Part I

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[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.

=Diagnosis.=—In the majority of cases chorea is easily diagnosed. The symptoms are generally very characteristic. In a few cases of hysteria there may be difficulty of diagnosis, but history and rhythmical movements will usually differentiate. In =hereditary ataxia= the slow, irregular movements, the scolioses, scanning speech, talipes and the existence of other cases in the family, will differentiate this from chorea. =Cerebral sclerosis= usually occurs in infancy; impaired mentality, exaggerated reflexes, rigidity and chronic course of the disease, are points which render the diagnosis easy.

=Treatment.=—Nearly all cases can be cured.[120] The predisposing causes of chorea, osteopathically, are usually found to be subluxations of the vertebræ or ribs at any point, but particularly in the cervical vertebræ. Chorea is one of the diseases of the nervous system, in which constant morbid changes are not found upon the post-mortem examination. Possibly the reason is because the lesions causing the diseased state are not deeply seated enough to primarily affect motor centers; but are lesions of the spinal column and ribs, affecting simply the nerve fibers reflexly, as they pass through the intervertebral foramina. There will be found well marked lesions, and upon their correction the osteopath finds complete recovery largely depends.

The muscle, or group of muscles, involved, will give a =direct clue= as to where the lesion will probably be found. In nearly all cases, it is in the spinal region of innervation to the affected muscles. Other cases may be due to cerebral lesions, as well as to intestinal and uterine disturbances. Search should be made for possible =reflex= irritation, such as intestinal parasites, adherent prepuce, eye strain, nasal abnormalities, etc.

All cases should be taken from school, carefully guarded from excitement, and placed under the most favorable =hygienic= conditions, with a certain amount of discipline as to self control. The more serious cases should be placed in bed, so that rest will be secured as well as diminished liability to heart complications.

The =diet= must be carefully watched and the bowels attended to regularly. A milk diet during the early stage is highly recommended. Do everything possible to restore the general health. Mild gymnastics, in most cases, will be found of service. Amusement should be given the child, in the open air if possible. In severe cases where the skin is harsh and dry, the hot air bath, providing the strength is good, will give considerable relief from the intensity of the disease. A few cases of acute chorea run into a =chronic form=, but the latter, as a rule, yields to osteopathic treatment.

Choreiform Affections

=Myoclonia= is a sudden contraction of a few muscle fibers, a single muscle or of a group of muscles. A neurotic tendency, infections and toxic conditions are factors. Occasionally epilepsy may be associated with it. Osteopathically there can be but little doubt that the innervation to the muscles involved is interfered with.

The lower extremities are usually first affected and it may be sudden or gradual in appearance. It is progressive and slowly involves the arms and, rarely, the face. Usually the spasms cease during sleep.

=Prognosis= is rather favorable. Examination should show the cause of the nerve interference and its correction bring relief.

=Dubini’s disease= is probably associated with certain diseases of the cord and brain and is characterized by sudden, sharp pains in the head, neck and lumbar muscles, extending to the lower extremities in the form of a short, sharp spasm, usually at regular intervals. Later there may be symptoms of hemiplegia. The disease is apt to progress and death may occur during a convulsion.

=Habit spasm= usually results from overstudy and nerve exhaustion with impairment of general health, and is incident to early life. The child is usually a neurotic. The symptoms are twitching of the mouth and eyelids, grimaces and jerking of the shoulders. =Treatment= for the general condition, with correction of any spinal lesions, will generally give relief.

=General tic= resembles habit spasms closely. In some cases the patient is apparently healthy, while in others there is some brain disorder. There are coordinate spasmodic movements of the head, face and upper trunk, swallowing and abnormal vocal sounds. The movements are rapid and frequently repeated. =Prognosis= is uncertain and will depend largely on general conditions. In =convulsive tic= there is usually a repetition of certain words or sounds with a convulsive twitching or movement of certain muscles.

Infantile Convulsions

(ECLAMPSIA)

=Infantile convulsions= may be due to various causes. A neurotic inheritance is an important predisposing factor. They may precede the development of many diseases of the nervous system, and also occur as the result of peripheral irritation. Dentition in association with rickets, and intestinal parasites are common causes. They may be the early symptoms of acute, infectious diseases. Scarlet fever, measles, pneumonia and smallpox are very frequently preceded by convulsions. They may be due to debility, resulting from gastro-intestinal disorders. Malnutrition is a predisposing cause. Disease of the bones, especially rickets, may be associated with convulsions. Lesions of the brain are other causes. A protracted instrumental delivery may cause a hemorrhage of the meninges.

=Symptoms.=—In severe cases the fit may be identical with epilepsy. It is more often not so complete as true epilepsy. Convulsions vary considerably, but there will be no difficulty in diagnosis. It may come on suddenly, or be preceded by restlessness, twitching, sometimes grinding of the teeth and fever. The spasms may be either of a tonic or clonic type preceded by a cry and loss of consciousness. The attack may be single, but the fits may follow each other with great rapidity and terminate fatally. It is rare for the child to die during a convulsion. Exhaustion and asphyxiation may cause a fatal termination. As in epilepsy the temperature often rises during the fit. A transient paresis sometimes follows, if the convulsions have been chiefly limited to one side.

=Diagnosis.=—The diagnosis is generally easy. The attack is usually due to the ingestion of some indigestible food or to some peripheral irritation, or an acute disease. Convulsions, appearing immediately after birth or injury, are probably due to meningeal hemorrhages or serious injuries to the cortex; although a few of these cases will present grave lesions of the cervical vertebræ, probably often due to protracted instrumental delivery. Infantile convulsions usually occur between the fifth and twentieth months. Convulsions occurring after the second year are more likely to be true epilepsy. The =prognosis= depends almost wholly upon the cause, severity and duration.

=Treatment.=—The =first step= in the treatment is to determine the cause if possible. Treatment in the region of the sixth and seventh dorsals will often give relief; thorough work along the lumbar region and the sacrum will many times be sufficient, if the convulsion is due to intestinal disorder. C. M. Proctor reports that in male infants he has relieved convulsions quickly, in several cases, by pushing back the foreskin and has always found, in such cases, either a phimosis or an adherent prepuce. In female infants it might be well to examine the clitoris. Dilatation of the rectal sphincter may be of aid. It may be necessary to vomit the patient, when it is due to undigested food in the stomach; and in some cases an enema should be used, when the irritation is in the intestines. In a few cases, when the convulsions are due to dentition, a lancet applied to the gums will be all that is required. A thorough treatment to the cervical region, to control the circulation, should always be given; at the same time apply ice to the head. The patient should be put in a bath of 95 to 98 degrees F., should the preceding treatment not have the desired effect, or, better still, use the bath at once and treat at the same time.

Owing to the neurotic tendency and the ofttimes trivial causes that precipitate an attack everything possible should be done to build up the general condition—adjustment of all lesions, regulated diet and disciplined habits.

Epilepsy

=Definition.=—A chronic affection of the nervous system, characterized by attacks of unconsciousness, which are usually accompanied by general convulsions. When there is merely a momentary loss of consciousness it is called =petit mal=. Loss of consciousness with convulsions is called =grand mal=. When the convulsion is localized, with or without loss of consciousness, it is called =Jacksonian epilepsy=. Certain cases of temporary loss of consciousness are termed =psychic epilepsy=.

=Etiology.=—Epilepsy usually begins before puberty, and comparatively seldom after the twenty-fifth year. Males suffer somewhat more frequently than females. Heredity predisposes to the disease to some extent, but probably not so greatly as many writers would claim. Neuroses, as insanity and hysteria, and intermarriage of relatives, are important elements to consider. When epilepsy is inherited, it is almost always due to some morbid state of the nervous system. Other predispositions to the disease may be caused from defective general development of the brain, from impairment of the general health, and from an exhausted nervous system.

Many =exciting causes= may be found: mental emotion, fright, excitement and anxiety; blows and injuries to the head; infectious diseases; syphilis; alcoholism; masturbation; ocular and aural irritation; disturbed and delayed menstruation. Epilepsy may be excited by reflex convulsions from intestinal worms, gastric irritation, etc. Also thickening of the membranes of the brain, pressure from a tumor at the periphery, uterine diseases and many other sources of irritation may be found, that are the exciting causes of epilepsy.

Important exciting causes of epilepsy are, undoubtedly in many cases, due to =lesions= of the =vertebræ= and =ribs= especially the vertebræ of the cervical region, although in some cases the lesion is in the lower splanchnic region or in the ribs (chiefly from the fourth to the eighth). These lesions to the spinal tissues disturb the nutrition to the vasomotor nerves. If the real seat of the disease is in the cerebral cortex and the medulla, the cervical lesion, and in fact other lesions, could readily affect the nerve force and circulation to and from these regions. The vertebral artery circulation, where a cervical lesion exists, may be involved and affect the brain. In cases where lesions of the vertebræ and ribs exist in the upper and middle dorsal region, the vasomotor innervation to the brain may be involved, for in this region the vasomotor nerves to the cranium, etc., pass from the cord into the sympathetics. Birth injuries may affect the brain tissue, through cervical lesions, hemorrhages and asphyxiation.

Conklin attaches considerable importance to stasis of the sigmoid and ascending colon. Lesions involving this region may result in toxins entering the blood and affecting nervous tissue.

To illustrate a specific exciting lesion, the following is interesting. The case was one of epilepsy that was evidently caused by a dislocated right fifth rib. By producing an irritation in the region of this rib, so that the lesion was increased, the patient could be made to immediately suffer from an attack of epilepsy. By resetting the rib, at once the sufferer would be entirely relieved. The case was cured after three months’ treatment, the chief work being to keep the rib in place. Rarely a subdislocated innominate bone, or some lesion remote from the brain, is located and found to be causing epilepsy. Important lesions in most cases will be readily located in the cervical region. Booth reports: “I have records of seven fairly defined cases of epilepsy—such as have been so pronounced by M. D.’s. I find in all of them =marked lesions= in the =upper cervical= and in most of the cases the occiput is posterior upon the atlas or twisted. In all cases there was a thickening of the soft tissues, especially in the upper cervical. The lower cervical was also much involved but not so noticeably. All of the cases also presented marked disturbances in the upper dorsal; most were decidedly anterior, and one very posterior. One was almost a confirmed drunkard; notwithstanding the fact, he recovered to such an extent that he went to work, and I understand has been holding his position for more than three years. He had had to give up his work entirely. One was a hopeless case in every particular and did not seem to receive any benefit from the treatment. I think it was entirely beyond help from any source. The others responded very well and the results were definite and decided. The length of treatment in successful cases ranges from about five weeks to a little over a year. But those that were treated the greater length of time were not treated continuously.”

After one convulsion has occurred, others readily occur, owing to the proneness to changes in the nerve centers. Very little is known as to the pathology of this disease. Convulsions may be caused from irritation of both the cortex cerebri and the medulla oblongata. From a study of the character of the auræ, one is led to believe that there is a disturbance, in most cases, in the centers of the cerebral cortex; and that the lesions so generally found along the spinal column are the true exciting causes of the disease. Perhaps in a few cases the irritation may be to the medulla reflexly. The lesions found on osteopathic examination may act reflexly, as has been stated, upon the centers in the brain and excite them; or the circulation is deranged, and consequently the nutrition to the brain and meninges, by vasomotor control and the vertebral vessels, is impaired.

The splanchnic area and the cervical region should always receive special attention. This in conjunction with all possible reflex sources, and, not least, the general health, restoring a stable nervous system if possible, are of greatest importance.

As a rule, =pathological= lesions are not found. To the naked eye the appearance of the nerve centers is largely that of healthy organs. The changes revealed by the microscope are most probably those of secondary origin. Recent experiments seem to show that the motor zone of the cortex is affected.

=Symptoms.=—These will be considered under the three varieties, known as grand mal, petit mal and Jacksonian. =Grand mal.=—In most cases the seizure is preceded by a pronounced sensation known as the =aura=. This differs greatly in various individuals. It may begin in a finger or toe and rise until it involves the head, when the patient screams and falls to the floor unconscious. In other cases the sensation may start from other parts of the body, as the epigastric region, where it may simply be a slight discomfort; or other sensations may be felt, as that of a ball rising from the stomach. The aura may start from any part of the body as a numbness, tingling, chilliness, etc., and may, also, be manifested through the optic, olfactory, auditory and gustatory nerves, by flashes, smells, sounds and tastes. “Intellectual auræ” may also be manifested. Some form of auræ is met with in nearly one-half the cases of epilepsy. Others lose consciousness so early that the patient is not aware of the onset. In cases not attacked suddenly and not preceded by an aura, a prolonged prodrome may be present for several hours or a day. The patient may feel irritable, dizzy or dispirited. Or he may be quiet and calmly await the attack. In a few cases certain movements may precede an attack, as running rapidly forward in a circle, or standing on the toes and rotating rapidly. The attack proper is sudden. The patient falls with a peculiar cry. The =convulsion= or fit may be divided into =three stages=, that of =tonic= spasm, of =clonic= spasm and of =coma=.

The =tonic spasm= succeeds the epileptic cry; there are loss of consciousness, pallor of the face and the contraction of pupils. The body assumes a position of tetanic rigidity, the head is retracted and rotated, and the spine curved, owing to an unequal affection of the muscles of the two sides. The jaws are fixed, the arms are flexed at the elbow, the hands at the wrist, and the fingers are clinched. The legs and feet are extended. The muscles of the chest are involved and respiration is suspended. This stage lasts a few seconds. The =clonic spasm= follows the tonic spasm. The muscular contractions become intermittent. From slight vibratory motions, the intermittent muscular contraction becomes general. The arms and legs are thrown about violently, the muscles of the face are distorted, the eyes rolled, and the lips open and close. The muscles of the jaw contract violently and the tongue is apt to be bitten. The pupils are dilated, the face cyanosed (though at first the face is pale and pupils contracted) and blood-streaked, frothy saliva pours from the mouth. The feces and urine may be discharged involuntarily. The temperature rises about one degree F. This stage lasts about one or two minutes. The period of =coma= may last from a few minutes to several hours. Usually if left alone, the patient will awaken after a few hours. In a few cases mental confusion follows the waking. During the stage of coma, the face is congested but not cyanotic. The muscles are relaxed and the breathing is noisy. Epileptic attacks during sleep, =nocturnal epilepsy=, are not rare. This may continue for some time without the patient being aware of it.

=Petit Mal.=—In this variety of epilepsy, convulsions are absent. The seizure consists of momentary unconsciousness with fixed, staring eyes, dilated pupils and rarely any twitching of the muscles. After the attack the patient resumes his work. There may be attacks of vertigo, without unconsciousness, and the patient may fall. In a few instance there may be auræ of various kinds. Petit mal may be a forerunner of grand mal or the two may alternate. Between grand and petit mal there are many grades of epilepsy varying in severity.

=Jacksonian Epilepsy.=—The affection is always symptomatic of lesion in the motor area of the cortex. The lesion is quite apt to be a tumor, though various injuries, inflammation, sclerosis, softening, hemorrhage or an abscess may be the cause. Consciousness is retained and the convulsions are limited in extent. Tonic and clonic spasms of the same character as in general epilepsy occur. A slight numbness, tingling, or twitching may precede the attack.

