Chapter XXXV: Introduction (20)

This is a rare, chronic disease, more often occurring in men, that is characterized by muscular and vascular weakness, digestive disturbances, and pigmentation. Tuberculosis of the adrenals has been the most constant lesion found. In others, syphilis and atrophy have been noted, while in a few the condition seemed to be functional. It should be remembered that it is possible that lesions elsewhere in the chromaffin system may be the cause in some cases, for all the chromaffin tissues secrete adrenalin.

It is quite likely that in most cases there is some constitutional defect of the chromaffin system which underlies a certain tendency to the disorder. Infections, injuries, physical and mental strains may lower resistance and predispose to the condition.

Osteopathic lesions of the splanchnics may congest the organs, or derange the secretions, or be of such a character that hemorrhages result, or fibrous changes follow, that would definitely incapacitate the cells and lower resistance.

=Pathologically=, the most common change is tuberculosis. Next in importance are atrophy and interstitial inflammation. Cancer of the organs has been noted in a few. The adrenal ganglia, the semilunar ganglia, and the solar plexus are often involved. The thyroid gland may be altered, which, when affected, is usually decreased in size. Brown atrophy of the heart is common.

=Symptoms.=—An insidious onset with muscular weakness, languor, and weak action of the heart are generally the first symptoms. Digestive derangements, such as nausea, hyperacidity, loss of appetite, may occur at the same time, or shortly succeed the general debility. Headache, insomnia, and depression frequently take place. Pigmentation, usually, shortly follows, though there are cases where it is only slightly noted. The disease is very chronic, of several years duration, with periods of intermission. Occasionally, a case runs a very rapid course.

The general weakness is most noticeable. There is low blood pressure. The derangement of the stomach and intestines is characteristic. And the pigmentation, which at first is light yellow later assumes a dark brown color. The pigmentation may be more or less general, but the axillæ, nipples, genitals, the palms of the hands, and the neck, waist or wherever the clothing presses upon the skin, are most pigmented. And pigmentation of the mucous membrane may be noted.

=Diagnosis.=—In typical cases, where there is esthenia, pigmentation, and gastro-intestinal disturbances, the diagnosis is not difficult. Where the clinical picture is incomplete, the diagnosis may be very difficult.

Pigmentation may occur in several other disorders, notably: in bronzed diabetes, abdominal malignancy, tuberculosis of the peritoneum, exophthalmic goiter, pellagra, marked intestinal stasis, stomach ulcer, pernicious anemia, certain skin diseases, etc., so great care has to be taken in atypical cases.

=Treatment.=—General treatment, with special attention to the adrenal innervation, diet, rest, and fresh air will accomplish something. In functional derangements, which are very few, recovery may follow. But owing to the often constitutional defect, the probability of tubercular, syphilitic, and other serious lesions, the prognosis is unfavorable.

FOOTNOTES:

[113] Paton and Finlay, Jour. Exp. Phys., 1917.

DISEASES OF THE NERVOUS SYSTEM

DISEASES OF THE NERVES

Neuritis

=Neuritis= is an inflammation of the nerve fibers. It may be confined to a single nerve, localized; or general, involving a large number of nerves, when it is known as multiple neuritis. Osteopathically, there are =invariably lesions= of the osseous or muscular tissues, that correspond to the nerve fibers involved. The lesion either irritates the nerve directly or disturbs the circulation to the nerve. In those cases where the osteopathic lesion is not the immediate exciting cause, there will be found anatomical irregularities that predispose to the affection.

=Localized neuritis= may be due to: Local osteopathic lesions; Exposure to cold; septic foci; traumatism; and inflammation of contiguous tissues.

=Multiple Neuritis= may be due to: Osteopathic lesions, which are associated with infectious diseases, as in diphtheria, typhoid, scarlet fever, etc.; prolonged strain or exposure; metabolic poisons, as in diabetes, anemia, tuberculosis, cancer, etc.; alcohol, lead, mercury and arsenic poisoning; and =beri-beri=, which is probably due to lack of vitamins, or possibly micro-organisms, or carbonic gas poisoning.

The inflammation may chiefly involve the connective tissue surrounding the nerve—perineuritis—or it may involve the deeper structure—interstitial neuritis. =Parenchymatous neuritis= is really a degeneration, due to excessive or prolonged irritation or pressure which cuts the nerves off from their centers. This is found in deeply seated osteopathic lesions. In experimental osteopathic lesions the first effect is degeneration of the medullary sheath. This is followed by degeneration of the axis cylinder. The local circulation is notably impaired. An acutely inflamed nerve is red and swollen. In =perineuritis= there is an infiltration of the nerve sheath with leucocytes. In the =interstitial form=, lymphoid cells are found between the nerve bundles. In the parenchymatous form, inflammatory signs are wanting. The muscles atrophy. Associated in all these forms the =osteopathic lesion= plays either an exciting or predisposing role, by disturbing nutrition to the tissue and thus setting up inflammation, which may lead to Wallerian degeneration[114].

=Symptoms.—Localized Neuritis.=—In the case of a sensory nerve, there is severe pain following the course of the affected nerve, with tenderness upon pressure. This may be followed by loss of sensibility. Trophic symptoms, such as glossiness of the skin and brittle nails, arise in more chronic cases, while in advanced cases, there is wasting of the muscles. Sweating, herpes, and occasionally effusion into the joints, occur. When a motor nerve is principally affected, muscular power is impaired, motion painful and muscular twitchings will occur. Finally contractions, wasting of the muscles, and even reactions of degeneration, may take place. A rare form is the so-called =ascending neuritis=, in which the inflammation extends upward from the peripheral nerves to the larger nerve trunks, or even the spinal cord, resulting in =myelitis=. This occurs most commonly in traumatic neuritis. The duration is variable. Many acute cases get well in a few days. Other cases may persist for months and even years.

