Introduction

The subjects herewith presented, while including certain of the most important sections of mental disease, make no claim to completeness either in the subject matter presented or in the attempt to cover the entire field of the psychoses. They cover those portions, however, with which we have come in closest touch at the Still-Hildreth Sanatorium, and in which we have the most complete records. I have been aided in the compilation of the essential facts and statistics by the able staff of the institution and wish to acknowledge especially the valuable cooperation of Dr. C. M. VanDuzer in the Dementia Praecox group, Dr. H. P. Hoyle in the Manic Depressive group, Dr. B. L. Jemmette in the group entitled Delirium, Confusion and Stupor, Dr. J. C. Snyder in the Senile Dementia group and Dr. G. S. Elkins in the Involutional group. The opinions concerning each type held by Dr. A. G. Hildreth are appended under its appropriate heading. I wish to state emphatically that the sole treatment carried out in the Macon Institution is specific corrective work upon spinal lesions, and it is upon this treatment that the statistics are based which are to be found throughout the text. These records cover more than 700 cases, including complete histories of the patients with the physical and mental findings on examination; these represent, therefore, by far the largest body of statistics ever accumulated in the study of osteopathic results in mental disorders. While the results naturally vary in different types of mental disease the grand total shows that more than one-half of all patients admitted recovered. Details for each group will be mentioned under its appropriate heading. While adjuncts such as diet and hydrotherapy have been utilized; we certainly cannot attribute any curative value to their influence.

It should be further emphasized that in no case whatsoever has medicine been used as a curative agent. And the same may be said of surgery. It has indeed been conclusively proved even in the medical world that medicines and surgical procedures are absolutely ineffective; from the osteopathic viewpoint this of course is perfectly reasonable since the theory calls for definite lesions as causative factors and these lesions can hardly be reached other than by the osteopathic method of correction. The results obtained, therefore, could only be attributed to the genuine osteopathic principle enunciated by Dr. A. T. Still who kept in close touch with the work and gave it his approval up to the time of his death. He had always maintained that the osteopathic principle could accomplish remarkable results in this field and considering the previous inefficiency of any other method his confidence has been fully justified.

Dementia Praecox

This condition refers to mental disorders arising usually during the period of puberty or adolescence, therefore, between the ages of fourteen and twenty-five for the most part, although apparently similar cases may arise in later years. The term dementia refers to mental deterioration and enfeeblement, while “praecox” signifies adolescence, though some writers infer that the term praecox may be used to indicate the early or precocious development of the mental enfeeblement. Certain it is that in most cases deterioration, with its resulting symptoms of mental enfeeblement giving rise to the term dementia, usually occurs in time, though by no means always early. It is a chronic progressive disease which may terminate in a complete loss of mentality; in other cases it may become arrested in any stage and remain so permanently; in still others it may recover, though this is rare. By reason of the variability of the symptoms, three groups are generally recognized, first suggested by Kraepelin. Each is differentiated by more or less characteristic symptoms and referred to under the head of the Hebephrenic, Catatonic and Paranoid types, although all have certain symptoms in common and there are mixed types.

=Etiology.=—According to the authorities some form of hereditary factor can be found in some fifty per cent or more of all cases; this is supposed to create a predisposition, a natural weakness of the nervous system, which renders it unable to bear the ordinary storm and stress of life, so that the mechanism becomes according to the French expression, “wrecked upon the rock of puberty or adolescence;” in other words, a premature giving way of the nervous system, being inherently unable to stand the strain of life. Another suggestion is that it represents the outcome of abnormal types or reactions of the individual to the environment, with a failure of proper adjustment to surroundings and the formation consequently of mental problems which to the patient are incapable of solution. This may be called the psychological theory. The most commonly accepted idea, however, is the physical causation. According to this the disease results from auto-intoxication, the intoxicant arising from the disturbances of the glands with internal secretions, more particularly the sexual glands. This endocrine theory is supposed to be supported by the fact of the appearance of this disease most commonly at the time of puberty and shortly thereafter.

The osteopathic conception fits in very well with this latter view, inasmuch as the spinal lesions are quite capable of explaining not only a disturbance of innervation to the glands with the resultant interference in their normal secretion, but also could produce disorder of the circulation and nutrition to the brain.

=Symptomatology.=—Although each variety of Dementia Praecox has special symptoms characteristic of the type there are certain symptoms common to all forms, and these will be first considered. All the functions of the mind in the course of time tend to become disturbed and to be weakened, but in the earlier stages we find marked differences as regards the disturbance of different functions, thus memory and orientation in most cases seem good; on the contrary, attention and association of ideas somewhat poor. Emotional life is almost always markedly affected, even in the beginning. Very commonly at first there is depression to be followed later by expansive feelings and then by apathy in general. The will power is altered early and the conduct is apt to be peculiar. The judgment becomes impaired. All of these symptoms mentioned are deviations from the normal in the patient and therefore presuppose that the patient was formerly normal. This should sharply differentiate the praecox group from cases of defective development (imbecility or idiocy). In this latter group there is an arrest of development of the mind, whereas in praecox there is a loss in a developed intellect. We see a young patient, for example, who has lost interest in things about him, neglects his work at school or at home, remains alone for long periods of time and seems unwilling to mingle with other people. He gives the impression of one depressed and worried about something he is trying to solve, perhaps he mutters to himself or gives way to unprovoked laughter, he may refuse to eat, or to talk unless questioned and may even then not answer. When he does talk it will be discovered that he knows perfectly well where he is, and knows people around him and understands everything that is going on; his memory will be found good, he can usually recall past incidents and tell what he has been doing recently. As the condition progresses, however, while the patient may still for a long time retain fair orientation and memory for past events, his accumulation of recent ideas will be found poor, so that he will recall them with difficulty. We notice that it is difficult to get the patient’s attention and concentration seems to be impossible, he may answer a direct question, but immediately seems to be occupied with other thoughts and it takes some little effort to gain his attention again. If he continues to talk it is plain that the association of ideas is poor, giving rise to disconnected phrases which usually come forth sluggishly and without show of emotion. Dissociation of ideas occurs; that is, different ideas expressed may practically contradict themselves. For example, the patient may say he is a king and yet when asked to sweep the floor will do it perhaps without hesitation, not considering that is hardly the kind of work a king would do. The dissociation is also marked in the contradiction found between the content of the thought and its associated emotional idea, for example, the patient may speak of a near relative as dying recently, yet with no show of emotion, even with a meaningless laugh. This dissociation may ultimately result in complete incoherence, in which no sense can be found whatsoever in his speech. Emotional indifference is noticeable early and sluggishness of reactions to stimuli, even failure of such reactions; the patient will neglect himself, stay away from meals, express no desires and make no complaints. In the earlier stages, however, the patient who may have been for some little time apathetic, suddenly without apparent cause becomes angry, noisy, and possibly violent and destructive, again gradually relapsing into his quiet, apathetic state. The thought content is commonly associated with delusions, that is obviously false ideas, but which the patient is unable to perceive are false. Delusions of persecution are most common, the patient feeling in a dim way that everything is not right; and in attempting to explain to himself the reason, often attributes causes to people or forces outside of himself, and on account of the feeling of bodily discomfort, also by reason of the depression, he explains the external forces as unfriendly to himself. Hallucinations may be present and furnish the material around which the delusions form; on the other hand hallucinations may result from the delusions. By hallucination is meant a false sense perception, as the patient may state he sees someone before him who is not there, or that he hears voices from individuals who are not around him; he may also complain of receiving electrical shocks, or wireless messages, which he usually states come from his persecutors. Symptoms of this nature form a good example of the so-called split personality, or “schizophrenia,” wherein certain idea complexes are split off from the main personality and address themselves to the main portion, the patient attributing these noises (voices), sensations (visceral and tactile), tastes and smells to an objective rather than a subjective source and subsequently forming delusions. However, unless we are dealing with the paranoid form the delusions are fragmentary, transient and absurd.

=Hebephrenia.=—This is a progressing mental enfeeblement, terminating usually in deterioration, and without showing marked peculiarities in thought or action aside from the progressing deficiency. The patient appears in general inactive, lacking in energy and ambition, indifferent, depressed, incapable of much concentration and hence the efficiency becomes progressively impaired until he is unable to accomplish anything. From time to time there may be periods of confusion, depression, passivity, at other times periods of excitement.

=Catatonia.=—In this form the general symptoms are similar to those of the simple type above described with the addition of the special symptoms referred to as catatonic excitement and catatonic stupor. The excitement period is manifested by an unrest and monotonous activity, stereotyped actions and speech, the patient constantly repeating some act, such as moving the hand, foot or head over and over again in the same way, or repeating the same word or phrase indefinitely. This occurs apparently involuntarily, the actions being automatic in character. The patient who has been in a semistuporous state may pick up a glass or chair and without show of emotion break it against the wall. In catatonic stupor the patient may show in the lighter degrees a simple loss of interest and feeling with sluggish reaction to stimuli, or a profound inactivity and stupor in which state he cannot apparently be reached by any stimuli; nevertheless, he apparently retains consciousness. In this type we observe the interesting symptom of negativism in which the patient always does the opposite of what he is requested, or refuses outright to obey any command. There may be a refusal of food so that the patient has to be fed by a tube, mutism may be present, the patient may go for weeks or months without saying a word; stereotype of attitude results in cataleptic poses and rigidity, in which the patient may maintain any particular pose for a prolonged period of time, and if placed in some other attitude may similarly retain the new attitude for a long time. This constitutes the so-called wax like rigidity, the patient reminding one of a wax figure. Pathologic suggestibility occurs in which the patient imitates movements, or repeats words and phrases that are spoken or performed before him.

=Paranoiac Form.=—In this type delusions predominate and are characterized by variability, inconsistency, illogicality and transitoriness on the one hand, with many gradations to the opposite extreme where they become more or less fixed, and often dovetail into each other forming apparently a systematic whole. They tend to be usually of a persecutory and hypochondriacal character and in later stages when the mind is distinctly weakened are often of a grandiose type. Sometimes the patients have some kind of explanations for them and at other times none whatsoever, and they are often curiously dissociated from the emotional accompaniment. The patient may state there is poison in his food, in an indifferent tone of voice or even with a laugh; he may claim that his teeth are all set in wrong and offer no explanations to these obviously false ideas. The patient commonly thinks that somebody “has it in for him,” someone will do him mischief, will kill him, that people are talking about him and criticizing him, everything that he hears or reads he thinks has some bearing on himself, so-called “delusions of reference.” Hallucinations may be present, the patient hearing voices, or receiving impressions or ideas which he claims come from without. These external impressions he misinterprets as voices or forces which are accusing, threatening and slandering him. Later on, the patient tends to change from the depressed persecutory stage to an expansive one, when he claims he is some celebrated person, king or president, or pope. The impairment of the judgment is clearly demonstrated in these cases since the patient who may claim to be the king of England may beg the attendant to change his place at the table or for a postage stamp.

=Pathologic Anatomy.=—This is obscure. Since a certain proportion of cases recover, there can evidently be no degenerative changes at the outset, though some cases deteriorate fairly early, others only after several years. In some chronic cases there have been observed degenerative changes in the cortical cells.

=Diagnosis.=—First, the common age of onset during puberty and adolescence, fourteen to twenty-four in the vast majority of cases, this being the only common mental disease occurring during this age period. Second, the progressive character terminating in mental enfeeblement or deterioration, that is “dementia” proper. Third, the evidence of defect or deficiency symptoms indicating that the patient’s mind has altered in the sense of deterioration from its former normal condition, whereas, in imbeciles or idiots the mind has failed to develop in the first place. Fourth, in the earlier stages particularly the marked dissociation of the brain powers, some being well maintained as memory and orientation (that is knowledge of time and space), others being weakened, such as judgment, power of attention and the like. Fifth, the early appearance of the emotional defect, a remarkable indifference and apathy of the patient to people and surroundings, the patient being unsocial and taking no interest in anything. Sixth, all the peculiar motor reactions, which are mentioned above under the catatonic head, and which very rarely occur in any other mental disorder. Seventh, the delusional content nearly always refers to the patient’s exterior, forces outside of him, people or things which are exerting an unfavorable influence upon him, delusions of persecution and reference. The patient practically never accuses himself, as is the rule in cases of true melancholia, never blames himself, but always the other party or the other force outside of him. Eighth, the delusions of grandeur are usually indicative of a stage of deterioration.

=Prognosis.=—Some authorities are inclined to doubt if any case ever completely recovers, claiming that in apparent recovery it may have been a question of mistaken diagnosis, or that the recovery is more apparent than real, that the patient is not truly well, or will have a relapse, so that a permanent cure will be impossible. Other authorities admit the possibility of recovery though in a very small minority of cases. The statistics of the Still-Hildreth Sanatorium, covering more than two-hundred fifty cases show total recoveries of at least one-third. This includes all types and all stages of progress, many being advanced on entrance. Of the less advanced cases and those of not more than two or three years’ standing there have been some fifty per cent recovery. Many cases make improvement or become stationary in greatly improved condition, but are not included in the thirty per cent. Of the three types, the catatonic offers the best prognosis, the hebeprhenic the poorest, while the paranoiac occupies an intermediate position.

=Treatment.=—Of the etiologic factors above mentioned, that of auto-intoxication, resulting possibly from endocrine disturbances or other sources, is most generally accepted in the medical world and agrees excellently with the osteopathic point of view. Spinal lesions are regularly found more particularly in the dorsal region, which are quite capable of disturbing the innervation to the glands; therefore, their nutrition and activity. A correction of these before the disturbance has continued too long, and hence before deterioration has set in, should theoretically normalize the glandular condition and therefore prevent deterioration and enable the patient to recover. Such is the probable explanation of the results, and in many cases the recoveries were obtained in patients previously considered hopeless.

Remarks by Dr. Hildreth

In a great majority of the cases the cause lies in the interference between the fourth dorsal vertebra and the eighth, which analyzed means a disturbance of the great splanchnic nerves, through whose interference would be caused the toxic condition and even the sexual disturbance described in so many cases from standard authorities. The same lesion, if deep seated enough, could produce an interference with the vasomotors and reflexly interfere with the circulation to the brain. In many we also find a first, second or third cervical lesion. The effects of these lesions on the equilibrium of the circulation to the brain are easily traced through the superior cervical sympathetic ganglia. These lesions, namely, the mid-dorsal and upper cervical, especially when corrected in the earlier stages, have thus far proven to produce successful results. In a lesser number of cases we find the cause to be from the first to the fourth dorsal vertebræ; our reasoning here being that the interference or the physical disturbance must be so deep that it reaches and interferes with the deeper nerve currents, both downward and upward, thus disturbing the equilibrium of the circulation to the brain. We have found this class to be the hardest to respond to treatment; however, that may be due to the fact that the physical defects at that point are harder to correct. Osteopathic treatment applied to the lesions above described without question offers therapeutics of intrinsic value to this class of patients.

Delirium, Confusion and Stupor

This clinical group has become well established, not only in its recognition from the dominant symptoms as indicated above, but also from rather definite causes. The immediate cause seems to be an abnormal blood state, or so-called toxemia, which may result from infectious diseases, or states of exhaustion, or autointoxications, or foreign poisons; the poison acts as an irritant to the brain. In states of exhaustion so-called “fatigue bodies” are formed and are apparently toxic in character. The autointoxicants may have various sources, such as chronic kidney disease, or diabetes, and the like. The most important of the foreign poisons are alcohol and morphine. This morbid group is further characterized not only by a toxic cause and dominant symptom complex of delirium, or confusion, or stupor, but by a similar onset and course. The onset is usually acute and the course somewhat wave like, gradually reaching a climax and subsiding, or resulting in death or becoming chronic. To emphasize the clinical symptoms of confusion which is so important the term “acute confusional insanity” has often been used, or “amentia,” according to the common German terminology. Hallucinations also play a prominent part, particularly those of vision; hence, another common appellation, “acute hallucinatory confusion.” Heredity is mentioned at most as creating a predisposition, though often the personal and family histories show no such evidence whatsoever. Intellectually there is a definite lack of orientation, the patient is unable to identify himself or his surroundings in time and space. He cannot clearly understand what goes on around him, that is, consciousness is “clouded;” the clouding may be of such extreme degree the patient’s mind becomes blank, due to complete psychic inhibition. This is referred to as stupor. The emotional life plays a secondary role subordinate to the intellectual content. The patient may be greatly excited for example, resulting from a frightful hallucination. The hallucinations are mainly of the visual type and are almost always present. The patient lives in a perpetual state of sense deception as if he were constantly dreaming; the hallucinations for the most part are of distressing, disagreeable or even frightful character. These may give rise to delusions, which are manifold, often fantastic and usually transitory.

Physical changes are always found associated with the disturbed mental status. If it arises during the active stage of an infectious process there is of course the high temperature and all other physical signs of fever. In a certain number of cases with temperature no definite signs can be found indicative of any of the well known fevers, hence has been called by various names, such as “Bell’s Delirium,” “Acute Mania Gravis,” or “Acute Febrile Delirium.” This ordinarily runs an acute rapid course with very high temperature, very marked delirium, followed by stupor and usually death from exhaustion. Even though no temperature be present the physical condition reminds one very much of that found in fever diseases. There is the lost appetite, resulting emaciation and malnutrition, insomnia, exhaustion, etc.

=Osteopathic Theory.=—While it may be admitted that the various factors mentioned above may take part as exciting or predisposing causes, it is obvious that in numerous instances mental disorders do not arise whatsoever, even when the patient is subjected to these factors. There must necessarily be other elements essential to produce the psychosis. The osteopathic theory comes in at this point to fill in and complete the chain of causes and to initiate the onset by the introduction of the idea of nutritional and circulatory disturbances resulting from the spinal lesions.

The records of the Still-Hildreth Institution show 18 of the toxic type, in which the poison is derived from without, who were treated, with 17 recoveries. There were 25 cases connected with the infection and exhaustion group, with 20 recoveries.

Remarks by Dr. Hildreth

In this group we have to do with blood disorders, resulting from the infections, conditions producing exhaustion, and the various toxins, or poisons, whether originating within the body or derived from without. These disorders are largely functional in character, resulting from brain irritation due to the toxemia or disturbance to the centers of nutrition. The main object of the osteopathic treatment, therefore, is to aid elimination and regulate and build up the nutrition. In most of the patients the physical lesions are found in the mid-dorsal area, chiefly from the 4th to the 7th, and in the cervical region, the 1st to the 3d. In aiding the kidneys in elimination the 10th and 11th dorsal vertebræ must be looked after. These conditions commonly respond very rapidly to the treatment and represent one of our most successful groups so far as results are concerned.

Manic Depressive Psychoses

The psychoses which are brought together under this classification include mental disorders which at first glance would appear to be of very wide variation, namely, conditions of maniacal excitement and those of depression. Further consideration, however, reveals the very evident reasons why they should be united as sub groups under the one head. The fact that these two mental states of seemingly opposite characteristics often appear alternately in the same individual, that in certain cases of each type there is a wave like feature in the nature of the attack and the frequency with which they tend to recur, together with other points of similarity in respect to duration, prognosis, etc., tend to point to their very close relationship. Kraepelin was the first to draw attention to these facts and advocate the present convenient and widely accepted classification of these disorders.

The outstanding feature is the disturbed emotional state which dominates and overshadows all other symptoms and is fundamentally the same whether expressed through the excitement of mania or the depression of melancholia.

=Etiology.=—Heredity is considered an important factor. Various authorities claim to have demonstrated direct hereditary influences in as many as eighty per cent and more of cases. Individual predisposition resolves itself into a matter of constitution and temperament in which there seems to be a greater tendency among those who are subject to the emotional extremes.

Early adult life is by far its most frequent period of onset, though it may arise also somewhat later. In certain cases the beginning of the disorder dates from some psychic or emotional shock. Just what importance these factors have as causes is little known since other cases develop in which the constitutional element alone seems responsible and no immediate exciting cause can be demonstrated.

The osteopathic viewpoint emphasizes the all important influence of spinal lesions as exciting factors. In individuals who have a tendency to this reaction their presence disturbing the cerebral circulation and nutrition may act as the direct causative factor.

=Manic Phase.=—The manifestation of this condition is brought about by the release of the inhibiting influences which normally govern all psychic function. Various terms as hypomania, acute mania, delirious mania, etc., have been used to differentiate the different degrees in which the symptoms appear.

In the milder types we find the following symptoms present. There is a marked feeling of well being. The patient, having lost sight of his personal limitations, feels a consequent exalted opinion of himself. His conduct is often rather boisterous, he talks a great deal, often swearing and using obscene language. He is inconsiderate of others and tries to impose his will upon those about him. There goes with this a certain unstability of the emotional tone as manifested by the quickly changing feeling of good humor, irritability and anger. There is a rapid flow of ideas with a marked loss in the ability to concentrate and direct thought. The ideas which pass through the mind do not coordinate themselves toward a definite goal, but deviate from the course of consecutive thinking by any passing association. Again there is a restlessness and activity beyond all normal bounds. The individual feels strong physically and mentally. The appetite is unusually good and if activity is not too extreme there may be a gain in weight. The period of sleep is diminished and the feeling of fatigue is reduced.

In the more exaggerated cases the flight of ideas becomes more marked, the associations are more rapid and superficial and the attention is focused but momentarily. Illusions and delusions may be present due to the imperfect preceptions from inability to concentrate attention and from abnormal associations. Rhyming speech, disconnection of phrases and even apparent incoherence are often present. The state of mind may be such that the patient tears his clothing, breaks up furniture, jumps, dances and shouts and often will not take time to eat. The most extreme cases which refuse food over some period of time progress rapidly to exhaustion and measures to conserve strength become imperative.

=Depressive Phase.=—In this phase of the disorder are encountered manifestations which are in direct contrast to those presented in the manic phase. In place of the exalted emotional state there is a depression. There is a tendency to worry over trivial matters of the daily routine and of instances in past life. Introspection is the predominant mental attitude and the whole outer world is colored by the inner feeling of worry and uncertainty. Replacing the rapidity of thought in the manic phase there is a distinct slowing of mental processes in the depressive phase. Thinking is more difficult and labored, questions are answered slowly and with an apparent effort and there is usually a tendency to avoid social life.

Again replacing the excessive activity in mania the depressions show a retarded action. There is disinclination or disability toward any effort either motor or mental. The patient feels weak and incapable of effort, the body assumes a bent attitude and the facial expression is one of despondency. The appetite is usually impaired with resultant loss of weight, the bowels are sluggish, the period of sleep reduced.

In the more exaggerated cases the retardation may be complete. Introspection is carried to the degree where the patient tries to take unto himself the responsibility for all the sin in the world. He himself is the arch sinner and he feels himself the subject of punishment by divine wrath in a manner in which no other individual was ever punished. Also the introspection tends to produce various hypochondriacal ideas. The patient may feel that he has contracted some incurable disease and that certain bodily functions have ceased operating.

Mental processes become not only retarded and difficult, but actually painful, a symptom which has been termed psychalgia. Suicidal tendencies are also quite frequently present.

In extreme conditions the patient may become so retarded in thought and activity that he apparently receives no stimulus from the outer world. He lives in a more or less stuporous state, even requiring that food be administered by tube.

=Circular Insanity and Mixed Forms.=—In addition to the conditions in which simply mania or melancholia are manifest there are certain cases which show variations and combinations of these forms. A common type is that in which there is an alternation of the manic and depressed conditions. The patient may pass directly from one state into the other, or there may be an intervening period of lucidity. The term circular insanity has been applied to this type. Other variations are those in which there are recurrences of the manic or depressive attacks often at more or less regular intervals, each recurrence being a practical repetition of the preceding.

There is also possible a considerable intermingling of the characteristics of the two types. In the manias may occur difficulty of thinking, passing feelings of depression and even almost stuporous conditions. In depressions there can exist a marked degree of restlessness and activity and a rapidity in the flow of ideas.

=Prognosis.=—The outlook for recovery from the individual attack is good. The attack may last from a period of days to one of a number of months and recovery comes with rarely any evidence of mental deterioration. There is a tendency to recurrence of the trouble. In fact recurrence is the rule rather than the exception. In the osteopathic handling of these cases it has been the endeavor to demonstrate that the correction of lesions had a tendency to lessen the duration of the individual attack and reduce the tendency to recurrence. Judging from the experience thus far gained in the observation of cases under treatment during the attack and the comparative few recurrences reported both of these aims have been attained.

=Treatment.=—The osteopathic measures are aimed at the correction of the spinal lesions, especially those located in the upper dorsal and the cervical regions. Some reflex effects from lesions in more remote areas may have their influence so that it is wise to look to the correction of any other structural variations when present.

Remarks by Dr. Hildreth

The mental disorders of this type are purely functional and may cover a broad scope as to causes; however, from the osteopathic viewpoint a great majority of them seem to have as their specific exciting cause, lesions in the upper dorsal and upper cervical regions. The treatment should be applied specifically to the cause which may range anywhere from the 1st to the 8th dorsal, or from the 1st to the 3d cervical, covering the nutritional and circulatory centers and thus controlling the nutrition and circulation to the brain. There can be no question but what the osteopathic theory of adjustment of physical defects forms the basis of permanent cure, since many of our recoveries had been previously under other methods of treatment without results. Our records cover over 200 cases with recovery in more than two-thirds, and very few recurrences up to the present.

Involutional Psychosis

In the mid years of life, between forty and sixty, a decline begins, which in the older years results in decay; it is especially true at this period of the sexual life and the organs underlying it. While these organs undergo a very definite change constituting the so-called climacteric period in women, it is not at first sight so evident in men; however, the evidence is that a somewhat similar process, though much slower, tends to occur in the male. Associated with the decay of the sexual organs is a disturbance presumably of the internal secretions; if this latter disturbance takes place slowly and evenly the body may not notice any marked changes; on the other hand, if it takes place more quickly, or unevenly, it may give rise to distinct symptoms which indicate a disturbance of the nervous system in general and often even of the mentality. Hence, the significance of the term, Involutional Psychosis. In a large majority of cases the mental disorder is marked by the dominance of depression and is frequently referred to as melancholia. For a long time it was considered that this represented a special mental disorder having little or nothing in common with other psychoses. In recent times Dumas has studied this group very carefully and shown that it in reality has very much in common with the depressed phases of the Manic Depressive Group of psychoses. Kraepelin himself, who was the first to demonstrate the unity of the Manic Depressive Group, has accepted the conclusions of Dumas and incorporated the Involutional Depressions as a sub type of his Manic Depressive Psychosis. Among etiologic factors have been mentioned hereditary elements, which have been claimed to have been found in at least fifty per cent of all cases, forming presumably a predisposition; it is also stated that a predisposition may be acquired through various debilitating causes. Exciting factors are claimed to be present, such as mental shock, grief, worry and the like. The disease would then seem to occur when we have a combination of exciting factors and predisposition. Careful consideration will show, however, that no such mental disturbance occurs at this age in many people who show evidences of such predisposition and of exciting factors, therefore it would seem that still other causes were necessary; if we consider the suggestion above mentioned that there are atrophic processes taking place in the sexual glands leading to a loss of the internal secretions and if we further consider that this may take place unevenly and in an unbalanced way, thus aiding in giving rise to the symptoms, we will find a definite point of contact for the osteopathic conception. Osteopathically considered, we may say that the spinal lesions lead to a disturbance of innervation and nutrition to the ductless glands, and therefore produce disordered secretions in those patients developing the disease, whereas such a condition may not be present in others who at the same age period do not develop the psychosis.

Symptomatology

The emotional tone of depression dominates the picture. Associated symptoms are anxiety, fears, particularly of impending danger, the loss of interest in the external world, with a concentration of attention upon self; psychic distress is usually present, often to an extreme degree, leading apparently to real mental pain, so-called psychalgia. Delusions are usually present and manifold in variety; they mainly refer to the patient himself and are of a self-accusatory nature; they frequently refer to notions of sins having been committed, also unworthiness of the patient, of poverty, nihilistic ideas, either about his own body or external things. He may claim for example that he has no stomach or kidney, or heart, that the external world is unreal and the like. His motor reactions become retarded, or even in the more extreme cases inhibited, producing a form of stupor. The inefficiency which results along with the psychic pain and distress may determine suicidal tendencies which are very frequent. Orientation is usually good, the patient remaining aware of his own identity and that of his surroundings; the judgment of course is impaired so that the patient is unable to appreciate the unreality of his delusions; as a result he sees no hope in the future and on account of present sufferings prefers death to life. The patient may remain in a perfectly passive mood, giving the appearance of extreme depression, paying no attention to the surroundings, possibly mute, giving no regard to the necessity of the toilet, paying no attention to his clothing and the like. This may continue for hours or days. Food often has to be forced on him, possibly even by the tube; the result is usually more or less emaciation and may result in marked malnutrition; similarly the sleep may be seriously interfered with, even though the patient is quiet. The resulting loss of sleep and malnutrition sometimes lead to the death of the patient. On the other hand, the patient may moan and wring his hands in anguish, walking up and down, crying out that he is a sinner and that he wants to die and the like. This is the so-called melancholia agitata.

The physical symptoms of importance are sleep disturbances, poor appetite, with emaciation, cyanosis, often a subnormal temperature, low blood pressure, slowed heart action and weakened circulation. The hair may become gray, the skin dry and harsh and indeed any of the signs of senile decay may appear.

=Diagnosis and Prognosis.=—These depend partly upon the mental symptoms, partly upon the physical. On the mental side is to be emphasized marked depression, with the relatively clear orientation, resembling the depressed phase of Manic Depressive insanity; also the dominance of the self-accusatory delusions. On the physical side the age period, and the evidence of previous attacks, even though very slight. The prognosis from the study of the mental symptoms depends on the presence or absence of signs of defect, or deterioration, as for example foolish and silly delusions. On the physical side the presence or absence of conditions like kidney or arterial disease; in general, it may be said if the physical findings are negative and the mental symptoms show no deterioration there should be a good outlook, particularly if the condition has not become too chronic.

A favorable outlook is always possible if the disease is treated early and the lesions disturbing the activities of the glands and of nutrition and the circulation are corrected and if the other physical findings are negative and signs of deterioration absent.

Since this is probably only a sub-group of the Manic Depressive Psychoses, as has been mentioned above, the results obtained under osteopathic treatment are noted under the Manic Depressive group.

Remarks by Dr. Hildreth

Our experience with this class of cases invariably lead us to the nerve centers which regulate and control the process of nutrition and circulation; it is a matter of keeping up normal equilibrium of all organic life and especially the circulation to the brain. The basis of the treatment therefore is to be found in the nutritive centers, as well as those centers which control the circulation to the brain, the ductless glands, etc.

Senile Dementia

Senile Dementia may be defined as an abnormal weakening of the mind arising in old age. As the word dementia implies, the intellectual change is quantitative rather than qualitative, the prime characteristic of the disease being mental loss rather than mental perversion.

It is commonly stated that a most important cause of the disease is the general malnutrition incident to age. Since only a small proportion of the aged develop dementia, this is probably only a cooperating factor. Other causes mentioned are overwork, emotional strain, traumatisms, intoxications (especially alcoholism), cerebral arteriosclerosis and perhaps heredity.

=Pathologic Anatomy.=—The disease is organic, the brain exhibiting definite pathological tissue changes. There is an atrophy of many nerve cells and a proliferation of neuroglia fibers, so that the cerebrum becomes shrunken and hard, with thickened meninges and thinned cortex, and shows a loss of weight. The cerebral arteries may or may not exhibit sclerosis, thrombosis, or miliary aneurisms, with resultant areas of softening. The cells show pigmentary degeneration and many of the association fibers have disappeared.

=Onset.=—The onset of this dementia is usually very gradual, the condition not being recognized until rather marked. It occurs mainly in the seventies and later and in the late sixties, being rare before sixty. It often follows financial reverses, emotional shock, or various diseases. The earliest symptoms are a change in the person’s disposition, slight disorders of memory, and trivial lapses of various sorts.

As the disease progresses the symptoms become more marked and fundamental, involving not only the intellectual but also the emotional and volitional phases of consciousness. Interest in the outside world begins to flag, attention to wander, perception to be incomplete and inaccurate, association of ideas to be slow, memory to weaken and judgment to be impaired. Memory of the most recent incidents is the first to be lost, of recent years next, and then of middle age so that the patient may not recognize his own children or know, for example, that his wife is dead; finally the memory even of youth is lost and the patient is to all intents and purposes a child, his condition being an exaggeration and aggravation of that commonly known as “second childhood.”

Several forms of Senile Dementia exist, of which the most common is probably the simple or non-delusional type. Other forms are fundamentally the same as the simple, but with certain superimposed symptoms. Fairly early in this type it becomes unsafe for the patient to continue in business. Due to impairment of memory and judgment he is apt to lose his property. Soon his work is poorly done or neglected entirely. He becomes garrulous and annoys his associates with tiresome repetitions of childish reminiscences, continually wandering from one subject to another. His speech becomes incoherent and his sentences fragmentary. He grows untidy and indifferent to the ordinary niceties and conventions of life. His appetite is either poor or voracious; in the latter case the weight may keep up fairly well. He may be either apathetic or turbulent. If the former, he seems stupid, indifferent, and sleepy. He is credulous, docile, and very suggestible. Patients of the turbulent type are restless and always moving about, either depressed or elated, giving unreasonable orders and then contradicting them. Sleeping poorly, they are apt to get up and wander about the house at night. In men, prostatic disease may cause a recrudescence of sexual feeling. Patients of either type eventually become filthy, soiling their clothing, etc. Even in well advanced cases, however, senile dements are often able to perform well certain habitual activities, such as signing their names, or playing certain games, such as checkers or dominoes.

=Confusional Type.=—Another form of Senile Dementia, which may in severe cases usher in the attack, but which usually, when present, is sequent to the simple form, of which it is a more severe grade, is the confusional. The additional symptoms of this type are probably due to defective elimination and the consequent toxicity. Usually unsystematized delusions, and sometimes hallucinations are present. Except for a possible occasional period of remission the confusion is continuous. It varies greatly in degree, now being mild and passive and again active, perhaps developing into delirium. Orientation as to both time and place may be lacking. Such patients may ask for dinner a few minutes after a meal, go to bed at noon, be unable to find their own room, or to recognize their own children. They are apt to be obstinate and peevish. Delusions vary in type but both these and the hallucinations are usually painful and, being referred to the patient’s associates, give rise to the thought that they are trying to kill or otherwise harm him.

=Delusional Type.=—A third type of Senile Dementia is the paranoid form. Dements of this type, owing to delusions of persecution and auditory hallucinations are sensitive and suspicious. Such cases may sometimes show good orientation, apparently unclouded minds, and little evidence of senility, requiring careful study to differentiate the condition from true paranoia. A patient may, on account of hallucinations of taste and smell, refuse food in the belief that it is poisoned. Members of his family who are devotedly caring for him are suspected of designs on his money, and this suspicious attitude frequently leads to unjust wills. The delusions and suspicions may be entirely concealed from the family. Wealthy paranoid elements are peculiarly apt to become the prey of scheming adventuresses, particularly in case of the above mentioned sexual recrudescence, and marry them. Opposition of the family is regarded as part of their general persecution or as due merely to their desire to get the estate. Some patients merely appear odd, suspicious, untidy, peevish, and childish. Some have expansive delusions and exhibit the euphoria so frequently found in syphilitic dements.

=Senile Delirium.=—A fourth type has been described by some psychiatrists under the title of senile delirium. This may appear as the initial form of the disease or as an acute attack in one of the above forms. It is characterized by great incoherence and restlessness, entire absence of orientation, and numerous rapidly changing delusions and hallucinations, the condition resembling delirium tremens. It is probably due to some somatic cause, such as nephritis, pneumonia, or cystitis, which is often fatal.

Complications may arise in Senile Dementia, such as apoplectic strokes, hemiplegia, epileptiform seizures and aphasias.

=Prognosis.=—It is evident from the pathology of the conditions that the prognosis is not at all good when the disease is well advanced. It is a chronic disease and usually progressive until death, which is due to one of the complications, malnutrition, or especially pneumonia. However, many cases have shown improvement, and in incipient stages recovery. A cure of advanced cases being impossible, the important consideration is prevention or arrest in its incipiency.

It is evident that this can be done only by preventing, or removing as far as possible, the predisposing causes. A glance at the list of these shows that much depends upon the cooperation of the patient by regulating his habits of life. Physical and mental overstrain must be avoided, deleterious habits, such as the use of intoxicants or narcotics given up. Much can be done by osteopathy to eliminate the effects of these upon the organism. Cardio-vascular and renal symptoms are very important and should be watched for in order that early treatment may check the process initiated. To this end the patient’s habits and diet must be regulated and treatment instituted to relieve toxicity and promote elimination. Lesions must be corrected, special attention being given to the lower dorsal that affect the kidneys, the upper dorsal that affect blood pressure, and both the upper cervical and upper dorsal that affect the blood supply and nutrition of the brain.

=Arteriosclerotic Dementia.=—This is a mental enfeeblement arising sometimes in the fourth, but chiefly in the fifth, decade of life, and associated with symptoms of arterial hardening.

The cause is arteriosclerosis, which may be secondary to some form of nephritis. The arterial hardening may be general or may be confined to the arteries of the cerebrum. It is likely that the arterioles supplying the cortical cells are especially involved in an atheromatous condition. The disease is organic, chronic and progressive. Hemorrhage, embolism, or thrombosis may occur, producing focal lesions and areas of softening, with hemiplegia, aphasia, etc.

The earliest symptoms may be headaches and dizziness. The blood pressure is usually found to be high but not invariably. An atheromatosis may be present in some one of the palpable peripheral arteries, such as the radials. Further symptoms on the physical side are quick fatigue, loss of energy, numbness and paresthesias of the extremities, and somnolence in the daytime or perhaps insomnia at night. Strokes may occur, usually slight and temporary, probably due to spasm in a degenerating artery or perhaps to serous effusion. Toxic symptoms appear, due to disorder in kidneys, liver, and other organs. Epileptiform seizures are possible. Mentally the patient shows impairment of memory, and perhaps some confusion and hallucinations. Rarely stupor occurs. He may be agitated and irritable or melancholy and depressed. Suspicious and persecutory ideas of the paranoid type may appear; also hypochondriacal ideas.

=Osteopathic Theory.=—In these psychoses of the older years of life the termination is usually dementia, which means mental enfeeblement, and which results from degenerative changes in the brain substance. As has been shown it is largely a nutritional question and the nutritional condition varies tremendously in different elderly people; it is well known that many old people preserve their brain powers fairly well to the end; on the other hand others fail relatively early, some even in the fifties; these cases of earlier failure are referred to as the “presenile type.” The osteopathic conception would be to find out the source productive of the nutritional disorder and correct it at the very outset, therefore making it quite possible to prevent the disease process from taking place. The prognosis then in the earlier stages is very good.

Remarks by Dr. Hildreth

While many cooperating factors may be found in the causation of the mental disorder of elderly people, our experience shows there is always very definite disturbance of nutrition and the nutritional centers. We find chief physical interference between the 3d and 8th dorsal vertebræ, most definite as a rule at the 4th, 5th and 6th, with the corresponding ribs on the right side. Contributing causes may be found in other areas, associated with the disturbances of the heart and circulation and of the kidney. In the cardio circulatory disorders we find abnormal spinal conditions in the upper dorsal region and especially the 5th rib on the left side. In the kidney disorders we find the lesions usually at the 10th, 11th and 12th dorsal. The above mentioned areas in general represent the centers of control of the splanchnic nerves and therefore the important processes of digestion, metabolism and assimilation. Specific treatment applied to these points is very helpful and results in marked improvement and indeed in relieving the patient’s symptoms completely when in the earlier stages of the disease.

DEFECTIVE CHILDREN

By RAYMOND W. BAILEY

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

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

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

Of the inherited tendencies, we have two kinds:

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

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

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

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

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

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

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

1. Traumatism. 2. Convulsions. 3. Rachitis. 4. Infectious fevers. 5. Meningitis.

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

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

Any influence which retards the

1. Inherent capacity of cell for growth or,

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

(a) Traumatism or Injury (b) Drink or Abuse (c) Dirt or Unhygienic surroundings (d) Depravity or Ignorance

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

I. Before Birth such as

(a) Abnormal condition of mother’s health during pregnancy as in disease of any nature, mental or physical or

(b) Injury to fetus direct by blow, fall of parent, or instrument.

II. During Birth from:

(a) Abnormal labor from any cause.

(b) Primogeniture.

III. After Birth.

(a) Traumatism.

(b) Toxic causes such as scarlet fever, whooping cough, meningitis, measles, mumps and exanthemata.

(d) Nutritional disturbances.

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

1. Instability of the nervous system.

2. Intensifying of constitutional defects.

3. Decrease in size of offspring.

4. Predisposition to disease through lowered vitality.

5. Impairment of reproductive function.

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

Mental Deficiency in Children

=Synonyms.=—Amentia; feeble-mindedness.

There are three grades of amentia:

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

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

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

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

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

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

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

(=3=) =Average= mass of mankind.

(=4=) =Dullards= or those of inferior intelligence.

(=5=) =Feeble minded=, merging imperceptibly into

(=6=) =Imbeciles= and by insensible gradation into

(=7=) =Idiots= and gross idiots.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1. Numerically fewer.

2. Irregular in arrangement.

3. Imperfectly developed.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

=Nose= is short and flat and has triangular nostrils.

=Teeth= are soft and ill formed and tend to decay.

=Hair= is usually scanty and wiry and very dry.

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

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

=Abdomen= is large and mushy. Umbilical hernia often present.

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

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

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

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

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

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

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

POST-OPERATIVE TREATMENT

By GEORGE A. STILL

At the convention of the American Osteopathic Association held in Boston in 1918, I gave a short talk on the above subject, and during the day after I had given the lecture, two women and one man, graduate osteopaths, asked me if I really meant to convey the impression that we actually gave osteopathic treatments to recent surgical cases. I do not know whether I convinced them or not, but I do know that they convinced me that there are people practicing osteopathy who have absolutely no concept of its merits and underlying principles.

To my surprise I have found that a great many osteopaths who consider themselves absolutely “pure” are just a bit startled at the thought of handling post-operative complications by treatment. These are invariably fellows who have had most of their experience in office work, and who do not come in contact with acute cases. Still it is difficult to conceive how a man can believe that osteopathy is specific for certain diseased conditions and not for others. As a matter of fact osteopathic treatment has not proved itself more satisfactory in any field of therapeutics than it has in post-operative conditions.

The common post-operative conditions are pneumonia, pleurisy, backache and headache, nephritis, vomiting, neuritis, phlebitis.

Taking up these subjects and discussing the least serious first we would of necessity discuss pneumonia last, as it is the most serious, and is less influenced by other conditions. It will also serve to illustrate many of the details in treatment.

We will therefore briefly take up the other conditions and then discuss pneumonia more fully.

Vomiting

We believe there is no question that a good part of the prevention of anesthetic vomiting is in the preparation of the patient, including a good cleaning out of the bowels without debilitating cathartics. In other words, the vomiting is increased if the alimentary tract is loaded, or if on the other hand it has been irritated to the extent of losing its tone. Combining a careful preparation with a straight ether anesthesia and osteopathic treatment to the neck and splanchnics we have been able to eliminate any serious post-operative nausea. I do not recall a case in the last few years that vomited on the following day unless the condition for which they were operated was one that essentially in itself would cause vomiting; for instance if the patient had peritonitis and had been vomiting due to the toxic ileus. They might even vomit after the abdomen had been opened. This could hardly be called “post-operative” vomiting.

The improvement in our records in post-operative vomiting is in proportion to our increased faith and use of the osteopathic treatment. Time and again patients have told us that they had taken anesthetics before and were sick from three to five days and even a week. Invariably we have been able to surprise these patients by the fact that they were sick less than a day.

The usual treatment with bismuth sub-nitrate, cerium oxylate, sour wine and the other usual remedies were not used in any case or in any amount. No drugs whatever were employed.

Backache and Headache

There is practically no difference in the post-operative headache and the office headache. There is of course the usual multiplicity of causes, and as a matter of fact in this condition treatment can more nearly approach the ordinary office treatment, and the results are about the same. As for backache, we find that speed of operating and not keeping the patient under the ether too long has a marked influence. Also we have a four inch Seely mattress on the operating table which helps some. Treatment does the rest and does it effectively. For this complication even the ordinary nurse knows enough to give a treatment of some sort.

Neuritis

Nine times out of ten the post-operative neuritis is really a local osseous lesion, a slipped innominate, rib, vertebra, clavicle, biceps tendon or something of the sort, and responds quickly to a specific treatment.

Phlebitis

This complication usually comes on quite late after an operation and at first it is sometimes hard to differentiate it from a neuritis. Absolute rest of the involved part with lower spinal treatment gives relief, but under no circumstances should the affected part be freely moved while there is active inflammation. The reason for treatment of the lower spinal area is that practically always one of the saphenous veins is involved.

Nephritis

This complication is to a very big extent eliminated by a careful urinalysis prior to the operation, and careful preliminary treatment in indicated cases, and in other cases the postponement or if necessary complete elimination of the operation where it is not a case of life and death. Where the condition does appear we have found it the hardest of the post-operative complications to control. Indeed it is the only one that we have not found very easy to manage.

We do not vary the treatment for a post-operative nephritis from what we would use in any ordinary case of nephritis. We have observed treatment of this condition in many cases under medical management, and while we are satisfied with the osteopathic treatment comparatively we are not yet satisfied that we have it developed to its greatest efficiency.

Pleurisy

This condition in nearly every instance can be corrected with one or two treatments of a twisted rib unless it is the pleurisy of a beginning pneumonia. As far as the pain is concerned the simpler type hurts as much as the one that is going to develop a real complication. For this reason relief obtained by a single treatment often seems little short of miraculous to the patient.

Pneumonia

When I took charge of the surgical work at Kirksville, osteopathy was not used in post-surgical treatment. Post-operative vomiting was treated medically, as were other post-operative conditions, including pneumonia. Cases of a real major surgical nature rarely got an osteopathic treatment.

The idea seemed to be that osteopathic post-operative treatment had to be along the same lines as it would be for such an illness as lumbago, brachial neuritis, or ordinary pneumonia, and other non-surgical conditions where the patient could be placed for giving a treatment in a position that was not permissible following an operation, as it would work great harm to the wound.

It seemed to me that if osteopathy was effective in a case of ordinary non-surgical pneumonia, it should certainly be good for a case of pneumonia that was post-operative and that all we had to do to handle the condition was to apply a new technique of treatment that could be used on a patient who had a surgical wound. All we had to do was to so manipulate the spine that we would get the results locally, and yet handle it in such a manner as not to affect the wound.

Many laymen, and even some physicians of our own school, express surprise at the suggestion that we do much osteopathic work in the after care of surgical patients. But the fact is we have worked it out so that now, except for pain, during the immediate after effects of the operation drugs are absolutely not used in our hospital for any of the post-operative complications. The opiate immediately following the operation, is really a follow up of the anesthetic, and we use that as rarely as possible. Needless to say, there are cases such as un-united fractures, extensive adhesions, etc., where the emergency conditions positively call for some relief of the pain for a short while, but that is the only condition that we cannot control with mechanical treatment.

I am very glad that I had the confidence to give this an early trial and a thorough trial, without being afraid to leave off the drugs. The big field, however, where osteopathic treatment has won the most impressive success and proved itself a most absolute specific, is in the field of post-operative pneumonia with which I am proud to announce a one hundred per cent. success for combined osteopathic treatment in my fourteen years continuous surgical work. Not to have lost a single case is partly due to luck. In other words, with any series of serious cases, it is impossible but that there be some fatality finally.

Post-operative cases have one advantage along with their disadvantage. While they have the shock of the operation to contend with, and the weakened condition from the disease for which they were operated, still except in extreme emergency they would not have been operated on unless they had a good heart and good kidneys and a good blood pressure, so that in cases in which we are most concerned in combatting pneumonia, we usually start with a patient who has those organs in a healthy condition.

=First Post-operative Pneumonia Cases Treated Osteopathically.=—At the Chicago Convention in 1911, I reported the first post-operative pneumonia cases that had been treated osteopathically. I believe at that time that there had been only three cases. At that meeting I mentioned the fact that some of the doctors and some of the internes who treated those cases felt sure that they were not treating them properly because they could not get away from the idea that pneumonia needed strychnin and other drugs. One of these cases got well in three days from the developed lobar pneumonia symptoms. The results were so miraculous that the young man treating it began to doubt whether it could have been pneumonia. He could not understand how he, a senior student, could overcome this dreaded disease by merely working on the spine. He could not believe that osteopathy, a science that he had been able to learn himself, so easily could cure a condition that he had thought must be almost necessarily fatal.

One of the weaknesses of osteopathy is the fact that there is no mysticism about it. It is so simple that any person with ordinary intelligence can learn to use it, and yet it is so simple that it takes an unusual intelligence to be able to grasp the fact that it is the therapeutic discovery of the age. Many, many times I have had young internes and students cure genuine lobar pneumonia and do it with such obvious ease that it caused them to wonder, in a way, if it really could be pneumonia. It is bred in our very tissues to look for some mysticism, something impossible to understand, something supernatural, something connected with the Unknown associated with the treatment of disease and accordingly it is just human nature to find it difficult to believe, even when we see it, that a simple method of treatment can actually effect a cure.

Real pneumonia, as we understand it, is a consolidation of the lung tissues characterized by fibrosanguinous exudate into the pulmonary tissues and spaces, associated with one or more particular germs as exciting factors and proved by the physical tests and the character of the expectoration. How many cases have been cured that had not entered consolidation I do not know because up until the time of actual consolidation there may be a question as to whether or not they would have had pneumonia. I know that many cases with marked symptoms of pneumonia have failed to develop under treatment or the case has been aborted.

Pneumonia lacks a great deal of being a self limited disease. The number of cases with beginning symptoms that fail to develop is too great to be ascribed to coincidence. Of course I know that some of these might have been only pleuritis, some only neuritis, etc. However, in giving the statistics of pneumonia cures we will give only those in which pneumonia developed and showed a hardening or consolidation of the lung tissue. In these cases there can be no argument as to whether there was pneumonia.

When we have an acute condition associated with the symptoms of consolidation, we can hardly be confused as to the diagnosis. We may make a mistake in our physical findings, but hardly after a little experience, and certainly when we are sure of the physical findings there will be no trouble in naming the disease.

=The Clinical Findings.=—Post-operative pneumonia is a little different from the common pneumonia. It always comes on a little more insidiously. One has to watch for post-operative pneumonia more closely than he would for the attack that we may meet in ordinary practice. A patient may have considerable pain from his wound, may have some pain in the back from the position he is in; there may be headache, and an upset feeling from ether; and the pain comes in the chest. All these symptoms are forerunners of pneumonia, but the pain in the chest is not noticed until it gets quite severe. In other words, there are other things to annoy the patient as well as the attendant, and at first, this condition does not cause complaint. A strong and healthy individual who feels a pain in his pleura, which is the forerunner of pneumonia, knows it at once, because that is the only distress he has. His entire attention is attracted and he asks for a physician’s help. But in the post-operative case, the physician has to keep a look out in order to prevent a case from getting well under way before it is recognized.

As an example of this I had a case of a man who was with a party driving an automobile and they tried to cross the railroad track in front of a train. This patient I speak of was one of the survivors. He had a fracture of the femur, fracture of the skull, fracture of three ribs, and otherwise more or less bruised up. Naturally the preliminary work consisted in getting the ribs and legs attended to as well as possible and looking out for cerebral hemorrhage or meningitis.

This patient developed consolidation in both lungs in spite of regular treatment, and it precipitated on him very rapidly, partly masked by the disturbed breathing from other sources of irritation. We put him on hourly treatment, but after a few hours his condition from the injuries and the pneumonia was such that his wife asked us not to treat him any more. She put it this way, that she knew he would die in spite of all that could be done and as long as he was going to die he might as well die easy. Every time he was treated it had the effect of bringing him out of his stupor, and he would complain, and she thought it would be a kind act to let him slide off into the next world uncomplaining.

Pneumonia in a case of this sort cannot be handled with kid gloves if we wish to save the patient. We must give firm, strong treatment. Light treatment in this condition will do no good. Indeed light treatments in any sort of pneumonia are of little avail. Many times I have changed internes in a pneumonic case that was not responding and the results were immediate. That is, the turn for the better was obvious from the beginning of the good strong treatment.

The case above mentioned was treated a good part of each hour for twelve hours. He had no strychnin, no oxygen, nothing but treatments, but he got well and is now living, and aside from a limp has no evidence of either his injury or his illness.

Some cases, in private practice, may get well on a treatment a day, but I would hate to handle the kind of cases we get in that manner. I have had severe cases, especially hemorrhagic cases, where the treatment was almost continuous for hours preceding the crisis. Of course, after the crisis we can ease up. On the other hand, it is not infrequent that a few good strong early treatments, given at the beginning of a case absolutely stop it. I have seen cases where a consolidation area of the apex of the lower right lobe as large as the palm was easily outlined, and this together with the clinical symptoms would be cleared up in two or three days.

There is no possible medical method by which this can be done. Medical authorities agree that under their treatment pneumonia runs an unshortened course; in other words, a course in the individual case that has not been affected by the medication. Medically, even where the crisis occurs early, the consolidation persists for some time, but I have seen it cleared up time and again under osteopathic treatment in the length of time that could have been brought about only by osteopathic treatment.

I have previously called attention to the fact that many of the medical text books on physical diagnosis mention a point that is a very practical and very plain demonstration of the efficiency of osteopathy in pulmonary conditions. These books only mention this fact without pointing any moral or drawing any conclusions. The point is this: that frequently when a professor is having a class or a section of a class examining a case of pneumonia, they will outline the size of the consolidation at the beginning, the instructor marking it off when he makes the first examination; then after the students have examined it, by percussion, palpation, etc., possibly a dozen or twenty of them, the later students will find that the area has shrunken perhaps an inch. This fact has been frequently noted. It is said, indeed, that if careful examination is made it will always be noted.