The =severity= of epilepsy =varies= extremely. The seizure may occur but once a year or it may occur several times in a day. In many cases a marked periodicity is observed. The mental functions are not, as a rule, injured, but when the seizures are frequent, the health fails and the mental capacity is reduced. Many sufferers from epilepsy are subjects of chronic gastric catarrh, and have at the same time an inordinate appetite. Quite frequently a fit may follow inordinate eating.

When there is a =series= of =convulsions=, which follow one another in rapid succession and which are associated with high fever, the term “=status epilepticus=” is applied. The most =common form= of epilepsy is the =major= form. About two-thirds of all attacks occur between eight a. m. and eight p. m.

=Diagnosis.=—=Uremic convulsion= closely resembles an epileptic convulsion. When the history of the case, analysis of the urine, increased temperature and the general health of the patient are all closely observed, error should be avoided. In =reflex convulsions= of =children=, a careful search, and if necessary waiting a short time, will readily determine the source of the attack. When =nocturnal convulsions= take place without the knowledge of the patient the attack is epileptic. In =hysterical convulsions= the patient rarely loses consciousness. They rarely hurt themselves, never bite the tongue, the temperature is normal, opisthotonos does not occur, and the duration is usually longer. In =Jacksonian epilepsy=, the attack is limited to some portion of the body, or it may gradually extend into a general convulsion. Care should be taken to recognize petit mal.

=Prognosis.=[121]—Records show that many cases have been cured and a much larger number have been benefited.

=Treatment.=—Osteopathic treatment has been especially successful in epilepsy, as compared with other treatment. Although the osteopaths do not claim a cure in every case, by any means, still about four out of every ten have been cured, while one-half of the remaining have been greatly helped in regard to the lessening of the severity of the attack, and in rendering the attacks less frequent. Conklin through his special treatment of fasting, dieting, enemata, spinal adjustment, and particular attention to the large bowel, especially cecum and colon, has increased this percentage. This is based on several hundred cases.

Important lesions are usually found in the cervical region, from the third to the seventh vertebra, though they may be as high as the atlas. These lesions may affect the brain in various ways; probably in the manner described under the etiology. Lesions are also found in the dorsal vertebræ and when occurring below the cervical region, the lesions are generally found in the upper and middle dorsal regions, though they may be located at any point along the spinal column.

The treatment is according to the rule that applies to all osteopathic work: an individual correction of the lesions presented in the case at hand. If any general movement or treatment might be given, it would be strong traction of the head to stretch the cervical vertebræ, or rather to separate them, so that the circulation to the brain may be equalized. Another general measure is to hyperextend the neck with fulcrum at juncture of atlas and occiput, thus releasing the upper anterior tissues that may impede cerebral circulation.

If the lesions in such cases are in the cervical vertebræ, probably they affect the cervical sympathetics. A =careful search= for a source of excitation must be made throughout the entire body. An irritation of the intestinal tract may be the exciting cause; or some irritation of the genito-urinary tract may be found, as phimosis, masturbation, etc., so that it is very necessary that great care be taken in the examination. Subjects of masturbation usually present lesions along the genito-urinary center in the spine. All possible reflex irritations should be eradicated.

Proper =hygienic measures= should be added. Pay particular attention to the bowels. Place the patient in the knee-chest position and thoroughly raise the cecum and ascending colon in order to improve circulation and promote elimination. Baths are important, and plenty of fresh air and outdoor exercise are of much significance. The patient’s mind should be occupied. The question of food is an important one; general diet—carefully regulated as to the amount given—should be prescribed. A vegetable diet is usually best. Reduction of salt seems to have a good effect. The patient must not be allowed to eat too much at a time, nor too often. If the bromides are being used, they should be withdrawn gradually.

In most cases of true epilepsy a continued treatment of several months is necessary. Unless the patient can follow out the treatment for several months, or even years, in a number of cases it will be entirely useless to take the treatment; although if the lesion present is very apparent, and the patient is enjoying fair health otherwise, and has not been affected long, a treatment for a few months, or even weeks, might be all that is necessary.

=Surgical interference= may be indicated in Jacksonian epilepsy. Trephining has been practiced successfully in a number of cases and the risk from operation with modern surgery is so reduced that one is frequently justified in advising an operation.

=During= an =attack=, a special treatment cannot be given to lessen the severity of the fit in all cases; in fact, most patients prefer not to have the seizure shortened as the after effects are more disagreeable. In some cases, at the beginning of the seizure, exerting a firm pressure upon the suboccipital will quiet the patient. This treatment probably controls the circulation of the brain, by way of the superior cervical ganglion. In cases where the exciting factor seems to be in the intestines, and the peristaltic action of the bowels is reversed, causing a reversion of the nerve current of the vagi, a rapid, firm kneading over the abdomen, so as to establish normal peristalsis, will suffice to prevent an attack, if one is notified of its approach. In some cases a rapid, thorough stimulation of the solar plexus will lessen an attack. Possibly it reduces the blood pressure in the brain, by bringing blood to the splanchnic region.

In all cases during the convulsion the patient should be carefully protected from injuring himself. A towel should be twisted and placed in the mouth, so that the tongue cannot be bitten. Do not place small articles as corks, etc., between the teeth, as they are liable to enter the pharynx and cause suffocation. The patient should be watched to protect him from any injury; otherwise the attack should usually be allowed to spend itself.

Migraine

(SICK HEADACHE)

=Migraine= or sick headache is a neurosis, characterized by a paroxysmal pain in the head, usually unilateral and periodical, with nausea, frequently vomiting, and disorders of vision.

=Osteopathic Etiology.=—The disease usually begins in the first half of life, rarely earlier than puberty and is slightly more frequent in females. Some weakened or depressed condition of the nervous system, due to lesions of the upper cervical vertebræ, lesions of the inferior maxilla, anxiety, overfatigue, anemia, digestive derangements, =eye strain= and menstrual disorders, is generally the cause. The hereditary factor is very important. This is frequently associated with derangement of the =large bowel=, especially cecum and ascending colon, resulting in toxemia.

It is supposed by some to be a =vasomotor= disturbance, because there are symptoms, as pallor and flushing of the skin, which show an involvement of the sympathetic system. It is possible a spasm of cerebral arteries, followed by vascular dilatation, takes place. The seat of the pain is believed to be in the meninges of the brain. Possibly in many cases where the atlas is found involved and causing the affection, some meningeal fiber of the fifth nerve is impinged by the lesion. Caries of the teeth and =nasal troubles= are causes of the disease in children.

=Symptoms.=—A =paroxysmal= headache is the principal feature of migraine. The attack may occur without warning, although there are usually malaise, restlessness and a disturbed vision preceding the headache. The =prodromal= symptoms vary to a great extent. Other prodromal symptoms besides those given, may be vertigo, spots before the eyes, tinnitus, chilliness, etc. The pain is of a sharp and stabbing nature and is oftentimes limited to the temporal region of one side. Others describe the pain as of a binding or of a boring nature. It is continuous. It may be in the occiput instead of in the side of the head.

=Hyperesthesia= of the surface is noticed, but the tender points of neuralgia of the fifth nerve are absent. The patient is sensitive to light and noise. Flashes of light occasionally attend the pain in the head. Hemianopia is not infrequent. The temporal artery may be contracted, the face pale and the pupil large. In others the eye is dilated, the face flushed and the pupil small. Nausea and vomiting are frequent, with loss of appetite. In some cases where the stomach is full, vomiting the contents will relieve the attack. Should the stomach be empty, vomiting of mucus may occur, and is later followed by vomiting of bile. Tenderness is commonly found about the region of the occipital and upper cervical muscles. Attacks rarely occur oftener than once in ten or fifteen days. During the intervals the patient may be quite well. The =duration= is anywhere from a few hours to several days.

=Diagnosis.=—The sensory symptoms, the paroxysmal character, the severity and definite course, usually readily distinguish migraine. =Growths= of the =brain= may be the cause of symptoms closely simulating migraine. In such cases an ophthalmoscopic examination may reveal a choked disc.

=Prognosis.=—Is usually favorable when the attacks are light and of short duration. Cases of long standing and of great severity are not so easily cured, although in most instances great relief can be given the patient. There are very few cases in which the severity and frequency of attacks cannot at least be lessened. Oftentimes attacks of migraine cease after middle life.

=Treatment.=—The =atlas= or one of the =upper cervical= vertebræ is almost invariably subluxated. This is not always the direct cause of migraine, but it is an important factor in the causation. =During= the =attack= many cases can be completely, or at least partially relieved, by a careful treatment in the upper cervical region. But there are some cases where treatment of the cervical region is entirely unsuccessful, and, in fact, aggravates the attack. The details of treatment vary in every case. If any defects in general health or any error in the mode of living can be found, these of course must receive first attention. Rest, diet (a vegetable diet is best) and regularity of meals are usually to be specially considered. Anything that is known to induce an attack must be carefully avoided. In some patients the attacks cease so long as they remain free from mental work, but as soon as they return to their studies the paroxysms occur.

Every case should be thoroughly examined before a course of treatment is laid down. Causal conditions can generally be found, and the correction of such usually results in a cure, or at least in great relief. Errors in diet; digestive disturbances, as a disordered biliary tract; disorders of the pelvic organs; eye strain; nasal disorders; mental and physical fatigue, and affections of the nose may induce attacks.

A beneficial treatment for many, aside from adjusting the spinal lesions, especially the cervical and usually a rigid splanchnic area, is to place the patient in the knee-chest position and thoroughly raise the bowels of the right side beginning in the right iliac, loosening possible adhesions, etc.

The earlier the treatment, the more likelihood of a cure. Cases of long standing are generally harder to cure. Preceding a paroxysm, relief can usually be given, but after the paroxysm has reached its height it is harder to give relief. The patient should rest in a quiet room which is darkened and well ventilated. Besides the indicated osteopathic treatment (generally a cervical one), hot applications to the nape of the neck and keeping the extremities warm are helpful. The nerves involved are the vasomotor, occipital, frontal and temporal. A free evacuation of the bowels will relieve a few cases, while washing out the stomach will help others. Hot fomentations over the splanchnics for thirty minutes may be beneficial. During the intervals, valuable adjuncts will be found in the use of systematic exercises and frequent bathing. Do not fail to have the eyes examined.

Occupation Neurosis

These are a group of maladies of the nervous system, due to excessive use of certain muscles in some oft-repeated act, and characterized by spasm of the muscles concerned. There are several varieties, as writers’ cramp, telegraphers’ cramp, piano players’ cramp, violin players’ cramp, typewriters’ cramp, etc.

Professional spasms, that involve muscles of the shoulder girdle, are not rare among osteopathic practitioners, due to prolonged faulty methods of technique.

=Osteopathic Etiology.=—A nervous temperament predisposes to the development of the affection. Previous injuries and strains of the involved parts are important factors. Faulty methods of writing, and in the other disorders, strained or cramped positions of the affected tissues, predispose to attacks. Slight =lesions= of the bones, joints, ligaments and muscles are commonly found, involving the motor and sensory nerves of the immediate locality. The majority of all cases occur between twenty and fifty years of age.

Distinctive =pathological= changes have not been found. Each case has particular lesions of its own. The details of the case are characteristic of the one case only. The affection is often primarily a spinal one, due to deranged action of the spinal centers concerned in the various acts; though, no doubt, excessive use of a group of muscles may result in contractions, spasms, contractures and nutritional changes, that in turn will establish definite osteopathic lesions. This is an illustration of a “vicious circle.”

=Symptoms.=—Symptoms of the various varieties of professional neuroses develop slowly and gradually. A cramp or spasm affecting the used member is an early symptom. Tremor, weakness, stiffness, fatigue and heaviness of the affected part are present most of the time. In severe cases neuritis may develop, and a glossiness of the skin be present. Associated with the inability to perform the usual work, may be mental worry and depression.

=Diagnosis.=—The history of the case and the limitation of the disease to one member, usually make the diagnosis easy: =Cerebrospinal= diseases, as hemiplegia; early =tabes=, affecting the arms; and progressive =muscular atrophy=, have to be carefully excluded.

=Prognosis.=—As a rule is favorable. Osteopathic treatment, in the majority of cases treated, has resulted in recovery.

=Treatment.=—Rest of the part, mental quiet and attention to the nutrition of the patient, are the first essential considerations. A change of occupation may be necessary if excessive use of parts and faulty methods can not be corrected. The treatment consists of a correction of the parts irritating or disturbing the spinal centers or nerves affected. The ulnar, radial and median nerves all innervate muscles employed in writing. Lesions of the cord affecting these nerves may be found from the fifth cervical to the sixth dorsal. In a few cases lesions occur as high as the atlas. When the =radial= and =median= nerves are involved the lesions are principally found in the upper dorsal vertebra. When the =ulnar= nerve is involved the lesions are usually slightly lower. The lesions may affect the fibers of these nerves directly (mechanically), but more probably the vasomotor nerves are involved, as in this region the vasomotor fibers to the arm pass from the cord to the sympathetic fibers. The brachial plexus originates higher than the upper middle dorsal region, still some of its nerves are frequently affected in the dorsal region by osteopathic lesions, for removal of the same relieves the disorder.

Other lesions affecting the arms are oftentimes found in the ribs on the side involved. Any of the first five ribs may become deranged and affect the innervation of the arm. The clavicle in a few cases may be abnormally low. A bursitis may be present. Occasionally slight subdislocations of the shoulder joint (especially anterior) and elbow joint are found. Gymnastic exercises of the arm and hand, coupled with a general treatment of the shoulder, arm and hand, are beneficial. Hydrotherapy, massage and friction of the involved member are useful. In severe cases “breaking up” fibrotic tissue, and muscle training frequently secures good results.

Hysteria

Oppenheim defines hysteria as “a psychosis, which does not express itself by disorders of the intellect, but in defects of character and emotional disturbances, whose real nature is hidden under an almost unlimited and varied number of physical symptoms of disease.”

The affection is about equally divided between the two sexes. A neurotic tendency, often inherited, is an important underlying factor. This condition, when associated with lack of mental discipline, is very apt to lead to the mental depression and outbreaks of hysteria. A large number of cases are between the ages of puberty and twenty-five. After forty-five the disorder is infrequent.

White, Osler’s System of Medicine, says: “The significance of Freud’s theory is the tracing of every case to sexual traumata during childhood. Sexual experiences differ, however, from ordinary experiences—the latter have a tendency to fade out, while the idea of the former grows with increasing sexual maturity. There results a disproportionate capacity for increased reaction which takes place in the subconscious. This is the cause of the mischief.” A distinction is made between the sexual and the sensual.

Anders points out that lack of proper mental development, improper hygienic surroundings and chronic toxemia are causes.

The =direct causes= of hysteria may be many, and include physical and mental influence, or both. Traumatism of various regions of the body, but especially of the spinal column, may excite hysteria. Some slight lesion of the vertebra or rib may be all that is discoverable. A correction of the same is occasionally all that is necessary to remove the direct cause; still there is usually considerable disturbance of the spinal tissues, especially slight curvatures and muscular contractions. Prolonged emotional excitement, overwork, defective education and many moral and mental influences are potent and frequent causes. Masturbation or an adherent prepuce occasionally is the cause of the affection in boys, or any excitation that produces exhaustion. Disturbances of the sexual system in both sexes are responsible for many cases. The menstrual period and the menopause are frequent periods for the manifestation of the disease. The disease often affects prostitutes. Disturbances of the digestive, nervous and circulatory systems, and general diseases of an exhaustive kind are exciting causes of hysteria. Dr. Still said that occasionally the colon is prolapsed and crowded down upon the pelvic organs. Hazzard[122] is of the opinion that “a majority of the cases show a depression of all the ribs, narrowing the thorax and often causing enteroptosis.”

