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EXAMINATION OF THE HEART AND LUNGS. Examination of the heart and lungs should be made with the patient stripped to the waist and seated upon a stool, with the arm dropped and hanging easily at the sides. When making an examination of the posterior part of the chest have the patient fold the arms to draw the scapulae forward and throw the lungs back against the chest wall by having the patient bend forward slightly. The chief method of examining the chest is by inspection, percussion, palpation and auscultation, or, in other words, by sight, feeling and sound. I have already given you the points for inspection and will not repeat them here, but will see what may be learned by percussion. In this form of examination place the left hand open, with the palm and fingers pressed lightly against the chest wall and with the middle and third fingers of the right hand strike lightly against the fingers, usually the second and third, of the left hand, moving the hand over the surface from above downward, beginning in the suprascapular region and examining both sides -- that is, examine a corresponding area on the opposite side each time you move the hand. Practice this until you learn the difference between normal and abnormal resonance or dullness, as the case may be. By this I mean resonance over the normal air cells of the lungs as compared with the increased resonance brought out by percussion over the emphysematous chest, which contains an abnormal amount of air, and the normal dullness which you get over any of the solid organs, such as the heart or liver, and the dullness caused by presence of fluid in the lung cells or pleural cavity. You may also distinguish by percussion whether the heart, lungs or liver, or for that matter any organ in the body is enlarged, if you know the normal boundaries, because by this means you can follow the dullness of the organ. By palpation we may distinguish the temperature of the skin, pulsation of arteries and any tumor or growth under the skin, or feel irregularities which are not visible upon inspection. Auscultation may be made either by applying
the ear directly to the chest wall, i. e., immediate auscultation, or by
the stethoscope, which is more satisfactory, though I always use both methods
because while the ear alone is not as sensitive, that which you do hear
is within the chest; while in using the stethoscope you must keep in mind
the creaking of the instrument or the brushing of clothing or hair against
it, or some sound from without which may simulate the sounds within the
chest. Here you must learn by practice to distinguish between the
normal and abnormal sounds. The air which is normally contained in
the lung cells gives a gentle little blowing sound which is heard alike
all over the chest. If there is mucus or other fluid in the bronchi
or lung cells you get what we call rales, which are divided into classes
and denote respectively the condition of the lungs or bronchi. If
there is inflammation the mucous membrane lining the bronchi and lung cells
is dry, hot and glazed, and as the surfaces come together and separate,
in inspiration and expiration they stick and pull apart, which gives a
little crackling sound like rolling hair between your fingers near the
ear. If there is congestion and the vessels are pouring out fluid
into the tubes or cells you will get a rattling or rustling sound, etc.
If the fluid is thick or has became fibrinous and solid you get no sound
through the air cells, but I cannot give you these different diagnostic
signs as I should in such a limited work, and so you must study these points
from better authority, such as Dr. E. F. Ingall's most excellent work on
physical diagnosis of the chest, and then only long practice will give
you a real knowledge of what the different sounds in the chest mean.
Many of the lung symptoms which you will find are due to external interference
with nerve and blood supply and you must look well to the vertebrae, ribs,
clavicles and muscles, and remember the influence which work upon the superior,
middle and inferior ganglion
THE HEART. The normal boundaries of the heart are as follows: The heart lies in a slanting position in the thorax, with the apex pointing to the left at the fifth-intercostal space, and we get the normal apex beat at a circle one inch and a half to the inner border of the nipple or three and one-fourth inches from the middle line of the sternum in the fifth intercostal space. The base of the heart lies one and a half inches
to the right of the sternum at the third intercostal space, and extends
across the inner border of the fifth rib posteriorly. Morris says
the base corresponds to the middle four dorsal vertebrae and the apex to
the chest wall on the left side, between the fifth and sixth rib cartilage.
A line drawn across the sternum about the level of the lower borders of
the second costal cartilages, passing half an inch to the right of the
sternum and one inch to the left, will indicate the upper limit and roots
of the great vessels. The adult heart measures about five inches
from base to apex and three and one-half inches across at its widest part.
It is about two and one-half inches at its thickest part, weighs about
eleven ounces in the male and nine in the female. The location of
the semilunar valves are behind the junction of the third rib with the
sternum on the left side. The semilunar valves are opposite the third
intercostal space at the left border of the sternum. The tricuspids
are near the middle line and behind the sternum at the level of the fourth
space. The mitral valves lie behind the sternum, opposite the fourth
cartilages of the left side. The murmurs from these valves are transmitted
so that the mitral sounds are heard most plainly at the apex, and if transmitted
to the left side denote mitral insufficiency and regurgitation. The
aortic murmur is heard at the right over the junction of the first rib
with the sternum, while the tricuspids are most plainly heard in the location
given above. The nerve supply, as you know, is through the pneumogastric
and the superior cervical ganglion, with the center in the medulla.
Quain, as quoted by Hazzard, says there are accelerator fibers for the
heart derived from the upper four or five dorsals, but chiefly from the
second and third. The spinal fibers end and sympathetic fibers begin
in the middle and lower cervical, also in the first thoracic region.
He also says that vasoconstrictor fibers to pulmonary vessels have been
found in the dog from the second to the seventh dorsal spinal nerves, and
this is where we treat to effect the lungs in man and get results.
Hazzard quotes also from Howell to show that stimulation of the pneumogastric
in the neck constricts pulmonary vessels, while stimulation of the sympathetics
of the neck dilate the pulmonary vessels. He notes, too, a reflex
contraction of the pulmonary vessels by stimulation of some other nerve,
as the sciatic intercostals, abdominal pneumogastrics or abdominal sympathetics,
and he quotes from Robinson the note that the heart and aorta are affected
alone by influences which affect the local sympathetic centers. Dr.
