Essentials of Osteopathy Isabel M. Davenport, M.D., D.O. 1903

LECTURE VII.

NATURE'S AID IN TREATMENT.

    Hence you will see and understand how it is that the Osteopath is able to affect the inner life or the internal organs by manipulating the body externally, and yet the point is made one for much ridicule by physicians who have condemned Osteopathy as perfectly foolish because they either did not understand the theory upon which the Osteopath works or they did not thoroughly know their Anatomy and Physiology.

    Remember that the tendency of Nature is to the normal or natural, and if given a little help she will readjust things to their normal course; and so in your work you will always have the assistance of Mother Nature if you do not work against her, and for this reason it is possible often to correct lesions and remove obstructions by stimulating the blood supply or by increasing the flow of blood through the body.  By throwing open the vaso-motors and flushing the capillaries you increase elimination.  The blood makes its circuit through the lungs more often and is purified, and the muscles and all tissues become strengthened and adjust themselves to their normal positions and conditions.  The old theory of keeping an injured part quiet is fast becoming nil.  It was one of the hardest things for me to get away from, but after I had seen and experienced the perfect rationalism of keeping the blood moving and not allowing venous congestion to take place or to remain I no longer hesitated to begin gently manipulating the sorest part (even to a bad sprain of my own ankle) at once, and by stimulating the surrounding vessels to aid them in carrying away the products of injury and inflammation, thus relieving pain and pressure, and to bring new blood to the injured vessels and tissues, and thus to rebuild and strengthen them on to resolution and complete health in a much shorter period of time than by the old method of bandages, casts and "perfect quiet." You will have some difficulty in inducing patients to walk on a sore limb or use a sick part when it is painful to do so, and there is a limit even to this method, for you must remember that you have an injured and weakened lot of vessels in the sick part and they will not be able to empty themselves of blood brought to them as readily as if they were normal, hence by over-treating or over-stimulating circulation you may keep too much blood moving in a given part and produce inflammation.  As an example, I had a patient who was suffering from synovitis of the knee joint due to an injury.  Her physician, a regular of high standing and of broad mind, referred her to me for treatment.  I visited her at her home because she was confined to her bed.  The knee and whole limb was badly swollen and excruciatingly painful.  I began by treating the back from the lower dorsal on down to the foot, treating both sides and gradually worked around to the sore knee.  The patient was so much relieved by the first treatment that, against my advice she insisted upon a treatment every day, and after the fourth day the limb was so much inflamed I was compelled to desist and allow the part to rest, when I resumed treatment, giving three a week and allowing the vessels to gradually empty and refill in the interim.  Under this procedure my patient was able to come to my office, although only by aid of crutches.  However, in two months' time she was able to appear upon the stage as the leading contralto in a concert, but if I had not understood the theory upon which I worked I could have done the patient, myself and Osteopathy irreparable damage.  Don't for the sake of a double fee treat patients too often.  It will not pay in the end.  Of course, if you have a pale, poorly nourished, anaemic patient who is warmed and improved by daily treatments give them by all means.  What I wish to impress upon you is that Osteopathy cannot be taken ad libitum or with irregularity any more than any other therapeutic measure.  Dose your patients as they need it and as best suits their case.  Don't be an egotist or faddist.  Remember that while Osteopathy is an excellent and most successful method of curing disease and ailments there are many things which aid and assist it.  No treatment will prove satisfactory if the patient is constantly making errors in his daily living, and so when you take a case in hand look well to his diet.  For instance, if a patient suffers from indigestion and a congested liver the case will not yield to treatment if he keeps up the trouble by drinking coffee and eating large quantities of starch food.  Without going into the subject fully here your Physiology will teach you the foods which are cared for by the stomach and intestines, and also the changes which take place in the liver.  Neither will your patient be benefited by the increased circulation which your treatment will make possible if he is shut up in an atmosphere of poisoned and vitiated air.  Or, again, if he does not bathe and keep the skin free from the accumulations of elimination.  Again, there are many ...