=Symptoms.=—The symptoms may be extremely varied, including any symptom of the many nervous diseases. The =sensory symptoms= are numerous. The most common is anesthesia, which may be found in certain parts of the body, usually one side (the left) of the body. Geometrical areas that bear no relation to the innervation is characteristic. The patient may not know of the sensory derangements until discovered by the physician. When there is =anesthesia= without other nervous symptoms, the case is commonly hysterical. The most marked symptom is analgesia, where the patient is insensible to painful impressions. A pin may be placed deeply into the flesh, and not be felt by the patient. The anesthesia may extend to the mucous surfaces, and even deeply down to the tissues of the joints. Organic and tendon reflexes are not changed. There may be other symptoms of disturbed sensation; as an absence of pressure, temperature and muscular sensation.

=Hyperesthesia= may be present nearly as often as anesthesia. Hyperesthetic areas may be found in various regions of the body, but especially along the spinal column and in the ovarian region. The “hysterical spinal irritability” is of special interest to the osteopath. The spinal column may be affected as a whole, or in segments, or confined to a single vertebra. Especially when a spinal irritability is in segments, or confined to a single vertebra, are local derangements of the spinal column apt to be found. Correction or even =pressure= upon these areas will often relieve the patient. Severe pain over the heart may simulate angina pectoris. =Globous hystericus= is of quite common occurrence.

Charcot refers to the ovarian hyperesthesia as follows: “It is indicated by pain in the lower part of the abdomen, usually felt on one side, especially the left, but sometimes on both, and occupying the extreme limits of the hyperesthetic region. It may be extremely acute, the patient not tolerating the slightest touch; but in other cases pressure is necessary to bring it out. The ovary may be felt to be tumefied and enlarged. When the condition is unilateral, it may be accompanied with hemianesthesia, paresis, or contracture on the same side as the ovarialgia; if it is bilateral, these phenomena also become bilateral. Pressure upon the ovary brings out certain sensations which constitute the aura hysteria, but firm and systematic compression has frequently a decisive effect upon the hysterical convulsive attack, the intensity of which it can diminish, and even the cessation of which it may sometimes determine, though it has no effect upon the permanent symptoms of hysteria.”

The =special senses= may be disturbed, although these symptoms are usually transient. There may be blindness; narrowing of the field of vision, due to anesthesia of the periphery of the retina; loss of hearing; loss of smell or loss of taste.

=Motor disorders= may be of different forms of paralysis, as hemiplegia, paraplegia or monoplegia. In fact all forms of =paralysis= may be found in hysterical patients. Osier says: “There is no type or form of organic paralysis which may not be simulated in hysteria.” The affected muscles do not atrophy. The paralysis is usually general, and contractures are common. Local paralysis, as of the bladder, vocal cords and other parts of the body, commonly occur.

=Contractures= and =spasms= may also occur. True epilepsy may even be simulated by hysterical spasms, but on careful observation the characteristic attack of epilepsy is found wanting. Firm pressure may increase the severity of an attack as well as bring it on. The spasms are of various parts of the body, as the diaphragm, bronchi, abdominal muscles, bladder, etc.

Various =disturbances= of the =viscera= may occur. Of the digestive tracts, the appetite may be disturbed or depraved. Diarrhea or constipation may be present. Flatulency is a common symptom. The respiratory tract may be another point of considerable disturbance in many cases. Dyspnea, aphonia, hiccough, cough, and exaggerated breathing, as when cold water is poured on one, are common manifestations. Various =cardiac= vascular symptoms may be manifested, especially a rapid heart. Various =vasomotor= derangements are common.

=Physical manifestations=, as amnesia, lack of will power and an excitable nature—easily moved to laughter or tears—are frequent. The moral tone may be lowered. Even delirium, catalepsy, ecstasy and trance, may be mentioned among the psychical phenomena.

The =hysterogenous zones= are of more than passing interest to the osteopath. Tyson writes as follows, in regard to the hysterogenous zones: “These are hyperesthetic areas especially studied by Richet, on which persistent pressure will sometimes excite a hysterical attack. While the ovaries are favorite hysterogenous zones, the zones may be in any part of the body; as for example, the sides of the trunk. Such pressure may also cause an existing attack to subside. Hysterical spasms may also be localized or limited to groups of muscles.” Especially when zones along the spine and side of the trunk are located, the attack of hysteria may be completely relieved by correcting the localized deranged tissues.

=Convulsive seizures= are not uncommon and may follow various prodromal symptoms. Some authors divide the symptoms of hysteria into convulsive and non-convulsive forms.

These are part of the many manifestations that are presented by various hysterical patients, and it is readily seen that an osteopath has to be continually on his guard.

=Diagnosis.=—The diagnosis is generally quite easy. The characteristic emotional symptoms, associated with any of the many other symptoms which have no organic lesion, are characteristic of the disease. Care has to be taken, though, in some cases where symptoms are presented which have organic lesions. The history, the attack and neurotic temperament, will largely decide the nature of the affection. After the “outbreak” the patient often feels decidedly better.

=Prognosis.=—Death may occur from exhaustion, but such a termination is rare. Recovery is the rule, although the duration may be long. Recovery usually takes place rapidly, after the exciting cause has been determined and removed.

=Treatment.=—First of all, the osteopath should have due appreciation of the mental characteristics of the disease. Whatever is dominating the patient mentally must be either changed or abolished. It is not always necessary to be harsh and severe with the patient; but one should be firm and unyielding. He can do a great deal by having complete mental control of the hysterical patient.

A most careful examination should be made for an exciting cause, and when found it should be removed. This naturally constitutes a very important part of the treatment. A light general treatment is commonly indicated. The general health, especially the bowels, should be carefully attended to. The hygiene, exercise and amusement of the patient should receive due consideration. One has to gain the confidence of the patient, and then be firm but kind to him. Relative to diet Yeo[123] says: “The diet should be simple, abundant, and supplied regularly, and at not too long intervals as is frequently the case in boarding schools. All strong stimulants are best avoided, and the hysterical should not indulge in strong tea or coffee, or exciting wines and liquors.”

The “rest cure” as introduced by Weir Mitchell, is applicable in some cases. This method consists of plenty of food, especially milk, absolute rest of the body and mind, massage and electricity with isolation of the patient from friends and sympathetic relatives. Doubtless a general osteopathic treatment would be much better than massage. Yeo says that to the application of hypnotism and suggestion “we look with little sympathy and less confidence.”

During the hysterical =convulsions=, the patient should be watched, but extreme measures should not be practiced. There is little danger of patients hurting themselves. Throwing cold water in the face, or a cold bath may produce the necessary mental shock. Pressure over the ovary as stated in hysterogenous zones, or some other zone of the body, or pressure upon a large blood vessel, as a carotid, will oftentimes stop an attack.

Neurasthenia

“Closely allied to, and in some cases almost inseparable from, hysterical states are those morbid conditions to which, in modern times, has been applied the term neurasthenia.” (Yeo). Neurasthenia is a fatigue neurosis that is characterized by mental and physical irritability and inefficiency. Headache, backache, insomnia, and debility of the gastro-intestinal tract are common symptoms.

The affection is often found in that class of people who are predisposed to hysteria. The disease is more common among men than women, usually occurring after the twentieth year. The predisposition may be inherited or acquired. Church states that “debilitating conditions in the antecedents of neurasthenics,” and “defective education that omits discipline and the cultivation of self control” are important predisposing causes. Many of the exciting causes that produce hysteria will cause neurasthenia. Various =lesions= along the spinal column, chiefly in the cervical and upper dorsal regions, include the predisposing causes of a large majority of cases. This spinal irritation, taken in conjunction with overstrain of mind and body, or probably in many cases the spinal irritation as the predisposing cause of the over strain, results in nervous exhaustion. Particularly overwork, associated with care and anxiety, is an exciting cause of great significance.

The neurasthenic patient is generally of a =neurotic temperament=. The affection may, also, result from various chronic diseases, toxic conditions, sexual excesses, alcohol and tobacco. Thompson[124] believes that improper sexual hygiene and perversion or abuse of the marital relation are most important factors in the development of neurasthenia in both sexes, and a regulation of this is imperative for a cure. The symptoms are due, to a greater or less extent, upon =spinal=, =cerebral=, =cardiac= and =gastric disturbances=, but all of these conditions are usually dependent upon =vertebral= and =rib lesions= of the upper dorsal and cervical regions. Care should be taken whether the condition is secondary to organic lesions. The lesions in the vertebræ are generally slight lateral deviations, in the ribs upward displacements of the vertebral ends, followed by contraction of the deep muscles in the neighborhood of the lesions. A posterior condition of the atlas and a lateral lesion between the third and fourth dorsal are especially apt to be found. As to spinal areas most affected Stearns[125] says the predisposing irritations are located particularly in the first two cervical, the first two dorsal and the last two lumbar vertebræ.

These various lesions probably cause an impairment of nutrition in the nerve centers of the cord and brain, or both. Definite =morbid anatomical= changes have not been found resulting from nervous debility or irritability. Still, it seems probable that certain changes in the nerve cells may result from excessive functional activity. =Traumatism= is a prominent causative factor in both =neurasthenia= and =hysteria=. =Railway= and other =injuries= frequently produce osteopathic lesions that result in nervous disorders. That there is a demonstrable pathological basis resting in sympathetics and spinal nerves, there can be no doubt.

=Symptoms.=—To enumerate the many symptoms of neurasthenia in detail is hardly necessary. The nervous debility may affect any organ of the body, owing to the exhaustion of the nervous energy, thus lessening the functional activity of that organ.

The most noticeable symptoms are various =sensory disturbances= and =muscular weakness=, dependent in part upon the spinal lesions. The patient generally feels weak and tired. Headache, pains in the back and sacrum, tender points along the spine, and various sensations of numbness, tingling, etc., are felt.

The =mental faculties= are oftentimes irritable and weak. An inability to concentrate the thoughts with depression, fear, vertigo, insomnia, and many other mental symptoms, may be manifested.

=Palpitation=, irregular action of the heart and pain over the precordia may be present. =Ocular= disturbances, particularly blurring of letters and narrowing of the visual field, =visceral= symptoms of many kinds, and =vasomotor= phenomena, as chilliness, flashes of heat and sweating, are among the many symptoms of which the patient complains.

=Genito-urinary= disorders in the male, and ovarian and uterine irritation and painful menstruation in the female, are occasionally symptoms dreaded by the sufferer. Polyuria is frequent.

The symptoms or signs of great importance to the osteopath in neurasthenia, as in many other diseases, are the tender points along the spinal column. They give direct clues as to where the lesion may be found.

=Diagnosis.=—Error in diagnosis can usually be prevented by a study of the history of the case and symptoms. Care must be taken in determining between symptoms of organic diseases and the symptoms of a true nervous exhaustion.

=Prognosis.=—Is almost invariably good. Only in cases where there is a tendency to mental disorder should the prognosis be guarded. Much depends upon the thorough cooperation of the patient. It usually takes some time to perform a cure among the poorer class, as the requirements demanded for a cure are oftentimes expensive.

=Treatment.=—Naturally the treatment, exclusive of the manipulation to correct the various lesions found, is extremely varied, owing to the many exciting causes and symptoms to contend with.

As has been stated, the lesions are usually found in the upper spinal region; still lesions are occasionally located in the lower spinal region, especially in female sufferers, when the pelvic organs are disturbed. The many mental symptoms, as inability to concentrate the mind, insomnia, vertigo, headache, etc., are best treated through the cervical region, with attention to the heart’s action and the excretory organs. Careful attention should be paid to the deep posterior muscles between the atlas and occipital bones.

=Rest= is very necessary. Changes of scene and occupation, attention to the surroundings, careful dieting, hydrotherapeutic measures, pleasant companions, relief from responsibility, bathing, etc., should receive careful attention and consideration by the osteopath. Set rules cannot be given. The details of treatment that should be adopted are dependent upon the individual case. Every well trained osteopath will be familiar with such measures.

Careful attention must be given to the secretions, excretory organs and the circulation. A study of each case will bring out the various irregularities that may exist.

When the nervous involvement is extensive, a “general treatment” may be given. Such a treatment would affect the entire nervous and muscular system, and tend to equalize disturbed nerve force. Bringing the muscular system into play and relaxing contracted muscles calls for more blood and nerve force, and consequently a nutritious diet.

The “rest cure,” as introduced by Weir Mitchell, may be employed to considerable advantage in many cases. Yeo says: “It is in certain cases of this disease that the ‘rest cure,’ devised by Weir Mitchell, has proved so remarkably successful. But there can be no sort of doubt that it has been applied far too indiscriminately, and that for this, as indeed for any special method of treatment, a careful selection of suitable cases is needful.” The diet should consist principally of milk at first, followed in a few days by soft boiled eggs, boiled rice, lamb chops, graham bread, stewed fruits and butter, and a little later by roast beef, vegetables and light puddings. Porter’s system of milk diet has proved effective in many cases. Tea, coffee and alcohol should be avoided.

During the entire course of the treatment, care should be taken to correct any lesion that may bear directly upon the cervical sympathetic, the solar plexus and the hypogastric plexus, as they are the great reflex centers of the body.

FOOTNOTES:

[119] A. O. A. Case Reports, Series IV.

[120] See A. O. A. Case Reports, Series II., III., IV., V.

[121] See A. O. A. Case Reports, Series I., III., V.

[122] Practice of Osteopathy.

[123] Manual of Medical Treatment.

[124] Cosmopolitan Osteopath, October, 1903.

[125] Journal of Osteopathy, January, 1904.

DISEASES OF THE SPINAL CORD

Acute Myelitis

=Acute myelitis= is an acute inflammation, with softening of the substance of the cord, giving rise to marked disturbances of motion, sensation and nutrition. When the whole thickness of a section of the cord is involved, the condition is termed =transverse myelitis=. When an extensive area is involved, it is termed =diffuse myelitis=. When the gray matter around the central canal is especially affected, it is termed =central myelitis=.

=Etiology.=—There can be no doubt that osteopathic lesions are very potent predisposing factors. Osteopathic lesions of the spine, even of a muscular nature, readily disturb the cord circulation. It may follow repeated exposure to wet, cold or exertion; or be a sequel to the infectious diseases, as smallpox, typhoid fever, typhus, puerperal fever or measles. It may be due to traumatism or disease of the vertebræ, as caries or cancer. Syphilis is a frequent cause.

=Pathology.=—To the untrained, naked eye, the cord may present little or no change. The nervous tissues are in various stages of degeneration. On section the substance of the cord is red and soft, the line of demarcation between the gray and white matter is lost or extremely indistinct, and minute hemorrhages are sometimes seen. In very acute cases, affecting the white and gray matter, after injury, when the membranes are cut, the substance of the cord may flow out as a reddish creamy fluid.

