of the breast are found at the clavicle, first rib, among the upper five or six ribs, or among the corresponding vertebrae. Abdominal tumors are commonly caused by lower rib and lower vertebral lesions, uterine tumors by sacral or lumbar lesions, etc. The simple TREATMENT is to remove lesion, correct lym- phatic and blood drainage, or remove any source of direct irri- tation upon the tissues. Correcting anatomical relation is the main point, and commonly no manipulation directly upon the tumor is required, yet such a measure is sometimes employed to soften a fatty tumor and aid in its absorption, or to loosen a fibroid growth, several such having thus been loosened and dis- charged per rectum or per vaginam. One instance is recorded in which external treatment upon the nose loosened and caused the discharge of a cancer in the upper nasal passage. It is a point worthy of note that in many instances fibroids, according to all evidences, have been absorbed by the renewed blood-currents. It indicates that new fibrous tissues, once formed, mav be absorbed under the treatment. 426 PRACTICE OF OSTEOPATHY. Index. PAGE Abdominal aorta ...................................... 52 Abdomen, general treatment of .......................... 53 Abdomen, osteopathic points of .......................... 52 Abscess, of kidneys .................................... 222 of liver ......................................... 197 Acidity of stomach .................................... 143 Acute yellow atrophy of liver ........................... 199 Acute nasal catarrh .................................... 105 Adhesions, uterine .................................. 66, 416 Alba dolens .......................................... 417 Albuminuria .......................................... 223 ; Alcoholism ........................................... 395 Alveolar emphysema ................................... 1 03 Amyloid degeneration of kidney ......................... 214 degeneration of liver ............................. 119 Angina pectoris ....................................... 251 Aneurysm ............................................ 263 cerebral ........................... . ............ 311 Ankle, dislocation of ................................... 72 Ankylosis, bony and ligamentous .................... 406, 407 Apoplexy .............................................. 308 Appendicitis .......................................... 167 Arrythmia ............................................ 249 Arterio-sclerosis ..................................... . . 262 Articulation, tempero-maxillary ......................... 27 Ascaris lumbricoides ................................... 393 Ascending paralysis, acute .............................. 311 Ascites ............................................... 183 Anemia .............................................. 349 Arthritis deformans ................................... 359 Asthma .............................................. 75 Ataxia, locomotor ........................ j ............ 280 Ataxic paraplegia ...................................... PRACTICE OF OSTEOPATHY. 427 Atlas examination of 23 treatment of 2& Atony of stomach 143 Autumnal catarrh (See Hay Fever) 85 Axis 24 B Bell's paralysis -. 300 Bladder, inflammation of 22."