How Manipulative Treatment Benefits

Doubtless this proved that accidental manipulations of the ribs helps clear up the congestion about the real consolidation and reduces some of the dull area. Very likely this explains some of the cases of partial or real results from spondylotherapy. Naturally, scientific osteopathic treatment would necessarily magnify such results very much.

It is a great wonder with the obvious failure of medical treatment in pneumonia, that at least some crude from of manipulative treatment has not been devised by those practitioners. We have already mentioned that the treatment of post-operative cases varies mainly in the manner of applying it. In other words, when we raise the ribs we keep the patient on his back, in treating the spinal centers we treat with patient on his back, and the physician who has no grip in his hands will not be able to treat a post-operative pneumonia to any advantage.

In these cases one has to get at the patient’s back by reaching under and the weight of the patient helps to give the treatment, but a strong grip is necessary. It is much safer for the wound to handle the patient in this way but not infrequently beginners wear their knuckles pretty nearly off before they get the finer technique; after which it is easy. In raising the ribs there is no more difficulty in treating in this position than there is with a patient who can sit up or turn from side to side and in some cases a patient can, of course, be partially turned.

Theory is all right but in these cases practice has been added to it in something over three hundred cases treated in this manner, and in this manner only. I have had no case die. None of my cases had oxygen and none of them had strychnin or alcohol unless it was a person who had used alcohol constantly or daily and in these cases I consider that the system has become sufficiently used to it that it is practically a food and that sudden withdrawal is apt to bring on delirium. It is not necessary in those cases that indulge deeply now and then, but it is advisable in those that take a small amount regularly, just as they take food. These patients are used to a constant heart stimulant and its withdrawal is also apt to be reflected in the heart action. These are the only cases in which I have ever authorized anything in the way of a chemical stimulant of the heart during pneumonia.

You will undoubtedly recall that in reading the newspaper accounts of men who are big enough and prominent enough to have bulletins in the newspapers when they are dying, that almost universally the next to the last bulletin was that oxygen is being administered. The last bulletin announces the time of death. You will also note that in case the patient lives that oxygen then is not mentioned, and a few days later the patient is all right. My observation is that the use of oxygen may attract the attention of the family, it may attract the attention of the patient, but as for any actual benefit on the patient I do not believe it is in the least helpful, and that the only treatment for pneumonia is osteopathic. I am so convinced of it that I am using only that method.

As to strychnin, some say strychnin must be given. Some say it must be given at the crisis, and others say it must be given from the inception of the disease. I do not believe the majority of cases will do as well under strychnin. I know they will not do as well under strychnin as under osteopathic treatment. I will not say they will not do as well as if under no treatment. It is possible that there would be an occasion for its use at the crisis, and I have seen such cases, and I have used it while studying medicine. I used it at the crisis, and I used it in cases where I am convinced that it helped them over the crisis, but I am also convinced now that by osteopathic treatment they would have done still better and the crisis would not have been so acute. In other words what strychnin does in favorable cases, osteopathic treatment does better in all cases.

In our post-operative cases study the charts and you will see that they do not have the acutely violent crisis that usually occurs under other treatment. They are under better control and if we can get them near the beginning, as we usually do, we can keep up the resistance so that where they would otherwise have a hard crisis they have an easy one. Instead of having a temperature of 105, pulse 165, respiration 70, or such a condition, they are more apt to run a temperature of 102, pulse 120, respiration 35 or 40 and they go through it without that suddenness and acuteness that is common under other methods of treatment.

In several instances, as an example of showing how this resistance is kept up, I had letters from boys in the camps. One letter told of a wide epidemic of severe tonsillitis. In one group of soldiers there were three osteopaths who treated all the men and this was the only group that was not sent to quarantine. This group developed sore throat and was treated osteopathically and the sore throats checked so that quarantine was unnecessary.

Among the detailed reports in the A. M. A. Journal there will be nothing about this, nor about many other instances where osteopathic treatment, given by men forced to remain in the ranks, has done things that medicine cannot do. These examples are too frequent to be coincidents. If I had had three cases of post-operative pneumonia and they had all got well, it would not be surprising. If I had ten cases and they all got well, there are medical hospitals that have been this lucky. But there are no medical hospitals in the world that can report one hundred cases or two hundred cases or three hundred with developed pneumonia and all lived. The percentage of pneumonia cases that die now in medical hospitals, is much less than formerly. But the cause of this is not vaccine, antitoxin or drugs. It is due to the fact that pneumonia cases now, like typhoid, are given very little medicine and are turned over to general nursing treatment; that is, in the best medical hospitals.

The mortality is in inverse ratio to the drugs given. The advance medical teaching is against so much drugs in pneumonia, though of course the hick doctors use it because they are practicing medicine of the by-gone age, before Andrew Taylor Still forced on the world the idea partly started by homeopathy, that the less drugs the better. Homeopathy failed in not quite discarding drugs and in not having a substitute that reproved drugs.

As a matter of interest I wish to mention that while in medical college I had the advantage of being taught surgery by the greatest surgeon that ever lived, John B. Murphy. I only wish that circumstances could have permitted me to have shown him what osteopathy could do in post-operative conditions, because Murphy was a broad minded man and no man living ever thought less of orthodox medicine and old fashioned drug treatment than Murphy.

He and the Old Doctor would have been great friends had they ever met. Murphy, whom I considered a most wonderful surgeon, and whose skill I never hope to approach, stated to me many times while a student that he lost more cases from post-operative pneumonia than any other condition and that in upper abdominal conditions like gall bladder, stomach, and similar operations, post-operative pneumonia constituted the most of his mortality.

This great man was afraid of post-operative pneumonia, while I, a much less skilled surgeon, am no more afraid of post-operative pneumonia than I am of something occurring in a distant state because with osteopathic treatment, we have eliminated post-operative pneumonia as a fatal condition.

PART SECOND

INFECTIOUS DISEASES

Fever

=Fever= is due to various causes, so that a definite statement cannot always be given as to the cause of fever in every disease. Each fever case, like all other disorders, is a law unto itself; different causes are found in different cases. Moreover, often only theories, and not absolute facts, can be given.

Fever may be present when a local disease assumes a constitutional character or when the constitutional character is manifested from the beginning of the disease. Fever may be a systemic disorder or a symptom of disease, and is characterized by an increase of body temperature. Other symptoms are usually present, as an accelerated pulse, disturbances of distribution of the blood, increased catabolism, and disordered secretions.

=Etiology.=—In infectious diseases fever is due chiefly to the action of various toxic or harmful agents, produced by the disease, upon the fluids of the body and upon the nervous system. Disturbances of the thermogenic centers and nerves of the brain or cord by harmful agents, or by lesions of the anatomical structures affecting these nerves, are sources of fever. Also disturbances of the vasomotor centers (in the medulla and auxiliary centers along the cord) and nerves are causes of fever in many instances. A disturbed or lessened function of the nerves controlling sweating is an important factor. The multiplication of micro-organisms in the body, acting directly on the tissues or by producing toxic substances which affect the nervous system, is a fruitful source of fever. A few cases may be caused by direct affection of the nervous system, as is shown by appearance of fever in epileptic attacks, or by the passage of a catheter into the bladder. In a large number of all cases a demonstrable cause can be found upon careful examination, whether the fever be due to a necrosed mass of tissue, the introduction into the system of decomposed food, infectious diseases, a lesion of some anatomical structure affecting a thermogenic, vasomotor or sweat center, a lesion to the innervation to the heart (vagi and cervical sympathetic) causing a rapid heart, or a lesion to the lymphatic system.

=Treatment.=—The treatment of fevers in a general way consists principally of thorough inhibition to the posterior spinal nerves of the upper cervical region in order that the center of the vasomotor system in the medulla may be affected, probably by the way of the superior cervical ganglion of the sympathetic. Thus the entire vascular system is equalized, for there is always a disturbance in the distribution of the blood in fever and if the center controlling the nerves that govern the lumen of the blood-vessels can be brought under control, there will result an equalization of the vascular system; if such occurs, health must ensue. Besides the vasomotor nerves to the blood-vessels being affected by this treatment, the nerves governing the lymphatics and the sweat glands will also be controlled. The sweat glands as a rule are rendered active by affecting directly the innervation of the glands, also the glands are controlled indirectly by the blood supply; this aids materially in lessening the temperature of the body. Treatment for a few minutes to the upper posterior cervical region would also affect the thermogenic centers and nerves of the brain reflexly in the same manner as the vasomotor and sweat centers and nerves are affected, thus tending to equalize the mechanism of the thermogenic system. Besides this action on the vasomotor, sweat, and the thermogenic nerves, there is produced an increased exhalation of moisture from the lungs, on account of an increase of vascular area in the lungs through vasomotor action. Also the large vascular area in the abdomen, under control of the splanchnic nerves, becomes constricted. Thus there is brought about a lessening temperature by evaporation, heat radiation, and perspiration; and an increased action of the general nervous system, a stronger cardiac force, an equalization of the vascular system, and a more perfect elimination of toxic properties by the skin, kidneys and lungs; consequently a reduction of the fever.

The foregoing treatment is successful to a limited extent, only in such cases where causative factors of the fever are involving the predominating centers controlling the heat production or dispersion and the vasomotor system directly; for if the lesion that is causing the disorder should be affecting an auxiliary center along the spinal cord instead of the predominating center, as is oftentimes the case, treatment of the predominating center would be useless as far as any permanent benefit is considered; although a temporary effect will be gained by lessening the fever at that point. Consequently, in many cases, the lesion lies within the jurisdiction of auxiliary centers which are situated at various points along the spinal cord. When such is the case, it will be of little benefit to give the cervical treatment. In such instances the lesion to the auxiliary center would have to be removed in order to cure. One cannot depend upon a set rule to reduce a fever; determine the cause, as in any other disease or symptom, and remove it.

In addition to the treatment to the cervical region and along the spinal column, as are indicated upon an examination, attention should be given to the heart’s action. The equilibrium between the accelerator and inhibitory nerves (cervical sympathetic and vagi) should be maintained. The interchange of gases in the lungs should be rendered as nearly normal as possible; this is best accomplished by raising and spreading of the ribs from the second to the seventh dorsals, particularly in the region of the fifth and sixth. Also stimulation of the vagi will aid by increasing the motor power of the lungs. The kidneys and bowels should be kept active so as to favor a rapid elimination of various toxic properties; besides they have control over large vascular areas. Treatment over the ureters will prevent any clogging that might occur in them from a condensation of the urine. Attention, also, should be given the tissues at the fifth lumbar and over the iliac vessels to influence the circulation in the pelvis.

The =food= of the patient should be liquid—milk, soup, broths, etc., and almost any quantity of water allowed if called for, given little at a time and at frequent intervals. The room should be well lighted, ventilated, clean and kept at an even temperature.

=Two points= should always be remembered relative to fever:

First—That there are many causes of fever; and in order to reduce the fever the cause must be determined and removed, the same as in any disorder. A definite fever treatment cannot be given any more than a definite constipation treatment; the case must be seen in order to determine the cause.

Second—The reduction of fever is not necessary; the fever should be treated only as a symptom of disease when it exists as such. In fact, fever is beneficial, for it is one of nature’s methods to relieve an over-burdened system from harmful agents, unless the temperature is excessive and continuous and is likely to cause more harm than the primary trouble.

Absolute =rest= in bed always is of decided benefit in lessening the temperature.

=Hydrotherapy= is of immense value in reducing a fever. It is an agent that has been greatly used, and if applied intelligently cannot but be of aid. There is much ignorance in regard to the principles and practice of hydrotherapy, not only among all classes of people, but among well informed practitioners in medicine. The most important function of the skin is as a heat regulator. Knowing this fact, the osteopath treats the vasomotor nerves that control the cutaneous circulation and the nerves that control the excretion of the skin; the nerve supply being from the cerebrospinal and sympathetic nerves. In many difficult and obstinate cases hydrotherapeutic measures should be used to aid the skin in regulating the temperature, as well as to enhance system functions for the same reason that osteopathic manipulations are given. Maintaining an equilibrium in heat production and heat dispersion is necessary in order that the standard of the body temperature may be kept; and the amount of the arterial blood circulating within a tissue determines its temperature.

The principal effect of water as a thermic agent when applied externally is due to the influence of the action of the water upon the cutaneous circulation. Lesser effects would be the mere extraction of heat from the body by evaporation and the equalization of temperatures of two bodies coming into contact. As the body is endowed with compensatory powers, this latter means would apply only to a limited extent. The temperature of the water used is important, as the colder the bath the less effective would its power be in reducing internal temperature. When a cold bath is used there is a driving of the blood away from the surface on account of the contraction of the peripheral vessels; consequently increasing the cutaneous circulation and cooling by radiation is prevented and less heat is lost. A collateral hyperemia occurs in the underlying parts which acts as a protection to the deeper tissues. The cold also inhibits the vasomotor nerves controlling the abdominal splanchnics, and thus a larger amount of blood passes to this immense vascular area. On the other hand, when a warmer bath is used the effect is opposite, and a lowering of the temperature is the result. The cutaneous vessels being dilated, the superficial blood is rapidly replaced by blood from the deeper vessels, thus allowing a cooling of the body to a large degree.

In the various fevers where hydrotherapeutic measures are employed, the object to be gained by such methods is not primarily an anti-thermic one but an anti-febrile reaction; consequently the use of cold water is employed. In mere heat reduction the warmer water would be more effective; but by the aid of the colder water the cause of the increased temperature, as in infectious fevers, is lessened; besides a refreshing and stimulating effect upon the entire system is gained. Thus the aim of the cold bath and friction, is not primarily to subdue the temperature by heat radiation or evaporation, but to correct disturbances governing the formation and the dissipation of heat caused by infectious fevers, and, moreover, to stimulate the nervous system, prevent heart failure, increase the eliminating power of the skin, kidneys and lungs, and to influence the corpuscular and chemical constituents of the blood to a more normal condition.

The full cold bath and friction (Brand Method) is commonly employed in infectious fevers. The half bath, wet pack, or sponging may be used. The modus operandi of each is given under the hydrotherapeutic treatment of typhoid fever.

Typhoid Fever

(ENTERIC FEVER)

In writing of these acute diseases which are self-limiting, it is understood that osteopathy aborts, overcomes symptoms and otherwise changes conditions frequently. When this occurs the case is not typical and it is a typical case which is here described.

=Definition.=—An acute, infectious disease caused by the bacillus typhosus. It is characterized anatomically by hyperplasia and definite lesions of Peyer’s patches and mesenteric glands, and enlargement of the spleen, and clinically by its slow onset, often diarrhea, abdominal tenderness, tympanites, fever, headache, and rose colored spots on the abdomen.

=Osteopathic Etiology and Pathology.=—Lesions to the lower dorsal and lumbar regions are always found, which impair the innervation and vascular supply of the intestines and cause defective nutrition. This is the most important predisposing cause, although general lowered vitality from overwork, improper food, unhygienic environment, and insanitary surroundings, are also of great importance. It is possible that one’s vitality may be so lowered that the bacillus of Eberth, if of sufficient numbers or virulency, will find a suitable medium wherein to multiply and grow, and thus the spinal lesions found in these cases are the result of reflex irritation. But the most probable underlying cause is the spinal lesion, and given two individuals with equal likelihood to infection, one with the spinal lesions and the other not, the former within all probability will be the more likely to suffer an attack. The severity and extent of the osteopathic lesion undoubtedly bears a direct ratio to the probability of attack from an infectious disease. Typhoid fever usually occurs between the ages of fifteen and thirty years. Some families are more susceptible than others. The autumn months, especially after a dry, hot summer, favor the disease. One may be reasonably certain that whenever there is a case of typhoid the individual has not been careful as to diet, or drinking water, or some rule of health, and wherever there is an epidemic it can always be traced to insanitary surroundings, the water supply, contaminated garden truck or other food, sewage, etc.; although this does not preclude the probability that the osteopathic lesion or lowered vitality of Peyer’s patches and mesenteric glands from other causes are important and many times primal etiological factors. The specific poison may be so virulent that practically no one escapes and again those of lowered vitality only will succumb to an attack.

The =exciting cause= is a special micro-organism, the bacillus of Eberth. The contagion may be carried through the air from one person to another, but this is rarely the case. Though the water is the most common mode of conveyance, the bacillus has been found during epidemics in both water and milk. The water may be contaminated by the intestinal discharges which have not been properly disinfected. Extreme cold does not destroy the typhoid germs. Milk may be infected from the milk-can being washed with the contaminated water or the unclean hands of the milker. In fresh milk the germs multiply rapidly. Salads, celery, ice and fruits may be contaminated. Oysters have become infected while being fattened or freshened. It is thought by some that the poison is not eliminated from the sick in a condition capable of transferring disease to a healthy person, but must undergo changes in the soil before it is able to cause the disease in another. Typhoid fever may be caused, however, by direct contact with the stools. Filth, sewers, or cesspools do not directly cause the disease, but they form a suitable medium for the preservation of the typhoid germs.

=Pathologically=, the characteristic lesions in typhoid fever consist of changes in the lymphoid elements of the bowels. These changes are most striking in the solitary glands and Peyer’s patches. The alterations which occur may be divided into four well defined stages: (1) =Infiltration=—the glands are enlarged from infiltration and there is marked cell proliferation, particularly Peyer’s glands in the jejunum and ileum and to a lesser extent those in the large intestine. The glands become pale and prominent. Occasionally the solitary glands, which are usually deeply imbedded in the submucosa, become prominent also.

=Microscopically=, the capillary blood-vessels are at first considerably dilated, but later become more or less contracted, giving an anemic appearance to the follicles. The adjacent mucosa and muscularis may become infiltrated. The cells have the character of lymph corpuscles, some of which are larger, epithelioid in character, containing several nuclei. From the eighth to the tenth day this medullary infiltration reaches its height and then undergoes either resolution or necrosis.

(1) =Resolution= takes place by a granular or fatty infiltration of the cells. This produces pitting of the swollen follicles, which may cause small hemorrhages.

(2) =Necrosis.=—With all the severe cases of cell infiltration, hyperplasia of lymph follicles reaches a stage where resolution is impossible and necrosis occurs. The necrosis is partly due to the choking of the blood-vessels and partly to the direct action of the bacilli. The necrosis may involve only the superficial layers of the mucosa or it may extend deep into the muscular coat and even perforate the outer or serous coat. Usually, however, this does not extend below the submucosa, mucosa, or muscularis. Not all of the patches necessarily slough, but as a rule it is always more intense toward the ilio-cecal valve.

(3) =Ulceration.=—The extent and depth of the ulcers depend upon the amount of the necrosis. Large ulcers are sometimes formed, especially in the lower end of the bowel, by the union of several. The edges are swollen and undermined. The base is usually smooth and formed of submucosa. Perforation of the bowel occurs in a small percentage of cases; more commonly the ulcers heal. The perforations may be multiple, but rarely exceed two in number.

(4) =Healing.=—Cicatrization begins about the fourth week. This granulation tissue covers the floor. It is sometimes formed with connective tissue and a new growth of epithelium results. The gland is ultimately replaced by a depressed scar with a smooth, pigmented surface. The majority of deaths occur before this stage is reached. The gland structure is never regenerated.

The =mesenteric glands= show intense hyperemia and later become enlarged and softened, but rarely ruptured. The glands at the lower end of the ileum are markedly involved.

The =spleen= is enlarged, softened, and diffluent. Occasionally rupture occurs. Infarction is not a rare occurrence.

The =liver= shows parenchymatous and granular degeneration, and the cells are found to contain much fat. Infarction abscesses and acute yellow atrophy occur in rare instances. Diphtheritic inflammation of the gall-bladder sometimes occurs and the bile is thinner and paler than normal.

The =kidneys= also show parenchymatous degeneration. They are pale in appearance, with slight cloudy swelling. Microscopically, there are seen granular and fatty infiltration of the cells of the convoluted tubules. Rarely, there is acute nephritis which may be hemorrhagic. There may be miliary abscesses in which typhoid bacilli have been found by some observers. Diphtheritic, but more frequently catarrhal, inflammation of the pelvis of the kidney may occur. Catarrh of the =bladder= is not infrequent and even sometimes diphtheritic inflammation is present. Rarely orchitis is encountered.

=Hypostatic= congestion of the =lungs= is not uncommon. Gangrene and hemorrhagic infarction are sometimes present. Lobar pneumonia may be a complication.

In the =larynx= ulceration is sometimes met with bacilli, however, have not yet been found in these ulcers. Diphtheritis of the pharynx and larynx may occur. Catarrhal or croupous pharyngitis may occur; while swelling of the follicles of the pharynx and base of the tongue is frequently noticed.

=Peritonitis= is always present in fatal cases in which perforation of the bowel has taken place. The perforation may occur in ulcers from which the sloughs have already separated, or it may be caused by a necrosis of all the coats. Extensive peritonitis may occur without perforation, and is probably due to extension of the inflammation to the peritoneum.

The =heart= may be affected. Endocarditis is rare, while pericarditis is much more frequent. Myocarditis is frequently met with, the cardiac muscles presenting parenchymatous and rarely hyaline degeneration. The =arteries= are frequently found to be involved. These conditions (obliterating arteritis and partial arteritis) may affect the smaller vessels, especially those of the heart, but more commonly affect the arteries of the lower extremities. Thrombosis of the veins, especially of the femoral, and more rarely of the cerebral veins and sinuses, occurs.

Granular and hyaline changes in the voluntary =muscles= may occur. This degeneration does not affect the whole muscle but involves only certain fibres. Regeneration takes place during convalescence.

With the nervous system meningitis is rare. The peripheral =nerves= are frequently the seat of parenchymatous changes. The ganglia of the trunks of the vagi present an inflammatory change.

The =blood= presents little change. During the first two weeks the red corpuscles gradually decrease in number until the first week of convalescence, after which they gradually increase in number. There is often a marked decrease in the number of leucocytes. Leucocytosis is absent. The hemoglobin is always reduced.

=Symptoms and Course.=—The incubation period varies from a few days to two weeks or longer. During this time the patient may feel in his usual health, but more often there is a feeling of languor and indisposition to exertion, loss of appetite, slight coating of the tongue, nausea, headache, chilliness, but seldom a decided rigor, pains in the back or legs and nose-bleeding. Any of these symptoms may be present and last usually from a few days to a week or more. These symptoms increase in severity and the patient takes to his bed. The invasion as a rule is gradual.

The =first week= dates from the onset of the fever which generally (but by no means in all cases) rises steadily during the first week a degree or a degree and one-half each day, reaching 103 or 104 degrees F. The pulse is quickened to 90 to 110 per minute and is full, of low tension and sometimes dicrotic. There is great thirst, also a coated tongue. The skin is hot and dry and there is rather intense headache. Unless the fever is high there is no delirium. The sleep is disturbed and there may be mental confusion and wandering. Cough with some thoracic oppression is not uncommon at the onset. The abdomen is slightly distended and tender. There may be either constipation or diarrhea. The spleen is somewhat swollen and a rose colored rash appears on the skin of the abdomen and chest.

During the =second week= the fever remains high and exhibits the continued type, the morning remission being slight. The pulse is accelerated. The headache disappears, but there is marked mental dullness and slowness and there may be a mild delirium at night. The tongue is coated and the lips are dry. The abdomen is tympanitic and tender. Diarrhea replaces constipation. The case may prove fatal during this week from the result of nervous or pulmonary symptoms, hemorrhage, or perforation.

The fever changes in the =third week= from a continuous to a remittent type. The pulse ranges from 110 to 130. The patient is very weak. Complications may arise, as pulmonary symptoms, feebleness of heart, intestinal hemorrhage, perforation, and peritonitis.

In favorable cases during the =fourth week= the fever begins to decline and the general and local symptoms gradually disappear. In protracted cases the =fourth= and =fifth= weeks may present the symptoms of the third week. Frequently the following aggravated symptoms are added: stupor, delirium, increased weakness, rapid, feeble pulse, and distended abdomen. Heart failure and inflammatory complications increase the danger.

During the =fifth= and =sixth weeks= a few cases will show irregular fever. Great care should be taken that complications do not occur.

The =fever= is the most important and characteristic symptom and from the temperature alone a diagnosis may be made. During these stages of development, which is the first four or five days, the temperature rises steadily; the evening temperature being about a degree or a degree and one-half higher than the morning remissions, reaching 104 or 105 degrees F. at the end of the first week. When the =fastigium= is reached the fever persists with slight morning remissions. At the end of the second and throughout the third week the temperature becomes more remittent and there may be a difference of three or four degrees between the morning and evening temperature. During the last stage the fever falls by =lysis=, forming a more or less regular step-like line of descent. The stage lasts from one week to ten days.

When the disease sets in with a severe rigor the fever frequently rises at once to 103 or 104 degrees F. In the lightest forms the fastigium may be almost absent; defervescence setting in upon the first day of the fastigium and in many cases defervescence occurs at the end of the second week and the temperature may fall rapidly, becoming normal in ten or twenty hours. This fall in the temperature may take place without any apparent cause or it may follow an intestinal hemorrhage. The temperature often falls many hours before the blood appears in the evacuations. The occurrence of peritonitis is also marked by a sudden fall in the temperature. =Hyperpyrexia= in typhoid fever is not very common except just before death.

After the temperature has been normal for several days there may be a sudden rise of the temperature to 102 or 103 degrees F. This may persist for a couple of days and then return rapidly to the normal. These =recrudescences=, as they are called, are quite common and are caused most frequently by errors in the diet, constipation, excitement or mental emotion. These elevations in the temperature are found most frequently in children and persons of a nervous temperament.

=Afebrile Typhoid= is of very rare occurrence. The patient has all the characteristic symptoms of typhoid fever with the exception of a fever.

The =rash= is highly characteristic. It appears about the eighth or tenth day, usually upon the skin of the abdomen or chest, rarely found elsewhere on the body. It consists of a variable number of rose colored spots distinctly elevated, and disappear on pressure. These spots last three or four days and appear in successive crops. Vivid red erythematous eruptions upon the chest and abdomen are commonly seen during the first week of typhoid fever. Urticaria is rarely seen.

Sweating characterizes some cases of typhoid fever, but generally the skin is dry. This may occur with or without chilly sensations or actual rigors. In some cases there may be recurring paroxysms of chills, fever, and sweats and they may be mistaken for intermittent fever. Edema of the skin may occur and is usually due to anemia or cachexia and sometimes to nephritis. Local edema may occur as the result of vascular obstruction, particularly thrombosis of the femoral vein. There is a peculiar musty odor exhaled from the skin in typhoid fever, particularly if the skin has been neglected. In all protracted cases =bed-sores= are likely to develop. The =hair= is apt to fall out but is generally renewed. The nails also suffer and ridges can usually be observed upon them.

=Intestinal symptoms= are very inconstant. Usually there is constipation at the onset and this may persist throughout the disease although a moderate diarrhea may occur throughout the disease. The severity of the diarrhea is due most probably to the degree of the catarrh rather than to the extent of the ulcers. It is probable that the discharges are more frequent when the catarrh involves the large intestine. The number of discharges average, as a rule, from two to four or more daily. The stools are either fluid or of the consistency of jelly, of a grayish-yellow color, alkaline in reaction and are very offensive.

=Hemorrhage= is a serious symptom, but by no means always fatal. This usually occurs in cases of considerable severity and it generally occurs at the time of the separation of the sloughs during the third week. When it occurs quite early in the disease it is generally the result of hyperemia. It may be so slight as not to be noticed by the eye or it may be from one to three pints. Intestinal hemorrhage, however slight, is always a grave symptom. There may be symptoms of collapse and fall of temperature, or it may occur without any symptoms.

=Meteorism= is an almost constant symptom, and when excessive adds to the seriousness of the case and corresponds generally with the extent of local lesions. Abdominal tenderness and gurgling upon pressure in the right iliac fossa may be present; pain is generally absent, and when present is usually slight.

=Perforation= almost invariably causes fatal diffuse peritonitis and is the most serious complication. It may occur at any time but is most common between the second and fourth weeks. It is usually indicated by sudden acute pains in the abdomen and symptoms of collapse. As a rule symptoms of =peritonitis= appear at once; distension of the abdomen, great tenderness, and rigid abdominal walls. Vomiting, pinched features, and rapid, small pulse shows general collapse of the circulatory system.

=Bronchitis= is almost invariably present as an initial symptom. It is indicated by the existence of sibilant rales. The cough is generally slight.

Hypostatic congestion of the =lungs= and edema, due to enfeeblement of the cardio-pulmonary circulation, in the latter part of the disease are not infrequent.

The =pulse= as a rule is not very frequent and is generally not in proportion to the fever until late in the disease; 90 to 120 is the usual range. During the first week it is about 100, full, and frequently dicrotic; later it becomes more rapid, feeble and small. In severe cases during the extreme debility of the third week the pulse may reach 150 or more (the so-called running pulse). During convalescence the pulse occasionally becomes subnormal and bradycardia is met with more frequently than after any other acute fever.

The =blood= presents definite changes, some of which are important. In cases where there is profuse sweating or copious diarrhea, the red corpuscles may be relatively increased; this is due to the loss of water. In most cases there is little change until the end of the second week. During the third week there is generally a decrease in the number of corpuscles and of the hemoglobin, which is always reduced. =Leucocytosis= is always absent. The white corpuscles are slightly diminished especially toward the end of convalescence.

During the first week there is generally persistent headache, sometimes neuralgia. There are a few cases in which the effects of the typhoid bacilli or their poison is manifested in the =nervous system= from the very onset. There are violent headaches, retraction of the head, rigidity, photophobia, twitching of the muscles, rarely convulsions, all indicating meningitis as which it is occasionally diagnosed. It must be remembered however, that all nervous symptoms may occur independently of a lesion of the nervous system.

=Delirium= may exist from the onset, but it usually is not present until the second or third week and only in the severer cases. As a rule it is most marked at night. It is generally of the low, muttering type, very seldom maniacal. When the patient picks at the bed clothes or grasps at imaginary objects there is indication of danger, as it is a serious symptom. Convulsions are rare.

The =urine= is diminished in quantity, high specific gravity, and of dark hue. Both urea and uric acid are increased and the chlorids are diminished during the first stages. About the stage of decline the urine becomes light in color and greater in quantity than normal. The specific gravity is lowered, urea and uric acid are diminished, and the chlorids are increased. Febrile albuminuria is very common but of no special significance. Acute nephritis may develop as a complication. Pyuria is not an uncommon complication and post-typhoid pyelitis may also develop.

=Malarial fever= may be associated with typhoid, especially in malarial districts. Persons with tuberculosis, epilepsy, chorea, and other forms of chronic nervous diseases are liable to typhoid fever. In epilepsy and chorea the movements and fits usually cease during the attack of typhoid fever.

=Varieties of Typhoid= are numerous and are named with reference to the degree of severity which varies from extreme mildness to extreme severity.

The =mild= or =abortive= form is of frequent occurrence. The onset is usually sudden. The symptoms are similar to those of a typical case but much milder and appear earlier than in the usual type. This form runs its course in about two weeks. The fever usually reaches 104 degrees F.

In the =severe= or =grave= form there is high fever and the nervous symptoms show a profound intoxication of the system. The grave types are those associated with serious complications or those cases which set in with pneumonia, Bright’s disease, or cerebrospinal symptoms.

In the =latent= or =ambulatory= form (walking typhoid) the symptoms are very slight, the patient being hardly sick enough to go to bed. The symptoms may be of this character throughout the attack, and the patient may be able to be up and about. In other cases the first symptoms are very mild, but later they may develop symptoms of the severest type.

The =Afebrile= form is rare. =Hemorrhagic= typhoid is a very fatal but rare form. In this type there are cutaneous and mucous hemorrhages.

=Diagnosis.=—As a general rule typhoid fever is easily recognized. The Widal test should be made. At times the diagnosis may have to be delayed until the distinctive signs appear, especially in those cases which come on with severe headache, delirium, twitching of the muscles, and retraction of the head. In these cases the diagnosis of cerebrospinal meningitis is invariably made, until the appearance of the colored spots on the abdomen, which must decide the diagnosis; cerebrospinal meningitis being a rare disease and typhoid fever with severe nervous symptoms quite frequent, it is more probable that it is typhoid. At least one-half of the cases termed brain fever belong to this class of nervous typhoid.

=Prognosis.=—A positive prognosis can not be made, as even the mildest cases are liable to have severe complications develop at any stage of the disease. Under osteopathic treatment the prognosis is undoubtedly more favorable than with the treatment of the older schools. If the osteopath can see the case early, the first week, there is always a chance to abort the attack. In all cases there is the probability that the attack will be shortened; this is a common experience. Price of Mississippi, has treated many cases, and invariably when the patient is seen early the attack has been shortened to thirteen or fourteen days, whereas under other treatment the disease runs the usual course. Adsit of Kentucky, White of New York, and the staff of the American School of Osteopathy (Kirksville), as well as many others, have had the same experience. And if the attack cannot be aborted or shortened there is the further probability that the severity will be lessened and complications prevented. The prognosis is always more favorable in winter than in summer, and especially favorable in children. More women die than men, and fat persons stand the disease badly.

=Treatment.=—Typhoid fever is one of the diseases that practitioners of all the schools are agreed that drug therapeutics avail but little in its treatment. The treatment of the older schools consists of prophylaxis, good nursing, attention to hygienic principles, dieting, and hydrotherapy. All of these have their places and are recognized by the osteopathic school. But the above methods are of the defensive only—allowing the disease to run its usual course and reducing the likelihood of complications. On the other hand the above treatment coupled with osteopathy, not only attacks the ravages of the disease defensively, but of more importance, the disorder is attacked offensively. Herein is where attacks are aborted, or shortened, or severity lessened, or complications prevented. The efficacy of osteopathy is due to the ability of the osteopath to treat disease, not only prophylactically and palliatively, but of more consequence, aggressively.

The correction of the spinal lesions in typhoid fever is of first importance. This treatment effects a tendency toward equalized circulation of the intestines. The vasomotor nerves are disturbed by the above lesions which in turn produces stasis in Peyer’s patches and the mesenteric glands. Reversely some of the spinal lesions may be due to reflex stimuli, for “Kirk ... states that muscular contractions produced by reflex activity are often more sustained than those produced by direct stimulation of the motor nerves themselves.”[51]

=Prophylactic= treatment is very essential, for typhoid fever as a rule is a preventable affection. Modern hygienic and sanitary resources enable a community to reduce the number of cases to a minimum. The number of cases in a locality depends almost directly upon the condition of the water supply and drainage. Care should always be taken in regard to the source of drinking water and milk. During an epidemic the water should be boiled for half an hour before being used. The patient should be isolated. In hospitals they should have special wards; in families a special apartment should be given them. Hygienic principles should be followed as in other infectious diseases.

The methods of disinfection must be rigid to prevent the spread of an infection. The excreta (stools, urine, vomitus, and sputum) are to be received into a bed-pan or any appropriate receptacle containing half a pint of carbolic acid (one to twenty). Three or four pints of the carbolic acid (one to twenty) should then be added to the bed-pan and the contents mixed carefully before emptying. All utensils used in handling the excreta are to be carefully disinfected by the same material, and dried. After every stool the nates of the patient should be cleansed by a cloth compress, wet with a solution of carbolic acid (one to forty) and the cloth burned. The sick room should be thoroughly ventilated each day. All utensils used about the patient in feeding should be boiled in water immediately after using. The bed and body linen is to be changed as soon as soiled and these, with all changed bath towels, blankets and rubber sheets, should be received in a sheet rinsed in carbolic acid (one to forty) and placed where they may be soaked in the solution for four or five hours. The clothes are to be boiled for half an hour. The rubber blanket is to be washed in the solution, dried and aired.

The =General Management=, careful nursing and a regulated diet, is of paramount importance in the treatment of typhoid fever. The patient should be placed in bed as soon as the disease is determined and there remain until the end of the attack. The room should be well ventilated and have a sunny exposure if possible. The single woven wire bed with soft hair mattress and two folds of blankets is best. A rubber cloth should be placed smoothly under the sheet. When a good nurse cannot be had, the attending osteopath should write out directions regarding diet, bed linen, and utensils, and the disinfection of the excreta.

A liquid =diet= should be administered. Milk is most commonly used; care being taken that it is thoroughly digested. If milk is not borne well by the patient, other foods, as whey, sour milk, buttermilk, and broths may be substituted. Give food that is easily digested and which leaves but little residue. When milk is used alone, three pints at least may be given to an adult in the course of twenty-four hours; and it should always be diluted, preferably with plain water. Beef juice, mutton or chicken broth may also be used when milk is not agreeable. Albumin water, prepared by straining the white of eggs through a cloth and adding an equal amount of water, is an excellent food. Well strained, thin barley gruel is considered by many an excellent food for typhoid fever patients. Cases not able to take nourishment into the stomach, on account of vomiting and other causes, should be fed rectally to support life. Do not force feeding to an unwarranted degree.

Recently a number of new diets have received commendation. These include the “high calory” diet, which includes three pints of milk with one of cream, two to eight ounces of milk sugar, eggs, butter; sometimes cereals, toast, potato, and other soft foods are given. A full sugar diet, as of candy alone, is based upon the immediate absorption of sugar, its value as a source of energy, and the fact that a plentiful carbohydrate supply lessens the danger of acidosis.[52]

The best drink for fever patients is pure, cold water and they should be encouraged to drink freely of it. Barley water, ice tea, lemonade, or even moderate quantities of coffee or cocoa, may be given.

By =Osteopathic Treatment= many cases of typhoid fever may be aborted, if treated correctly, during the first week. If the stage of necrosis of Peyer’s patches has set in, one can either lessen the severity of the attack or, at least, shorten the usual course. During the stage of infiltration, treatment to the intestinal splanchnics (chiefly from the ninth to twelfth dorsal, the innervation to the jejunum and ileum) and careful treatment over the abdomen is indicated. This treatment will tend to lessen the intestinal catarrh and diminish the infiltration and cell proliferation of the lymphoid elements of the intestines, and thus produce unfavorable the conditions for the bacillus of Eberth. In other words, increase the tone and activity of the intestines so that the micro-organisms of typhoid fever will not find the proper tissue-soil in order to grow and multiply.

All cases of typhoid fever present lesions in the dorsal or lumbar spine and this is really the great predisposing cause of typhoid fever. Correcting these lesions is absolutely necessary in order to abort the disease. Some patients may have such a lowered vitality to begin with that the recuperative powers of the body cannot be rendered forceful enough in a short time to combat the effects of the micro-organism. Carefully raising the cecum is very effective (A. T. Still), but this must be done with the greatest of caution and judgment. Dr. Still considers a posterior condition of the third, fourth and fifth lumbars as typical in typhoid and that it inhibits the lymphatics to the intestines.

R. L. Price has had excellent success in shortening the usual typhoid course. His first treatment is to thoroughly empty the bowels by enemata. This is followed by spinal, liver and splenic treatment, and a liquid diet.

E. C. White has also treated a large number of typhoid cases with marked success. He prefers to employ the Brand method (and it must be properly used) from the start. He is, also, a thorough advocate of the spinal treatment. In cases of constipation give a very light treatment over the left iliac fossa. With all patients observe careful dieting. White believes that many lesions of the spine arise from reflex irritations during acute attacks. Careful, frequent attention to the spine is demanded.

Hildreth, relative to abdominal and spinal treatment, writes as follows: “In the abdominal treatment of typhoid fever, too much care cannot be exercised; or in the spinal treatment, too much judgment used in giving just the right kind of manipulation. There can be no question relative to the seat of the disease, and consequently there should be no trouble in knowing where or how to affect the nerves to control the same. That Peyer’s patches or the right iliac region is always involved, we all know. The spinal treatment should be applied from the eighth dorsal to the first lumbar inclusive; this affects all the lesser splanchnics and thus controls the circulation of the entire bowel. And this treatment should be given, according to the symptoms indicated, in each and every case. If the patient is constipated, then the treatment should be more of a stimulative character, but if diarrhea is present, as is commonly the case, the treatment should be an inhibitory one. In the above I always finish with a very careful treatment of the floating ribs on the left side; this affects the lesser splanchnic nerves. In all cases I always carefully treat the lower two or three lumbar vertebræ, which directly affects the hypogastric plexus of nerves, and thus controls the circulation to the lower bowel.

“In all cases I always treat the bowels directly, more or less, but this treatment =must= be given with the very greatest =care= and the best judgment, always governed by the condition of the bowel. By no means manipulate the bowel, but just lay your hands flat on the abdomen, and with the most gentle pressure inhibit the peripheral nerves, thus either quieting an excited peristalsis or equalizing a disturbed circulation. And with this treatment remember that the two specific points in typhoid fever are the lower dorsal and lower lumbar nerves.

“The above treatment is used, of course, in connection with all the other necessary treatments, such as dieting, nursing, sponging, relieving the headaches, etc. I am unalterably opposed to ice-packs for the bowels in typhoid, for the reason it is too much of a shock. Cold cloths are good and much better than ice, and should always be used instead of ice.”

After the disease has become thoroughly established always make it a point during each visit to examine the entire length of the spinal column carefully and readjust any tissue, whether it be vertebra, rib, or muscle, that may be found disordered. The bowels are to be watched carefully and if constipated, they should be moved with a light enema. Great care must be taken not to treat the abdomen roughly, if at all, after the first week. The treatment might be very injurious to the structures diseased. A light treatment over the liver and kidneys each time is a wise precaution. The heart’s action, should be watched carefully. In addition to the hydrotherapeutic treatment, the general fever treatment should be employed. The patient should usually be seen twice a day.

=Abdominal pain= is best relieved by light treatment over the abdomen and by thorough treatment of the lower dorsal or lumbar region. Applications of hot water will be helpful.

=Meteorism= can be relieved by raising the lower ribs and by direct treatment to the abdomen. A change of diet may be beneficial. When gas is in the large bowel an enema may be given to remove it.

=Diarrhea= and =constipation= are best controlled by the usual treatment given the spine in such cases, and over the abdomen and the liver. Light enemata may be given for constipation. The stools should be examined when diarrhea occurs, as the presence of curds may cause the aggravation.

=Hemorrhage= from the bowels demands absolute rest. It is probably better to have the patient use the draw sheet for the evacuation. Immediate and thorough treatment must be given to the spinal column in the region of the intestinal nerves to the diseased area, so that existing lesions may be corrected and the vascular area of the mesentery equalized. Ice should be given freely and an ice pack placed over the abdomen. Food should be restricted for ten or twelve hours. If the peristalsis of the intestines is increased, an effort should be made to control it through the vagi and splanchnic nerves.

In =perforation= hot applications, rest and thorough treatment of the innervation to the peritoneum are of value, but immediate operation is usually advisable.

=Insomnia= is best relieved by attention to the cervical region. Relaxation of the muscles in this region and a quieting treatment to the posterior occipital nerves, coupled with cold sponge baths, will usually induce sleep.

In =delirium= attention to the circulation of the brain, by careful treatment of the vasomotor system, and the Brand method of baths will relieve this distressing symptom.

During =convalescence= the patient should be restricted from any mental or physical exercise for a week or ten days and then should move about with care. Solid food should not be given for ten days or two weeks. If the temperature has been normal for ten days, it is then safe to allow such food as eggs, milk puddings, and milk toast. If diarrhea should persist, being due to ulceration, the diet should be restricted and the patient confined to the bed. If constipation is troublesome relieve it by enemata.

There are several beneficial effects obtained by =hydrotherapeutic measures= that should receive careful consideration. Probably it is of the least significance to lower the temperature; other beneficial effects being of greater importance. When the baths are systematically carried out, (1) there is obtained a general improvement of the nervous system, the mind is rendered clear, muscular twitchings are lessened, sleep is induced and the heart’s action strengthened; (2) the respiration is stimulated, thus diminishing the liability of lung complications; (3) the activity of the renal function is increased, consequently allowing more rapid elimination of toxic matter; (4) reduction of the temperature, and overcoming ill effects of high fever.

A cold water bath, or what is generally termed the Brand method, is commonly employed. The following plan is usually followed. When the temperature is above 102.5 degrees F., rectally, a bath of 70 degrees F. is wheeled to the patient’s bedside and he is placed into it for ten or fifteen minutes. The patient should be lowered into the bath by means of a sheet. Enough water is used to cover the body and neck of the patient. The head is sponged and the limbs and trunk are rubbed =thoroughly= during the entire procedure. When the patient is taken out he is wrapped in a dry sheet and covered with a blanket. This procedure is gone through with every three hours if the case is severe, otherwise once every seven or eight hours will be sufficient.

The luke-warm bath is occasionally used in private practice when one is unable to use the Brand method. A bath of 90 degrees F. is employed, which is gradually cooled ten or twelve degrees, after the patient has been placed in it, by pouring cold water on the patient. This bath is found very helpful. Also in private practice the cold pack is found satisfactory. The patient is wrapped in a sheet wrung out of water at 65 degrees F. and cold water is sprinkled over him. Whenever there is objection to any of these methods the body may be sponged off with tepid or cold water when the temperature rises above 102.5 degrees F., rectally. One limb should be taken at a time and then the trunk, occupying altogether some twenty or thirty minutes.

The Great War brought the subject of typhoid vaccination before the world with emphasis but its results are not, as yet, in shape so an unbiased opinion can be formed. The army medical department will tell us that it was an unqualified success but we do know that there were serious outbreaks among inoculated troops who were living under most hygienic surroundings in America. There were, also, outbreaks among protected troops in France to the extent that the medical authorities felt called upon to warn all medical officers that vaccination should not be considered as protecting against unsanitary surroundings and that great precaution must be observed, the same as under non-vaccination conditions. This does not imply implicit confidence.

It is, also, a historical fact that the Japanese army, during the Russo-Japanese war had as low a rate of typhoid without vaccination as can, probably, be shown with it in this war. At that time they depended entirely upon pure water and sanitation.

See reports of typhoid fever in A. O. A. Case Reports as follows: C. M. T. Hulett, Series I, p. 7, J. H. Wilson, Series III, p. 3, F. E. and H. P. Moore, and F. A. and E. S. Cave, Series IV, pp. 4 and 5.

In =paratyphoid fever=, an acute infectious disease caused by the paratyphoid bacillus, the treatment is the same as for typhoid fever. It is milder and similar to typhoid fever.

Typhus Fever

=Definition.=—An acute, infectious disease; characterized by sudden invasion, high fever, marked nervous symptoms, a peculiar maculated and petechial eruption and a termination by crisis about the fourteenth day.

=Etiology= and =Pathology=.—Typhus fever is becoming less frequent than formerly and is rarely seen in this country. It was very destructive during the Great War, particularly in the Balkan states. Filth, over-crowding, famine, intemperance and bad food are the predisposing causes. Typhus fever is highly contagious and is transmitted by the pediculus corporis (cootie) as was first discovered by the American Red Cross workers in Serbia. Probably infection may come by contact and fomites. The specific organism is the bacillus typhi exanthematici (Platz).

=Pathologically=, there are no constant lesions. There is a general hyperplasia of the lymph follicles, but no ulceration. The blood is dark, thin and lessened in fibrin. Hypostatic congestion of the lungs and bronchial catarrh are frequently met with. The liver, kidneys and spleen are found to be somewhat enlarged and softened. The petechial rash remains after death.

=Symptoms.=—The =incubation period= is about twelve days. The onset is usually sudden, ushered in by chills. The temperature quickly rises to 104 or 105 degrees F. There is headache, pains in the muscles, especially of the back, and early, profound prostration. The pulse is at first full and strong, 100 to 140, but soon becomes weak and frequent. There may be distressing vomiting. The face is flushed, the eyes injected, the expression stupid, and there is generally low, muttering delirium. The tongue is furred and white, soon becoming dry. The bowels are constipated and the urine is usually scanty and of high specific gravity. There is great thirst. Conjunctiva injected; pupils contracted; early prostration.

The =eruption= appears about the fifth or seventh day. It first makes its appearance upon the abdomen and chest. It rapidly extends all over the body with the exception of the face. The eruption is of two kinds—rose spots, which disappear upon pressure, and those which become hemorrhagic (petechial); pressure has no effect upon them. During the second week the symptoms are increased. The tongue is dry, brown and fissured, and sordes appear on the teeth. Retention of the urine, due to paralysis of the bladder, is common. The breathing becomes more rapid and the heart’s action more feeble; the patient may die from exhaustion. This ushers in the typhoid state with low, muttering delirium, ataxic symptoms, subsultus, tremors, and maybe bronchial symptoms. In favorable cases the crisis occurs at the end of the second week. Patient sinks into a sound sleep, the temperature falls rapidly, there is profuse sweating and a critical diarrhea but the patient now gains rapidly.

=Convalescence= is usually rapid; relapses rarely occur. The urine is scanty, high colored and frequently albuminous. Bed-sores are common. The temperature continues high, reaching 106 degrees F., or more, with slight nocturnal remissions. In fatal cases the fever often rises to 108 or 109 degrees F. just before death.

=Diagnosis.=—The sudden onset, frequent chills, early profound prostration, character of the rash, history of exposure to the poison and unhygienic surroundings decide the diagnosis. During an epidemic there is usually no doubt, but in sporadic cases the diagnosis is sometimes extremely difficult.

=Prognosis.=—This is usually grave, but the mortality rate is being greatly reduced in consequence of the better sanitary arrangements.

=Treatment.=—Typhus fever is highly contagious and great care should be taken in controlling the disease. Isolation, disinfection and extermination is imperative. So far as known none of the osteopaths have had experience in the treating of typhus fever osteopathically, but there is no reason why the disease should not be treated with the same success as is met with by osteopathic treatment in other diseases. It is claimed that the disease should be treated in the open air, in tents, as the recovery of the patient and the safety of the attendants are greatly favored.

For high temperature, besides the treatment given to remove any disorder that may be found, the general fever treatment is indicated, and hydrotherapy would also be of aid—sponging the surface of the body, or the use of the bath. Asthenia is wherein the greatest danger lies, and a stimulating treatment along the spine and to the heart should be given; although correction of the primary trouble may be sufficient. Hydrotherapeutic measures, the systematic use of the cold bath, would be of service the same as in typhoid fever.

Headache and delirium which are apt to arise, caused by too much blood in the head, may be relieved by treatment of the cervical spine. Also cold applied to the head will aid. The bowels should be watched carefully; treat the splanchnics thoroughly and the intestines and liver directly. Nourish the patient as in typhoid fever by nutritious liquids—milk, broths, etc.

Although typhus is now a comparatively rare disease, an outline has been given to emphasize what correction of unhygienic conditions and insanitary surroundings will accomplish. It is particularly a disease of filth.

Malarial Fever

(AGUE)

=Definition.=—An infectious disease caused by the hemocytozoon of Laveran. “It is characterized by paroxysms of intermittent fever of the quotidian, tertian or quartan type, a continued fever with marked remissions, a pernicious or rapidly fatal form, and a chronic cachexia with anemia and enlarged spleen.” (Halbert). The varieties of malarial fever are: intermittent fever; pernicious intermittent; remittent fever; malarial cachexia; masked intermittent; malarial hematuria.

=Osteopathic Etiology= and =Pathology=.—Malarial fevers are caused by a parasite known as the hematozoon of Laveran. Three varieties of the parasite have been separated, corresponding with the three leading forms of the affection. The parasite of tertian fever is about as large as a normal red blood-corpuscle, beginning as a small hyaline ameba in the red blood-corpuscles. The parasite of quartan fever is very similar in its appearance to the tertian parasite but smaller; its ameboid movements are slower and the red blood-corpuscle embracing it shrinks about the parasite, assuming a deeper greenish color. The parasite of the estivo-autumnal fevers is still smaller. “If only one group of parasites exists the paroxysms—quartan intermittent—will occur every fourth day. Double quartan infection will result in paroxysms on two successive days with an intermission of one day. Infection by three groups of parasites will create daily paroxysms—the quotidian intermittent. Infection by more than three groups is rare.” (Anders). Only in the earlier stages of development, small hyaline bodies are to be found in the peripheral circulation; being, in the later stages, in the blood of certain internal viscera, spleen, and bone marrow, particularly.

It is an accepted fact among medical observers that to the mosquito, anopheles, is due the spread of malaria and it has been the subject of much investigation in all parts of the world. The mosquito becomes infected from biting an individual whose blood contains the malarial parasite, this is then developed in the mosquito to maturity and later is transmitted to the next subject bitten. This explanation would show why certain localities favorable for the breeding of mosquitoes are particularly given to malarial outbreaks. Low, marshy grounds, banks of rivers, small ponds, etc., as well as warm weather, are needed to produce the conditions for the development of the anopheles. As the country has developed the intensity and extent of malaria has diminished until it is now confined largely to the southern states. It is practically unknown in the northwest and in the St. Lawrence basin. Regions which have never had cases, however, have developed them when the anopheles has appeared. Whiting notes cases in Southern California, the result of the insect being brought in by ships from Mexican or Central American ports. In certain regions the anopheles is present but has not apparently come in contact with a malarial victim, so is incapable of spreading the disease. Also in colder climates this species is harmless.

By draining the lands and preventing the breeding places, the number of the pests is reduced, while the screening of houses and care against exposure to the bites make it possible to live in malarial sections and not become infected. Naturally the resisting power of a patient is called into account when bitten by the mosquito. Where it is epidemic the inhabitants will be found, generally, poorly nourished or debilitated from climatic or other conditions. This renders infection easy, for immunity must come from the ability of the blood to combat the invading parasite.

The =osteopathic predisposing causes= for malaria are usually interference with the vasomotor nerves to the spleen and liver, as these two organs are so concerned in maintaining the stability of the blood tissue. Ligon, of Alabama, notes that most cases have lesions between the ninth and twelfth dorsal on the right side.