The nerve fibers are much swollen and the axis cylinders broken up. Blood discs, leucocytes, and numerous granular fatty cells may also be present. The blood-vessels are distended and dilated. There may be thickening and hyaline degeneration of the vessel walls and hemorrhagic extravasation.

=Symptoms.—Acute Transverse Myelitis.=—This is the type most frequently met with. The symptoms differ with the situation of the lesion, which is generally in the dorsal cord. At the onset there may be pain; numbness and tingling in the back, radiating into the limbs. There is usually moderate fever, malaise, chills, muscular pains, a coated tongue and constipation. Symptoms of =motor paralysis= soon develop, which may become more or less complete. Both motor and sensory symptoms vary to a marked degree, depending upon the pathologic involvement. The reflexes are lost at first. They may soon return and are exaggerated below the lesion. Following this the muscles often become rigid and contracted. Unless the lesion is in the lumbar or cervical cord, reaction of degeneration or much wasting of the muscles, as a rule, does not occur. A girdle sensation frequently occurs at the level of the disease. At first there is retention of the urine and feces, later incontinence. Bed-sores soon develop; also drying and hardening of the skin. The nails become thick and brittle. Death may occur from exhaustion, or heart or respiratory failure, but it is rare; segments of the cord may be completely and permanently destroyed, causing persistent paraplegia. H. A. Greene[126] reports a case, due to injury, which was greatly benefited by treatment.

=Acute Diffuse Myelitis.=—In the acute forms the course of the disease is rapid. The trophic disturbances are more marked than in the former type. This form is likely to follow exposure to cold, injuries, tumors, syphilis or one of the infectious diseases. There may be chills, fever, malaise, pain in the back and limbs, and occasionally convulsions. The reflexes are generally lost. The motor functions are rapidly lost. There is incontinence of urine and feces, rapid wasting of the muscles and bed-sores develop. The disease may prove fatal in from six to ten days.

=Diagnosis.—Landry’s Disease.=—In this the bladder and rectum are not affected. Trophic disturbances are absent. There is but slight loss of sensation, no reactions of degeneration and no girdle pains. =Multiple Neuritis.=—Both arms and legs involved, and slow onset. The bladder and rectum are rarely involved; the girdle pain is absent. =Acute Poliomyelitis.=—There are no sensory symptoms and the rectum and bladder are not affected.

=Prognosis.=—In very acute cases death occurs in from three to ten days. Milder cases generally recover with some loss of motor power, although in a few cases treated by osteopathy recovery was complete, due probably to the case being seen early and thus degeneration prevented.

=Treatment.=—Lesions of the vertebræ are usually readily found in cases of myelitis. Generally, deranged vertebræ are found in the upper dorsal region, and occasionally lesions are located in the lumbar and cervical vertebræ. The treatment of myelitis is chiefly to correct these lesions, so that the normal circulation of the cord may be reestablished. One has to be very =careful= when treating the lesions not to cause additional injury to the cord. An inhibitory treatment to the muscles about the lesion may be all the treatment that can be given at first; nevertheless, it aids nature just so much in overcoming the excessive irritation of the cord tissues. Nature has the curative means, provided they may operate unobstructedly. In a few cases the ribs in the region of the spinal lesion will be found deranged and interfering with trophic fibers, blood-vessels and lymph vessels of the cord. The patient should be kept in the prone posture at first.

Warm baths and massage will be found of additional value. The bowels and bladder should receive special attention. An ice-bag to the spine may be beneficial. If there is any danger of bed-sores, use alcohol to stimulate and harden the skin. Rest, liquid diet and good nursing are necessary. Later on careful exercising of the limbs will be beneficial.

=Chronic Myelitis.=—This defines the conditions when the inflammation is subacute with the paraplegia and other symptoms which then naturally appear, present, and also with the signs of both degeneration and repair. The symptoms develop slowly as compared with the acute form. It should not be confused with atrophy, pachymeningitis or tumors of the cord. =Treatment= is practically the same as in acute form. Surgical measures may be indicated. Loudon[127] reports a case due to injury which was greatly benefited.

Poliomyelitis

(INFANTILE PARALYSIS)

=Definition.=—An acute infectious disease occurring most commonly in young children, characterized by paralysis, rapid wasting of certain muscles, and fever. It is an acute myelitis that affects the anterior horns of the cord. There are no sensory symptoms.

=Etiology.=—It usually occurs in children under ten years of age, and the majority of cases occur before the fourth year. It is more common in summer than in winter. The infection seems to gain entrance through the nasal mucous membrane. Traumatism, exposure to cold and overexertion, are probably predisposing causes. It has occurred in severe epidemic form.

=Morbid Anatomy.=—The disease is most frequently seen in either the lumbar or cervical enlargement and is usually unilateral, though there is considerable variation in the extent of the lesions. In very early cases, the condition of acute hemorrhagic myelitis, with degeneration and rapid destruction of the large ganglion cells, has been found. In older lesions the anterior cornu in the affected region is atrophied and there is destruction of the multipolar ganglion cells. The anterior nerve roots are atrophied, the muscles are wasted and undergo a fatty and sclerotic change.

=Symptoms.=—The child may have a slight fever, malaise, muscular twitching, headache, some rigidity of the neck, and sometimes vomiting. This may last a day or several days or only a few hours, when paralysis sets in abruptly. The =paralysis= is rarely complete and groups of muscles only may be affected. As a rule, the paralysis comes on abruptly, but it may come on slowly, taking several days to develop. In a few weeks, atrophy sets in and the limb becomes flaccid, soft and wasted. The paralysis remains stationary for a time when improvement takes place, but complete recovery is rare. Sometimes the growth of the bone of the affected limb is impaired. Usually there are no sensory disturbances and the bladder and rectum are not affected. The condition of the reflexes is dependent upon the extent of involvement of the cornual cells. Occasionally the bulbar muscles are affected.

=Diagnosis.=—This is not difficult except in the early stages. Careful study of the case is commonly all that is necessary. Landry’s paralysis and peripheral neuritis are to be differentiated.

=Prognosis.=—Complete recovery is rare. Improvement is the rule. Ivie[128] tabulates sixteen cases, all showing good results. W. B. Davis[129] reports a case cured by six months treatment and still well after three years. T. M. King[129] one case cured and one greatly benefited and A. S. Craig[129] one much helped. Florence Gair, F. P. Millard, A. G. Walmsley and others report gratifying results in many cases.

=Treatment.=—In the treatment of chronic cases, F. P. Millard[130] says “Five minutes’ time is sufficiently long in treating a patient, and sometimes too long. * * * Start in and move every spinal joint. That takes about two minutes. Spring the sacro-iliac articulations just enough to get motion. Then give a specific cervical treatment. Do not stop to relax muscles in a child. Adjust as rapidly as possible. Make every spinal joint yield to motion. Spend only one minute, or possibly two, on the cervical vertebræ. So far we have consumed four minutes. The last minute we loosen up the wrist or ankle, according to the extremities that are involved.” This outline has been followed with gratifying success by Gair, Green, Bush and others in many chronic cases. The procedure in acute cases is condensed from A. G. Walmsley[130]: “Isolate, keep cool and absolutely quiet. Stop all food until the temperature drops to 100° F. or lower and until the pain subsides when fruit juices may be given followed by heavier foods. Give patient all the water he will drink. Where the spine is sensitive, and it will be in many, use hot fomentations until a specific treatment can be given. If the fever is running high cool compresses will be grateful and help reduce temperature. Irrigate the colon twice daily with saline water. Do this first thing when called. Later once daily will do and then discontinue. Look carefully to the nose and throat and wash with saline or boracic solution. Keep feet warm as they may be cold even with high fever. Treat the case over a long period. See that he does not overdo and observe all dietetic and hygienic measures.” Both these men lay great stress on the importance of specific adjustments and massage of muscle tissue has little place in their treatment. This, with drill at home can be attended to by the mother.

Ivie[131], among other good ideas on treatment, gives the following: “May I suggest that when such severe results (the acute stage) follow a slight infection, that we may expect to find a lesion located at such a point as will interfere with one or more of the anterior root arteries which join and supply the anterior spinal plexuses. As there are only five or ten of the anterior root arteries (Dana), the lesions affecting them can be located throughout a wide range of the spine. In a great many cases we find that the correction of lesions well up in the dorsal and even in the cervical region have increased the amount of the improvement well beyond that received in the correction of the lumbar lesions alone. To =promote resolution=, correct the lesions, both muscular and bony, and relax the muscles of the spine daily; move every vertebra to the limit of all its possible motions; use flexion, extension, rotation, and lateral flexion at least once every day for at least a week; and help to overcome stasis by keeping the child off its back, turning it from side to side, and letting it lie on its stomach as much as possible. The limb, to be kept in its best condition, should be kept warm; treated gently; held in a natural position by the use of sand bags and clothes cradle, thus beginning early the =prevention= of deformity; the paralyzed muscles should not be kept on a stretch, as that will retard any possible improvement; stimulating rubs and baths should be given frequently.” In the =chronic stage= he advocates: “Now that the nerve cells have been given a chance to regenerate (removal of lesions), the best thing to do is to force them to work if possible. To do this, the so-called resistance exercises or educational movements are to be strongly recommended; the idea being to place the limb in a given position and then ask the child to fix all its attention on the limb and to earnestly attempt to hold it there while you move it, or to keep making the attempt while you move the limb through its whole range of motion in that direction. These movements should be so calculated that the resistance of the child will exercise the group of muscles affected. The mother or nurse can give these exercises every night on going to bed.”

Acute Ascending Paralysis

(LANDRY’S PARALYSIS)

=Definition.=—An acute disease, characterized by an advancing paralysis, beginning in the legs, passing upward to the trunk and the arms and finally it may involve the centers in the medulla. =Toxic= and =infectious= influences that congest the nerve courses and ultimately destroy the cells seem to be the important factor. The anterior gray matter of the cord is involved, and it is probable that many cases are a form of acute poliomyelitis. The spleen is congested and in some instances the lymphatics.

=Etiology.=—A definite cause has not been found, although osteopathic lesions are important predisposing factors. A toxic cause seems probable. The disease is most common in males between twenty and forty years of age. It may follow traumatism, exposure, cold or the infectious fevers.

=Symptoms.=—Weakness of the lower extremities is generally the first symptom, though the arms may be involved first. This is shortly followed by paralysis. The paralysis then extends to the trunk and within a few days the arms are also affected. The muscles of the neck are next involved and finally those of respiration, deglutition and articulation. The reflexes are abolished. The muscles are relaxed, but generally do not waste or show electrical modification. Sensation is usually not affected, but there may be tingling, numbness, hyperesthesia and muscular tenderness. The sphincters are not involved as a rule. The spleen is usually enlarged. The =course= is variable. Death often occurs in from two days to a few weeks. When the improvement takes place, the part last affected recovers first.

=Diagnosis.=—This is not always easy. It is sometimes impossible to differentiate between this disease and =multiple neuritis=. The history, the motor paralysis, the absence of wasting and of electrical modification, as well as the absence of involvement of the sphincters, will definitely aid in the diagnosis.

=Prognosis.=—The prognosis is unfavorable. A large majority of cases prove fatal. In a few cases treated osteopathically, results were favorable if the patient was seen early. The muscles of the spinal column were markedly contracted.

=Treatment.=—The treatment of Landry’s disease consists principally of thorough treatment of the spine, especially of the lower dorsal and lumbar regions, and attention to the underlying toxic condition. The treatment should be most thorough; the vertebræ and ribs found disordered should be corrected and each vertebra should be carefully separated (if conditions permit) from its neighbor. When the paralysis has extended to the trunk and neck, a thorough treatment all along the spinal column should be given with a view to relaxing the contracted muscles and to render flexible the entire spinal column, so that the cord may be properly nourished and the progress of the disease checked. Careful relaxation of the contracted spinal muscles unquestionably has a potent effect upon the cord circulation, which tends to check and retard degenerative processes. Treatment of the limbs directly will be found a help, as well as direct treatment of all tissues paralyzed. If swallowing is impossible, the patient should be fed through the rectum, or by the stomach or nasal tube. See that the patient is carefully nursed. Massage is beneficial.

Locomotor Ataxia

(TABES DORSALIS)

=Locomotor Ataxia= is frequently met with. It is a disease of the spinal cord wherein the ultimate effect is a sclerosis of a progressive character of the nerve courses of the posterior column. It is claimed that the origin is in the protoplasmic processes of the posterior spinal ganglion. The characteristic symptoms are incoordination, Argyll Robertson pupil, lightning pains and loss of knee-jerk.

=Osteopathic Etiology= and =Pathology=.—Most cases develop between the ages of thirty and forty, although it is occasionally seen in young men, and rarely in children from hereditary syphilis. Males are much more frequently affected than females (10 to 1, Osler), and the disease is much more frequent in cities. Predisposing causes are given as syphilis, prolonged exposure to wet and cold, and sexual excesses, although there is a disposition on the part of neurologists to confine the cause of true tabes to syphilis, some records showing as high as 90 per cent. of the cases from that cause. Tabetic symptoms develop in from five to fifteen years after syphilitic infection. There are no data to show the probable proportion of syphilitic cases which later develop tabes, but it is undoubtedly small. As all cases of tabes examined by osteopaths show spinal lesions, it is reasonable to suppose that by interfering with the nutrition to the spinal cord, they allow consequent degeneration. It is also quite probable that osteopathic treatment for syphilis would, for the same reason, prevent sclerosis and resultant tabes. That syphilis is not the only cause, is also held by some authorities. Starr cites a true case from a severe blow in the dorsal region. Osteopathic observation would lead to a differentiation of tabes, according to the cause. Cases have been recorded, which simulated true tabes in most symptoms, which did not have a history of syphilis. J. Knowles makes the point that probably certain cases simulating tabes have reached what might be called an irritation stage (pathologically) of the nerves and their centers, sclerotic changes not having taken place; and he believes these cases would naturally yield to osteopathic treatment. Teall confirms this view by being of the opinion that these cases are the ones largely due to traumatism, exhaustion or exposure, and the probabilities are that in time sclerotic changes would take place, resulting in true tabes. In such cases there can be no question as to the osteopathic lesion, which would be sufficient to materially interfere with the peripheral sensory nerves and disturb the protoplasmic processes to the spinal ganglia and sensory tract. As a rule they are in the lower dorsal and lumbar regions. Cases are reported which had marked sacral and coccygeal lesions.

=Pathologically=, Dana speaks of locomotor ataxia, “as a post-infective degeneration, which first attacks the posterior spinal ganglia or corresponding cells of the special senses, due to a prolonged poisoning of these parts by the toxins of the infection.” The first change is in the posterior roots. Without doubt osteopathic lesions can readily affect the nutrition of these roots. This is shown upon examination in cases where the vertebral lesions impinge the tissues surrounding the spinal nerve at its exit, (or otherwise damage nervous stimuli and circulation) and also where the displaced head of the rib crowds upwards against the spinal nerve and again where the rib impinges the corresponding sympathetic ganglion which lies anterior to the head of the rib. Very likely in many cases the syphilitic infection is an exciting factor, but it seems plausible that osteopathic lesions, traumatism, cold, exposure and excesses predispose by disturbing the circulation to involved areas. The changes are at first inflammatory, followed by degenerative changes in the nerve courses which cause connective and neuroglia overgrowths to take the place of fibers in the sensory tract, and finally in the motor tract. Thus from the posterior ganglia, a section between the columns of Goll and Burdach is involved, and the progress of the sclerotic change is upward in the cord. The pia mater and coats of the vessels are thickened. The principal changes in the cord are in the lower dorsal and upper lumbar segments and the cord may be changed in shape. In long standing cases there is degeneration of the ascending antero-lateral tract, of the direct cerebellar tract, and of the pyramidal tract. The cerebral changes in some cases consist of sclerosis in the restiform bodies in the inferior peduncles of the cerebellum, and of certain cranial nerves, especially the third, optic, vagus and auditory nerves, and also cortical changes may occur.