Still is quoted as saying that the aorta may be constricted at the opening
through which it passes in the diaphragm, which may be relaxed at its vault
and cause a constriction about the aorta. Thus, he says, the heart
goes to pounding to force the blood through, and the result is palpitation.
Dr. Still diagnosed such a condition in himself which he said was relieved
by compressing the lower part of the thorax and allowing the diaphragm
to bulge upward. In somewhat the same manner and probably more often
the stomach distends with gas and makes pressure upon the aorta or the
heart itself and causes violent action of that organ. In examining
the heart do not neglect the pulse beat, which is most commonly sought
at the left wrist at the radial artery should be from 72-78 per minute.
You may tell by the pulse whether the heart beats too fast, too strong,
or vice versa; whether it is regular, irregular or intermittent; whether
easily compressed or bounding. In short, if you learn the character
of the normal pulse you will be easily enabled to tell when it is abnormal.
Before I leave the thorax I wish to give you much that Dr. Hazzard says
on the splanchnic nerves, because I know of no one who gives them so well,
and I hope every one who sees this imperfect little work of mine, which
owes so much to him, will provide themselves with a copy of "Hazzard's
Principles of Osteopathy."
THE SPLANCHNIC NERVES. Hazzard says, "The splanchnics are some of the most important tools with which the Osteopath works. They are of such far-reaching connection that their importance becomes apparent, hence their constant use by the Osteopath." The splanchnics are the nerves which govern the viscera and they are the sympathetics from the lateral chains of thoracic ganglia. The great splanchnic arises from the fifth or sixth dorsal and from all the thoracic ganglia below down to the ninth or tenth. It perforates the diaphragm and joins the lower part of the semilunar ganglion. In the chest it sometimes divides and forms a plexus with the smaller splanchnic. The fibers are white, medulated, most of them, and come from the anterior roots of the spinal nerves. The greater splanchnic gives branches to the aorta and front of the vertebrae; the smaller splanchnic arises from the ninth and tenth, sometimes from the tenth and eleventh, thoracic ganglion, or it may arise from the sympathetic cord itself without the intervention of ganglia. It also passes through the diaphragm, sometimes separately, sometimes with the cord of the greater splanchnic. Like the greater splanchnic it joins the lower part of the semilunar ganglion and sends branches to the renal splanchnic, if that is lacking or is small. The smallest or renal splanchnic, if present, arises from the last thoracic ganglion and passes through the diaphragm with the sympathetic cord and goes to the renal plexus. A fourth splanchnic is sometimes found in the cervical region. Hazzard quotes Gaskell, as quoted by Quain and substantiated by Byron Robinson, as saying there are visceral branches from the second, third and fourth sacral nerves, and these he calls the sacral or pelvic splanchnics. The cervico-cranial rami viscerals are visceral branches from the spinal accessory, pneumogastric, glossopharyngeal, and facial nerves. "So," Hazzard says, "you see that visceral nerves have their origin, from these cranial nerves, also a branch from the ciliary ganglion from the third nerve." He quotes Byron Robinson as saving, "There are certain fine white medulated nerves which Gaskell mentioned and which pass from the spinal cord in the white rami communicantes between the second dorsal and second lumbar nerves, inclusively, to supply viscera and blood vessels. These nerves should be called, as Gaskell suggests, splanchnics. Hence we will have first the thoracic splanchnics, second the abdominal splanchnics and third the pelvic splanchnics." Hazzard says above the second dorsal and below the second lumbar gray rami communicantes are found, and Robinson calls them peripheral supplying the parietes of the body. He quotes further from Quain that "The medulated fibers such as we find in the splanchnics which pass in the sympathetic system are classed by Kolleker as (a) sensory, (b) vaso- and visceroconstrictors, and (c) vaso- and visceroinhibitors," and says, "Hence we have passing from the spinal cord into the great prevertebral plexuses in the different regions these sensory- vaso-dilator and constrictor and visceroinhibitor and constrictor fibers." Quain says the sensory are found only passing from the cranial nerves, but that the visceral and vasomotor fibers are found all the way down the cord. Hence the visceral and vasomotor fibers are found in the splanchnics. He quotes Quain further in that the splanchnic nerves proper act first as visceroinhibiting fibers for the stomach and intestines, second as vasomotor fibers to the abdominal blood vessels, third as afferent fibers from the abdominal viscera -- that is, fibers from the abdominal viscera back to the center, and says that explains why it is that we get secondary lesions, as we call them. You may have some trouble in a viscus, knowing that you can have different fibers from the viscus to the center you can account for the center being affected and the impulse coming out from it to the posterior spinal nerves, for example, and causing contraction of the muscles in the back. Hazzard goes on to show the significance of the splanchnics to the Osteopath by saying, "In the first place they must be connected with the spinal cord itself, since they arise from the anterior roots and run through the cord to the brain. It is doubtful how close a connection they have with the brain centers, but they have at least a close connection with the bulbar center, the vasoconstrictor center of the medulla. Then it is probable that these splanchnics have a close connection with cardiac and pulmonary fibers arising from the upper part of the spinal cords, because we have seen that the center for the lungs extends from the second and seventh dorsal and that we work in the upper dorsal region for the heart, and there are certain vasomotor fibers from these regions to the heart and lungs, so that it is almost indisputable that there is a connection between the splanchnics and what we might call other splanchnics for the heart and lungs. "In the next place we have seen that the first two splanchnic nerves join the semilunar ganglion, and the third the renal ganglion and they are connected directly with the solar plexus and through it with the other great prevertebral plexus, the hypogastric plexus, and through that with those secondary plexuses such as the superior and inferior mesenteric, hemorrhoidal, portal, Auerbach's and Meissner's, and the various plexuses throughout the pelvis and elsewhere. Hence any one who sees the significance of osteopathic work will see the significance of this far- reaching connection with visceral and organic life. Then, again, remember that in the thorax the first or greater splanchnic sends branches directly to the aorta itself. Hence it is that the operator so frequently works upon the splanchnics. It does not make any difference what kind of trouble you may have, the general health is likely to be affected and it must be attended to; and whether you are working upon the stomach, liver, portal system, upon the intestines or pelvic viscera, you will work in part upon the splanchnics." I have quoted so much at large from these excellent
authorities because I want you to fully understand the great importance
of the splanchnic nerves. They and their connections explain the
osteopathic centers and the manner of influencing local or general circulation.