The chief =morbid changes= are clue to the direct effect of the malarial parasite upon the blood. There are also changes in the liver, kidneys, and spleen, which changes usually vary with the duration and intensity of the disease. The disintegration of the red blood-corpuscles, accumulation of the pigment thus formed, and the toxin engendered by the malarial parasite are responsible for the morbid lesions of the disease.

In =pernicious malaria= the blood is more or less hydremic, and the discs are seen in all stages of destruction. The spleen is enlarged and soft and the pulp dark from the accumulation of the pigment, and spontaneous rupture has occurred in a number of cases. The liver is swollen and turbid; pigmentation occurs, but is generally only visible by means of the microscope. By the aid of the microscope all the tissues of the body, even the brain, may be found to be pigmented.

The =spleen= in =chronic malaria= is greatly enlarged, firm, pigmented and the capsule thickened. The =liver= is enlarged, the color varying from a slight gray to a deep slate gray, according to the amount of pigment. The =kidneys= may be enlarged and deeply pigmented, as is also the mucous membrane of the =stomach= and =intestines=.

R. W. Connor observes that the kidneys and liver are most noticeably involved, vasomotor obstructions the rule, the spleen in the majority of cases shows engorgement and that special attention to these centers will give the best results. He invariably finds spinal lesions from the seventh dorsal to the first and second lumbar, most frequently the eighth, ninth and tenth dorsals. A lowered vitality predisposes to infection from the bite of the mosquito.

=Symptoms.=—=Intermittent Fever.=—This form is what is known as fever and ague, in which chills, fever and sweat follow each other. The period of incubation varies from six to fifteen days, but it may be months after exposure before the first paroxysms set in. The paroxysm is usually preceded by a feeling of uneasiness and discomfort, sometimes by nausea or headache. The paroxysm consists of three stages, cold, heat and sweating.

In the =cold stage= the chill usually begins gradually; it is generally intense, the teeth chatter and the body shakes violently. The skin is cool and pale, the lips are blue, the face is pinched and the patient looks very cold. During the chill the temperature rises rapidly. Nausea, vomiting and headache are common. The pulse is frequent, small and hard. The urine is increased in quantity and of low specific gravity. The chill lasts from a few minutes to a couple of hours.

The =hot stage= succeeds the chill. The skin gradually loses its coldness and becomes hot. The face is flushed, there is great thirst, the mouth is dry, and the tongue is coated. Usually at the termination of the chill the temperature has reached its maximum level, from 104 to 106 degrees F. The pulse is full, and there may be a throbbing headache. The duration of this stage is from half an hour to three or four hours. During the =sweating stage= drops of perspiration appear upon the face; the perspiration soon becomes profuse, extending all over the body. The temperature soon falls, the headache disappears and in a couple of hours the paroxysm is over.

The entire duration of the paroxysm is from eight to twelve hours; the patient usually feeling perfectly well between the paroxysms. The spleen is enlarged. If the paroxysms of fever occur daily at the same hour they are called =quotidian= intermittent fever; if every other day they are known as =tertian= intermittent; and if every third day they are called =quartan= intermittent. If there are two paroxysms in the same day the term =double quotidian= is used; if the paroxysms occur a couple of hours later each successive day they are called “=retarding=;” if a couple of hours earlier they are named “=anticipating=.”

=Remittent Fever.=—(Estivo-Autumnal Fever).—This is characterized by a continued fever with paroxysmal exacerbations and remissions. It occurs especially in warm and tropical climates. In temperate climates it usually occurs in the late summer and fall. It is also termed bilious remittent fever on account of the intensity of the gastro-intestinal manifestation. The estivo-autumnal parasite is the exciting cause.

It is very often preceded by malaise, headache, nausea and vomiting. The onset is usually gradual and the chill may be wholly absent. As a rule, however, a chill generally occurs at the onset, but it is less severe than that of intermittent fever. After the chill the temperature rises rapidly to 102 or 104 degrees F. or even higher. The pulse is full, rising to 100 or 120. There is violent headache, flushed face, pains in the limbs and loins, nausea and vomiting, and delirium when the temperature is very high. The urine is scanty or even suppressed, slightly albuminous, sometimes bloody, high colored, and deposits a sediment of urates. Jaundice is not infrequent; the spleen is enlarged and herpes labialis is quite common. After six to twenty-four hours the symptoms abate and slight sweating occurs. The temperature usually drops to 100 degrees F., the headache disappears and vomiting ceases; this is followed by a new exacerbation of fever at the end of about twelve hours, generally without the chill; and this hot stage is in turn again followed by the remission. These attacks may last three or four weeks.

=Pernicious Malarial Fever.=—This is rare in temperate climates and is always associated with the estivo-autumnal parasite. The principal types are the cerebral and algid.

The =cerebral type= usually begins with a severe chill; sometimes, however, the chill is absent. The patient is violently seized with grave cerebral symptoms, as acute delirium or sudden coma. The comatose condition lasts from twelve to twenty-four hours when consciousness usually returns, the primary paroxysm rarely proving fatal; it is, however, often followed in a short time by fatal relapse.

The =Algid= variety is characterized by intense prostration and extreme coolness of the surface with the internal temperature high. The gastric symptoms are extreme nausea and vomiting. The pulse is feeble; the breathing frequent and shallow. There is intense thirst. The voice is feeble and indistinct. The mind is clear. The urine is suppressed. In this type the parasites gain entrance to the gastro-intestinal mucosa, sometimes forming distinct thromboses of the smaller vessels. This form may be confused with yellow fever.

=Malarial Cachexia.=—This is a chronic condition which often occurs in cases that have not been properly treated or in persons that live in malarial districts and are constantly exposed to the infection. The two most striking symptoms of this condition are anemia and an enlarged spleen or “ague cake.” There is fever at intervals, but chills rarely occur. The skin is of a dirty yellow color. The spleen is greatly enlarged and the blood is profoundly anemic. There is debility, and frequent sweating, and the hands and feet are cold. The digestion may be deranged and there may be slight jaundice. Sometimes there is edema of the feet and even dropsy occurs. Hemorrhages of the various mucous surfaces are common. Paraplegia and orchitis are rare symptoms. These cases usually do well under proper treatment, and if the patient can be moved from the malarial district.

=Masked Intermittent.=—Malarial neuralgia most frequently involves the supraorbital branch of the trigeminus; also the occipital, the intercostals, sciatic and brachial nerves may be affected. Such forms of malaria are called “masked malaria.” In this form there is no fever and as a rule it is very hard to diagnose. A blood analysis should be made to confirm the diagnosis. In some cases one or more stages in the paroxysm of intermittent fever is omitted; this is especially true with the chill, in which case it is termed “dumb ague.” Malarial cachexia is also sometimes called “dumb ague” and both are found among the older inhabitants of malarial districts. Persons living in malarial districts are sometimes affected with constipation, headache, loss of appetite, nausea, vomiting and a languid feeling; this is called “latent intermittent fever.” Frequently “bilious attacks” are of a malarial origin.

=Malarial Hematuria.=—Hemorrhages may occur from the mucous membrane in all severe and persistent types of malarial infection. It is a frequent symptom of the pernicious variety. The parasites destroy the red blood-corpuscles; this is the cause of the hemoglobinuria. Prostration and anemia are marked. In =blackwater fever=, a tropical disorder, acute hemolysis, is the cause of the hemoglobinuria.

=Diagnosis.=—This is usually easy. The characteristic stages of the paroxysms, the periodicity, residence in malarial districts and the alterations in the blood will usually remove every doubt as to the diagnosis.

=Typhoid Fever= may simulate malarial fever, but a careful analysis of symptoms and blood examination will differentiate.

=Prognosis.=—This is almost always favorable under early and persistent treatment. The unfavorable symptoms are uremia, hemorrhage and marked jaundice.

=Treatment.=—Attention should first be given to =prophylactic measures=. Environment, isolation of the patient, and destruction of the mosquito are important considerations. Cases of malarial fever present distinct lesions in the vertebræ and ribs corresponding to the vasomotor nerve supply of the spleen and liver. The most common lesion found is a marked lateral deviation between the ninth and tenth dorsal vertebræ and a consequent downward displacement of the tenth ribs. A disturbance will always be found in the region of the eighth to the eleventh dorsal vertebra, inclusive, or in the corresponding ribs on either side. These lesions undoubtedly derange the vasomotor nerves to the spleen and liver; thus permitting a weakness or lowered resistance of the system, especially of the blood. The blood resisting powers are lessened, probably on account of the spleen being affected, as it is an elaborating gland of the blood; and the liver’s action is somewhat dependent upon the action of the spleen; besides, the liver is a secretory and excretory organ.

The principal =osteopathic treatment= given in cases of malarial fever is correction of these subdislocations, and thorough treatment to the liver and spleen directly. Ligon observes that when the case does not respond quickly to treatment it is very liable to be of considerable duration, although in the majority of cases the disease is controlled from the third to seventh day; the most constant lesions found are from the eighth to tenth dorsal and also the fourth lumbar.

During the =chilly stage= thorough treatment of the vasomotor nerves in the upper cervical, the upper dorsal, the lower dorsal and the lumbar regions is indicated; this treatment is given to equalize the vascular system.

During the =hot stage= the same treatment as in the chilly stage should be given to control the vascular system; besides a thorough treatment of the spleen and liver is necessary. Sponging the body with water will be of some aid in reducing the temperature.

During the =sweat stage= thorough inhibition at the superior cervical ganglion to control the sweat center of the medulla, and treatment at the upper dorsal and first lumbar to control auxiliary sweat centers are indicated.

The bowels should be kept active. When in a comatose form and when internal temperature is high, place the patient in a bath. In chronic cases, change of climate with thorough systematic treatment will usually result in recovery.

Tete[53], of Louisiana, makes the following interesting statement: “A specific osteopathic treatment given within an hour before the expected chill is a specific cure for malaria.” He follows this up by treating on the third, fifth, seventh, fourteenth, and twenty-first days, on account of the tendency of the return of an attack on those days. His observation of the value of treatment just before the attack is borne out by a report by Teall[54] where the case was cured in one treatment, but the lesion was as high as the fourth dorsal. N. Chapman confirms this as being her experience in many cases. The spleen has been observed by Bandel to become engorged and upon emptying there would follow a rise of temperature of one fourth to half a degree. This has also been spoken of by Tucker as the “splenic wave.” Ligon makes the statement that where the osteopathic lesion (the predisposing cause) has been of long standing prior to the attack, and as a consequence hard to correct, it is difficult to shorten the malarial attack.

This would emphasize the point that the essential treatment must be a thoroughly readjustive one, and that stimulatory and inhibitory work can only palliate. This is borne out by several practitioners who have had considerable experience. Very satisfactory results follow adjustment of the seventh to tenth dorsals.

Quinine has been accepted by medical authorities as a specific for malaria. It is supposed to act directly upon the intracorpuscular hematozoa. That it is not infallible is shown by the numerous cases which come to the osteopath, suffering from both the disease and the quinine. And even drug authorities state that other treatment is also required. It has remained for Dr. Still to demonstrate that excellent results follow osteopathic treatment in malaria. Frequently a single treatment has been sufficient to free and regulate the body fluids and forces so that the parasite was rendered inert, and this treatment was directed chiefly to the fourth and twelfth dorsals. Whereas the osteopath recognizes and appreciates the importance of micro-organisms as exciting and determining factors in many diseases, still he values them as secondary factors only and relies primarily upon removing the predisposing and true etiologic factors, so that nature’s forces may not be obstructed and thus predominate. Osteopathic etiology and pathology has shown so conclusively, in a large number of cases, that the existence of micro-organisms is dependent upon devitalized tissue, whether the tissue is a local one or a circulating one, as the blood; and just so soon as the anatomical is adjusted the physiological will function and antitoxic and antimicrobic substances are secreted.

“When the patient has the quartan parasite, as soon as the temperature begins to fall I give him from two to six ounces of red meat juice, extracted from rare beefsteak, sometimes as much as five pounds in the first twenty-four hours following the chill. In almost all cases of quartan malaria the blood is built up sufficiently by the time they reach the second cycle to pass without the paroxysm, or chill. By the time for the third cycle, which is the seventh day, I always have built up the patient’s resistance so as to enable him to pass by this cycle without any symptoms of malaria whatever. In cases of double or triple I find the same treatment causes about the same results. I do not give any other diet, except dry toast if they eat the beef instead of taking the juice. If they can take the steak I prefer their taking it, but almost all cases prefer the juice. * * * The treatment for the tertian type of malaria is practically the same as the treatment for the quartan.

“The estivo-autumnal type of malaria differs from the quartan and tertian types; first, in that the paroxysms are, as a rule, much more irregular; second, they are much longer in duration; third, the chills are more frequently absent; fourth, the fever is often irregular, intermittent, remittent, or continuous in character. This type very often takes the form of blackwater or hemoglobinuric type with hemorrhagic symptoms, with hemorrhage from nose, gums, and bowels. The first thing to do in a case of hemorrhagic malaria is to put an ice bag on the abdomen, which will tend to control the hemorrhage from the kidneys. Give the patient all the red beef juice you can get him to take, provided he has not developed a very sick stomach; if so, give him high saline enemas and in one-half hour give him four ounces red beef juice per rectum. Repeat the feeding per rectum in four hours. As soon as he can retain anything on stomach give him all the juice he can take comfortably. Treat the liver thoroughly—at least three times in the first twenty-four hours. At the end of thirty-six hours the yellow cast will be very much lighter, which is a sure sign that the patient is getting better. Watch the urine closely. The third day there may occur a suppression. If so, give strong stimulation to the renal plexus through the abdomen, and be sure there is a thorough relaxation of the dorsal and lumbar muscles.

“It is an established fact that people in the malarial districts eat very little beef. I find that ninety-nine per cent of the cases of malaria never eat it, or when they on rare occasion do, it has been so overcooked that all the blood-building substances have been destroyed. The beef raw would be better in my opinion; although, the possible chance of getting a tape-worm or animal parasite is so considerable that I would advise that the beef should be heated to 250 degrees.”—E. C. ARMSTRONG, Clinical Osteopathy.

Septicemia

This term is applied to any toxic condition caused by the invasion of the blood by pathogenic micro-organisms, with or without any visible site of infection.

=Etiologically=, the micrococci, streptococci, pneumococci, or staphylococci, as to frequency, in order named, are the cause. The infection is usually introduced by a wound, of any degree of severity. The uterus is a frequent seat following miscarriage, parturition or operation. The virus may be absorbed by the mucous membrane. It may also arise from infection of the deeper tissues. =Pathologically=, the changes are not marked, but consist in brownish color of the muscles, ecchymotic spots in the pia mater and dark appearance of the blood, which is also less coagulable. Spleen, liver and lymphatics are enlarged with some changes in the other organs.

=Symptoms.=—The incubation period is from four to six days and the onset is gradual, though often announced by a distinctive chill, followed by a profuse sweat. The most common type is the continuous form of fever, which may, in morning remissions, become subnormal. Pulse is rapid at the beginning, but as cardiac failure comes on, it becomes weaker. In the earlier stages there may be vomiting with diarrhea later. There are punctiform hemorrhages of the skin and possibly other eruptions. Blood examination will settle any doubt as to diagnosis.

=Prognosis= is good in large percent of cases and depends upon the general health of the patient.

=Treatment.=—“Incise and drain the infected part; if possible, apply hot boracic acid compresses or keep part suspended in hot boracic acid solution. Osteopathic treatment will aid materially in stimulating and strengthening the patient. Bowels, kidneys and skin must be kept active. Normal salt solution, hypodermically or per rectum is of value. Diet should be liquid, fruit juices, broths, soups until temperature has remained normal twenty-four hours then milk, eggs etc., in gradually increasing amounts until general diet is restored. Amputation of the part may be necessary.”—L. E. BROWNE.

Pyemia

A febrile disease arising from an invasion of the blood by pathogenic bacteria, wherein sepsis and multiple abscesses occur from absorption and metastasis.

=Etiologically=, the cause may be traced to various specific organisms which enter the blood stream and produce thrombophlebitis. From these points and from other bacteria, new foci are established. Occasionally the lymphatics carry the germs. The disease may also start from ulcerative endocarditis or when the appendix is infected.

=Pathologically=, thrombosis of the vein may take place in any region. Abscesses may form in the lungs, liver, spleen or other internal organs. The small abscesses may unite and form a large one. The skin presents eruptions and hemorrhagic extravasations, while there may be ulcers of the mucous membrane, also the serous surfaces may be purulently inflamed. The muscles, subcutaneous and osseous tissue occasionally have abscesses. Ulcerative and suppurative heart lesions occur.

=Symptoms.=—The incubation period is short. There may be slight fever, but commonly a chill is the first symptom, which may reoccur for some time. The fever is either remittent or intermittent and when the temperature is low, sweating is a feature. The pulse becomes rapid and weak, when the disease is severe; breathing becomes difficult. Skin symptoms, such as eruptions and pustules, generally occur. In a word, there is a general intoxication. There is a lessened number of red blood corpuscles and leucocytosis is a characteristic. In grave cases, delirium and coma are present.

=Diagnosis.=—The history of the case and symptoms will usually render diagnosis easy, although care is necessary to determine from septicemia. Malaria, typhoid and acute tuberculosis must be excluded.

=Prognosis.=—Much depends on asepsis and surgery but on the whole it is unfavorable.

=Treatment.=—Surgical interference and treatment as outlined under septicemia is the only hope.

Dengue

(BREAKBONE FEVER)

=Definition.=—An acute infectious disease; characterized by a double febrile paroxysm, severe pains in the muscles and joints and sometimes a skin eruption.

=Etiology.=—It is a disease of tropical and subtropical regions. Unhygienic conditions predispose to an attack. During an epidemic a single attack is the rule. The disease spreads from place to place along the lines of travel, attacking both sexes, and all ages. It occurs in epidemics, practically affecting every one. The specific germ has never been isolated as it is probably ultra-microscopic but there is no doubt but that it is carried by the mosquito Culex fatigans.

=Symptoms.=—The incubation period lasts about four days. The onset is abrupt with a slight chill, headache, and extreme pain in the joints and muscles, of a boring or breaking character. The joints become red, swollen and painful. The fever rises gradually to 103 or 106 degrees F., or over. The pulse is rapid and full and the respirations are much quickened. The face is flushed, the tongue coated, the appetite is lost, and slight nausea occurs. “Black vomit,” similar to that of yellow fever, has been observed in this disease. Hemorrhages from various organs may occur and the lymphatic glands are swollen. The urine is scanty and the bowels constipated. Febrile albuminuria and delirium are rare.

At the end of three or four days the temperature falls and there is a period of remission; the patient is free from pain, but profoundly prostrated. During this time the eruption generally appears, but is never constant in character. After a remission of two or three days, the symptoms reappear and a second febrile paroxysm sets in. This is usually milder and shorter than the first, lasting two or three days, when convalescence begins. The duration is, according to medical writers, from seven to ten days, and convalescence slow. Death seldom occurs, so practically no pathological changes have been recorded. By osteopathic treatment, E. B. Ligon has been able to confine the attack to four or five days duration; this is confirmed by the experience of N. Chapman.

=Diagnosis.=—During an epidemic the disease attacks all classes alike, and the distinct remission renders the diagnosis comparatively easy. An occasional case might be mistaken for acute rheumatism, but the absence of any glandular swelling or eruption, while the pain is more closely limited to the joints, will aid in the diagnosis. Care has to be taken that yellow fever is not mistaken for dengue.

=Treatment.=—The indications of the treatment are to maintain the patient’s strength and to treat the leading symptoms as they arise. The severity of an attack can probably be lessened at the start by strong and thorough treatment of the suboccipital, upper dorsal, lower dorsal and lower lumbar regions, respectively, so as to control the large vascular areas by means of the vasomotor nerves of the cranial region, of the lungs, of the splanchnic region, and of the lower limbs, thus equalizing the entire vascular system. Elimination should be pushed and the excretory organs stimulated. Ligon has observed that the cervical and lumbar regions are especially tender on the second day and the lower dorsal region on the third day. The most severe symptoms disappeared within a few hours after treatment and the attack was markedly shortened.

The high fever may be treated by the usual methods and by the external application of cold water. The pain is to be controlled, according to the region affected, by a correction of parts impinging upon the nerve tissues and by strong inhibition. The entire spinal region should be kept constantly in a relaxed condition, as far as muscular contractions are concerned. Particularly should the treatment be extensive along the spine during prostration. N. Chapman, in addition to the osteopathic treatment, has the patient drink considerable hot water; also employs the hot bath. The treatment frequently shortened the attack. During the entire attack of the disease, the patient should be kept in bed and a carefully regulated diet administered. Relapses are not infrequent. A suitable change of air may hasten convalescence.

Cerebrospinal Meningitis

=Definition.=—A specific, infectious disease caused by the diplococcus intracellularis meningitidis, occurring sporadically and in epidemics. It is characterized by inflammation of the membranes of the brain and spinal cord and an irregular course.

=Osteopathic Etiology= and =Pathology=.—The specific exciting cause of the cerebrospinal meningitis is due to the diplococcus intracellularis meningitidis of Weichselbaum. Lesions are found in the vertebræ corresponding to the cervical and dorsal enlargement of the cord, as well as in corresponding deep muscles; also, as is well known, the muscles of the entire back are severely contracted, especially of the cervical, upper and lower dorsal regions. More commonly it attacks the young, although it may occur at any age. Overexertion, exposure, overcrowded and illy-ventilated buildings, barracks and tenements, and depressing mental influences are predisposing causes. Many times the disease occurs among the poorer classes. Sometimes the disease prevails in the country rather than in the city.

In cases that prove speedily fatal there may be no characteristic changes; simply marked congestion. Other cases in which death occurs after the disease has been fully developed, there is found every degree of inflammation from slight hyperemia to suppurative changes. There can be no doubt that the osteopathic lesion, as vertebral and rib lesions and deep muscular contractions, affects the circulation of the meninges of the brain and cord and thus favors the invasion of the specific micro-organism. The arteries, veins and sinuses are greatly engorged. The walls of the ventricles soften and the ventricles contain serous exudate. The brain matter may be congested and softened in spots. In the spinal membranes similar changes take place and at times there is extravasation of blood. The changes are more marked on the posterior than the anterior surface of the cord. Abscesses sometimes form. The exudate may follow the lymph sheaths of the cranial nerves, especially the auditory and optic. In long standing cases the membranes become thick and adherent and areas of softening or atrophy of the cortex develop. The thickening and adhesions of the membranes may cause various symptoms for months or even years after recovery from the acute disorder.

The spleen may be normal in size, but when the fever has been intense, it is apt to be slightly enlarged. Bronchitis, pneumonia, endocarditis and pleurisy may occur. The liver may become hyperemic and the kidneys congested.

=Symptoms.=—The prodromes vary, although the onset is apt to be sudden with a decided chill; headache; vomiting, and pain in the neck and back, which is usually severe, but may be so slight as not to be noticed by the patient. The temperature rises to 101 to 102 degrees F., in most cases. However, it may rise to 105 degrees or 106 degrees and even to 108 degrees in fatal cases, and the pulse is full. Hyperesthesia, photophobia, and dread of noise are apt to be prominent symptoms. The muscles of the neck and back become rigid, and there are pains in the limbs. Orthotonos occurs more frequently than opisthotonos. Convulsions are common in children. There may be paralysis, especially of the muscles of the face and eyes. Delirium usually appears early; it may be mild, but it is often maniacal. The bowels are usually confined, though there may be diarrhea. There is moderate and constant leucocytosis and jaundice has been met with.

The urine is sometimes albuminous, and sugar has been noted in rare cases. The urine may be increased, but more often it is lessened as in other infectious diseases.

Herpes facialis occurs shortly after the onset in more than half the cases. The contents of the vesicles may be purulent and one or two may coalesce. The petechial eruptions are occasionally numerous and cover the entire skin; they do not disappear upon pressure and the number of spots varies greatly. Other eruptions as sudamina, ecthyma, pemphigus, urticaria, erysipelas, rose colored spots, and gangrene of the skin (rarely) have been met with.

In cases that are =rapidly fatal=, the onset is sudden, usually with violent chills, headache, depression, and in a few hours coma and collapse, which are soon followed by a fatal termination. The temperature may rise slightly, but it is often subnormal. The pulse is feeble; breathing is labored. These cases occur more frequently at the beginning of an epidemic. They occasionally occur sporadically.

The =abortive= form terminates abruptly after the development of one or more pronounced, characteristic symptoms.

The =mild= form can only be recognized during the prevalence of an epidemic. The symptoms are very mild; slight vomiting, little or no fever, headache and slight pain in the back and limbs.

The =intermittent= form is characterized by increase in the fever every day or second day. The strict periodicity seen in malaria is not observed; the fever resembles that of pyemia.

In the =chronic= form the condition may persist for weeks or months.

=Complications.=—Pneumonia (lobar and lobular) is a frequent complication. Pleurisy, pericarditis, parotitis, arthritis, enteritis, optic neuritis and otitis media may be other complications.

=Sequelæ.=—Blindness, deafness, keratitis (rarely), persistent headache, chronic hydrocephalus, abscess of the brain, mental feebleness, defective articulation, aphasia, and paralysis of certain cranial nerves or of the lower extremities have occurred.

=Diagnosis.=—=Typhoid fever= begins slowly and is unaccompanied by vomiting, muscular spasms or rigidity, or hyperesthesia. In typhoid the fever is higher and there is a characteristic temperature curve. Widal’s test will confirm.

=Tubercular meningitis= is not epidemic and has no characteristic eruption. It is usually less sudden in its development and is invariably fatal. Retraction of the neck, muscular spasms of the legs and arms are not so marked as in spinal meningitis.

=Pneumonia= may be complicated with meningitis, especially when the meningitis is confined to the cerebrum. If the case is not seen early, it is almost impossible to say which is the primary affection, as pneumonia may have meningeal complications or cerebrospinal meningitis may be associated with pneumonia. There will be motor spasms and tremors, but the head is rarely retracted, and there is less myalgiac pain than in cerebrospinal meningitis.

=Prognosis.=—This varies according to the severity of the type. It is a grave disease. Cases have been treated successfully by several osteopaths. The duration is very variable—from two or three days to weeks or even months, but probably in all cases this time can be materially shortened by judicious osteopathic treatment. Convalescence is very slow and relapses are prone to occur.

=Treatment.=—The osteopathic treatment of cerebrospinal meningitis requires most thorough, but very careful, work along the spinal column, especially the cervical region and the region of the dorsal enlargement of the spinal cord, in relaxing and keeping relaxed the deep muscles on either side of the spine and correcting the derangements of the vertebræ, particularly in the upper cervical spine. Such treatment has a marked effect on the circulation of the spinal cord and brain. Probably, a large amount of the work along the spine, in all cases where muscles are relaxed, has a direct effect upon the circulation of the spinal cord. This treatment constitutes the primary osteopathic work in cerebrospinal fever and should be frequently applied until a cure is obtained. Even in chronic cases where limbs have been greatly affected by pressure upon the nerve centers, due to a thickened membrane, continued osteopathic treatment along the spine has had a marked effect in absorbing the pathological condition and restoring strength.

The preceding spinal treatment is also a very great safeguard in keeping the various viscera healthy and thus preventing complications. In all constitutional diseases of an acute nature, it is a wise precaution to thoroughly examine the entire length of the spinal column at each visit; and if such precaution is taken many serious complications will never occur that might otherwise have taken place.

The patient should be isolated in a somewhat darkened room, and care taken that the disease is not allowed to spread. Keep the patient upon his sides as much as possible. The diet should be a nutritious one of milk and broths. They should drink freely of water. Cold to the head and spine will be of service in controlling the inflammation; it should be applied with an ice-cap and a spinal ice-bag. Sponging the body should be employed if the temperature is above 102° F. The general bath, as in typhoid fever, may be employed if practicable. Direct treatment to the bowels, kidneys, liver and spleen should be given at each treatment.

Lumbar puncture and the Flexner-Jobling serum are considered of value by those who have had an extensive experience.

Diphtheria

=Definition.=—An acute, infectious disease, caused by the Klebs-Loeffler bacillus, and characterized by a membranous exudation on the mucous membrane of the fauces, larynx or nose, and by constitutional symptoms. The presence of the Klebs-Loeffler bacillus distinguishes true diphtheria from any other form of membranous inflammation. The term diphtheroid is applied to all such forms as are not due to the Klebs-Loeffler bacillus.

=Osteopathic Etiology= and =Pathology=.—The exciting cause is the Klebs-Loeffler bacillus. The predisposing cause is obstruction to the circulation of the pharynx and tonsils by subdislocations of upper cervical vertebræ, and even the lower cervical and upper dorsal, and severely contracted deep muscles of the neck. The stasis of blood favors the growth of the bacillus.

Link[55] says: “The cause of nasal, pharyngeal or laryngeal diphtheria is obstruction of the blood and lymph through the neck and the obstruction occurs as a result of lesions in the cervical region, affecting the cervical sympathetics, or lesions in the upper thoracic region whence the vasomotor fibers arise. A derangement of the vertebral articulation of the first rib is usually found. (This affects the stellate ganglion and fibers of the sympathetic chain). These lesions cause a condition of lowered vitality of the mucosa of the nose and throat; the abnormal secretion favoring the rapid multiplication of the Klebs-Loeffler bacillus—the exciting cause of the disease.”

Dr. Still believed that, among other lesions, contracting of tissues involving the scaleni and disturbing the relations of the first rib with the clavicle and vertebra are causative factors. The constitutional symptoms are produced by the toxins generated by the bacillus and absorbed from the diseased spots by the lymphatics and blood-vessels. The bacillus is non-motile and does not usually penetrate the mucosa, but remains very near the site of the local changes although there are instances where it may enter the blood and other tissues. The bacillus is very resistant and can maintain an existence for months outside of the body. There is great variation in the virulence of the Klebs-Loeffler bacillus; it has been found in healthy throats, and sometimes the bacillus may exist in the throat after an attack of diphtheria for months after all the membrane has disappeared. It has also been found in cases of simple catarrhal angina without membrane, and in simple tonsillitis Of the bacteria associated with the bacillus of diphtheria, the streptococcus pyogenes is the most common and probably the most active. The staphylococcus, micrococcus lanceolatus and bacillus coli communis are also found.

The contagion is communicated, as a rule, through the air, by means of fomites from the membranous exudate or discharges from the diphtheritic patients, or during convalescence, from secretions of the nose and throat. Infected milk may cause the disease. Most cases occur in childhood, between the second and seventh year. The disease is most prevalent in the cold autumn and spring months. It is most frequently met with in temperate and cold climates. Defective drainage, catarrhal conditions of the throat, enlarged tonsils, general weakness, and feeble resisting power are predisposing factors. One attack does not confer immunity from another, but rather predisposes to a second.

The =false membrane= is usually found on the tonsils, the pillars of the fauces and the pharynx, and in fatal cases it may be extensive and involve the uvula, the soft palate and the posterior nares, and even the trachea and bronchi. At first this membrane is yellowish white, but later may become gray; it is more or less adherent and when torn off leaves a raw surface. The diphtheritic poison coming in contact with the throat leads to, first, a necrosis or death of the epithelial cells, especially the more superficial, and the leucocytes. The second change is the hyaline transformation, and simultaneously coagulation; hence the term coagulation-necrosis. The irritation produced by the bacilli causes a migration of leucocytes and these are destroyed and undergo hyaline transformation. This process proceeds from without inward and is usually superficial, and the necrosis may be extensive, involving the deeper tissues, causing ulceration and a gangrenous condition of the parts. The erosion of the tonsils may be so severe as to attack the carotid artery. The lymphatic glands are considerably swollen. The spleen is commonly enlarged. The kidneys show parenchymatous changes. The blood is dark and fluid. Fatty degeneration of the heart is not infrequent. Sometimes fibrinous coagula are found in the heart. Capillary bronchitis, catarrhal pneumonia and areas of collapse are almost constantly found on examination of the lungs in fatal cases. The =urine= is typically febrile with early albumin and often tube casts and renal epithelium. The =blood= shows an excess of red blood cells which may reach 7,500,000. Hemoglobin is slightly reduced. There is considerable anemia during convalescence depending upon severity of toxemia.

=Symptoms.=—The incubation period varies from one to ten days, usually two or three days. According to the location, diphtheria may be divided into pharyngeal, laryngeal and nasal forms.

In =Pharyngeal Diphtheria=, which is most common, there is first a slight chill or chilliness, followed by fever and sore throat, both of which increase rapidly. The throat is swollen and red and the patient complains of difficult swallowing. The membrane begins on the tonsils in the form of grayish-white patches; it then spreads from the tonsils to the soft palate, sometimes covering the uvula. The cervical glands are swollen and tender. The neck muscles are contracted and somewhat difficult to relax. The temperature rises to 102 or 104 degrees F. The pulse is rapid and feeble, ranging from 120 to 140. There is loss of appetite. There is more or less prostration depending upon the gravity of the constitutional symptoms. The average duration is from one to two weeks.

=Laryngeal Diphtheria= (Membranous Croup) may be secondary to extension from the fauces or it may be primary. At first there is slight hoarseness and a harsh, metallic, ringing cough. These symptoms may persist for a day or two, when the child suddenly becomes worse; there is marked dyspnea and the lips and finger tips become livid. The child soon becomes very restless. The temperature may be slightly above normal and the pulse increased in frequency. In favorable cases the dyspnea is not very marked and the child probably will have only one or two paroxysms, when it will fall asleep and wake in the morning feeling very comfortable. The next night, however, the attack may be more pronounced. In extreme cases death may result from suffocation. In some cases the suffocation is slower and results from extension of the membrane downward into the bronchi. Dr. Still found same conditions as in diphtheria, but also the hyoid is involved with the superior laryngeal nerve. The sacral and lumbar nerves are also involved. He always emphasized chilling of gluteal region as a cause for croup and that heat should be applied at the inception of the disease.

=Nasal Diphtheria= is generally secondary, but it may be a primary affection. In many cases no membrane is found; in others there may be a pseudo-membrane formed in the nose, but there is absence of any systemic disturbance. The Klebs-Loeffler bacillus is sometimes present in these membranes. Nasal diphtheria may be a very grave disease—the constitutional symptoms being great prostration, high fever, marked glandular swelling, irritating and offensive discharges from the nose, and epistaxis. Inflammation occasionally extends through the tear duct to the conjunctiva.

A diphtheritic membrane may grow where the skin has been cut or bruised, but the bacillus cannot live on normal skin. It nourishes on a raw, moist surface and membranes have grown on the lips, tongue, vulva, glans penis, and on ulcerative surfaces and wounds. Diphtheria occurs occasionally in the conjunctiva and the external auditory meatus.

It should be remembered that there are many atypical forms of diphtheria. Bacteriological examination should always be made in suspicious and puzzling cases.

The complications of diphtheria are nephritis, hemorrhages, rashes, capillary bronchitis, pulmonary collapse, catarrhal pneumonia, myocarditis, arthritis, otitis media, and paralysis.

=Diagnosis.=—The presence of the Klebs-Loeffler bacillus will at once decide the diagnosis of diphtheria.

=Prognosis.=—The prognosis should always be guarded. The nasal and laryngeal forms are always grave. The causes of death are involvement of the larynx, septic infection, heart failure, bronchopneumonia during convalescence, and rarely, uremia.

=Treatment.=—Hygienic and prophylactic measures are important. A room should be selected that is ventilated and exposed to the sunlight. All unnecessary articles of furniture should be removed. Great care must be taken against the spread of the disease. Always isolate the patient and disinfect everything that has come in contact with him. The greatest danger lies in the spread of the disease during convalescence and in the ambulatory form, when patients are about and coming in contact with individuals, especially children with catarrhal conditions of the nose and throat. The physician should be careful about disinfecting himself.

In view of the fact that many osteopaths have treated successfully numerous cases of diphtheria and that the osteopathic treatment is peculiarly indicated and effective, the probable requirement of antitoxin (the use of which we do not feel called upon to discuss) would be lessened. Relative to the antitoxin Osier says: “The principle of action depends on the circumstance that the blood serum of an animal rendered immune, when introduced into another animal, protects it from infection with the diphtheria bacilli, and has also an important curative influence upon diphtheria, whether artificially given to animals, or spontaneously acquired by man.”

“The treatment of diphtheria by osteopathic methods is often a pleasure rather than a trial because of the success which rewards us for our efforts. There has been considerable discussion by the members of our profession regarding the methods to be employed in successfully overcoming this disease, and many have expressed the view that since antitoxic serum is a physiological remedy, which naturally belongs to all schools of healing, it should be employed by the osteopathic physician in cases of diphtheria. I have no objections to the use of the serum therapy by members of the profession who conscientiously feel that they need it in their practice to secure the highest success. However, I feel, on the other hand, that if they were well acquainted with the technique of the methods * * * they would not feel it to their advantage, from the standpoint of success, to use injections in a single case.”—R. D. EMERY, Clinical Osteopathy.

The local treatment should be carefully, but vigorously, given. By proper treatment of the throat the extension of the disease may be prevented. The muscles about the throat, especially the deep ones, should be thoroughly relaxed and the cervical vertebra; corrected if displaced. The vasomotor nerves to the blood vessels of the affected region require careful treatment at the superior cervical ganglion, and the cervical lymphatics from the atlas to the first rib should be closely watched. The nerves to control are the vagi, glosso-pharyngeal, spinal accessory, and sympathetic nerves to the pharyngeal plexus, and in cases of nasal diphtheria the fifth nerve has to be carefully treated. An external treatment to the pharynx will have the greatest effect on these nerves. An internal treatment to the nerves of the soft palate will be of considerable service. The parts diseased should be disinfected and kept as clean as possible. Bichloride of mercury (1 : 4000) used as a spray will be found satisfactory, although there are several other disinfectants and germicides that may be used. Pellets of ice in the mouth will be a comfort to the patient. Cold applied externally will be found best for the adult; heat externally is better for the child.

Every possible means should be used to prevent the disease from spreading. One of the chief dangers of diphtheria is the spread of the disease to the larynx, trachea and bronchi. When the disease has extended to these parts it presents all the symptoms of =true croup=. The deep cervical muscles should be thoroughly relaxed to aid in relieving the passive hyperemia and with a view of disorganizing the exudate. Attention should be given to the upper ribs, as interferences with the vasomotor nerves of the mucous membrane of the trachea and bronchial tubes usually occur. Direct treatment over the larynx and local treatment through the mouth upon the soft palate will be of aid. A thorough relaxation of all the dorsal muscles, even as low as the tenth dorsal, should be given. Inhalations of slaked, freshly burnt lime may be useful in loosening the exudation. In desperate cases tracheotomy or intubation of the larynx should be performed. Willard[56] says, relative to membranous croup: “It matters not whether or not the laryngeal inflammation was immediately caused by a germ; it would not, nor could not, have been produced by such had there not been an unnatural condition of the circulation of and about the larynx.”

A constitutional treatment should always be given with a view of preventing the spread of the disease from one organ to another and to prevent complications. The heart’s action should be carefully watched throughout the entire course of the disease. Treatment of the spinal cord will guard against paralysis that sometimes follows the venous hyperemia of the vascular linings and substance of the brain and spinal cord. Pay particular attention to the upper dorsal region to prevent possible heart involvement. Post-diphtheritic paralysis seldom if ever occurs in cases that are treated osteopathically. This is a common sequela and is present in from 10 percent to 30 per cent of cases, appearing within three weeks of apparent recovery. Sometimes it is the only result to show diphtheria was present. It seems to follow use of antitoxin rather frequently. Attention to the splanchnics and to the abdomen directly will tend to keep the stomach, liver, kidneys, and intestines in a healthy state. The diet of the patient should consist of liquid food—milk, broths, meat juice, raw eggs and barley water. Let the patient drink freely of water. Treatment of the rectum may be employed with benefit when the pharynx is greatly disturbed.

Various =sequelæ= and =complications= are best relieved or prevented, according to Link, as follows: “First, limiting the production of toxins by a most thorough relaxation of the muscles of the neck, thereby favoring the unobstructed circulation of the blood and lymph; second, by the correction of lesions which affect the vasomotor of the head and neck; third, by spinal treatment affecting the vasomotor to the areas involved; fourth, by increasing the activity of the excretory organs, by treatment in the splanchnic and lumbar areas, that the toxins may be more rapidly eliminated. In cases where laryngeal stenosis is marked and suffocation is imminent, intubation should not be delayed.” Post-diphtheritic paralysis usually yields to osteopathic treatment. Apply treatment according to location.

Dysentery

(BLOODY FLUX).

=Dysentery= is an infectious disease wherein the large intestine is inflamed, with ulceration of the mucous membrane; is characterized, clinically, by frequent stools containing blood and mucus; fever and exhaustion. =Osteopathic lesions= of an osseous character and deep muscular contractions of the lumbar region are always present. These involve the vasomotor nerves to blood vessels and lymph channels. Catarrh of the intestinal tract is an important predisposing cause. The disease usually occurs in the summer and autumn, and is more common in hot, malarial regions, although it is found in various climates. Unhygienic conditions are also important predisposing factors. In no disease more than dysentery does specific correction of the osseous lesion effect quick and satisfactory results.

Acute Ileocolitis

(BACILLARY DYSENTERY)

This is the variety most frequently found in temperate climates. It occurs either sporadically or endemically. The Flexner bacillus is frequently found, as well as pus micro-organisms. There are various strains of the bacillus. There is a catarrhal inflammation of part or the whole of the large bowel. Other forms may occur, as ulcerative and membranous.

=Osteopathic Etiology= and =Pathology=.—Sudden atmospheric changes and simple irritants, such as unripe and indigestible food, are usually the immediate causes. The predisposing cause of acute catarrhal dysentery is always found by the osteopath to be due to spinal derangements in the lumbar region. The lesion is generally a slight lateral deviation of a vertebra. It is generally found at the second or third lumbar; still, the trouble may be found at any point in the lumbar section. The lesion involves vasomotor nerves to the intestinal mucous membrane, thus causing the inflammation. The drinking of impure water in itself may not be the cause of the disease, but is a favorable medium for the development of the organisms which may excite it. Dyspeptic conditions and constipation seem to predispose to the disease.

The mucous membrane is injected and swollen and often covered with bloody mucus. The follicles of Lieberkuhn are enlarged from retention of their contents, the result of the swelling; the follicles are often ruptured and the mucous membrane sloughs off in patches, forming ulcers. These may extend along the whole colon and frequently into the ileum.

=Symptoms.=—Diarrhea is the most common initial symptom; the stools being copious and painless. The stools soon become small and frequent, covered with mucus and streaked with blood. These are passed with straining and tenesmus, accompanied by colicky abdominal pains of a griping character. Chills are rare. The tongue is furred and moist: later it becomes dry. Nausea and vomiting may be present, but not as a rule. There is fever and often excessive thirst. Later the stools become green in color, due to the bile which causes a burning sensation in the rectum.

On examination there are found red blood-corpuscles and leucocytes, and large, round and oval epithelioid cells containing fat drops and vacuoles. In mild cases, the course is about eight days; severe cases subside within four weeks, but if the =osteopathic treatment= is careful and specific, the usual duration can generally be reduced one-half.

=Prognosis.=—The prognosis is generally favorable in the catarrhal form when the disease is treated properly. The previous general health, hygienic conditions, and sanitary surroundings are of great importance. When there is ulceration or membranes the prognosis should be guarded. The condition may become =chronic=.

=Treatment.=—The bowel should be thoroughly washed out by warm water enema, several times, if necessary, to remove irritating material. Invariably a lesion of the spinal column is found at the third and fourth lumbars or near by. It is generally a subluxation, of a lateral nature, between these vertebræ: rarely is the lesion above or below this point. The treatment should be applied immediately and directly to this region. Time is valuable in these cases and one should go to work at once to correct the irritation. An attempt should be made at each treatment to correct the disorder. This should not be delayed by wasting time in relaxing muscles and inhibiting, for unusually this gives only temporary relief. When a slight movement has been accomplished between disordered vertebræ, treatment should be stopped and results watched, because the adjustment may have released all obstructions or irritations causing the disease. In many cases, to get an anatomically correct spine is an impossibility, from the fact that the displacements may be of long standing and naturally the subluxated vertebræ have conformed themselves to some extent to their unnatural position. In other words, what has been lost in the position and relation of a vertebra may have been compensated by reducing the effect of the lesion to a minimum. A lesion of this nature at the third lumbar impairs the innervation to the colon and consequently produces a stasis of blood in the mesenteric circulation, followed by inflammation, bloody discharges, cramps, etc. A single treatment is usually quite sufficient in milder cases. Other cases require treatment every few hours or thereabouts, until recovery.

Treatment directly over the abdomen through the mesenteric circulation and glands is an effective treatment in most cases and especially when the attack is severe. It relaxes the tissues about the mesentery, thereby relieving the stasis and freeing the circulation. The greatest care, however should be exercised in giving this treatment.

The constant desire to defecate, that is common to many cases, is a very annoying symptom. Strong, thorough treatment over the sacral region, by inhibition over the sacral foramina and by relaxing the tense muscles of the sacrum, will relieve this condition. In relaxing these muscles, place the whole hand against the muscles and push upward toward the occiput. This treatment inhibits the nerves to the rectum and lessens the =tenesmus=.

Attention should be paid to the liver to keep it active. Washing out the large bowel with tepid water produces a soothing effect, besides having a tendency to allay inflammation. The blandest of liquid foods, as peptonized or boiled milk, broths, beef juice, barley and rice, should be given. The patient should remain in bed until completely cured.

Amebic or Tropical Dysentery

This form prevails in the tropical and subtropical countries for the most part, and is caused by an animal parasite, the ameba dysenteriae. This is constantly found in the stools, the tissue of the intestine and also in the pus of the liver abscesses, which are secondary to dysentery. Amebae are sometimes found in the stools of healthy men, having probably entered the system through the drinking water or uncooked food.

=Pathologically=, the mucous membrane of part or whole of the large intestine is swollen. Round or irregular ulcers which undermine the mucous membrane, especially of cecum, ascending and pelvic colon, are found. In later stages there is infiltration of the connective tissue followed by necrosis. In some cases false membranes and sloughs are formed.

=Symptoms.=—The onset may be either sudden or gradual, with a very irregular diarrhea, moderate fever, and copious, liquid stools, abounding with the amebae coli. The straining may be less severe and persistent than in catarrhal dysentery and may be absent. Sometimes there is nausea and vomiting.

Abscess of the liver is the most common complication, which may be single or multiple. When single it usually involves the right lobe. Multiple abscesses are small. The more recent abscess walls are necrotic; the older have whitish, smooth, fibrous walls. These abscesses do not contain pure pus, but a fatty and granular debris containing the amebae and a few cellular elements. Sometimes they extend into the lung.

=Diagnosis.=—This depends upon severity of attack and general condition of the patient. Relapses often occur and the case may become chronic. Cases have been treated osteopathically with success.

=Treatment.=—In this form of dysentery the treatment is largely the same as in acute ileo-colitis. The spinal lesions affect the innervation to the intestine, thus producing a stasis in the circulation; this condition favoring, and in fact, inviting the retention of the ameba coli in the system at this point.

The diet is the same as in other forms of dysentery. Rectal injections and hot applications to the abdomen are useful. In all cases where strong treatment has been given to the spinal column, a quieting treatment to the nervous system and an inhibitory treatment to the heart will be gratefully received by the sufferer. Both of these effects can be accomplished at the same time by simple inhibition to the occipital nerves. The stools should be taken care of immediately and disinfected. Ice water enemas given frequently are reported as giving good results. For the tenesmus, inhibit strongly at 3d, and 4th, sacrals.

Chronic Dysentery

This is generally resultant from an acute attack, though the amebic form may be subacute from the onset.

=Pathologically=, the coats are generally thickened, especially the submucosa and the muscular coats being hypertrophied. Ulcers are usually present, although there are cases in which there are no ulcers. Cicatricial contractions sometimes follow and the calibre of the bowels is reduced, strictures being rare.

=Symptoms.=—There is a progressive loss of flesh and strength, little or no tenesmus, slight, colicky pain and extreme anemia. The stools contain mucus, at times blood, and the bowels move from two to twelve times a day.

=Diagnosis.=—The history of the initial symptoms will establish the diagnosis. It is not always possible to distinguish between chronic dysentery and chronic diarrhea. The duration is from a few months to several years, although osteopathic treatment has proven very efficient in many instances.

=Treatment.=—Rest and a liquid diet are most essential. Foods that are easily assimilable and nourishing, with a minimum amount of residue, are required. Beef juice, beef peptonoids and peptonized milk are the types of food. Change of air, hygienic measures and environment are important.

In cases that become chronic, the spinal column oftentimes exhibits lesions above and below the lumbar region. Undoubtedly they are lesions of secondary importance in comparison to the lumbar lesions, but it is important that they be corrected. The treatment requires thorough, careful work of the disordered spinal column and lower ribs. Occasionally a slight kyphosis is present in the dorso-lumbar region that demands persistent work in order to correct it. An occasional rectal injection is beneficial, especially in cases that have slight ulceration of the sigmoid flexure or rectum causing colicky pains and a few loose stools in the morning, the patient being fairly comfortable during the rest of the day.

Erysipelas

=Definition.=—An acute, infectious, specific disease, characterized by a peculiar inflammation of the skin, due to the streptococcus erysipelatis, with a tendency to spread.

=Osteopathic Etiology= and =Pathology=.—Osteopathically, lesions are found to the vasomotor nerves and lymphatics of the affected area. Dr. Still gives lesions of the “inferior maxilla, the cervical vertebræ, the clavicles or the upper ribs” as specially important factors. These lead to congestion and predispose to infection. It occurs in epidemic form, especially in the late winter and spring. One attack predisposes to a second. Family predisposition exercises a slight influence. Abrasions, lacerated wounds, especially of the scalp, may be the starting point of an attack. Persons having skin diseases and wounds, and women who have been recently delivered are liable to be affected. Chronic Bright’s disease, chronic alcoholism, syphilis, debility, phthisis, organic heart disease and unhygienic surroundings are predisposing causes.

The specific virus is the streptococcus erysipelatis, which acts as a local irritant producing the dermatitis. These are found in the lymph vessels and cutaneous connective tissue. The fever and constitutional symptoms are due to toxic agents.

It is an inflammation of the skin, and if uncomplicated, no other structures are involved. Subcutaneous and mucous tissues may be involved, but rarely; if so, there is apt to be suppuration. Visceral complications are of a septic character. Endocarditis, pericarditis, pleuritis-pneumonia, and nephritis are possible complications.

=Symptoms.=—The incubation period varies from two to seven days. The onset is generally sudden with chill, followed by fever, 104 or 105 degrees F. There may be nausea, headache, and pain in the back and limbs. The local inflammation of the skin follows, usually on cheeks and bridge of nose, or at site of an abraded surface. The area is red, smooth, and edematous. It spreads rapidly, the patch being elevated above the surrounding tissue and tense. The swelling may be so great as to close the eyes and distort the features. The cervical glands are swollen. The temperature continues high for four or five days and falls by crisis. The eruption begins to subside and a moderate desquamation occurs. If the disease takes a fresh start the fever again rises and continues as long as the disease spreads. There is usually headache and sometimes delirium. The tongue is furred, and bowels constipated and the urine scanty. As a result of intense infiltration the part may become gangrenous. Suppuration frequently occurs in facial erysipelas. The inflammation may extend to the mucous membrane of the throat and mouth.

=Diagnosis.=—This is not difficult. The fever, the acuteness of the disease, the rapidily spreading eruption, and the constitutional disturbances will serve to distinguish it from all others.

=Prognosis.=—This is usually favorable; healthy persons rarely die. Convalescence may be slow.

=Treatment.=—Isolate the patient for the disease is contagious, and a third person may convey the virus. The poison may cling to clothing, furniture, etc. The physician should not take care of confinement cases.

A number of cases of erysipelas have been cured by correcting disorders in the region of the second, third, fourth and fifth dorsals. The lesions are principally subluxations of the ribs and severely contracted muscles. The disorder at the points named interferes with the vasomotor nerves to the face, thus predisposing to an attack of erysipelas by allowing the micro-organism congenial tissue for its devastations. In many other cases derangements have been found higher than the upper dorsal, principally through the middle and upper cervical vertebræ. Lesions in these regions would also interfere with vasomotor fibres, especially through the fifth nerve directly.

The treatments on the whole are to examine for lesions to the innervation of the affected region and remove them, besides giving special attention to the bowels, a nutritious diet, and absolute rest. In cases where there is much restlessness and insomnia, treat the upper cervical region, especially the deep posterior muscles[57]. Locally, use cold water applications; adhesive strips applied near the inflamed area or tincture of iodine, may prevent the disease spreading.

Yellow Fever

=Definition.=—An acute, infectious disease, characterized by a febrile paroxysm followed by short remission and then relapse, jaundice, toxemia, suppression of the urine, and gastric hemorrhage.

=Osteopathic Etiology= and =Pathology=.—While a specific germ is the cause of yellow fever, it has not as yet been isolated. Extended tests by United States Army surgeons in Cuba show conclusively that the infection is alone carried by the stegomyia fasciata, but “It remains somewhat uncertain whether the mosquito is the sole means of transmission.” (Anders). Season is the chief predisposing cause as the outbreak is usually in summer and a frost ends its spread. Immunity is generally conferred by one attack. Tucker[58] noted that all cases examined had liver lesions and that most of the patients were of the malarial or bilious type. Spinal lesions were not marked in some cases, but when present were in the liver and renal areas. Tete[59] believes it to be a virus secreted in the human organism under certain atmospheric and other conditions in certain types, i. e. people subject to hepatic and renal disturbances. He also says the vagus is an important factor.