[sorry, missing page 33]

... body freely with pure water.  Drink it copiously, thus flushing the alimentary tract and the kidneys.  The vaginal douche has been much overdone and yet it is a comforting, cleanly measure, but should never be absolutely cold, neither extremely hot, simply comfortably warm --such heat as one can hold the hand in without wincing is a good guide in the absence of a thermometer, when 100 - 110⁰ F. is about correct.
 

LECTURE VIII.

VARIATIONS FROM THE NORMAL CURVES OF THE SPINE.

    In examining the spine you will often find an increase or accentuation in the natural curves of the spine.  Sometimes this means simply an unusual thickening of the spinous processes or of the tissues covering them, but more often they are due to an actual change in the curves of the spine.  As a general rule the center in the location of the lesion is affected, either the cerebro-spinal or sympathetic, or both.  If only the superficial muscles are at fault the cerebro-spinal system only may be affected, but, of course, this may later be transmitted through the sympathetics to an internal organ.  On the other hand, if the lesion is deep, the sympathetics will be affected and the parts which they supply.  You may find a flattening between the shoulders or an increased curve, and the centers for the stomach are affected to the eighth dorsal; or you may get an increase in the curve in the lumbar region, when the bowels and pelvic organs will suffer, etc.  This is not the actual spinal curvature, which I shall take up later, but merely a deviation from the normal curve, but enough to cause considerable trouble.

    The coccyx is often displaced because of the fact that it is the end bone of the spine and movable.  The most common abnormal position of this bone is an extreme anterior displacement which encroaches upon the rectum and is a common cause of constipation, hemorrhoids and uterine congestion, to say nothing of the reflex troubles which it is possible to cause.  Again, the coccyx may be deflected to one side or the other, and here the sciatic nerves may be affected through connecting branches, or directly or by interference with the sympathetic centers.  The uterus and nutrition are involved, as well as the blood supply to the bowels and pelvis.  I have had two cases where the coccyx was completely displaced in a backward position and was extremely painful because constantly irritated and injured by pressure from the patient's clothing and movements, making it painful for the patient to lean back against a chair or anything hard.  One of these cases I was able to correct because recent, but the chronic case was only relieved by treatment and by wearing a small soft rubber ring applied by adhesive plaster straps about the coccyx for protection.

    In the neck the atlas may impinge upon nerves affecting the superior cervical ganglion and by its connection with the fifth nerve, the retina of the eye.  Again, the atlas may be displaced in such a manner as to act upon the cord or as to shut off circulation to the brain, causing paralysis, insanity, hysteria, etc.  In fact, any abnormality of the structures in the neck is probably most serious.  The position of the first and second ribs is of great importance, also, to the Osteopath, because by pressure of the first rib or structures about it there is interference with the cardiac ganglion and the heart is affected thereby.  If the second rib is involved we have difficulty in breathing, and pressure from this rib is the most common cause of asthma.  But more of this when I take up examination of the thorax.
 

LECTURE IX.

RIGID SPINE.

    It sometimes happens that the back in found to be very stiff and rigid, either in one locality or the whole length of the spine.  This condition is due to a constant contraction of the multifidious spinae, interspinales and intertransversalis which are the small muscles attaching one vertebra to another, etc.  These contractions bring the vertebrae so close together that motion between them is inhibited and is one cause of the little clicking or cracking sounds which you will often get in examining a patient, and is due to the snapping or grating of the tendons or the moving of surfaces one upon the other, rather than to dislocations, which the new operator will be led to take them for unless he keeps this fact in mind.  Of course these noises may be due to displacements, but you must know how to diagnose between them.  Rigidity is most common in the neck, probably because of exposure to cold draughts.  However, I find it often the case that patients say, "Why, doctor, I did not realize until since taking treatment that I have not been turning my neck, but if I wished to look around I turned my whole body."