=Symptoms.=—Authorities divide the symptoms into three stages—the preataxic, ataxic and paralytic. This division is largely an arbitrary one. =Motor symptoms= are usually the most prominent. There is inability to coordinate the muscles. The patient first notices that he cannot walk steadily when in the dark or when he has his eyes closed. Later he finds that he cannot maintain his equilibrium even in daylight; this is ascertained when the patient places his feet together and the eyes are closed (sign of Romberg). As a rule this is unaccompanied by muscular wasting, so there is no loss of motor power. Soon the gait becomes characteristic; in walking the feet are lifted high and are brought down heavily on the heel; the ball of the foot comes down last, producing what is called the “double step;” the walk is straddling: the limbs are thrown about, and there is staggering, due to =incoordination=. Incoordination also develops in the hands, but usually later in the disease. Sudden involuntary movements and palsies are other motor symptoms. The latter occur in about twenty per cent of cases and as a rule are of short duration. Paralysis and muscular atrophy do not develop until after a few years.

=Pain= is an early symptom and always present; it is of a darting, shooting or stabbing character and appears in paroxysms. It is most common in the legs, lasting but a second or two, and often accompanied by a hot, burning feeling. Herpes may appear along the course of the nerve. Anesthesia and hyperesthesia of certain areas may occur. A girdle sensation may be a noticeable symptom. The =muscular sense= is more or less impaired; there is a feeling as if there were cotton between the patient’s feet and the floor. Retardation of tactile sensation is a common symptom. The power of localizing pain is often lost. The =knee-jerk= is lost early in the disease. Occasionally, however, cases are met where it is retained. The skin reflexes are also impaired; in some cases they may be increased at first, but later are sure to be involved with the deep reflexes. The =pupil= does not respond to the light, but still accommodates for distance, constituting the =Argyll Robertson= pupil. Ptosis may develop with or without strabismus. Optic atrophy, which may lead to blindness, paresis of the ocular muscle, and contracted pupils, may occur. The ocular symptoms may appear early in the disease.

The =visceral pains= or =crises= are chiefly gastric and are sometimes accompanied by obstinate vomiting. Laryngeal, rectal, urethral and nephritic crises may occur, and at times are exceedingly severe. Laryngeal crises may be manifested by intense dyspnea and noisy breathing. Constipation is common. There may be retention of the urine resulting in cystitis. Sexual power is generally lost early.

=Trophic changes= occur later in the disease. The so-called arthropathies, or joint lesions, may occur at any period of the disease. It consists of an enlargement of the joints, associated with serous exudations, which rarely become purulent; atrophy of the heads of the bones; destruction of the bones and cartilages; or spontaneous fracture or dislocation may occur, owing to the brittleness of the bones. There is no pain and the large joints are most frequently affected; these may be excited by an injury. Herpes, skin ecchymoses, edema, local sweating, alterations in the nails, perforating ulcer of the foot, onychia, decay of the teeth and atrophy of the muscles may occur. The auditory nerve is rarely affected, but in some cases there may be deafness. There may be attacks of vertigo. Olfactory symptoms are rarely met with. Cerebral symptoms are rare. =Paralysis= may develop and the patient becomes bed-ridden. The disease itself does not prove fatal; the patient may live for years until some intercurrent disease causes death.

=Diagnosis.=—This is usually easy when the characteristic symptoms are developed. The presence of lightning pains, absence of the knee-jerk, early ocular palsies, a squint, ptosis and Argyll Robertson pupil make the diagnosis conclusive. Care has to be taken in making diagnosis from peripheral neuritis, paresis, ataxic paraplegia, cerebral disease and some diseases in which the posterior columns are disturbed.

=Prognosis= will depend largely on the exciting cause, as it is least hopeful from syphilis, but the earlier the case is treated the better the chance. The progress of the disease can sometimes be arrested and occasionally cases presenting symptoms of the first and second stage are entirely relieved with persistent treatment.

=Treatment.=—Experience in the treatment of locomotor ataxia has been that often the disease can be checked and the symptoms relieved; but curing a case of locomotor ataxia, except in the early stages, is seldom possible. When there is degeneration of nerve centers, there is no hope for a cure. Those with a syphilitic history are by far the hardest to relieve. Antisyphilitic treatment should be considered. Cases with a syphilitic history presenting preataxic symptoms, Argyll Robertson pupil, lightning pains and loss of patellar reflex have been cured; unfortunately these cases are not always diagnosed.

The treatment consists of thorough correction of the spinal derangements found, especially through the lumbar and lower dorsal regions. If the disease has involved the arms or brain, thorough treatment should be given the entire length of the spine with a view to increasing the circulation in the spinal cord and brain, and thus checking or preventing the tissue degeneration. “In the early stage, deep massage to the muscles of the back promotes the flow of venous blood through the spinal vessels and their anastomotic branches, and is the best means of relieving the congestion which is supposed to exist.” (Starr) The lower spine will be found to be rigid and should be well sprung to get mobility.

Careful treatment of the limbs should be given, but be exceedingly =cautious= in the treatment of the limbs of =advanced cases=, as there is considerable danger of producing fractures. Stretching the thigh muscles and internal and external rotation treatment of the legs should be given. See that the bowels are moved daily and be positive that there is no retention of the urine in the bladder. A catheter has to be used in some cases. The patient should be careful about taking too much food, and especially beware of indigestible food, as it irritates or excites gastric crises.

During =painful attacks= the patient should rest in bed, and with careful treatment the attack can generally be relieved. Hot applications are of considerable aid.

At all times excesses should be avoided. Occupation of some character should be given the sufferer. Do not promise to cure the patient, and make it plain at the start that it will probably require a long time to show much improvement. Systematic exercises to reestablish coordination should not be neglected.

Hereditary Ataxia

(FRIEDREICH’S ATAXIA)

This is a rare hereditary disease, due to sclerosis of the columns of Goll and Burdach and the pyramidal tracts. There are ataxia, muscular weakness, nystagmus, speech disorders and loss of knee flex. Almost invariably there will be found a neuropathic history. Alcoholism, syphilis and insanity in the parents are predisposing causes. Tuberculosis may be a factor. Acute diseases, especially infectious fevers, dentition and injuries to the spine may be exciting causes. It occurs most frequently in males about the seventh or eighth year and very seldom after puberty. Several members of the same family are apt to be affected. The disorder is transmitted by the female. “The degeneration of the posterior and pyramidal columns seems to occur at the time of cord development, when malnutrition or hereditary dyscrasia would disturb it most.”

=Pathologically=, “the spinal cord is smaller throughout than normal; we have also a combined disease of the posterior and lateral tracts (Schultze), a degeneration of Goll’s tract in toto, of Burdach’s almost entirely, and of the direct cerebellar, the crossed pyramidal (?), and of Clarke’s columns, in which we find not only atrophy of fibers, but also a degeneration of the ganglion cells. Gower’s tract may likewise be involved.” (Oppenheim).

=Symptoms.=—Impaired coordination, beginning in the legs and later extending to the arms, is the first marked symptom. The gait is peculiar; it is swaying and irregular and it lacks the pronounced stamping gait of locomotor ataxia. There is a loss of reflexes, while no sensory symptoms are present as a rule. The sphincters are normal. Nystagmus is present and is a characteristic symptom. The speech is scanning. Talipes and lateral curvature of the spine are common. The mind becomes sluggish in later stages. The course is always very slow.

=Diagnosis.=—This is not difficult as a rule, owing to the usual family history presented. The spinal curvature, nystagmus, incoordination, scanning speech, irregular gait, and deformity of the feet are symptomatic. In =locomotor ataxia= the gait, sharp pains, anesthesia and Argyll Robertson pupil will differentiate between the two. Differentiation will also have to be made from chorea, ataxic paraplegia and multiple sclerosis.

=Treatment.=—The same treatment as in locomotor ataxia is followed. Lesions presented have been found at the tenth and eleventh dorsals, and at the second and third cervicals, although, as a rule, the entire spinal column is quite debilitated. Some improvement will be noted in these cases, but not much can be expected from treatment; contractures may be prevented.

Spastic Paraplegia

=Spastic paraplegia= begins as a stiffness in the legs, with no sensory symptoms, but finally the muscles become rigid and slowly paralyzed. The reflexes are exaggerated.

It may occur, in a few instances, as a primary disease, “being a degeneration of the motor neurone, whose body lies in the brain cortex and whose axone lies in the lateral pyramidal tract.” Usually it is secondary to tumors, inflammation and softening of the brain. Multiple sclerosis, hemorrhage, transverse myelitis, syringomyelia and other diseases of the cord, injury, exposure and overexertion are exciting causes. Syphilis may be a cause. It generally develops between the ages of twenty and forty.

=Pathologically=, the degeneration involves the lateral pyramidal columns of the cord. It begins at the periphery and extends upward until finally the axones atrophy and neuroglia overgrowth takes place and sclerosis of the motor tracts results.

=Symptoms.=—Muscular stiffness in one leg is usually the first symptom, which gradually disturbs both sides. The muscular stiffness increases to a rigidity, and even cramps, so that it is with considerable difficulty that the patient moves about. The reflexes are exaggerated. The joints, as well as the muscles are stiff, so that the toes are dragged upon the ground and the legs are kept close together, abduction of the limbs being difficult. On the whole, there is much tiredness, stiffness, rigidity and hardness of the leg muscles, so that all motions with them are performed with great effort. Sensory and trophic symptoms are lacking; control of the bladder and rectum is usually normal. The progress of the disease is slow. The upper extremities may be involved in after years, but the common extensive disturbance is with the legs, so that they may be entirely useless and the muscles atrophy from disuse, although rigidity and contractures remain.

=Treatment.=—The prognosis is usually unfavorable, though frequently the patient may be considerably benefited. A few cases that have been =caused= by =traumatism=, cold or exposure have yielded to osteopathic treatment and all symptoms disappeared. The treatment is largely that of locomotor ataxia. The lesions are readily located in the spinal column. In a few cases a slight posterior curvature of the dorso-lumbar region is found, but the majority of the lesions are in the lower dorsal region. Special care should be given to the bladder and bowels. Prolonged warm baths are beneficial. Treatment of the legs is always secondary to that of the spine. The diet should be nutritious and one easily digested. Give the patient plenty of fresh air and sunlight with cheerful surroundings. E. C. Link[132] reports two cases, one of over one year’s standing, completely recovered, and another much improved.

Ataxic Paraplegia

In =ataxic paraplegia= there are ataxic and spastic symptoms, due to both posterior and lateral sclerosis. Traumatism, cold and exposure are etiologic factors. It is found in diffuse myelitis, general paresis, leptomeningitis and in toxic conditions as in pernicious anemia. The posterior and lateral columns are degenerated, so that in the former there is an ascending degeneration and in the latter a descending.

=Symptoms.=—These comprise those of =tabes= and =spastic paraplegia=. Incoordination, ataxia, lightning pains, anesthesia, rigidness of muscles and exaggerated reflexes are the principal symptoms. The muscles easily fatigue; sensory symptoms are not so troublesome as in tabes; there may be visceral crises, sometimes Argyll Robertson pupil; and possibly spasms of the upper extremities and jaw. The course of the disease is slow.

=Diagnosis.=—This is not difficult as a rule. First, there is ataxia; then increased reflexes, fatigue of the muscles and paraplegia. =Tumor= of the =cerebellum= may confuse the diagnosis.

=Treatment.=—There is frequently a chance to greatly benefit these cases, and even in some instances a cure may be performed, provided the case is seen early. Thorough treatment of the spine to relax the muscles and to adjust the ribs and vertebræ is the indication. Stretching the spine, if carefully done, is beneficial. Muscular manipulation improves the spinal cord circulation, and osseous correction removes probable impingements to nutrient channels and nervous influences induced by cold, exposure, traumatism and secondary disturbances. Care of the general health, hygiene, diet, etc., are important.

Syringomyelia

=Definition.=—A chronic affection of the spinal cord in which there is an embryonal neurogliar overgrowth about the central canal, with cavity formation. It is characterized, clinically, by progressive muscular atrophy, peculiar disturbances of sensation and various trophic and vasomotor disorders. The onset generally takes place before the thirtieth year. Males are much more commonly affected than females. It is claimed by some that the disease is infectious. It frequently follows trauma.

=Pathologically=, the condition begins with an overgrowth of embryonal neurogliar tissue. This is followed by degeneration of the gliomatous tissue with a formation of cavities, or this cavity formation may be the result of hemorrhage. The disease, in most cases, involves only the cervical or dorsal regions, and is usually in the posterior or postero-lateral tracts. The cavity may prevail throughout the entire cord, but usually only the cervical and dorsal regions are involved. The cavities lie in the gray matter outside of the canal.

=Symptoms.=—The onset is slow. The symptoms depend upon the situation and extent of the cavity. As the disease most frequently involves the cervical region, the neck and arms are usually affected. At first neuralgic pains may develop in the muscles. Later there is progressive muscular atrophy and loss of painful and thermic sensations. Tactile and muscular senses are usually intact. The reflexes are increased and a spastic condition is present. The lower limbs usually escape, but when they are involved the clinical picture may be that of =amyotrophic lateral sclerosis=. A lateral curvature is present. When the disease extends into the medulla, there will be various bulbar symptoms. Trophic changes and vasomotor disorders are common.

A form of syringomyelia, known as =Morvan’s disease=, is characterized by neuralgic pains, cutaneous anesthesia and painless felons.

=Diagnosis.=—The progressive muscular atrophy, the retention of muscular and tactile senses, and the loss of thermic and painful sensations are typical symptoms. The diseases with which it may be confounded are: =Cervical Pachymeningitis.= The pain is usually greater, the tactile sense is lost and it runs a more rapid course. =Anesthetic Leprosy.= The trophic changes are more marked, tactile sensation is lost and the phalanges often drop off. =Progressive Muscular Atrophy= and =Amyotrophic Lateral Sclerosis=. Sensory symptoms are wanting.

=Prognosis.=—The prognosis is unfavorable. Duration is from five to twenty years.

=Treatment.=—Little can be done except attending to the diet and hygiene of the patient and meeting urgent symptoms. Probably, continued treatment along the spinal column would influence to some extent the circulation of the cord in the region of the involvement. Hot applications are of value in relieving pain and cramps. The X-ray has proven of some benefit in checking the progress of the disease.