=Multiple Neuritis.=—Inflammation involving several nerves which are affected simultaneously or in rapid succession. =Acute form.=—The attack usually follows overexertion or exposure to cold and wet, with probably some infection. This form is characterized by a chill, followed by a rapid rise in temperature which may reach 103 or 104 degrees F.; headache; pains in the back and limbs. There is weakness of the legs or arms, depending upon region involved, which may be so severe that the muscles atrophy. Sensory symptoms are variable. Most cases recover, though there are instances where the vagi, the nerves to the bladder, rectum, or heart, may be involved.

=Alcoholic Neuritis= results from a moderate amount of alcoholic drinking, continued over a long time. The first symptoms are usually numbness and tingling in the fingers and toes. Loss of power soon becomes marked, first in the lower, and then in the upper, extremities. The extensor muscles are most affected, causing wrist and foot drop. Occasionally there is paraplegia. There are hyperesthesia, tenderness and pain, especially in the legs. The cutaneous reflexes are commonly intact, and the deep reflexes, as a rule, are lost. Delirium is common, and hallucinations or illusions occur.

Neuritis from =lead poisoning= usually present the “wrist drop” and “foot drop”, with colic, and “blue line” on gums.

=Infectious Diseases= neuritis is due to an attack of some infectious disease, and may be local or multiple. It is due to toxic materials absorbed into the blood. It is most common after diphtheria. The symptoms presented are those of neuritis due to any other cause.

=Senile neuritis= is probably due to arteriosclerosis.

=Diagnosis.=—As a rule, the diagnosis is not difficult. In the alcoholic form in some instances, there may be difficulty, and in cases with paralysis, care should be taken. The =prognosis= of neuritis is generally favorable.

=Treatment.=—It is very evident that the successful treatment of neuritis depends upon being able to ascertain the cause. Rest is important in all cases. Rarely has one any difficulty in locating the deranged structures that are predisposing to the attack; and usually correction of these disturbances, which are in the region involved will give considerable relief. If the parts are too sensitive to handle insist on absolute rest and hot fomentations. The affected area should be kept warm and protected. Attention to the diet, and free elimination, are important. Metabolic disorders should be corrected, if possible. Give particular attention to any septic foci. A change of occupation may be necessary in some cases.

In alcoholic cases, the alcohol should be stopped as soon as possible. Passive movements and massage are helpful, but of course bear no comparison to specific osteopathic treatment. Relaxation of muscles along the spinal column and along the course of the nerve will at least give temporary relief.

If contractures and other changes remain after the acute attack, persistent treatment will generally result in recovery. (See also Painful Shoulders, Part I.)

=Sciatica= is usually a neuritis of the sciatic nerve, although all painful affections of the nerve are termed sciatica. In some cases it is a neuralgia when the nerve is swollen and presents an interstitial neuritis.

=Osteopathic Etiology.=—This affection occurs more frequently in males than in females. The usual period for sciatica is from the twentieth to the fiftieth year and the principal causes are =vertebral lesions= of the lower dorsal and lumbar vertebræ, especially lesions to the fourth and fifth lumbar. Occasionally the lesion is a subdislocated innominatum, a downward displacement of a floating rib or a partial dislocation of the femur. Other causes are exposure to cold, contraction of muscles, gout, rheumatism and syphilis. Contraction of the pyriformis muscle may bring direct pressure on the nerve. Focal infections, arthritis of the articular processes of the lower spine, and sacro-iliac and hip-joint disease should not be overlooked. In a few cases there are intrapelvic causes, such as uterine and ovarian tumors, rectal accumulations and the fetal head during labor. Enlarged prostate may be a factor. It is possible for the roughened edges of the sacro-iliac joint, internally, to irritate the sacral plexus as it passes over and thus keep up the pain. This may explain the occasional failure of treatment.

=Symptoms.=—Pain in the nerve along its course is the most constant symptom. The pain is most intense back of the thigh and above the hip-joint. The pain radiates downward through the entire nerve; it is of an annoying character and walking is especially painful. In rare cases there is wasting of the muscles, cramps, herpes and edema. In a few cases the neuritis may extend to the spinal cord.

=Diagnosis.=—The diagnosis of sciatica is usually easy. Care has to be taken in the examination to determine whether the affection is primary or secondary. It is difficult, in some cases, to locate the origin of the disturbance, especially if it is in the lumbar vertebræ, as frequently a very slight deviation of a vertebra will cause the disease; or some focal infection may be difficult to locate; or malformation of the fifth lumbar may be present; or asymmetry of the legs or the body be a factor. Careful palpation, measurements, and the X-ray are of diagnostic importance. =Hip-joint disease= and =sacro-iliac disease= can generally be easily distinguished from this affection. The lightning pains of =tabes= may simulate sciatica, but then there are other well defined symptoms of the disease.

=Treatment.=—Sciatica rarely runs a very long course, though there are cases that last for years. The treatment almost wholly depends upon the cause. If the cause can be determined at once, the probabilities are that severe cases may be relieved by a few treatments. Correction of the vertebræ, to relieve impingements to the nerve fibers as they pass through the intervertebral foramina, usually constitutes the primary treatment. Carefully examine the pelvic organs for disturbances. Occasionally deep treatment over the iliac vessels will be of great help. The innominatum, if deranged, should be corrected and all troubles of the hip-joint that are found must be corrected.

Cases of rheumatism and gout should receive their separate treatments, besides careful manipulations of the affected leg. Rest in bed should be insisted upon; this will usually markedly lessen the duration of the inflammation. Adjustment of the special points found deranged and a thorough treatment, if conditions permit, of the entire leg will be beneficial. Hot fomentations applied along the course of the nerve, and an inhibitory treatment back of the trochanter will at least give temporary relief. Extension of the leg is effective. Placing a patient upon his back and flexing the leg and thigh upon the abdomen, at the same time keeping the leg straight and the foot flexed, is an effectual stretching method. As a rule, sciatica readily responds to osteopathy.