> Bleeding from nose 36 Blood disease 345 Bloody flux 392 Brachycardia 249 Brachial plexus 25 Bright's disease, acute 210 chronic 212 Bronchiectasis 84 Bronchitis 80 Bony ankylosis 406 '' Breaking up" treatment 311 Bulbar paralysis 16 C C'alculi, renal 219 Cancer of liver 119 Cancer of stomach 144 Cardia, spasm of 1 42 Cartilages, palpation of 21 Carpo-metacarpal dislocations 6& ( 'ataract C'atarrh, nasal 105 Catarrh, ear 35 Catarrh, autumnal 85 Catarrhal croup 371 Catarrhal Enteritis 158 fever, epidemic 375 pneumonia 97 Cerebro-spinal fever 391 Cephalodynia 27<> Cerebro-spinal meningitis 391 428 PRACTICE OF OSTEOPATHY. Cerebral hemorrhage 308 aneurysms 263 apoplexy 308 Cervical vertebra 23 Cerumen of ear 33 Children, diarrhreas of 160 Chickenpox , 388 Cigarette habit 395 Cholera morbus 161 infantum 161 Cholangitis 195 Chorea 267 Circulatory system 230 Cirrhosis of the liver 189 atrophic 190 billiary 190 malarial 191 hypertrophic 7 191 Clitoris, inhibition of 413 Clavicle treatment of ."> 1 Climacteric 417 Coccyx, treatment of 18 Coccygodnia 320 Colds 105 Colic 1 59 Colitis mucous 161 simple ulcerative 157 Colon 149 Comparison of limbs 60 Comparison of size of thorax 38 Congestion of kidney 215 Constipation 145 Congestion of liver 188 lungs 97 ovaries 416 Contractures of spinal muscles 10 Conjunctiva 31 Consumption, pulmonary 93 PRACTICE OF OSTEOPATHY. 429 Constitutional diseases 353 Convulsions, infantile 213 ursemic 224 Crepitus of vertebra 24 Cricoid cartilage 21 Croup 371 Croupous enteritis 158 Curvatures of spine 8 Cystitis 225 D Deafness 34, 342 Deformities 40, 398 Delirium tremens 396 Deviation of spine 8 Deformities of sternum 40 Diabetes mellitus and diabetes insipudus 365 Discharges from ear 35 nose 105 Diarrhoea 150 of children 160 nervous 150 Diphtheria 370 Displacements of spine 9 Diseases, infectious 370 Disease, Pott's 402 Dilatation of stomach 142 of heart 261 Dislocations of ankle 72 carpo-metacarpal 68 carpal 68 of elbow 67 of hip 73 of knee 72 metacarpal-phalangeal 68 phalangeal 68 radio-ulnar 68 of shoulder 69 of vertebra 16 430 PRACTICE OF OSTEOPATHY. of wrist 68 Duodenal ulcer 155 Dyspepsia 142 Dysentery 392 Dysmenorrhoea 414 E Ear, -discharges from 35 drum of 33 cerumen of 33 examination of 33 itching and tenderness 33 Ear diseases 339-44 Edema of lungs 98 Elbow, dislocations of 67 Emphysema 103 Endocarditis 252 Enteritis 150 Entorrhagia 156 Enterospasm 161 Enteroptosis 175 Enuresis 227 Epilepsy 271 Epistaxis 110 Esophagus, spasm of 132 stricture of 132 Esophagitis 131 Equilibrium of spine 20 Erysipelas 385 Eustachian tubes 33 Exaggeration of lesions 13 Examination, general 8 of atlas 23 of innominates 58 of larynx 21 of limbs 67 of neck 19 of plevis 36 of rectum . . 63 PRACTICE OF OSTEOPATHY. 431 Examination of spine 7 of thorax 38 of trachea of vagina 64 Exhaustion, heart 397 Exudative nephritis 212 Eye, treatment 31 foreign bodies in 31 diseases of 328 F Fallopian Tubes 412 Fatty degeneration of heart 255 of kidney 214 of liver 198 Female disorders 407 Fever, cerebro-spinal 391 epidemic catarrhal 375 scarlet 389 spotted 391 thermic 397 typhoid 380 Fifth lumbar vertebra, treatment of 17 Fifth nerve, branches 32 treatment of 32 Flatfoot 320 Flux, Bloody 392 Folicular ulcer 156 Foreign bodies in nose 36 in eye 31 French measles 388 G Gallstones 191 ( lastralgia 138 Gastritis, acute 133 chronic 133 Gastroptosis 1 44 Generative organs, male 418 Genitalia. vaso-motors of. . 412 432 PRACTICE OF OSTEOPATHY. German measles 388 Glands, thyroid 21 cervical lymphatic 21 Gout 360 Gonorrheal arthritis 358 Glossitis 118 Gluteal arteries 62 Gonorrhoea 422 Granulation of Eye 32 Growths of nose 36 Gynecology 407, 413 H Hardening of Spinal Muscles 10 Hay fever 85 Head...' palpation of 28 position of 20 rotation of 22 temperature 22 Head mirror, use of 33 Hearing, impaired 34 test for 34 Heart, diseases of 230 Heat stroke 397 Hematurea Hematozoon of Leveran 393 Hemorrhage, cerebral 309 intestinal 156 of lungs .' 