=Pathologically=, there is more or less jaundice and hemorrhagic extravasations under the skin. The blood serum is red-tinted, owing to the destruction of the red cells. The liver is pale and presents extensive fatty degeneration, with necrotic masses in and between the cells. The gastro-intestinal mucous membrane is swollen, congested and presents numerous minute hemorrhages. The kidneys show parenchymatous inflammation. The spleen is not enlarged. The heart sometimes shows fatty degeneration. The stomach contains more or less of the “black vomit,” which is a mixture of transuded serum and transformed blood pigment.

=Symptoms.=—The incubation period varies from one to five days. The attack generally begins with a chill, fever, 102 to 105 degrees, headache and pains in the loins and legs. The pulse is accelerated, the face is flushed, the tongue is coated, the throat sore, the bowels constipated and the urine scanty and albuminous. Recent observers state that bile is present in most cases before the albumin is noted. Nausea and vomiting may be present at the onset, but become more severe about the second or third day when the black vomit appears. The =febrile stage= or stage of invasion, lasts from a few hours to several days and is followed by a decline in the fever when the severity of the other symptoms abates. This is called the =stage of remission= and in favorable cases convalescence sets in or the patient may pass into the second febrile paroxysm. The temperature rises again, jaundice appears rapidly, nausea and vomiting return. The tongue becomes dry and coated. The stools are black and offensive, the urine is albuminous, scanty and may be suppressed; there may also be hematuria. Death may occur from exhaustion or from uremia. Recovery may follow the gravest symptoms, even when there has been black vomit. The duration of the entire attack covers about one week. Relapses sometimes occur.

Price says there is a point in differential diagnosis in yellow fever and it is a symptom not met with in any other febrile affection. It is the progressive fall of the pulse-rate during the congestive stage of the first sixty or seventy hours, i. e., a variation of from five to ten beats less each morning and evening. He adds, “As long as the kidneys are active there is but little to fear.”

=Diagnosis.=—=Remittent fever= has not the deep jaundice, the clear mind, the black vomit, or the albuminuria of yellow fever. The enlarged spleen and the presence of the organism of Laveran in the blood in remittent fever will decide the diagnosis. =Dengue= is sometimes confused with yellow fever.

=Prognosis.=—This is always a grave disease, and in its severe forms very fatal. Recovery, however, may occur after the severest symptoms have been manifested. Black vomit is not always a fatal sign. Enough cases have been treated osteopathically to state that osteopathy is particularly effective. Improved sanitation is doing much to reduce mortality.

=Treatment.=—Prophylactic treatment should be carefully carried out. All patients should be quarantined and carefully screened so they cannot be bitten by the mosquito and the disease spread further. People that are not acclimated should keep away from infected districts. All pools, cisterns and other places which can breed mosquitoes should be drained or screened. A systematic warfare should be waged against them. The patient must be put to bed at once and plentifully supplied with fresh air. Everything must be scrupulously clean—body and bed linen. Use a tube for nourishment and a bed-pan for excretions as the patient must not make the slightest exertion.

Spinal lesions may or may not be found. They have been observed in the cervical, eighth dorsal and second lumbar.

The treatment on the whole is symptomatic. The chills and fever of the first stage should be controlled by thorough work at the upper cervical, upper dorsal, lower dorsal and lower lumbar regions. Treatment at these points controls the superficial and deep vascular areas of the body through the vasomotor nerves. The irritable stomach, delirium and severe neuralgic pains of the head, back, epigastrium and limbs are to be treated according to the conditions and severity of the symptoms. The kidneys and bowels should be watched carefully, and at the onset should be freely opened and control of the kidneys never lost. Let the patient drink freely of water, which will aid. Hydrotherapeutic measures, as a cold bath or sponging, may be employed to aid in controlling the fever, the nervous symptoms, and the eliminative power of the excretory organs. Discontinue the use of hydrotherapy when a spontaneous fall of temperature occurs.

At the beginning of the first stage and during the stage of remission are the periods that the osteopath should do very effectual work by paying particular attention to the four large vascular areas of the body, viz.: head, lungs, abdomen and legs. Treat the vasomotor nerves to these regions, thoroughly, as given in the treatment of the first stage. During the third stage everything should be done that is possible to support the system. Ice slowly dissolved in the mouth will be of aid to an irritable stomach. Hemorrhages and the various symptoms are to be treated as they arise.

Good nursing, dieting, ventilation and keeping the skin, kidneys and bowels active are the primary points to consider. During the period of depression, the heart must be closely watched. The diet should be a light, liquid one, of the nature of peptonized milk or light broths. No food is recommended by some at the onset nor until the crisis is passed. Others feed during the stage of remission and give stimulants. During the last stage rectal feeding is suggested if gastric irritability is pronounced.

Tetanus

(LOCK-JAW)

=Definition.=—An infectious disease, caused by Nicolaier’s tetanus bacillus, characterized by persistent, tonic spasms of the muscles with violent exacerbations.

=Etiology= and =Pathology=.—The exciting cause of tetanus is a specific bacillus which usually gains access to the system through some wound. The site of infection is the only place the germs are found.

The disease is much more prevalent in some localities than in others. It is found in hot countries, as in India and the West Indies, far more commonly than in temperate regions. Exposure to damp cold is one of the recognized causes, also those localities where there are rapid changes from cold. Such regions seem to produce conditions favorable to the existence and growth of the bacilli.

Earth mould, particularly where putrefaction is taking place, as in soil that has been manured, is especially favorable to the existence of the bacillus. It is frequently found in the intestinal tract of the horse, so that the soil about stables is apt to contain the germs. The highly fertilized soil of France and Belgium rendered it a special menace to the wounded of the Great War. Antitetanic serum, according to all reports, was particularly efficacious.

Wounds and abrasions of various kinds, particularly contused and punctured wounds of the hands and feet, favor the excitation of tetanus. When an open wound is present, the term =traumatic tetanus= is given to the disease; =idiopathic tetanus= when no wound is discoverable; =tetanus neonatorum= when it attacks infants—this form is usually due to insanitary conditions, especially the improper care of the umbilical cord; =lock-jaw= or trismus when the jaw alone is affected; =cephalic tetanus= when the throat and face is involved.

Characteristic lesions have not been found in the cord or the brain. The bacilli develop at the site of the wound where the toxin is manufactured. The bacilli do not invade the blood and organs. The toxalbumin is one of the most virulent poisons known.

Congestion occurs in various organs, due to obstruction of the movement of the blood during a spasm. The brain, cord, lungs and muscles are congested. The nerves are often found swollen.

=Symptoms.=—The period of incubation is from one to twenty days. This is time required for the poison “to be absorbed by the end plates in the muscles and to pass up the motor nerves to the spinal cord.” In most cases the incubation is from five to ten days. A chill precedes other symptoms in a few cases. The onset is quite sudden, with stiffness in the neck, jaw and tongue. There are headache, stomach disturbance and languor. Opening the mouth is difficult, but is not painful. Deglutition is difficult. The stiffness increases and extends to the spinal muscles, abdomen and legs which are held in a firm spasm. Thus, the trunk and legs are inflexible.

These symptoms vary in degree of severity, dependent upon the extent of involvement. The jaws may be firmly locked or they may yield to forced extension—“lock-jaw.” The muscles of the face may be involved, the angle of the mouth drawn out, and the eyebrows raised—“risus sardonicus.” The neck and trunk muscles affected produce opisthotonos. Spasms of the pharynx and esophagus may occur, especially when there are injuries to the fifth nerve.

Associated with these tonic convulsions is intense pain. The distress of the patient is extreme when the chest muscles are affected. All symptoms are increased during the paroxysm. A foot fall, the slamming of a door, a draught of air or any slight sensory impression may excite a paroxysm. The paroxysm may relax and during the interval the patient may walk about. The spasms vary in frequency from a few minutes to one in several hours. During spontaneous or induced sleep the spasm usually ceases. The febrile reaction is generally slight and apparently of nervous origin; in many cases 102 degrees F. In severe cases the temperature may be considerably higher. Perspiration is excessive. The urine is scanty and high colored. The bowels are usually constipated. The mind remains clear throughout. Death is generally caused by exhaustion. =Chronic tetanus= presents similar symptoms, but less marked, and it develops slowly.

=Diagnosis.=—The history of a wound followed by the characteristic symptoms would rarely occasion an error. =Strychnine poisoning= differs from tetanus in the history, in the more rapid development of the symptoms, no trismus at the beginning, marked involvement of the extremities, and absence of rigidity between the paroxysms. In =tetany= the extremities are chiefly affected by the spasms, the muscles are relaxed during intervals, and trismus is a late or very rare condition. In =hydrophobia= trismus does not occur and the respiratory spasm is caused by attempts at swallowing. The mental symptoms increase.

=Prognosis.=—The prognosis is unfavorable. Eighty per cent of traumatic and fifty per cent of the idiopathic cases prove fatal. Cases that are fatal usually die within six days. Cases where there is slight elevation of temperature, and where the spasm is localized to the muscles of the face, neck and jaw, or where muscle stiffness is late in appearing, are more likely to recover.

=Treatment.=—Free incision and thorough disinfection with hydrogen peroxide and cauterization with pure carbolic acid, of the wound are necessary. The patient should be put in a dark room and there remain as quietly as possible. Avoid all sources of peripheral irritation. Liquid food is to be given, and if the jaws are firmly set, rectal feeding may be employed or food may be passed through the nose with a catheter.

For the spasms, strong inhibition of the nerve centers controlling the affected muscles may be of use. Probably the most effectual treatment for the paroxysms would be strong, thorough treatment of the upper cervical region. Hot baths give relief to the spasms. All the excretory organs should be greatly stimulated, particularly the kidneys, lungs and bowels. Other symptoms are to be treated as they arise. Tetanus antitoxin is highly commended by surgeons who used it during the Great War. As death is at a two to one ratio any method of treatment is justified. A few cases have been treated osteopathically with fair success, following antiseptic measures.

Simple Continued Fever

=Definition.=—An acute, febrile disease, mild in character, of short duration, not excited by any special organism and depending on a variety of irritating causes.

=Osteopathic Etiology.=—The most frequent cause of this form of fever is probably gastro-intestinal disturbance. In children it may be due to gastro-intestinal derangement, or to the eating of decomposing food or to exposure to wet and cold. It may be caused by exposure to the sun or great heat, or mental or physical fatigue. It may be the result of exposure to cold sufficient to produce a slight bronchitis, tonsillitis or other affection producing an unnoticed localized inflammation. It may follow a prolonged exposure to noxious odors or gas. Lesions, osseous or muscular, are always present, corresponding to the tissues and organs disturbed. Muscular lesions, especially, are prominent.

=Symptoms.=—The onset is usually sudden with a feeling of lassitude, weariness, chilliness, and headache. The temperature rises quickly to 102 or 103 degrees F. or over, and is usually apt to terminate suddenly by crisis on the third or fourth day. The pulse is frequent and the face is flushed. The child is often irritable. Mild delirium may occur. Anorexia is present, and the bowels are constipated. Convalescence is rapid.

=Diagnosis.=—This depends upon excluding other probable diseases. If the fever cannot be attributed to some of the causes already referred to, there may be a doubt as to its character for the first twenty-four hours, but, if after a careful examination, one finds no other cause and no symptoms develop of any of the recognized diseases, acute continued fever can hardly be mistaken for any other disease.

=Prognosis.=—Always favorable, recovery without sequelæ being the rule.

=Treatment.=—It is necessary to find out the irritative cause in order for one to be able to treat intelligently. Rest in bed with treatment of the disturbing factor of the disease, whatever that may be, is the principal treatment to be given. Careful examination of all the organs, with due consideration of the symptoms, will generally leave no doubt as to the cause, and treatment applied accordingly will be sufficient. If there is any gastro-intestinal disorder, thorough treatment of the splanchnics, anterior treatment to the abdomen and thorough evacuation of the bowels are indicated. Use an enema if necessary. Besides the usual fever treatment, sponging the body with tepid water at the time of day when the fever is highest will aid in lessening the temperature and render the patient more comfortable. In cases where nervous symptoms are prominent, care should be taken against any excitement and, if insomnia results, a quieting treatment in the cervical region is usually sufficient. Use plenty of water internally, which is not only necessary for the tissues on account of the fever, but is of great aid in keeping the skin and kidneys active, and thus a great help in the elimination of waste material. A liquid, nutritious diet is best. Milk, broths and soups will be enough. The demands on the digestive tract are not great when a light diet is administered, besides not exciting the nervous and vascular systems unduly.

Tuberculosis

=Definition.=—A general or local infectious disease caused by the bacillus tuberculosis of Koch. The bacillus produces specific lesions of the form of nodular bodies called tubercles that undergo caseous necrosis with a tendency to involve neighboring tissue. There may be a diffusion of the infection by way of the lymph and blood vessels to various tissues and organs.

=Osteopathic Etiology and Pathology.=—Tuberculosis exists in all countries. It generally prevails more extensively in warm than in cold climates, and is of more frequent occurrence in the city than in the country. Altitude, however, exerts more influence than latitude. The disease rarely occurs in mountainous countries, owing to the purity of the atmosphere. The disease is very prevalent in the West Indies and the South Sea Islands. Tuberculosis is frequently met with in Canada among the French Canadians and the English. All races are subject to tuberculosis, but the Indians of this continent, the South Sea Islanders and the colored race are very susceptible to the disease. It is estimated that from seven to ten percent of the present death rate in the United States is due to tuberculosis.

The tubercle bacillus was discovered by Koch in 1881. It is a short, straight or slightly bent, rod. This bacillus has an exceedingly tenacious hold on life and is found in greater or less numbers in all tuberculous lesions.

It can live almost indefinitely outside the body. The bacilli are found in great numbers in the sputum, which dries and flies in the atmosphere in the form of dust. The organism is thus widely spread in regions frequented by phthisical patients. The bacillus gains entrance into the body by way of the respiratory tract in the vast majority of cases. Milk from tuberculous cows will produce the disease, especially in children, causing intestinal and mesenteric tuberculosis. The meat of tuberculous animals is not necessarily infectious, although there is a possibility of infection by this means. Tuberculosis may be transmitted by direct inoculation; this does not often occur in man, but when it does, the disease usually remains local, although general infection may occur. Persons who follow certain occupations, as butchers, dissectors of dead bodies, and handlers of hides, are more or less subject to local tubercles of the skin. The virus may enter the body through any fissure or excoriation on the skin; thus by washing the clothes or bed linen of phthisical patients, by the bite of a consumptive, or by a cut from a broken sputum glass of a consumptive, one may become infected. It is stated that there may be hereditary transmission. In some cases the virus may be transmitted and the disease may not appear for many years.

=Predisposing Causes.=—Hereditary predisposition, which renders the person more liable to accidental infection; delicate constitution; scrofulous tendency; previous infectious diseases, as influenza, whooping cough, measles, typhoid fever; diabetes mellitus, etc. In young children meningeal, mesenteric and lymphatic forms of tuberculosis are the most frequent. Pulmonary tuberculosis is usually met with in adults, especially between twenty and thirty years or age. The development of tuberculosis is favored by damp localities; by improper and insufficient food; constant inhalation of impure air; injuries to the chest, with or without laceration of the lungs, and various osteopathic lesions that weaken the tissue through faulty nutrition. Corresponding to the innervation of the organ or tissue diseased will always be found anatomical derangements. “Every case has a defective spine and thorax.” (Hayden[60]).

Bronchial catarrh, tonsillitis, diseases of the stomach and intestines, especially enterocolitis, tubercular pneumonia, pleurisy (rarely), intrathoracic tumors and congenital or acquired contraction of the orifice of the pulmonary artery increase the susceptibility to infection. Lessened vitality of the tissues, whether inherited or acquired, is necessary before the germ can become implanted and proliferate, producing tuberculosis of the tissues and organs. In nearly every instance, when the lungs are involved, lesions are found at the second, third, or fourth ribs. These lesions undoubtedly predispose to the tubercular infection, by lessening the vitality of the lung tissues through interference with the innervation or vascular supply. Possibly a lesion at the second rib or second dorsal vertebra would interfere directly with the vasomotor nerves of the upper thoracic ganglia. The condition of the middle and lower cervical vertebræ should be carefully examined, for lesions at that point would involve the lymphatics of the lungs. The lowered vitality caused by the lesion is the predisposing cause and the tubercular bacillus is the =exciting cause= which determine the character of the affection.

C. A. Whiting in Clinical Osteopathy says:

“=The spinal outline= characteristic of tuberculosis and of the pretubercular stages presents the following peculiarities: The cervical spine presents various abnormalities, usually lesions involving single vertebræ and associated with irregular muscular tensions. The upper thoracic spine is anterior, the ribs drooping and rather more freely movable than normal; the vertebral articulations are less movable than normal; the tissues in the neighborhood of the upper two or three dorsal spines are abnormally sensitive and the muscles innervated from these segments are contracted irregularly when the disease involves the apices. The lower interscapular region is found sensitive and these muscles are contracted when the lower lobes of the lung are involved, and the location of these sensitive areas may be employed in the localization of the lung area infected.

“In every case recorded in this clinic, lesions involving the area of the origin of the upper and middle splanchnic nerves have been found. The typical tuberculosis spine must include lesions of the lower dorsal area. Probably these lesions are predisposing factors in tuberculosis, partly because of the effects produced upon nutrition thereby, but doubtless the lack of the normal mobility of this part of the spine prevents the normal stimulation of the liver, the spleen, perhaps the pancreas, thus the normal opsonic index is lost, and immunity broken. The treatment of tubercular cases should include careful attention to the splanchnic area, the maintenance of the normal mobility and structural relationship of the entire spinal column, and such stimulating movements to the ninth and tenth thoracic neighborhood as is indicated in each individual case.”

=Pathology.=—In adults the most common site of tubercles is the lungs; in children it is the lymphatic glands, joints and bones. No organ is exempt; the salivary glands and pancreas are the least frequently involved. The military tubercle is the beginning of tubercular deposits. This may develop in any tissue where the tubercle bacillus is found and it is only distinguished by the presence of a tubercle bacillus, as similar conditions are produced by the aspergillus glaucus and actinomyces.

In the development of a tubercle there is proliferation of the fixed tissue cells, particularly those of the connective tissue and the endothelium of the capillaries, due to the irritation of the bacillus, producing the epithelioid cells and in some instances the giant cells, in both of which bacilli may be found. The epithelioid cells vary in shape. The giant cells are formed by enlargements of the epithelioid cells and a repeated division of their nuclei or possibly by fusion of several cells. On account of the inflammation produced by the bacillus, there is migration of leucocytes from the adjacent vessels and lymphoid cells. The leucocytes are largely polynuclear and are rapidly destroyed, but later mononuclear leucocytes appear, which are able to resist the action of the bacilli so that they are not so readily destroyed. A reticulum of connective tissue is formed around the various cells. The tubercles are non-vascular and when once formed undergo caseation and sclerosis.

=Caseation= is a process of coagulation-necrosis or destructive change, beginning at the central part of the growth, due to the action of the bacilli. The primarily transparent tubercular tissue may become a gray gelatinous body containing bacilli. Frequently the caseation is followed by softening; less frequently, calcification, or it may be surrounded by fibrous tissue.

During the time the cell destruction is going on at the center of the tubercle, hyaline and fibrous changes may render the tissues =sclerotic=. These changes, =caseation=, the destruction of forces, which are dangerous to the patient, or =sclerosis=, which is a healing process, depend upon the power of the body to produce an antitoxin to overcome the effects of the special toxin produced by the bacilli.

There may be a widespread =tuberculous involvement=. This is the result of fusion of the new foci of infection or of miliary tubercles. The lungs are the usual site of infection, varying from a small area, to a lobe or a still greater area.

The irritation of the bacilli is capable of producing =associated inflammatory processes= in its own neighborhood. There may be an overgrowth of interstitial tissue. In other instances, changes to catarrhal or croupous pneumonia may occur. Suppuration is associated with tuberculosis, especially of the lungs, and is due to a mixed infection or the presence of pus organisms. Some authorities claim that the tubercle bacilli alone are able to produce suppuration; it is, however, more probable that suppuration is due to a mixed infection. The constitutional features in tuberculosis are more dependent upon this secondary infection, especially by the streptococci, than upon the primary infection.

Tuberculosis of the Lymph Glands

(SCROFULA)

=Scrofula= is a true tuberculosis of the lymphatic glands. The virus is less virulent than that from other sources, which accounts for the slow development and milder course of tuberculosis of the glandular system.

=Tuberculous Adenitis= may occur at all ages, but is most common in children and young adults. It is rarely congenital. Catarrhal inflammation of the mucous tissues weakens the resisting power of the lymph tissue, thus allowing the bacilli to develop, and is an important predisposing cause. The glands most frequently affected are those of the neck; more rarely there is involvement of all the lymphatic glands of the body. Invariably lesions of the upper and middle cervical vertebræ and upper dorsals and corresponding ribs are found, as well as lesions to the lymphatics at various points along the spinal column and ribs. These lesions affect the innervation to the lymph glands, as well as mucous membranes, and thus predispose to the disease. In all cases anatomical derangements are found in the region of the innervation to the involved gland.

In =general tuberculous adenitis= all the lymph glands of the body are more or less involved, while the other organs and tissues are rarely affected. All the visible glands are found to be swollen, tender and painful. There is more or less protracted fever, with wasting and debility. This is a rare affection.

In =local adenitis= the glands of the neck are most frequently affected and this is especially the case with children. Negroes are more frequently affected than whites. It is seen especially among those living in an unsanitary environment. Measles, whooping cough and an hereditary tendency are predisposing factors. The submaxillary glands are usually the first affected. At first they are swollen to various degrees and are tender; later they suppurate and rupture if one is not able to cure them. There may be fever. The skin over the glands is usually freely movable; it may, however, be adherent.

The glands above the clavicle, those in the posterior cervical triangle, and the axillary glands may all be affected. In such cases it is likely that the bronchial glands are also involved and may infect the living tissue.

Lesions of the upper and middle cervicals and deep muscles are always found and undoubtedly are the underlying causes. Lesions of the lower cervical, upper dorsal, ribs and clavicle, are of frequent occurrence. Infection may gain entrance by way of the pharynx and tonsils.

The affection often runs a slow course.

The =bronchial= glands may be affected primarily, but usually secondarily to infection of the lungs. The primary form is seen most commonly in children and is apt to be associated with suppuration. Lesions of the upper and middle dorsals and of the cervicals will be found. Catarrh of the bronchial tubes is a predisposing cause. The X-ray is of great value in the diagnosis.

The most noticeable symptoms are those due to pressure or irritation.

Systemic infection may follow rupture into a vessel. Local infection of the lung may occur and the pericardium become infected.

=Mesenteric= cases occur among children and may be primary or secondary. The primary form is rare. Swallowed sputum is a frequent cause. The trunk and limbs are puny. The child is anemic, and often the abdomen is tympanitic. Diarrhea is marked and there is pain and indigestion. Fever is almost constantly present and of an intermittent type. The disease is most frequently met with among poor children in unhygienic, poorly ventilated houses. There may be an associated tuberculosis of the peritoneum.

Acute Tuberculosis

This shows best the truly infectious nature of tuberculosis. In it miliary tubercles develop in many and various parts of the body. In some cases these growths seem to be uniformly distributed throughout all the viscera. In other instances they are localized in the lungs or in the meninges of the brain. In nearly every instance it is an auto-infection, arising from an old tuberculous focus, which may be latent and quite unsuspected. General infection, in most instances, arises from the rupture of a nodule into a vein, from tuberculous lymph glands, tuberculosis of the bones, joints, or even the skin.

=General Miliary Tuberculosis or Typhoid Form.=—This is similar to a general infection of the body and resembles, to a marked degree, the symptoms of typhoid fever. The onset is rarely rapid.

In most cases there is a period of incubation, during which the health fails, the appetite is lost, headache occurs, and the patient soon becomes feverish, with increased debility. The temperature rises and the pulse is rapid and feeble. The tongue is dry. The respirations are increased. Delirium may be present. In rare cases, there may be little or no fever. The temperature ranges from 101 to 103 or even 105 degrees F. It is irregular and marked by evening exacerbations and morning remissions. Occasionally there is an inverse type of temperature in which it rises in the morning and falls in the evening. In some cases the pulmonary symptoms are marked, while in others the meningeal symptoms are more prominent. Tubercle bacilli are rarely found in the sputum.

The spleen is usually enlarged. Constipation is present, as a rule, but there may be diarrhea, and hemorrhage from the bowels may occur. The urine may contain traces of albumin. There may be excessive sweating, and herpes is often present. Choroid tuberculosis is frequently met with. In doubtful cases the blood should be examined for tubercle bacilli, although they are not always present. The duration is from two to four weeks, the disease usually terminating unfavorably.

=Diagnosis.=—It is often very hard to differentiate between this form of tuberculosis and typhoid fever. In =typhoid fever= epistaxis is a common, early symptom. The temperature curve of the continued type is quite diagnostic. The Widal test should be made. The respirations are moderately hurried and the pulse is often dicrotic. Diarrhea is frequent. Typhoid rash is diagnostic. No tubercles are found on the choroid. No tubercle bacilli are found in the blood. Hemorrhages from the bowels are common.

=Pulmonary Form.=—When the lungs are chiefly affected the pulmonary symptoms are marked from the onset. It may develop suddenly or there may be a long period during which the general health fails markedly. In children the disease may follow measles or whooping cough. There is dyspnea, cough and the expectoration is mucopurulent. There is broncho-vesicular breathing with sibilant and subcrepitant rales. The temperature is high, ranging from 103 to 105 degrees F., or higher. Respiration and pulse are rapid.

The disease may last from several weeks to months, or, on the other hand, it may prove fatal within a few days. As the end draws near the signs of suffocation become intensified.

=Diagnosis.=—The history and general symptoms, together with the dyspnea and cyanosis, will generally decide the diagnosis. The blood should be examined for malarial parasites. The Widal test will differentiate typhoid.

=Cerebral or Meningeal= (Tuberculous Meningitis).—This form which is sometimes called acute hydrocephalus, occurs quite frequently and is an infection of the pia mater of the brain or cord.

It occurs most frequently in the first two years of life, although it may occur later. It is usually tuberculous in some other region, especially in the bronchial glands. Rarely does the disease involve the meninges primarily.

The meninges at the base of the cerebrum is the principal involvement. There is more or less inflammation, with fibrous purulent exudation. There are tubercles along the blood vessels. The ventricles may be distended.

=Symptoms.=—The onset is slow, lasting one or more weeks. Headache, constipation, vomiting and chills, followed by a fever, are the initial symptoms. When the onset is sudden, the disease is generally ushered in with a convulsion. The fever rarely rises above 102 or 103 degrees F. The pain is often severe, causing the child to give a sudden cry—the hydrocephalic cry. During sleep the child is restless and there are slight muscular twitchings.

The =irritative symptoms= now abate. The child becomes quiet and is dull and apathetic. Constipation still persists. The abdomen is boat-shaped, and the neck may be retracted. The pupils are dilated. Convulsions and other cerebral symptoms may occur. The temperature ranges from 100 to 103 degrees F. The respiration is irregular and sighing.

Following this, the mental faculties are lost and coma occurs. Convulsions or spasmodic contractions of the muscles of the neck, back and limbs may occur. The pupils are dilated and do not respond to light. The pulse is frequent, irregular and small. The temperature rises to 103 to 105 degrees F., or it may be subnormal. The duration is from two to five weeks; chronic cases may last for a number of months.

=Prognosis.=—Generally very unfavorable.

Acute Pneumonic Phthisis

The infection of the lungs is rapid and may be primary or secondary. This form is met with most frequently in children and young adults, but may occur at any age.

The =Pneumonic form= is more rare than the bronchopneumonic form and may be very rapid in its course. The attack sets in abruptly with a chill and the temperature rises rapidly. There is pain in the side; cough; dyspnea and mucous and rusty sputum, which may contain tubercle bacilli. There is impairment of resonance, increased fremitus, and bronchial breathing. The whole or part of the lung may show signs of consolidation and dullness, all the symptoms of pneumonia being present. The patient rapidly loses flesh. This attack may come on a person in good health after exposure to cold; but there may have been a debilitated condition, or a predisposition to phthisis. Death may occur in the second or third week or the case may continue from three to four months.

One or both lungs may be involved. The lung is heavy and airless, sinking quickly in water. There is destruction of lung tissue and upon section, cavities are found. The cavities are generally small and are surrounded by tubercles. Older caseous areas of a yellowish white color may be visible. Miliary tubercles are found upon careful examination.

The =bronchopneumonic form= is the most common and occurs most frequently in children. It often follows the infectious diseases, especially measles and whooping cough. The child may be taken ill suddenly with what seems to be an ordinary bronchitis, the temperature rises, the cough is severe, and there may be consolidation with submucous and subcrepitant rales. Rapid respiration and sweating are often marked. The course of the disease varies. There is rapid loss of flesh, and in many cases the disease develops into chronic phthisis. In other instances death occurs in from three to eight weeks.

The disease may attack the adult whose resistance is impaired. Chills, fever, pain in the chest, hemorrhages, wasting are most noticeable symptoms; these are the various signs of bronchopneumonia. Tubercle bacilli are often found in the sputum. The course is usually from three to eight weeks, while a number pass into a chronic stage.

Areas of caseous tubercles are found, which later suppurate, break down and form cavities. The bronchial lymph nodes are found enlarged, and usually there is acute tuberculous pleurisy.

=Diagnosis.=—In the =pneumonic form= it may be impossible to make a diagnosis early in the disease. Tuberculosis may be suspected if the patient has been in bad health, has a predisposition to phthisis, or has had any pulmonary disorder. Pneumonia will present the typical symptoms, but if fever continues, tuberculosis will be suspected. Examination of the sputum will probably decide.

In the =bronchopneumonic= form it is very difficult, in the early stages, to distinguish it from simple bronchitis and bronchopneumonia. The irregular fever and rapid loss of flesh are important signs. The sputum will show elastic tissue and tubercle bacilli early in the disease and should be carefully examined.

Chronic Pulmonary Tuberculosis

The chronic form of the disease is more common than the acute. It seems probable that many cases of pulmonary tuberculosis are due to inhalation of the tubercle bacillus, though no doubt, particularly in children the bacillus frequently gains entrance to the system through the intestinal tract from infected milk and food. =Deformities= of the chest, especially where there is constriction and rigidness of the upper part, with more or less immobility of the first, second and third ribs and the junction of the manubrium and gladiolus, associated with weak muscles and a stooped posture are definite predisposing factors. This condition may be congenital or acquired. The local innervation, blood supply and lymphatic drainage is involved, so that the individual is less resistant and consequently susceptible to infection. The bronchi are thus weakened, favoring the infectious process so that the disease may advance and involve the neighboring tissues, or if infection has gained entrance to the lymph or blood stream elsewhere, the susceptible pulmonary organs may become diseased.

Owing to the above predisposing factors the =primary lesion= of the lungs is often in the bronchus a little below the apex near to the posterior and external borders. A lower lobe may be involved, or several lesions may occur at the same time, involving one or both lungs. Frequently the other lung is infected from the lesion or lesions of the first.

In the acute cases the exudative process involves the lung tissue, becomes caseous and softened, and later necrotic with cavity formation. In the =chronic type= the exudative process is slower, with thickening of the walls of the air vesicles and increase of fibrous tissue. =Cavities=, the result of caseation, are of various size, ragged, often coalesce and open into the bronchus. Fibrous tissue forms about them and frequently arrest the process. In the necrotic involvement blood vessels are often injured causing hemorrhages. Pleurisy, empyema, catarrhal bronchitis, and bronchiectasis are often associated involvements.

In addition to the tubercle bacillus, other micro-organisms, streptococcus and staphylococcus pyogenes, influenza bacillus, and diplococcus pneumoniæ, are often found, and no doubt are important exciting factors.

The =bronchial glands= are swollen, and contain tubercles. They may undergo purulent disintegration. Tuberculosis of the =larynx= is common. In severe cases there may be amyloid changes of =liver=, =kidneys=, spleen, and mucous membrane of the intestines. Tuberculous lesions are found in the intestines, spleen, kidneys, and brain in nearly equal proportions; then come the liver and pericardium.

=Symptoms.=—The onset of the disease is either abrupt or gradual. Frequently it succeeds influenza, measles, or bronchitis. There is a cough, expectoration, loss of weight, afternoon temperature and probably night sweats. The disease is likely to develop slowly. In other cases gastro-intestinal disorders are the first symptoms, especially with weakness and debility. Again, the disease may follow pleurisy. When the attack is abrupt, pneumonia is simulated. However, the apex of the lung, instead of the middle or lower lobe, is involved; expectoration is considerable and the fever is not so high and pronounced. Hemoptysis frequently occurs.

The =local symptoms= are important. =Pain= is an early either moderate or severe, symptom, although there are cases where it is absent. When associated with pleurisy, it is severe. The pain is usually situated at the base, anteriorly or laterally, of the scapulæ, but may be between them. =Cough= is present, in the majority of cases, throughout the entire course. It usually grows worse, and is dry and hacking at the beginning but looser and paroxysmal and accompanied by a mucopurulent expectoration later on. The =expectoration=, at first, is slight and there may be more or less blood mixed with it, or even hemorrhage may occur. With the formation of cavities, the expectoration increases and is of a greenish-gray or greenish yellow color. In some instance the sputum is more or less fetid. The expectoration is composed of pus cells, blood, elastic tissue, fat globules and tubercle bacilli. =Hemoptysis= is present in a majority of cases. Early hemorrhages are usually slight, due to rupture of weakened vessels. When there is softening or cavity formation, erosion of vessels may be pronounced and hemorrhage considerable. Dyspnea is a variable symptom, but is characteristic of lung changes.

=Fever= is a characteristic symptom. It is probably always present at the beginning and the afternoon increase of temperature is common. Where there is softening and formation of cavities, a remittent or intermittent type is present. The pulse is frequent, regular and compressible. =Sweats= may occur at any time, but especially during sleep. They indicate fever activity, and are increased during cavity formation. =Emaciation= is a prominent symptom. This is due to gastro-intestinal disorders and prolonged fever. Loss of weight is gradual, especially if the disease is advancing. Where the lung is considerably diseased, heart disturbances are common.

Other disorders, as of the gastro-intestinal tract, genito-urinary, cutaneous, and nervous systems, are frequent, especially in long standing cases. The =gastro-intestinal disturbances= are gastric catarrh, vomiting, loss of appetite, coated tongue, constipation, and later on, diarrhea. Among =genito-urinary symptoms=, albuminuria is frequent. The kidney involvement may be either of an acute or chronic character. Pyelitis and cystitis are present in some cases, and amyloid degenerations are not uncommon. With the =cutaneous symptoms=, the skin is frequently dry and scaly, and the hair of the head dry. The hectic flush is common. Upon the chest and back there may be pigmentary stains. The =nervous symptoms= vary according to the involvement. Tuberculous meningitis is rare. The mind usually is clear and even in advanced stages the patient is always hopeful.

=Physical Signs.=—=Inspection= reveals that the shape of the chest is often characteristic. A phthisical thorax is flat, especially the thoracic opening with wide intercostal spaces, prominent costal cartilages, and depressed sternum. Sometimes the lower sternum forms a deep concavity (funnel breast). Another type of thorax is long and narrow, with very oblique ribs, and little expansion. In other instances the chest is of apparently normal build. Defective expansion is observed early, especially at the apex of the affected side. The clavicle of the affected side often stands out more prominently.

=Palpation= shows there is decreased expansion and increased fremitus. Normally, the fremitus is stronger at the right than at the left apex. If the pleura is thickened, the fremitus is decreased, but increased in lung involvement.

On =percussion=, if the diseased areas are minute, the percussion note may not be changed. Always compare the two sides of the chest. Dullness is first noted, as a rule, above, on or below the clavicle. As the disease progresses, the dull sound increases. The size of the cavity, its walls and the amount of secretion modify the note. Large, thin-walled cavities elicit the “cracked-pot” sound. Consolidation, thickened pleura, large amount of material in a cavity and a connecting bronchus impair resonance.

On =auscultation= the breathing is harsh and the expiration is prolonged and high-pitched (bronchial). Early in the disease crackling rales may be heard. After consolidation takes place there is bronchial breathing and crepitant rales. When softening occurs they become moist, louder and sometimes bubbling. These may be heard upon inspiration and expiration. Pleuritic friction sounds, as in case of pleurisy, may be heard at any stage. Vocal resonance is increased.

The =signs= of =cavity= are: =Percussion.=—There is more or less defective resonance or tympany. Over large cavities a “cracked-pot” resonance is obtained. This is best obtained when the patient has his mouth open. There may be normal resonance if the cavities are covered with a considerable thickness of unaffected air cells.

=Auscultation= may detect cavernous or amphoric breathing, pectoriloquy and coarse, bubbling rales. Metallic tinkling may be heard over large cavities. Vocal resonance is increased.

=Complications.=—The larynx and trachea frequently undergo tubercular inflammation, due to invasion from the lung tissue. Pneumonia is of common occurrence. Gangrene, pleurisy and endocarditis are other complications.

=Diagnosis.=—Bacilli may be found in the sputum before the physical signs are well developed. It may be necessary to examine the sputum several times before the tubercle bacilli are detected. The presence of bacilli will set the diagnosis at rest, provided clinical symptoms are present. Fever, hemoptysis, cough, emaciation and a continuous, local induration are diagnostic. The X-ray should be employed as an aid in diagnosis.

=Prognosis.=—The prognosis of pulmonary tuberculosis varies greatly in different cases. Undoubtedly a number of cases have been cured; many arrested; even spontaneous cures have occurred. A great deal can be done to prolong life and to make the patient comfortable. The average duration is about three years, although by careful treatment this time is probably being increased.

Fibroid Phthisis

This term is applied to a form in which there is induration, followed by contraction of the affected lung tissue, due to an overgrowth of fibroid tissue. The greater number of cases are primarily tubercular, but have run a fibroid course. Other cases are primarily fibroid, followed by tuberculous infections. It may begin as an ordinary ulcerative phthisis, or it may begin as an inhalation bronchitis. In other instances it may follow a chronic tuberculous bronchial pneumonia or pleurisy.

The =onset= is extremely insidious. There is persistent cough, often paroxysmal in character. Dyspnea is marked, especially on exertion, but little or no fever is present. The expectoration is profuse and mucopurulent. There is slight loss of weight. In the later stages edema is marked. It is a disease of long duration, lasting from ten to twenty years. The patient is often able to pursue some occupation and may have fair health.

There is marked dullness over the affected side, which is commonly much depressed. There is distinct bronchial breathing at the base, while at the apex there may be cavernous sounds. The heart is frequently displaced and the right ventricle hypertrophied. The bronchi are dilated. The clinical history is identical with that of simple cirrhosis of the lung from which it is often separated with difficulty. Both lungs may become the seat of tuberculous disease. Prolonged suppuration results in amyloid changes in the liver, spleen, kidneys and intestines. X-ray plates are of value in diagnosis.

Tuberculosis of Other Tissues

The =alimentary tract= is frequently the seat of tubercular inflammation. The intestines may be involved primarily or else secondarily from the lungs or peritoneum. The =primary form= is most common in children. There is slight fever, pains of a colicky nature, irregular and persistent diarrhea. The disorder is commonly unrecognized, being mistaken for appendicitis or other intestinal disorders, until emaciation, sweats, the continued fever or lung involvement are manifested.

The stomach, esophagus, pharynx, tonsils, palate, tongue and lips may be the seat of a tubercular lesion.

The =serous membranes= are usually secondarily involved. The peritoneum is generally invaded from contiguous organs, especially the intestines, although the pleurae may be the starting point (and in the female the generative tract is a source). The disease may be either acute or chronic. In the former it starts abruptly with vomiting, pain in the abdomen, fever, and possibly diarrhea. In the chronic form there are fever, pains, emaciation, weakness and the abdomen is distended. The enlarged glands may be felt through the walls. There may be ascites, or the walls of the peritoneum are adherent, or the tubercles may ulcerate.

The endocardium is occasionally the seat of acute or chronic tuberculosis. It is usually secondary. Likewise the pleurae are sometimes involved. The chronic form is more common.

The =genito-urinary system= is subject to tuberculosis. The bladder, ureters and pelvis of the kidney are attacked, and from these the kidney; or possibly the kidney involvement is part of a general tuberculosis. (See pyelitis). The ovaries, Fallopian tubes and uterus are also subject to tubercular invasion. The =diagnosis= depends upon finding the bacilli, the symptoms indicating, oftentimes, an inflammation only. Also the prostate, testicles and seminal vesicles are attacked.

Tuberculosis of the mammary glands is rare. In miliary tuberculosis the liver is commonly affected, often secondary to other tissues, especially the peritoneum, lymphatics and lungs.

The blood-vessels and heart are sometimes involved from nearby organs or from miliary tuberculosis. The brain and cord are also at times invaded. This has been described under meningeal tuberculosis.

=Diagnosis and Prognosis of Tuberculosis.=—The osteopath should be familiar with the various forms of the disease. An understanding of the pathology and clinical symptoms is essential. The finding of the bacillus, provided there are symptoms of inflammation, is diagnostic. Much depends upon the patient’s constitution, hygiene, sanitation, food, fresh air and general management. The osteopathic lesion is decidedly an important factor, but the treatment must be balanced from both the distinctive osteopathic view and that of general management. Then the patient’s part is as necessary as the osteopath’s. Under proper care and treatment, unless the disease has progressed to a marked degree, there is always a tendency toward recovery, but, to emphasize again, the osteopathic treatment, the environment and general hygiene should be thoroughly understood and appreciated, for at best, the disease is treacherous. Even after an apparent recovery is made, the patient should be under observation; there is always danger of recurrence. Tuberculosis can often be treated successfully, or arrested, provided the disease has not progressed to a late stage; although many times, in the later stages, life can be considerably prolonged by careful treatment.

=Treatment of Tuberculosis.=—The =prophylactic treatment= of tuberculosis should receive first consideration. The sputum should be thoroughly disinfected and care taken that the patient does not spit about carelessly. A spit-cup should be provided and the sputum collected and destroyed by burning and the cup sterilized. The patient should be well taken care of and given a separate apartment, so that the danger of conveying the disease to others is reduced to a minimum. He should occupy a single bed. All unnecessary furnishings of the room should be removed and the objects that remain in the room should be frequently aired and disinfected. The general and sanitary environment of the patient should be as favorable as possible to hygienic living. Many times a change of residence is of great benefit. When possible the patient should be out of doors and light exercise taken. The body should be well protected by flannels, the year around.

Keene[61] would carry prophylaxis to careful examination of the pregnant woman to avert a sudden development of tuberculosis after parturition; also of the child, after birth, to remove any predisposing lesions. The mother with a tubercular tendency should, under no circumstance, nurse the child and should be instructed to observe any disposition on the part of the child to acquire malpositions in sitting, standing or walking.

Another important consideration in the prophylactic treatment is the inspection of dairies and slaughter houses. The disease may be transmitted by infected milk. There is less danger of infection through meat; although all animals that present distinct lesions should be confiscated. Sanatoria and other special arrangements for the care of patients should be encouraged.

The =Treatment of the disease= consists primarily in locating the cause of the devitalized condition of the cellular tissue. This is the vital point to be considered and requires a thorough examination of anatomical structures in the region involved. There is a reason why the tissues are in a depraved state and it is our work to examine thoroughly the structures that might become deranged anatomically and cause an obstructed innervation or vascular supply. The disease is not primarily due to the bacilli; the bacilli would not have infected the system had it been in a healthy state. Hence, the object of the treatment in tuberculosis is to favor a building up of normal, well-nourished tissues so that it is impossible for the bacilli to infect the region. Of course, destruction of the bacilli is important, but we cannot expect to do much by the use of a parasiticide, for we are not then influencing or affecting the real cause of the disease. If we can improve the arterial circulation to the diseased tissues, we will be striking at the root of the disease and the healthy blood will be the only parasiticide necessary. This is where the osteopathic theory of the cause of disease differs from that of other schools of medicine. At the local points of infection there is a decided malnutrition of the tissues, due to a lack of proper blood to the parts, thus favoring the lodging of micro-organisms; by reestablishing normal nutrition nature will repair the tissues if the condition is curable. Hence, it can be seen at once that if the case is curable osteopathic treatment will meet the demands scientifically.

The preceding is the keynote of osteopathic therapeutics; not only in the treatment of tuberculosis, but in all diseases where micro-organisms play an important part. In =tuberculosis of any part of the body=, it is the duty of the osteopath to carefully examine the structures that may become anatomically deranged, from any cause, affecting the nerve, blood and lymphatic supply to the tissues or organs diseased. Correction of anatomically deranged tissues and attention to the hygiene, diet and general health of the patient constitute the treatment.

On the subject of Pulmonary Tuberculosis, W. Banks Meacham says:

“In cases of =pulmonary tuberculosis= it should be remembered that the pathological lesion in the lung is a result of a general systemic interference—an interference so great that the body as a whole loses its stored-up heat in excessive temperature, loses its reserve nutrition, as manifested by early and continuous loss of weight.

“Therefore the causative osteopathic lesion should not be sought alone over the site of the pathological lung lesion but rather in that area where general nutrition is osteopathically affected.

“A few general considerations of =osteopathic mechanics= involved in nutrition should be ever present with the searcher for the cause of pulmonary tuberculosis. For instance we know that ingested fat is acted upon by the pancreatic enzymes; that the invertin of the intestine is an endocrine secretion. In diet we seek to administer an excess of fats to take the place of fat-loss in this disease, often losing sight of the fact that some mechanical maladjustment prevents fat-splitting into a form suitable for tissue assimilation.

“It is common osteopathic knowledge that lesions of the upper dorsal area have a profound influence on general nutrition. Consequently it is to this area that we must look for the causative osteopathic lesion in this disease. The influence of this area is due to the fact that the nervous mechanism of the secretory glands gets its most direct disturbance in this area where the nerves leave the spinal cord to become distinct innervation to these organs.

“Apart from the nutritive and general circulatory influence of upper dorsal lesions we must consider the germicidal action of the endocrinous secretions in devitalizing the specific bacterial agent in tuberculosis. Undoubtedly these internal secretions have marked effect in agglutinating the bacilli, thus enabling the phagocytes to perform a larger duty.

“The correction of upper dorsal lesions, with due regard for the pathological condition within the thoracic cavity gives a scientific physiological and bacteriological therapeutic action in tuberculosis.

“=Other lesions= may and do demand attention and correction when possible. But we must not lose sight of the fact that our specific action comes from a corrected relation of the upper dorsals. In the cloud of unproved theories and guesses in the literature of pulmonary tuberculosis nothing seems nearer an established truth than that it is a disease contracted in infancy, that it develops, later, in those persons who retain the infantile type of chest—thorax of large antero-posterior diameter in contrast with the lateral diameter.

“In the progress of the disease we do get a costal malformation giving the ‘horse-collar’ thorax, with an apparent lesion of the osseous walls of the thoracic cavity. But these lesions are the result of nutritive changes brought on by the active infection already present; and are not in any true sense, causative factors in the establishment of pathological areas within the lung.

“The =osteopathic treatment=, then, of this disease is, manifestly, a correction of a plastic posterior upper dorsal lesion. And where the pathological lesion of the lung contraindicates forceful correction, mobility of the area should be sought.

“The =general care= of the case should look to the normal functioning of all organs, with emphasis on ease to the patient. The =diet= should be what the patient can assimilate properly even though it be much less than the amount a normally active person should ingest. =Altitude= has a favorable effect in selected cases only. It is remarkable that many cases recover in the extremes of the Rockies and the coasts of California and Florida.

“No violent =exercise= should be undertaken on account of the possible embarrassment of an already overworked heart and in consideration of the possibly engorged pulmonary vessels. For these reasons, too, rest in bed is advisable with temperature above 99° F. and pulse above 85.”

In =scrofula=, lesions will be found to the lymphatic glands, impairing their innervation and function. The treatment is not to be applied over the glands directly. First, it is necessary to locate the lesions of the bones, ligaments and muscles or such tissues that would cause disturbances to the glands, then readjust the parts. The object of the treatment is to modify the soil conditions on which the bacilli multiply, by correcting the local derangement of the tissues. The entire body is not in such a depraved state that the bacilli will grow and multiply wherever they happen to come in contact with the body; tissues of any organ favor a receptivity for the bacillus only when these local tissues are in a morbid condition. It is then our work to aid nature in relieving obstructed forces that are causing such an effect.

There are =general measures= which influence the tubercular process. The diet of the patient should be nutritious. A diet of milk, buttermilk, egg albumen and meat juice will probably be found best, although many will be able to take ordinary food. The patient should be out of doors as much as possible. Meacham[62] says “Fresh, pure air, wherever found, is essential; elevation is an individual requirement, an even temperature is not necessary and sunshine is important only as it allows the patient to be out of doors. Exercise should not be taken when the patient has a temperature above 99 degrees.” The dry, even climate of the Southwest certainly tempts the patient to be out of doors more than one with opposite conditions. Even when the patient is greatly debilitated and weakened, insist upon his taking outdoor exercises or rides. Gymnastic and methodical breathing exercises are essential in widening and strengthening the chest. Bolles[63] believes that the appetite should control the diet and forced feeding be not insisted upon. Fasting, to test the sense of food desires, has points well worth looking into, as gastric disturbances with a loss of strength follow overfeeding. He also recommends deep breathing and physical culture to elevate the ribs and increase thoracic expansion. Outdoor sanatoria are being established over the country, in many cases by state appropriation as, “the treatment of tuberculosis itself has not been a satisfactory procedure except by climatic changes or the outdoor treatment persistently applied.” (Halbert). The fresh air treatment may be taken at home by sleeping in the open air or by appliances fitted to the window of the room so only the head is exposed to the air. The only factor is to get the air. The skin, as well as the excretory organs, should be kept active. Always make it as comfortable for the patient as possible.

The =fever= is indicative of the activity of the disease, so that treatment to influence the process and to promote elimination is best. Sponging with either cold or tepid water will be helpful. The =cough= is a troublesome symptom. Attention to the underlying irritation is demanded, although one cannot hope to influence, to any great extent, the cough dependent on cavity formation. Catarrhal processes in the respiratory tract can be lessened. Lesions that are acting as a cause of irritation, will frequently be found in subluxated ribs or vertebræ. The seventh and eighth dorsals are frequent sources of cough. The tissues about the pharynx and larynx, and the hyoid bone, disturbing the vagus and other nerves, should be carefully watched, also possible reflex irritation from the abdomen and pelvis. =Night sweats= are due to tubercular processes weakening the system and particularly lessening nervous control. These will subside as the body is strengthened. Sponging will be of service. Disorders of the =stomach= and =intestines=, such as nausea, vomiting and diarrhea, require treatment of the splanchnic area and regulation of diet. Considerable can be done to relieve =tubercular laryngitis= by careful treatment of the larynx and contiguous tissues. =Hemorrhage= is likely to be self-limiting. Attention to the upper dorsal vertebræ and ribs and muscles will tend to equalize the circulation. Rest and use of ice upon the chest, as well as internally, will be beneficial.

McIntyre, in an article on “Fat Food in Consumption,” sums up the treatment for tuberculosis in the following words: “The treatment, then, for consumption should include rich, stimulating diet, proportioned to the digestive power of the patient, containing an excess of fats in most digestible form, of which sweet cream, fresh butter and well-cured bacon are the best examples, and the free use of pure drinking water, coupled with the promotion of blood flow, respiration and elimination of waste by osteopathic means.”

Surgical measures may be necessary where glandular or other tissue has broken down and is a menace to recovery.

Spanish or Epidemic Influenza[64]

By GEORGE M. MCCOLE

The epidemic of influenza which swept over the world and reached the United States in August 1918, starting in at the Atlantic sea-board cities, developed rapidly there and passed westward over the country. It reappeared the following winter.

=Epidemiology.=—In the United States it was called Spanish influenza, as it was at its worst in Spain at the time it broke out here and was thought to have been brought from that country.

In Europe it was called the Ukrainian influenza and in southern Russia it was said to have emanated from the Orient. No country in the world was exempt. It was at one time thought to be a type of the pneumonic plague and while plague is the severest toxemia known many cases of Spanish influenza were equally as prostrating and fatal as the ordinary type of pneumonic plague. The bacillus pestis was never proved to be the cause of this pandemic of influenza but the clinical analogy was very evident.

A study of European conditions of health and hygiene shows how reasonable it is to believe that some disease would develop and sweep a world lowered in vitality and immunity by the abnormal conditions of war. Every known communicable disease was raging in Europe and Asia where millions of people existed under exceedingly poor hygienic conditions.

The period of incubation of influenza was extremely short, averaging about two days. All ages were attacked, although persons over 60 rarely. Those between 25 and 35 seemed to be the most susceptible but it was, perhaps, because they were in active life and more exposed. There is considerable evidence that the disease was not air-borne but conveyed by contact with active cases. The secretions of the mouth, nose and eyes were considered the active carriers. Masks, made of several layers of gauze fastened over the face, have been worn by many people but experience taught that their use did not avail against infection.

=Mortality.=—The mortality under drug medication as shown in a statement by Henry S. Bunting was as follows: “New York City 9.8%; Chicago 14.5%; Boston 27%. Osteopathy’s influenza salvage represents the difference between these figures and the low score of one fourth of 1%.” He gives the following statistics on pneumonia following influenza under drug medication. “Reports from 148 health commissioners show an estimate (called conservative) of 33% of fatalities in epidemic pneumonia under medical care. In some large centers it ran as high as 68% to 73%. As officially compiled to date, the fatalities in epidemic =pneumonia= in our army and navy cantonment hospitals amounted to 34½. Osteopathy’s fatalities were only 10% which included all those eleventh-hour appeals to Osteopathy.

“The Chicago and New York departments of health figures, each show total death losses of 18% in all of their epidemic cases. Osteopathy’s remarkable salvage of life is best measured from this point of comparison. Its total death rate from both influenza and pneumonia has been actually less than one percent.” And this is based on 110,000 cases reported to the American Osteopathic Association.