Neuralgia

=Neuralgia= means simply “nerve pain.” The term neuralgia should be restricted to such nerve pains as are not caused by structural changes in the nerves. In cases where the pain is due to organic changes in the nerves, the disease should not be classed as a neuralgia, although it is practically impossible to draw an absolute line between functional and organic disturbances for the one may gradually progress (pathologically) into the other. In neuralgia there is always =disturbance= of the =blood supply= to nervous tissue, which may be of the character of congestive irritation, ischemia or altered states of the blood wherein it contains toxic substances or is below normal quality. It is well known that osteopathic lesions are very common etiological factors.

=Osteopathic Etiology.=—Neuralgia is essentially a disease of adults. It rarely occurs before puberty or late in life. Women are more prone to neuralgia than men and the tendency may sometimes be hereditary. Sufferers from neuralgia often present a peculiar “nervous temperament.”

The exciting causes of neuralgia are impairment of general health; irritations of the nerve fiber or trunk by a displaced bone, ligament or muscle, which may affect the nervous tissue directly by mechanical irritation, or indirectly, by the disturbance of its blood supply, or toxic agents; exposure to cold or damp; overwork and worry; toxic influences of various diseases, as malaria, lead poisoning and alcoholism; irritation from carious teeth, and various septic foci.

=Symptoms.=—Pain, which is spontaneous and paroxysmal, is the most prominent symptom. It may be described as “darting,” “shooting,” “burning,” “stabbing,” “boring,” etc. The pain is usually unilateral, following the course of the sensory nerves, and there are generally tender points along the course of the nerve. Especially are there points of tenderness near the central end of the nerve, where the displaced structures are irritating it. After the pain has continued for some time the skin becomes tender, reddened and swollen. The redness and edema are supposed to be due to vasomotor changes. Muscular spasms, trophic disturbances, skin eruptions, herpes and grayness of the hair are of rare occurrence. The duration of an attack varies from a number of minutes to a few hours.

=Neuralgia of the Fifth Nerve.=—This is by far the most frequent variety of neuralgia, and it is generally due to a displaced =atlas= or =inferior maxilla=. The teeth sinuses, and other possible regions of focal infections should be thoroughly investigated. Anemia and products of metabolism may be underlying factors. All the branches of the fifth nerve are rarely involved. The =ophthalmic division= is most often affected; pain and tenderness being present about the supraorbital notch or foramen, the palpebral branch at the outer part of the eyelid, the nasal branch, and occasionally an ocular pain will be felt within the eyeball. When the =infraorbital branch= is involved, pain and tenderness are principally present at the infraorbital, nasal and malar points. When the =third division= is affected, the chief tender places are the inferior dental, temporal and parietal points. In nearly all cases of neuralgia of the fifth nerve, there is extreme tenderness in the region of the articulation of the atlas and the occipital, particularly the side on which the fifth nerve is involved. This tenderness in a few cases may be found as low as the second or third cervical vertebra. The pain may be so severe as to cause edema along the course of the affected nerve fibers, grayness of the eyebrows and locks of hair chiefly in the temporal region, and convulsive twitching of muscles.

=Tic Douloureux= is a vastly exaggerated neuralgia of the fifth nerve and is supposed to be a primary affection of the Gasserian ganglion. Starting in middle life from no apparent cause it increases in severity until it becomes unbearable and suicide is not an infrequent result.

Many methods to relieve have been tried including destruction of the ganglion but with various results.

Treatment should be the same as in the milder form of neuralgia but it will require critical examination to determine the causes which are liable to be obscure.

=Cervico-Occipital Neuralgia.=—This variety involves the =posterior branches= of the =first four cervical= nerves, affecting the region of the posterior part of the neck and head. The pain may extend as far forward as the parietal eminence and the ear. The chief tender points are about midway between the mastoid process and the spine, between the sternomastoid and trapezius (branches of the cervical plexus), and a point just above the parietal eminence. This form of neuralgia is chiefly due to =subluxation= of the =upper four= or =five cervical= vertebræ irritating the posterior branches of the spinal nerves. A draught of air or exposure to cold are common exciting causes. The pain is of a sharp lancinating nature or else it is heavy and tense. Tuberculosis of the cervical spine may be an underlying cause.

=Cervico-Brachial and Brachial Neuralgia.=—In these forms of neuralgia the pain is referred to the area supplied by the =four lower cervical= and the =first dorsal= nerves. The tender points are in the axilla along the course of the ulnar, the circumflex at the posterior part of the deltoid and points at the lower and posterior part of the neck. The =lesions= exciting this form of neuralgia are usually found in the upper dorsal and upper cervical spines, but they may be as low as the sixth dorsal or as high as the atlas. As far as neuralgia of the ulnar nerve alone is concerned, it can be traced to the seventh and eighth cervical and first dorsal, and the lesion may be found occasionally at the fifth dorsal vertebra or rib. How a lesion as low as the fifth dorsal affects the ulnar nerve, it is hard to say definitely. There may be fibers directly to the ulnar nerve as low as this region, the nerve may be reflexly affected, the vasomotor supply to the ulnar nerve may be disturbed, or possibly the lesion interferes with fibers of the deep layers of the back muscles and thus contraction of muscles for some distance above the lesion would affect the ulnar and other nerves. The scaleni may be affected and involve the plexus. A bursitis may be present (See Painful Shoulders Part I). Focal infections are sometimes factors.

=Trunk Neuralgia.=—This includes dorso-intercostal and lumbo-abdominal neuralgia. The former, =dorso-intercostal= neuralgia, affects the intercostal nerves from the =third= to =ninth dorsal=, and is characterized by pain along the intercostal spaces, or in a few of them. The pain may be bilateral and symmetrical, which usually shows a vertebral lesion. Three points of tenderness are usually noted, viz., near the median line in front, and midway between these two points in the mid-axillary line. The pain is usually dull with acute exacerbations. =Lesions= of the =vertebræ= and =ribs= in the locality affected are by far the principal causes. Cold, exposure, strains, etc., are exciting causes of every day occurrence. When the pain is bilateral and symmetrical the lesion is usually in the vertebra; when unilateral the rib alone may be involved. The most common lesion is a crowding together of the ribs anteriorly at the fifth and sixth interspaces. Carefully exclude a possible tuberculosis of the spine or ribs, aneurism, etc.

