The practice of osteopathy

By Raymond W. Bailey

It is our purpose here to impress on osteopaths the almost unlimited possibilities in the study and treatment of mental conditions of children, which heretofore have been considered hopeless. Osteopathy has demonstrated that it has much to offer to this class of defectives but the profession has not thoroughly appreciated its great possibilities. It has been the custom to send these children to institutions where they have received care with some attempt toward education but with absolutely no effort being made through physical treatment to overcome their debility. We shall show that the osteopathic lesion is of prime importance in these cases, and that we have been slow to realize the efficacy of osteopathic treatment for such seemingly hopeless children. We cannot emphasize too strongly the importance of accepting and treating these cases wherever possible.

The mental diseases are considered under two general heads: (1) Inherited, and (2) Acquired Tendencies.

1. Inherited Tendencies.—In this class are those cases arising from poor endowment of the protoplasmic structure through lowered vitality of the parents or other progenitors. These taints may come from either parent, or both, and may exist in the offspring from some preceding generation. Such diseases are constitutional and are amenable to supporting treatment in direct proportion to the amount of endowed energy inherent in any given organism.

Of the inherited tendencies, we have two kinds:

1. Congenital Diseases. (a) From any influence of an inherited nature not directly acting on the environment of the parent while the fetus is in utero, and

(b) From any influence which directly affects the development of the ovum through imperfect fertilization coming through either parent or both.

2. General Impairment.—This condition exists (a) Where a similar defect has existed in foregoing generations and is strictly hereditary;

(b) Where general vitality is diminished from such causes as neuropathic parents, or where there have existed constitutional defects, such as tuberculosis, syphilis, epilepsy, alcoholism, abuse, overwork, strain, acute inflammatory diseases, and poor health of the mother during gestation; also consanguinity.

(c) Premature birth tends to impairment physically and mentally of growth of organism and frequently leaves its manifestations of marasmus, rachitis and other nutritional disturbances.

(d) Prolonged labor may leave its mark on the child where more or less asphyxia has occurred resulting in obstruction to cerebral circulation.

Causes acting after birth to the already impaired germ cell and resulting in many of the afflictions of early life, both mentally and physically, are

All of these seriously affect the metabolism within the newly-born, a process which is begun, doubtless with difficulty, and susceptible to easy derangement, and the same effect magnified with growth into its subsequent mental and physical deformity.

2. The Acquired Tendency.—In this the second great class are those conditions arising subsequent to conception where germ plasm is healthy but growth is arrested by some external factor either intra- or extra-uterine. Thus the acquired tendency may be given to the fetus in utero and not be considered congenital as in case of injury affecting health and growth of otherwise healthy conception. In short, the acquired has its beginning at conception or subsequent to it while the congenital is previous to conception or already inherent in the germ plasm leading to conception.

Any influence which retards the

1. Inherent capacity of cell for growth or,

2. Adequate blood supply either in quantity or quality results in enfeebled offspring and these causes are enhanced by

Factors entering into acquired tendencies affecting offspring direct are divided into three classes, those:

Consanguinity or intermarrying of blood relations, or in-breeding results in:

1. Instability of the nervous system.

2. Intensifying of constitutional defects.

3. Decrease in size of offspring.

4. Predisposition to disease through lowered vitality.

5. Impairment of reproductive function.

Immediate consanguinous offspring may manifest a high degree of intellectual or physical attainment but successive processes tend to neurotic types and are prone to physical weaknesses and insanity. This practice is found among Quakers and Jewish peoples, inhabitants of the Islands north of Scotland, in isolated rural localities, and among African tribes.

Mental Deficiency in Children

Synonyms.—Amentia; feeble-mindedness.

There are three grades of amentia:

1. Morons: those whose mental age corresponds closely to their chronological age or is nearly normal.

2. Imbeciles: those in whom there is a wide disparity between the mental age and the chronological age.

3. Idiots: the lowest form of arrested mentality or those whom it is impossible to teach.

Definition.—Mental deficiency is a pathological stage in which the mind has failed to attain normal development.