    The lumbar region is the next which is most commonly rigid, but often it is the whole spine, and you will be able to feel the deeper layers of muscles hard and cordy through the superficial ones under your fingers upon deep pressure.  The treatment is a thorough kneading of the whole muscular system, with attention to the vaso-constrictor centers, relaxing them and relieving the congestion in the muscles, and after relaxation is established then movements.  The danger of this condition is serious, because the pressure and friction of one vertebra upon another may set up an inflammatory condition which can be carried to the meninges or membranes covering the spinal cord, to say nothing of the impingement of nerves and blood vessels, and the least dangerous but nevertheless painful condition of the sore muscles of the back and neck.

    Spinal Relaxation. - On the other hand you may have an abnormal relaxation of the spine due to flabby tendons and muscles, and this is not necessarily the case in an anaemic patient, but is often found in an apparently fairly well nourished and full-blooded person in whom the blood supply to this one part is insufficient.  In this case you will find a stoop or if the patient is straight it is through great effort.  On examination you may find separation of the vertebrae, one or several, with great sensitiveness at the point of separation -- not soreness, but light pressure causes the patient to jump and show irritability.  The whole skin is very sensitive in these patients also, probably because the cord is less protected at these points.
 

LECTURE X.

SPINAL CURVATURE.

    This condition is commonly found, especially in children; the lateral curvature more often than any other and the posterior next, but the anterior is most difficult to treat when present.  In true spinal curvature there is generally a compensatory curve.  These little blocks of bone piled one upon the other begin to topple because the attachments on one side are contracted, while those of the other are either normal or too relaxed.  At least one side pulls harder than the other and to offset this another set of muscles on the opposite side and lower down or higher up begin to contract, and so the vertebrae are pulled and pushed out of line there.  If I find curvature of long standing in an adult I never expect to fully correct it, but in children it yields readily to treatment, and some of the most brilliant and gratifying results I have had were in this class of cases.  My experience shows me that it is a mistake to put braces on a patient with view to correcting and displacement or deformity, inasmuch as the pressure made upon the muscles causes them to atrophy and become flabby, thus making them too weak to hold the parts in place when the brace is removed, and so I give a thorough muscular treatment followed by an adjustment of the bony parts every other day and the results are very satisfactory, both to the patient and physician.
 

LECTURE XI.

EXAMINATION OF THE THORAX.

    In making an examination of the thorax strip your patient to the waist, seat him on a stool and then observe carefully the appearance.  Normally the right side is a little larger than the left --bulges more, as it were.  You may also find a flattened condition of the anterior surface.  Note whether there is a sinking above the clavicle or between the ribs whether the soft parts sink in below the ribs, all of which denotes difficult breathing and cause must be found.  On the other hand, you may find a bulging of the entire anterior wall (pigeon breast).  Note the ensiform cartilage.  I have found it hard and sticking out in front; also in other cases depressed and pointing inward.  Note the attachment of the ribs, or their cartilages, to the sternum, often I have found them very irregular and the end of the rib either too much depressed or drawn up too close to its neighbor, engaging the intercostal nerves, causing neuralgia and pain.  Note the clavicle, sometimes you will find either end flattened or depressed or down too far, in or out.  Learn the structures under these articulations and their functions, then you will know what the result ought to be by interference with them.  Because of a tightening of all the muscles of the thorax or of the intercostal muscles the chest walls are rigid and all of the ribs are drawn too closely together; in such cases you will generally find intercostal pain and soreness along the course of the ribs and sometimes the nerves of the arm are involved.  Not all of the irregularity which you may find on the surface of the thorax is due to displacements, for you may have here or in the vertebrae one rib heavier and thicker than its mate, and of course it will make an irregularity.  But find the articular ends and note their approximation to the other articular surfaces.  Hazzard gives the following rules for counting the ribs:
 

RULES FOR COUNTING THE RIBS.