The pain of =herpes zoster= is not neuralgic, but neuritic, involving the posterior spinal ganglion. =Pleurodynia=, strictly speaking, is neuralgia of the pleural nerves, and not of the intercostals, but a deranged rib over the region of the pain is commonly the cause of the pleurodynia.

=Lumbo-abdominal= neuralgia involves the posterior branches of the =lumbar nerves=. Tender points are found near the vertebræ, middle of the iliac crest, lower part of the rectus, and in the male occassionally in the scrotum, in the female in the labia. These are often bilateral and are usually of a constricting nature. The ilioscrotal branch is the one most commonly affected.

=Subluxation= of the =vertebræ=, and other lesions, as contracted muscles, are found along the lumbar vertebræ, and even as high as the lower dorsal vertebræ. Also lesions are found at the lumbo-sacral articulation. Pelvic disease is also a cause.

A downward displacement of the =lower ribs=, eleventh and twelfth, is a common disorder and may be the cause of severe neuralgic pains in the region of the iliac fossæ. It may simulate ovarian inflammation, renal colic, or even appendicitis if on the right side. And septic kidney has been wrongly diagnosed from these lesions. In fact it may be a cause of inflammation of the deeper structures, such as the ovary and Fallopian tube.

A subluxation of the vertebræ at the fourth and fifth dorsals may cause severe neuralgic pains in the epigastrium.

=Neuralgia of the Spinal Column.=—According to medical writers this is especially found in weakly women and after concussion of the spine; that it is a troublesome symptom in hysteria, and in many cases it is due to a reflex stimulus from diseased viscera. Most of this is undoubtedly true, but they have not found out the real significance of these neuralgic pains. The various =tender points= along the spinal column are of paramount importance to the osteopath as a =guide= to his =diagnosis=; not only in certain cases, but in nearly every case. The tender points are not due, in nearly every instance, to reflex stimuli from diseased organs, but these tender points are often the result of a local lesion, and are many times the cause of the disorder to the diseased viscus. The neuralgic pains are simply a symptom that a lesion exists in the immediate locality.

=Neuralgia of the Sacral Region and Coccygodynia.=—This form involves the nerves in the sacral and coccygeal regions. The nerves between the bone and the skin are affected. The cause of the pain is generally due to derangement of the articulation of the =lumbar= and =sacrum=, and to severely contracted muscles over the sacral foramina; also to lower lumbar lesions. It may be a reflex from various possible disorders of the organs and tissues of the pelvis. In coccygeal neuralgia, the =coccyx= is commonly displaced in any one of the various displacements that are liable to occur. Special attention should be given to the fibro-articulation of the coccyx, and to the status of the lumbo-sacral and innominata. In adjusting the coccyx, place forefinger in rectum up to proximal end of coccyx, and with thumb externally over the section, exert traction until articulation is released; then adjust.

=Neuralgia of the Legs and Feet.=—This includes the =crural form=, in which the front of the thigh is the seat of the pain; also the form in which tender points are found along the course of the =sciatic= nerve. The latter form is quite a common one, although sciatica is rarely a neuralgia. It is a neuritis and will be found classed under that heading. The tender points presented are the lumbar, sacro-iliac, gluteal, peroneal, maleolar and external plantar. The various neuralgic pains of the legs and feet are generally due to =lesions= of the =lumbar=, =pelvic= and =thigh= regions, and to =weak arches=. =Metatarsalgia= occurs when the fourth metatarso-phalangeal articulation is partially dislocated. Neuralgia in the heel, ball of the foot and toes may be due to local causes or to lesions higher up. Aside from the above care should be taken that there are no toxic factors that may be exciting causes.

=Visceral Neuralgia.=—This is a term applied to neuralgia of the gastro-intestinal tract, the kidneys, and the various pelvic organs.

=Diagnosis and Prognosis of Neuralgia.=—Neuralgia is to be diagnosed chiefly from neuritis, rheumatism, and the effects of severe pressure upon the nerves. In =neuritis= there is oftentimes a symmetrical affection, while in =neuralgia= there is a unilateral distribution and there are many remissions and intermissions and a varying of the pain from one place to another. In severe forms of neuritis, anesthesia succeeds the hyperesthesia of the sensory nerves. In cases of severe pressure upon nerves, the pain is continuous and neuritis will soon be manifested. In =rheumatism= the pain is localized in muscles or groups of muscles and does not follow the course of the nerve. The pain is increased by motion.

The =prognosis= is generally favorable, no matter how severe the attack. The prognosis is influenced only by the age of the patient and the cause.

=Treatment of Neuralgia.=—Consists, first, in the control of the paroxysm and, second, in the removal of its cause. In controlling the paroxysm, frequently one will be able to remove the cause. In a large majority of neuralgias the cause is directly due to a =displaced tissue=, generally a bone or muscle in the locality affected; often all that is necessary in order to perform a cure is to adjust the disordered tissue and the pain will cease. This usually can be done immediately, although there are cases which require several treatments before an adjustment of the parts can be accomplished; besides, in acute cases the involved region will be so tender that an attempt to correct the tissues sufficiently to relieve the paroxysm will be unbearable to the patient. In such instances when the cause cannot be removed at once, firm pressure or inhibition over the involved nerves for a few minutes and local application of hot packs generally disperse the pain for the time being. The rules of hygiene should be observed in all cases.

The best time to =remove= the =cause= of neuralgia is between the attacks when the tissues are not as tender or contracted to such an extent as during the paroxysm. A diagnosis can then be made much more easily, and the tissues adjusted with less pain to the patient.

The details (as to the locality treated) for each form of neuralgia will be found under the discussion of each variety. The general health and diet should be considered. Peterson[115] says: “Morphine is, among the alkaloids, the most frequent cause of insanity. It is a sad commentary on the heedlessness of some medical men, but the family physician is responsible, in almost every case, for the development of the morphine habit and its far-reaching consequences. It should be looked upon as a sin to give a dose of morphine for insomnia or for any pain (such as neuralgia, dysmenorrhea, rheumatism) which is other than extremely severe and transient.”