=Pathology.=—The pathology of Spanish influenza is practically a study of lung involvement. There we find an exudative pneumonia of a rapidly confluent type, a transudate of blood serum and red cells appearing in the lower lobes of both lungs and rapidly flooding the entire space. Air bubbles were scattered through the serum soaked lungs, giving a frothy appearance to some parts. At times some parts of the lungs showed drops of liquid pus.

Where pneumonia did not develop there was no typical pathology. The toxins left an irritated bronchial tube, intestine or kidney just as in any other severe toxemia.

Bronchial and the old type of lobar pneumonia also appeared as a complication of Spanish influenza, making three types of pneumonia which were to be guarded against.

=Symptoms.=—The attack is usually ushered in by a chill or prolonged chilly sensations, sometimes lasting for two or three hours; fever 103° to 105° F.; if it does not fall in three days or if it comes up after once falling, pneumonia is to be suspected; pulse, full and bounding with a varying rate; headache usually general in type and in severity from slight discomfort to a most violent type; intense pain in the back and legs; tenderness the whole length of the spine but especially distressing in the upper dorsal, lower lumbar and sometimes the upper cervical; a dyspnea which is best described as being a constricted feeling of the chest with air hunger; often the bronchial tubes are raw and dry, the patient feeling as if the breathed-in air were hot to the bronchial tubes, an active exudative bronchitis developing; sometimes there is an active bronchitis with distressing cough; nose bleed is a frequent symptom (and is often a sign of threatening pneumonia); most cases sweat more or less, some have drenching sweats; sleeplessness; albuminuria frequent.

When the temperature breaks it practically always falls below normal during the course of that day. A typical case of severe character often presents all of the above symptoms; the lighter cases perhaps only two or three of them, of which the chilly sensations, fever and bounding pulse are the most common encountered.

A severe case is impossible to differentiate from the first symptoms of smallpox. Where a case of this type is encountered, it is always advisable to get history of vaccination or smallpox.

=Examination.=—The successful treatment of disease calls for attention to little things. Some little thing properly cared for very often gives us our margin over adverse conditions and spells success in the care of our patient.

During the epidemic I found a few cases which ran a temperature much below normal, sometimes as much as three or four degrees, and still with enough symptoms to be easily diagnosed as influenza.

=Pulse= was taken at the time the thermometer was in the mouth. Pulse was practically always bounding and hard. Its rate varied widely, being influenced by many other conditions. I often, early in the attack and where other symptoms were indefinite, made a diagnosis principally from the pulse.

=Respiration= was taken while holding the watch and with the finger on the pulse so that patient would not know that breathing was being watched.

Many patients complained of a sensation of weight on the chest and difficult breathing—hardly what one would term true =dyspnea= yet a real air hunger and sensation of constriction in the chest. The breath was often tainted with the odor of acetone, indicating a high degree of acidosis and giving an important diagnostic point.

The =heart= was then examined, both by auscultation and percussion.

The examination was then extended over the lungs and pleural rub listened for.

Patient was questioned as to having had a chill, general health, occupation, undue exposure, fatigue, what physic if any, had been taken or other drugs used, bowel movements and bloody stools, food taken, sleep the night before, and dreams, headache and backache.

The full examination could not be given at each call and not all of it to each patient, as time would not permit during the height of the epidemic.

Throat was always examined. This is an important point.

The urine was examined in a great many cases and often albumin and sometimes casts were found.

=Treatment.=—I consider it advisable to give a strong deep treatment if the patient is seen before the attack has gained full headway; after that I give short light treatments.

If the disease has not developed much at the time of the first visit vigorous treatment with adjustment of the deep-lying and tightened-up ligaments over the spinal cord is indicated. Subsequent treatments are given to overcome the invariable and recurring contractions along the spinal cord. The spine is gently sprung and the muscles pulled away from the intervertebral foramina so that arteries, veins and nerves of the spinal cord are free to function.

I might note here that I consider Spanish Influenza does its damage through the attack of its peculiar and virulent toxin and the accompanying acidosis, on the body’s reservoir of energy—the spinal cord and related structures, the vegetative glands and nerves.

If the patient is in a serious condition he is often treated in the position in which found, so as not to disturb him. Care is particularly taken to keep a patient who is moist with sweat from taking cold or being exposed. An extra covering is thrown across the neck and shoulders, and pulled down as the bed covers are moved to get to the area to be treated.

The musculature of the upper dorsal and cervical region is given special attention, the region of the first and second cervical and the first to sixth dorsal being special seats of trouble. The region between the spine and scapula on the left side, first to sixth ribs left, and the region of the suprascapular notch on the left side are given specific treatment to free them of contractions. The tissues of the suprascapular notch are in direct connection with the nerve supply of the heart muscle and treatment here is astonishingly effective.

This treatment for the heart is best given with the patient lying on the right side, leaning a little forward, with his left forearm against the chest, hand at neck or chin. Stand then at the patient’s head and with the thumbs give all the region on the left side at the base of the neck and around the suprascapular notch thorough muscular adjustment for circulation and removal of contractions which disturb the heart’s vitality. Treat first to sixth dorsal region.

I consider this treatment specific for the heart debility of influenza and many other heart conditions, as well. I have found it especially effective in the weakened and nervous states following influenza and in so-called “run down conditions” generally.

Vibration with the tips of the fingers on the anterior chest wall is often used. Tender and contracted tissues are often found along the anterior ends of the ribs which are involved at their spinal ends. These are gently treated. Children are often given vibration, holding their chests with my hands under their arms.

If the patient is stout and not easy to treat I have him sit up in bed and give the upper dorsal thorough percussion with the side of the hand[65]. About 100 strokes at each treatment are usually given. I remember one very fat patient in the eighth month of pregnancy to whom I could give hardly any other treatment. It was especially valuable here and we saved the mother after a hard fight, though the child was still-born.

When nature is meeting the emergency and holding her own in the battle against infection we have a moderate fever—a benign fever. When the body is overworked with other duties and irritations the fever may rise dangerously high. Here it is that the physician must give further aid. Here it is that osteopathic treatment further aids by giving rest to the patient, easing pain and promoting general circulation (this in itself often quickly reduces fever). Here it is that the attention we give to clothing, diet, ventilation, quietness, good nursing, etc., comes in. The body is relieved of all duties but the one. Its functions are all turned to one end—the destruction of the invading infection. The osteopathic physician adjusts. Nature cures. It is all a matter of adjustment.

For labored breathing, an effective treatment is to have the patient with hands clasped and arms raised above the head, patient being in bed, face up. Stand directly at head of patient. Reach over patient’s arms and under the upper dorsal and lift up against the heads of the ribs with your fingers, thus raising the chest, beginning as far down the spine as you can and working up as you treat. Relax the muscles at the same time.

=Frequency and Amount of Treatment.=—Frequency and extent of treatment depend upon the condition of the patient. In influenza the patient is approached with the idea of a daily visit. If then there is any doubt about his being entirely safe for 24 hours he is seen in 12 hours or as often as the condition indicates. Patients are usually seen more than once a day.

The average time which the patients are confined to the bed is about five days. Some are free from fever in three days; some not for six or seven days. According to conditions they are then kept in bed from one to three days longer.

As to the amount and length of treatment, I agree with James M. Fraser, who says adjustment of the soft tissues should be made and made with as little disturbance to the patient as possible. He says[66]: “The ill effects of too long-drawn-out general treatments, or in short, over-treatment, I consider one of the most important questions for osteopaths because I incline to the belief that in many acute infections more harm may be done by such fatiguing over-treating than if the patient were really not treated at all. A “flu” or pneumonia patient should never be treated over fifteen minutes at the longest in one treatment. It is much better to treat often and not treat so long, as over-treatment may result from a desire to be thorough. If we always would stop and think what we are doing and just what we are trying to prevent we would be more careful when we treat these infectious cases. A patient’s resistance may really be lowered, his bowels inhibited, his heart overstimulated, his muscles fatigued and his nerve force depleted by treating overtime. When the reaction begins, stop.”

Congestions and contractions should be removed wherever they are found, be it in the region of the throat, spine, ribs, liver or spleen. I order a daily enema and give positive instructions—after having had one or two almost fatal cases from this cause—to use no physics. Purging killed more people here than any one other thing. If a heavy physic be given two or three times and the patient comes to a crisis, so much vitality has been taken out of the blood that he does not have enough strength to carry him over and he dies.

If the patient comes to pneumonia I find it good and effective to use the “constipation treatment.” It is best to let the bowel take care of itself. Nature can do many things, and caring for the bowel in a crisis is one of them, providing the correct diet has been given the patient. If the patient is getting nothing but fruit juices there may be a natural bowel movement and even if he has been getting other food it is better to leave the bowel alone until after the crisis and then give the enema.

A patient with a frank pneumonia following influenza has but little chance of living if his strength is being drained from the blood stream through the bowel every few hours.

I see to it that no draft blows on the patient’s bed. In a windy location a cold draft can appear suddenly and do great damage in a short time. The patient should not breathe cold air. Fresh air is all right but it must not be cold air. I order extra covering for the neck, arms, shoulders, back and chest. I like a wool workshirt best but use pneumonia jackets, extra undershirts, sweaters, etc., when the wool shirt is not to be had. In fact continued warmth seems to be an almost necessary condition to the proper handling of influenza. It is because heat, even the heat of the fever itself seems to aid the nervous system in building up antitoxins.

The patient is instructed that if a sweat comes on, either from a hot bath, hot drink or as a result of the disease, to lie and take it, for throwing off the covers is a sure way of taking cold and inviting pneumonia.

If the house is cold or the patient weak or very sick the urinal and bed pan are used. In fact I prefer their use even when those conditions are not present, as the less the exposure the less chance of pneumonia and the quicker recovery. =Rest= lying in bed is absolutely necessary to a satisfactory course and quick recovery.

For lung congestions and bronchial irritation, in addition to osteopathic treatment along the spinal cord, raising the ribs and chest, and vibration of the chest wall, I sometimes use the old fashioned mustard plaster (made with one teaspoon each of flour and mustard, mixed with olive oil or with water and white of egg), keeping it on about ten to thirty minutes or until a good, red reaction is brought about. The feet must be kept warm with hot water jugs. A hot mustard foot bath is excellent when the feet persist in staying cold.

At first I did not use the hot tub-bath. I am now ordering it if I see the patient early in the attack and where there is no contraindication, such as a dangerous heart condition. I do not use it unless it can be given properly and without undue exposure to the patient. I never give it late in the disease.

A good method is to get the patient into the tub, lay two canes or sticks across the tub, and cover all with a blanket or rug. Place a bath towel for the head to rest on and pull the blanket around the neck. The patient can then take a good hot sweat in comfort. His arms and shoulders, his knees and legs will not be exposed to chill. When he gets up the blanket can be drawn about him if desired. He then goes back to bed for a good rest and sweat. A cold towel is placed on the head and water given to drink.

Every patient should have a good sweat early in the attack. Another good method is to cover with a blanket and place outside fruit jars or jugs filled with hot water, cold towel to the head and several glasses of water or lemonade to drink.

The use of cold compresses on the chest I do not favor. They are used by some osteopathic physicians, but I believe the result is better with other methods. Applied in a hospital where the technique is well in hand they might be successful, but personally I fear them. I am even careful about putting an ice bag on the heart. Cold packs are sometimes used in my practice but only on the head for pain or delirium. Chill must be avoided. Warmth must be conserved, even the fever is benign.

Neither do I favor “rub-on” of camphor, turpentine or onions when they irritate the patient. If the patient has been used to them or has faith in them and wants them I order them. I also order something of the kind where “something must be done”. When a family calls a doctor they “want something done,” and it is best to do something; ever keeping in mind, however, that our patient’s strength must be conserved.

I do favor “rub-ons” in that I think it is well to keep the skin soft with some oil. It helps to keep an even temperature and the skin active. The skin should be wiped dry often, however, to remove the skin secretions which if left on become stale.

I remember being called to see one little girl who could not get her breath, and found she was holding her nose with the bed clothes. She told me that the smell and stickiness of the lard and turpentine and the onions made her so sick and uncomfortable that she felt she could stand it no longer. When she was cleaned up, and clothed in nice clean white cotton she showed a wonderful improvement, and it was real as well as apparent.

As to =baths= in influenza, I instruct the nurse to bathe the patient only as necessary for cleanliness and his comfort. Dabbling around in water is not a safe procedure in a disease where pneumonia is so easily contracted.

I do not use alcohol rubs where the patient is in anything like a serious condition, as alcohol closes the pores and dries out the skin. A rubbing or massage by the nurse is good for a restless, nervous patient, but it had better be done with olive oil or some other good oil. In influenza we do not want the pores closed. We need elimination, and all we can get. A small saving of vitality or a little elimination of toxins may be the margin that saves a patient for us. I do not favor the use of turpentine, for if it is absorbed it irritates an already sick kidney; if it is not absorbed it is useless. Why disturb the patient?

For the bronchial irritation, in addition to osteopathic treatment, and the accessory mustard plasters, inhalation of steam is often used. A pan of boiling water is set by the bed and the patient leans over the edge of the bed with a bed-sheet or paper over the head and steam vessel, breathing the steam as long as it lasts.

For the =throat= most any cleansing gargle can be used but I prefer the use of the common baking soda gargle. I have about one-half teaspoonful of soda placed in a glass and boiling hot water poured over it. As soon as this is cool enough to use I have the patient gargle thoroughly. The idea is to get the mouth, pharynx and tonsillar area clean and free from accumulations. Lemon-water gargle is often gratefully accepted.

If a very sick patient breathes through a dirty and dried-out mouth, all the stage is set for him to draw into the devitalized lung large quantities of infectious material. For this reason if not for the comfort of the patient it is necessary that the mouth be kept clean and also moist.

It is not possible to kill this germ life with any antiseptic. The field must be made and kept clean.

The =nasal passage= also should be looked after, to keep it clean as possible and also to allow the patient to breathe through the nose.

For the nasal passage any good non-irritating oil is effective but I like best 2½ iodine in oil. It is a good lubricant and as far as possible we do get the germicical action of the iodine.

Patients asking me what to do to avoid influenza are advised to keep the mouth clean and closed and to use the oily solution of iodine in the nasal passages.

And when treating the respiratory tract we must keep in mind the fact that all healing comes from the blood side of a membrane. No healing ever comes to a membrane from its exposed surface. Local treatment to a membrane must be a treatment which removes irritation, not one which adds more. Healing must come from within. “The rule of the artery is supreme.”

=Diet.=—The diet used is liquid, so that the digestive functions will be taxed as little as possible, for they are weak at this time. Fruit and vegetable juices only are used.

The influenza germ propagates largely in the intestine and if the intestine has in it the products of a full diet the bacterial growth soon overpowers the patient. Germ life cannot develop on fruit and vegetable juices.

Another reason for using the liquid and fruit diet is that influenza is a disease running a short course and feeding is not necessary. If it were a disease such as typhoid, running a fever for several weeks, we would then give a more liberal diet, but the patient’s strength will not be lost on a liquid and fruit-juice diet in three or even eight days.

The frequency with which the urine contains albumin in this disease shows us what a heavy load the kidneys are carrying. This makes a salt-free diet advisable and again brings fruit juice to our favorable attention.

To activate the kidneys and thus relieve the headache we give always plenty of water and often hot lemonade. Orange juice and lemonade are used frequently as are blackberry, raspberry, pineapple, loganberry and grape juices. When the acid juices are not well borne we use non-acid juices, such as pear and raspberry juice. A ripe, cooked pear mashed with a fork and mixed with one or two different fruit juices makes a satisfying dish.

Bottled sweet cider is also a most valuable food and a good beverage. We use it in almost every case and find it the most acceptable to the patient of any food offered. I am of the opinion that apple cider has been neglected as an article of diet, both in disease and health, but especially in fevers. It contains considerable iron for the blood, as well as having considerable food value. It has the added virtue of being pleasing to the patient.

In addition to these juices we often use spinach juice. I have the nurse get a can of the best grade spinach and serve the juice hot, as a broth, with a little salt and pepper and perhaps celery salt and a piece of bacon in it to flavor it and to appeal to the patient. Spinach juice contains much iron and iodine in a form readily absorbable by the blood. It also is useful in maintaining the alkalinity of the blood and body fluids, thus counteracting the acidosis of the disease. It renders the urine alkaline and thus relieves the kidneys of the irritation of acidosis and of an acid urine. Where the kidneys are or are likely to be involved the spinach juice must be served without salt.

All the mentioned fruit juices tend to counteract acidosis and produce alkalinity, but are not so effective as the spinach juice. They have the advantage, however, of being used in larger quantities. The spinach juice has considerable food value and has the added value of appealing to the patient’s reason, when the iron and iodine content is explained to him. It is especially useful when treating those patients who are wondering if they should not be getting some sort of “tonic.”

The juice taken from ground fresh lettuce is also valuable. It contains more iron, iodine and phosphates than the spinach but it is not so easy to prepare. I have used it in the cases of several anemic and quite sick babies and consider it well worth all the expense and effort it took to secure it.

The breaking down of the alkaline reserve of the body and the consequent acidosis, comes early in the disease and is disastrous, and all the attention given to the diet is amply repaid in results. Careful attention to the diet is the only way the acidosis can be overcome.

Raw fruit and vegetable juices also supply that most valuable element, vitamines. For this one thing alone is the raw fruit juice most valuable. I do not believe too much attention can be given to securing a liberal supply of vitamines for the body, especially during an attack of fever.

Some especially interesting points are brought out by contributors to the Journal of the American Osteopathic Association in the March, 1919 number. I wish here to add a discussion of these points. The contributors are physicians and good representatives of our profession and they report uniform and excellent success in handling the recent epidemic.

It seems to be the consensus of opinion that the treatment should be specific and light to avoid fatigue, with the possible exception of the first treatment, which often should be general and vigorous.

All are agreed that the patient should be kept in bed, not even leaving it to go to the bath room. The patient must be protected in every way from fatigue and exposure. The enema was used by all. A number of writers state plainly their opposition to the use of physics and laxatives. A hot tub-bath is recommended by several, but there is opposition to much bathing.

Practically all the writers used the fruit-juice diet. However, a few gave a heavier diet and were successful with their patients, which is one more proof that the osteopathic treatment is the deciding factor in bringing about a cure.

J. R. Thornton wrote after having had about 100 cases. He speaks especially of his cases of pneumonia. They resolved by crisis. There were no deaths. He says: “All cases were, preceding the first treatment, given a generous plain water enema. Orders were left for two enemas per day until told to discontinue, and in most cases the patient got the enema. A few cases, with the highest fever, the stationary fever, were given tap-water enemas, one each hour until the temperature dropped two or three degrees.

“Sponge baths were given to reduce fever in every case. Diet was liquid until the temperature was normal.

“The osteopathic treatment of the usual spinal work, paying special attention to cervical and dorsal areas, and strong inhibition.

“Pneumonia cases were treated three to five times a day and had as much time as they required at each visit. They required action. Heating compresses were used on each case, except the ice bag to the heart when rapid. One case of delirium was treated with ice caps to the head and neck. Normal salt solution per rectum. Murphy drip was given in each case. Diet, liquid consisting of egg-nog, milk, strained soup and broth.”

Mary Alexander Patton: “Treatment should be quick, every motion significant so as not to tire the patient, for exhaustion is always present. Each patient was treated two or three times a day until temperature became normal. The nasal douche was given twice a day followed by K-Y jelly. Hot soap bath followed by soap enema and enteroclysis when fever persisted.”

W. Curtis Brigham ordered “Hot packs the full length of the spine twenty to thirty minutes, three times a day. This will produce profuse sweating and often put the patient to sleep.”

I have used this same treatment, especially in nervous cases, and hold it in high esteem. I have the patient put a bath robe on backwards so that the arms and legs are well protected but the spine easily accessible. The hot packs can then be used and covered over and the patient not exposed.

R. H. Nuckles maintains that lung and ear trouble will not follow influenza where osteopathic treatment has been given to adjust the cervical and upper dorsal circulation.

H. A. Price: “We have kept particularly in mind, first, the nerve, blood and lymphatic supply to the lungs; second, the circulation to the spine (meaning spinal cord); third, the internal secretory functions and to the general excretion.”

Ralph M. Crane says: “A great deal of my work is among the Italians. It was necessary to give quick specific treatment that I might do as much good as possible to the greatest number. I did not treat them as often as I would like to, and because of this fact I learned that osteopathy got control of the ‘flu’ immediately, the first treatment sufficing to start them on the road to recovery; in fact, many of them got no more than one treatment.”

FOOTNOTES:

[51] Hinckle—The Scientific Basis of Osteopathy.

[52] Clinical Osteopathy.

[53] Journal of Osteopathy—Prize Article July, 1906.

[54] A. O. A. Case Reports—Series I.

[55] E. Link, Diphtheria—The Bulletin, 1905.

[56] A. M. Willard, Membranous Croup—Journal of Osteopathy, March, 1904

[57] See Dr. Still—Philosophy and Mechanical Principles of Osteopathy.

[58] Journal of Osteopathy, October 1905.

[59] Journal of Osteopathy, October 1905.

[60] Journal of the American Osteopathic Association, March 1906.

[61] Journal American Osteopathic Association, December 1904.

[62] Journal American Osteopathic Association, May, 1905.

[63] Journal American Osteopathic Association, May, 1905.

[64] Rewritten from article in Osteopathic Physician, June 1919.

[65] This treatment was described by Henry M. Stovel, in The Osteopathic Physician of January 1917.

[66] O. P. June 1919.

ACUTE ERUPTIVE FEVERS, MUMPS AND WHOOPING COUGH

By EDGAR S. COMSTOCK

GENERAL CONSIDERATION

In the consideration of these diseases, it is well to bear in mind that lowered resistance is the primary condition that has made the infections possible, and that lowered resistance implies an imbalance of or obstruction to the vital fluids and forces of the body, thereby interfering with the functional activity of the body’s normal protective mechanism.

The imbalance of or the obstruction to these vital fluids and forces, which is structural in nature, is produced by many conditions, as fatigue, exposure, sudden changes of heat and cold, emotions, dietetic errors, physical force or violence, etc. These conditions, because of the response of the tissues of the body to environmental changes, produce contractures of the elastic tissues, such as muscle, fascia, etc., which disturbs the structural integrity of the body and thus produces obstructions, irritations or interference with the media of exchange of these vital fluids (blood and lymph) and forces (nervous energy) of the body.

It is evident, then, that the most potent curative factor in the treatment of these diseases, as in all others, is the removal, whenever possible, of the obstructions and interferences that pervert the activity of these protective forces. It is necessary, therefore, to remove the exciting causes (fatigue, dietetic error, etc.) and by such physiological means as may seem necessary to readjust the structures of the body so as to remove the above mentioned obstructions and interferences.

The structural lesions most frequently found in the infectious diseases are of the muscular and fascial type and are very evident to the careful observer. The interosseous lesions are probably often the predisposing factors to the susceptibility of the softer tissues to reaction to environmental changes, but it has been the experience of the writer that the adjustment of the softer tissues was of greater primary importance in the acute stages of these diseases. The interosseous lesions may be easily adjusted in the very early stages of these diseases, that is before the severe symptoms have appeared, but after the more severe conditions have appeared it has been our experience that the soft tissue work was sufficient unless the interosseous lesions were very easily adjusted.

It is the writer’s desire to impress upon the reader the necessity of careful attention to the structural lesions that are always constant in these diseases, using whatever physiological means seem necessary to adjust these lesions and keep them adjusted, and to insist upon carefully restricted diet; continuous, thorough elimination of the waste products of the body; hygienic surroundings and well-regulated environments both mental and physical. Then Nature, which has given the body its own protective mechanism, may have full control of the situation and all of the normal protective chemicals and forces in the body organism are utilized in the battle with the invading infective forces: the glands secrete the chemicals of protection; the antibodies are rapidly developed and thrown into the battle area; metabolism begins to return to normal; elimination becomes increased because of the stimulating action of foreign substances in the body structures; and the work of repair and recuperation begins.

If reliance is placed upon the inherent protective forces of the body, the knowledge of the special type or character of the invading organism is of little importance from the standpoint of the treatment of the disease after it has become established. The value of the knowledge of the specific organisms is in preventive medicine, in seeking out the habitat and breeding ground of the organism and its mode of transmigration. Knowing these, effective measures may be adopted to prevent their propagation and spread. Examples of this are Yellow Fever and Malaria.

Variola

(SMALLPOX)

=Definition.=—=Variola= is an acute, specific, highly infectious and contagious, epidemic disease. Its beginning is sudden with a chill, vomiting, severe headache and lumbo-sacral pains. It has a typical fever curve and a typical eruption on the skin and mucosæ of macules, papules, pustules and crusts successively.

=History.=—Prevailed in China and India at least 1000 years before the Christian era. Epidemics occurred in the sixth century and during the crusades. Its first clinical description was given in Arabia during the ninth century. It was brought into Mexico about 1520 by the Spaniards and between three and four million people contracted the disease. In 1718 preventive inoculation was introduced into England and in 1796 Jenner discovered vaccination.

=Etiology.=—The specific agent which is the cause of this disease is unknown, but the virulence of the agents is retained for a long period and is the most virulent found in all diseases. There is no period from the initial fever to the final desquamation that the disease is not contagious, although the stage of suppuration is the most violent. Although the disease is so highly contagious and the entrance of this particular poison into the system produces this disease, still no one has yet been able to discover a germ nor what the nature of the infective agent is. To contract the disease it is not necessary to touch an individual already afflicted, not to even approach the sick room. It may be only necessary to touch a garment that has once been in contact with a smallpox patient, or which has simply hung in his vicinity.

The blood is infectious at a very early stage. As smallpox is contagious without eruption it seems that the secretions and excretions convey the virus. The dried pustules seem to have the greatest infectiousness. Cadavers of smallpox (Variola) victims are very dangerous and relatives of them should be carefully warned. The disease often persists in infected communities for years. The disease is evidently spread by fomites, contact with the pustular contents, and crusts or scales of the desquamating skin. It attacks all classes, ages and conditions of people, which is unlike other erythematous diseases.

A previous attack usually confers immunity. Vaccination is claimed to confer immunity but apparently in not all instances, for there are records of “successfully vaccinated” individuals having severe attacks of the disease.

The susceptibility to smallpox, as to all other infectious diseases, varies in different individuals, in different races, and under the influence of conditions as yet unknown. Some persons are not susceptible to the disease, nor are they to vaccination, and yet others have been known to have had the disease as much as three times. The Negro and Indian races seem to be more susceptible than the Caucasian. Then again at intervals of a few years, the general susceptibility of the people seems to be increased so that cases of smallpox become far more numerous than usual.

A point of considerable interest is the fact that the child, while in the mother’s womb, may experience the disease along with the mother and thereby acquire, before birth, the usual immunity conferred by one attack of the disease. In most cases of smallpox in pregnant women, abortion or miscarriage occurs, yet a sufficient number of instances are on record in which healthy children have been born, exhibiting the characteristic pitting of smallpox, and possessing no susceptibility to vaccination. Again there are other cases in which pregnant women have smallpox and the babes in the wombs have escaped entirely; while the most singular fact is that while the fetus may experience the disease, the mother through whom the exposure was effected, escapes, either because of a previous attack or possibly because of vaccination.

While there seems to be no reason for believing that an attack of smallpox can be, or ever has been, aborted by artificial means, yet there is a prevalent belief that this process occurred during certain epidemics of smallpox, cases having been known in which individuals presented all the symptoms indicating the invasion of smallpox, and yet no eruption occurred, and yet such individuals were thereafter insusceptible to smallpox or vaccination.

The mortality of smallpox varies like the susceptibility of it—with the age of the patient and with some unknown conditions of the atmosphere or soil which favor the occurrence of the epidemics. The average in scattered cases—sporadic—is probably not greater than one in nine or ten. A fatal result occurs more frequently in the second week of the disease than at any other time.

=Pathology.=—Granular and fatty degeneration occurs in the liver, spleen, kidneys and heart. Infiltration is found in the adrenal glands and testicles. During the papular stage, there is local hyperemia of the papillæ, with interstitial exudation and colliquative necrosis of rete cells, so that a vesicle is formed, peculiar in that it is traversed by delicate bands of epithelial cells. This, with the fact that coagulation-necrosis occurs mainly in the center, gives it the umbilicated, or depressed appearance. The contents of the vesicle are plasma, fibrin and cell detritus. Leucocytic invasion converts vesicles into pustules. This has a more globular, elevated appearance than the umbilicated vesicle. Pyogenic organisms are found in the pus. When the inflammation injures the corium, scars are apt to result; this occurs when the skin is scratched. The actinic light rays increase the danger.

=Diagnosis.=—Mistakes in the diagnosis of the first cases of smallpox in an epidemic are almost inevitable. Hemorrhagic scarlatina or measles sometimes cause confusion; in the hemorrhagic scarlatina the mucous membrane hemorrhages are less frequent than in smallpox. The prodromal eruptions plus purpura are very suggestive. The invasion stage lasts about three days.

Smallpox is characterized by sudden onset with violent chill and shivering; agonizing pain in the back and legs; intense headache, mostly frontal; temperature rapidly reaching 102 to 104 degrees F.; full, strong, rapid pulse, going to 100 to 140; uncontrollable vomiting; pharyngitis; red face, bright eyes, coated tongue; anorexia; constipation; sleeplessness; delirium; often copious perspiration and extreme prostration.

An “initial exanthem,” clearing within 24 to 48 hours, appears. It is either hemorrhagic or erythematous. About the third day the true eruption appears, first upon the forehead and in the scalp, then the rest of the face, the backs of the wrists, trunk, arms, and lastly the legs, most abundant upon the parts exposed to the atmosphere. With the appearance of the eruption, all symptoms abate, the temperature falls, and the patient may feel quite comfortable. The eruption consists of coarse, red spots upon the body, like flea-bites, rapidly becoming, within 24 hours, slightly raised red papules, feeling hard and shotty to the touch, and each surrounded by a broad red inflammatory band, the areola. Usually by the sixth day the papules become converted into umbilicated vesicles, at first clear, then turbid. They are hard and indurated to the touch, and on the eighth or ninth day they become pustular. The areola becomes much darker, the temperature rises to 103 to 105 degrees F., and the pulse to 110 to 120. The other symptoms all reappear, with salivation and delirium. Marked edema of the skin renders the skin unrecognizable. The pustules are painful, especially in places where the skin is thickened. The maturation lasts about three days, when the fever falls by lysis. If fatal, death usually takes place about the tenth day, preceded by feeble and more rapid pulse, marked delirium, subsultus and sometimes diarrhea. About the eleventh day, desiccation begins, the pustules begin to dry, forming tight scabs which are closely adherent. The fever and other symptoms subside but itching becomes annoying. The odor from the pustular stage on is a peculiar greasy one.

After the rupture of large pustules the centers frequently dry and sink in, often in the shape of the Maltese cross. This is most typically seen on the backs of the hands and is pathognomonic. Toward the end of the third week the scabs fall, leaving red glistening pits which disappear or change into deep white striated scars. The hair falls but may grow again. The diagnosis is not certain until the eruption is seen. In the smallpox without eruption the diagnosis must be made from the history of exposure, the presence of an epidemic, fever, lumbar and head pains, delirium, and possibly the initial rash.

Mistakes in diagnosis may be made even by smallpox experts, but attention to the history, somatic findings and the course of the disease, rather than to the eruption, will prevent disastrous results. Always isolate any and all suspected patients.

Varicella Compared with Variola

Vaccination and smallpox never Smallpox may closely resemble prevent. chicken pox; especially mild cases.

AGE—usually before puberty, may Usually after puberty (many occur in adults. exceptions.)

Initial stage practically absent. Initial stage severe, even in mild cases.

TEMPERATURE,—no remission on Typical remission and secondary onset of rash. fever.

White cells normal or decreased. Leukocytosis.

Prodromal rash very exceptional. Prodromal rash quite frequent.

Vesicles in crops. Vesicles never in crops.

Vesicles rarely shotty. Vesicles, following macules, are hard and shotty.

RASH EVOLUTION,— RASH EVOLUTION,— Very rapid, vesicles on first or Much slower, vesicles on seventh second day. day.

Eruption is universal, successive Development progresses downward, crops, most abundant on back, face first, then wrists, begins on body, less on face, trunk, arms and lastly legs. Less scalp, hands and feet. on trunk.

Vesicle is superficial and fluid Fluid pearl-colored and NOT transparent. transparent. Thicker covering.

Halo (areola) usually absent. Areola is marked.

Involution is quite rapid. Involution is slow.

The =Secondary Toxic or Septic Rash= appears during the stage of decrustation, sometimes with a mild fever. It may be either scarlatiniform, morbilliform, or hemorrhagic. The skin immediately surrounding the drying pocks is often exempt leaving an anemic halo. The rash lasts about three days and fades or desquamates. With the development of the skin eruption, an exanthem appears upon the mucous membranes of the body cavities, developing into ulcers. This may develop before the dermal rash and be of diagnostic importance.

Forms or Varieties

I. Variola Vera. { a. Discrete. { b. Confluent.

{ c. Purpura variolosa II. Variola Hemorrhagica. { (black smallpox) { d. Variola hemorrhagica pustulosa.

III. Varioloid. e. Smallpox modified by vaccination or partial immunity.

=Discrete Variola Vera.=—Incubation symptomless and averages 12 days.

Prodromal stage, from first symptom to eruption. Averages three days. The longer the stage the more severe the infection. Intensity bears little if any relation to prognosis; however, if onset is mild, disease will not be confluent or hemorrhagic.

Invasion begins with severe chill, often repeated. Initial fever rises suddenly to 103° or 104°, and reaches maximum on second or third day. Pulse is rapid and full. Skin is red, hot and dry. There may be sweating in the discrete form and in the favorable cases. The headache appears with the chill and is usually frontal. When severe and accompanied with neckache and vomiting it may suggest meningitis. The backache appears with the chill and lasts about two days. It is a lumbar pain, very like lumbago; it occurs slightly less frequently than the headache and vomiting. This pain is rare in other fevers likely to be confused with smallpox. Vomiting is constant in children and usual in adults. The initial eruptions, which are present in about 10 to 12 per cent, are of considerable diagnostic importance. They are usually limited to the lower abdomen, inner side of the thighs, axillæ, and sometimes on the extensor surfaces of the knees and elbows.

=The Eruptive stage= consists of the following sub-stages: =macules and papules; vesicles, and pustules=.

The macules and papules occur on the fourth day and progress for about three days. They begin on the forehead, near the hair, with itching and burning and resemble flea-bites. These soon become papules, which are reddish, elevated, circular, hard or shotty and discrete. On second day of this stage they appear on the body, and on the next day on the extensor surfaces of the extremities. If the eruption appears on the second day the confluent type may be anticipated; if on the third day of the disease, the discrete type.

The vesicles which occur on about the seventh day of the disease, contain lymph. Umbilication occurs in the centers of many of the vesicles, and it is suggestive of smallpox.

The suppurative stage begins about the ninth day with clouding of the vesicles and inflammation around them. This continues for three days. The pustules become opaque, then yellow, and a thick pus obliterates the umbilication. The inflammatory “halo” becomes more vivid and edema may follow around these haloes. This edema causes increased tension and deformity, particularly of the face, and produces great tenderness and pain. The pustulation follows in the order of eruption, from the face downward, and are the thickest on the extremities and head. The pustules evacuate spontaneously, or may dry up without rupture. The skin gives off a peculiar, offensive odor. Bed-sores are now most likely to develop.

The eruptions also may occur in the mucous membranes, particularly in the mouth and nasopharynx. These pass through the successive stages as do those of the skin, but less typically. With the pustulation there is usually a gradually rising =secondary fever=. In the discrete type the secondary fever does not remain high more than twenty-four to thirty-six hours, with morning remissions. A marked leucocytosis occurs with the secondary fever and its extent depends upon the severity of the infection. Delirium, albuminuria, acute exhaustion and heart paralysis are to be guarded against during this stage.

The state of involution, or decrustation, begins about the twelfth day. It follows the order of eruption, and is accompanied with a decrease in edema, redness and pain, but is attended with intolerable itching. Crusts form, the hair falls out and by the end of the second week the temperature returns to normal. If fever persists during this stage it indicates some complications. Scars occur when the true skin is involved and lasts three or four weeks. Complete convalescence follows the disappearance of the last crust.

=Confluent Variola Vera.=—This is a malignant type and used to be more prevalent than now. The initial stage is violent, and the headache and backache very agonizing. The fever remission is very slight or absent, and attended with hardly any improvement in symptoms. The earlier the exanthem occurs in variola the more likely it will be of the confluent type. The confluent eruptions occur especially upon the face and head, sometimes on the hands and feet. It is largely discrete on the body and extremities. Great edema appears with the fusion of the eruption, with the swelling and erosion of the mucous membrane, the eyes close and the nostrils become obstructed. The fever is high, pulse high and rapid (often irregular), dilirium, albuminuria, persistent nausea and vomiting, great thirst, husky voice, enlarged cervical glands, salivation in adults and diarrhea in children are symptoms present. Death occurs from acute toxemia, usually within a week, but may last a little longer. Recovery from confluent variola is very infrequent.

=Purpura Variolosa.=—This is “Black Smallpox.” That is, smallpox with primary hemorrhage in the initial stages. It is the worst type and results almost invariably in death. It is very important because it is so difficult to diagnose. Its incubation period is short (6 to 8 days), invasion very severe, lumbar pains almost unbearable, prostration great, pulse soft, small and rapid and respiration unusually high. The initial pains and vomiting may last until death.

On the first or second day a plum colored eruption appears, with brick-red, purple or inky ecchymoses particularly about the eyes. The condition is desperate. Hemorrhages may occur from any cavity of the body, sometimes accompanied by gangrene of the pharynx. The disease does not usually reach the period of real eruption, because death usually occurs within four or five days. The diagnosis of this condition is by history of exposure to smallpox and the characteristic prodromes.

=Variola Hemorrhagica Pustulosa.=—This is the type with the =secondary hemorrhage=, or the hemorrhage after the eruption appears, and is more common than primary hemorrhage. It occurs in weakly and alcoholic subjects. The initial stage is severe, and the hemorrhages occur into the vesicles or pustules. There may be epistaxis, hematuria and metrorrhagia. The outcome is almost always fatal, though the hemorrhage at the vesicular stage may be followed by rapid abortion of the rash and recovery.

=Varioloid.=—This is modified or mitigated smallpox; also known as variola benigna. Persons exposed to smallpox sometimes suffer from varioloid, and persons who have had smallpox may suffer from varioloid at subsequent exposure to smallpox. Vaccination appears to initiate an attack in persons peculiarly susceptible, or as a result of improperly performed vaccination. The lesions remain in the epidermis, the course of the eruption is shorter, the papules vesicate by the fifth day, the process of suppuration is abridged, decrustation occurs rapidly with little or no scarring, and all symptoms are milder. There are many modifications.

=Other varieties= are (1) Variola sine exanthemate, which has the usual symptoms without the eruption; (2) Variola verrucosa, which has large, solid, conical papules with small vesicles at their apices, which rapidly desicate and form crusts, and finally disappear without scars; (3) Variola cornea (horn pox) which is known by the large mahogany crusts.

=Complications and Sequelæ.=—Variola is often accompanied by many complications and sequalæ which are an early severe toxemia and a later secondary infection. During the secondary fever, there may be bronchopneumonia, pleurisy, dysentery, hemorrhages of all kinds, ulcerative eye, ear or laryngeal conditions, purulent arthritis, orchitis, gangrene when the swelling is great and subcutaneous abscesses form, often attacking the penis and scrotum, erysipelas attacking the face, and rarely nephritis.

During convalescence, carbuncles, boils and other subcutaneous abscesses are very common. Disturbances of the peripheral nervous system as neuritis, paralyses especially of the palatal muscles, neuroretinitis, and otitis media are less common. The sequalæ most common are boils, abscesses, deep pitting, otitis media, blindness and permanent baldness.

The =urine= has the usual febrile changes. =White blood= cells reach 10,000 to 20,000 or more. Lymphocytosis occurs during pustulation; polymorphonuclear cells are decreased to 40%, sometimes to 12%; myelocytes and irritation forms are found. During the febrile stage there is a polycythemia followed by an anemia to 3,000,000 or less during the pustular stage. Regeneration is slow, lasting about fourteen days. Normoblasts are rare except in hemorrhagic forms. Exudate taken from the pustules show streptococci, staphylococci, and pseudodiphtheria bacilli.

=Treatment.=—The imperative demands of treatment are isolation, ventilation, cleanliness and disinfection.

If symptoms are suspicious of smallpox, =notify the proper authorities at once and isolate patient=. When diagnosis is made, cut hair and beard very short.

1. Isolate patient in room free from draperies, rugs, carpets, curtains, pictures, etc.

2. Disinfect all vessels used in room of the patient in carbolic acid solution or in bichloride of mercury solution.

3. Family of patient should be isolated for from sixteen to twenty days.

4. Room should be well ventilated, with windows screened and slightly darkened with red curtains to exclude the ultra-violet rays of light. Temperature should be maintained at 65 degrees. Door-way may be protected by a sheet dampened with a 1:60 carbolic solution.

5. Nurse must be robust, perfectly immune and not afraid. If male nurse, hair must be very short and must have no beard; if female, hair must be short and must wear close fitting cap.

6. Absolute cleanliness is secured by plenty of baths, clean bed and personal linen, and careful nursing. Physician must put on special suit with cap and gloves which are kept in the house, but not in the sickroom.

The first symptoms being the headache, nausea and vomiting and the lumbar pains, the first points of attack in the treatment would be the relief of these pains in the head and back by thorough relaxation of the spinal muscles, paying particular attention to the suboccipital, mid-dorsal and lumbar areas. The headache may be partially relieved by steady pressure between the frontal and occipital regions. No interosseous adjustments requiring painful or difficult technique should be given after the more severe symptoms have appeared. Patient should be visited from one to three times per day, and the reflex contractures of the muscles must be relieved as often as they occur.

Dysentery and diarrhea are controlled by strong inhibitory pressure in the sacral and lumbar regions. Give vasomotor treatment to the superior cervical ganglion. Stimulate the anterior aspect of the solar plexus to stir up its acid function, the blood being alkaline in smallpox.

During all the stages up to the stage of pustulation, the patient responds very readily and successfully to osteopathic treatment. The headache, the backache and the aching joints respond to treatment as readily as, if not more readily than, the headache and backache of influenza do to osteopathic care. The constipation is usually quite readily relieved. It has been the experience of those who have handled smallpox cases, that the tendency to the confluent type is greatly reduced by this treatment and that the response of the patient to osteopathic treatment is very gratifying. Indeed, those of experience have less fear of the outcome of their smallpox cases than do they have of scarlet fever or pneumonia.

After the pustules have formed, each pustule is treated with iodine painted on the pustule with a camel’s hair brush. During the pustular stage it is not necessary to give manipulative treatment, and indeed it is sometimes impractical because of the tenderness of the skin. However, about all that is needed during this period is good hygienic treatment and good nursing. During convalescence constitutional treatment should be given.

=Diet.=—During period of vomiting, pellets of ice in the mouth are comforting. During periods of fever give plenty of water with, preferably, lemon juice. As the fever declines begin with barley and oatmeal water with lemon juice; then follow with easily digested and nutritious diet of milk, eggs, broths, beef juice and gruels. Feed every three hours during that period but not large quantities. During convalescence a full, well-regulated, nutritious diet should be ordered.

=Hygienic Care.=—Keep nose cleansed with glycerine, cold cream or olive oil, which keeps the crusts soft. The mouth and nasopharynx may be cleansed with any mild antiseptic. The eyes are washed with warm boric acid solution. Cold compresses applied over the eyelids assist in reducing the edema. A daily tepid sponge bath is necessary. Bath may be given with bichloride of mercury solution (1:20,000) or creolin (1:500).

=Headache.=—Deep, steady digital pressure in the suboccipital fossa and at eighth thoracic spine; ice bag to the head; or a mustard plaster at the back of the neck may relieve.

=Vomiting.=—Thorough relaxation and adjustment of the great splanchnic and cervical areas, with deep, steady digital pressure in the occipital triangles, and at the fourth and fifth dorsal vertebræ on the right side will usually control the condition.

=Fever.=—Relaxation of the upper dorsal area, relaxation of the cervical area, and deep, steady pressure in the suboccipital region often reduce temperature. Warm sponging in lower grades of fever, bath at 70° F., and cold pack may be needed. If temperature goes very high give a continuous cool colonic irrigation.

=Pitting.=—Cold wet dressings of lint soaked in any comfortable mildly antiseptic solution, or of ice water and glycerine, are to be used on the hands and face to prevent pitting. Hot water dressings are more comfortable to some patients. It is well to protect the skin from the light, especially from the ultra-violet rays. This, however, must not lead to any lack of ventilation. When crusts are forming keep them moist with vaseline, oil, glycerine, or carbolic acid in lanolin or vaseline.

=Odor.=—Baths, the daily toilet and the use of dusting powder or 5% iodoform powder, an open bottle of smelling salts or of weak ammonia are good. Plenty of fresh air is best of all.

=Cardiac Weakness.=—If pulse is feeble and frequent, a general quieting treatment should be given, including relaxation of the cervical area and of the fourth and fifth dorsal segments. An ice bag in flannel directly over the heart is often very useful. Gentle, careful spinal extension is very restful and eases the spinal circulation.

=Delirium= is usually relieved, or prevented, by spinal extension, the prolonged warm bath or the cold pack, if given when signs of nervousness appear. Morphia or chloroform may be necessary in violent and suicidal cases.

=Laryngeal Obstruction.=—Usually caused by edema and may require tracheotomy.

=Bed-sores.=—These and abscesses may occur even under the best of care. Place patient upon a water-bed or in a continued warm bath.

Convalescence is not complete until the skin is entirely free from crusts and is perfectly smooth.

=Prognosis.=—Prognosis depends upon age of patient; complications; and environment from which patient comes, as well as upon the nursing. In varioloid the prognosis is recovery; in the discrete variety, good; in the confluent type over 50% are fatal; in the malignant types practically all die. In patients under five years old and over forty years old the prognosis is very grave. A filthy environment predisposes to complications. Recurrences seldom occur; second attacks are usually varioloid.

=Prophylaxis.=—Usual rules of health authorities are: rigid quarantine or isolation, vaccination, disinfection of the skin and all fomites, and final fumigation. Quarantine of a suspected individual is sixteen days after exposure. Isolation continued until every trace of eruption has disappeared. The dead body is very dangerous and a public funeral is not permitted. The clothes used by the patient must be steamed and other articles must be washed with bichloride of mercury and fumigated with formaldehyde vapor. Disinfection of the hands, face, beard and hair of attendants with bichloride solution is imperative.

Vaccination

(VACCINIA; COW-POX)

=Definition.=—=Vaccinia= is an eruptive disease of the cow, communicable only by inoculation and causing, when transmitted to the human being, local reaction in the form of a pock and constitutional disturbances which are followed by a more or less lasting immunity against smallpox. =Vaccination= is the artificial inoculation of vaccine virus for the purpose of producing an immunity against smallpox.

Arm to arm vaccination was formerly very generally practiced but has been practically discontinued because of the possibility of infection from syphilis and other infections. When it is necessary to use the human lymph it should be taken upon the eighth day from a typical unbroken vesicle in a perfectly healthy child at least three months old. The vesicle must be pricked at several points, care being taken not to draw blood. The bovine vaccine lymph is now in general use because it practically eliminates the possibility of syphilis and other infections. Also because it is more easily transported.

It is thought best by many authorities to vaccinate in infancy after the sixth month, at the seventh and eighth year, at puberty, and thereafter at intervals of about seven years, but depending considerably on the prevalence of small pox. The virus is prepared under sterile conditions from carefully selected and tested calves. It is put up under aseptic conditions in hermetically sealed capillary tubes or, in the old style, on ivory points.

There is a great variety of opinions as to the efficacy of vaccination in producing immunity against small pox, this variety of opinion being very prevalent among representatives of the medical schools. Dr. F. P. Millard of Toronto says the lymphatic system is the keynote, and that vaccine virus poisoning spreads through the lymphatics, causing diphtheria and allied throat affections. Dr. A. T. Still said, “We are opposed to vaccination.” He repeatedly emphasized the fact that “Nature furnishes within the body all the remedies necessary to cure disease.” In the recent Canadian epidemic (1919-1920) the medical authorities have met with a most strenuous opposition. The Homeopathic profession, almost to a man, went on record as opposed to compulsory vaccination. The Illinois Supreme Court has ruled that compulsory vaccination is unconstitutional.

=Technic.=—The area usually selected is the left arm at a point above the insertion of the deltoid muscle. Some prefer the leg over the junction of the two heads of the gastrocnemius muscle, because it is more easily cared for, and, because of the style of wearing short sleeves among women, it does not expose the scar which results from the vaccination.

The surface must be washed, dried, with a soft towel, and then sterilized with alcohol. With a sterilized needle or lance scratch an area about a quarter of an inch in diameter, being careful not to produce bleeding but merely an oozing of pinkish lymph. A drop of the virus should be deposited upon the abraded surface, rubbed in with the side of the needle and let dry. A thin layer of sterilized gauze should be lightly applied and held by means of adhesive plaster, not encircling the limb. This should be occasionally removed and redressed. The pock should be kept dry and clean, and may be lightly dusted with starch or toilet powder. “Persons exposed to the contagion of small pox should be immediately revaccinated. The immunity conferred diminishes with time.” It is the writer’s personal opinion that, with the amount of complications that so frequently follow vaccination and with the fact that “it is necessary to revaccinate during an epidemic or after exposure,” it were better to defer vaccination, if parties are favorably inclined to the practice, until such time as the presence of small pox in the community make it apparently necessary.

=Typical Vaccination.=—The period of incubation varies from three to five days. At the end of this time local reaction shows itself in the form of reddish papules at the point of inoculation. In about five days these develop into compound vesicles, which at first have clear and then later opaque contents. About the eighth day the vesicle is fully developed and is round or oval with prominent and well defined edges and a depressed center. An erythematous areola usually appears about the tenth day and the contents are purulent. The surrounding skin is swollen and tender, and a scab now begins to form in the center of the pock and rapidly extends toward its edges. About the end of the second week the areola fades, and the pock is changed into a thick brownish crust which becomes dry and hard, and comes off between the twentieth and twenty-fifth days after vaccination. A dusky red scar is left and this gradually becomes white and pitted. During the evolution of the pock the glands through which lymphatic drainage takes place become slightly enlarged and tender.

The constitutional reactions are usually moderate fever, restlessness at night, irritability and loss of appetite. These symptoms usually appear about the fourth day and continue about three to five days. At any time during the vaccinia erythema, roseola or urticaria may appear. The constitutional reaction in revaccination is sometimes very severe.

There are many atypical symptoms following vaccination as variation in the number of the pocks, in the size, in the severity of the constitutional symptoms, in the contents of the pock, in the healing and formation of the scar and in the transmission of specific diseases as syphilis, tuberculosis, leprosy, cancer and tetanus.

=Complications.=—All cases are not benign, as due to impurity of vaccine, carelessness in technic, improper care in dressing, handling of the wound by the patient himself, scratching it with the finger nails, and other accidents of like nature, infections may set in and very serious complications arise. These result in abscesses, erysipelas, tetanus and various eruptions. Otitis media may leave deafness.

The writer knows personally of a young man in the Army during the World War who was vaccinated while in the Army and two abscesses developed which ate entirely through the arm, one abscess passing through the arm just anterior to the humerus and the other just posterior to it. It was many, many months in healing, and nearly caused loss of the arm.

There are many cases of record where vaccination was followed, directly or indirectly, by paralysis, deformities, and chronic constitutional diseases. It is usually claimed these conditions were due to accidents following the vaccination and not due to the vaccination itself. However, it can not be denied that the vaccination was at least the indirect cause of these deplorable conditions.

=General Vaccinia.=—(Vaccinal eruptive fever; Vaccinola). This consists of a vaccine rash, developing usually from the fourth to the tenth day following vaccination, and appearing in various parts of the body, particularly about the wrists and on the back. The secondary pocks usually develop about the eighth or tenth day after vaccination and are usually more abundant on the vaccinated limb than on any other part of the body. As the pocks appear in successive groups, all stages of the disease may be seen at one time, and the condition may last for many weeks. Fever may be absent or present, but is usually proportionate to the extent of the eruption and the associated complications.

=Treatment.=—After vaccination, the patient should be told to return in seven days, when the dressings should be removed, and if the vaccination has been successful, a pearl-like vesicle will be present. If the vesicle has been broken by accident or by rubbing of the gauze, the free portions of the dressing should be cut away and the adherent part left undisturbed. A new gauze should be applied in any case, and in five or six days more, the dressing should be again changed, and this changing continued at intervals until the crust falls, which is usually during the third or fourth week.

If no vesicle forms by the tenth or twelfth day, the vaccination has not been successful. It is suggested by the vaccination advocates that another attempt should be immediately made.

=Prognosis.=—Uneventful recovery is to be usually expected. Pitting from generalized vaccinia; various constitutional diseases; paralyses and other maiming disabilities sometimes occur. While it is not usually considered dangerous to life, there are nevertheless many cases of record where death has resulted. It is not wholly unattended with danger.

The best of care should always be taken following vaccination to prevent the possibility of complications, though even then they do occur.

Scarlet Fever

(SCARLATINA)

=Definition.=—Scarlet fever is an acute, specific, contagious, infective disease of unknown origin, characterized by very sudden onset, fever, vomiting, sore throat and diffuse exanthem.

=History.=—It was first recognized in the sixteenth century, but first fully described and differentiated from measles by Sydenham in 1660. It was introduced into America about 1735.