Various degrees of intelligence or mental capacity in man lie between:

(1) Genius such as Bacon, Newton, Plato, Galileo, Shakespeare.

(2) Lesser Ability but still conspicuous in development such as our great leaders in science, literature, reform and the arts and medicine, furthering, each their respective causes. These merge easily into

(3) Average mass of mankind.

(4) Dullards or those of inferior intelligence.

(5) Feeble minded, merging imperceptibly into

(6) Imbeciles and by insensible gradation into

(7) Idiots and gross idiots.

The mentally defective is wholly incapable at maturity of adapting himself to his environment or local conditions in order to maintain existence independent of any external support.

Dementia is a disease of the mind or that which was once possessed, and by some neuronic disturbance is lost totally or partially.

Insanity is a disturbance of neuronic function which may or may not end in degeneration of brain tissue.

Physiology.—The normal brain begins its development shortly after fertilization of the germ cell, by the expansion of the anterior end of the rudimentary spinal cord into four primary cerebral vesicles. These develop into a series of elaborate infoldings, each with multiple cells around them. At or about the sixth month of fetal life this embryonic brain assumes the shape of the adult brain, minus the secondary fissures and convolutions which are characteristic of full development.

At birth there are sometimes many convolutions and the brain weighs from 280 to 330 grams. Growth is then rapid and at six months it weighs from 560 to 680 grams;

At one year, 750 grams. It continues to increase until

At 12 to 14 years it weighs 1150 grams in the female, and 1300 in the male;

At 20 to 21 years the weight is 1244 grams in the female and 1374 in the male.

Growth is slow from this time until at 25 to 35 years the average weight of the brain is 1269 grams (45 oz.) in the female, 1421 grams (50 oz.) in the male.

This growth of the brain is due, first to the rapid multiplication of nerve cells and, secondly, to the individual enlargement of each nerve cell. These cells arise from the floor of the four primary vesicles and are each similar to its fellow. They finally show differences in feature and become characteristic in size and shape which process continues throughout life. This process of differentiation of nerve cells results in the peculiar laminated appearance of the brain cortex. At the period of lamination, the nerve cells throw out delicate processes which pursue definite directions throughout the brain mass constituting a system of association fibers which link together in a most complicated manner all parts of the brain, and are called the association fibers of Flechsig. Projections from these cells form the various pathways by which the brain is connected to the various parts of the body.

Nerve cells in the different parts of the brain mature at different periods, those areas which have to do with the highest intellectual functions, viz., the frontal and parietal regions, maturing last.

At the seventh month of intrauterine life the brain cell is a small round type of neuroblast, undifferentiated, lying in a matrix. The cells increase in size until about the second week (extra-uterine) of life, tiny processes begin to develop. At the third to fifth year these cells are mature and possess axons, dendrons and geminules. These communicate, forming the above named association system conveying impulses to and from all parts of the cerebrospinal system. They multiply and elaborate after puberty into a complicated system up into middle life after which growth ceases and they slowly diminish.

Greatest Growth is between the first appearance of the primitive brain and the end of the sixth month of life (extra-uterine), hence it is during this period that any adverse conditions relative to development of nerve cells may cause the greatest damage.

Mind and Brain.—Whatever may be the connection between these two, we know that the former develops with the growth of brain cells and fails with their decay. Amentia is associated with the incomplete development of brain cells and Dementia is coincident with their degeneration and death.

Pathology—Brain.—Structural abnormality of the brain tissue may exist without variation of mentality or defect. Early observers gave these gross defects as a cause for amentia. However, it has been demonstrated beyond doubt by microscopic examination of cerebral neurosis that cellular changes occur and that imperfect and arrested development exists and is an essential basis of amentia.

Histology—Blood Cells.—Cortical blood cells in the ament are

1. Numerically fewer.

2. Irregular in arrangement.

3. Imperfectly developed.

4. Microscope reveals changes proportionate to the deficiency during life.

Blood-vessels in Amentia show no marked changes from those of the normal brain. Hyaline degeneration may be present; also pigmentation. These conditions are not constant in amentia hence cannot be considered causal.