It is a favorite plan, both in medicine and Osteopathy, to increase circulation
at one point to relieve congestion, and because of the immense blood supply
and of the splanchnic control here the abdomen is a common ground for such
a result. The M. D. will give a cathartic with a view to increasing
the amount of blood in the intestinal tract and thus taking it from the
head, lungs, liver or whatever part may be over-gorged. It has been
said that a man may bleed to death within his own belly, meaning that you
may attract all of the blood of the body to the abdomen and thus deplete
the brain, heart, lungs, etc., as to cause death. For another example:
It was a common treatment at the Illinois Eastern Hospital for the Insane
to give sleepless patients food during the night, instead of medical hypnotics,
because we figured that the blood naturally is attracted to an active part.
It goes where it is most needed and so by inducing gentle digestion or
setting the stomach to work the blood is attracted from the brain to the
stomach, and the brain being relieved of the over-amount of blood becomes
quiet and the patient sleeps; and so by treating the splanchnics you often
get such a result. Headache is largely relieved in this way, when
it is reflex as well as when due to local congestion.
THE ABDOMEN. Landmarks. In examining the abdomen have the patient assume the dorsal position, with the knees flexed and the head slightly raised in order to relax the abdominal muscles. The regions of the abdomen are the epigastric, umbilical and hypogastric. The epigastric region lies between the diaphragm above or between the lower end of the sternum and a line drawn from the anterior tips of the tenth ribs. This space is divided again upon each side by a line which would pass down from the nipples to the lower border of the epigastric region, and these side regions are known as the right and left hypochondriacs. Below the epigastric region is the umbilical, bounded below by a line drawn from tip to tip of the crest of the ilium, and this region is divided, as is the epigastric, into three divisions by a line passing down from the tips of the tenth ribs and forming on either side of the umbilical region the right and left lumbar regions. Below these three regions comes the hypogastric in the center, and on either side of the line, which comes from the anterior tip of the tenth rib to the pubic spines are the right and left iliac region, and just over the pubes the pubic region, which is bounded below by the two Poupart's ligaments, one on each side. It will be good practice if you take blue chalk and outline these regions on the living subject. However, you will find them well diagramed in your anatomy. The stomach when empty or not abnormal lies in the epigastric region, with one lobe of the liver lying partly across it. The pyloric orifice is found on the right, at the edge of the sternum, about where the cartilage of the eighth rib joins, and is covered by the liver. The cardiac orifice is just below the cartilage of the seventh rib, where it joins the sternum. Remember, the stomach is a movable organ and may become so distended with gas as to push the other organs out of their normal positions, and often presses up on the heart and lungs, causing dyspnea or difficult breathing. The liver lies in the right hypochondriac and partly in the epigastric regions, for, as I told you, one lobe of this organ lies over the stomach and extends into the epigastric region as far as the inner border of the left mamma and downward half way to the umbilicus. Upward the liver ascends to the diaphragm, or about an inch below the nipples, and the lower and posterior borders of this organ are at the tenth dorsal spine. Of course these are dimensions for the normal liver. The gall bladder is behind the edge of the liver at the tip of the ninth rib, and cannot be felt distinctly, but is treated at this point. The gall duct is in a reversed S shape, and extends from the gall bladder to a point a little to the right of the umbilicus. The spleen lies to the left, below the ninth, tenth and eleventh ribs, and if enlarged may be felt here, and is treated at this point. The pancreas lies back of the stomach and crosses the aorta and spleen transversely at the level of the second lumbar vertebra. It cannot be outlined when normal unless in a very thin person. The kidneys cannot be felt, but may be treated by pressure at the outer edge of the erector spinae muscle, between the lower ribs and the crest of the ilium, and as you will see are in a different location than the laity place them, for people almost universally place their hand over the sacrum as their location for the kidneys. The kidney really corresponds in position to the lower two dorsal and upper two lumbar vertebrae. If the kidney is enlarged or tender pressure here will produce pain or a sense of deep soreness, and you may be deceived in examining through the abdominal walls by masses of fecal matter in the bowels, taking them for enlarged kidney or a tumor. The ascending colon is in the right lumbar region, over the kidney. The ileocaecal valve lies in the right iliac fossa. The descending colon and sigmoid flexure are in a corresponding position on the left side and transversely above the umbilicus is the transverse colon. The small intestine lies behind the umbilicus.
The ileum contains Peyer's patches, which lie in the location of the ileocaecal
valve, at the edge of the right iliac fossa. These glands are important
in typhoid fever because first involved, and the tenderness and gurgling
in this region is, with other symptoms, diagnostic of typhoid fever.