    "In passing your fingers down the sternum in front you can readily detect where the first part ends and the second part begins.  Here is the junction of the cartilage of the second rib with the sternum.  The first rib is found by feeling behind the clavicle above, at about the junction of the middle and inner thirds.  You can by deep pressure come to the first rib.  The first and second ribs give a great deal of trouble, and it is important to keep in mind this rule to find them.  In the male the nipple is usually between the third and fourth ribs, three-quarters of an inch external to the line of the cartilages.  It is said that the lower border of the pectoralis major corresponds in direction with the fifth rib; that a horizontal line drawn from the nipple around the body will cut the sixth intercostal space at a point midway between the sternum and the spine.

    "When the arm is raised the highest visible digitation of the serratus magnus corresponds with the sixth rib, and the seventh and eighth digitations correspond with the seventh and eighth ribs  below.  I have already noted that the scapula lies on the ribs from the second to the seventh inclusive.  The eleventh and twelfth ribs are readily recognized, even in fleshy persons, at the outer edge of the erector spine, sloping downward.  The sternal end of each rib is lower than the end which joins the spine, and it is said that if a horizontal line were drawn from the middle of the third costal cartilage at its junction with the sternum, it would touch the body of the sixth dorsal vertebra.  The end of the sternum is upon a level with the tenth dorsal vertebra, its length
varying some in different individuals, more in females than in males."  Along the posterior surface of the thorax you may field the ribs too widely separated or the ends dislocated from the vertebrae -- not torn away, but slipped or twisted in any direction.  The first and second ribs are usually drawn upward.  That is the most common abnormal position for them, and it is just as common a rule that the last two are drawn down, probably because in the upper ones the scalene muscles are attached in such a manner that when contracted they draw the ribs up, while in the lower ones the Quadratus Lumborum is attached to the last and draws both it and the eleventh one downwards.  The position of the first and second ribs is of great importance because by pressure upon the sympathetic ganglion and all the important nerve and blood supply in that locality the heart and lungs are very much affected, and often serious symptoms may be relieved by reducing pressure, either from these ribs, the clavicle, or from vertebrae, and it may be all three structures in this region.  It is such cases as this which have been diagnosed as organic heart trouble, which the Osteopath cures miraculously, so it appears to those who do not understand the theory of Osteopathy.  To make a diagnosis of malposition in these ribs first find whether the clavicle is in its normal position, then feel down about the middle of the clavicle, press down and back, and you will find the first rib.  If it is slipped up it will come to or near the upper margin of the clavicle.  If it is down the distance between them will be greater.  Hazzard says, "A depression at the junction of the end of the first rib with the sternum usually indicates that this rib is raised and thus drawn away from the articulation.  A prominence at the same place indicates the reverse.  Such points are usually tender to the touch and the tenderness may extend along the rib as far as the clavicle."

    The second rib is more difficult to treat, but the articulation in front is at the juction of the manubrium or upper bone of the sternum with the second bone or gladiolas in the back.  A dislocation of this rib may be determined by a soreness over the attachment with the first dorsal.  You can make deep pressure upon the head of this rib by measuring one inch outward from the posterior spinous process of the first dorsal vertebra.  Of course the head of this rib cannot be well distinguished because of the thick muscles at this point, but you can detect soreness and work about the head is such a manner as to relieve its pressure upon other structures.

    The floating ribs often overlap one another at the loose ends.  Sometimes this gives no inconvenience, when of course you let them alone, but again they are often responsible for pain in the side or limb, and may even and indeed often do press in upon the liver, spleen or intestines, causing congestion, pain and inhibition of these organs.  The position of all the lower ribs is rather easy to determine because of the softer walls about them and because by raising the limbs of the patient you may relax the muscles of the abdomen and feel through them the hard rib.
 

LECTURE XII.

THE CLAVICLE AND ARM.

