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,