In treating both in this fever or in enteritis you must be very careful
for fear of causing hemorrhage or perforation.
EXAMINATION OF THE ABDOMEN. In making an examination of the abdomen inspection, palpation and percussion are the most common methods. By inspection you may notice the color of the skin. If the liver is chronically inactive you will often find the abdomen marked by yellow or brown patches. In pregnancy there are many discolorations and the linae albae are always present, and are small white lines under the skin. If there is hernia or any tumor or enlargement present the eye may usually detect it; and in eruptive diseases, as in typhoid or scarlet fever, the eruption may often be found here when it does not show on any other part of the body. Palpation is the most useful method of examination, and in examining or treating this region be careful to gently lay the palm of the hand flat upon the surface and move slowly and gradually, for the reason that any sudden blow or movement against the abdominal walls causes the muscles to contract and you can tell nothing of what the condition is beneath them. In palpating first notice temperature, whether normal and equal. In some liver troubles there are cold areas and where a nerve is obstructed at the spine you may find a cold streak following the course of the nerve. In any disease which causes dypsnea or difficult breathing, as in pulmonary tuberculosis, the abdomen is apt to be retracted, and in emaciated people you will often find, the abdomen retracted. In painful diseases of the thorax, as in pleurisy, the respiratory motions of the abdomen are increased, but if there is great pain in this region, as in peritonitis, the abdominal movements are restricted. In intestinal indigestion and constipation there is much distention. By gentle pressure you may feel the pulsation of the aorta, and where there is fecal impaction the mass may be felt under the hand. Hazzard says, "If there is pain in the stomach, which increases upon pressure over the pit of the stomach, it is inflammatory, as in catarrh of the stomach; if it disappears, it is said to be nervous." If the liver or spleen or stomach are enlarged you will be able to feel them and sometimes a floating kidney is easily outlined, as is an ovarian or fibroid tumor, which may arise out of the pelvis into the abdominal cavity, and in rare cases the bladder may be so greatly distended as to be felt here. Percussion will show you the location of the
solid organs, which give a dullness on percussion. Where there is
gas, as in the intestines or in the stomach, you get a high-pitched tympanitic
sound. Practice will teach you the difference between the tympanitic
sound where gas is present and the resonant sound where there is air in
a cavity, as in the chest. The liver, as I have told you, lies very
near the surface in the median line, and when much enlarged may extend
well down below the ribs and across the front. It feels smooth and
elastic if not hardened or congested, when it has an inelastic or putty
feeling to the examining hand. By gently going deeply into the abdominal
cavity you may feel the bodies of the vertebrae and the large nerves and
blood vessels which lie along on the inner or anterior surface of the spinal
column. The appendix may be felt if it or the tissues about it are
much swollen or tender at a point about midway between the umbilicus and
the anterior superior spine of the ilium. The gall bladder
may be felt also if there is much distention and tenderness or if there
are gall stones present, and the bile duct may be felt at the umbilicus
if swollen or tender from catarrh or if containing gall stones.
THE PELVIS. Landmarks. The pelvis, as you know, is the bony basin formed by the innominate bones and the sacrum and coccyx, or of the ilium and ischium on either side, the pubes in front and the sacrum and coccyx behind, and contains the lower bowel, the uterus and its appendages in the female and the bladder. The superior spines and crest of the ilium may be easily outlined, and these landmarks are important points for measurements and as guides to the surgeon. McBurney's point, for instance, is midway between the umbilicus and the anterior superior spine of the right ilium, and is the point of operation for appendicitis. The pubis, of course, is very distinct across the front and for external examination marks to the hand the limit of the false pelvis, which lies above it and in the flare of the iliacs. By making gentle pressure with the palm of the hand above the pubes you may engage the fundus or top of the body of the uterus, you will be able to detect it at once as a small hard ball which easily fits into the hollow of the hand. Poupart's ligament is a thickening of the aponeurosis of the external oblique muscle and extends from the anterior superior spine of the ilium to the spine of the pubes, and marks the diagnostic point between inguinal and femoral hernia, the first being above the ligament. The spine of the pubes is also a point of diagnosis, the hernial sac lying to the inside of the public spine in inguinal hernia, while the reverse is the case in femoral hernia. The bladder may be outlined if filled and must be distinguished from the uterus or a uterine tumor by the fluctuating elastic feeling in distinction to the hard, solid uterus. The ovaries are not discernible to the examining hand on the surface unless greatly enlarged by tumor or other abnormal condition, as they lie behind Poupart's ligament in the inguinal region. The perineum externally is the space between the external genitals and the tip of the coccyx and is the floor of the pelvis. It is bounded by the rami of the pubes and ischim, the tuberosities of the ischiae, the great sacro-sciatic ligament and the tip of the coccyx. Hazzard says, "The healthy perineum bows or curves up to support and hold up the pelvic contents." Posteriorly we find from above down the promontory of the sacrum and on either side the superior posterior spines of the ilia, on a line which would pass through the second sacral spine and mark the articulation of the sacrum with the ilium. In the middle line are the spines of the sacrum and the coccyx. The third spine of the sacrum is the limit of the membranes of the cord and of the cerebro-spinal fluid in the spinal canal. The glutei muscles form the buttocks and unless flabby, as in emaciation, mask the important structures beneath, although pressure here illicits pain over an engaged nerve. The fold of the buttock is the lower edge of these muscles and the thigh, and is the point for pressure upon the great sciatic nerve. The great trochanter is what is commonly called the hip and is about midway between the tuberosity of the ischium and the superior spines of the ilium. You may also find the sciatic nerve by deep pressure between the tuberosity and the ischium and the trochanter. The tuberosity of the ischia are the parts of the pelvis upon which we rest when seated, and perhaps for external examination may best be described as located between the anus or opening from the bowel and the great trochanter. The great sacro-sciatic notch may be determined
by rotating the thigh forward and drawing a line from the posterior superior
spine of the ischium to the top of the trochanter, when the top of the
notch and gluteal artery is found at the junction of the upper with the
middle two-thirds of the line. The spine of the ischium is located
by drawing a line from the posterior superior spine of the ilium to the
outer side of the tuberosity of the ischium, and the pudic nerve and artery
cross the ischial spine. By stimulating this nerve Hazzard says you
may cause contraction of the perineum, and by stimulating the lower sacral
nerves you cause a contraction of the coccygeus muscle and help to raise
the bowel and pelvic contents. He also says, "Pressure upon these
vessels, as by continued sitting, is a common source of uterine and pelvic
disorders."