Amyotrophic Lateral Sclerosis

“This is a chronic, progressive form of spinal paralysis, characterized by the symptoms of progressive muscular atrophy in the arms and by lateral sclerosis or spastic paraplegia in the legs.” (Starr). It is similar to progressive muscular atrophy, except, in addition, there is sclerosis of the pyramidal tract. (See Progressive Muscular Atrophy.) Osler classes progressive muscular atrophy of spinal origin, amyotrophic lateral sclerosis and progressive bulbar paralysis as diseases of the whole efferent or motor tract, wherein these disorders may simply be various stages in the same case. He says, “A slow, atrophic change in the motor neurones is the anatomical basis, and the disease is one of the whole motor path, involving, in many cases, the cortical, bulbar, and spinal centers.” There can be no question that for the student, a classification of spinal cord diseases according to the whole motor tract, the upper motor segment, the lower motor segment, etc., is a scientific classification from our present knowledge of the histology and physiology of the neurone, but for clinical purposes the usual classification is given. Osteopathically, we are greatly in need of a new nosology, either according to the cause of the disorder or to the physiological disturbance.

=Amyotrophic lateral sclerosis= does not occur so frequently as progressive muscular atrophy. Heredity plays a part, and it affects older people. =Injury= to the =spinal column= is undoubtedly an important factor. Exposure and cold may be exciting causes. Infectious diseases and syphilis are probably important causes.

=Pathologically=, there are atrophy in the anterior cornu and sclerosis of the crossed and direct pyramidal tracts. There is sclerosis of centers in the medulla.

=Symptoms.=—Atonic atrophy, muscular weakness and fibrillary contractions, of varying degrees, are characteristic. The reflexes are exaggerated; the arm and leg muscles become weak and finally rigid and atrophied. This results in deformity. Disturbances of sensation are not pronounced. The sphincters may be slightly affected.

=Diagnosis.=—The disease is not so prolonged as progressive muscular atrophy. Differentiation has to be made from multiple arthritis and transverse myelitis and syringomyelia.

=Treatment.=—The same treatment as outlined for progressive muscular atrophy is indicated. The disease may be retarded and life prolonged.

Progressive Muscular Atrophy

A disease characterized by a slow, but progressive, loss of power and by muscular atrophy. Anatomically, it is characterized by degeneration of the ganglion cells of the gray matter in the cord. This atrophic affection develops just opposite to that of chronic anterior poliomyelitis. It is commonly a disease of males in middle life. Syphilis, rheumatism and lead poisoning predispose. It sometimes follows cold, wet, exposure, traumatism, mental worries, overuse of certain muscles, or prolonged emotional excitement. Hereditary influences are present in some cases. In all cases =lesions= are detected in the =vertebræ= and =ribs=, corresponding to the innervation of the diseased areas. Very likely these lesions are the starting point of the disease, by impairing nutrition to the motor cells of the anterior cornu, and thus resulting in atrophy.

=Pathologically=, the muscles are wasted, the fibers undergo fatty degeneration and there is an overgrowth of connective tissue. The peripheral motor fibers are degenerated. The anterior nerve roots leading to the horns are atrophied. The large ganglion cells of the anterior horns are atrophied, or even entirely removed. The neurogliar tissue is increased. There is sclerosis of the anterior and lateral pyramidal tracts of the cord in the majority of cases. (See Amyotrophic Lateral Sclerosis). The pyramidal tracts have been found degenerated through the pons and internal capsule, even up to the motor cortex. When bulbar symptoms are present, there is degeneration of the motor nuclei of the medulla. The posterior columns are not involved.

=Symptoms.=—Irregular pains, numbness or exhaustion are usually felt in the region that is soon to become wasted. The upper extremities are first affected. The muscles of the ball of the thumb waste first, then the interossei. From atrophy of the interossei and lumbricales and contraction of the long extensor and flexor muscles, the deformity known as “claw hand” results. The wasting creeps up from the forearm, arm and shoulder. The muscles of the trunk are gradually affected. The muscles of the lower extremity may escape entirely. The platysma myoides does not waste and is often hypertrophied. The face muscles are attacked late or not at all. The affected muscles often twitch. Deformities and contractures develop, notably lordosis. Sensation is not impaired although the patient may complain of numbness and coldness. The bladder and rectum are not affected, but sexual power may be lost. The paralysis is flaccid and the reflexes absent in the so-called =atonic cases=. In =atonic= atrophy there is more or less spasm, the reflexes are greatly increased, there are often contractures and the wasting is usually trifling.

=Diagnosis.=—Differential diagnosis has to be made from syringomyelia, chronic anterior poliomyelitis, lead palsy and muscular dystrophies.

=Prognosis.=—The prognosis of progressive muscular atrophy is not favorable, although a number of cases have been greatly helped by an extended course of treatment.

=Treatment.=—The treatment consists of a thorough, stimulating treatment of the innervation of the affected regions, with manipulation of the muscles and parts diseased. =Correction= of the =lesions= to the =vertebræ= and =ribs=, which are involving the innervation to the diseased tissues, is of primary importance. A cure cannot be expected when degeneration of the nerve centers has occurred; still, the progress of the disease may be checked in many cases, and the patient occasionally gain considerable strength. When atrophy starts in the muscles of the ball of the thumb, the lesion is to the median nerve, and derangements of the cervical vertebræ, from the fifth to the seventh, may be found. Attention to the general health is important. Outdoor life is preferable and gymnastic exercises are of value, but do not overtax the strength.

Bulbar Paralysis

(LABIOGLOSSOLARYNGEAL PARALYSIS)

A progressive atrophy and paralysis, invading the lips, tongue, pharynx and larynx, due to involvement (sclerosis) of the motor nuclei of the medulla oblongata that supply these tissues. It is rarely primary, more =frequently secondary= to tabes, amyotrophic lateral sclerosis and diseases involving the motor nuclei of the medulla. Diphtheria, syphilis and lead poisoning are said to predispose. =Osteopathic lesions= of the upper cervical are also important factors in many cases. Halbert says: “The nuclei of the hypoglossal, the spinal accessory, the facial and the motor part of the trifacial nerves suffer most decidedly from the sclerotic degeneration. The nerve trunks and the muscles which they supply gradually show the effects of a similar degeneration.”

The =acute form= results from hemorrhage, embolism or inflammatory softening. The onset is usually sudden. The speech is difficult or entirely lost. There are dribbling of saliva, difficult swallowing, flabbiness and flaccidity of the lips and frequent choking spells occur. These cases may prove rapidly fatal.

The =chronic form= may result from progressive muscular atrophy, insular sclerosis, amyotrophic lateral sclerosis, acute ascending paralysis or chronic poliomyelitis. The paralysis starts in the tongue, the first symptom being a slight defect in the speech. When the lips become involved, the patient cannot whistle and speech is rendered still more difficult. The lips are prominent and the lower one drops. The saliva is increased in amount and there is drooling. Mastication of the food becomes difficult. The tongue becomes atrophied and the mucous membrane wrinkled. Fibrillary tremors of the lips and tongue are present. Sensory symptoms are not present. Taste is normal. Paralysis of the larynx is not so pronounced as of the other parts.

=Diagnosis.=—This is generally easy as the symptoms are well marked. The =prognosis= is unfavorable.

=Treatment.=—Little can be done in the majority of cases. Only in those cases where the paralysis is caused by =cervical lesions= can much hope be given. Derangements of the cervical vertebræ, especially the atlas and axis, occasionally influence the circulation in the medulla to such an extent that the motor nuclei are greatly involved. The subluxated vertebras may interfere with the blood-vessels directly or through the vasomotor and trophic nerves. When the onset is not abrupt, the prognosis is more favorable. When deglutition is impaired, the stomach tube should be used in feeding the patient to prevent the food passing into the trachea.

FOOTNOTES:

[126] A. O. A. Case Reports, Series V.

[127] A. O. A. Case Reports, Series II.

[128] A. O. A. Case Reports, Series V.

[129] A. O. O. Case Reports, Series I.

[130] Millard, Poliomyelitis.

[131] Journal of the American Osteopathic Association, February 1906.

[132] Journal of Osteopathy, Oct. 1904.

ORTHOPEDIC SURGERY

By H. S. HAIN

Orthopedic surgery deals with the mechanical or surgical prevention and correction of all deformities, especially those of children. It is not alone justifiable, but imperative, that orthopedic surgery be given a prominent position in any up-to-date text on the Principles and Practice of Osteopathy. The justification is threefold: though orthopedics was practiced to a limited extent before the Science of Osteopathy was developed, it has always been considered to be outside the realms of true surgery, in that it is practically bloodless, and those engaged in such practice have sought to establish it upon a platform of its own.

The basis of the practice of orthopedic surgery and osteopathy is similar, if not identical, in that it deals almost entirely with bony abnormalities. It is recognized by the whole osteopathic profession, and unconsciously by some adherents of medical science, that the maintainance and restoration of normal function are alike dependent on a force inherent in bioplasm and that function perverted beyond the limits of self-adjustment, is dependent upon a condition of structure perverted beyond those limits. This, then is the platform upon which the two sciences of osteopathy and orthopedic surgery are erected.

The technique of osteopathic practice consists of passive manipulative measures, designed to render to the organism such aid as will enable it to overcome or adapt itself to the disturbed structure; and does not seek, in itself, the aid of any instrument, mechanical appliance or plaster of Paris cast.

Surely it is but a short step from our osteopathic therapeutics to a system of therapeutics where we find all sorts of mechanical and plaster of paris appliances, etc., to help our passive manipulation in rendering to the human organism such aid as will enable it to overcome or adapt itself to a disturbed structure. This latter, of course, is the modern science of orthopedic surgery, and because of the shortness of this step, I insist that it is one of the most valuable adjuncts of the science of osteopathy. It is frequently necessary for the osteopathic practitioner to take this step as conditions are met with that have progressed beyond the possibilities of passive manipulations and again other conditions of perverted structure can be much more quickly reduced by the aid of each.

It is then indisputable that the therapist who approaches disease from the osteopathic standpoint, above enunciated, is far more competent to deal with the mechanical problems of orthopedic surgery than any other known therapist. Secondly, in many conditions originally treated by orthopedic methods, subsequent ordinary osteopathic manipulations obtain a much more satisfactory and more lasting result than if it is withheld. Thirdly, in order to avoid possible error, it is of extreme importance that all osteopathic practitioners be particularly familiar with the conditions hereinafter described, more especially tubercular conditions of the spine, bones and joints, primary spinal curvatures and others.

It is reasonable and furthermore true that osteopathic physicians are confronted in practice with an unusually large percentage of cases indicated above, and the early recognition of such conditions is of fundamental importance in order that osteopathic manipulations be withheld and supplemented or replaced by orthopedic methods.

Space of course will not permit of the entire discussion of this vast subject but the most important and serious conditions met with in general practice are fully discussed in the following pages of this chapter.

Perhaps the commonest condition coming under this line of therapeutics, and one in which we, as osteopaths, are most vitally interested is rotary lateral curvature of the spine. From my personal observation and from experiences of some of the most prominent members of our profession, I am led to believe that this is one of our most difficult lesions to overcome osteopathically, hence my desire to go further into this condition than most of us might expect. I had opportunity to obtain personally some very valuable information from Dr. Joachim Stahl in the King’s Charity Hospital in Berlin, and to him I am deeply grateful for many of the ideas of treatment presented in the following article. I believe that I have an accurate conception of the pathological condition that exists in connection with this deformity, and I believe that my treatment of it has been more successful than any that I have seen under other methods, in that I have gotten most excellent results, in selected cases, in a comparatively short time, entirely because osteopathic manipulations and exercises were used in connection with the modified Abbott method.

Scoliosis or Rotary Lateral Curvature

Scoliosis or Lateral Curvature of the Spine is a deformity where the spine is deviated in whole or in part to one or the other side of the median line, which deviation is accompanied by an element of rotation. Though usually considered as a spinal deformity its =effects= are obvious outside the spinal area in so much as it will cause deformity of the pelvis, legs, ribs, sternum, scapulæ, and in severe cases, of the thoracic and abdominal viscera.

Curvatures of the spine are the result of one of two distinct factors: first where there is a primary disease of the bone causing more or less destruction of the bone and spinal articulations, and resulting in permanent spinal curvature. The most common example of this condition is seen in the angular curvature of Pott’s disease. =Rickets= is usually responsible for a general long posterior curvature of the whole spine, as is osteomalacia with the superimposition of some lateral deviation. Further, any type of inflammation or trauma is capable of producing curvatures of various types. Second, where there is no primary disease of the bone, joints, or ligaments, and where the curvature is due to external forces acting constantly or at frequently recurring intervals on the spine.

Scoliosis or lateral curvature belongs to the second class. It is unfortunately necessary to further subdivide scoliosis into two classes; one where the curvature is a position permanently maintained but capable of being reproduced by extreme physiological movement of a normal spine, and secondly, a position which no normal spine can assume and which necessarily implies a change in the normal shape of the bones and intervertebral discs. The first may be described as a functional or postural lateral curvature, and the second as an organic or structural lateral curvature. Further, I might say that the first type may progress until it becomes the organic type.

=Pathology.=—In scoliosis the spine undergoes not only curvature or lateral deviation but also rotation of the vertebral bodies which you will note always takes place towards the convexity of the curve.

=Changes in the Individual Vertebræ.=—The bodies may be either wedge shaped or lozenge shaped. In wedge shaped vertebræ, the bodies are compressed on the concave side and extended on the convex side, the intervertebral discs being atrophied on the shortened side. In the lozenge shaped type, the change in the bodies is most marked at the junction of the opposite curves, and is thus more commonly observed in compound curvatures. The pedicles are directed more antero-posteriorly on the convex side and more transversely on the concave side. The transverse processes on the convex side are more antero-posterior than normal, causing the vertical furrow between them and the spine to be narrower on this side. The spines point towards the concavity in structural curvatures and toward the convexity in the functional type. The vertebral foramen is rounded in the convexity and pointed in the concavity. The edge of the anterior common ligament toward the convexity is greatly thinned while it has a well marked edge on the concave border. A fibrous degeneration occurs in the muscles on the convexity owing to stretching, while atrophy from disuse takes place in those on the concave side.

=Associated changes in the Viscera.=—The =dorso-lumbar= curvature decrease in the volume of the lower thorax on the dorso-convex side tends to cause pleural adhesions with obliteration of the pleural sac and consequent collapse. Tuberculosis of the =lung= is common in patients who suffer from scoliosis. The =heart= is often overworked but the above lessening of the pulmonary area in turn results in hypertrophy and dilatation of the right ventricle and subsequent general venous stasis. The =kidney= on the convex side is compressed, and as a result degenerative changes are prone to occur. The =spleen= is frequently displaced upward and is liable to pathological changes. Organs such as the stomach, transverse colon, esophagus and trachea are frequently displaced owing to the bony deformity and are thereby more prone to pathological change.

=Etiology.=—The essential factor in the production of scoliosis is spinal insufficiency, which includes spinal muscles and ligaments as well as the bones. In many instances, however, the following factors have an important augmenting or predisposing effect.

=1. Occupational Deformity.=—Primarily under this classification, I have found faulty positions adopted by school children as being the most comfortable, to be perhaps most important. Occupations such as those of nurse-maids, hod carriers, or stone cutters, are apt to induce scoliosis.

=2. Diseases of the Central Nervous System.=—Unilateral weakness or paralysis of the muscles of the trunk are common causes of scoliosis. Anterior poliomyelitis plays a particularly important part as it may induce deformity by distortion of the lower extremity or by any inequality in the length of the limbs due to retardation of growth, as well as inducing general weakness of the muscles of the trunk. Other nervous disorders that should be considered are spastic paralysis, locomotor ataxia, syringomyelia and Friedreich’s ataxia.

