The Practice and Applied Therapeutics of Osteopathy Charles Hazzard, D. O. 1905      CHAPTER V   OSTEOPATHIC POINTS CONCERNING THE HEAD AND ITS PARTS  
 
    As stated, the chief lesions affecting the head and its parts occur in the neck, and have already been described.  More detailed points in examination and treatment of these important structures will be considered in lectures upon their specific diseases in the second part of this work.  The present chapter will embrace only general osteopathic points.
    INSPECTION AND PALPATION are the methods of examination. By the former one notes the size and shape of the skull, the complexion, expression, eyes, etc.  By palpation he notes the presence of tumors or other growths, open fontanelles, etc.
 
 
A.  THE EYE

    Those lesions most frequently affecting these organs occur at the atlas and axis, and along the cervical and upper dorsal regions as low as the fifth dorsal vertebra.
    I. The conjunctiva lining the lids may be examined.  The lower lid is drawn out and down, pressure being made at the same time below it, causing it to become prominent.
    The upper lid is turned back by grasping the edge slightly toward the outer canthus and raising the lid, while at the same time pressure is made upon it from above near the inner canthus.  This inverts the tarsal cartilage and exposes the membrane.
    If while this lid is turned back the lower one is also treated as above, both together stand out more prominently and may be observed together.
    Granulations appear as minute white or pale red elevations.
    II.  With the patient supine, direct pressure is made, with the palms of the fingers, upon the eye-balls, pressing them directly back into the orbits.  This impinges nerves, blood-vessels, muscles and all the orbital structures.  It presses excess of blood from the vessels, and tones the muscles, nerves and the structures of the intra-ocular mechanism.
    III.  Tapping upon the eyeball has much the same effect.  It is performed by placing the palms of one or two fingers over the closed eye, and lightly tapping them with the index finger.  Toning of the nerves, of the ball and its structures, and of the optic nerve is thus accomplished.
    IV.  Granulations are crushed by squeezing them between the finger and thumb, the finger being inserted beneath the lid.
    V.  In pterygia, the small blood-vessels formed upon and in the corneal conjunctiva as feeders, may be broken up by draining the back portion of the edge of the finger-nail across them.  Care must be taken not to wound the conjunctiva.
    VI.  In strabismus the weakened or tensed muscle may be treated by pressing the fingers into the orbit about the eyeball.
 
 
B.  THE FIFTH NERVE

    This nerve is reached at various points about the head, as it sends many branches out over the head and face.  Its treatment is especially important in headaches, neuralgias, diseases of the eye, nose, etc., for the reason that it carries vaso-motor and trophic fibres to these parts.
    I.  Its supra-orbital branch may be traced from the supra-orbital foramen out over the forehead to the temple.  It forms an angle of about fifty degrees with the superciliary ridge.  It may be felt under the skin like a fine whip-cord, and it may be manipulated along its course by passing the fingers transversely across it.  Often one nerve is more plainly felt and often one is more tender, than its fellow.  Though not invariably so, it is often noticed that the nerve which is seemingly slightly enlarged and more plainly felt is the one in abnormal condition.
  II.  The infra-orbital and mental branches may be manipulated at their respective foramina.
By clinching the fingers beneath the malar process several branches of the former may be impinged.
The tissues over the foramina and along the courses of all of these different branches should be thoroughly relaxed to remove irritation.
    III.  A supra-trachlear branch is located slightly to the outer side of the midline of the forehead, a lachrymal branch about the middle of the upper eyelid, a temporal branch external to the outer canthus of the eye, an infra-trochlear branch upon the nose opposite the inner canthus, and a nasal branch at the lower third of the side of the nose.
    All are subcutaneous and are readily manipulated after knowing where to locate them.
 