EXAMINATION OF THE PELVIS. Examination of the pelvis is entirely by palpation. The whole pelvis may be slipped forward or backward, or it may be twisted. Very commonly there is a tilting of the pelvis to one side or the other one innominate may be slipped in any direction, and a very common dislocation I find is between the sacrum and last lumbar vertebra. In these displacements the sacral plexus is involved and the nerve and blood supply to the lower limbs is much interfered with. I have to my credit here the cure of a so-called case of locomotor ataxia which was nothing else than an interference with nerve conduction by a slipping of the whole pelvis posteriorly, making such pressure on the spinal and sacral cords that all symptoms of locomotor ataxia were present. This diagnosis had been made by several of the most eminent neurologists and I should have done the same if I had not possessed some knowledge of Osteopathy. Sciatica is also commonly caused in this way or from pressure within the pelvis from the pelvic organs, and much of the disease and disorder of the bowels uterus, ovaries and bladder are all often due to pressure at some point or points about the pelvis. Of course you will remember the different causes of pressure, that made by the muscles especially. Dr. Hazzard states that when the innominate bone
is slipped forward you have a shortened leg and when displaced backward
the leg is lengthened. He quotes Dr. Harry Still as saying that "a
twisted or tilted innominate may shorten a leg as much as three inches
and may be mistaken for dislocation of the hip."
EXAMINATION OF THE HIP. Because of the heavy muscles about it the hip has no landmarks for the Osteopath aside from those already given for the pelvis. Dislocations or slippings are very common here. You ma find the femur upward or backward, and in this case the leg is shortened and the toes turned inwards. Or it may be backward into or near the sciatic notch when the leg is shortened and toes turned in, but not so much. Third, you may find a thyroid dislocation into the obturator foramen. In this case the knee is bent and the toes are turned either inward and point down or outward, or the head of the femur may be forward against the pubic arch and the toes are turned out. So in reality only the first two are difficult to
diagnose as to position, especially if you are sure it is not a displacement
of the pelvic bones. The pelvis and hip are especially difficult
and only a thorough knowledge of the anatomy and a good experience in examining
patients will make it possible for you to treat these cases.
EXAMINATION OF THE LEGS AND FEET. In examining the lower limbs and feet place the patient on a table in the dorsal position. See that he lies straight, then place your hands one. on either ankle, and pull the limbs down, placing your thumbs on the internal malleolus, or so-called ankle bone, and if your thumbs come together evenly you feel pretty sure that the legs are of the same length; but, however, this is not reliable, for the pelvis may be tilted down or up on one side, which must be determined by placing the fingers on the anterior and posterior superior spines of the ilium, or, as I told you, by having the patient while lying flat on his back hold a tape measure between his front teeth and then stretch it down to first one anterior superior spinous process of the ilium, then the other and so on with the knee and ankle, noting the difference if any by measurements. It is a fact that you will find very few people perfectly symmetrical, so if the deviation is slight and there is no pain or discomfort which may be attributed to this it will be better to let it alone. If there is a real affection the affected side will be sore, especially the sacral articulations and the symphysis pubis if the trouble is in the hip or pelvis. The knee is a very delicate joint because much exposed and a strain of the muscles attached to the bony prominence about the knee is very often found. You will have to diagnose between a sprain, synovitis and rheumatism. If I find a knee swollen red and painful I do not move the limb, but gently manipulate it from the sacrum posteriorly and front the iliac region anteriorly on down to the toes, to relax the tense and contracted muscles and free the blood supply. I gradually work about the knee and in the popliteal space for fifteen or twenty minutes, then order a hot compress of antiphlogistine to be changed every twelve hours until the third day, when I treat again. After the acute inflammatory condition subsides I begin to give gentle and limited motion, increasing this as the patient can bear it until the knee can be moved, when I favor a .limited amount of use as soon as possible. You may have dislocation of the joint between the femur and the tibia, or the fibula and tibia alone may be displaced, but for some reason dislocations are not so commonly found here as the above-mentioned disorders. At the ankle rheumatism and spasm is most often found, though this is a very favorite joint for dislocations, and is treated in the same manner as given for the knee. The foot is so often abnormal that it is difficult
to give all the abnormalities, but the broken arch and consequent flat
foot and bunions are most frequent If you study the skeleton foot
and the muscular attachments you will see how easy it is for all of these
little blocks of bone to slip out of their natural positions and put the
ligaments and muscles on a strain, thus causing pressure and pain.
Talipes, or clubfoot, is an extreme of this condition and the Osteopath
shines in treating all of these disorders of the legs and feet. Scarpa's
triangle and the popliteal space are locations in which you can reach much
of the blood and nerve supply for the lower limbs, and it is here that
much of the treatment is given for these parts.