=3. Incidental Deformity.=—Scoliosis may be caused by direct injury or by fracture, Pott’s Disease, or organic affections of the spine. Marked deformity caused by Sciatica or lumbar neuritis, if persistent may finally induce permanent deformity.

=4. Deformities Due to Diseases of the Chest.=—In =empyema= or =pleurisy= one side of the chest is retracted and it will be noticed that the curvature occurs toward the healthy side. Chronic pulmonary tuberculosis producing fibrosis of the lung gives the same result as empyema and pleurisy.

=5. Deformity due to obliquity of the pelvis.=—This type may be due to any inequality of the limbs, such as equinus of the foot. Congenital dislocation of the hip may play a part while one naturally lays stress on pelvic and lower lumbar lesions.

=6. Deformity due to Distortion of Other Parts.=—Unequal visions, unequal hearing, and torticollis by causing malposition are etiological factors especially in school children. The loss of an arm will tend to cause an asymmetrical position of the trunk.

=7. Congenital Deformity.=—Congenital scoliosis occurs, but is usually associated with other congenital deformities of the spine, such as the reduction or increase of the vertebræ, cervical rib, elevation of the scapula, etc. The deformity is usually not apparent until later years, though it may occur at birth.

=8. Spinal Lesions.=—Any osteopathic lesion predisposes to curvature because it interferes with the nerve supply and tonicity of the spinal muscles and could readily cause the faulty position.

Functional or Postural Lateral Curvature

This is a condition where there is a gradual curve to one side unaccompanied by any marked rotation. The maximum deviation may be no more than one inch and a half from the middle line, which point is generally found about the tenth dorsal vertebra. In the vast majority of cases deviation is to the left and in such the following alterations will be noticed: a general convex curve to the left; elevation, and anterior displacement of the left shoulder; posterior displacement of the right shoulder; in extension, the right side of the back will be higher than the left and in addition some torsion to the concave side, which is easily understood if one recalls the exact changes that take place during side movement of the normal spine. It is important to remember that functional scoliosis disappears when the patient is suspended or assumes the recumbent position.

Organic or Structural Scoliosis

This term is applied to cases where definite change has taken place in the vertebræ. Organic curves may be simple when the deviation is unaccompanied by any compensatory curve, or compound when a compensatory curve is present. We shall consider the deformities as they present themselves in the various regions of the spine.

=Cervico-Dorsal Curvature.=—This condition is comparatively rare and according to Lovett occurs in only three and six tenths per cent of cases. The head is slightly deviated towards the concave side, the shoulder on the concave side is lowered, while on the opposite side or the side of the convexity it is naturally at a higher level. The angles of the upper ribs are prominent due to the co-existing rotation.

=The Dorsal Curvature.=—The shoulder is raised on the convex side, and the rotation of the vertebræ is very marked, causing a very definite projection of the angles of the ribs on the convexity. This rotation also projects the scapula backwards on the convex side. On the concave side the scapula is flat and sunken, and the inferior angle rotated inwards and at a higher level than the opposite side. Viewed from the front the thorax may not be displaced at all, or it may be displaced toward the convex side, and if the latter is the case it is, of course more prominent on the concave side. In severe cases the lower end of the sternum is deviated towards the convexity and you will find that usually the arm hangs further from the convex side than from the opposite one.

=The Lumbar Curvature.=—Here we find the trunk displaced toward the side of the convexity, and the waist retracted on the opposite side. The difference in the level of the hips is the most prominent deformity in this region, and it will be found that the hips are raised on the concave side. Rotation in this region is much less evident than in the dorsal region, but can be demonstrated by a fullness on the convex side of the curve, due to the projection of the transverse processes.

=Dorso-Lumbar Curvatures.=—This condition is similar to a certain extent, to a severe functional scoliosis. The findings observed in the last two regions above described will naturally be present in this type of curvature. It is not so frequently associated with compensatory curves as in the other types described.

=Compound Structural Curves.=—The appearance in this type of scoliosis will, of course, be a combination of those described above according to the types of curvature in combination, that is to say right dorsal and left lumbar, etc. If one type predominates the appearance will be chiefly that found in that particular type of curvature. The relative frequency of the common type, as given by Schaltless, in eleven hundred and thirty seven cases is as follows; functional scoliosis, 15.39%; lumbar, 11.7%; dorsal, 19%; dorso-lumbar, 20%; cervico-dorsal, 3.6%; compound, 30%.

=Diagnosis.=—To the osteopathic physician the diagnosis of scoliosis is not difficult. Let me caution you that true scoliosis must be distinguished from the lateral curvatures caused by Pott’s disease. Vertebral rotation, the absence of pain, the extreme rigidity, the characteristic appearance of the ribs and thorax should, however, make the diagnosis of scoliosis easy.

=Treatment.=—In general the treatment of scoliosis is difficult to present, because every case is considerably different, and the amount of correcting force used in any form is almost entirely a matter of judgment, as is also the time when corrective pressure should be discontinued. Continual practice in the treatment of these conditions is most essential to your success with them. I have had most gratifying results in a comparatively short time simply because I used osteopathic treatment and exercises along with a modified Abbott method.

Functional or False Scoliosis

The functional or false scoliosis might be regarded as a habitual inability to stand correctly, simply a postural malposition and lack of muscle tone without marked structural change, which is maintained for a considerable length of time or where the position is repeated several times daily. The treatment of selected types of this deformity is most successful and may well be divided into three procedures: first, the substitution of a correct attitude for the faulty one, that is careful investigation should be made to ascertain the condition which might be the cause of the incorrect position such as poor school desks which might cause the child to reach either up or down to write, poorly fitting clothing which causes a pulling on the shoulder, eye strain which would cause tilting or twisting of the neck, congenital shortening of one limb or too rapid growth, should all be looked for and removed; second, regular osteopathic manipulation, at least three times per week to increase the tonicity of the already weakened spinal muscles and aid correction, are highly essential and shortens the time required for a complete cure; third, supervised gymnastic exercises of various kinds are very beneficial to develop and bring the musculature back to normal. Such simple exercises as crawling on the hands and knees in a small circle towards the side of the convexity, and the hanging from a horizontal bar by the arm on the side of the concavity will prove to be helpful. Some authors recommend the regular army setting up exercises for some cases or a frame by means of which the hips are fixed, and rotating and side bending exercises of the head and trunk given. These last two exercises are indeed very reasonable procedures but I have found them unnecessary mainly because I used osteopathic manipulations instead.

In advising and supervising exercises it is best to have the patient’s back bared so that the effect of each movement can be noticed and the exercises directed accordingly. Care and judgment should be used as to the number and severity of the exercises and would depend of course on the vigor of the child. Treatment should continue until the condition has been overcome, and the patient should be under observation for a couple of months afterwards so that any recurrence of the deformity would be noticed and attended.

Organic or Structural Scoliosis

The treatment of organic or structural scoliosis is more complicated for it must be remembered there are two elements of the deformity demanding correction; one, the lateral curve to be corrected by a side force, and the other, the rotation of the vertebræ to be corrected by a twisting force. I find both osteopathic manipulation and gymnastic exercises are of great value in the correction of this deformity as they help to loosen the curve and develop the musculature but used alone good results can rarely be obtained especially in obstinate curvatures. I believe that I have improved nutrition and probably prevented further deformity by treatments and exercises, but I am quite positive that it is not possible to correct an organic scoliosis without the forcible correction used in the Abbott method.

As the details of treatment are tedious to follow, we will take for example a case of right dorsal curvature presenting a marked hump deformity, with a compensatory curve to the left in the lumbar region, as this is the most common type. I might say here that whether or not a compensatory curve is present, makes no difference, as treatment is directed entirely to the primary curve on the assumption that overcorrection of it will cause a secondary curve to disappear by compensation.

The patient is prepared by putting on a snug fitting undershirt and sewing pads of saddler’s felt over all bony prominences, especially the crest of the ileum and anterior superior spine. Sometimes I take a piece of felt of four or five inches wide and long enough to go around the entire pelvis, just high enough to cover the brim, and fasten it in front with adhesive. Next I make a bunch of pads two or three inches in thickness and large enough to fill up the concavity of the left side, and first sew them together, and then with a few stitches fasten them to the undershirt thereby filling up the space on the concave side. The edges of the pads should, of course, be trimmed down to conform with the general contour of the body, the main thickness being in the middle. I then sew a single pad on the right side of the thorax in front and a little to the right side.

[Illustration: Patient suspended on canvas hammock in regular Abbott frame ready to apply cast for a right dorsal curvature. Notice manner of applying the correcting canvas straps.]

The patient is now ready for the Abbott frame and is placed on a canvas hammock about twelve inches wide, which is cut on the bias so the right side is three inches shorter than the left. The hammock can be adjusted to the desired degree of flexion by a ratchet at the foot of the regular Abbott frame. The limbs of the patient should be elevated to increase the flexion as this has a tendency to unlock the articulation and thereby help in overcoming the rotation. Next a canvas bandage four inches wide is passed around the patient under the axilla of the concave side and fastened to the frame on the opposite side, and another one is placed around the pelvis and fastened to the same side of the frame, both on a level with the body plane. A third bandage is next placed around the point of greatest convexity and fastened to the opposite side of the frame in such a way that it can be tightened and a direct pull be made on the curve. Before tightening the last bandage the left arm and shoulder should be brought up high beside the face and pulled backward toward the floor as it is this twisting force that produces some rotation of the thorax. The correcting bandage is now tightened being careful not to cause the patient too much discomfort.

[Illustration: Cross section sketch of a right dorsal curvature showing deformity in the thorax and rotation of the vertebræ, also windows which are cut in the cast to allow expansion in these two directions and the directing force of the pads. These are placed over the angles of the ribs. Arrows show directions of the various forces.]

I always use ordinary absorbent cotton for padding, which is held in place by the regular gauze bandage. The plaster of Paris bandages should be applied high up under the left shoulder and well down over the sacrum and innominate bones and should be of a uniform thickness of half an inch. Sometimes I carry the plaster over the right shoulder to hold it down and back, though not always. I always let the cast set pretty well before removing the patient from the frame and if it has been applied in the morning I find it best to wait until afternoon before trimming and cutting the windows because there is less danger of breaking it. In trimming I always smooth up the edges, lower the right shoulder, but keep the left well up, trim off enough at the bottom in front to allow the thighs to be readily flexed without obstruction, and leave it low behind so as to maintain the flexion. Next, two holes or windows are cut in the cast, one over each area where the pads were inserted, and remove them. The hole in the back on the left or concave side permits expansion of the chest to the back, while the hole on the right side in front allows the ribs, which are posterior, to move forward under pressure or the pads to be inserted at the posterior angle or backward prominence of the ribs of the convexity. The canvas bandages or straps around both the axilla and pelvis are removed, but the one about the convexity of the curve is left in place so as to assist in the after treatment. The patient usually suffers some discomfort such as difficulty in breathing and the inability to move the body freely, and should remain in bed a day or two after the cast has been applied. Usually they sleep very poorly the first few nights, but the spine soon gives under the pressure and they become comfortable. When the cast has become quite comfortable an assistant pulls on the canvas bandage which was left around the convexity, while pads are inserted so that the greatest pressure is exerted on the angle of the ribs to further overcome the rotation and decrease the lateral deformity. Also heavy felt pad may be inserted over the bulging ribs in front of the left side to push them back. Care should be taken that too much pressure is not brought to bear on the side of the convexity because if more pressure is exerted here than on the angles of the ribs, it will tend to increase rather than decrease.

Casts should be worn for different periods, some being changed in a month while others can be worn for three months. It is entirely a matter of judgment. My best results have been secured by only slightly correcting the curvature at the time the cast was applied, and relying more on the proper insertion of the pads. Often at the end of a month or six weeks, in selected cases, I have split the cast down the front and removed it by springing it apart, and administered osteopathic manipulations to the spine freely in all directions, thoroughly loosening up the muscles. Then I replace the cast and hold it together in front with moleskin adhesive and insert the pads as before. I repeat this procedure three times per week for another month, together with daily exercises each morning and evening of drawing the left shoulder up and forward while in the cast to develop the muscles of the left shoulder girdle. The treatments and exercises certainly do build up the spinal muscles for it must be realized that they have suffered in nutrition to a great extent as a result of wearing the cast. Next the cast can be worn during the day and removed at night, and gradually it can be left off several hours at a time. If no bad results occur it can be left off for longer periods until finally its use can be discontinued. However, the patient should still be under observation once a week for a couple of months to determine any recurrence of the deformity. The resumption of active corrective treatment, or increasing relaxation in gymnastic work, will, of course, depend upon the progress of the case.

In the more obstinate cases, casts should be applied as long as further correction can be obtained. The procedure is entirely the same, only the time required for correction is longer, sometimes a year or year and a half, and when overcorrection has been maintained, it is better to use a removable jacket made of celluloid or light stiffened leather, with large windows cut over the region where pressure is to be avoided, than the removable cast described above.

In closing let me say that this method of correcting lateral curvature is best adapted to patients during their growing period and though it may be employed in older cases you will usually be disappointed in the final result. The only reason I can see for treating older cases is purely mercenary.

Congenital Dislocation of the Hip

Unilateral

Undoubtedly as far back as 1829, the actual recognition of this condition was due to the pathological research of a French surgeon Dupuytren, who described this deformity with great accuracy and insisted that there was no possible chance of correction. From then on until 1886 nothing was done by medical science to overcome the deformity, though it is claimed some were made. It was in this year that the famous Bavarian surgeon, Hoffa, gave to the medical profession the results of his successful attempts at reduction by opening the hip joint from behind and enlarging the acetabulum to a size sufficient to hold the head of the femur.

Orthopedic surgery has to thank the irritating effects on the skin, of antiseptics necessary in preparing his hands for ordinary surgery, as it was due to this triviality that Lorenz, a promising surgeon of Vienna, transferred his energies to the field of bloodless surgery and gave to us the most valuable early work and present day technique in the bloodless reduction of congenital dislocation of the hip.

The name, of course, is applied to a congenital deformity which involves one or both hip joints, resulting in lameness, due to a misplacement of the head of the femur from the acetabulum. Of all congenital dislocations the hip joint is by far the most common and most important. The misplacement is far more often unilateral than bilateral and far more frequent in females than in males, the cause for the latter probably being the difference which exists in aspect and position of the acetabulum as well as the disproportionate laxity of the capsule in the two sexes. It must be remembered that normally at birth, the acetabulum covers only about one-third of the head of the femur, and our most accepted theory as to the cause of this deformity, is a defective development of the acetabulum or its posterior margin, which may be primary or secondary to an abnormally prolonged fixation of the limb in a position of flexion or adduction while in utero. At birth it is quite probable that the dislocation is a subluxation only, which becomes complete by muscular action and the use of the limb in standing and walking.