 
C.  THE EAR

    With the ear, as with the eye, lesion of the atlas, axis, or upper cervical region is the most usual cause of disease.
    The auricle should be drawn up and back in order that the external canal may be inspected for the presence of growths, boils, foreign objects, discharges, etc.
    Attention should be given to the condition of the cerumen.  It is sometimes seen to be dry and flaky, indicating poor circulation and imperfect secretion.  Or it may be abundant, forming a plug, which gathers in the deeper part of the canal and obscures the drum, generally, but not always, impairing or quite obstructing the hearing in that ear.  If it presses upon the drum it is apt to cause vertigo, or a sense of congestion in the head.
    In some cases the cerumen will be found to be entirely or almost, lacking, in one or both ears.  This commonly indicates greatly impaired, local circulation, due to cervical lesions, poor general health, or both.  In many cases treatment has restored the normal secretion of wax.
Itching and extreme tenderness of the canal are sometimes noted.
    The head-mirror and ear-speculum should be employed in the examination of the deeper parts of the canal, and of the tympanum.  Sometimes a plug of cerumen can be detected by this means only.
By the use of these instruments the student should become familiar with the appearance of the normal drum.  A good textbook, with its illustrated plates, showing the appearance of the various abnormal conditions of the drum, is a valuable aid to this study.
    The patient should be instructed to close the mouth, hold the nostrils shut, and blow.  This will reveal whether or not the Eustachian tubes are open, by the presence, or lack, of the crackling sound and sensation of fullness in the ears as the air is forced against the inside of the drum.
    When this act is performed, a perforation of the drum is betrayed by the whistling of the air through the aperture, or by the gushing through it of secretions or pus from the middle ear.
    Impaired hearing may be due to fault in the outer, middle or inner ear, auditory nerve, or brain center.  A watch is a very handy and delicate instrument to employ in testing the hearing.  This should be done in a quiet room.  First the watch should be held quite close to the ear, and gradually removed from it, to test the distance at which the ear may catch the ticking.  Both cars should be tested in this way.  The less acute power of one ear is often thus discovered.  Sometimes the watch may not be heard to tick unless pressed close against the auricle.  The ear which stands this simple test is sound, as to its hearing power, throughout the auditory mechanism.
    If the ear fails to hear the ticking when the watch is held near or against the auricle, the watch should then be held rather firmly against the upper part of the mastoid process, just behind the auricle.  If now the hearing fails, the trouble lies, probably, in the inner ear, but may  be located in either the auditory nerve or in the brain center.  As a matter of fact, the causes of deafness lie, for the most part in the middle, or inner ear, or in the Eustachian tube, being rarely referable to the auditory nerve proper or to the center.  Deafness due to causes affecting nerve or center may be distinguished from strictly aural deafness in a simple way.  In the former case the ticking can be heard only faintly or not at all whether the watch be held away from the ear or be brought near to it or pressed against the auricle or the mastoid.  But in the latter the watch may be heard more distinctly when it is held against the mastoid, since by bone conduction the sound is carried to the nerve.
    Sometimes the test is applied by having the watch held between the teeth.  If the Eustachian tube is occluded the sound is heard less distinctly upon the affected side. But if the obstruction is in the middle ear, as from thickening of the tissues and rigidity of the ossicles, the sound may be heard more distinctly upon the affected side (through conduction).  Sometimes, also, this occurs when there are impactions of cerumen against the membrane tympani.
    Tinnitus Aurium, or "ringing of the ears," consists of a variety of subjective sounds due to nervous disease, anemia, catarrhal conditions, and various other causes.  Generally speaking, the dull, throbbing or buzzing noises are due to obstructed circulation in the ear, especially in the fine capillary network spread upon the drum.  This commonly results from colds and catarrhal affections.  This class can often be bettered.
    On the other hand, ringing, screeching, or whistling noises commonly denote some affection the nerves of the auditory apparatus, as is sometimes seen resulting from lagrippe.  These cases are usually difficult to help much.
    Of the discharges from the ear, pus and blood are the most significant, and their source should be carefully sought.
    Treatment of the ear is discussed under the heading of Diseases of the Ear.
 