100 of spinal cord 310 of stomach 144 uterine 415 Hemorrhagic infarct 100 Hemothorax 114 Hip, dislocation of 73 Hydrocephalus 311 Hydroperitoneum 183 Hvdrothorax . . 114 PRACTICE OF OSTEOPATHY. 433 Hyoid bone 20 treatment of 28 muscles, treatment of 21 Hyperacidity of stomach 143 Hypertrophy of liver 198 Hypertrophy of heart 260 Hypogastric plexus 63 I Iliac blood vessels 63 Impotence 421 Infantile convulsions 313 paralysis 309 Infectious diseases 370 Influenza 375 Innominate bone, treatment 58 Insanity 323 Insomnia 293 Insolation 397 Inspection of spine 7 of tonsils 20 Interstitial nephritis 212 Intestinal neuroses 157 obstruction 171 parasites 393 tumors 166 ulcer 156 Intussuseption Intoxications, The , 395 J Jaundice 185 Joint affections 398 K Kidney, abscess of 222 amyloid 214 congestion of 215 fatty degeneration of 214 movable 222 Knee-chest position 54 28 434 PRACTICE OF OSTEOPATHY. Knee, dislocation of 72 L Lagrippe 375 Laryngeal tenderness 21 diphtheria . 371 Laryngitis 116 Lateral deviation of spine 8 Ligaments, lesions of 10 tenderness of 60 Ligamentous ankylosis 406 Lateral structures of neck 23 treatment 28 Leg, milk 417 Leveran, Hematozoon of 393 Leucorrhoea . 416 Limbs, comparison of length 60 Lightning stroke 398 Lithemia 223 Liver, abscess of , 197 acute yellow atrophy of 199 amyloid, infiltration of 199 cancer of 199 cirrhosis of 189 fatty degeneration 198 hypertrophy of 198 sclerosis of 189 Locomotor ataxia 280 Longitudinal traction of spine 13 Lumbricoides, ascaris 393 Lungs, congestion of 97 Lumbago 358 Lungs, edema of 98 hemorrhage from 100 tuberculosis of 93 Luxations of ribs, treatment 47 of sternum 40 M Male generative organs 419 PRACTICE OF OSTEOPATHY. 435 Malaria 378 Manipulation of coccyx 18 of hyoid bone 28 of spine 12 Maxillary, inferior, in whooping cough 375 Mastodynia 320 Measles, French, German 386-378 Metacarpal phalangeal dislocations 68 Menses irregular, suppressed 413-414 Men, diseases of 418 Meningitis, cerebro-spinal 391 Menstrual disorders 411-414 Menstruation vicarious 416 Middle cervical ganglion 26 Migraine 276 Milk leg 417 Motor neuroses 160 Mucus enteritis 158 Mumps ' 127 Morphine habit 395 Muscles, diseases of 316 stretching of 15 of spine 10 Myotonia congenita 316 Myocarditis 250 Myxedema 352 N Neck anterior 19 lateral structure of 23 palpation of : 20 posterior structures of 23 posterior aspect of 19 treatment of 28 thickening of tissues 25 Nephritis acute 210 chronic 212 Nephroptosis 222 Nephrolithiasis 21 436 PRACTICE OF OSTEOPATHY. Nerves, auricular 25 brachial 25 fifth 32 laryngeal 21 middle cervical 26 occipital 25 phreni c '2'2 pneumogastric 21 recurrent laryngeal 21 superior laryngeal 21 superior cervical ganglion 25 Nervous dyspepsia 142 Neuralgia 316 Neurasthenia 289 Neuritis localized 322 brachial 322 multiple 323 Neuroses, intestinal 157 motor 160 occupation 285 secretory 158 sensory 159 Nose, bleeding from 36 examination of 35 foreign bodies in 36 growths in 36 secretions 35 treatment 36 O Occupation Neuroses . 285 Obesity 362 Obstetrics 407, 413, 418 Opium Habit 395 Orchitis 421 Ovaries 411,416 Ovaritis 416 Osteopathic points of abdomen 52 head . . 7 PRACTICE OF OSTEOPATHY. 437 Osteopathic work per rectum t> :> > vagina 04 Oxyuris vermicularis :'>'.):> P Paralysis 297 ascending 311 agitans 284 Imlbar 311 infantile 312 penman's 280 of cartilages 21 neck 20 spine 8 Parasites 393 Pancreatitis, acute 201 chronic 127 Paratitis 8 Patient, general examination of Pelvic plexus 03 Pelvis, examination of 55 Peritonitis 178 Perforation of ear drum 33 Perineum 07 Pert ussis 373 Phrenic nerve 22 Phlegmasia alba dolens 417 Pharyngitis : . . . 