THE PELVIC ORGANS. The organs contained in the pelvis are the rectum and bladder, the uterus, ovaries, Fallopian tubes and vagina in the female and in the male the rectum, bladder and prostate gland. You must not expect the anatomy of these organs here. I merely wish to give you a method of examination and help you to become familiar with that which the examining hand or finger meets. If it is necessary to examine the rectum place the patient upon his left side in the Sims position, i. e., with the right limb drawn up across the abdomen. The anus or opening of the rectum is the external sphincter and presents a corrugated orifice. Inspection will show the presence of any abnormal growth or condition. A protruding hemorrhoid will have the appearance of a small blue tumor, something like a grape (but not always as dark in color), and is very sensitive to the touch. You may also find the rectum prolapsed and protruding, but you can diagnose this condition from hemorrhoids by the fact that it is not tender and is pink, whereas the hemorrhoid, being an enlarged vein, is blue, and is painful. Then upon spreading the folds of the anus you may find small bleeding or raw-looking fissures or cuts, which are very painful upon defecation and cause a dull aching pain at the tip of the coccyx, or even up over the sacrum. Upon passing the finger into the normal empty rectum you will find a smooth elastic tube, upon passing the finger a little way ... [sorry, missing pages 81 and 82] ... or abnormal development of the external genitals. In the male the most common, probably, is an elongated or adherent prepuce, or an occlusion of the external orifice. In the female you may find an elongated or adherent clitoris, or small painful growths about the urethra, which are neuroma. Or you may find cysts, of which, a cyst of the gland of Bartholin is most common and requires surgical measures. Elephantiasis is an overgrowth, of the labia of the vulva, or of the scrotal sac in the male. Sarcoma comes as a hard, painful nodule and may be taken for a bubo. Carcinoma also attacks the external genitals and can only be determined by the exclusion of the less malignant or benign growths. Lower down at the orifice of the vagina you notice the presence or absence of the hymen. If intact you find the membrane almost closed in; if not intact, it is stretched and ragged, and in a woman who has had children the thin tissue becomes lost in the folds of mucous membrane lining the labia. Occasionally you may find an impervious hymen, i. e., one without any opening, and in young girls at the age of puberty there may be an accumulation of fluids which have not been able to escape and cause much backache, pain in the limbs, and bearing down by their pressure. Further down you come to the perineum, which is the
pelvic floor and is the space between the orifice of the vagina and the
anus or opening of the lower bowel. In childbearing women you may
find this ruptured and if this condition exists it should be repaired by
surgical means without delay, because it weakens the support of the internal
organs and makes displacement most certain sooner or later.
DIGITAL EXAMINATION OF THE FEMALE PELVIC ORGANS. Digital examination of the female pelvic organs is made by passing either the index finger alone or both the index and middle fingers into the vagina with their dorsal surfaces backward. The vagina is a membranous canal or collapsed tube extending in from the vulva to the uterus and lying between the urethra and bladder in front and the rectum behind. It is between five and six inches in length, the anterior wall being shorter than the posterior and extending from about the urethra or opening into the bladder backward and upward under the bladder, with which it is united, and then is reflected down a short distance onto the anterior lip of the cervix of the uterus, forming the anterior fornix or little pocket into which the examining fingers pass. In the same manner the posterior wall extends from the vaginal orifice upward and is reflected upon the cervix forming the posterior fornix. The posterior wall is curved, the curves varying with the position of the uterus and the amount of distention of the bladder and rectum. In the center between these two walls and extending into the vagina the examining fingers meet the cervix or neck of the uterus, which will be felt as a small hard body with a depression, the os, or mouth, in the center; and should normally point backward and a little upward and lie well up in the vagina, about five or six inches from the opening. The virgin cervix extends about 1/4 - 1/2 inch into the vagina and is about an inch in diameter. The Os is a crosswise slit with lips, the anterior lip being thicker than the posterior. You may feel whether the cervix points in the normal direction, whether too low, whether the cervix is enlarged, whether the Os is smooth and regular or vice versa, and whether there is any discharge lodged in the Os. You may also feel the broad ligaments on either side, whether there is any exudate which may be felt as a putty-like substance under the tissues, and if the ovaries are slipped down you may find them in the folds of the broad ligaments on either side of the uterus, or one or both may be behind the uterus. You will know them by the tenderness to touch and the presence of a small soft elastic body. The normal position of the ovary is so well up in the inguinal regions that it is difficult to find them, though bimanual pressure an inch and a half inward from the anterior superior spine of the ilia will produce tenderness; but do not persist in this simply for the sake of locating the ovary, because if this organ is much enlarged or there is a tumor or cyst you will cause pain with very little pressure. It is not well to poke about the pelvis too much. Don't do it unless there are grave symptoms of disease or disorder in these organs, or the patient's symptoms do not yield to treatment and you suspect reflex disturbance from this quarter. Hazzard says the treatment for the ovaries is given through the lumbar region from the second to the fifth -- that is, vasomotors of both kinds go to the internal genital organs. The center for the blood supply for the ovaries is from the tenth to the twelfth dorsal, or between these. "The eleventh dorsal seems to be the arterial center for control of the blood supply to the ovary." The spermatic artery in the male and the ovarian in the female is opposite the second lumbar vertebra, above and back of the umbilicus and transverse colon, and you may by working in deeply follow this down to the ovary and, as Hazzard says, stimulate the arterial flow, while by working in the reverse direction you stimulate the venous flow. At the fifth lumbar you get the center for the hypogastric plexus, through which comes the pelvic plexuses. Now to continue with the digital and bi-manual examination of the pelvic organs, while the examining fingers are