    Displacement of the clavicle is of great importance because it is a landmark for the first and second ribs and because of so many important attachments to it, and more than all else because of the important nerve and blood supply under and about it.

    The clavicle may be displaced in any direction, at one end or at both.  The most common displacement is downward at the outer end because of the attachment of the deltoid and Pectorals major muscles.  Dr. Still's manner of correcting this is to place his fingers against the anterior edge of the sternal end of the clavicle, then with his other hand to draw the patient's arm inwards across and close to the chest, thus relaxing the muscles; then, while pushing upward upon the anterior edge of the clavicle, to draw the arm up and backward.  If the clavicle is slipped up at the acromial end it will probably impinge on the fibers of the brachial plexus, causing pain, or catch some fibers of the deltoid muscle and the patient comes to you complaining of rheumatism of the shoulder, neck and arm.  Here Dr. Still raises the arm to relax the muscles over the shoulder, and placing his fingers behind the part that is slipped up moves the arm in different directions until the end slips back to its normal place.  At the sternal end you treat in much the same way, bringing the arm forward, first to relax the muscles and give room for the fingers of your other hand, there move the the arm to relax the muscles over the shoulder, and arm forward, downward and backward, thus tensing the muscles and making them draw the bone back while you push it.  The forward or backward positions are not as frequent, though perhaps that is an error, for in asthma I almost invariably find the clavicle drawn back and downward, making great pressure upon the blood supply and trachea.  In asthma there is a general spasm of muscular tissue, and the muscles about the neck and chest are in a state of contraction all the time, which accounts for this malposition, and by manipulating the muscles, relaxing them, removing the clavicle and perhaps the first and second ribs from their false positions, and finally by making gentle pressure over the recurrent laryngeal and phrenic nerves I have relieved many asthmatic patients who were suffering intensely because of difficult breathing.  In these cases I free the clavicle by placing the fingers of one hand above and behind it while I raise the arm up and bring it across the patient's face and over the head and back and then downward.

    Of course while you are examining the clavicle the head of the humerus must be looked to, for much of the pain in the axilla, chest, shoulder or back, swelling of the lymphatics and pain in the arm or hand may be due to pressure from the head of the humerus.  One very common displacement is a slipping of the head of the humerus out against the acromion or coracoid process.  Probably it is more often drawn into this position by the contracted muscle, causing the tendons to bind or hold it here, or there may be some of the deltoid fibers under the coracoid process.  At any rate we often find patients who complain of a catch there and of inhibition in movements of the arm upwards or backwards, and by drawing the arm slowly upward and backward, then manipulating over the process and drawing the arm out and downward, you may relieve the difficulty.  Or you may find the biceps contracted and by straightening the arm and drawing it backward you bring tension upon it and inhibit its nerve force, thus relaxing the spasm and relieving the pain.
 

THE ARM.

    Going on down the arm you may find soreness the whole length upon deep pressure, especially along the course of the median nerve, which shows pressure at some point upon this nerve; usually from the muscles, which you may find hard in small areas.  These sore spots in the muscles are probably due to a congested area which retains the poisonous gases or ptomaines from the venous blood, but when you find soreness the full length of the arm you may expect to find the median nerve engaged some place.

    At the elbow you may find different dislocations.  The ulna and radius may both be drawn backward or internally or externally.  The ulna may be displaced backward and the radius forward.  The olecranon process of the ulna and the condyles of the humerus are your guides as to normal positions of the articulation at the elbow.  After injury you may have simply a stiffness of this joint, due most commonly to contracted muscles and tendons, and sometimes to inflammatory exudate, or, if of long standing, ankylosis.  A systematic manipulation of the muscles, not alone of the arm but of the shoulder and back, gradually relaxing and stretching them with movements of the joint to favor circulation and carry away inflammatory products, relieving stiffness of the joint, has always given me a most perfect result.