=Etiology.=—The causative organism or agent is unknown. The virus of scarlet fever produces severe necrosis, but no suppuration. The streptococcus is the most important factor in the production of complications and in their mortality. It is claimed to be the cause of the malignancy of the disease but not of the disease itself. Susceptibility to the disease is by no means universal as only 38% of children and but 5% of adults exposed to the infection acquire the disease. Over 90% of the cases occur under ten years of age, and rarely during the first year of life.

“Scarlet fever is a toxic superficial expression of internal malnutritive conditions of the blood as a tissue. The cause of the toxicity is usually overfeeding, or the feeding beyond the demands of the proximate principles of the body, or the overfeeding under unhygienic conditions.—J. MARTIN LITTLEJOHN.

“It was once held that the virus was disseminated during desquamation, but oral, nasal and otitic discharges probably perpetuate the infection, perhaps months after scaling is complete. In no other disease is the virus so tenacious. It may persist ten years on clothes, furniture, etc.”—A. R. EDWARDS.

The light forms are as contagious as the severe ones, and inoculations have occurred from the living subjects as well as from autopsy cuts. In degree of infectiousness smallpox ranks first, measles second and scarlet fever third. The infection may be spread by any third person or by articles coming in contact with the patient, and often the mode is obscure. Sporadic cases apparently frequently appear. The reason for the sporadic cases may easily be explained by the theory of J. Martin Littlejohn, given above. One attack usually confers immunity, but not always. This disease occurs more often in the autumn and winter, and is more prevalent in cities than in the country. (Measles is more prevalent in the country.) Scarlatina sometimes occurs with other infections, such as diphtheria or measles, and more rarely with varicella, pertussis, etc.

=Predisposing Factors.=—Age, one to ten years; lowered resistance from overfeeding, unhygienic environments, exposure to sudden temperature changes; lesions, both muscular and interosseous which interfere with the distribution of the fluids and vital forces of the body; season of the year (autumn and winter); puerperal women, and wounds.

=Pathology.=—No specific lesions are found. No trace of the rash shows after death except in the hemorrhagic form. The anatomical changes in cases coming to autopsy are those of simple inflammation, follicular tonsillitis, or diphtheroid angina. Streptococci are abundantly found in the glands and foci of suppuration.

=Symptomatology.=—Scarlet fever is divided into four stages: (1) Incubation, (2) Invasion, (3) Exanthem, (4) Desquamation.

=Incubation Stage.=—Has no noticeable symptoms and lasts from two to four days. Some authors claim as high as ten to fourteen days.

=Invasion.=—The invasion lasts one day. The onset is very sudden beginning with a chill which is followed by a characteristic vomiting, occurring in 75% of the cases, which is more frequent than in any other disease of childhood except pneumonia.

The vomiting is followed by headache and the beginning evidence of sore throat, which usually soon develops into a tonsillitis. The severity of the sore throat is indicative of the severity of the scarlet fever that follows. The temperature suddenly rises to 103° or more, the pulse becomes unduly rapid for the temperature, 120 to 160 per minute, and the respiration is increased. The skin begins to burn, there is dysphagia and intumescence of the cervical glands. The muscles of the back become hypersensitive to touch and to extremes of heat and cold; and particularly sensitive spots are found over the transverse processes of the first to 4th cervical vertebras, the 4th and 5th dorsal and the 11th and 12th dorsal vertebras. At these points will be found intensely contractured tissues which must be kept relaxed.

=Exanthem.=—The eruption appears at the end of the first day or early the second day, showing first over the clavicles and on the neck, then over the upper trunk, next the lower trunk and limbs. The eruption on the extremities appears particularly over the flexor surfaces of the joints. By the end of the second day the eruption has covered practically the entire body, leaving a white circle about the eyes and mouth. The eruption pales, or disappears on pressure, quickly returning to the scarlet color on the removal of the pressure. Frequently, the skin itches and is very uncomfortable.

A punctiform eruption in the arm-pits, over the groins, or on the roof of the mouth is considered positive proof of scarlet fever.

The eruption at first consists of small red spots which fuse as the skin swells and results in an intense lobster-colored erythema. This lasts four to six days. The tongue, at first, is red at the tip and margins with a greyish-yellow or whitish fur in the center through which is often seen the swollen red papillæ, the “strawberry tongue.” The “fur” desquamates on the third or fourth day, leaving a surface intensely red with marked raised, swollen papillæ, the “raspberry or cat tongue,” which lasts nearly a week. The breath has a heavy, sweet odor. The pharynx, uvula and tonsils become swollen, and often creamy-white patches cover the mouths of the tonsillar follicles.

Between the second and third day the eruption reaches its height, when it has a vivid scarlet hue unlike any other eruption, and becomes darker each day until it may be a bluish-red, when it gradually fades and desquamation begins. By the seventh or eighth day the rash has disappeared, together with the fever.

=Desquamation.=—Scaling begins on the face first, from the sixth to the ninth day and lasts several weeks. The skin looks somewhat stained, is a little rough like “goose-flesh” and gradually the upper layer begins to separate, and the scaling begins in large lamellæ or flakes. Casts of the fingers or toes may be shed. The swelling of the glands disappears, and the fever falls by lysis, and convalescence begins, unless complications intervene.

=Diagnosis.=—In typical cases diagnosis is easy, especially during epidemics or when the eruption is accompanied by other criteria.

1. Sudden onset, with nausea and vomiting, sore throat, quick appearance of fever and rapid development.

2. Punctate spots in the throat, swelling and dysphagia are usually present. The severe sore throat symptoms with the above are always very suspicious.

3. Strawberry tongue is constant.

4. Eruption, typical in character, appearing on second day, first showing on the neck above the clavicles, intense on the body and practically absent around the mouth. Eruption confluent, with no intervening free areas of the skin, followed by desquamation.

5. Lymphadenitis much more pronounced in the inguinal and other glands than in the cervical.

6. Desquamation, tender joints and albuminuria will force the conclusion of scarlet fever, if former symptoms have been indefinite.

In the atypical cases we may have very light attacks with all the symptoms present but very poorly developed; or some symptoms absent as in cases with no temperature, or others with no rash. Some cases are so atypical as to be impossible of diagnosis. The writer has very recently had the experience of one case when there were absolutely no typical symptoms present after being called on the case, but four days after the invasion of the disease in the patient a sister of the child developed typical scarlet fever, and not until the sixth day did any eruption or sore throat appear, and then the eruption was more characteristically measles than scarlet fever. Consultants with the writer agreed with him that the case was one of an atypical, non-eruptive scarlet fever.

=Differentiation.=—Scarlet fever is not always easily differentiated from other diseases, such as a septic rash, drug rashes, diphtheria, measles and German measles.

A. R. Edwards gives this differentiation between scarlet fever and septic rash.

=Scarlet Fever= =Sepsis=. Bright red erythema, with small A very deep purple-red rash, red papules. sometimes spreading over the entire body. The eruption is much the same in both diseases, the same places being exempt. Miliaria are rare. Miliaria are frequent. Rather typical desquamation. Desquamation observed less frequently. CRITERIA: angina, tongue, onset, Etiology, chills, sweats, fever glands, etc. irregularity, polymorphous exanthems, etc.

=Diphtheria.=—Often difficult to differentiate. The simple erythema is sometimes observed in diphtheria, but is darker, more on the trunk, and more transitory than in scarlet fever.

=Drug Rashes.=—These rashes are caused by belladonna, iodoform, quinine, iodide, chloral, copaiba or aspirin. They may be easily differentiated if the cardinal symptoms of scarlet fever are considered instead of the rash alone. At the present time, perhaps the most frequent drug rash that we meet is that produced by aspirin. It is sometimes hard to diagnose because the aspirin has been taken for a sore throat or tonsillitis, which so resemble the early symptoms of scarlet fever.

=Measles and German Measles.=—The symptoms of the invasion stage of these diseases is sometimes quite similar, and even the rash may be quite similar; the differentiation will be discussed under measles (q.v.).

=Types and Forms.=—(a) Mild and abortive form (scarlatina sine eruptione). In this the rash may be scarcely perceptible, while the fever, sore throat and strawberry tongue are present. Desquamation may be present and it may be followed with a severe nephritis.

(b) Malignant forms, (1) Atactic variety, violent intoxication, onset of great severity, fever very high (107° to 108°), extreme headache, delirium, and often convulsions. Initial delirium gives place to coma; dyspnea may be urgent; pulse very rapid and feeble; and death occurs before eruption appears. (2) Hemorrhagic variety: there are hemorrhages into the skin, beginning with scattered petechiæ, becoming more extensive and ultimately involving the whole skin. It is characterized by severe fever and brain symptoms at the onset; incomplete exanthem, necrosing angina, marked glandular and splenic swelling; subcutaneous, serous and mucous membrane hemorrhages with ulceration. Death may take place on the second or third day. This is more common in enfeebled children, although it may attack adults in apparently full health.

(c) Anginose form (Scarlatina anginosa.) This form resembles septic diphtheria, with marked toxemia, necrosis and adenitis. The throat symptoms appear early and progress rapidly. Temperature high, cyanosis, diarrhea, rapid weak irregular pulse, and stupor occur. The fauces and tonsils are covered with a thick membranous exudate which may extend to the posterior wall of the pharynx, forward into the mouth, upward into the nasal chambers, and may occasionally reach the trachea and bronchi. The Eustachian tubes and middle ear are usually involved. The glands of the neck rapidly enlarge and become the seat of brawny induration, and the inflammation extends beyond their limits. Necrosis occurs in the tissues of the throat, fetor is extreme, the constitutional symptoms are great and the child dies of toxemia. If he does not die, extensive abscess formation in the tissues of the neck takes place with sloughing and danger of hemorrhage from the opening of a large artery.

=Blood Pressure.=—Rises at first, thereafter it follows the pulse and temperature. After the seventh or eighth day it may be below normal. Cases of albuminuria show hyperextension and slowing of heart action. With the subsidence of the kidney irritation the pulse-rate is increased and the blood pressure returns to normal.

=Urine.=—Shows ordinary febrile character, being scanty and high colored. Slight albuminuria is rather common after the stage of eruption, even a few tube casts may be present without any serious irritation of the kidneys. Urinalysis should be made daily.

=Blood.=—The red cells are moderately reduced to 3,000,000 or 4,000,000 per c. mm. during convalescence. There may be some poikilocytosis, and normoblasts are occasionally seen. Leucocytosis is early, 15,000 to 30,000 per c. mm., falling with the decline of the fever usually by the fourteenth day, but may persist for weeks after the temperature is normal. The count runs roughly parallel to the temperature. Over 40,000 leucocytes per c. mm. are of bad prognostic omen. Polymorphonuclear cells are increased to 80% or 90%; early returning to normal in favorable cases.

Eosinophilia is present in all but malignant cases. It reaches its maximum two or three days after the rash appears and returns to normal after the leucocytosis has disappeared. The early presence of eosinophilia excludes septic conditions. When these cells are absent in scarlet fever, myelocytes are to be found.

=Treatment.=—Clinically scarlet fever represents, from the osteopathic viewpoint, (a) a toxic condition due to internal malnutrition and a decrease of the detoxinating function of the thyroid gland; (b) secondarily associated with the sore throat is a type of toxic tonsillitis, but it is due to the toxic elements in the blood; (c) in the lesion field it is associated with extreme stiffness and muscular tension in the upper cervical area and also in the entire dorsal area, overlapping the upper lumbar. The eruption is a superficial expression of the attempt of the body to eliminate the toxins, and this elimination should be aided by enhancing the activity of all the other eliminative functions. Cases are on record where patients have been exposed to scarlet fever, have gone the usual incubation period and developed the invasion symptoms, and by thorough, oft-repeated osteopathic treatments, with the aid of enemata and copious hot water drinking, have not gone beyond the invasion period and the disease apparently aborted within two or three days. It is therefore well to give thorough, oft-repeated attention to these cases during the very early stages.

(1) In all cases where the first symptoms indicate the possibility of a contagious disease, the patient should be immediately isolated and kept isolated until all danger of contagion is past. In scarlet fever cases get a competent nurse. Keep room light, quiet and thoroughly ventilated with a constant temperature of as nearly 70° as is possible. (It were better to have two rooms if possible, one for day and one for night: have room or rooms on upper floor if in a house). Arrange suitable means for thorough disinfection of all articles used in the sickroom. These are very essential.

(2) Patient should be clothed in usual night wearing apparel. The bed clothing should be warm, but not heavy. The physician should wear an operating gown or a sheet which thoroughly covers his clothing, also a cap. He should carefully wash his face and hands immediately after leaving the sickroom. The quarantine should be maintained for the legally required period, and even after if there continue discharges from the nose, nasopharynx or the ear. Bichloride wrappings should be placed about the body of the dead, and funeral must be private.

(3) Have enema given immediately to cleanse the lower bowel. Follow this with frequent draughts of hot water, or better hot lemonade for the first day. Place hot water bottles at feet. If eruption is slow in coming out, it may be aided by a hot bath, followed by wrapping the patient in warm blankets to prevent chilling.

(4) Thorough osteopathic treatment should be given along the entire spinal area from the atlas to the sacrum, inclusive, to keep the muscles well relaxed, giving special attention to the relationship of the vertebræ and the tension of the muscles from the occiput to the fourth cervical; the third to the sixth dorsal; and the tenth to the twelfth dorsal areas. Also give special attention to the deep cervical muscles, particularly those at the angle of the inferior maxilla, and at the articulation of the inferior and superior maxillæ. Remember the tendency of the kidneys to complication in scarlet fever, therefore do not neglect the renal splanchnics, for here you not only control the renal functions but also regulate the adrenal functions and their internal secretions. Keep the clavicles properly adjusted and articulate them by bringing them well forward to relieve any irritation that may have started in that area. Careful direct treatment to the abdomen should usually be given at each visit besides the work in the splanchnic area to keep the bowels, kidneys and liver active.

=Diet.=—Water must be given freely. If fever is very high, pellets of ice held in the mouth will give comfort. During the height of the fever it is preferable to withhold all nourishment, but if in a particular case it seems to be indicated, confine the nourishment to fruit juices, especially oranges. Never force feeding during the fever. For infants cut down their feeding to at least half, making the milk very thin with water or gruel. After defervescence, carefully increase to a light diet using sparingly of nitrogenous foods except milk. After four weeks in the usual case, gradually return to the ordinary diet. This is a good time to make corrections in the ordinary diet if any are needed.

The =bowels= must be kept regulated. An enema is usually indicated after the onset of the disease. During the time that food is permitted it should be of a laxative character. During the fever stage the enema should be given daily to help keep the bowel cleansed and to help reduce the temperature. If bowels are persistently sluggish and the fever is constantly high the abdominal heating compress (so-called “cold compress”) will give much relief.

The =nose and throat= should be constantly looked after. The nose may be cleansed by instillation by means of a medicine dropper, using normal salt solution. If the throat symptoms are mild, a gargle of warm normal salt solution is enough for cleanliness of the membrane. If the throat symptoms are too severe to permit the use of the gargle, or if the patient is too small to be taught the use of the gargle or to wash the throat, irrigation may be employed. The use of raw lemon juice, or of raw pineapple juice, on a cotton swab is of great value in cleansing the tonsils and throat. The swabbing should be repeated several times per day.

The =teeth= should be carefully and thoroughly cleansed twice per day.

The =skin= must be constantly cared for. During the fever it is well to cover the skin with linen or soft cotton. Daily sponge baths of carbolized water (1:40) of tepid temperature followed by applications of cocoa-butter will give much comfort. Use only good toilet soap and do not use the so-called antiseptic soaps because, authorities claim, there is a chance of renal injury. During the period of desquamation the use of the cocoa-butter will assist in limiting the source of infection by preventing the diffusion of the dry scales which are considered infectious by many physicians. A. R. Edwards says: “During desquamation, oil-rubs were once employed to decrease the dissemination of dry scales, but they decrease the function of the skin, which is of great importance when the kidneys are involved; also, infection is carried by means of throat secretions. Soap and water serve equally well.” Some authorities suggest that during the desquamation, after bathing the patient, the skin should be thoroughly rubbed and then the oily application used, using cocoa-butter, unmedicated cold cream, liquid albolene or the like. Olive oil and vaseline are usually irritating. The writer inclines to the opinion that the soap and water bathing is sufficient, except perhaps the use of cocoa-butter over the areas that are desquamating severely.

The =temperature= can usually be controlled by the usual osteopathic methods; steady deep pressure applied in the suboccipital region for a few minutes, followed by relaxing the muscles of the back from the first to the eighth dorsal, by raising and spreading the ribs in the mid-dorsal area, and by light inhibition over the solar plexus. The tepid enema will assist in lowering the temperature. If temperature is high and patient is delirious and has other nervous symptoms the cold pack is useful. The ice cap may be used almost constantly in high fever. If glands are swollen treat by crowding the tissues toward the gland =but never work upon the gland itself=.

If pain is felt in the =ear= immediate attention must be given it. Correct any deviations of the atlas or other upper cervical vertebræ, relax the deep muscles at the angle of the jaw, and relieve any impingements in the lower cervical and upper dorsal regions. The ear should also be treated with copious boric solution irrigations, as hot as can be borne and at low pressure. The condition of the ear drum membrane must be watched daily and if there is bulging and congestion it is safer to puncture the drum under cocaine than to await spontaneous rupture. Use small amount of boric powder after rupturing.

The =heart= must be examined daily. Vigorous treatment through the thoracic region is indicated, if cardiac symptoms appear, and the patient must be kept quiet and in bed. If heart seems feeble it may be well supported by the cold packs directly over the heart.

=Nephritis= is most common in the second and third weeks of the illness, but may develop later. In all cases where any symptoms of nephritis appear, light or severe, the patient must be =confined to bed= for at least four weeks, and kept on a milk diet. All irritants must be absolutely avoided. Hot baths should be given twice daily to increase the sweat and the urinary functions, the bath lasting half an hour and the patient kept afterward between blankets. Treat thoroughly, daily, the splanchnic and renal areas, paying particular attention to the tissue conditions in the lower dorsal region.

In the milder cases, the urine contains albumin and a few tube casts, very rarely blood, and edema is slight or transient. Though the patient improves, he remains pale and there is a slight trace of albumin in the urine for months. If recovery does not take place, then chronic nephritis becomes established.

In the more severe cases there may be a puffy appearance of the eyelids, slight edema of the feet, urine diminished in quantity, smoky, containing albumin and tube casts. The kidney symptoms dominate, dropsy persists and there may be effusion into the serous sacs. The condition may become chronic, the patient may succumb to uremia, but in the majority of cases recovery takes place.

The nephritis may be hemorrhagic, in which the urine is suppressed or there may be a very small amount of bloody fluid laden with albumin and casts; constant vomiting and convulsions follow and the patient dies with symptoms of acute uremia.

Other =complications= are arthritis, malignant endocarditis, severe toxic myocarditis and acute phlegmonous inflammation, the last three of which are usually fatal. Chorea is a fairly frequent nervous complication. The mental symptoms are mania and melancholia. Progressive paralysis of the limbs with wasting, may simulate infantile paralysis. The fever may persist after the eruption disappears and the child remain in a septic state (scarlatinal typhoid).

=Relapses= are rare. Scarlatina may coexist with almost any other acute infection. It lowers the resistance of the body to disease and is often followed by other acute infections or by tuberculosis. Therefore the necessity of care during the entire convalescent stage.

Measles

(RUBEOLA; MORBILLI)

=Definition.=—Measles is an acute infectious, contagious, erythematous disease, occurring in epidemics, characterized by an initial coryza, bronchial catarrh and an eruption of a general maculopapular type; also by the presence of Koplik’s buccal spots.

=Etiology.=—=Predisposing Influences=: The chief predisposing factor in measles, as in all other contagious diseases, is a lowered resistance in which some structural or functional change has taken place that reduces the functional activity of the body’s inherent protective agencies. These predisposing factors may be classed under three heads, namely; (a) structural, (b) environmental, (c) dietetic. Under the first we find structural disturbances in the upper cervical area affecting the functional control of the nose, throat and head, as well affecting the thyroid and its internal secretions: structural disturbances in the upper and mid-dorsal areas affecting the vasomotor control to the head, neck, and chest, thereby perverting nutrition to all these structures and rendering them more susceptible to the infective organisms; also the dorsal lesions disturb the functional integrity of the lungs and heart, with the result of disturbed respiration and circulation, both of which are vital factors in body resistance: we also find structural lesions in the lower dorsal region, affecting the function of the kidneys and their elimination and the function of the adrenals and their internal secretions. Under the second or environmental, we have unsanitary and unhygienic conditions, exposure to sudden changes of temperature, wet clothing, fatigue, etc., all of which produce secondary structural lesions and the effects above mentioned. Under the third or dietetic classification, we have the errors of diet so common in children and adults as well; such as too much candies and other sugars, also too much starches, as well as over eating and unbalanced diet.

Measles prevails in all climates and attacks all races, the Negroes appearing to suffer more severely than the whites and to be more subject to complications. Outbreaks are more common in winter and spring, but occur at all seasons. The disease is particularly a children’s disease but adults may contract it if not protected by an attack in early life, and with adults the disease frequently manifests the more aggravated forms. It is more common after puberty than scarlet fever.

=Exciting Cause.=—While the disease is probably produced by a micro-organism, it has not yet been demonstrated. Inoculation experiments upon human beings have shown the presence of the infecting principle in the blood, in the tears, in the secretions of the nasal, pharyngeal and bronchial mucous membranes, and in the contents of vesicles occasionally present. Inoculation with the epithelial scales thrown off at the end of the disease has been unsuccessful. Ordinarily the transmission of the disease takes place through the breath or the nasal and bronchial secretions. The disease may be carried by a third person or by fomites. The infecting principle is intensely active, but not so tenacious nor persistent as scarlet fever. Measles is communicable throughout its entire course from the earliest appearance of the coryza. The individual predisposition toward measles is apparently so general that few, upon exposure, escape it, though we have observed cases where children have been directly exposed and who were immediately thereafter put under osteopathic care and did not develop the disease. Second, or even third, attacks may occur at intervals of some years, but these are unusual. Sporadic cases do occur and are often the starting points for epidemics. Extensive outbreaks occur at intervals of five or six years.

The incubation period is from seven to eighteen days, usually about ten days.

=Symptoms.=—Prodromes are common, usually consisting of loss of appetite, restless sleep, fretfulness, and often feverishness. There are three stages, (a) Invasion, (b) Eruption, (c) Desquamation.

(a) Stage of Invasion. The prodromal symptoms are intensified. There is often chilliness but seldom distinct chills. The temperature rises, often reaching 102 to 104 degrees, upon the first and second day. It then falls one degree or more to rise again upon the appearance of the eruption. Nausea, vomiting and headache are often present. The tongue is furred. With these symptoms coryza has developed and is sometimes intense, often simulating severe influenza. Irritation and smarting of the eyelids, lachrymation, photophobia, persistent sneezing, running of the nose, sore throat, discomfort in swallowing, hoarseness, and cough, at first of a croupy character, appear in rapid succession and with varying intensity. These initial catarrhal symptoms are characteristic and occur in the mildest cases in which chilliness, fever and the associated signs of the reaction of the organism to general infection are not observed. The vessels of the conjunctivæ are injected, the eyelids swollen, the nasal mucosa tumid and reddened. The mucous membrane of the mouth and throat is erythematous, while upon the soft palate and the roof of the mouth, and particularly upon the buccal mucous membrane, are to be seen pin head or split pea sized, circumscribed, round or irregularly shaped reddish blotches slightly or scarcely at all raised above the surrounding tissues, usually discrete, but sometimes confluent. This eruption also shows itself in the larynx and is undoubtedly the cause of the croupy cough and other throat symptoms. In a strong light there may be seen upon some of the spots on the mucous membrane of the cheeks and lips minute bright whitish, or bluish-white flecks which are called Koplik’s Spots. These spots appear early and soon disappear, and as they are not found in any other disease they are of value in the early diagnosis of measles. The duration of this stage is usually three or four days; rarely it is shorter or it may be as long as a week.

(b) Stage of Eruption. On about the fourth day the temperature again rises, increasing as the rash develops, often to 104 or 105 degrees and reaching its maximum about the sixth day when it usually falls by crisis; followed on the seventh or eighth day by normal temperature. The pulse-rate increases with the fever, often reaching 140 or higher. The eruption usually appears on the fourth day, and shows first about the hair line on the forehead, spreading to the face, chest, trunk and the arms and legs. The eruption is attended by itching and burning, and completely develops in from twelve to thirty-six hours, the catarrhal symptoms persisting during this time. During this time, in the more severe cases, delirium or stupor may be present, and the patient complains of sore throat and general discomfort, and is restless and wakeful. Usually upon the second or third day of the eruption, great and rapid amelioration of all these symptoms takes place and the fever falls to normal or subnormal. When the eruption is fully developed the individual spots are irregularly circular or oval, and differ greatly in size, averaging about the size of a split pea. The eruption is unevenly set, but usually close together and sometimes confluent, especially on the face, buttocks, hands and feet. Frequently they take on a crescentic arrangement and the spots are circumscribed, the intervening skin being normal or slightly hyperemic.

About the ninth day the rash begins to disappear, on the face first, then the neck and the rest of the body in about the same order as the eruption appeared. The skin takes on a yellowish discoloration and the rash disappears in a bran-like desquamation which lasts several days to a week. In the beginning of the stage of eruption, and in many cases throughout its course, the skin is moist and often bathed in free perspiration. At the height of the eruption the superficial lymphnodes of the neck, and elsewhere, are often slightly swollen and tender.

(c) Stage of Desquamation. The fine branny scales of desquamation are often so fine as to be easily overlooked. This process occupies about a week. The catarrhal symptoms in uncomplicated cases gradually disappear, so that, by the end of the second week from the initial coryza, convalescence is fully established. The cough frequently persists and is of a bronchial nature. Epistaxis is common at the height of the attack. Relapses of measles are extremely rare. Diarrhea is apt to occur at some time during the attack, without any particular significance.

=Varieties.=—Atypical cases may occur but are not common. They are as follows: (1) Morbilli Papulosi, development of distinct papules, hard to the touch but not extending deeply into the skin. (2) M. Vesicular; a vesicular form. (3) M. Sine Exanthema, cases in which the eruption does not appear, but general symptoms and coryza are present. (4) M. Sine Exanthema, in which the mucous membranes are not involved.

=Variations in constitutional symptoms.=—(1) M. Afebriles, rare cases in which there is no rise of temperature. (2) M. Hemorrhagica. This is the malignant form and in it the organism is unable to withstand the intensity of the infection and death takes place in the course of two or three days after sustained hyperpyrexia, profound adynamia, or hemorrhages into the skin and mucous membranes. These malignant forms are very rare in private practice, but they occasionally occur in asylums and in the fierce epidemics of camps, and were common in the first outbreaks among the natives of the Fiji Islands, where measles prevailed as a scourge. Death may occur before the rash appears or a few papules may show themselves upon the forehead and wrists. This is also known as =black measles=, and it is characterized by convulsions, delirium and coma, petechiæ, bleeding from the mucous surfaces and profound constitutional depression. The patient is rapidly exhausted, the pulse frequent and thready, the skin pale and cold, and death occurs. (3) Adynamic measles is a serious type in which the symptoms are grave from the onset but without hemorrhages and a typhoid status is early present.

=Complications.=—In the absence of complications, measles is comparatively a benign disease, but these complications are frequently enough present to place measles among the more serious diseases of childhood. The ordinary complications are due to the extension or intensification of the catarrhal processes peculiar to the disease.

(1) Otitis media is quite common, and may result in perforation of the tympanic membrane and permanent impairment of the hearing; or lead to sinus thrombosis, meningitis, or abscess of the brain. (2) Bronchopneumonia is the most common complication. (3) Purulent conjunctivitis may occur and in neglected cases infiltration and ulceration of the cornea. (4) Catarrhal laryngitis is a frequent complication. (5) Pseudo-membranous type is very uncommon but very dangerous. (6) Edema of the glottis is not common but does occur. (7) Diphtheria is much less common in measles than in scarlet fever. The high death rate of measles is due to the bronchopneumonia complication in which the lesions become extensive, the symptoms become urgent and a large proportion of these cases die. (8) Acute enterocolitis is a frequent and serious complication. (9) Gangrenous stomatitis occurs in young and debilitated children, and in girls gangrene of the pudenda occur during convalescence with greater frequency than in other infectious diseases.

=Sequelæ.=—The more common sequelæ are chronic local inflammations, conjunctivitis, otitis, nasal catarrh, laryngitis, and bronchitis. Tuberculosis is a common sequel.

=Diagnosis.=—During an epidemic, coryza, persistent sneezing and fever are suspicious. The appearance of the eruption on the third or fourth day upon the mucous membrane of the mouth and throat, and Koplik’s spots are positive.

Measles is often confused with 1. Rubella or German measles, 2. Variola, 3. Typhus Fever and 4. Scarlet Fever, which see. Occasionally =drug exanthems= are confused with measles. These may be caused by salicylates, antipyrin, quinine, turpentine or copaiba. These rashes are not accompanied by fever or throat symptoms unless they have been given to allay these very conditions.

=Treatment.=—Measles is so often a serious disease that it should not be attended with carelessness as it so often is, but the best of care and attention given. Parents should be informed of the danger of complications and of the absolute necessity of proper care and attention.

As soon as a susceptible individual is exposed to the measles, he should be immediately isolated, watched and corrections made of any dietetic errors, unsanitary conditions or structural lesions that may exist. He should be protected from sudden atmospheric changes and carefully watched for the first symptoms of the prodromal coryza.

On the appearance of the prodromal, or invasion symptoms the patient should be put to bed in an isolated, well ventilated room of as nearly constant temperature as is possible, from which all hangings, rugs and unnecessary furniture have been removed. The windows must be shaded to protect the eyes from direct or strong light, and any artificial lights in the room must also be well shaded.

The cases can usually be easily handled by careful, well-directed osteopathic treatments. In the manipulative treatment we must pay especial attention to the muscular and other soft tissue conditions in the suboccipital region, over the transverse processes of the upper four or five cervical vertebræ, under the angle of the lower maxilla and the lateral cervical tissues to remove any obstructions to the circulation and nerve control of the head and throat; see that the muscles in the lower cervical and upper dorsal areas are kept well relaxed, and articulation of these vertebræ, the upper three ribs and the clavicles are kept free; remove all lesions in the mid-dorsal area, whether muscular or otherwise, to prevent involvement of the lungs or heart, and to keep up function of the respiratory and circulatory systems; treat and keep normal the tissues and the articulations at the kidney and adrenal center, 11th and 12th dorsal; raise the ribs and keep them freely movable, this especially for the bronchial cough. Painful manipulations should be avoided and are not necessary. Dr. Still said, “The arms must be raised and the axillary region freed and kept so.” During the acute stage two or three treatments per day are advisable. Do not treat severely or to cause discomfort to the patient. Best results are obtained in the gentle, but thorough, treatments.

In the beginning of the case have the bowels cleansed with an enema, and then careful attention must be constantly given to the bowels and kidneys. The bowels can be kept open by manipulations and diet. The diet should be light and easily digested; during the fever it is best to withhold all food but give plenty of water. Follow fast with fruit juices and then the light diet.

The temperature is usually controlled by treatment, but if it remains high for some time and if the physician cannot reach the patient, the nurse should be directed to give a tepid sponge bath of ten to twenty minutes duration, and repeated at intervals of two or three hours. Also the tepid enema will often reduce the temperature.

For the itching of the skin, a tepid bath with water at 100 degrees given twice daily should be used, the patient dried carefully, and an application of olive oil, cold cream, liquid albolene, or a two per cent menthol salve, rubbed over the entire body will give relief.

The cough is best relieved by thorough treatment of the anterior thoracic regions and the correction of any upper rib or clavicular lesions. Keeping the air of the room moist with vapor is agreeable to the mucous membranes. The dropping of a few drops of eucalyptus oil in the boiling water produces a very soothing vapor.

If the eyes are much involved, they should be bathed every hour or two with a three per cent solution of boric acid, using cotton which is immediately destroyed after use. Dark glasses in a well ventilated room is better than an unaired darkened room.

The nose and mouth should be carefully cleansed at regular intervals and the cloths burned. The throat should be carefully examined daily at first, and at least every other day later, until the case is discharged. The conditions of the lungs must be observed by daily examinations, and the lung and bronchial areas should be daily treated to prevent the possibility of respiratory involvement.

If rash is slow in appearing and the temperature is high, a hot bath (105 to 110 degrees) for three to five minutes will often bring out the rash and relieve the more serious symptoms. During convalescence the patient must be protected against cold. Recovery is hastened by the continuation of treatment during convalescence and treatment given should be indicated by the symptoms present.

=Prognosis.=—Practically all uncomplicated cases recover. In the hemorrhagic and adynamic types, the majority succumb. One attack usually confers immunity. Sequelæ are frequent under the “old school” treatment, but are infrequent under careful, conscientious osteopathic treatment and careful nursing.

“In and of itself measles is usually not particularly serious, but the after effects are so far-reaching and so serious that students of the history of medicine rank measles third among infectious diseases for causing death. During recovery from measles the patient stands in special danger from pneumonia, and pneumonia following measles is more dangerous than uncomplicated pneumonia. There is a considerable length of time during which he is particularly susceptible to tubercular infection. This is so often insidious, and its evidences are so obscure, that by the time the disease has fully developed, one may have forgotten the mild attack of measles which really paved the way for the serious malady.”—C. A. WHITING.

Rubella

(GERMAN MEASLES; RUBEOLA NOTHA; ROTHELN; EPIDEMIC ROSEOLA)

=Definition.=—A specific acute, contagious, infectious, eruptive disease, characterized by a diffuse maculopapular eruption and swelling of the superficial lymphatic glands. It is attended by a mild fever, suffused eyes, mild cough, slight sore throat but no catarrh, a macular rose-red eruption of the throat accompanied by the swelling of the cervical lymph glands and by a rose-red eruption of irregular size and shape appearing on the first day of the disease.

Rubella, in some ways, resembles scarlet fever and also measles and was at one time considered a hybrid of the two. It is now known to be an independent disease.

=Etiology.=—The exciting cause, or the infective principle, has not yet been discovered. The disease is probably carried by fomites, is readily transmissible, attacks children especially, and usually occurs in epidemics, though sporadic cases are frequently found. The epidemics usually occur at intervals with several years intervening, during which time there are comparatively few cases. Persons of all ages are susceptible unless having acquired an immunity through an attack of the disease at some former time. Rubella does not confer immunity against any other disease, as scarlet fever or measles, nor do these diseases confer immunity against rubella. One attack of rubella confers immunity against any succeeding attacks.

The incubation period is from five to twenty-one days and is without symptoms.

The predisposing factors are the same as in measles or other infectious or contagious diseases.

=Symptoms.=—=Invasion Period.= This stage is usually of very short duration, lasting from a few hours to perhaps two days. The initial symptoms are usually mild, being a sudden chilliness, but not chills; mild fever of about 100 degrees; a slight headache; mild sore throat; swollen cervical and post auricular lymphatic glands; little or no coryza; sometimes slight pains in the back and legs; and the macular rose-red eruption in the throat which is constantly present. Often the initial symptoms are so mild that the presence of a disease is not recognized until the eruption appears, which usually occurs on the first day and rarely not until the fourth day.

=Eruption Period.=—The rash, which consists of round or oval reddish spots about the size of a split pea, mostly discrete, but sometimes confluent, and surrounded by areas of hyperemic skin, usually shows first upon the face and follows a wavelike progression over the body and limbs. The rash usually begins to fade upon the face before it has appeared upon the last affected areas, and usually remains in one region from a few hours to a half day. It extends over the entire body in from twenty-four to thirty hours. Occasionally the skin is so hyperemic in extensive tracts that the rash more resembles scarlet fever rather than measles. The crescentic arrangement of the papules usually seen in measles can not be made out in rubella. In the course of two or three days the rash disappears with very fine desquamation, leaving a faint pigmentation, which remains for a short time. Slight etching usually accompanies the rash.

Relapses are rare and complications infrequent. There are no special sequelæ, but albuminuria, bronchitis and pneumonia have been noted. Although one attack usually confers immunity, second attacks have been reported, which may have been real second attacks or the first attack may have been an error in diagnosis.

=Diagnosis.=—Early or sporadic cases may present great difficulty in diagnosis, but when an epidemic is present diagnosis becomes much easier. The =direct= diagnosis of the disease rests upon the very mild nature of the disease, its short initial onset, the character of the eruptions and the early enlargement of the glands with the absence of severe throat symptoms and coryza.

Rubella is frequently mistaken for mild cases of measles or scarlet fever. Unlike measles, it does not have the prominent catarrhal symptoms, the higher fever, the crescentic grouping of the eruption and Koplik’s sign. In measles the adenitis is not so severe as in rubella, and especially are the suboccipital and post-auricular glands involved in rubella. Scarlet fever has a very sudden onset with severe symptoms, a very sore throat, the characteristic tongue and the peculiar rash, all of which are decidedly different from rubella. In the latter stages the character of the desquamation is also a distinguishing feature.

=Treatment.=—Patient should be kept in a properly heated and well ventilated room, being careful that no draughts chill the patient, and should remain in bed for at least two days. Patient should be isolated. Treatment should be directed to the upper cervical, mid-dorsal and lower dorsal areas to keep normal the function of the internal secreting mechanism, and to normalize and keep normal the respiratory and circulatory systems. Treat carefully to upper lymphatics, working around the enlarged glands and not directly over them. Watch the excretory functions and keep them active by judicious measures. If annoying itching occurs, the hot bath followed by being wrapped in a soft warm blanket will usually relieve. Daily tepid sponging should be given and if hot bath does not relieve itching an application of olive oil or cold cream will often relieve. Diet should be reduced and regulated according to age of patient and severity of the case. Usually the above is all that is indicated, but if more severe symptoms present themselves vary your treatment according to the symptoms present.

=Prognosis.=—Recovery is the general rule. Relapses sometimes occur, and are usually much more severe than the initial attack. The symptoms are often more severe in adults than in children. Like measles, this disease seems to lower resistance to other infections, and therefore especial care should be taken to protect the patient from exposure to other diseases for some time after recovery from rubella. See that the patient is built up constitutionally after recovery by plenty of fresh air, suitable exercises and good food.

Varicella

(CHICKEN POX)

=Definition.=—Chicken pox is an acute, specific, contagious, slightly febrile, eruptive disease, usually of childhood, affecting the whole organism through the blood. It is an epidemic disease that spreads rapidly, is highly contagious but not inoculable, and confers immunity.

=History.=—Varicella was first recognized about 1553 and was distinguished from smallpox by Trousseau.

=Etiology.=—The agent that causes the disease is not known; the disease usually affects children under ten years of age, but does occasionally attack adults. It bears no relation to variola, except the very slightly similar eruption. It is transferred by direct personal contact, by the air or by a third person. It is infective from the first symptoms until all the crusts have disappeared. Although the disease usually occurs in epidemics, frequently we see sporadic cases.

As in all other contagious or infectious diseases the predisposing causative factors are those conditions which lower the resistive powers of the body, such as fatigue, improper diet, exposure to sudden temperature changes and imperfect elimination of the body wastes. The structural lesions found as predisposing factors are contractured muscles of the neck and behind the jaw, and muscular and interosseous lesions of the upper cervical, mid-dorsal and dorso-lumbar areas, also of the clavicle and upper ribs.

=Symptoms and Diagnosis.=—There are three stages to the disease: (1) Incubation, (2) Prodromal, (3) Eruptive.

1. Incubation Period.—This period lasts about fourteen days though it may vary from seven to seventeen days. During this period there is practically no symptomatology except perhaps the last two or three days, when the child shows evidence of a little excitability and irritability. Often on the day before the first noticeable symptoms the child appears even more active than usual.

2. Prodromal Stage.—Prodromal symptoms are not common and usually last but about twenty-four hours. The first noticeable symptom is the irritability of the patient, which is followed by a temperature, usually 99° to 101°, which temperature persists during the course of the disease. There are sometimes thirst, anorexia, constipation, seldom vomiting, and a furred tongue. Some cases have been observed to have the following as prodromal symptoms, but these we believe are usually due to concurrent conditions that exist at the time of the infection: delirium, convulsions, angina, conjunctivitis, dysphagia, bloody vomiting and stools, and an initial erythema, usually scarlatiniform.

3. Eruptive Stage.—The eruption comes within twenty-four hours and is often the first symptom that is noticed. It appears first as hyperemic macules and then rose colored papular spots, somewhat comparable to the typhoid roseola and not hard. These papules rapidly become raised, flattened, ovoid, pin-head to pea-sized vesicles containing a fluid at first watery and then pearly. They disappear on pressure. The vesicles mature within twenty-four hours, are very superficial, and leave a slight areola about them, which is not inflammatory as in smallpox. The eruption appears first on the chest and then on the neck, face, scalp, and then trunk and limbs in the order named. The eruption is most abundant upon the back, and over the entire body they may number anywhere from eight to many hundred and are usually scattered.

The vesicles are not umbilicated, but some may have slightly depressed centers, are discrete, and appear in successive crops which require from three to six days to complete. Pustulation and hemorrhage into the vesicle rarely occur. On the third or fourth day yellowish-brown crusts form and gradually disappear. Scars may result from scratching or infection. By the fifth day we may find all stages of the eruption because of the appearance of the successive crops. There may be an efflorescence upon the mucous membrane of the oral cavity and of the pharynx causing slight difficulty in deglutition.

The itching may be more or less intense. As scratching may cause pitting it should be guarded against. The fever which is usually slight may persist during the entire eruptive stage, but if it is high and persists as high temperature it suggests complications. Muscular tension of the cervical muscles, especially those in front, and around the angle of the inferior maxilla are usually found, and often the clavicles are bound down, and relation of ribs is disturbed. Ulceration sometimes follows scratching, and even gangrene may appear around the vesicles in debilitated children, especially those who are tubercular or congenitally syphilitic. It is apt to be fatal in these cases. Complications of tubular nephritis, which occurs within two weeks; cardiac hypertrophy; uremia; otitis media; and bronchial affections, are sometimes met with.

=Treatment.=—Isolate patient so as not to come in contact with other children. The younger children should be put to bed until the crusts have formed; older children may be allowed to be up around the room if their cases are light. Pay particular attention to the muscular lesions of the neck, lower maxilla, mid-dorsal and dorso-lumbar regions, keeping them relaxed by gentle relaxing treatments. A general systemic treatment is soothing and helps to prevent complications.

“Be very careful and very thorough in your neck adjustments. Loosen the atlas and axis and draw forward the inferior maxilla from its pressure upon the vessels and nerves back of its angle. Draw the hyoid bone forward and secure good circulation of blood throughout the entire cervical area.”—A. T. STILL.

Give treatment at the 4th and 5th dorsals to stimulate the superficial circulation and thus increase elimination through the eruption as well as the sweat glands. Remember the eruption is the expression of the body’s attempt to eliminate the toxins within.

Keep the bowels active by splanchnic and abdominal manipulations and by laxative diet. If bowels are persistently inactive use enemata. Diet should be bland and easily digested. During fever, diet should be liquid or better restricted, giving only water in abundance.

During the eruptive stage do not use tub baths. Daily tepid sponges with either plain water or boric acid solution answers both as an antiseptic wash and bathing. After the daily sponging, and as often as necessary to control itching, anoint with a 10% boric acid ointment or with carbolized vaseline. If scratching can not be controlled, the hands should be tied in muslin bags. As in smallpox the ultra-violet rays seem to irritate the eruptions and to increase the tendency to scarring, therefore the windows and lights should be screened with a dull red material.

=Prognosis.=—Invariably favorable unless complications set in, which is seldom. Recurrences are very rare.

=Prophylaxis.=—The child should be kept in quarantine for three weeks or until the skin is entirely clean.

Epidemic Parotitis

(MUMPS; EPIDEMIC PAROTIDITIS)

=Definition.=—Mumps is an acute, infectious, contagious disease, occurring in limited epidemics, and characterized by inflammation of the salivary glands, particularly the parotid, swelling slight fever and pain over the involved glands. There is special liability to orchitis or to mastitis.

=Etiology.=—Predisposing Factors: Mumps is peculiarly a disease of childhood and adolescence, not being common in infancy or after the twentieth year. It affects boys nearly twice as often as girls. Mandibular and upper cervical lesions, both of the interosseous and soft tissue types, are undoubtedly potent predisposing factors, as they obstruct and interfere with nerve and circulatory function to the glands affected. Also any condition which lowers the child’s resistance to infections makes them more susceptible to this disease than to any other, these conditions being fatigue, exposure to dampness and sudden weather changes, dietetic errors, etc. The cases are more numerous in the spring and autumn seasons. Extensive epidemics are infrequent, but do occur in reformatory institutions and children’s homes. It is much more widespread in large cities than in the country or villages.

=Exciting Cause;= The specific cause has not been demonstrated. The disease is usually transmitted by direct contact, but there are instances where it has been transmitted by a third party or by fomites. There are two views as to the mode of infection; the first being that the active principle travels along the course of the salivary ducts from the mouth to the glands, probably most often through the duct of Stenson to the parotid gland. This is the most generally accepted theory. The second is that the infection is a general one to which certain structures are more susceptible, principally the salivary glands, and the parotid in particular.

=Symptoms.=—The period of incubation is from fourteen to twenty-one days. Prodromes are usually absent, though in the more severe cases constitutional disturbances, with chilliness, vomiting and mild fever may precede the local inflammation. In the milder cases the local swelling may be the first manifestation of the disease. The temperature is usually moderate but may rise to 103 or 104 degrees in the more severe cases. The left side is more often affected than the right. The disease is characterized by a feeling of tension with soreness just below the ear. Soon a slight swelling may be observed directly under the ear and in the course of forty-eight hours it reaches its maximum size. The parotid gland becomes greatly enlarged and the adjacent tissues of the neck and face become tense and edematous. The skin becomes hard and glossy and usually white in color because of the obstruction to the circulation from pressure. The swelling is between the angle of the jaw and the mastoid process, pushing the ear upward and its lobule is pushed sharply outward. In the majority of cases the other side becomes affected in two or three days, but sometimes the spread of the disease to the other side is delayed for several days, and occasionally the other side escapes the infection. Frequently the swelling of the other side is so slight that it is only recognized by the closest scrutiny. Infrequently the submaxillary glands become affected without involving the parotid glands, but these cases are rather rare.

The patient is usually unable to open the mouth without considerable pain; acids, and rarely sweets, produce spasms of the jaw muscles; speech and even deglutition are difficult; the salivary secretions are usually increased but quite frequently they are decreased. The breath is foul and the tongue is furred. The mucous membrane of the cheek and pharynx are reddened and there may be a slight angina.

The spine shows subluxations of the upper cervical area, particularly of the atlas and axis, also upper rib lesions and upper dorsal lesions are frequently found. The lesions of the second and third dorsal, and their ribs, are most frequently found when the submaxillary gland is involved.

The symptoms persist from six to fourteen days, when the swelling disappears and the patient regains normal health. Orchitis occurs in about one-third of the cases after puberty. In infancy and childhood it is extremely rare. Usually one testicle is involved, and is characterized by weight, swelling and pain in the scrotum. The testicle may become greatly enlarged when the pain becomes intense. Atrophy may result and if both testicles are affected the loss of reproductive ability may result. In females, usually after puberty, the breasts may become enlarged and tender, pain and tenderness of one or both ovaries, hematoma of the labia, or a vulvovaginal discharge may occur. However these complications are very rare. As a rule the patient is not very sick and relapses are very uncommon. The attack confers immunity which is practically permanent.

=Diagnosis.=—Under ordinary conditions, especially during an epidemic, the diagnosis of mumps is very easy. The swelling in front of and below the ear, with the displacement of the lobule outward is quite indicative of mumps. The relative rapidity with which the swelling appears, develops and subsides is characteristic of mumps. In acute cervical adenitis the swelling is below the angle of the jaw and does not at any time correspond with the outline of the parotid gland. In Hodgkin’s disease, which is a chronic affection of the lymphatic glands, the salivary glands are not involved.

=Treatment.=—The patient should be kept away from other children, and should remain in a well lighted, well ventilated room of even temperature, and if the temperature is high or moderately high he should be kept in bed.

The correction of all interosseous lesions is indicated, especially of the upper cervical area, though the second and third dorsal should be given attention because of the influence of these dorsal nerves upon the submaxillary glands. Also correct upper rib lesions that may exist. As mumps is an infective disease the channels of elimination should be watched and stimulated. Build up the body resistance by treatment at the mid-dorsal area to affect circulation and respiration; and lower dorsal area to affect kidney and adrenal function. Watch the bowels and keep this avenue of elimination functioning freely, using enemata if necessary.

The diet should be liquid, of fruit juices, thin gruels, milk and plenty of water. Tepid sponging allays the fever and restlessness. Relaxation of the deep muscles of the neck and shoulders will do much to make the patient comfortable, also the muscles under the angle of the jaw. A very gentle relaxing of the tissues around the gland itself, by crowding them toward the gland, assists in relieving the tension by securing a better venous and lymphatic drainage.

Hot applications to the swollen glands will give a considerable relief; these may consist of hot fomentations, hot salt bag, electric heating pad, hot water bottle, etc. The mouth is kept in good condition by the use of a mild antiseptic mouth wash.

Orchitis should not occur if the boy is kept warm and in bed. If it does occur the best treatment is relaxation of the lower dorsal and upper lumbar spinal muscles, rest in bed, support and protection of the scrotum with cotton wool, cold applications, correction of any bony lesions affecting the pelvic viscera.

If mastitis occurs, rib lesions will be found and should be corrected, as they are probably the predisposing factor to this complication. Treatment would consist of correction of these lesions, if it can be done without irritating the inflamed glands. The manipulation of the surrounding tissues, with gentle crowding of the normal tissues toward the inflamed glands, without exerting any pressure on the gland itself, is helpful and comforting. Free tissues back to the axillary lymphatics.

=Prognosis.=—The outcome is usually favorable. In the rare fatal cases, meningitis is the usual cause of death. Under osteopathic care the duration of the swelling, fever and pain is usually greatly lessened.

Quarantine of twenty-four days is necessary.

Whooping Cough

(PERTUSSIS; TUSSIS CONVULSIVA)

=Definition.=—It is a specific, epidemic, infectious, contagious disease affecting the respiratory organs, characterized by a cyclic course, a severe convulsive cough, paroxysmal, with the characteristic “whoop.”

=Etiology.=—It usually occurs in children, most frequently during the fourth year, and extremely seldom after the twentieth year. It appears to be slightly more frequent among girls, and most cases occur in March and April. Pertussis is highly contagious, being carried by direct contact and by fomites. The Bordet and Gengou bacillus is the specific cause. This is found in the sputum most abundantly during the first week, the most infectious period, and becomes gradually less. One attack usually confers immunity.

The incubation period is from seven to ten days. The patient may be considered non-infectious five weeks after the first whoop.

Lesions of the cervical and upper dorsal vertebræ and of the first, second and third ribs, affecting the vagi, the phrenic, the sympathetic, the recurrent laryngeal or the vasomotor nerves predispose to the disease.

The bacteria were found by Mallory and Horner to be characteristically between the cilia of the trachea and the bronchi. They interfere, mechanically, with the movements of the cilia, preventing the normal removal of secretions.

=Symptoms.=—The disease is divided into three stages: 1. The catarrhal stage, which lasts one to two weeks; 2, the spasmodic stage, three to six weeks; 3, the declining stage, three weeks.

=The Catarrhal Stage:= Characterized by headache, photophobia, conjunctivitis, coryza and a cough which becomes drier and harder toward the end of this stage. Often the invasion is insidious and sometimes well marked with a temperature of 100° to 102°. Frequently this stage cannot be differentiated from a “hard cold,” except toward the end of the stage when the cough becomes worse instead of better, and the child will seek some support to steady itself during the coughing paroxysm. Also the eyes will water freely during the coughing spell and the child will not be able to “get his breath” between coughs, but will have a number of coughs without inhaling.

One to two weeks.

=The Spasmodic Stage:= This stage dates from the “first whoop.” The fever now usually ceases, unless there are complications. The cough becomes paroxysmal, consisting of a succession of fifteen or more short, rapid expiratory puffs with no intervening inspirations, immediately followed by a deep, loud inspiration, which is the characteristic “whoop,” and is due to the partial closure of the glottis. Each paroxysm is composed of three or more such spells, the last one often followed by the expectoration of a small plug of mucus or by vomiting. During the paroxysm the facies presents a swollen, dusky appearance, eyeballs protruding, eyes reddened, and puffy, pinkish lids. The child is well except for the paroxysm, which has an aura, tickling in the larynx, thoracic constriction, a creeping sensation, when the child attempts to brace himself, or runs in terror for support. The “whoop” is a deep, singing or whistling inspiration which is absolutely characteristic. During the cough the child’s body is bent forward and he is perfectly helpless, often passing urine and feces involuntarily. Cyanosis often occurs from the strain.

After the attack patient regains control of himself, the respiration is fast, and there is fatigue, sweating and often pain in the abdomen from the strain of coughing. During the severe cough petechiæ of the forehead, ecchymosis of the conjunctivæ, epistaxis, bleeding of the external auditory meatus or from the frenum of the tongue may occur. Ulcer of the frenum of the tongue is quite common. The parosyxms vary from four to a great many per day, averaging about twenty.

Three to six weeks, usually four weeks.

=The Terminal or Declining Stage:= This stage is longer in proportion in the mild cases. The paroxysms occur at longer intervals, are of shorter duration and of less intensity, the catarrhal symptoms are more marked, the expectoration becomes thinner, fluid, mucopurulent, and looser. The “habit cough” may follow. It is during this stage that complications are most likely to occur, therefore it is the most dangerous.