inserted in the vagina and the left hand is placed gently over the lower part of the abdomen to push the uterus down a little you may feel the body through the vault of the vagina. The uterus, as you have learned from your anatomy, is normally a small flattened pear-shaped organ, consisting of a body and neck or cervix. The body is called the fundus and in the multiparous woman does not rise above the brim of the pelvis, hence cannot be felt in the hypogastrium. It is a hollow organ, possessing thick, muscular walls, and is lined with mucous membrane. When unimpregnated and normal it is about three inches in length, two inches wide at the top, and one inch thick. The fundus is directed forward and lies upon the bladder or against the bladder, hence lies in a slanting position with the top slightly down and forward, while the cervix is slightly upward and backward. The uterus is partially held in position by the broad ligaments, which are folds of peritoneum thrown over the body, and part way down on the cervix, then fold back, and are attached to either side of the pelvis, dividing it transversely. In the folds of the broad ligaments besides the uterus are the Fallopian tubes, which run along the upper borders of the broad ligament from the ovary, which is also in its folds, to the upper corner of each side of the fundus, and open into the cavity of the uterus by very small orifices. And so, by pressing gently from above and exploring carefully with the finger inside, you may feel all the contents of the pelvis, and by knowing the normal condition learn the abnormal. As you pass your finger up the anterior wall of the vagina you will feel a soft cushion-like body, which is the bladder and is easily found unless perfectly empty. The uterus has in addition to the broad ligaments, two round -- two utero-sacral and two utero-vesical ligaments -- the latter two pairs being folds of peritoneum between the uterus and sacrum and the bladder and uterus, as their names indicate. The round ligaments are fibro-muscular cords from four to five-inches in length, and pass from the upper corners of the body to the internal inguinal canal, and are lost in the tissues forming the mons veneris over.the pubis. They probably help to prevent retroversion of the uterus when the bladder is greatly distended. The uterus being movable is retroverted or anteverted somewhat by the bladder as to whether it is full or empty. However, the uterus is not kept in its normal position by the ligaments alone, but more by the shape of the pelvis, the surrounding tissues, intestines and organs, and the floor of the pelvis or perineum. Probably the axis of the pelvis is the best support which the uterus has and yet it is most prone to malpositions. Indeed, in twelve years' medical practice (four of which was spent as resident physician and gynecologist to the Illinois Eastern Hospital for Insane at Kankakee, where I had the most excellent advantages for observation, having made over eight hundred examinations and treatments, in my last two years' service there) I have found a very small number of women with the uterus in its normal position. This can probably be accounted for in this way: The distended bladder naturally pushes the fundus of the uterus back. This brings it into the incline of the pelvis and some sudden jar or fall causes it to slip downwards past the promontory of the sacrum, and when it gets into the curve of the sacrum there is nothing to prevent the heavy fundus from tipping backwards (retroversion) or in slipping on down the incline, prolapsus. The uterine displacements are as follows: 1st. Anteversion, or forward displacement, when the fundus tips forward on the bladder and to a degree is physiological, but if extreme causes uncomfortable pressure upon the bladder, and also causes the cervix to tip too far back, making a condition of sterility. 2nd. Anteflexion, i. e., a bend in the anterior wall of the uterus at the junction of the body and cervix. Here you will find the cervix in its normal position, but the body is too far forward, and as is the case in all flexions the canal of the uterus is narrowed or occluded, making menstruation difficult. 3rd. Retroversion or backward displacement, where the fundus points back, and, if extreme, downward, and the cervix is forward and upward. This condition causes pressure upon the sacral nerve and the rectum, pulls on 'the broad ligaments, and the ovaries are usually dragged downward and may be backward. 4th. Retroflexion when the cervix points in the normal direction and the body is bent backward. 5th. Lateral version where the uterus is drawn to one side by adhesions or by a shortening of the broad ligament, in which case there will be tenderness and inflammation in the ovary and broad ligament of the opposite side because of the dragging strain upon them by the tightened condition of the other side. 6th. Latero-flexion, i. e., the body is bent to one side while the cervix may be in its normal position. 7th. Prolapsus or downward displacement, in which there are three degrees, namely, lapse, prolapse and procidentia lapse, where, as I have said, the uterus is pushed back by the bladder and slips down slightly; prolapse, where the organ falls down until it crowds the rectum and the cervix, and is at the opening of the vagina. Procidentia, the condition in which the uterus protrudes outside of the vagina, and I have found a number of cases where absolutely the whole organ was outside of the body; and yet, except in these extreme conditions, I have been surprised at the amount of displacement present without any effect upon the health or comfort of the patient. All of the flexions cause dysmenorrhea more or less because they obstruct the uterine canal and the versions if extreme, by pressure, cause pain and distress at all times; but I have been surprised to find so many cases of uterine displacement, which apparently gave no discomfort whatever, and I have learned that if the circulation can be kept free and the bowels are well emptied, and not over-distended with gas the patient can bear a good deaf of malposition of this organ without being conscious of it. I know that this is adverse to the usual opinion of gynecologists, but I have long since concluded and find that many of the best physicians concur with me in the opinion that the local examination and treatment of the female organs of generation has been greatly over-done; so I avoid the use of the speculum and sound (especially the latter) except in an occasional case for diagnostic purposes. One of the most celebrated gynecological surgeons of this city told me only a short time ago that his speculum and uterine sound were locked up in the cupboard to stay there, for he thought, as I did, that the time of probing and poking about the pelvis and of packing it full of unyielding cotton two or three times per week had passed, and when I asked him what treatment he would give in place of the