    At the wrist you most often have both bones dislocated either backward or forward, though it may be only one of the long bones; but the small bones of the wrist may be shoved or pulled about in many ways, and the sore points will show this at once.  The fingers are easily dislocated and easily readjusted.  Always treat the muscles about a dislocation first, thus relaxing them, then pull gently and gradually out upon the displaced bone before moving it in the direction in which it needs to go. The tendency to the normal will help greatly in correcting all displacements.

    I have said little so far about the scapula which is bound down so securely by muscles that the only trouble from it will be contraction of these muscles which draw it too closely down or a relaxed condition which with a bulging of the chest walls gives the scapula the wing-like appearance which we sometimes see.  We often stretch these muscles and raise the scapula when
there is too much pressure upon the nerve and blood supply beneath.
 

LECTURE XIII.

THE NECK, FACE AND HEAD.

    Examination of the neck, face and head.  As I have told you the neck is a most important point to the Osteopath and much more important to the patient.  The structures here are very superficial and through them and their connections the operator may influence the entire body directly and indirectly.
 

LANDMARKS OF THE NECK

    The median line of the neck is called by surgeons the line of safety because in this locality there are no important nerves or blood vessels and the trachea is very superficial, making it possible to operate here for membranous croup or for other cause with comparative safety.  Beginning from above just under and well up on either side of the angle of the lower maxilla are the tonsils which may be readily felt externally and are easily treated here, next is the hyoid bone, on a level with and just beneath the middle of the lower jaw.  The gap just below it corresponds to the apex of the epiglottis.  The thyroid cartilage is easily traced, especially the upper and lower cornuae.  The lateral lobes of the thyroid gland lie on each side of the thyroid cartilage, and is important because of the common enlargement of the gland known as goiter.  The superior thyroid artery lies across the center between these lobes and you may feel the pulsation by the finger.  The circo-thyroid membrane is next in line and is the usual point for the operation of laryngotomy.  The cricoid cartilage, which is next, corresponds to the junction of the fifth and sixth cervical vertebrae and is the level of the oesophagus.  The superior opening of the oesophagus is about an inch and a half above the superior border of the sternum.  The trachea arises above the sternum for the length of 7 to 8 rings, but cannot be felt because covered by muscles and is deeper than the structures above it.

    At the sides of the neck the sternomastoid muscle is the most prominent and is attached to the mastoid process of the temporal bone above and to the sternum and clavicle below.  The carotid artery and pneumogastric nerve pass down under the anterior margin of this muscle and under the rectus capitis anticus muscle.  The external jugular vein corresponds to a line drawn from the angle of the lower jaw or inferior maxillary bone to a point at the middle of the clavicle.  In the suboccipital fossae or hollows of the neck, between and under the mastoid process and the attachment of the trapezium muscle, you get the great and suboccipital nerves, and in this region you often find soreness, especially in patients who suffer from stomach trouble, indigestion, etc., probably because of the proximity of the pneumogastric nerve and also the spinal accessory, which with the glossopharangeal makes its exit through the same foramina (the jugular) with the pneumogastric.  The phrenic nerve arises from the third, fourth and fifth cervical nerves, and may be reached at the anterior border of the scalini muscles in front of the transverse processes of the vertebrae.  You may also reach this nerve at the inner side of the sternoclavicular articulation, and this is the usual point for treatment of this nerve.  By making pressure upon the nerve at this point you rarely fail to stop hiccoughs, no matter how persistent.  Of course you will note the position of the vertebrae and the greater thickness of the skin in the back of the neck, also the ligamentum nuchae deeper in and extending from the occipital protuberance to the spinous process of all the cervical vertebrae.

    The lymphatic glands may be and often are enlarged in the neck and along the spine, and the latter are especially irritating to the nerves by the friction which they make in slipping over them with the patient's movements.
 

LANDMARKS OF THE FACE.