Diseases of the Cranial Nerves

=Olfactory Nerves.=—This nerve may be affected at various points from its origin to distribution. The disturbances may produce hyperosmia, or anosmia. The lesions may be tumors, injuries to the head and various diseases of the brain, or diseases of the nasal mucous membrane.

The =treatment= of the nerve (beside treating the disease causing the disturbance) is to the cervical region with a view to controlling the blood supply.

=Optic Nerve and Tract.=[116]—The retina, optic nerve, chiasma and optic tract may be affected by various lesions.

The affections of the =retina= are organic or functional. Under organic there is hemorrhage and retinitis. Retinitis may be due to several diseases, as syphilis, Bright’s disease, anemia, etc., Functional includes toxic and hysterical amaurosis, tobacco amblyopia, nyctalopia, hemeralopia and retinal hyperesthesia.

Included in the lesions of the =optic nerve=, are optic neuritis and optic atrophy.

Under lesions of the =chiasma= and =tract= are diseases of the chiasma and unilateral regions of the tract. Lesions of the tract and centers may be found in the tract itself, in the optic thalamus and the tubercula quadrigemina, in the fibers of the optic radiation, in the cuneus, and in the angular gyrus.

A brief summary, only, has been given of the lesions found, it being the idea not to dwell upon symptoms, morbid conditions, etc., but to bring out essential osteopathic features in regard to the cranial nerves. For the various effects of these lesions and points of diagnosis, the reader is referred to the various works on nervous diseases.

=Lesions= peculiar to =osteopathic= practice, that affect the optic nerve and tract, are found chiefly in the upper and middle cervical vertebræ. The disorders to these vertebræ may involve fibers of the optic nerve directly—those that are supposed to originate in the cervical spine; they involve the retina and optic nerve by way of the fifth, as claimed by some; and the above lesions especially affect the blood supply to the optic nerve and tract, either interfering mechanically with the blood-vessels or obstructing and irritating vasomotor nerves. The most common lesions are subdislocations of one or all of the three upper cervical vertebræ. Still, lesions may be located as low as the third or fourth dorsal vertebra, which may influence vasomotor and sympathetic nerves, or the lymphatics. The three or four upper ribs should also receive due consideration.

=Motor Oculi.=—Lesions of the third nerve may affect its center or the course of the nerve. These lesions produce spasms or paralysis.

The only way that we can control the motor oculi is by way of the superior cervical sympathetic; also, it has a connection with the fourth, fifth and sixth nerves, and we can influence it to some extent by direct treatment to the eyeball and orbital muscles. It should be remembered by the osteopath that many of the lesions affecting the cranial nerves, are found upon post-mortem examination, to be the effect of lesions in the spinal region; that many predisposing lesions are the disordered anatomical spinal tissues; as for instance in the third nerve, derangements of the atlas or axis may affect the nerve sympathetically (reflexly), or possibly by direct fibers, and produce the secondary effect—the so-called primary lesions of other schools—at the center or in the course of the nerve.

=Patheticus.=—This nerve may be involved by tumors at its nucleus, or as it passes around the outer surface of the crus into the orbit. Aneurisms or the exudation of meningitis may also compress its fibers. This nerve is purely motor, although it receives a few recurrent sensory fibers from the fifth nerve.

This nerve is controlled osteopathically, principally at the superior cervical sympathetic. It has connections with the sympathetic by way of the cavernous plexus.

=Trigeminus.=—Lesions of this nerve are found in its nucleus and in the pons, and include sclerosis, hemorrhage, disease and injury at the base of the skull, tumors, aneurisms, inflammation of the nerve, and subdislocations of the =upper three cervical= vertebræ, or the inferior maxillary.

This nerve is an extremely important one from an osteopathic point of view, as it has a vasomotor influence over various vessels of the head and face, and secretory fibers to the lachrymal, parotid and submaxillary glands; also, it controls mastication, and to some extent deglutition, and influences hearing (tensor tympanum muscle). Diseases of the nasal mucous membrane and disease of the anterior portion of the eyeballs are largely due to the =vertebral subdislocations= and to derangements to the inferior maxilla. Our principal work upon this nerve is at the upper cervical vertebræ, the inferior maxilla, and the deeply contracted muscles in the upper cervical region. For the facial points of treatment =see neuralgia of the fifth nerve=. This nerve is closely related to the sixth, seventh, eighth, ninth, tenth, eleventh and twelfth nerves. Particular emphasis is given to the importance of treating this nerve in nasal catarrh and in eye diseases of the anterior portion of the eyeball. It contains trophic fibers to the eye, sensory fibers to the sclerotic coat and iris, and vasomotor fibers to the choroid plexus.

=Abducens.=—This nerve is especially liable to be affected by tumors and meningitis. It is controlled osteopathically at the superior cervical sympathetic, being connected with the sympathetic at the cavernous plexus.

=Facial.=—Lesions may occur in the cortical centers of the nerve, the nucleus and the nerve trunk. Paralysis of the facial nerve occasionally occurs (Bell’s paralysis); also facial spasm may occur. This nerve is controlled at the stylomastoid foramen. =Lesions= to the =atlas=, anteriorly or laterally, are commonly found. In the region of the stylomastoid foramen, the nerve communicates with the great auricular of the cervical plexus, the trifacial, the vagi, the glosso-pharyngeal and the carotid plexus of the sympathetic. The facial nerve may be affected directly as it passes above the angle of the jaw.

Nearly every case of =Bell’s paralysis= can be cured by osteopathic treatment. There are usually lesions to the upper two or three cervicals. Correction of the cervical vertebræ and massage of the paralyzed muscles, with care of the general health, will suffice, provided there is not an extensive central lesion. Although the disease may be due to syphilis, meningitis, tumors, etc., the most frequent causes are lesions of the =atlas=, =axis=, and =third cervical= and =exposure= to =cold=. The cold produces a neuritis in the Fallopian canal, and deep treatment beneath the angle of the jaw is effective. The =prognosis= of Bell’s paralysis is favorable.