medicated tampon he replied "pelvic massage, and if I use medication it is by capsule or suppository"; and as Osteopaths you have a much more effective method of treating these disorders and diseases than massage. My manner of managing these cases is as follows: I make my diagnosis by inspection, palpation and an internal digital examination. Then I give a general treatment to stimulate the general circulation and to free the bowels, treating well in the lumbar and sacral regions, and in the hypogastric and inguinal regions. Placing the palms of my hands well down in a gentle manner in each inguinal region, I lift up on the deep structures and use vibration plentifully over all this region. Then I place one or two fingers in the vagina and the palm of the left hand on the outside and manipulate gently between them all the tissues and pelvic parts, at the same time working, always carefully and gently, against any abnormal position I may have found. If prolapsus or retroversion or retroflexion is present the patient is given the knee chest position, and I spread the vaginal walls, allowing the air to rush in and force the uterus up. It is far more effectual than to try to replace this organ by pushing or pulling it in the desired direction, either with the fingers or instrument. Of course it won't remain in position permanently at once and perhaps never will, but it would not if you packed the vagina full of cotton and you would only have a foreign body there to add to the crowding and pressure; but by frequently relieving the interference with the pelvic circulation, by stimulating the nerve life and thus strengthening muscular tissue and the ligaments you are helping the natural tendency to the normal and will gain much more, I assure you, than by any other method of treating these cases. I often find it necessary at first to give the patient a cathartic to free the bowel of a large fecal mass and deplete the blood vessels, but once or twice will suffice if the patient takes treatment regularly, for you can keep the bowels free after a few treatments, and in many cases it will be necessary to treat in the rectum, which is apt to be flabby and to show inertia. I also instruct the patient to assume the knee chest position for ten minutes each night and morning, and if I find much engorgement of the uterine and pelvic blood vessels and the uterus large in consequence I use suppositories of glycerine with 10% ichthyol to keep up the depletion of the vessels, but of course without your medical degree you are not at liberty, I suppose, to use this measure and can still do much good work by treating the patient every day or four times per week, instead of three times as is my custom. In anteversion and the other displacements the same means may be employed except the knee chest position, which would by force of gravity increase anteversion or flexion, but the vaginal walls may be spread in the dorsal position, allowing the entrance of air, as in the knee chest position. And so in a superficial and somewhat limited way I have given you the osteopathic landmarks and most of the nerve centers. Hazzard quotes from Howells' text-book as follows: He says, "Howells' text-book gives vasomotor fibers for the external genitals as follows: There are two groups, one coming from the lumbar region and the other from the sacral region -- those of the lumbar region from the second, third, fourth and fifth lumbar nerves, running forward in the white rami communicantes. They pass through the pelvic plexus and pudic nerve, and thus reach their termination. The pudic nerve contains some vasomotor fibers for the external genitals. As for the sacral group, these leave the anterior roots of the nerves in the sacral region. A stimulation here causes dilatation of the vessels of the external genitals. "Vasoconstrictors for the Fallopian tubes, uterus and vagina in the female and for the seminal vesicles and the vasa deferentia in the male are contained in the sacral nerves. Also some fibers from the second, third, fourth and fifth lumbar nerves. Hence the second, third, fourth and fifth lumbar are the same for the external and internal genitals. We get vasomotor fibers from both. We work upon the sacral region, springing the sacrum, relaxing the ligaments about it, and also stimulating the peripheral termination of the nerves in the muscles along the sacral region." The fifth lumbar is the center for the hypogastric plexus and the second lumbar is the center for blood supply to the uterus and the tenth and eleventh dorsal the blood supply to the ovaries. Hence these are given as special points for treatment of the internal and external genitals. Hazzard notes that in diseases of the genital organs the sympathetic filaments supplying these parts carry the irritation back to the spinal nerves and thus it may go down the sciatic or may influence the muscles at the lower part of the spine, causing lameness there. He also gives a case of Hilton's, a gentleman who came to be treated for supposed bladder and urethral trouble. The patient had much pain externally in the genitals of one side and he traced the pain along the peripheral branch of the pudic nerve, along the ramus of the pubic and ischium, to the external genitals. Hilton traced the nerve back and discovered at the tuberosity of the ischium on the side affected a thickening of the tissues which impinged upon the nerves, causing pain at the end filaments. I had in my own practice a male patient who suddenly complained of urethral pain, frequent micturition, and indeed every symptom of an acute gonorrhoeal affection. Not wishing to treat him myself, I sent him to a male medical friend, who, though the patient protested earnestly and vigorously to the contrary, said, except that he did not find the gonococcus present he still thought it an acute gonorrhoeal infection and treated him accordingly for a month, in which time the symptoms increased and became so extreme that the only resource was an opiate. At this point I decided to have a male osteopathic physician treat him and with that end in view a graduate of Dr. Still's school, examined and treated him osteopathically. He found nothing except a tense condition of the pelvic muscles and tissues, but the first treatment made an entire night's rest without an opiate possible and the second treatment relieved the whole condition completely. In both instances as soon as the doctor began treatment in the rectum the patient became comfortable. Evidently there was a contracted muscles or other pressure within the pelvis which irritated the nerve supply of the urethra and the treatment relieved this as well as inhibited the nerves and the patient was relieved. It is useless to state that this patient is a devotee to Osteopathy. I give these little incidents as examples of what nerve pressure will do and of how closely the symptoms may simulate an infectious disease without the microscope to confirm the diagnosis. |