Chapter XI: Introduction (8)

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

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

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

Phlebitis

(Phlegmasia alba dolens; milk leg)

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

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

Chronic Phlebitis

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

THE RECTUM

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

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

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

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

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

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

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

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

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

Hemorrhoids

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

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

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

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

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

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

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

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

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

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

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

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

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

GENITO-URINARY

THE PROSTATE GLAND

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

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

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

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

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

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

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

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

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

Varicocele

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

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

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

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

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

Impotency

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

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

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

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

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

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

FOOTNOTES:

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

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

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

[50] Vecki, Sexual Impotence.

HEAT STROKE

(Heat Exhaustion: Sunstroke)

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

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

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

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

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

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

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

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

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

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

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

DEPARTMENT OF OPHTHALMOLOGY

By C. C. REID

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

How to Examine an Eye

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

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

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

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

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

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

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

The Lumbar Region

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

The Dorsal Region

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

The Cervical Region

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

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

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

The Ciliospinal Center

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

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

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

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

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

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

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

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

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

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

“Somatic Reflexes”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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