 
D.  THE NOSE

    In the examination of the nose its external aspect should be noted.  Deformities from operation, violence, or disease are common.  The nose often indicates chronic catarrh by being bent somewhat to one side, following ulceration of bones or cartilages, or surgery.
    A peculiar "club-shaped" nose, with a large, rounded end is sometimes seen in the scrofulous.
    A red, or livid nose, with enlarged and injected vessels, is a common indication of bibulous habits, and this member sometimes becomes grossly hvpertrophied and deformed by excessive indulgence in alcoholic beverages.  Redness of the nose very often results from congestion due to chronic valvular heart-disease, from congestion of the liver, or from tight-lacing in women.
    The internal examination should be made by use of a convenient dilator, head-mirror and speculum.  The examiner should note the condition of' the mucous membrane for redness or inflammation or for paleness and atrophy as in chronic catarrh.
    The character of the secretions and discharges should be noted, and, if abnormal, their source or cause carefully sought.  Very offensive mucous discharges and pus indicate advanced catarrhal conditions, and may result from ulceration in the tissues of the nose or from abscess or ulceration in the frontal sinus or antrum.
    Bleeding is usually from the membrane and due to local irritation, or from congestion of the vessels of the head, causing rupture of small vessels.  After violence one should consider the probability of fracture of the base of the skull as a source of bleeding.                      I
    Foreign bodies; growths, such as polypi and adenoids; "spurs" of bone, due to hypertrophy resulting from catarrh; enlargement of the middle or inferior turbinated bones; or a deflected septum may be found.
    The NOSE, apart from neck treatment, is sometimes treated by local manipulation.
    I.  Manipulating and loosening all the tissues along the sides of the nose affects the blood-supply of its mucous membrane through branches of the fifth nerve.  It will also operate to free the channel of the nasal duct.
    II.  With the patient supine, the palm of the hand is placed upon the forehead, the other hand is laid upon the first, and the practitioner, bending over the head of the table, brings his weight upon the patient's forehead.  This pressure is continued for several seconds and repeated a few times.  It frees the nostrils and in acute colds frequently at once restores freedom of breathing through the nose.
The affect is probably gotten by the pressure affecting the branches of the fifth nerve upon the forehead.  It is greatly increased by first applying momentary pressure, with the thumbs, to the internal jugular veins, which are thus dilated back to the capillaries by the pent-up blood, after which they carry away more blood, relieving the congested head and mucous membrane of the nose.
    III.  In colds and catarrh, pain in the frontal sinus may be relieved by tapping with the knuckles upon the frontal bone over the sinus.
    The MOUTH and THROAT are sometimes treated internally by sweeping the palm of the index finger from the, midline of the posterior portion of the hard palate outward and downward over the soft palate, pillars of the fauces, and tonsils.  The uvula may also be touched.  The nerves and blood-vessels of this region are thus toned.
    The Uvula, being thus treated by digital application, elongations of it are overcome through restoring tone to its muscles and vessels.  It is usually elongated by conditions which congest it and the surrounding tissues, and the elongation is due to the loss of tone thus induced in the azygos uvulae muscles.  This condition is often the cause of a little hacking cough in children.
    The TEMPORO-MAXILLARY ARTICULATIONS are examined.  Inequality in their action is discovered by standing behind the head of the patient, who is lying supine.  The mouth is opened and closed, and deviation of the midline of the chin from the median plane of the body noted.  Deviation of this nature indicates luxation of one of the articulations, the jaw usually deviating away from the side of the lesion, though often toward it, by reason of tightened condition of the articulation on the affected side.
    I.  The ligaments of the articulation may first be loosened as described under II of Chapter IV.  Pressure upon the opposite jaw while the patient is closing the mouth will bring the condyle back into place.
    II.  Sometimes it is necessary to place a small cork or piece of wood between the posterior molar teeth upon the affected side.  Pressure is now made beneath the chin, tending to close the mouth, and the jaw is slipped into place.  The corks may be inserted at the same time between the molars of both sides in case of bilateral luxation.
    Treatment I, may be alternately applied in such case.
    Opening the mouth against resistance (II, Chap.  IV), manipulation of the throat to free the action of the carotid arteries, and treatment of the superior cervical region (XIII, Chap. III) are, together with removal of specific lesions, the chief methods of treatment in diseases of the eve, ear, nose and throat.  They produce affects by building up the blood-supply.
    Treatment along the midline of the skull, from the nasion to the occipital protuberance, thence outward along the sides of the head, affects the circulation in the longitudinal and lateral sinuses through connected nerves and veins.  It also affects the sensory nerves of the scalp, they congregating about the vertex.