228 Phalangeal dislocation 08 Pianist's paralysis 280 Pin worms 393 Pleurisy Ill Pneumonia 93 Pneumo thorax 114 Points of spinal weakness ~ . 10 Position of waist line 01 of head - 20 Posterior iliac spine GO Pott's disease . . 402 438 PRACTICE OF OSTEOPATHY. Posterior structure of neck 23 aspect of neck .- 19 Prolapsus uteri 416 Ptyalism 121 Pubic symphysis, tenderness of 60 Pudic nerve 62 artery 62 Pulmonary hemorrhage 100 tuberculosis 93 Pulsation of abdominal aorta 52 Pyelitis 221 Pyelonephritis 221 Pyonephrosis 221 Q Quadratus lumborum muscles, to stretch 49 Quinsy . / 126 B Radial ulnar dislocations 68 Rectum, examination of 63 treatment of 64 Reduction of dislocations 68 Still's method 16 Relaxed spine 10 Relaxing ligaments 15 Relief of tension 12 Renal calculi 219 dropsy 229 Ribs, abnormalities of 38 treatment of 43 Rickets 364 Rigid spine 10 Rheumatism 354 Rubella 388 Rubeola 386 S Sacrum, treatment of luxations 18 Salivary glands 121 Scaleni muscles 25 PRACTICE OF OSTEOPATHY. 439 Scarlet fever 389 Sclerosis of liver 189 Sciatica 321 Separation of spinal processes 9 Seat worms 393 Secretory neuroses 158 Secretions of nose 35 Sensory disorders 143 Skull.' 37 Smallpox 390 Sore throat 128 Spiral treatment of 30 Solar plexus . . 55 Spermatic vessels 63 Spermatorrhoea 421 Spastic paraplegia 280 Spasmodic croup 371 Spinal curvatures 402 Splenitis 199 "Spine, typhoid 381 Stomach disease 137 Stomach supersecretions 143 Stomach ulcer of 144 cancer of 144 Strains 406 St. Vitus' dance 267 St. Anthony's Fire 385 Sternum, deformities of 40 Sternum, luxations of 40 treatment 50 Stroke, lightning 398 heat 398 Stomatitis 118 Sub-acidity 143 Sunstroke 397 Strabismus, treatment of 30 Spine, rotation of 14 Syringomyelia 31 440 PRACTICE OF OSTEOPATHY. Superior laryngeal nerves 21 Superior cervical ganglion 25 Superior laryngeal 21 Suppressed menses . . . '. 413 Spinal cord hemorrhage 310 Sounds of spine 11 Stercoreal ulcer 156 Suppurative cholangitis 197 Strangulation of bowel 171 Syphilis 422 T Trenia latum 393 saginata 393 sodium 393 Tape worm - 393 Temperature of spine 9 Thermic fever 397 Treatment of spine 11-18 Temperature of head 22 Tests for hearing 34 Tenderness of symphises 60 Thread worms 393 Treatment of axis ' ~ 29 of neck 28 of spine ' 30 of clavicle 50 of coracoid 21 of thorax 43 of abdomen 53 of eye 31 of rectum 64 Thorax, temperature of 39 examination of 38 comparison of sides 39 Tonsils, treatment of 21 Tuberculosis of lungs 93 Tonsillitis 123 Treatment of vagina 66 PRACTICE OF OSTEOPATHY. 441 Tubes, fallopian 407-412 Tumors 422 Typhoid fever 380 spine 381 U Uvula 37 Ulcer of stomach 144 follicular 156 Urinary diseases 203 Uremia 223 Uterus 66 Uterus, adhesions of 416 hemorrhage of 415 motors of : 412 prolapsus of 416 sympathetic supply of 412 vaso-motors of 412 V Vagina, adhesions 66 examination 64 treatment 66 relaxation of 413 vaso-motors of 412 Valvular heart disease 258 Varicose veins 265 Varicella 388 Variola 390 Varicocele 421 Vaso-motors of genitalia 412 Vertebra, reduction of 16 fifth lumbar, treatment 17 cervical, deviation of 23 crepitus of 24 Vicarious menstruation 416 W Women, diseases of 407-64 Worms 393 pin 393 442 PRACTICE OF OSTEOPATHY. Worms, round 393 seat 393 thread 393 tape 393 Wrist, dislocation of 68 Whooping cough 373 X Xerostoma 121 PRINTED IN U... CAT. NO. 24 161 J.SOUT, 000 556 897