=Auditory.=—Lesions[117] affecting this nerve may occur anywhere from its cortical center to its distribution in the cochlea and vestibule. Disorders resulting from lesions to this nerve are nervous deafness, auditory hyperesthesia, tinnitus aurium, and Meniere’s[118] disease.

The control of the nerve and the treatment of lesions affecting it, are effected principally at the =first= and =second cervical= vertebræ. The atlas is especially apt to be subdislocated anteriorly or in a rotary manner. The condition of the =upper dorsal= region should also be carefully examined, as vasomotor nerves to the ear may be impinged at this point. The auditory connects with the fifth, sixth and seventh nerves.

=Glosso-Pharyngeal.=—This nerve may be affected by tumors, degenerations, meningitis and various lesions. It is often very hard to determine exactly the pathology, on account of its various connections with other nerves, the vagi, facial, spinal accessory, olfactory and optic nerves.

This nerve is chiefly controlled at its exit at the jugular foramen. Osteopathically, =lesions= of the =cervical= vertebræ and =upper dorsal= vertebræ affect it. The deep muscles of the anterior and lateral regions of the neck and subdislocations of the atlas especially affect the nerve.

=Pneumogastric.=—On account of its extensive distribution, and the importance of its functions this is one of the most important nerves in the body. It distributes fibers to five vital organs—heart, lungs, stomach, liver and intestines—and to other organs of secondary importance. This nerve is associated with deglutition, phonation, respiration, circulation and digestion.

Hemorrhages, softening, etc., may involve the nucleus of the nerve, while the trunk may be impinged by tumors, thickened meninges, aneurism of the vertebral artery and =subdislocation= of the =upper five= or =six cervical= vertebræ, chiefly the atlas.

The nerve is most easily controlled at its exit from the foramen. Inhibition of the suboccipital region, between the mastoid process and transverse process of the atlas, will influence the nerve markedly, probably reflexly; also direct treatment may be given the nerve as it passes along the anterior part of the neck near the trachea. The superior laryngeal branch may be treated below the great cornu of the hyoid bone and attention is particularly called to this in all affections of the throat where coughing is a feature; the inferior laryngeal, at the inner side of the lower part of the sternocleidomastoid muscle. The inferior laryngeal nerve may be affected by dislocation of the first and second ribs, producing pressure upon the nerve as it winds about the subclavian vessel. Fibers of the nerve have been traced to the spinal accessory nerve, as low as the sixth and seventh cervical vertebræ; consequently, lesions to the vagi nerves may occur anywhere in the cervical region.

=Spinal Accessory.=—Lesions of this nerve may cause paralysis or spasms to the structures to which it is distributed. The lesions consist of =subdislocations= of =cervical= vertebræ, chiefly the upper three or four. The nucleus may be involved by wounds, abscesses, caries of the vertebræ, tumors and meningitis. These lesions may also involve fibers of the trunk.

The special points of control of the nerve are at the jugular foramen, the sixth and seventh cervicals and the second, third and fourth cervicals.

=Torticollis= or =Wry-neck= is spasm of the muscles of the neck supplied principally by this nerve. There will be found either derangements of the =middle= or =lower cervical= vertebræ or the muscles are swollen from exposure to cold or from a blow. Sometimes the lesion is in the upper dorsal. The disorder is mainly a neurosis and, unless it has become chronic, the =prognosis= is favorable, and even in chronic cases, often considerable benefit can be obtained.

=Hypoglossal.=—This nerve may be affected by cortical, nuclear and infra-nuclear diseases, as well as by subdislocations of the upper cervical vertebræ. It communicates with the superior cervical ganglion, the vagi, the upper cervical nerves and the gustatory branch of the fifth nerve. We control the nerve at the anterior condyloid foramen and at the superior cervical ganglion.

Diseases of the Spinal Nerves

=Cervical Nerves.=—The =great occipital= nerve may be controlled at a point on the occiput between the mastoid process and the first cervical vertebra. The =small occipital= and the =great auricular= nerves may be controlled at a point just behind the mastoid process. The great auricular nerve and the frontal branch of the trigeminus nerve meet over the parietal protuberance. The preceding points are the places where one may inhibit the nerves and control certain headaches or neuralgic attacks, although subdislocations of the upper cervical vertebræ, or contracted muscles between the atlas and occiput are usually the cause of such disturbances. Adjustment of the lesion will usually correct the disturbance. Carefully exclude possible caries or tumors.

=Treatment= of the upper cervical region, by relaxing muscles and correcting deranged vertebræ, constitutes the principal treatment of an ordinary =headache=. It is best to have the patient flat upon his back and the osteopath stand at the head of the patient, and, first, thoroughly relax these contracted muscles or correct the derangement of the vertebræ; then after the foregoing has been accomplished, give an inhibitory treatment of the suboccipital region. In inhibiting, place the fingers over the contracted and tender tissue; hold tightly for several minutes, or at least until the tissues have thoroughly relaxed. Many times one will be able to detect a slight twitching underneath the fingers, and when such is felt, he knows at once that the headache is relieved. In inhibiting at any point along the spine, seek the contracted fibers and tender points and inhibit exactly over the area. Headaches that are due to a disturbed circulation of the brain, may be relieved by this inhibitory treatment in the suboccipital region. The treatment tends to reestablish a normal circulation to the brain. Although the large vascular areas such as the splanchnic, should, if possible, be normalized. Headaches may also be due to lesions at various points along the spine and ribs, and a correction of such points is necessary in order to cure the affection. A place often found involved is the upper dorsal region. =Reflex headaches= can be cured only by relieving the irritation. The treatment to the head would only be temporary. In headaches of the chronic type it is well to examine the scalp and if not freely movable over occipital region it may be adherent to the skull and cause pressure on the occipital nerves.

Lesions to the =phrenic nerve= usually occur in the region of the third, fourth and fifth cervical vertebræ. The lesion may be due to a deranged vertebra, or to disease of the membrane of the cord, or of the anterior horn of the gray matter (See Hiccoughs).