=Complications.=—Catarrhal inflammations are common in the initial stage. =Bronchopneumonia= is the most frequent and severe complication. Lobar pneumonia, exudative pleurisy, endocarditis, pericarditis, meningitis and nephritis are infrequent complications. Spasms of the glottis in nervous or scrofulous children is largely nocturnal, and may cause death from asphyxia even in the lightest cases. Hemorrhages may occur in the skin, conjunctivæ, nose, throat, ears or cerebrum. The writer knows of one case where death was sudden from a cerebral hemorrhage in an apparently mild case. Other complications are cardiac dilatation, emphysema, bronchiectasis, pneumothorax, aneurysm hernias, muscular ruptures, and visceral prolapses.

Spasmodic cough from diseased bronchial glands very closely resembles whooping cough. Barthez and Sannee give the following differentiation:

=Whooping Cough vs Enlarged Glands=

1. Contagious, epidemic. Isolated, not contagious. 2. Three periods, 2nd parosyxmal. No distinct periods. 3. Paroxysmal cough with whoop, Paroxysms without whoop, vomiting, viscid expectoration. expectoration or vomiting. 4. Respiratory sounds normal. Signs of enlarged glands sometimes present. 5. Respiration normal in interval; Asthma in some cases, febrile apyrexia if simple. movements, sweats, wasting, etc. 6. Voice natural. Voice sometimes changed. 7. Acute. Chronic.

=Treatment.=—Isolation of patient in well ventilated, sunny room where there is plenty of fresh air day and night is essential. Children exposed to infection should be disinfected and isolated for three weeks, as the disease can not be diagnosed during the catarrhal stage. If case is at all severe, patient should be put to bed.

Cases receiving early treatment are sometimes aborted. Treatment of the whole respiratory tract with correction of vertebral and rib lesions, and relaxation of the contracted muscles should be given. Treatments for the first few days should be at least twice per day. Pay especial attention to the vagi and phrenic nerves. Lesions of the first and second ribs will affect the recurrent laryngeal nerves which will aggravate the cough. The muscles of the shoulder girdle are always very tense and should be kept well relaxed, as should the subscapular muscles. Frequently after treatment the child will have a coughing spasm and raise large quantities of mucus, after which there will be no more spasms for several hours.

Children who play and live out of doors get along best. To support the diaphragm and abdominal muscles from the strain of coughing a muslin bandage tightly pinned about the trunk is very valuable, a pad being placed over the stomach under the bandage. In a very young child instruct the nurse to strongly flex thighs on abdomen during the severe coughing. Inhalations of steam from water with a very few drops of eucalyptus oil in it often relieves the first tickling sensations.

If cyanotic symptoms appear they may be relieved by raising the ribs, especially those over the heart; by relaxing the subscapular muscles; and by supporting the heart by application of cold cloth over the heart. Elevating the abdominal viscera and diaphragm is, also, of distinct benefit.

The diet should be nutritious and easily digested, restricted to liquids during the fever. The child should be warmly clad and protected from drafts. The excretory systems should be kept active by plenty of water drinking and by diet. Treatment should be continued during the terminal stage to prevent the possible complications. Irritants, as beef-tea, stimulants, dry bread, cookies and overfeeding, provoke coughing and vomiting. Food should be given at frequent intervals in concentrated form—gruels, milk with lime water, zwieback in milk, eggs, meat juice, etc. Older patients tolerate more solid food.

=Prognosis.=—With the complications, this is the most fatal of the acute infections under five years of age. Infants and little children should receive special care. Ordinary uncomplicated cases are favorable for recovery. The prognosis depends upon the age and strength of the patient, the severity and number of the paroxysms, and the presence or absence of complications. No recurrence is to be expected.

Death is due to spasm of the glottis or to extensive subdural hemorrhage, occurring chiefly in the children of the poor and in delicate infants.

Prophylaxis consists of isolation, disinfection of sputum and final fumigation of the premises. Children should be protected from exposure to infection from whooping cough. It must be realized that it is a very serious disease.

CONSTITUTIONAL DISEASES

Rheumatic Fever

(INFLAMMATORY RHEUMATISM)

=Definition.=—An acute, febrile, non-contagious disease; it is infectious, although there is some controversy as to its exact nature; characterized by a multiple arthritis and a tendency to involve the heart.

=Osteopathic Etiology= and =Pathology=.—The prevailing thought is that the disease is an infection due to a diplococcus. This micro-organism is called by others micrococcus rheumaticus and streptococcus rheumaticus.

“Rheumatic fever occurs most frequently in the temperate zone, among people who live under conditions which are unhealthful and which especially induce focal infection. It is most prevalent in the young and in the more exposed male of all ages. The excess of lymphoid tissue in the pharynx and nose of the young explains the frequency of the incidence of the focal infection and the subsequent rheumatism. The frequent association of the onset of rheumatic fever with lowering of the body temperature by exposure to cold and a wetting is explained by the increased specific virulency of the bacterial cause acquired by a low temperature and the coincident lessened resistance of the patient due to the exposure. The frequent absence of evidence of acute focal infection at the onset of the systemic disease is not an evidence that no focus exists. The latent chronic streptococcus infection of tonsillitis, pyorrhea alveolaris, sinusitis, etc., may suddenly acquire increased virulence and specific pathogenic affinity with varying degrees of focal tissue reaction. This transmutation of type and pathogenicity certainly occurs in the focus of infection. The removal of the tonsils and other sites of focal infection has been followed by complete recovery of prolonged, subacute and chronic types of arthritis and has unquestionably prevented recurrent attacks of rheumatic fever to which the susceptibility is increased by one or more attacks. The occurrence of rheumatic fever after the removal of an apparent focus may be due to secondary systemic latent foci in lymph nodes proximal to joints, in the neck or elsewhere. The streptococci of these secondary foci may take on new virulence and specific pathogenicity, from the same causes which induced like changes in the pathogenic bacteria of the primary focus.[67]”

Osteopathic lesions play an important role, both in their relationship or bearing upon the tissues of a possible site for a focal infection and upon systemic conditions that derange general bodily tone. This has been definitely confirmed in those cases of rheumatism where correction of the osteopathic lesions, with attention to hygienic measures, have resulted in recovery. This is a feature of osteopathic etiology and therapy that can hardly be over-emphasized, for an intact innervation, circulation and chemism of the organism is basic to both preventive and curative therapy. Rheumatism, like most diseases, is of local origin and if tissues and structures can be kept up to the normal, infectious or the other pathologic processes can rarely become active.

=Pathologically=, the synovial membrane is hyperemic. The muscles and ligaments are inflamed. The fluid is serous with more or less fibrin and leucocytes. In severe cases slight erosion of the cartilages is found. Acute rheumatism is rarely fatal; when death does occur it is generally due to the complications which arise.

=Symptoms.=—The onset is usually sudden; although it may be preceded by slight fever, aching in joints, chilliness, and sore throat. It generally involves the larger joints and is almost always multiple; it has a tendency to move from one joint to another. The pain in the joints usually develops rapidly with slight chilliness and a rapid rise in the temperature from 102 to 104 degrees F. The pulse is frequent, often disproportionately to the fever. There are profuse acid sweats, often causing sudamina. There is loss of appetite and thirst is present. The urine is scanty, high colored, very acid, and deposits urates upon standing. The tongue is coated and the bowels are constipated. The joints are reddened, swollen, extremely painful and tender to the touch. Every movement, jarring of the bed, or the pressure of the bed clothes is agony to the patient. The blood is greatly deranged, anemia develops rapidly and there is well marked leucocytosis. The duration varies from a few days to several weeks.

=Complications.=—The temperature may rise to 106 or 109 degrees F.; this is often associated with delirium, great prostration and a feeble, frequent pulse. Endocarditis, pericarditis, myocarditis, pneumonia, pleurisy, iritis, chorea, convulsions and meningitis may occur. Coma may develop without preceding delirium or convulsions; this is very serious and may prove fatal. Subcutaneous fibrous nodules attached to tendons and fascia sometimes develop. They vary in size and are most common in children and in young adults, occurring most frequently in the fingers, hands and wrists. They are also sometimes seen about the elbows, knees, scapulæ and spines of the vertebræ. They usually last a few days, sometimes for months, and generally develop during the decline of the fever. Cutaneous affections, such as urticaria, erythema, nodosis, purpura and sweat vesicles sometimes appear.

=Diagnosis.=—This is seldom very difficult; there are, however, several affections which resemble acute articular rheumatism. In =septic arthritis= its association with some other septic process and the tendency of the inflammation to end in suppuration with more or less destruction of the joints, will determine the diagnosis. Septic arthritis may develop during the course of pyemia, puerperal fever, or acute osteomyelitis. =Gout= is rarely mistaken for acute rheumatism. Gout occurs later in life and usually affects the greater toe; history and mode of onset will usually render the diagnosis easy. In =gonorrheal rheumatism= the history of recent infection, its obstinate character and being generally connected with a single joint from the start are diagnostic. It especially affects the knee. Heart complications are rare. =Rheumatoid arthritis= begins in the small joints; then attacks them all, leaving permanent deformity. There is no fever or sweats and the heart is not affected. Acute arthritis of infants usually attacks the hip or knee. The effusion becomes purulent.

=Prognosis.=—Recovery is the rule, but the prognosis nevertheless, must be guarded. Relapses and recurrences are common.

=Subacute Rheumatism.=—In this form both the local and general symptoms are of a milder type and are more prolonged than in the acute form. The temperature seldom rises above 101 degrees F. The inflammation of the joints is not so severe and fewer joints are involved. It may last for weeks or months, and then it may pass into the chronic form. Usually though, when the course is prolonged, the joints return to their normal state.

=Treatment.=—Place the patient in a room that is well ventilated and maintain a temperature of about 70 degrees F. Avoid draughts of air. The bed should be soft and smooth and blankets should be used. The diet should consist largely of milk, and let the patient drink freely of water. Oatmeal, barley water, egg albumen and meat juices may also be used.

Treatment should be given along the entire spine, especially if the rheumatism changes from one joint to another; otherwise treat the innervation directly to the affected joint. Correct any derangements that may be found along the spinal column and carefully relax the deep back muscles. Particular attention should be given to the bowels and kidneys. Also, treat the liver most thoroughly during each treatment. The liver is many times considerably enlarged and tender in rheumatism and a thorough treatment of it seems to favor a more rapid cure.

Carefully treat the affected tissues. If you cannot treat over the joint, then manipulate the tissues above and below the joint; and usually after a few minutes’ manipulation the swelling is somewhat relieved so that direct treatment of the joint can be given. It is best to wrap the inflamed joints in flannel if the pain is severe. Besides treatment of the innervation of the joint, hot applications will be helpful. Some claim that cold compresses are of aid to the inflamed joints.

=Complications= are to be treated separately. Besides the ordinary fever treatment for the fever, the cold bath is very effectual. After =convalescence= has been established, the patient should be carefully protected for several days from cold and damp. For any stiffness that may persist, manipulation and hot baths will be quite sufficient.

H. M. Still[68] writes “If the fever is not over 103 degrees I do not try to reduce it.... After treatment in a majority of cases, the fever is reduced within twenty-four hours unless complications have set in. These are usually of the heart, so no matter how mild the attack, keep this in mind. If the action is irregular and weak, stimulate it two or three times a day. If it is rapid and high fever, go to the vasomotor centers and reduce fever, then inhibit the heart action and keep the excretions active. If the joints are affected I always move them gently no matter how great the inflammation. As yet I have never had a case of rheumatism in which cardiac lesions or ankylosed joints were a sequela.”

If the tonsils are evidently badly diseased and osteopathic treatment does not clear them up do not hesitate to have them removed.

Chronic Articular Rheumatism

=Osteopathic Etiology= and =Pathology=.—This disorder should be studied in connection with arthritis deformans owing to similar sources of infection and various common factors. It usually develops slowly and follows an acute or subacute attack and is common among the poor, especially those exposed to damp and cold. Heredity, advanced years, although the disease may appear at any age, and constant exposure to cold and wet are predisposing causes. Chronic lesions to the spinal column corresponding to the affected area are found. Too much stress from an osteopathic point of view cannot be placed upon the importance of lesions to both the digestive organs and to the joints especially involved. Then, in addition, particular attention should be given osteopathically or surgically, or both, to sites of focal infection.

=Pathologically=, the capsules and ligaments of the joints are thickened also, the sheaths of the tendons around the joint, so that in long standing cases the movements are impaired. In severe cases the cartilages may be eroded. Atrophy of the muscles covering the joints sometimes occurs, especially when there is neuritis; thus producing marked deformity. This muscular atrophy is particularly marked when the shoulders or hips are involved. The atrophy is caused partly from disease; in cases where the joint is distended with effusion, the wasting may be due to pressure upon the muscles or blood-vessels.

=Symptoms.=—Several joints are usually affected; but it may be limited to one joint, particularly the knee, hip or shoulder. Pain and stiffness are the most common symptoms. The pain is increased upon motion, while the stiffness is often lessened by using the limbs. The joints are slightly swollen, but seldom reddened and are usually tender upon pressure. All the symptoms are aggravated on the approach of stormy weather. There is fever but the general health is not greatly impaired. There may be distortion of the joints and ankylosis may occur. Arterial degeneration and chronic endocarditis may develop as complications.

=Prognosis.=—This should be guarded so far as a complete cure is concerned; although most cases are greatly benefited.

=Treatment.=—The treatment of chronic articular rheumatism is largely correcting lesions of the spinal column, which affect the diseased tissues as well as the digestive organs, local treatment of the joints, and removal of focal infections. A certain percentage will respond to osteopathic measures alone, though surgery has a definite place in others. The joints and limbs should be thoroughly treated so as to restore a better circulation and relieve the inflamed tissues. Wrapping the affected joint with cold cloths and then covering the cloths with flannel and oiled silk is often helpful. Due attention should be given the general health, such as nourishing food, free elimination and outdoor exercise.

Probably in some cases where the primary infection has been eliminated secondary foci are present and a general treatment will arouse sufficient reaction to cope with the condition.

Arthritis Deformans

(RHEUMATOID ARTHRITIS)

=Definition.=—A chronic affection of the joints, characterized by progressive changes in the cartilages and synovial membranes, and by new osseous formations restricting the motion of the joint and causing deformity.

=Osteopathic Etiology= and =Pathology=.—It is due to lesions of the spinal column affecting the spinal and sympathetic nerves as well as disturbing the circulation to the cord. Lesions of the spinal column and ribs are found corresponding to the innervation of the diseased joints. The osteopath has been able in every case to demonstrate clinically important osteopathic lesions. In addition the symmetry of joint involvement, muscular atrophy, sweating, etc., point to nervous lesions. Falli found upon autopsy that the anterior horns had undergone atrophic changes. Nervous lesions are probably of a predisposing character while some infection is the exciting cause. A thorough search of the entire body should be made for foci of infection. Malnutrition, traumatism, exposure to cold, and pelvic diseases are important causative factors. In all cases lesions will be found disturbing the organs of digestion. Females are more frequently affected than males. The disease is frequently seen in women suffering from ovarian and uterine troubles, especially at the menopause. Hereditary influence may be a factor, also auto-intoxication. The disease is most common between the ages of twenty and thirty. Mental worry, anxiety, grief and injury are also predisposing factors.

=Pathologically=, in one class of cases, the cells of the cartilages and of the synovial membrane proliferate. The cartilages undergo atrophy, or may become soft, degenerate, and are absorbed, leaving the ends of the bone bare. The bones naturally atrophy and become smooth. In another class the edges of the cartilages where the pressure is slight, thicken and form outgrowths which ossify and enlarge the heads of the bones, forming osteophytes which greatly impair the motion; true ankylosis is rare. The synovial membrane becomes thickened, also the capsule and ligaments, thus greatly restricting the movements of the joints. The muscles around the joints atrophy. In the spinal cord atrophic and degenerative lesions are found. In Still’s disease there is an enlarged spleen and marked changes in the joint.

=Symptoms.=—Pain and swelling of the joints and fever and enlargement of the lymphatics near the joint are characteristic. The spleen is congested and later on there is gastro-intestinal disturbance. =Multiple arthritis deformans=, also known as Heberden’s nodosites, is characterized by nodules developing at the sides of the distal phalanges. It occurs most frequently in women between the ages of thirty and forty, and gradually increases with age. At first the joints are swollen, tender and painful and then apparently become better. These attacks may appear at different intervals while the nodules at the sides of the joints gradually increase in size. The larger joints are rarely affected. The progressive form may be either acute or chronic. The acute form at the onset may resemble articular rheumatism. It is more common in women between the ages of twenty and thirty, but may occur in children. Pregnancy, recent delivery, lactation, the menopause, and rapid child bearing are common antecedents. There is swelling and tenderness of the joints and slight fever. Several joints are usually involved. The =chronic form= is most common. Symmetrical joints are usually involved. The affected joints slowly enlarge and are painful and red. Usually the hand is first affected; then the wrists, knees, toes, jaws and spine; in extreme cases every joint is affected. The vertebræ, =spondylitis deformans=, may be attacked. The cervical spine may be alone involved, in which case the head cannot be moved up or down, although rotation usually remains. In some instances the entire spinal column is affected and may become perfectly rigid. In some cases there is hardly if any pain, while in others the pain is agonizing and is almost constant. The joints gradually become deformed, stiff and creak when moved; later they become completely ankylosed. This deformity is due partly to the thickening of the capsule, to the presence of osteophytes, and to the contraction of the muscles. These contractures flex the leg upon the thigh and the thigh upon the abdomen. Muscular atrophy increases the deformity. Numbness, tingling, pigmentation and glossiness of the skin, and local sweating may be present and are of trophic origin.

The =monoarthritic form= affects old persons chiefly, and women more frequently than men. It affects particularly the hips, the knees, the shoulders, and the vertebral articulations. This is often caused by an injury. The muscles waste away and the knee-jerk is usually increased upon the affected side.

=Diagnosis.=—Care has to be taken in not confusing it with rheumatic fever or gout. Radiographs should be made.

=Prognosis.=—If treated early there is a fair chance for curing the disease. Advanced cases usually improve under treatment. The osteopathic treatment should be persistent for at least several months.

=Treatment.=—Osteopathic treatment, if long continued in rheumatoid arthritis, has given satisfactory results, although owing to the extent of the deformity, a cure in advanced cases cannot be expected. An important cause of the disease is probably a trophic or vasomotor disturbance to the tissues of the joint. Osteopathically, there is never any difficulty to locate disorders in the spinal column corresponding to the innervation of the involved joints. The fact that many of the joints are affected symmetrically indicates that the lesion is a spinal one involving the nerve center. During the incipiency marked improvement is the rule.

A thorough attempt should be made in every case to discover the source of infection and remove it, though this does not preclude the essential osteopathic adjustment.

The treatment consists of attempts to correct the spinal derangement and careful manipulation of the diseased joints to restore vitality and motion in them. The preceding simple, but effective treatment, must be continued two or three times per week for months or even years in order to be of particular value. Coupled with the specific treatment should be a careful consideration of the general health. The emunctories should be kept active and the food of the patient be nutritious. The osteopath should require the patient to take considerable physical exercise at regular intervals, warm baths and plenty of fresh air. Massage and friction of the diseased joints will be of aid in absorbing effusions and in restoring the tone of atrophied muscles. Hot compresses are a help. The baths at various hot springs are sometimes of benefit, and change of climate is invigorating.

O. J. Snyder[69] has this to say: “I must be very emphatic, however, to here advise exceptional caution in your manipulative procedure. * * * You cannot attempt to move the joint, for, if you do you will cause excruciating pain and do irreparable harm in that you will cause breaking down of the cartilage and cancellous bone tissue. Your first endeavor should be to reduce inflammation and to mitigate pain. * * * Osteopathically much comfort and reduction of pain can be accomplished by inhibition in the proper spinal areas. A little friction and very gentle extension or traction of the joint can be attempted as soon as the condition of the joint, by the foregoing treatment, has been made possible. At no time should rotation or sidebending, or any other manipulation that produces irritation of tissue be attempted.”

In stout adult women a villous arthritis of the knees may develop owing to faulty posture and poor elimination. These conditions are often amenable to treatment.

Muscular Rheumatism

=Definition.=—A painful disease of the voluntary muscles and of their fascia and the periosteum. It is regarded by many as a neuralgia of these muscles. The pain is greatly increased by motion and pressure.

=Osteopathic Etiology= and =Pathology=.—Osteopathic experience with cases of muscular rheumatism shows that the nerves, as they pass to and from the spinal muscles, are affected. The lesion is caused, principally, by subdislocations of the vertebræ, ribs or pelvis, according to the region involved. A gouty or rheumatic diathesis, heredity, exposure to cold and wet and previous attacks are predisposing causes. Men are more often affected, owing to their more frequent exposure. The disease affects persons of all ages. It occurs in acute, subacute and chronic forms.

In cases of frequent recurrence focal infections and intestinal toxins are often important factors. Vertebral and muscular lesions, septic foci, intestinal stasis, exposure to cold and drafts are principal causes.

=Pathologically=, there is swelling of the muscles of the nature of myositis. In chronic cases there is often atrophy of the muscles, due to interference of the trophic nerves.

=Symptoms.=—These are generally local and are never accompanied by marked constitutional disturbances. There is seldom fever, and the pulse is only slightly increased in frequency. Pain is the chief symptom; it is increased by motion or pressure. Tenderness is generally present and there may be swelling of the tissues. Rheumatic nodules have been found. The duration is usually three or four days, though it may last longer with frequent recurrences.

=Lumbago= is a painful affection of the muscles of the lumbar area and their tendinous attachments. The onset is generally sudden. In severe cases it sometimes renders the patient helpless. In =torticollis,= or stiff neck, the muscles of the side and back of the neck are affected. It is usually confined to one side of the head. Any attempt to turn the head causes a sharp pain. In =pleurodynia= the intercostal muscles, and sometimes the pectorals and serratus magnus, are affected. It usually affects but one side, more frequently the left; it is the most painful form of the disease, since the pain is aggravated by breathing. The respiratory movements are consequently restricted on the affected side. The absence of fever and physical signs will distinguish it from pleurisy. In =intercostal neuralgia= the pain follows the distribution of the nerves and there are tender spots along their courses. =Cephalodynia= affects the muscles of the scalp. =Scapulodynia=, =omodynia= and =dorsodynia= affect the muscles of the shoulder and upper dorsal. =Abdominal rheumatism= affects the muscles of the abdomen.

=Prognosis.=—The prognosis is good. Favorable results are the general rule under careful treatment.

=Treatment.=—Muscular rheumatism is usually an easy affection to cure. The cause of the disturbance is generally found in the region involved, and is due, in the majority of cases, to some dislocated tissue, usually osseous, that irritates the nerves to the muscles. In addition to correcting the lesions, removal of septic foci, free elimination, lessened diet, stretching of the muscles, application of heat, ironing and rest are beneficial.

In =lumbago= there is invariably found a slight lateral deviation of some vertebræ along the lower dorsal or lumbar region. Occasionally deformity of the vertebræ, asymmetry, or arthritis are factors. The radiograph may be a diagnostic aid. Occasionally, a floating rib or an innominate becomes displaced. Stretching the loins by placing the patient upon his side or back and flexing the thighs on the abdomen is very beneficial. Maintain the tension for three or four minutes. Hot fomentations and rest are helpful.

=Torticollis=, or stiff neck, is generally due to a lesion of the middle cervical vertebræ. The lesion is usually between the third, fourth and fifth vertebræ, occasionally as low as the second dorsal. A reduction of the subdislocation will often relieve the attack. Stretching of the muscle and application of heat will also be of aid. In some cases of torticollis (chronic) there is a curvature of the cervical spine, and occasionally the muscles are more or less fibrinous. Surgical measures may be instituted. In such instances a cure cannot always be accomplished. The tonsils, nose and teeth should be examined for sources of infection.

A few cases of acute torticollis are caused by some of the deep muscular fibres becoming caught around a process of a vertebra. Severe contraction of the muscles by cold or extensive rotary flexions of the neck, may result in torticollis. Occasionally a case is found due to injury at birth. The cervical vertebræ should be carefully examined. The spinal accessory is the nerve generally involved. Lesions to the spinal accessory occur commonly at the third, fourth and fifth cervicals, or the atlas and axis. The muscles involved in torticollis are the sternocleidomastoid, trapezius, splenius and scaleni. Operations should not be performed until a thorough course of treatment has failed to relieve.

=Pleurodynia= is often a neuralgia of the pleural nerves. It is usually caused by subdislocations of the ribs exactly over the regions involved. Occasionally, a lesion may exist to the corresponding vertebra, but rarely. The rib is at times completely dislocated. Applications of heat and rest of the part are of aid. Strapping of the region will give considerable relief.

In =cephalodynia= the muscles of the scalp are generally involved by lesions in the upper five cervical vertebræ. In =scapulodynia=, =omodynia= and =dorsodynia= the muscles of the shoulder are usually affected by displacements of the second and third ribs, although the lesion may be found slightly lower in the ribs, or in the corresponding vertebræ. The lower cervical vertebræ may also be at fault. In recurring and chronic cases carefully examine for infectious sources. Dislocations of the shoulder occur frequently; and muscular fibres may slip out of the bicipital groove (rarely). In a few cases muscles may become contracted about the coracoid process, or the acromial end of the clavicle may become dislocated.

=Abdominal rheumatism= is generally caused by lesions in the lower six dorsal vertebræ, which involve the innervation to the muscles. In some cases lesions of the lower ribs are found, and in a few instances a lesion may be discerned in the upper lumbar vertebræ.

=Myalgia= of the =upper extremity= is caused by lesions of the cervical or upper dorsal vertebræ or upper ribs. Occasionally some trouble may be found in the shoulder or elbow joints. In the =lower extremity= lesions may be found in the lower dorsal or lumbar vertebræ, or there may be derangements of the pelvic bones. Occasionally disorder is found at the hip and knee joints.

Gout

=Definition.=—A nutritional disorder in which there is an abnormal accumulation of uric acid and other purin bodies in the blood and tissues; and arthritis, deformity of joints and visceral derangements being the characteristic features.

=Osteopathic Etiology= and =Pathology=.—Hereditary influences are the predisposing factors of about one-half of the cases of gout. Men are more frequently affected than women. It rarely develops before the age of thirty. Overeating, sedentary habits, drinking alcohol, especially fermented drinks, and lead poisoning are predisposing factors. Emotional disturbances may excite an attack. Gout is not confined to the rich by any means; but there is also a “poor-man’s gout,” due to poor food, unhygienic surroundings, and to an excessive use of malt liquors. Uric acid seems to be a causative factor, but whether there is an increased formation or a diminished excretion of the uric acid has not yet been fully decided. The ultimate result is the same in either case; there is an accumulation of uric acid and other purin bodies in the blood, which is responsible for some of the effects of the disease.

Osteopathic experience with cases of gout shows that lesions affecting the nervous system are important factors that control uric acid accumulation or excretion. The nerve centers controlling the affected portions of the body are almost invariably involved, as well as the nerve control to the digestive and excretory organs. A neurosis of these nerve centers probably occurs and is thus a predisposing cause of gout. Considerable can be accomplished in the treatment of gout by careful examination of the spinal column, in the region corresponding to the innervation of the affected area, for vertebral lesions, and correcting them. Usually, slight dislocations of the bones of the foot are found, when that region of the body is involved. The most common subdislocations of the foot are involvements of the astragalus with its articulations and the metatarsals.

=Pathological= changes are those of the joints principally. There is deposit of uric acid in cartilages, synovial membranes and ligaments. The joint of the great toe is most frequently affected, then the fingers, ankles, knees, hands and wrists. The exudates become hard and are then called tophi. In severe cases the cartilages of the ears, nose, eyelids and larynx are involved. Finally the joints become stiff, deformed and ankylosed, and sometimes there is ulceration.

The kidneys are usually the seat of chronic interstitial inflammation with a deposit of urates. The heart and blood-vessels almost always present changes. Arterial sclerosis is quite a constant lesion; the left ventricle of the heart is hypertrophied. Urate of sodium has been found deposited upon the valves. There is an excess of uric acid in the blood. Chronic bronchitis, emphysema and asthma are among the changes in the respiratory system.

=Symptoms.=—In =acute gout=, before the attack, the patient may complain of dyspeptic disorder, restlessness and twinges of pain in the small joints. He is apt to have irritability of temper and depression of spirits. The first symptom of the attack is great pain in the metatarso-phalangeal joint of the great toe, which usually comes on suddenly at night with swelling, heat and discoloration of the joint. The temperature rises to 102 and 103 degrees F. Towards morning the symptoms generally abate to recur again the next night. This lasts for several days, the symptoms gradually abating. The urine is scanty, high colored, of high specific gravity and acid in reaction. It deposits urates and often contains a small quantity of albumin. There may be gastro-intestinal symptoms—pain, vomiting, diarrhea, faintness and a rapid, feeble pulse. Pharyngitis is an occasional symptom. The cardiac symptoms are pain, shortness of breath and irregular action of the heart. These attacks may appear with varying severity. In some cases there may be severe cerebral symptoms.

=Chronic gout= follows repeated attacks of the acute form. The articular symptoms continue for a longer time and the condition extends to other joints. The chalk deposits slowly increase until the joint becomes swollen and deformed. The morbid changes already described are characteristic. The urine is increased in quantity, is of low specific gravity and may contain albumin and hyalin and granular casts. Involvement of the heart and blood-vessels gradually occurs.

=Irregular gout= or =lithemia= is seen in persons who have been gouty or have a hereditary predisposition. It includes a set of symptoms that are not alone distinctive, but when taken with this gouty tendency, all forms of irregular gout can be recognized. There are various gastro-intestinal disturbances; cutaneous eruptions; heart and blood vessel changes; pains in the various muscles and joints; nervous symptoms, as headache, neuralgia and neuritis; urinary symptoms, and pulmonary and ocular disorders.

=Diagnosis.=—Only the irregular form of gout should be difficult to diagnose. Differentiation is to be made from arthritis deformans and acute and chronic rheumatism.

=Treatment.=—The hygienic treatment of gout is very essential. The patient should live a quiet life, avoiding mental and physical strains. Plenty of fresh air, exercise and regular hours should be insisted upon. Alcoholic drinking should be avoided and the food taken in moderate quantities. Keeping the skin active by the use of cold baths, if the patient is strong, and warm baths should he be weak, is a helpful measure. The dress of the patient should be warm and suitable for the climate.

A regulated diet of nutritious food, taken at regular hours, is necessary. Each patient should receive separate instructions as to diet. The food given may be small amounts of beef, mutton and chicken, with fresh vegetables; with the exception of strawberries, tomatoes and bananas, fruits may be used; fats, milk and stale bread are also suitable. The patient should avoid tea, coffee, pastry, hot breads, highly seasoned dishes, and such articles. The free use of water is beneficial.

The =osteopathic treatment= consists of careful correction of the lesions of the spinal column in order to free the nerve force to the affected region. The spinal treatment in gout is the most essential treatment and is effective. A most thorough examination should be made of the tissues about the diseased area; in the foot the astragalus oftentimes is subdislocated from its articulations, causing obstructions to the local vessels and nerves. The metatarsal bones should receive due attention, as occasionally one of the bones corresponding to the affected tissues is dislocated, usually downward. All the joints between the diseased tissues and the spinal nerve centers should be carefully manipulated so as to favor a better circulation. During a severe attack of gout, besides careful treatment of the blood supply to the diseased region, wrapping the joint in cotton wool and applying warmth and moisture to the joint may be helpful.

The kidneys, liver and bowels are to be kept active. A light treatment to the kidneys and liver each time is very helpful in aiding the organs to eliminate the waste material, and especially in controlling any inflammation that may exist in the kidney. The essential treatment in gout is to relieve the disorder of the nerve centers, to increase the activities of the emunctories and to regulate the hygiene of the patient.

Diabetes Mellitus

=Definition.=—A nutritional disorder in which there is an abnormal amount of sugar in the blood, characterized by an excessive urinary discharge, in which grape sugar is constantly present, and by a progressive loss of flesh and strength.

=Osteopathic Etiology= and =Pathology=.—Almost invariably there will be found a posterior dorso-lumbar curvature wherein the spinal column tissues are much contractured. This condition probably involves the sympathetics (vasomotor and trophic) to the pancreas, liver and intestines. Important lesions may also be found as high as the occiput. Tenderness and congestion over the abdomen, especially the liver, are frequent. It affects men more frequently than women and is a disease of adult life, ranging between the ages of thirty and sixty, though cases have occurred in the very young. It is more serious in the young, the very young seldom recovering. Hereditary influences are believed to be a predisposing cause. It affects the better classes principally and especially those of a neurotic temperament. The Hebrew race is specially predisposed. The colored race is seldom affected.

Obesity, certain chronic diseases (malaria, gout, syphilis), occupations taxing the mind, and pregnancy are predisposing influences. Injury or disease of the spinal cord or brain frequently cause diabetes, especially any irritation of Bernard’s diabetic center in the medulla. Derangements of the endocrine system are important. Injuries to the spine, chiefly in the dorso-lumbar and sacral regions, and to the abdomen, and diseases of the pancreas or liver are, as has been stated, oftentimes causes. Lesions to the spine may disturb the glycogenic function of the liver, the glycolytic ferment of the pancreas, or produce an alimentary glycosuria. Extirpation of the pancreas is immediately followed by diabetes, but if a fragment of the pancreas is left it is not always followed by diabetes. The normal amount of sugar in the blood is 1-1000 while in diabetes the amount of sugar is 3 to 4-1000 up to 7 or 8-1000. The healthy kidney will not excrete sugar when it is at the normal ratio. Concerning the presence of acetone-bodies von Noorden[70] says: “The excretion of acetone-bodies may serve, like glycosuria, as a measure of the intensity of the diabetic disease ... it will be at once understood that in no other disease do the acetone-bodies occupy so important a position as in diabetes.” Irritation of the centers of the vasomotor nerves to the liver or direct stimulus to the liver cells is followed by glycosuria. Interference with the pneumogastric nerve also influences diabetes.

=Pathologically=, the liver is enlarged, firmer and darker in color than normal. Often there is fatty degeneration of the organ. The pancreas is diseased in about one-half of the cases of diabetes, especially the islands of Langerhans. The lesions found are granular atrophy, occlusion of the pancreatic duct, atrophy from pressure, fat necrosis, and sometimes it is small, soft and anemic. The kidney changes are those of catarrhal nephritis. In the fatty degeneration hyalin changes take place. The heart is hypertrophied in a few cases. Arterial sclerosis is frequently met with. In the lungs bronchitis, pneumonia and tuberculosis occasionally develop. In the stomach and intestines catarrh is common. The blood presents an increase of sugar. In the nervous system are found many lesions, especially congestion, extravasation and sclerosis of the brain; disturbances of the posterior part of the cord, and congestion and sclerosis of the sympathetic ganglia. The bony lesions, however, (almost invariably a posterior lower dorsal and lumbar) must involve the sympathetics, via the splanchnics, to the extent of profound metabolic disturbance, for in no other way can the results of osteopathy be explained. The importance of specific treatment at this point cannot be over estimated.

=Symptoms.=—The =onset= is gradual; thirst and frequent micturition being the first symptoms noticed. After an injury or a sudden, severe nervous shock, diabetes may set in abruptly. As the disease progresses there will be marked thirst, polyuria, an abnormal appetite, wasting and debility. The tongue is dry, red and coated. There is constipation and the skin is dry and harsh. Temperature is often subnormal; pulse frequent with increased tension.

In some cases the =urine= is not increased in quantity; usually however, the amount varies from four to five pints to several quarts in twenty-four hours. It is pale in color, of high specific gravity and acid reaction. Sugar is present in variable quantities from one or two per cent to five or ten per cent. Sugar in the urine must be constant in order that the affection is a true diabetic one. Albumin is often present; urea is increased and uric acid may be slightly increased. Acetone-bodies are often found and usually indicate a more serious condition.

=Diabetic Coma= is the most important and gravest complication. There is either a sudden or gradual loss of consciousness. This may occur after some form of exhausting exercise. There may be previous headache or a feeling of intoxication. It may be preceded by nausea, vomiting, colicky pains or some local affections, such as pharyngitis or pulmonary complications. Peripheral neuritis, neuralgia, numbness, are possible symptoms. Impairment of hearing, cataracts, strabismus, diabetic retinitis and atrophy of the optic nerve may occur. The sexual function is lost early in the disease. Eczema, with burning and itching of the labia and vicinity, (and in men a balanitis), furuncles, boils and carbuncles are common. Gangrene and edema are not uncommon. Acute pneumonia, bronchitis and tuberculosis are possible complications. =Progressive loss of flesh= is a serious indication.

=Diagnosis.=—The diagnosis is easy, as there is no other disease with which it can be confounded. Careful urinalysis should always be made. Examination for acetone, diacetic acid and oxybutyric acid is valuable.

=Prognosis.=—Many cases have been cured by osteopathic measures while nearly all treated have been benefited. If the patient is put upon a diet free from carbohydrates, in mild cases the sugar will disappear, while in severe cases it will still be present. Mild cases usually yield readily to treatment. In cases over forty years of age the outlook is quite favorable, but in cases under forty, and especially the young, the prognosis is not so favorable. In cases under puberty the results are apt to be fatal. Stout persons bear diabetes better than lean. All cases are liable to complications, which render the prognosis more serious. It is a disease of long =duration=, although death has occurred in a few weeks.

=Treatment.=—In nearly all cases of diabetes mellitus examined there have been found posterior conditions of the lower dorsal and lumbar regions. The posterior curve has always been fairly well marked and generally is a symmetrical curve. By that is meant a spinal curve that is not irregular and the relation of the various vertebræ, one to the other, is not seriously deranged. Correction of this condition of the spinal column has almost invariably given satisfactory results and in the majority of cases the condition of the patient has improved remarkably, and many entirely cured. To get the best results the patient should be laid on his side on the operating table and the knees drawn up so that the thighs are flexed upon the abdomen. The osteopath standing in front of the patient throws his weight against the flexed thighs and reaching over upon the spinal column springs the entire weakened portion of the spine toward its normal position, stretching the spinal column to separate each vertebra from its neighbor so that the deranged nerves, as they pass through the intervertebral foramina, may be released. Meeker[71] reports a case with a marked kyphosis which was treated two years before enough motion could be had between the vertebræ to produce any results, but after that they were favorable. Direct treatment to the abdominal organs to correct liver congestion and stimulate the pancreas and increase activity of the intestines is essential.

The nerves affected by the posterior pathological curve of the spine, mentioned above, and by separate lesions that may exist within the pathological curvature, are probably the vasomotor nerves to the portal system, pancreas and the intestines. The vasomotor nerves to the portal system branches are given off principally from the fifth to the ninth dorsal vertebræ, although fibres may escape from the cord as low as the first lumbar vertebra. The nerves to the intestines are given off principally from about the ninth dorsal to the lower lumbar vertebræ. Possibly there are nerve fibres direct to the hepatic cell protoplasm.

How lesions in the dorso-lumbar region cause diabetes mellitus is an important question and is hard to answer. An unnatural acceleration of the portal circulation may cause an increased quantity of sugar to pass to the liver, resulting in part of the sugar not being changed into glycogen and thus passing into the circulation; or a paralysis of the vasomotor nerves to the liver causes congestion and slowness of the blood stream. Thus a disturbed circulation of the liver may cause accumulation of sugar in the liver, so that the blood ferment has time to act upon the glycogen and transform it into sugar; or there may be a saccharinity of chyle or blood in the portal vein, due to an impeded conversion of sugar in the intestines into lactic acid; or there may be an accelerated absorption of sugar due to an abnormal state of the intestines; or the nervous control to the pancreatic functions may be disturbed. Hence, one or many pathological changes may occur and influence a case of diabetes, due to a disordered dorso-lumbar region.

The center for the hepatic vasomotor nerves, “diabetic center,” is in the floor of the fourth ventricle at the level of the origin of the vagi nerves. A lesion of the “diabetic center” or an obstruction to the pneumogastric anywhere along its course may cause diabetic symptoms; hence, there may be lesions of the cervical region that would affect reflexly the diabetic center, or lesions of the pneumogastric may occur, particularly at the atlas or axis, and cause diabetic symptoms, or, at least, these may influence the course of a case of diabetes mellitus. Or the upper cervical lesions may disturb the pituitary gland which is of importance in carbohydrate metabolism.

There are nerves from the superior and inferior cervical ganglia of the sympathetic that have considerable influence upon the liver. These nerves do not pass down the cord to the splanchnics, but pass in the sympathetic to the celiac and hepatic plexuses and then to the liver. Stimulation of these nerves causes the hepatic vessels at the periphery of the liver lobules to become contracted. Possibly in a very few cases, a stagnation of blood in other vascular regions of the body may cause the blood ferment to accumulate in the blood to such an extent that diabetic symptoms occur.

=Dietetic treatment= is essential, but is not so necessary as some medical authors would have us believe. A regulated diet should be insisted upon in all cases, but one should not go to extremes in dieting. A complete elimination of the carbohydrates is no longer considered the best treatment, as it withdraws too important an element from the diet, producing weakness without any corresponding return for good. A patient’s appetite is often inordinate and it will be necessary to regulate the quantity and character of foods. Proctor[72] mentions a case which recovered when carbohydrates were restored, as the patient was too starved to build up. Under osteopathic treatment much more liberty can be allowed in selection of foods. Von Noorden[73] reported a number of cases in which excretions of sugar continued upon the strict anti-diabetic diet, but which were sugar free when they received a large amount of oatmeal along with some vegetable proteid or white of egg and butter, other carbohydrates being excluded. It is suggested by the editor of the Series that the oatmeal may be used alternately with diabetic diet, and relieve the monotony greatly. It can also be used as a test of the patient’s digestive and sugar destroying powers. The following food may be included in the dietary:

Animal Foods.—Meats of every variety, except livers; game, poultry, fish and eggs.

Vegetables.—Cabbage, cauliflower, celery, lettuce, green string beans, the green ends of asparagus, tomatoes, spinach, mushrooms, cucumbers, watercress, young onions, or any other green vegetable.

Bread and Cakes.—Made of gluten flour, bran flour or almond flour; griddle cakes, biscuits, porridges, etc., may be made of these flours.

Beverages.—Skimmed milk, buttermilk, coffee and tea without sugar, and carbonated water.

Relishes.—Pickles, cream cheese and nuts of all kinds except chestnuts.

Fruits.—Oranges, lemons, cranberries, cherries, strawberries, all in moderate quantities.

Other foods may be used, but each case requires a thorough study in order to determine what is best to do.

Various foods should be tested out and controlled by urinalysis. The point is to increase metabolism so that the body can store up considerable carbohydrates without the appearance of sugar in the urine.

In severe cases Allen’s fasting treatment to be followed by a low diet should be instituted. However, it should be remembered that the correction of dorsal and upper cervical lesions is invaluable.

Mental excitement and worry should be avoided as much as possible. Frequent bathing and regulated exercise will be of considerable value. The diabetic patient should have a well ventilated room and plenty of rest and sleep; flannels are to be worn next to the skin the year around.

Various symptoms and =complications= are liable to arise, which the competent osteopath is prepared to meet by following general rules.

Keep the bowels open. And frequently examine for acetone and diacetic acid. If there are any symptoms of =coma= fast the patient, and neutralize the acid intoxication with bicarbonate of soda until the urine is alkaline.

Diabetes Insipidus

(POLYURIA).

=Definition.=—A constitutional disorder in which there is a continued excessive secretion of urine, free from albumin and sugar. There is constant thirst.

=Osteopathic Etiology= and =Pathology=.—This disease is more frequent in males than in females. It occurs most commonly between the ages of twenty and thirty. It is due to chronic disturbances of the nerves. The lesions usually found upon osteopathic examination are lateral derangements of the vertebræ in the renal splanchnic region, (ninth to twelfth dorsal inclusive) or a slight kyphosis in the same locality. Such lesions probably affect the central nervous system in the region of the sympathetic nerves to the kidneys, by a paralysis of the muscular coat of the renal vessels. The disease may be associated with other conditions, as injuries and diseases of the nervous system elsewhere; exposure to cold; prolonged debility and fatigue; cerebral diseases, as meningitis, paralysis of the sixth nerve, tumor of the brain, and blows on the head; injuries of the cervical region; sunstroke; cerebrospinal fever; malaria; syphilis; pregnancy; hysteria; hereditary influences, and drinking too freely of cold water. There are many diseases and conditions which may be associated with diabetes insipidus; and which act as irritants, directly or reflexly, upon the center in the medulla oblongata (which is just above the diabetic center), or upon the sympathetic ganglia in the abdominal region. Thus, there is a vasomotor neurosis, due either to central or reflex lesions.

Second in importance to lesions of the renal splanchnics are lesions of the upper cervical region. Irritations in the cervical region may act upon the center in the medulla or the lesions may affect some of the sympathetic fibres as they pass from the brain to the renal sympathetics. The pituitary gland may be disturbed. Probably axis and atlas lesions are factors.

Lesions of the nerve centers and of the sympathetic ganglia have been found upon post-mortem examination, but they are not constant. Nervous lesions have been found in the region of the base of the brain. The kidneys are sometimes congested and enlarged. The tubules may be dilated.

=Symptoms.=—Great thirst and an enormous secretion of urine of a pale, watery and slightly acid nature are the characteristic symptoms. The skin is usually dry and harsh, the bowels are constipated, and the appetite may be voracious. The health on the whole is quite perfect, although if the affection is not arrested, considerable loss of flesh and strength may result. There is a tendency for the disease to become chronic.

The nervous lesion causing polyuria may be the outcome of a debilitated condition of long standing or the symptoms may occur suddenly. Preceding the large flow of urine such symptoms as nervousness, irritability, headache, sleeplessness, failure of memory, and inability to concentrate the mind commonly occur. Other symptoms may be present in addition, as debility, diarrhea, epigastric and lumbar pains, and impaired sexual function.

=Diagnosis=.—The diagnosis is not difficult. Thirst, polyuria and the absence of albumin and sugar characterize the disease. In =diabetes mellitus=, finding of grape sugar in the urine would at once exclude polyuria. In =paroxysmal diuresis=, the increased amount of urine is not permanent. In =interstitial nephritis=, there is albumin, casts, etc.

=Prognosis.=—Depends upon the cause. The disease yields to treatment much quicker than diabetes mellitus and is without doubt much less serious. The disease, in a large majority of cases, can be cured. Under osteopathic treatment most cases will yield good results or be cured in from a few weeks to six months.

=Treatment.=—The treatment of the disease causing diabetes insipidus is of first consequence, but frequently such a disease is undiscoverable. There is often a tendency toward neurasthenia; consequently, habits, environment, etc., should be carefully attended to. Examine for sexual, rectal and other reflex irritations.

Correcting lesions of the renal splanchnics is important; in fact, in a fair number of cases treatment of this locality will entirely cure the disease. A very effective treatment, in addition to the ordinary methods of treatment, is to have the patient lie flat upon the back while the osteopath reaches around the patient on either side, placing the fingers firmly upon the transverse processes of the lower dorsal vertebræ and springing the spine forward by lifting upward on the patient, enough even to raise the patient from the surface he is lying on. This treatment is especially effective in lessening the increased amount of urine. Attention should be given to the false ribs on either side and to the condition of the spine below and above the renal splanchnics. The cervical vertebræ should be examined carefully for disorders, and if any are found they should be removed at once, if possible.

=Hygienic treatment= is of as much importance as in diabetes mellitus. The clothing should be warm, warm baths taken, and general friction and care of the skin utilized so that the circulation may be somewhat diverted from the kidneys. Restriction of water is not always necessary, except in cases where excessive drinking has become a habit, as the thirst is caused by the diuresis and not the diuresis by the large ingestion of water. Regulate the diet and see that the bowels are acting normally.

Rickets

RACHITIS

=Definition.=—A constitutional disease of children, characterized by impaired nutrition and changes in the growing bones, causing deformities. The physical growth is disturbed and the bone deformity is due to an over growth of cartilages and delayed calcification.

=Etiology= and =Pathology=.—Rickets may occur in the new-born, but it rarely begins before the child is six months old. It is a disease of the first and second years of life. Heredity is probably not a factor but certain races, especially the Negro and Italian, have a tendency to be rickety. The disease is much more common in the large cities than in rural districts; also it is more common in Europe than America. The disease is most frequently met with among the ill-fed and badly housed poor of the large cities, though it is not rare to find it among the well-to-do. Lesions to the digestive organs predispose. Breast-fed children seldom have the disorder. Improper or insufficient food (a diet too low in fats and proteins) bad air, want of sunlight, prolonged lactation, exposure to cold and dampness are predisposing factors.

=Pathologically=, the most marked changes are seen in the long bones and the ribs. The cartilage between the epiphysis and shaft is thickened and is soft and irregular in outline. Underneath the periosteum the tissue is spongy. Microscopic examination shows an increase of proliferation of the cartilage cells with scanty calcification. The bones are soft and there is a diminution in the calcareous salts. In a word ossification is delayed and the bones are not perfectly developed. In the cranium the frontal and parietal eminences are prominent, while the top of the head and the occiput are flattened, giving the head a square appearance. The fontanelles remain open until the second or third year of life. The ribs become affected very early. At the point where the ribs join the costal cartilages, bulging occurs, forming the so-called “rachitic rosary.” The normal shape of the chest walls is markedly changed. Just outside the junction of the ribs with the cartilages, the ribs fall in, producing a shallow depression, while the sternum and cartilages are pushed forward. The bones of the leg may be distorted. The normal curves of the spine are occasionally disturbed. The liver and spleen are often increased in size.

=Symptoms.=—The =onset= is slow. In many cases digestive disturbances, with their usual effect upon the nutrition, precede the appearance of the characteristic lesions. The child is irritable and restless, and there is usually slight fever and profuse sweats. The child is often languid, pale and feeble. The lymph gland are enlarged. The tissues are soft and flabby and skeletal changes begin to make their appearance. Among the first are changes in the ribs and head, already described under pathology. Changes sometimes occur in the bones of the face, particularly the maxillæ. Dentition is delayed. The spinal column is frequently curved antero-posteriorly or laterally. The long bones are curved and their extremities become thickened. The pelvis is distorted and twisted and in women this may seriously complicate labor. “Chicken breast” and “bow legs” are common, as well as muscular weakness, and the child walks late. The abdomen is large and prominent, due to flatulency and to the enlargement of the liver and spleen.

=Diagnosis= and =Prognosis=.—By observing the symptoms, diagnosis is not difficult. Prognosis should be guarded, owing to danger from other diseases; still, on the whole, prognosis is fairly favorable.

=Treatment.=—Rickets being a disease of malnutrition due to weakness of the digestive organs, improper food, or to influences of disease, the treatment must be principally following hygienic rules and good dieting. The child under six months, if not nursed satisfactorily by the mother, should be given diluted cow’s milk. Salts may be obtained from barley gruel and whole wheat. Diluting the milk with barley water is highly recommended. Fresh meat juice and cream are invaluable. If curds are found in the stools, the digestion is not perfect and is usually due to overfeeding the child. The child should be out doors as much as possible. Fresh air is a necessity. The worst air outside is better than the best air of the house as far as purity is concerned. Protect the child carefully with warm clothes, and when sitting or walking the child should be supported. Baths will be found beneficial.

In the older child, beef juice, light meats, yolks of eggs, green vegetables and fruits may be given. Lessen the amount of carbohydrates. Careful osteopathic treatment of the various affected tissues of the child will aid a great deal in correcting deformities. Attention to the lesions found will also aid in increasing the nutrition to the involved tissues as well as correcting digestive disturbances. This, also, is of distinct benefit in improving the assimilation of lime salts. Possibly treatment of the “nutritional” centers, (fourth dorsal and fourth lumbar) would be effectual. Carefully guard against complications of the nervous and respiratory systems. After ossification the deformities may be corrected by the orthopedic surgeon, though in the young child considerable can be accomplished by repeated attempts at straightening by bending and molding the long bones. All those conditions which predispose to rickets should receive attention; chief among these is the care of the nutrition of the mother during pregnancy. Nursing should be regulated, and possibly future pregnancies discouraged.

Obesity

=Definition.=—Obesity is essentially a nutritional disease and is an inconvenient accumulation of adipose tissue in the body, sometimes impairing the bodily function. With some individuals obesity is a normal condition. In others it means impaired health, especially poor elimination.

=Etiology= and =Pathology=.—Heredity, overeating, sedentary habits, hot, moist climates are predisposing causes. Exciting causes are especially the eating of fat-making food, excessive use of alcohol and insufficient exercise. Obesity may follow the menopause or an infectious disease. Osteopathic lesions are frequently found in the upper and middle dorsal region. These probably are causes of a disturbed metabolism. An excessive diet of starches and sugars will indirectly act as a fat producer. In young people the possibility of hypopituitarism should be considered. Lesions of the upper cervical, in these cases, are frequent.

=Pathologically=, adipose tissue is deposited throughout most of the tissues. Usually the abdomen is encumbered with a large amount. Passive congestion probably favors the deposition of fat, for in cases of pendulous abdomen, simply drawing the abdomen in and up and the patient, through voluntary effort, keeping it up, will frequently cause absorption of the fat in a few days or weeks. The fat is distributed underneath the skin, throughout the viscera and about the heart. The tissues may suffer from fatty infiltration, especially the heart, arteries and veins; also the liver, kidneys and stomach. There is an increase of specific gravity of the blood. Edema occurs from passive congestion, due to weak heart.

