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.