Paralysis of diaphragm from the phrenic may be single or double. When single it is not very noticeable. When double, respiration must be carried on by the intercostals and accessory muscles. When quiet, the patient may not notice it but on exertion there may be temporary dyspnea. Bronchitis with its constant coughing is a bad complication.

Various disorders of the phrenic nerve are principally treated in the area of the origin of the phrenic nerve. Tumors, aneurism, caries, and neuritis are possible complications.

Lesions to the =brachial plexus= are usually derangements of the cervical or upper dorsal vertebræ. Focal infections should not be overlooked. Direct injuries, contraction of muscles, a deranged clavicle, a cervical rib, or a dislocated shoulder are to be thought of. (See, also, Painful Shoulders, Part I) The X-ray as a diagnostic aid may be invaluable.

In obstructions to the =musculo-cutaneous= nerve, the power to flex the forearm upon the arm is greatly impaired. The lesion is most likely to be found between the fifth and sixth cervical vertebræ.

Clinically, the =median nerve= is of special interest from the fact that atrophy of the muscles of the ball of the thumb, which is pathognomonic of progressive muscular atrophy, may be caused by an affection of this nerve. The lesion is usually from the third to the seventh cervical vertebræ.

Lesions of the =ulnar nerve= may arise between the sixth and seventh cervical vertebræ, but are oftentimes found as low as the fifth dorsal, especially at the fifth rib on the side affected.

Lesions of the =circumflex nerve= may be found in the lower cervical vertebræ, but are commonly caused by dislocations of the humerus and clavicle.

Lesions of the =suprarscapular nerve= occur most frequently from the fifth to sixth cervical vertebræ.

The =posterior thoracic= may be lesioned at the fifth or sixth segments, or by pressure injuries to the serratus magnus.

=Dorsal Nerves.=—The essential osteopathic points of the dorsal nerves have been considered under intercostal neuralgia. It might be stated that the posterior fibers of the sixth and seventh dorsal nerves supply the skin of the pit of the stomach. This is of value, clinically, as severe pains in the epigastric region which may result from impingement of these nerves, are supposed by the patient to be due to stomach disorder.

Diseases of the =liver= may be manifested by =pains= in the region of the right scapula. It has been suggested that the stimulus passes from the liver up the pneumogastric to the spinal accessory and down the spinal accessory to the trapezius muscle and thus causes the “liver pain.”

=Intercostal neuralgia= is more common on the left side of the body. The intercostal veins of the left side empty into the left superior intercostal vein or the left azygos. Thus the blood, to reach the vena cava, is obliged to take a circuitous route and stagnation is more likely to occur than on the other side.

The glandular structure of the =mammary glands= is supplied by intercostal nerves from the third to the sixth interspace. Lesions here will cause various diseases of the breasts and adjustment will cure many of them.

=Lumbar Nerves.=—The lumbar nerves may not only be deranged by various growths, inflammatory processes and abscesses in the abdomen, but by lesions, infections, parturition, and developmental defects of the lumbar vertebræ. Tuberculosis of spine, sacro-iliac and hip joints, is not rare. In doubtful cases utilize the X-ray plate.

Lesions in the region of the =first lumbar= may affect the =iliohypogastric= and =ilio-inguinal= nerves and causes various irritations of the penis, scrotum, labium and thigh. Also, the perineal region may be involved, as well as connecting branches of these nerves to various visceral nerves underneath.

The =genital organs= may be affected by lesions to the =genitocrural= and =external cutaneous= nerves, caused by vertebral lesions of the second and third lumbar vertebræ. The latter nerve may be irritated by pressure underneath Poupart’s ligament.

Lesions at the third and fourth lumbar vertebræ and sacro-iliac articulation may affect the =obturator nerve=.

=Sacral Nerves.=—Lesions to the sacral nerves are especially liable to occur when an innominatum is subdislocated, as that changes the relative position of the femur with the body and causes impingement to the sacral nerves. Contraction of the pelvic and thigh muscles also affect sacral nerves. Other lesions to the sacral nerves may be located at the fifth lumbar and sacrum. It should be remembered that the centers of the sacral nerves are in the lower dorsal and upper lumbar region. Various lesions to the sacral nerves may be caused by pelvic inflammation, compressions by growths, and injuries and contractions of muscles within the pelvis. Sciatica has been described under neuritis.

FOOTNOTES:

[114] See Osteopathic Lesion—Journal of American Osteopathic Association. May, 1906, and Deason’s Physiology.

[115] Nervous and Mental Diseases, p. 622.

[116] See Diseases of the Eye, Part I.

[117] See Ear Section, Part I.

[118] R. D. Emery reports a case of Meniere’s disease as cured. A. O. A. Case Reports, Series IV.

GENERAL AND FUNCTIONAL DISEASES

Paralysis Agitans

(SHAKING PALSY)

=Definition.=—A chronic, nervous disease, characterized by tremors, muscular weakness, muscular rigidity and alterations in the gait.

=Etiology.=—The disease usually commences after forty years of age, but occasionally it occurs from the thirtieth to fortieth years. It is more frequent in males than in females. Heredity seems to have but little influence in the cause of the disease. Among the principal causes are physical injuries, exposure to cold and wet, emotion, worry, alcoholism, sexual excesses and acute diseases. Physical injury, in conjunction with exposure to cold is the best determined cause. Disorder of the vertebræ of the cervical or dorsal regions, or of the upper and middle ribs, can generally be found. Traumatic influences probably affect the nerve centers, causing a disturbed innervation, either by the direct effect of the deranged structures upon the nervous tissues or obstructing nutritive channels to the nervous tissues.

In most cases no changes have been observed in the central nervous system or in the sympathetic ganglia. Some observers have noted induration of the pons, medulla and cord, but these changes may be due to senility or to the indirect consequences of the long disturbance of function. In a few cases, interstitial sclerosis of the peripheral nerves is observed; these are probably secondary changes. Osteopathic experience regards paralysis agitans as an affection of the central nervous system, due to a disordered structure in the locality affected.