Neuroglia in Amentia.—Sclerosis and hypertrophy occur in a large proportion of cases. This is diffuse throughout the brain, with here and there certain circumscribed areas forming nodules.

Nerve Fibres of Cortex in Amentia.—Association system fibres are always diminished in number and not so complicated.

Clinical Varieties of Amentia.—There are two varieties of amentia and conventionally for sake of study we must arrange them into those from

(1) Congenital causes and (2) acquired causes.

Among those which arise from congenital causes we have the microcephalous and Mongolian types. In both cases there exist constitutional taints through successive or immediately forgoing generations of such diseases as syphilis, tuberculosis, epilepsy, and acute alcoholism affecting proper collaboration of germ cells previous to fertilization and hence impaired germinal endowment through a weakened nervous system.

Those arising from acquired causes are from injury to mother or fetus.

Macrocephalus.—A person whose skull measures less than seventeen inches in its greatest circumference. This class comprises less than 10% of all aments.

Cause.—The type is neither a freak reversion of the species to a lower grade of development nor accidental, but due to an inherited blight on the nervous system arising from constitutional disease, alcoholic and sexual excesses, consanguinous unions and too numerous latter-life pregnancies in undermined health states. They come entirely from neuropathic stock and their brothers and sisters are degenerates. Many dwarfs exhibit this type.

Characteristics of Microcephaly.—(1) Circumference of skull diminished; (2) Brain smaller; (3) Stature small (5 feet); (4) Rarely live to advanced age; (5) Die of tuberculosis; (6) Mostly imbeciles and idiots (few morons).

They have their sensory impressions intact and are generally vivacious and muscularly active, even restless. They have good sight and hearing and are highly initiative but have not the ability to any sustained effort. They are actively observant and the majority are affectionate and well behaved. Some are unsteady in walking, others are helpless, and about one-half are subject to epileptic fits.

Mongolian Amentia (Mongolism).—This type (Kalunk or Tartar variety) received its name from Dr. J. Langdon Down from their facial resemblance to members of the Mongolian race. They number about 5% of all aments including the semi-mongols who have only a few of the characteristics of this type.

Cause.—Eleven out of twenty-five are from syphilitic origin. Glandular or nutritional defects are suggested as a cause. They will show negative Wassermann test and positive tuberculin tests. Uterine exhaustion and ill health of mother during gestation are factors suspected of entering into this condition. The latter-born of large families are frequently affected.

Pathology of Mongolian Idiocy.—The brain of the Mongolian ament is considerably under-sized and has less convolutions and is more shallow. The pons, medulla, and cerebellum are about half the size of ordinary feeble minded types. The cells by microscopic examination show an immature condition. This lack of brain development results in deficient expansion of base of skull, hence the characteristic physiognomy. There is no glandular abnormality.

Description of the Mongol Type.—This type is distinguished by characteristics of skull, eyes and tongue and is usually observed at birth.

1. The skull (Brachycephalous) is rounded and diminished in size particularly through the antero-posterior diameter. The face is flattened, there being no recession of frontal and supra-occipital regions.

Eyes.—The palpebral fissures are narrow and slope obliquely downward and inward. Lids inflamed.

Tongue protrudes, is large and marked by large papillæ and scored by transverse fissures due probably to tongue sucking, predisposing to inflammation of the mucous membranes.

Ears are small and round and have poorly developed and irregular lobules.

Nose is short and flat and has triangular nostrils.

Teeth are soft and ill formed and tend to decay.

Hair is usually scanty and wiry and very dry.

Cheeks are flushed. Palate is high and narrow and mouth is open, and lips are cracked. Adenoids exist in all cases.

Hands and Feet are broad and clumsy. Flat foot and knock-knees are common. Skin is rough, coarse and dry.