The pathology of this disease is clearly established, and varies, of course, with the age of the patient in strain and friction to which the misplaced parts have been subjected. In children over two and one-half years of age the acetabulum is usually shallow and small, and filled with a deposit of fat and fibrous tissue. It is covered with normal hyaline cartilage and nearly always the ligamentum teres is present, but is so badly stretched and ribbon-like that ultimately the artery accompanying it fails to function, resulting in a malformation of the head of the femur. The capsular ligament is elongated and thickened to accommodate the upper displacement of the femur, and the anterior wall of it is stretched tight across the acetabulum like an hour glass. The interior of the capsule is always partly lined with synovial membrane. Usually a secondary acetabulum is found upon the ileum, formed by the direct pressure of the head of the femur through the capsule and the result of irritation of the periosteum of the ileum, but it is as a rule, not deep enough to form a secure support for the head of the bone. The neck of the femur is usually shorter than normal and the upper extremity of the bone is somewhat atrophied. The pelvis is usually slightly atrophied on the affected side, and a lateral inclination of the spine may be present. The long muscles of the thigh are shortened; while those attached to the pelvis and trochanter are changed in direction and are usually lengthened.

[Illustration: Typical congenital dislocation of the hip, showing the “hour glass” constriction of the capsular ligament.]

=Symptoms.=—As a rule congenital dislocation of the hip is not accompanied by the defective development or deformity elsewhere, and the symptoms are so diagnostic that there is little difficulty in recognizing this condition even without the X-ray which is, of course, a positive diagnosis.

Rarely does the displacement attract attention until the child begins to walk. Often the child does not walk as early as it should. Sometimes it may be delayed until the eighteenth month or second year and then it walks with a limp which becomes more pronounced as the child grows older until at the fourth or fifth year it is very decided. The limp is peculiar and its character is explained by its cause; for the shortened limb, owing to the elasticity of the capsule, becomes still shorter when the weight is borne upon it, thus causing a peculiar lunge of the body towards the short side like the normal motion of walking downstairs. In compensation, of course, the pelvis is tilted towards the short limb and its inclination is thereby increased, so that the anterior superior spine lies at a lower level and in advance of the opposite side. Usually the affected limb is about an inch shorter than the sound one, and in adult life it is considerably more. The range of abduction is much diminished, but flexion, extension and adduction are quite normal, and the trochanter will be found elevated about an inch above Nelaton’s line. If the thigh be flexed and adducted to its extreme limit, the neck and head of the femur can be easily distinguished moving under the gluteal muscles when the limb is rotated, or the head can usually be readily palpated in front when the limb is extended. Then, too, by fixing the pelvis and using traction and upward pressure on the limb, the abnormal mobility or telescopic motion is easily demonstrated and this, I might add, is a very important test.

[Illustration: Outline of a radiograph following reduction and removal of the first cast in unilateral dislocation of the hip. Notice the head in the socket and the thigh still flexed and abducted.]

Rarely do we find a unilateral anterior dislocation, in which the head of the bone lies beneath the anterior superior spine, but when this position is present, the symptoms are much less marked than in the ordinary form because the relation of the pelvis to the femur is more nearly normal. The limp and the shortening of the limb are less noticeable because the tissues attached to the anterior superior spine form a relatively secure support.

The X-ray, of course, makes the diagnosis complete. Even though the clinical diagnosis is certain, a radiograph is indispensable in every case, particularly for the purpose of ascertaining the exact position of the head and condition of the acetabulum and femur. The acetabulum is usually shallow and poorly developed, more particularly the iliac portion of its rim. After the reduction of the dislocation, an X-ray picture should always be taken within the first few weeks, and before the plaster of paris cast has been removed, to ascertain whether the head of the femur is still in place.

[Illustration: Outline of the same case following removal of the second cast. The head of the femur is firmly fixed in the acetabulum and the position of the limb is nearly normal.]

As to bilateral dislocation of the hip, the pathology, of course, is the same as in the unilateral type. The shortening of the limbs is as a rule equal or nearly so, and when both femurs are displaced backward, the pelvis is tilted forward thus presenting a marked lumbar lordosis and protruding abdomen. The pelvis seems to be abnormally wide, both buttocks are flattened and the thighs are separated by a considerable space. The characteristic limp in this condition is an exaggerated waddle, often spoken of as “sailor gait.” Again in this condition rarely do we find an anterior dislocation, but when such is the case, the entire body is swayed entirely backward, though the lumbar lordosis is not increased, in fact usually presents a peculiarly flattened appearance. Other symptoms differ only in a slight degree from those of the ordinary posterior displacement. The physical signs are the same as the unilateral displacement and are even more readily recognized by the peculiar appearance and distinctive gait of the patient. The swaggering gait of lumbar Pott’s Disease is somewhat similar, but this is an acquired clinical condition of the spine in which the hip joints are normal in appearance and nearly so in function.

Before taking up the usual procedure for the correction of congenital dislocation of the hip, it might be interesting to touch on several cases of this deformity in young children that I have reduced without an anesthetic. If future experience proves as successful as these cases it will entirely revolutionize the treatment of this condition especially in children under twenty months of age. To begin with, these children had just started to walk and it must be remembered that at this stage the acetabula are nearly normal and there has been no muscular or ligamentous contraction because very little weight has been borne on the limb.

First the pelvis is held fixed by the assistant, and the thighs completely flexed on the abdomen. Next firm pressure is made on the knee to force the head of the femur beneath the acetabulum and as the limb is abducted in the flexed position, the head is raised into the acetabulum with the thumb of the operator’s other hand. The whole procedure takes but a moment’s time and the child should be placed at once upon the floor and allowed to walk. Time will tell if the reduction has been successful, and if failure of retention develops, the Lorenz method followed by plaster of Paris fixation can still be used. I should always recommend the trial of this method in children who have walked not longer than six months, before resorting to the following Lorenz treatment.

=Treatment by the Lorenz Operation.=—This treatment is based on the fact that there is normally present an acetabulum of sufficient size and capacity to retain the head of the femur, providing the limb can be fixed in a favorable attitude, and as soon as possible weight borne upon it to deepen the rudimentary acetabulum. The typical operation of today is best divided into four distinct steps; first, to overcome the resistance of the tissues surrounding the joint; second, to reduce the dislocation, or rather to force the head of the femur over the posterior border of the acetabulum; third, to increase the security of the articulation by stretching the anterior border of the capsule; fourth, to fix the parts in a plaster of Paris bandage.

The child is completely anesthetized, and an assistant firmly fixes the pelvis on the table with his hand. The operator first flexes the thigh to a right angle with the body and forcibly abducts, at the same time kneading and stretching the tense adductor muscles and if necessary rupturing the adductor tendons in order to bring the limb down to the plane with the body. Next to overcome the contraction of the posterior tissues, the limb fully extended is flexed upon the trunk and gradually forced downward until the toes touch the patient’s face. To overcome the resistance of the tissues on the front of the joint, it is best to move the patient to the edge of the table and forcibly extend the thigh downward behind the plane of the body. It is also well to apply direct traction in the line of the body. This preliminary stretching is absolutely necessary, because all the tissues about the joint are so shortened, and it will now be noted that with slight traction the trochanter can be drawn down to Nelaton’s line.

Next reduction is attempted by grasping the limb with one hand at the knee and strongly abducting it while the palm of the other hand is placed on the anterior spine of the ilium with the thumb placed beneath the great trochanter to act as fulcrum. As the limb is gradually forced downward to and behind the body plane, the head of the femur is forced upward until it finally slips over the posterior and inferior border of the acetabulum. In the more resistant cases a padded wedge-shaped block placed behind the trochanter will be an aid in pushing the head forward and upward while the patient’s knee is forced downward. A successful reduction is usually accompanied by a distinct jar and audible thud, and it would be observed that the tension upon the ham string muscles causes fixed flexion of the leg. After reduction has been made, the limb should be brought down carefully into a straight position to test the security of the re-position. If dislocation appears during this manipulation, the tissues must be still further stretched and the displacement further reduced. If displacement occurs readily due to a shallowness of the acetabulum the prognosis is not so good as where the stability remains when the limb is brought down into a straight position, and one must be more particular in the fixation of it. I have also observed that the more difficult the reduction the more stable the end results. The easy replacements are usually just as easily displaced. Sometimes the head slips into the socket quietly without the distinct jar or thud but the results in these cases are just as good provided they are properly cast.

[Illustration: Patient in position for the first cast in a left unilateral dislocation. The thigh should be a little past a right angle in relation to the trunk, with about 80° abduction.]

The application of the plaster spica is by far the most important part of the treatment, as the reduction is usually quite easily accomplished in children under six years of age. If the cast is improperly applied, the hip will slip out of the socket and the case is a failure. A pair of soft knitted cotton drawers are put on and the patient is placed upon a pelvic rest with the limb held in the position of greatest stability at a right angle with the trunk, or even slightly more and about eighty degrees abduction. In a case where the socket is very shallow, the position to be cast should be about one hundred degrees flexion, and in abduction the limb should lie slightly behind the plane of the body to secure the best results.

[Illustration: Correct position and proper application of cast for double congenital dislocation of the hips.]

The limb and pelvis are covered with ordinary absorbent cotton which is held in place with a roller gauze bandage. A snug fitting plaster of Paris cast is now applied around the pelvis and well down over the knee. I leave this over the knee for five or six days or until the child ceases to be fretful, then I cut it away just back of the knee joint to permit motion there. The ends of the drawers are drawn back smoothly over the cast and are sewed to each other. For about a week following the operation the adductor region is swollen and discolored and more or less painful due to rupturing and stretching of those tendons. After this discomfort has passed away, walking is encouraged on the theory that the weight bearing and the stimulation of functional activity will increase the stability of the joint by deepening the acetabulum.

[Illustration: Proper position of the limb in the second cast for unilateral dislocation.]

The first cast should remain from three to six months according to the stability of the joint at the time of reduction. If in young children the cast becomes offensive, it must be changed as often as is necessary. When the first cast is removed, the limb is pulled down to about thirty degrees abduction and the same amount of flexion, without an anesthetic, and a second cast is applied, which extends only to the knee, to be worn from three to six months longer. After removal of second cast, the child is permitted to get about carefully. The limb will be everted and slightly flexed, which position invariably causes much concern among the relatives of the patient, but this abnormal condition disappears after a few months’ time. Sometimes for even a year following removal of the second cast there will also be a noticeable hitch in the walk of the child; but this, too, disappears and in the course of two years’ time one could never tell that such an operation had been performed. Massage of the posterior and lateral muscles of the hip always helps considerably towards the relief of any stiffness or lameness.

Reduction by Open Incision

In the more resistant older cases, where manipulative reduction has failed, reduction by incision can be employed with success, but this procedure requires the exercise of care in order to do as little injury to the muscles as possible. A crucial incision of the capsule is made and the capsular constriction and ilio-psoas tendon divided. With a little traction, the head of the femur slips easily into its socket. The capsule is stretched firmly around the neck and the incision into the capsule is then closed by suture, and the limb fixed in a plaster of Paris spica in the fully abducted position. The operation should of course be done under the strictest asepsis.

Talipes or Club Foot

The word talipes signifies some deformity of the foot and is quite common in orthopedic practice, being found in nearly ten per cent of the cases coming under this branch of the science. Club foot may be classified into two types—the congenital and the acquired. The congenital type is the most common and is due probably to abnormal intrauterine pressure or to a perversion of normal intrauterine development. The acquired type is due usually to injury or infantile paralysis, but either joint disease or cerebral paralysis may be the cause. The deformity presents six different forms with most characteristic clinical pictures which, with the exception of talipes planus I have taken up in the order of frequency.

[Illustration: Illustrating the more common types of talipes. A combination of any may be present.]

=Talipes Equinovarus= is usually congenital and is the most common type. It is characterized by inversion and torsion of the foot with elevation of the heel. The weight is borne on the outer side of the foot and in extreme cases upon the dorsum as well. Calluses are always present which are red and painful upon the point where the greatest weight is borne. The most common method of treating this condition is to divide the tendo Achilles at a level with the malleoli. The operation should be done aseptically and under complete anesthesia. As an assistant raises the end of the foot so as to stretch the tendo Achilles the surgeon enters the knife parallel to the border of the tendon through the skin and tendon sheath into the tendon itself. Next with a tenotome inserted into the incision and turned at right angles to the tendon, the tendon is divided first on one-half then on the other. Care should be taken to disturb the tendon sheath as little as possible for it serves an important purpose in repair. When the division is complete as indicated by the separation of the divided ends, the tenotome is withdrawn and the minute opening in the skin, from which there is only slight bleeding, is covered with aseptic gauze. The foot is forced into dorsal flexion and if in severe cases the deformity is not then corrected, the tendons on the outer side of the foot may be shortened, while those on the inner side may be lengthened in the same manner as the tendo Achilles. A plaster of Paris cast is then applied well up to the knee with the foot in the over corrected position, care being taken that no undue pressure is brought upon the seat of operation, as this might interfere with the effusion of plastic material. Personally I believe that functional use of the limb and foot stimulate repair, and I always encourage the patient to stand and walk after the discomfort of the operation has passed. At the end of four weeks the space between the two cut ends will be filled with new material and the cast can be removed, and in another month the splice, which is somewhat larger and thicker than normal, should be strong enough for use. In the course of a year the lengthened tendon is perfectly normal.

=Talipes Equinus.=—In this type the patient walks on his toes with the heel highly elevated, in the same position as the horse, and it will be noticed that the foot has no dorsal flexion whatsoever. Infantile paralysis affecting the anterior muscles of the leg is usually the cause of this condition, though sometimes shortening of the leg following knee joint disease, or fracture may lead to an adaptive equinus which serves to make the limb of equal length for walking. This type is by far the easiest to remedy, and the results following operations are perfect. A simple division of the tendo Achilles is made under anesthesia and a cast applied as above, in a position of exaggerated dorsal flexion. Functional use of the limb after the cast has been removed overcomes any stiffness that might occur and perfect results are obtained in a short time, compared with the other types.

=Talipes Calcaneous.=—This is a condition in which the foot is held in a position of dorsal flexion. The patient walks on the heel with an inelastic gait because the spring of the foot is absent and the whole weight is borne upon the os calcis. The best procedure in this type is manipulative treatment into a position of plantar flexion to overcome the contraction of the anterior muscles of the foot and leg, and bring about contraction and shortening of the posterior muscles. A tenotomy of the anterior tendons or an anesthetic is rarely indicated, though in severe cases, a series of casts holding the foot in position of plantar flexion may be necessary to secure good results. I have found it a help to have a shoe with a heel prolongated backward, or a steel splint laced to the leg to prevent the foot from upward motion.

=Talipes Valgus.=—This is a very uncommon type of deformity, characterized by eversion of the foot. The patient walks on the inside of the foot and, as a rule, experiences very little trouble. I find a manipulative treatment is best for this condition, aided by braces.

=Talipes Cavus.=—This form is sometimes called “=hollow foot=” and is very uncommon in this country. It is characterized by a markedly high arch sometimes as in Chinese women to the extent that the anterior part of the foot is approximated to the heel. The plantar fascia is badly contracted and one can distinctly palpate the bands beneath the skin. This condition is practically the same as the ordinary so-called “=contracted foot=” except that it is much more exaggerated. The ordinary high arch of today is usually the result of wearing too short a shoe, and if painful, long last shoes, aided by manipulations, will usually correct the trouble. In severe cases of contracted foot the plantar fascia may be divided, under anesthesia and the arch brought down