=Symptoms.=—The round, fat face, double chin, hanging cheeks, large waist, the thick, prominent, sometimes pendulous abdomen, and the bulky extremities form characteristic features. At first obesity presents no harmful symptoms. Usually the first troublesome symptom is increased frequency in the breathing, due to a weak and overworked heart, and to the fact that the motion of the lungs is hampered by the heavy chest walls, and also by the interference with the descent of the diaphragm on account of the enlarged liver. Dyspnea, passive congestion, anemia, poor digestion, uterine disorders, and mental inactivity are common. There is cardiac hypertrophy; later the heart is overlaid with fat. The pulse is usually frequent, but may be irregular and slow.

=Treatment.=—Obesity being a nutritional disease it seems but reasonable that alterations of the anatomical structures will produce a change in the proper balance of nutrition. Along osteopathic lines, derangement of tissues affecting the nerves to the digestive and lymphatic systems will produce obesity. In the majority of cases examined have been found disturbances at the sixth and seventh cervical, fourth and fifth dorsal and from the tenth dorsal to the second lumbar. Lesions at these points could readily interfere with the thoracic duct and the receptaculum chyli, as well as with the processes of digestion, assimilation and elimination. It is claimed that stimulation of the splanchnic nerves causes dilatation of the receptaculum chyli. Direct treatment to the abdomen and to areas of fatty deposit will aid very materially in absorption.

The =dietetic treatment= is essential, the principle being to furnish less food to oxidize. Restrict fats, sugar and starches and limit the amount of water. Alcohol should be prohibited. Another important point in the treatment is exercise, which must be carried out in a systematic way. Rules can be laid down only in individual cases and should be governed by the osteopath in charge. The principal effect of general mechanical treatment is to promote oxidation. Massage and baths are beneficial. The patient can do much for the abdomen by keeping it in and up, and walking erect.

Scurvy

=Definition.=—A constitutional disease, characterized by extreme general weakness, anemia, spongy condition of the gums, disintegration of tissue and a tendency to hemorrhages.

=Etiology= and =Pathology=.—In comparison with former times scurvy is now a rare disease. Lack of fresh vegetables or their substitutes, over-crowding, dampness, bad hygienic surroundings, and prolonged fatigue under depressing influences are the predisposing causes. Arctic explorers have shown that fresh bear’s meat and bear’s blood are a preventative.

There are extravasations of blood into the skin, muscles and mucous membranes. Hemorrhages may occur in the internal organs, especially the kidneys and liver, and in the serous membranes. The gums are swollen and spongy. The teeth decay. The spleen is soft and enlarged. Parenchymatous degeneration of the heart, liver and kidney is frequent. Ulcers occasionally occur in the skin and bowels. The blood is thin but there is no leucocytosis.

=Symptoms.=—The disease is usually slow in development. The general manifestations of anemia with debility are among the first symptoms. The gums are swollen, soft and spongy, they bleed easily and in severe cases there is ulceration. Petechial spots appear upon the body. Subcutaneous ecchymosis occurs, first on the legs, then on the arms and trunk. The eyes and face are swollen; the patient appears as if he had been bruised. Hemorrhages from the mucous membrane frequently occur. The temperature is usually normal. The pulse is small, feeble and frequent; sometimes irregular and slow. The appetite is impaired and constipation is present at first, as a rule, although this may be followed by scorbutic dysentery.

=Diagnosis.=—The disease is readily recognized when several cases occur together. It is somewhat hard to recognize in isolated cases, and to be able to distinguish it from certain forms of =purpura=. The etiology, the gingival changes and the hemorrhages usually decide the diagnosis.

=Prognosis.=—Scurvy being a disease due to malnutrition, it is necessary to remedy such condition by attention and correction of the faults producing it. Hygienic surroundings and a wholesome diet will do more in curing the disease than anything else. An outdoor life and good ventilation with anti-scorbutics, as fruit juices, especially lemons and oranges, fresh vegetables, (onions, potatoes, etc.) and fresh milk, are necessary.

It is held by Garrod that scurvy is caused by an absence of potash, for a deficiency of potassium salts is found in the blood. The anti-scorbutics named above contain potash. A careful treatment along the splanchnics would help to improve the appetite and digestion. Treat the gums and ulcers according to surgical indications.

Infantile Scurvy

SCORBUTUS

This form usually follows the prolonged use of condensed milk, sterilized milk or proprietary foods for children. The disease occurs during the first two years of life, but it is most common from the seventh to the fourteenth month.

It develops rapidly. Joint pains, anemia and irritability are early symptoms. The child is pale, has a muddy complexion and may show signs of rickets. The gums may be soft and spongy. There is tenderness and pain on motion. There may be hemorrhages under the skin. The lower limbs are drawn up and motionless. The bones become thickened from sub-periosteal hemorrhage, and there is apt to be softening between the shaft and epiphysis. The back and legs become very weak. The lesions are usually symmetrical. The temperature is variable.

=Treatment.=—The treatment of scurvy in children consists in, first, omitting all proprietary foods and substituting fresh cow’s milk, meat juice, strained gruel and a moderate quantity of fresh orange or lemon juice. Under this treatment, cases that have not progressed too far will promptly recover.

Northrop says: “It is a significant fact that the country which furnishes most of the literature on scorbutus in children is the same which is posted from end to end with advertisements of proprietary foods.”

Purpura

=Purpura= is a symptom rather than a disease. It is characterized by extravasation of blood into the skin and bleeding from the mucous membranes, irrespective of direct injury. These extravasations do not disappear upon pressure and vary greatly in size. They may be small, (petechiæ) or large (ecchymoses). They are bright red and gradually become darker. Clotting of normal blood requires three to five minutes, purpuric blood, ten to fifteen minutes.

It is a symptom of =infectious diseases=, as in pyemia, septicemia, mycotic endocarditis, typhus fever, smallpox, etc. =Toxic=, as produced by venomous snake bites and by =certain medicines=, as copaiba, mercury, quinine, iodides and others in overdoses. =Cachectic purpura= may be observed in cancer, tuberculosis, Bright’s disease, scurvy, etc. In =senile purpura= the spots are generally confined to the extremities. In certain =nervous diseases=, bleeding spots appear on the skin, as in tabes, myelitis and severe neuralgia. =Mechanical purpura= is seen in venous stasis; this is rare.

=Purpura simplex= affects only the skin. It occasionally follows attacks of infectious diseases. The spots are found upon the legs, more rarely upon the trunk and arms. Articular pains may or may not occur. Fever is seldom present. Loss of appetite, diarrhea and slight anemia may be manifested. The duration is one to four weeks.

=Purpura rheumatica= is a much more serious affection, characterized by multiple arthritis of rheumatism. Seldom seen under five years, and lasts about two weeks. The joints are swollen and painful and the temperature rises to 101 and 103 degrees F. The amount of edema varies greatly and occasionally it is quite excessive. In addition to the purpura there is usually urticaria. =Henoch’s purpura= is seen most frequently in children and is characterized by severe gastro-intestinal disturbances as pain, vomiting and diarrhea, hemorrhages from the mucous membranes and acute enlargement of the spleen, in addition to the symptoms already named under the foregoing form. There is some danger of hemorrhage into the kidneys.

The disorder of =purpura hemorrhagica= is usually associated with rheumatism, malaria and other infectious diseases. This is the most serious form of purpura. It is most commonly met with in delicate girls during early life; but it may occur at any age and in the most robust of either sex. Fever, weakness, vomiting and diarrhea are the early symptoms. After a couple of days of languor and weakness, purpuric spots appear upon the skin; and bleeding occurs from the mucous membranes and may cause profound anemia. Hemorrhages into the internal organs occur. Favorable cases recover in ten days or two weeks. Others may end fatally. Care should be taken not to confuse the disease with scurvy.

=Treatment.=—In the treatment of purpura the disease from which it develops should receive due attention. Occasionally there is danger of overlooking the primary disease and treating some symptoms of the disease, although it is true that sometimes an important symptom is nearly all that is manifested. Outside of treating the conditions under which purpura arises, general measures should be considered, as a nutritious diet, rest, fresh air, and general treatment of the patient so that normal circulation and strength may be restored. The treatment of the purpura locally should be such as to restore normal circulation of the part by removing any obstruction or irritation of the blood supply that may be found, by careful manipulation of the tissues. As stated the management of the disease under which it arises should be embraced in the treatment. In cases of hemorrhage from various organs see article under hemorrhage. Some cutaneous hemorrhages are best relieved by local manipulation.

Hemophilia

(BLEEDER’S DISEASE).

Hemophilia is a hereditary condition manifested by a tendency to uncontrollable hemorrhage with or without injury. The usual mode of transmission is through the female line, rather than by the male. The mother does not necessarily have to be a bleeder, but the daughter of one, in order to transmit the disease to her offspring. Atavism through the female alone is almost the rule. Not all the children of a bleeding family are afflicted; the male children are more subject to the condition than the female children. The tendency usually appears within the first two years of life. The families of bleeders are often large and are commonly healthy looking and have fine soft skins. It is claimed blondes are most likely to be afflicted.

=Pathologically=, an unusual thinness of the blood-vessels with a fatty degeneration of the intima has been noted. In many cases there is deficient coagulability of the blood and a lessened number of leucocytes. Hemorrhages have been found in and about the capsules of the joints, and in a few instances inflammation of the synovial surfaces. The arteries are situated superficially, but that does not explain anything. The real nature of the disease has not been determined. Emotional excitement is a factor, consequently vasomotor disturbances may be important. The frailty of the blood-vessels and the peculiar constitution of the blood preventing thrombotic formation are the two facts of importance that have been recognized.

=Symptoms.=—Hemorrhages occur from the most trifling injuries. Blowing the nose may cause severe epistaxis; the extraction of a tooth is a frequent cause of hemorrhage; the prick of a pin, a slight cut, a scratch, or a blow may result in profuse bleeding. The bleeding may occur spontaneously from the mucous membrane of the mouth, nose, lungs, intestines, etc.; or it may occur directly from the fingers, toes, back of the hands, and lobes of the ears. The hemorrhages may last several hours. As soon as checked the patients rapidly resume natural appearance providing the bleeding is not often repeated, thereby causing a permanent anemia. There may be attacks of arthritis with fever, as with acquired hemorrhagic tendency, closely resembling rheumatism.

=Diagnosis.=—Hereditary tendency and persistent hemorrhage from slight injury.

=Prognosis.=—In a few cases the tendency to bleed gradually diminishes until at last it entirely ceases. The younger the subject the more is it liable to prove fatal. In the majority of cases death occurs between the first and eighth years. After maturity the chances of an attack are much lessened.

=Treatment.=—Members of the bleeder’s family, particularly the boys, should be guarded against traumatic influences, and operations of all kinds should be avoided. Outdoor exercise, fresh air, bathing and plain nourishing food, in fact, the hygienic surroundings, and all food should be carefully watched so that the threatened subject may become strengthened and hardened. Marriage should be discouraged, especially with the daughters, as it is through them the tendency is propagated. Possibly, coupled with the foregoing prophylactic treatment, a stimulation of the glands of elaboration of the blood will be of service to build up the physical constitution of the patient. During attacks absolute rest and the required symptomatic treatment should be given. For resultant anemia the usual treatment is to be employed.

In severe cases direct transfusion should be considered.

FOOTNOTES:

[67] Billings, Focal Infection.

[68] Massachusetts Journal of Osteopathy, Jan. 1906.

[69] Journal of the American Osteopathic Association, November 1919.

[70] Diabetes, p. 90.

[71] Journal of the American Osteopathic Association, Oct., 1904.

[72] Journal of the American Osteopathic Association, Oct., 1904.

[73] Practical Medical Series, 1905.

DISEASES OF THE DIGESTIVE SYSTEM

Diseases of the Mouth

Stomatitis

=Definition.=—Inflammation of the mouth.

=Etiology.=—Chemical, mechanical, thermal or parasitic irritations; secondary to disorders of the gastro-intestinal tract, scarlet fever, measles and variola; cachexia, due to such diseases as cancer and phthisis; dentition; artificial feeding; hot weather and poor hygienic surroundings are the most common causes. Lesions to the innervation and vascular supply of the mouth are found, principally, in the upper cervical vertebræ, occasionally in the upper dorsal vertebræ and corresponding ribs.

=Varieties.=—Catarrhal, aphthous, ulcerative, parasitic, gangrenous.

Catarrhal Stomatitis

=Etiology.=—Most common in infants and children. Hot and irritating substances; secondary to diseases of the stomach, to measles, scarlet fever and variola; difficult dentition; alcoholic or tobacco excesses.

Hazzard says in all cases of stomatitis “there is generally lesion to the bony or other tissues in the cervical region (sometimes also in the upper dorsal), which deranges vasomotor control of the tissues of the mouth and tongue, obstructs venous return, weakens the tissues and lays them liable to the effects of some particular irritant, local or in the system, but there is, generally, lesion affecting the gastro-intestinal tract which is the real underlying cause of the trouble.”

=Symptoms.=—Diffuse, red swelling of the mucous membrane, heat and pain in the mouth, increased flow of saliva, fetor of breath, restlessness and languor. In children there is a disinclination to nurse and a slight fever may be present. The sense of taste is blunted and there is commonly a bitter taste in the mouth. The neck glands are enlarged.

=Treatment.=—Removal of the exciting cause is the most important point in the treatment. Good hygienic conditions must be enforced. The mouth should be kept clean. Wipe it out at frequent intervals with a soft piece of absorbent cotton and cold water. A borax solution is frequently used. Attention should be paid to the diet and secretions. Light but thorough treatment of the upper cervical region is to be given, with careful attention to the tissues about and below the angles of the jaw, so that the innervation, blood and lymphatic supply may be equalized.

Aphthous Stomatitis

(CANKER)

This disease is characterized by little, painful, grayish-white spots upon the superficial layer of the mucous membrane. They consist, primarily, of an exudate of fibrin and wandered-out leucocytes. It is principally a disease of childhood. Among the common causes are difficult dentition, disorders of digestion and uncleanliness of the mouth, such as neglect to cleanse the child’s mouth after nursing. It may be a symptom of measles or of local diseases.

Probably the innervation to the region of the little grayish-white spots or canker is obstructed at some points by a disordered tissue. The lesion may be mechanical or it may arise from a disordered digestion. If one is able to locate such a lesion and remove it, a cure will be hastened. The seat of the infection is the internal surface of the cheeks, gums, roof of the mouth, tongue and lips.

=Symptoms.=—There is redness of the mucous membrane of the mouth, followed by the appearance of the vesicles with a red areola. Pain in the mouth and an increased flow of saliva occur. Mastication, deglutition, and even speaking, may be painful. This condition is followed by sleeplessness, feverishness, diarrhea and fetor of the breath.

=Treatment.=—Removal of the cause, as in other varieties of stomatitis, is paramount. Give attention to the food. The milk should be sterilized. The disordered digestion should be corrected at once. All secretions must receive prompt attention. The child should be nursed at regular intervals. Locally, keep the parts clean and carefully treat the innervation.

Ulcerative Stomatitis

This is a disease of children, although it may not be limited to them, as it occasionally occurs in epidemics and affects all ages. It occurs chiefly in the families of the poor and in places where the hygienic surroundings are bad, the food poor and personal cleanliness lacking. It may begin as an aphthous stomatitis. Often sufferers from severe, acute diseases are subjects of attack.

=Symptoms.=—The gums of the lower jaw are chiefly affected. They are at first congested, swollen and bleed readily. Pain is increased by mastication and deglutition, the mouth is hot, the breath fetid, the saliva dribbles and the digestion and bowels are disordered. The ulcers may appear at various points upon the cheeks, lips and tongue; the deposit is yellowish-gray.

In the more severe cases the gums are spongy and the teeth are loosened. In proportion to the constitutional disturbances, fever and enlargement and tenderness of the submaxillary glands occur. Even necrosis of the bone may follow.

Parasitic Stomatitis

(THRUSH)

The exciting cause is a fungus known as Laccharomyces albicans. It is claimed that a catarrhal stomatitis is the soil upon which the fungus develops. Parasitic stomatitis is chiefly a disease of nursing children and is promoted by unhygienic conditions. It is seldom seen after ten years of age, occurring in adults only in the last stages of consumption, cancer, and severe chronic diseases.

=Symptoms.=—Upon inspection there are seen numerous milk-white elevations. These appear first about the angles of the mouth, soon extending to all parts of the mouth, and in a few cases, even to the pharynx and to the esophagus. When removed bleeding points are left. The general symptoms of stomatitis are present—pain upon mastication and swallowing; fetid, hot breath; increased saliva; increased temperature; restlessness; swollen lips and disordered digestion occur.

=Diagnosis.=—The microscope will remove all doubt as to the nature of the affection. In aphthous stomatitis the ulcers are preceded by the formation of vesicles.

=Prognosis.=—Is favorable in the majority of cases.

=Treatment.=—Hygienic measures, absolute cleanliness, correction of the disorders of the gastro-intestinal tract and local treatment as in other forms of stomatitis, is the required treatment. A boric acid solution will be found beneficial.

SPINAL LESIONS AND THEIR RELATION TO DISEASES OF THE GASTRO-INTESTINAL TRACT

Acute Gastritis, Chronic Gastritis, Gastric Neurosis, Gastric and Duodenal Ulcer.

By CHARLES J. MUTTART

The instant relief that Osteopathy can give in acute indigestion is one of its outstanding achievements. It impresses the patient and his friends with a deep conviction of the superiority of osteopathic therapy. The results in these cases are not, in any sense, a matter of chance. They follow logically from the osteopathic viewpoint, teaching, reasoning, and practice. In dealing with the manifestations of disease, such as heredity, onset, course, duration, subjective and objective symptoms, etc., and in the effort to differentiate cause from effect, and to reconstruct a mental picture of the sequence of cause, effect and sequelæ, the osteopath has the advantage of binocular vision in that he recognizes two distinct pathologies cooperating to produce the symptom complex, syndrome or disease which he is called upon to treat. One pathology is to be found in one or more of the vertebral and rib articulations and the immediately adjacent or corresponding segments of the spinal cord. The other is in some one or more of the organs or tissues connected with the pathological segment or segments of the cord.

=The function of the joint is MOTION.=—Unrestricted normal range of motion is essential for the normal function of all parts of the articulation as well as for the nutrition of the nerve mechanisms immediately adjacent. When a spinal articulation ceases to perform its function all of its parts are more or less impaired, muscles atrophy, ligaments lose their tone, and circulation to and from the spinal segment is interfered with because action is a large factor in promoting the flow of blood and lymph and maintaining normal stimulus.

As a result of this spinal pathology, internal organs and tissues, supplied by nerves arising in the segment that is in lesion, will be variously disturbed in their function.

Dr. Carl P. McConnell says: “My observation of lesioned animals so far as the digestive organs are concerned is that the lesion affects the reflexes of and through spinal and sympathetic ganglia so that the vasomotors are involved with a consequent hyperemia of the submucous coat. This means involvement of the endothelial layer of the blood-vessels, diapedesis, derangement of the secretory function and disturbance of the motor mechanism, all of which lead to functional upset and disturbance.”

The dominant part played by the osteopathic lesion as a causative factor in acute and chronic diseases of the alimentary canal becomes increasingly evident as clinical observation and laboratory research permit a more thorough appreciation of the anatomy and physiology of the parts involved. The abnormal stands out more clearly from the normal. Finally, the task of restoring normality is becoming a clear-cut problem to which the correction of the osteopathic lesions furnishes an almost complete solution.

The normal alimentary canal transports food, macerating it, mixing it, and treating it with various chemicals and enzymes on the way, breaking it down physically and chemically, and absorbing from it such end-products as are needed to maintain metabolism. The abnormal alimentary tract may be at fault in any of these functions. This delinquency is generally traceable to a mechanical origin. Correction of the mechanical deviation is followed by restoration of normal function except in cases where extensive tissue changes have occurred.

=Thorough mastication= is essential to good digestion. Any dental defects or deficiencies should be corrected. =The temporo-mandibular articulation= should be examined, and full free motion restored if lacking. The muscles on the affected side are softer than on the sound side. Tonic spasm rigidly closes the mouth. It may be due to tetanus, caries of the lower teeth, cutting of the lower wisdom tooth, or other irritations to the sensory branches of the inferior maxillary nerve. There is enough space back of the wisdom teeth to pass a catheter to administer food.

=The tongue= assists in mastication and deglutition and is the seat of most of the nerves of taste. The hypoglossal nerve, which supplies it, leaves the skull through the anterior condyloid foramen and may be impinged there or lower in its course. =Lesions of the occiput and upper cervical vertebræ= and obstructions to the lymphatic drainage at the angle of the jaw may cause pressure on this nerve and cause disturbances in the movements of the tongue, atrophy, swelling, etc. Swelling may be due also to endocrine disturbance, constitutional diseases, anemia, glossitis, local irritants, injuries, etc. Pressure may be made on the hypoglossal nerve behind the angle of the jaw.

=The special sense of taste= plays an important role in normal digestion. The lingual nerve supplies the anterior two-thirds of the tongue with taste. The sense of taste may be lost, impaired, perverted or otherwise abnormal.

The sense of smell plays an important part in our appreciation of flavors, and when it is impaired by colds, adenoids, or other affections of the nose or pharynx, the sense of taste is measurably impaired. =Normalization of nose and pharynx= restores the sense of taste in such cases. Impairment or loss may also be due to lesions of the chorda tympani, or glosso-pharyngeal nerves. Lesions of the mandible, hyoid, occiput or upper cervical nerves, parotid disease or obstructed lymphatic drainage behind the angle of the jaw may cause pressure directly or indirectly on the glosso-pharyngeal and chorda tympani nerves. Perversion of taste occur in pregnancy, hysteria, epilepsy and insanity.

=Foul taste=, fetororis in the mouth is frequent in pneumonia, typhoid fever, peritonitis, septicemia and other severe fevers; also after ingestion of pungent foods or strong drugs; in constitutional diseases; as a result of inattention to oral hygiene, excessive smoking, mouth breathing at night, furred tongue, etc. It clears up on removing the cause.

=Furred tongue= occurs in gastritis, fevers, and a variety of other conditions. The fur is composed of broken down epithelium which would normally be removed by friction with solid food. When none is taken, the fur accumulates. When blood or hematin becomes mixed with the broken down epithelium, the fur is brown. Ordinarily it is white. =A clean red tongue= is frequently found in hyperacidity. It is probably due to vasodilatation due to hyperactivity of the autonomics or inhibition of sympathetics. The sympathetic supply is from the =superior cervical ganglion=. It may be affected by lesions of the occiput, atlas, axis and third cervical vertebra, of the hyoid, by anterior cervical muscular contractures, by obstruction to venous and lymphatic drainage and blood supply. Correction of the lesions named and normalization of the other structures involved will usually restore the tongue to normal condition.

=The salivary glands= have a two-fold innervation. The thin, full, watery, salty secretion is produced by activity of the cranial autonomic fibers; the sparse, viscous secretion containing the organic elements, ptyalin, etc., is produced by the sympathetics. =The sympathetic nerve supply= is from the middle and superior cervical ganglia and can be disturbed by lesions affecting them as mentioned above. The secretion of ptyalin may be disturbed by any lesion from the fifth dorsal up.

It must not be forgotten that a =posterior occiput= draws the superior cervical ganglion back against the axis and third cervical with just as much pressure as is exerted by an anterior atlas or third cervical. This pressure or stretching tends to inhibit it, preventing vaso-constriction and permitting vasodilatation of the internal carotid artery and its branches and congestion of the parts supplied, mid-brain, cerebrum, etc.

If, for any reason, the venous drainage from the lateral sinus into the internal jugular vein, or the ebb and flow of the cerebrospinal fluid between brain and cord, is reduced or hampered, an extra burden is thrown on the cerebral veins and sinuses, and the intra-cranial pressure is raised at each heart-beat, ultimately producing pressure on the meninges and causing violent headache over the fifth and tenth cranial nerves which supply the meninges with sensation. These nerves are intimately connected with the digestive system. Any increase of intra-cranial pressure causes increased irritability and hyperactivity of the cranial nerves, many of which are concerned with various functions of the digestive system. Moreover, the nuclei of these nerves lie on the floor of the fourth ventricle which is supplied mainly by the vertebral arteries and the basilar artery. Lesions of the cervical vertebræ affecting the plexus on the vertebral artery or filaments to it from the upper parts of the cervical gangliated sympathetic cord, may impair the blood flow through the vertebral arteries and cause similar increased irritability of the nerve cells in the medulla, mid-brain and cerebellum. Such disturbance is reflected in awkward movement, hyperesthesia, and symptoms due to increased irritability of the autonomic nerves such as slow pulse and respiration, watering of the mouth, hypersecretion and hypermotility of the gastro-intestinal tract, rapid digestion and poor assimilation, vasodilatation, impoverished blood, and so through a vicious cycle back to still greater impairment of nutrition to the nerve cells within the cranium. Until the lesions are corrected, the condition becomes progressively worse till exhaustion occurs.

Ordinary medical hygiene can do little or nothing. The palliative remedies employed simply mask the symptoms, or actually accelerate the destructive process. Lesions that irritate the cervical sympathetics would cause vaso-constriction and give rise to opposite symptoms, namely, cerebral ischemia, decreased flow of saliva, atony of stomach, lack of digestive juices, sluggish intestinal peristalsis, rapid pulse and respiration, etc. Correction of the lesions and restoration of normal blood supply and drainage to the brain and removal of any lesions tending to inhibit the sympathetics from the fifth dorsal up, will usually in a short time restore the activity of the salivary glands to normal. The otic and sphenopalatine ganglia can be disturbed by abnormal conditions within the pharynx. These must be corrected when found.

=Deglutition=, or swallowing, is a very rapid, highly complex movement. It takes not more than a second for the food to cross the pharynx. The soft palate and larynx are raised to close off the air-way, making the food-way practically continuous for the second needed to complete the transfer of the food across the air-way. The tongue is pressed against the roof of the mouth and the mylohyoid contracts vigorously and shoots the bolus of food across the pharynx. Bolting the food leads to serious digestive disturbances, not the least of which is the loss of the normal reflex which prevents swallowing unprepared food. When lost, this reflex can be restored by thorough mastication for three or four months.

The voluntary part of swallowing is performed by the motor portion of the fifth cranial and the hypoglossus. The involuntary part involves afferent impulses over the superior laryngeal and efferent impulses over the inferior laryngeal. The levator palati which raises the soft palate is probably supplied by the spinal accessory nerve through the pharyngeal plexus. This nerve can be affected by lesions of the occiput, atlas, mandible and hyoid, and by any obstruction to lymphatic drainage which increases pressure behind the angle of the jaw. In paralysis of the levator palati, as =after diphtheria= or other peripheral neuritis, fluids regurgitate through the nose during the act of swallowing. The raising and closing of the larynx is accomplished by the superior and recurrent laryngeal nerves by way of the pharyngeal plexus. Pain in swallowing is generally due to some inflammation or infection of the tonsil or pharynx. This does not occur when everything is normal from the fifth dorsal up.

The second and third stages of swallowing occur in the =esophagus=. The esophagus receives esophageal branches from the vagus, carrying autonomic fibers which contract its longitudinal muscles and dilate its arteries. It also receives sympathetic impulses from the plexus on the arteries which supply it. These sympathetic impulses convey vaso-constriction and constriction of the circular muscles of the esophagus. Any lesion from seventh cervical to ninth dorsal might affect the esophagus; probably fifth dorsal is the most nearly specific, as the heartburn which results from regurgitation into the esophagus is usually localized there.

Lesions of the upper six dorsal vertebræ interfere with digestion and nutrition in another vital way by reducing the activity of the lungs and consequent =intake of oxygen= into the system. If there is not sufficient oxygen to oxidize the proteins to amino-acids there will be harmful products left for the tissues to neutralize. Lesions of the third, fourth and fifth cervical affecting the =phrenic= may have a like effect. Sub-oxidation must be noted when present and treated by removing lesions affecting respiration, by deep breathing exercises, and by diet rich in the needed mineral salts, and properly balanced. An improperly balanced diet changes the structure of the tissues and amounts in effect to an osteopathic lesion which causes disturbed function. It must be searched for, found if present, accounted for, corrected and kept corrected to obtain maximum therapeutic results.

The stomach, intestines and rectum are intimately related with the other abdominal viscera.

It will therefore be readily seen that any disturbance of the liver, gall-bladder, pancreas, spleen, duodenum, pleura or peritoneum will disturb the function of the stomach, and that any disturbance of any organ will disturb the function of the intestine. In fact, clinically, it would seem that the majority of cases can be accounted for by the lesions found, the stomach or intestinal disturbances which are regarded as reflex from some other organ, being in reality caused by the same lesion as disturbed the organ which first manifested disturbance.

Going more deeply into the nature of the mechanism whereby symptoms of gastro-intestinal disturbance are produced, we find that the alimentary tract has an ingenious conveyer mechanism with a number of sphincters. These are operated by intrinsic sympathetic or myenteric nerves, called plexuses of Meissner and Auerbach. In conveying food, impulses are passed from one portion of the tract to the next over these myenteric arcs. Normally the peristaltic movement is always forward because the point of highest irritability is at the proximal end. There is an exception to this rule in the ascending colon, where antiperistalsis occurs normally. When the irritability of a distal point of the alimentary tract becomes greater than the more proximal points, an antiperistaltic wave is set up causing vomiting. The myenteric activities are regulated by the autonomic impulses over the vagus, and by the sympathetic impulses over the splanchnic nerves. The autonomics contract the longitudinal muscles, dilating and shortening the tube. They also stimulate secretion of digestive juices and fluids and mucus and dilate the blood-vessels. The sympathetics contract the circular fibers and sphincters, narrowing and lengthening the tube, retarding the food, inhibiting the secretions and constricting the blood-vessels. The myenteric reflexes can continue after the vagi and splanchnics are cut. The vagi simply stimulate them and the splanchnics inhibit them. The pathways are from the coeliac plexus where the vagi and splanchnics meet with various other plexuses on the arteries and following the courses of the arterial supply to the minutest parts of each organ. Each cell is surrounded by nerve fibers. Visceral-afferent fibers over both vagi and splanchnics convey impulses to the cord segments and medulla which modify the systemic blood supply, drawing blood from the head and surface by constricting their arteries during digestion and filling the abdominal arteries. If opposite impulses should be received drawing blood away from the abdominal arteries, digestion would be interfered with. Any lesion or other condition causing hyperirritability or overstimulation of the vagus will result in overstimulation of the myenteric nerves, with vasodilatation, hypersecretion, contraction of the longitudinal coat, widening and shortening of the digestive tube, sluggish peristalsis but rapid movement of food through the sphincters, incomplete digestion and undernourishment. Inhibition of the splanchnic nerves will produce a like result. The opposite condition would come about as a result of inhibition of the impulses over the vagus to the myenteric nerves, or of overstimulation of the splanchnic nerves.

Inhibition of the splanchnic nerves may be secured by extreme flexion of the spinal column. This raises the cord in the spinal canal, lengthens it, stretches or draws on the nerve roots and vessels, squeezes the fluid out of the cord, and inhibits the splanchnics in two ways, first by a partial anemia or ischemia of the cord, and secondly by direct traction of the visceral afferent fibers in the posterior and anterior roots.

Conversely, stimulation of the splanchnic nerves may be secured by complete extension of the spinal column. This lowers the cord in the spinal canal, shortens it, releases the strain on the nerve roots and vessels, flushes the cord with blood, and tones up the sympathetic impulses in two ways, first by increasing their relative and absolute nutrition, through richer supply of richer blood, and secondly by releasing the nerve roots from strain, permitting free entry of afferent impulses over the posterior roots, and free exit of visceral-efferent impulses over the anterior roots.

Any lesion, inasmuch as it limits or alters the normal motion in a joint, produces an exaggeration or diminution of the normal spinal curves, and more or less lateral curvature. The altered equilibrium thus produced affects the viscera in three ways: 1. Mechanically, by pressure, gravity, altered position of ribs, vertebræ, diaphragm, etc.; 2. Reflexly, influence on nerves to and from affected segment; 3. Directly, by interference with nutrition of nerve cells by hyperemia or ischemia.

There is always a functional kyphosis in visceroptosis or splanchnoptosis. The nerves in the cord are inhibited. The skeletal muscles are hypotonic, allowing the functional kyphosis to occur, and the viscero-motor nerves are inhibited, allowing the abdominal viscera to become hypotonic and sag out of place within the abdominal cavity. The ribs are held up by the cervical fascia, and the abdominal muscles are held up by the ribs. The hypotonic condition extends to intercostals and abdominal muscles, with the result that the abdominal muscles are unable to play their part in maintaining the viscera in their proper places. The contraction or tonus of the abdominal muscles, the external and internal oblique, transversalis, rectus abdominis, diaphragm and levator ani, maintain the viscera firmly in position. It is only when the muscles of the abdominal wall have lost their tone that any strain or weight is thrown on the peritoneal and vascular supports. The inhibition of the restraining sympathetic impulses via the splanchnic nerves, allows hypersecretion and hypermotility of the alimentary tubes and further complicates the clinical picture by a colicky diarrhea or spastic constipation.

There are eight sphincters of circular unstriped muscle in the alimentary tract. Inhibition of sympathetic supply or increased autonomic supply causes sphincter insufficiency, overstimulation by sympathetic impulses or an insufficient supply of balancing autonomic impulses causes sphincter spasm, stasis, vomiting, fermentation, putrefaction, auto-intoxication. At each of these sphincters food is held back and controlled till the proper time has elapsed and the proper chemical environment is prepared for it in the next portion of the tract. Normal function of these sphincters is absolutely essential to normal metabolism and nutrition. The upper esophageal sphincter controls the entrance to the esophagus; the cardia controls the entrance to the stomach, the pylorus controls the entrance to the duodenum, the X-Ray shows a duodenal sphincter that controls the entrance of food into the jejunum. Here the food enters the long tract of the jejunum and ileum which measures twenty-five feet when the longitudinal muscles are relaxed and the circular muscles tonic, and which a short time later may measure only fifteen feet when the longitudinal muscles are contracted and the circular are relaxed. This section ends at the ileo-cecal valve, which controls the entrance of food into the cecum. There is the mid-colic sphincter about the junction of the proximal third with the distal two-thirds of the transverse colon, and the recto-colic sphincter which controls the passage from the sigmoid to the rectum. The rectum ends in the internal sphincter ani. There is some evidence of a ninth sphincter, the mid-gastric at the point where the peristaltic waves of the stomach begin. Absorption takes place mostly from the ileum and jejunum and it is worthy of note that four of these sphincters hold the food up on its way into this part of the tract, and four of them hold it back on its way out. Any lesion may affect one or other of these sphincters. It is believed that antiperistalsis from the mid-colic sphincter to the cecum during digestion is normal permitting more complete absorption of nourishment. Yet here, after absorption is complete, and at all times elsewhere in the alimentary tract, peristalsis is normally forward because the point of highest irritability is at the upper esophageal sphincter and the irritability decreases as the tract is further from the esophagus.

When the splanchnics are inhibited and the vagus autonomic impulses are normal or increased, the intestinal sphincters from the pylorus down may all be incompetent, so that food passes along too rapidly to be properly digested and absorbed. This results in undernourishment.

Any lesion anywhere in the body will affect =peristalsis=. It begins at the lower third of the stomach where it joins the pyloric portion and goes forward to the internal sphincter ani, being modified in its course by local conditions. Compensation may be established. Many cases of diarrhea and constipation are thus to be accounted for. =Diarrhea= is a symptom due to vasodilatation, hypersecretion and relaxation of the circular muscles especially at the sphincters. When these three factors are cleared up by correction of the lesions and hyperextension of the spine, the diarrhea stops unless some other factor is at work to irritate the myenteric nerves or to excite the autonomics or inhibit the splanchnics. Lesions from the sixth dorsal down are usually accompanied at first by some diarrhea, which afterwards becomes constipation, through loss of tone in the longitudinal muscles especially in the distal part of the colon. In these cases, correction of lesions, and extreme flexion of the lower dorsal and lumbar spine will give relief while the body is returning to normal.

When gastric digestion begins, simultaneous action is set up in the ileum. When disease of the cecum, appendix or ascending colon is present, there is contraction of the ileo-cecal valve causing stasis of the lower ileum and disturbed or retarded action of stomach and duodenum. These reactions are brought about by impulses to and from the myenteric plexus. The sympathetic and autonomic nerves affect the motor system of the alimentary tract not directly but through the myenteric or Auerbach’s plexus.

The =external sphincter ani= muscle is supplied by the pudendal nerve from the third and fourth sacral segments. It is in a state of tonic contraction, and having no opposing muscles keeps the anal orifice closed. The autonomic supply to the longitudinal muscles in the descending colon and rectum is from the second and fourth sacral. Inhibition here will, therefore relax the longitudinal muscles and external sphincter and permit free peristalsis in the descending colon and rectum. Pelvic disturbances may affect these nerves, or pressure due to visceroptosis, etc. The circular muscles of this section are supplied from the lumbar cord. They may be affected in any lumbar lesion, with the end result of spastic constipation by reason of a shortened markedly distended descending colon, sigmoid and rectum, and little peristalsis because of inhibition of the circular fibers, and contraction of the external sphincter ani.

The fundus of the stomach, lying in the left dome of the diaphragm, always contains a cushion of air which supports the left dome of the diaphragm, as the convexity of the liver supports the right. Normally the air is regulated and causes no symptoms. A lesion, usually of the mid-dorsal or lower dorsal segments may inhibit the circular fibers and permit distension, which becomes enormous when the pylorus is obstructed. The shortness of breath, palpitation of the heart, etc., accompanying this distension are probably due to pressure on the heart and lungs from which the stomach is separated only by the diaphragm.

Eighth, ninth and tenth dorsal lesions play a large part in peptic ulcers by permitting hyperemia, hypersecretion, and lowered vitality of the mucosa, and pyloric incompetence or spasm, because the pylorus, pyloric end of the stomach and first part of the duodenum get their chief sympathetic supply from the ninth and tenth dorsal segments of the cord. The tenth vertebra is more freely movable than the higher dorsal joints and is therefore more frequently in lesion, which helps to account for the greater frequency of duodenal ulcer.

The main sympathetic supply to the appendix seems to be derived from the eleventh dorsal segment. The appendix has the same motor and secretory mechanism as the rest of the alimentary tract but is richly supplied with lymphoid follicles. One of the twigs from the eleventh dorsal nerve pierces the rectus muscle to supply the skin at McBurney’s point, thus explaining the great frequency of pain and cutaneous hyperalgesia at this situation in appendicitis. Lower dorsal and upper lumbar lesions are unquestionably causes of many cases of appendicitis and other obscure diseases traceable to appendicitis. Correction of these lesions has restored the appendix and related structures to normality in hundreds of cases.

Sensory reflexes are shown in hyperalgesia and pain or tenderness in the abdominal skin and muscles and the parietal layer of the peritoneum from the ensiform cartilage to the pubes in an area extending about two inches on each side of the mid-line, corresponding to the distribution of the twigs of the lower six thoracic nerves which supply sensation to this region. =Esophageal= disturbance at the cardia causes pain in the region supplied with sensation by the fifth and sixth dorsal, near the ensiform. =Gastric derangement= causes pain midway between the ensiform and umbilicus, which radiates to the left, in the area supplied by the eighth dorsal. =Hepatic disturbance= causes pain on the right of the median line, radiating to the right in the sensory distribution of the ninth dorsal. =Intestinal pain= is located in the sensory distribution of the tenth dorsal nerve in an oval area around the umbilicus. Pain due to =duodenal ulcer= is sharply localized at a point about an inch or two above and to the right of the umbilicus where twigs of the tenth dorsal nerve come to the surface. This point corresponds closely to the normal position of the underlying duodenum, though the duodenum may be displaced, and the sensitive spot remain at the same point. The pain from =fundal gastric ulcer= or =carcinoma= is usually localized sharply about an inch or two to the right of the median line midway between the ensiform and umbilicus, at the spot where the twigs from the eighth dorsal nerve pierce the rectus and come to the surface. In the disease of the =pylorus=, reflex pain is lower; of the =cardiac end=, higher. The reflex pain at McBurney’s point in =appendicitis= has been referred to, but it must be borne in mind that pain from disturbance in the =colon= also shows in the sensory distribution of the eleventh dorsal nerves midway between the umbilicus and pubes. Pain may also be referred to areas supplied in the back by the corresponding segments. These reflex pains can usually be stopped by inhibiting along the spine corresponding to the sensory area affected. This reduces the impulses entering the posterior roots and lowers the irritability of the segment.

The =motor reflexes= from gastro-intestinal disturbances result in muscular contractures of spinal, abdominal and other muscles supplied by motor nerves arising in the anterior horn of the segment which innervates the part of the viscus that is affected. Stomach, liver, gall-bladder, pyloric and duodenal disturbances cause increased tone, contraction, contracture and rigidity of the rectus muscles above the umbilicus, for instance, and the other viscera contract it in lower portions. More important are the extreme contractures of the musculature of the back which is supplied by the segments which supply the affected part of the viscus. These contractures produce some distortion and loss of motion in spinal joints and thereby produce the same effects as primary lesions, causing widespread disturbance which persists until the spinal musculature is normalized. In =colic=, the lumbar segments being involved, there is marked contraction of the ilio-psoas which causes the characteristic drawing up of the thighs on the abdomen, while the extreme contraction of the rectus abdominis draws the thorax down.

Most persistent vomiting may arise reflexly from other organs as in so-called biliousness, jaundice, pregnancy, brain affections, appendicitis, onset of acute infectious diseases, alcoholism, sea-sickness, colic, hernia, intestinal obstruction, migraine, shock, and anesthesia. Irritation of any sensory branch of the vagus or of nerves which connect with it in the medulla, or reflexly from consciousness via the cerebral cortex, as in the case of nauseating sights, smells, tastes, as well as irritation from any viscera innervated from the sixth dorsal down, may overstimulate the corresponding efferent nerves going to parts of the alimentary tract supplied by that segment, increase its irritability and start antiperistalsis. Similarly disturbances in almost any viscus may reflexly disturb the normal balance between sympathetic and vagal autonomic stimuli resulting in hypersalivation, hyperchlorhydria, pylorospasm, distension, gastric atony, gastrosulcorrhea, enterocolitis, spastic constipation, achylia, or colicky diarrhea. In these cases, the derangement of the viscus reflexly disturbs the alimentary tract through central nerve connections. Correction of the primary trouble is followed by removal of the reflex symptoms. In this connection it is important to note that the visceral reflex symptoms may arise from irritation of the alimentary tract by improper diet, poor cooking, or wrong combinations. Carbohydrates digest quicker than proteins, and these more rapidly than fats. Food is handled by the fundus in the order in which it was swallowed. If the fats are swallowed first, the starches may be held up for five or six hours, subjected to the acid stomach secretions and allowed to ferment causing distension, which reflexly produces a variety of symptoms.

Mental exertion, strong emotions, heavy physical exertion, interfere with the function of the alimentary tract and set up disturbances in the balance of sympathetic and vagal autonomic impulses, through the nervous reflexes via the cortex, and through the demand for blood, which impoverishes the abdominal circulation at a time when it needs all the blood it can get. The ischemia produced in this way has about the same effect as ischemia produced by a spinal lesion. Conversely, disturbances of the alimentary tract produce profound changes in character and personality, by reflexes to the cerebral cortex causing dullness of perception, in all the senses, poor memory, sluggish thought, erratic judgment, irritable disposition, fear, worry, lack of ambition, indecision, lack of energy, vacillation, and finally a psychosis in which manic depressive symptoms are balanced by paranoiac symptoms.

The alimentary tract is so intimately bound up with the whole stream of vital activity, whether vegetative, sensorimotor, or psychic, that any disturbance of body or mind is likely to affect it in some part, and conversely any disturbance of the alimentary tract is bound to affect all the rest of the body and the mind. A satisfactory classification of its diseases is therefore difficult to make, but the one here adopted is probably the best for the purpose. The early stages of gastro-intestinal diseases are often so similar that it is nearly impossible to differentiate them with certainty; the classification is therefore based on the clinical picture and pathology of advanced stages. Fortunately, with the exception of cancer, diseases treated in the early stages usually clear up when the lesions are corrected, and the necessary attention given to the other causative factors present.

Acute Gastritis

Acute dyspepsia is one of the frequent disorders of the stomach. It may occur as an early symptom of an infectious disease, but very often it is due to some non-specific irritation. The usual exciting causes are errors of diet, over-indulgence in improperly cooked and highly seasoned food, or food that has been spoiled, such as meat, fish and milk, or over or under ripe fruit. Food that is either too hot or too cold may develop an attack. Alcohol is a common cause in those not accustomed to its use. Overuse of tobacco may bring on an attack. Many acute “bilious” attacks are brought about by some mental shock or excitement at the time of taking food, for it has been shown by the researches of Pawlow that both gastric motion and secretion are altered by mental irritation during digestion.

Unquestionably osteopathic lesions of the splanchnics and vagi are important predisposing factors. These lesions produce a lowered resistance of the tissues, which will frequently explain why certain exciting factors that will initiate an attack in one individual will not do so in another. A healthy mucosa will not be so readily irritated by either indigestible or partly decomposed food.

Osteopathic experimental work reveals that the vertebral and rib lesions readily affect both the spinal nerves and the sympathetic ganglia, which is followed by vasomotor and trophic disorder to the mucous and submucous coats of the stomach, as shown by eccymosis and hemorrhage of the submucosa and beginning parenchymatous degeneration of the free ends of the glands of the mucosa. Upon the other hand irritation of the muscles from dietetic errors always causes more or less contraction of the muscles in the upper and middle dorsal, which, in turn, may produce through imbalance of tension and fibrositic changes, constant interosseous lesions and thus be the cause of the catarrh becoming chronic. This vicious cycle phenomenon should not be overlooked. Viscero-motor, viscerosensory and viscerotrophic reflexes may be factors in the pathogenesis of the osteopathic lesion.

=Pathologically=, the mucous membrane is more or less covered with mucus. Upon removal of the mucus the membrane is found red and swollen, and the epithelial cells of the glands are granular. This is especially noted in the pyloric area. There are minute extravasations of blood and hemorrhages of the mucous coat, and infiltration of the submucous layer.

=Symptoms.=—Acute gastritis occurs at all ages, so particularly in children care has to be taken that the attack is not the beginning of some infectious disease. A careful inquiry into the history, and examination of the vomitus will usually make the diagnosis clear. The sudden onset of nausea, vomiting, pain in the epigastric region referred to the back and head, vertigo in some cases, if the infections can be ruled out should leave no doubt as to the nature of the disorder.

Other symptoms are weakness, and chilliness which later if the attack is severe, is followed by fever. The tongue is coated, the lips dry, and there may be herpes. Belching of gas, constipation in some and diarrhea in others, and dark colored urine are noticeable. There is tenderness on palpation over both the stomach and splanchnic areas. Examination of the stomach contents show deficient hydrochloric acid, the presence of organic acids, bile and undigested food, and considerable mucus.

=Diagnosis.=—In young children acute gastric indigestion is common, though a casual gastritis is rare. In the former prostration, vomiting, and undigested, greenish stools are noted. In some cases there is no fever, while in others it may range from 102 to 105 degrees. In all cases care should be taken, as has been stated, that the attack is not the beginning of some infectious disease. Appendicitis, acute bowel constriction, pregnancy, uremia, meningitis, gall-stone colic, and gastric crises of tabes dorsalis should be differentiated. Most attacks of acute dyspepsia are over in twenty-four hours. The prognosis depends upon eliminating the cause. The X-ray may be of value in protracted cases.

=Treatment.=—If the case is seen early, emptying the stomach by induced vomiting or the stomach tube is the first indication. If several hours have elapsed and much of the stomach contents have passed into the intestine, emptying the colon with an enema will commonly give quick relief. Withhold all food for from twelve to twenty-four hours, or longer if necessary. In some cases the sipping of hot water will be beneficial, while in others pellets of ice in the mouth will give some relief.

Whether or not there existed previous spinal lesions there will always be found muscular tension and spinal rigidness during an attack of acute gastritis. These should be corrected for immediate relief, but what is of greater importance, if these acute lesions are not corrected the patient’s recuperative forces are interfered with and recovery is delayed. Then, also, these lesions tend to chronicity and predispose to future attacks. Treatment should be given daily, or oftener if special indications arise. Though the most common area that demands attention is from the fourth to tenth dorsals, still the vagi nerves, especially the right, should not be neglected. Lesions of the upper three cervicals are the most frequent disturbances of the vagi.

=Vomiting= is a common and distressing symptom. Pathologically, it is due to an antiperistaltic contraction of the stomach and a spasmodic contraction of the diaphragm and the abdominal muscles. It is caused, usually, by irritation of the vagus in the stomach, or in the pharynx by irritation along the spine (particularly in the cervical and upper dorsal regions), or to the sympathetic nerves or to various parts of the body, or by direct influence of the brain. Relief can usually be given by inhibition of the vagus in the occipital region or by inhibition at the fourth or fifth dorsal vertebra on the right side. In a few instances, placing the patient in the knee-chest position and gently raising the abdominal organs gives relief. If this does not suffice the stomach and colon should be emptied, providing the vomiting is protracted. A frequently effective measure for nausea and vomiting that can be carried out by the attendant, is the application of hot fomentations to the dorsal spine.

=Flatulency= may be very distressing. The spinal treatment may be sufficient to control this condition, or careful direct pressure for a few minutes over the pit of the stomach. Adjustment of the lower ribs, especially of the left side, may be effective. Occasionally the gas can be passed into the intestines by careful inhibitory treatment in the region of the eighth and ninth dorsals. The inhibitory treatment causes relaxation of the pyloric orifice; also, inhibition of the left vagus relaxes the pylorus. Inhibition at the sixth and seventh dorsals relaxes the cardiac orifice, thus favoring the passing of the gas from the stomach out through the esophagus.

In all cases subject to gastritis the dorsal spine should receive considerable attention in order that recovery may be complete. The habits of the patient should be thoroughly regulated and overfatigue guarded against. And, also of special importance in recurring attacks, is the fact that a number of cases present some derangement of the biliary tract, or duodenum, or the appendix region.

=Diet.=—After twenty-four or forty-eight hours, if the attack has been severe, albumin water may be given in small quantities; also whey, milk, bouillon, and chicken or lamb broth. If there is no return of gastric distress, add junket, custard, cornstarch pudding, gelatine, dropped eggs, scraped beef, and white meat of chicken; vegetables purees made with cream or meat stock are usually well borne at this time. Foods containing much cellulose, fats and sweets should be withheld until all symptoms have subsided.

Chronic Gastritis

It is unnecessary here to repeat the causes of acute gastritis, any one of which continued over a long period of time will cause chronic catarrh of the stomach, as it is sometimes called.

Spinal and rib lesions anywhere from the occiput to the coccyx, but more particularly from the fourth to the tenth dorsal, will predispose to chronic gastritis, the particular type and degree of local pathology depending upon the exciting factor.

A commonly found en bloc lesion is a flattening of the normal convexity in this region, with more or less immobilization, shown by attempting to reestablish the normal convexity through flexion.

In addition there may be single spinal or rib lesion in the same area, or cervical lesions affecting the pneumogastric, which is the secretory nerve to the stomach. (See chapter on the “Lesion and Its Applied Anatomy.”)

=Pathology.=—Chronic gastritis probably never develops as such without going through several preliminary stages beginning with alimentary hypersecretion, or hypersecretion occurring only during the active period of digestion. These are the cases usually classified as hyperchlorhydria. At this time no actual pathology can be demonstrated in the glandularis.

If the condition is not treated intelligently at this time the next step will be periodic attacks of what is known as “hypersecretion periodica chronica” followed by “hypersecretion continua chronica.” The stomach contains abnormal amounts of gastric juice even after a night’s rest. At this stage there is a transition from the functional to the organic condition. All stages are characterized by an abundant secretion of mucus.

If allowed to go on there will finally result a destruction of the secreting cells known as Atrophic Gastritis or Achylia Gastrica in which the stomach presents a smooth functionless appearance.

=Secondary Chronic Gastritis.=—Portal obstruction from any cause predisposes to chronic gastritis. The most common of these is failing compensation in heart lesions, which through back pressure causes portal stasis; the same thing may follow obstruction in the liver itself. Chronic gastritis is also a late accompaniment of the nephritic trinity, kidneys, heart and arteries. It may also be associated with diabetes, gout, anemia and other constitutional disorders.

Tuberculosis is commonly ushered in by symptoms of chronic gastritis. We should be constantly on the alert to avoid the mistake so commonly made of treating the stomach as an entity and overlooking the real trouble in some other part of the anatomy.

It is probably safe to say that there are only two primary diseases of the stomach, ulcer and cancer. All others are suspiciously associated with diseased processes elsewhere, and when the spinal lesion is given its full significance even these will be found to be directly traceable to anatomical perversions somewhere within the mechanism of local nutrition.

=Symptoms.=—These are governed by the stage of progress in which the patient is seen. During the stage of hypersecretion of acid gastric juice there will be vague feelings of distress, fullness and burning in the stomach, and “heartburn” during digestion. When the stomach is empty all symptoms will subside. Later there will be periods of a few days or weeks when there will be more or less continuous distress with some vomiting of highly acid gastric juice containing mucus.

When the condition has progressed to the stage of continuous hypersecretion there will be continuous symptoms as above, but with nausea, vomiting becoming more frequent especially late at night or in the morning, always accompanied by sticky mucus.

Appetite is variable, there is often a disagreeable taste in the mouth (the “dark brown” taste of the chronic alcoholic). Heart palpitation and vertigo and other vagus symptoms are common.

=Diagnosis.=—On physical examination the stomach is found distended, and in some cases displaced (gastroptosis). There will be diffused tenderness on pressure over the whole organ which should help to distinguish it from gastric ulcer or cancer in which the tenderness is quite localized.

Chronic gastritis cannot be =positively= diagnosed without making a gastric analysis. Many cases are wrongly diagnosed through neglect of this very important procedure.

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The practice of osteopathy (part 4 of 6)

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Introduction