    The most important points here are the three terminal branches of the fifth nerve, which make their exits from the supraorbital, infraorbital and mental foramina.  Hazzard says "a line passed from the supraorbital foramina (which is at the inner and upper borders of the orbital arch, or just at the inner edge of the eyebrow) between the two bicuspids will pass over the remaining two foramina."  He also says, "The supraorbital branches of the fifth nerve run from the supraorbital notch back over the temple, forming an angle of about forty degrees with the line of the superciliary ridges.  They may be easily felt beneath the tissues and can be traced back over the temples." The supraorbital branch is usually found to be very sore at the place of exit., i. e., the supraorbital notch, in headache and neuralgia, and friction or pressure over this point, with a thorough loosening of all tissues of the neck, head and face, relieves both these symptoms.

    The superior and inferior dental nerve runs along the upper border of the superior maxillary and the inferior maxillary bones respectively.  The seventh nerve may be reached at the middle of the outer edge of the ramus of the inferior maxillary bone just in front of the lobe of the ear.
 

LANDMARKS OF THE HEAD.

    At the junction of the inner and middle thirds of the supraorbital arch you will be able to feel the pulsating supraorbital artery as it passes up over the forehead.

    The temporal artery may be an inch and a quarter behind the external angular process of the frontal bone.

    The bony prominences of the head are the occipital protuberance, which is the thick prominence at the back of the head, just above the hollow of the neck.

    The parietal eminences are on either side of the head above the ears, and the temples, as you know, are the thinnest portion of the skull.

    The occipital artery is felt near the middle of a line drawn from the occipital protuberance to the mastoid process, which is the prominence just back of and below the ear.

    The posterior auricular artery may be felt near the apex of the mastoid process.  The scalp is thick and should be easily moved over the cranium, but is often found tight and immovable.  You may find small tumors of the scalp, which are usually benign and only enlargements of the sebaceous glands.  A tumor of the skull will be immovable, while these move about under the examining finger.  The scalp is usually tight and contracted in headache cases, and in treating for this disorder always treat well over the head, moving the scalp in all directions.  The anterior fontanelle in the infant is a diagnostic point.  Normally it should be level but if there is an abnormal accumulation of cerebral fluid it will rise above the level, while if the child is suffering from any depleting disease, such as diarrhoea for instance, you may find the fontanelles sunken.

    The eye, ear, nose and throat come under consideration in examining the head.  I never meddle with the ear.  Let a specialist treat this delicate and difficult organ, but much may be done by treating the eye osteopathically.  The superior cervical ganglion is the chief point from which to treat the eye through the ascending branch to the carotid and cavernous plexuses and through the connection which it has with the fifth nerve.  The ciliary ganglion also connects with the superior cervical ganglion, and hence by freeing the muscles in the neck and face and stimulating or inhibiting the superior cervical ganglion we may relieve congestion and inflammation, and by treating the end nerves through the eye itself we may affect the nervous organism.  I have found that many of my patients who wear glasses are able to leave them off and do without them after being treated osteopathically.  The muscles of the eye may be strengthened and the glands and superficial blood vessels emptied.  One of my most successful methods of treating conjunctivitis is to slip my forefinger up under the upper lid and gently roll the lid between the finger and thumb.  It relieves the swollen blood vessels and the roughness and scratching which they cause to the cornea.  The tear ducts, which, you know, begin at the inner canthus of the eye, may be occluded and swollen.  They may be relieved by treating all around them and making pressure over the infraorbital artery.  The nose, mouth and throat may show hyperaemia or growths, such as polypi in the nose, or hypertrophied turbinated bones.  In the pharynx and throat you may find an inflamed, reddened mucous membrane, with enlarged tonsils and uvula, and besides the thorough treatment about the neck I treat inside the throat, over the hard palate, to the tonsils and uvula.

    So far we have had in a superficial manner the landmarks and examination of the spine, thorax, arm, neck, face and head.  I have given them in this order because it is my manner of examining a patient.  My next move always is to make a thorough examination of the heart and lungs before leaving the thorax and upper part of the body.