Abdomen is large and mushy. Umbilical hernia often present.

Circulation is rarely good, causing blueness and coldness of extremities, with sores and chilblains. Heart lesions are frequent. Lesions of a chronic inflammatory nature in respiratory and digestive tracts exist. Nasal and bronchial catarrh and diarrhea are common. Mongols die early (about 14 years) usually of phthisis.

Available statistics show the various types and variations of these conditions in great detail; however, the above will enable the reader to classify and properly diagnose in given cases. It is not the writer’s intention to portray here what is easily a treatise by itself.

Osteopathic Consideration of Amentia.—During a period of five years, observation of the various types has led me to believe that much can be done to correct circulation to cerebral structure with consequent development of brain tissue and function, where discoverable trauma exists. From all available sources there is traumatic interference in from 15 to 45% of these cases, according to different authors. Where history involves constitutional findings (syphilis, tubercular, glandular and chronic alcoholism) I have treated them with the intent of relieving only until the next phase of the condition would appear. Where trauma alone exists and the family history is good, I know the case is in the field of osteopathy alone, and can be developed to a degree limited only by the intelligent care of those having the case in charge. Especial attention should be given to discipline, housing, sanitation, personal hygiene and general environment.

Lesions.—Atlas, generally rotated. Rarely posterior but frequently resting beneath a posterior occiput. Lateral mass on the posteriorly resting portion of misplaced atlas will become interlocked with transverse process of axis in a few instances, combining the amentia with a progressive inflammatory tendency to the middle ear which by successive abscesses ultimately destroys structure and function; possibly traumatic epilepsy, and surely catarrhal inflammations in all mucous membranes of the head.

Many bony and ligamentous irregularities exist in the various types of mental defective where the cause is inherited weakness, nutritional diseases or kindred sources. Spinal luxations exist singly and in series, causing various palsies, spastic muscles, and deformity. Postural defects, particularly of ribs and costal cartilages cause functional disturbance throughout the thorax and abdomen.

Treatment.—Invariably the care of aments entails wisdom of procedure. Reconstruction is the prime object in every instance, hence time and number of treatments must not be considered. Treat to correct structure; teach as far as possible; train always.

Deft and intelligently applied technique are certainly required in the correction of these cervical lesions. Treatment should be given thrice weekly (never less than twice for progress) with definitely established mental tests before, to discern the mental level, and at succeeding periods of three months each, noting progress, if any. The Binet-Simon scale or some other available mental test should always be made and record carefully kept of each case for your own benefit as well as the patient’s. After six months, if no appreciable gain is shown treatment is discontinued and the case must be cared for in another manner as beyond your special field of effort. Usually it is apparent by the end of the third month if anything can be done to improve the mentality. The physical advantages, in some cases warrant continued treatment where there is no appreciable mental gain. Institutional care of these types is the only practical means of handling them properly from an osteopathic standpoint, as it requires some one properly equipped to make your tests and keep your record;—it is sufficient for the doctor to do the work demanded. They can thus be classified and progress systematically shown. The higher grades must be taught and though self dependence may never be attained they can in many cases by training be capable of useful pursuits and quite frequently remunerative work. It makes for happiness at least to keep them busy and forestalls the mischief that would otherwise result. Even imbeciles can help in routine work of an institution or home, and idiots may, by training, gain some power of self help and cleanliness. Training depends on the individual capacity for such in each case—his habits, and general character of his propensities. Prevention of their marriage should be positive and for prevention of their propagation this and their sterilization by operation are the only two measures at hand. Sterilization, however, is repugnant to some elements of society and could be abused, hence the segregation of aments would appear to be our only solution at present. The ultimate intention of treating any case is to use any measure tending to stabilize the nervous system. Corrective effort alone is not sufficient but these osteopathic endeavors in conjunction with proper discipline, good food, regular rest and personal hygiene both mental and physical and a scrutinizing restriction tending to any kind of excess is rendering the osteopathic procedure in such cases rapidly indispensable for the treatment of amentia.