=Symptoms.=—The onset is usually gradual, but may come on quite suddenly after exertion. The =initial= symptoms are usually tremor, stiffness or weakness in one hand. In rare cases, at first there may be neuralgic pains, dizziness and symptoms of a rheumatoid nature. The tremor can be controlled by the will at the onset of the disease. The affection gradually extends until an entire side or the upper or lower limbs are involved. At this =advanced stage= of the disease, a peculiar muscular rigidity of the involved region takes place. Muscular weakness comes on at about the same time as the rigidity, and the loss of power varies much in degree. The condition is most marked in the fingers and hands, whence it extends to the arms and legs. It commonly passes from the right arm to the right leg, then to the left arm, and then to the left leg. At this stage the movement between the thumb and fingers is like that of crumbling bread. The writing is greatly affected and in time it is impossible to write. The trembling may be so violent as to prevent sleeping. There is occasionally an intermission of days in the tremor.

On account of the rigidity of the muscles, the patient assumes a characteristic =attitude= and =gait=. The position of the body is that of a tendency to go forward, the head is bent forward, the back curved outward, the arm bent at the elbow and held away from the body, and the knees so close together that they rub in walking. The gait is a “propulsive” one, and when once started in a forward walk, the patient’s gait becomes more and more rapid and he cannot stop until he comes against some object. The expression of the face is stiff and mask-like, the speech slow and monotonous and the voice shrill. The patient is generally restless and troubled with insomnia. The general health is in fairly good condition. Reflexes are usually normal. The intellect is generally retained, although the physical ailment may cause mental depression.

=Diagnosis.=—Is usually easy and can oftentimes be made at a glance. =Disseminated sclerosis= has a tremor, but is shown particularly in voluntary movements. The speech is scanning and the gait ataxic. The disease begins in the lower extremities, the attitude is different from that of paralysis agitans, and there is nystagmus. In =chorea= the movements are general, irregular and more intermittent, and it particularly involves muscles of the face. Also chorea is a disease of children and young adults.

The =tremors= of old age, hysteria, and certain toxic conditions due to tobacco, alcohol, etc. are generally easily diagnosed.

=Prognosis.=—The disease does not necessarily shorten life; the patient oftentimes dies with some intercurrent disease. Improvement usually results from careful, prolonged treatment. Early treatment, of course, will give the most satisfactory results, and occasionally, if taken very early, the case can be cured.

=Treatment.=—A most careful examination of the physical structures of the patient should be made, particular attention being paid to the =cervical= and =dorsal vertebræ=, the upper and middle =ribs= and the =muscles= along the spinal column. All irregularities found should be corrected if possible, and strong, thorough treatment given to the region of innervation of the affected parts. Traction of the rigid areas is of some value. Treatment of the arms and legs will also be of aid. All mental strain and physical exhaustion should be prevented if possible. General =hygienic measures= are to be employed. The life of the patient should be quiet and regular. Bathing, fresh air, massage and outdoor life will aid in improving the general health. =Persistent= treatment will retard the progress and frequently improve the general condition. Simple and hysterical tremor must not be confounded with that of paralysis agitans. E. Ashmore[119] reports an interesting case which shows about what may be expected under treatment.

Acute Chorea

(ST. VITUS DANCE)

=Definition.=—A functional disorder of the nervous system, chiefly affecting children, more than twice as frequent in females as males; characterized by irregular involuntary muscular contractions, often slight mental disturbance, and liability to endocarditis.

=Osteopathic Etiology.=—The disease affects children of all stations, but is more common among the lower classes. The greater number of cases occur before the age of twenty. It sometimes develops during the early months of pregnancy, when it often assumes the maniacal type. Chorea is frequently associated with endocarditis and rheumatism and delayed menstruation. It occasionally follows infectious diseases of childhood, especially scarlet fever. Fright, mental worry, sudden grief and overstudy may bring on an attack. Children of neurotic stock are more susceptible. Heredity plays some part as a predisposing cause. Reflex irritation from worms or from genital irritation has a slight influence upon the disease. Overwork in school is an important factor. =Derangement= of the =anatomical structures=, involving the nervous system along the spinal column, is the most common predisposing cause. Most of the anatomical displacements are found in the cervical vertebræ, although the upper dorsal may be involved.

=Pathologically=, as yet, no constant anatomical lesions have been found. Emboli occur in some cases, but this might be expected, as endocarditis so frequently occurs as an effect and not the cause of chorea. “In cases not rheumatic, the most probable explanation of the symptoms is to be found in vascular changes, having their origin in disturbed nutrition.” (Holt) According to osteopathic theories and investigations, the disease is due to various irritations to the spinal centers and nerves of the affected region. The disordered nerve cells may be the result of direct pressure, hyperemia, anemia, etc., and the action upon the brain centers is possibly a reflex act. Of late acute chorea is regarded by some as an infectious disease.

=Symptoms.=—In the majority of cases the muscular movement is not severe. They are purposeless and the child appears awkward. Restlessness, disturbed rest at night, crying spells, pain in the limbs, headache and irritability, are some of the premonitory symptoms. In =mild cases= one hand, or the hand and face, are involved. Occasionally there is some difficulty in talking. The irregular, jerky movements are characteristic of this disease. The child is anemic, and the muscles are weak. In =severe cases= the movements are general, the power of speech is lost, and the patient is unable to get about. The condition usually occurs after one or more mild attacks, although it may occur primarily. During an attack of chorea, the child’s disposition changes, he becomes irritable, cannot concentrate his mind, memory is affected and hallucinations may occur. The reflexes do not usually differ from the normal. =Maniacal chorea= is most serious, and often proves fatal, although recovery may occur. This form occurs most frequently in pregnant women. Speech is greatly affected and insomnia, fever and maniacal delirium develop. The =duration= is from six to ten weeks, in the average case. Mild cases may recover in a month or less, others last six or more months. There is a tendency of chorea to recur; rheumatism seems to favor this tendency. In children recovery is the rule.