The practice of osteopathy (part 5 of 6)

The practice of osteopathy (part 5 of 6)

The cases in which gastric analysis should be made are so well stated by Lockwood that we will take the liberty of quoting them in their entirety.

“(1) Gastric analysis should always be made in every case of dyspepsia, no matter whether these symptoms be apparently gastric or intestinal, unless passage of the tube is contraindicated.

“(2) Gastric analysis should be made in every case of chronic diarrhea that is not due to evident disease of the colon or rectum.

“(3) Gastric analysis should always be made in all cases of intestinal toxemia, or recurring headache of toxic origin, and in patients who complain of the symptom complex which is spoken of by the laity as ‘biliousness’.

“(4) Gastric analysis should be made in all cases of anemia and general physical wretchedness without known cause and which are rebellious to treatment.”

The finding of excessive gastric mucus intimately mixed with food remnants is the chief differential point in the diagnosis of chronic gastritis.

=Differential Diagnosis.=—A complete statement of differential diagnosis by Kemp cannot be well improved upon.

“CHRONIC GASTRITIS.—No severe pain, no circumscribed spot, painful to pressure; no hematemesis; no cachexia; no marked emaciation, except in severe cases of long duration; free hydrochloric diminished or absent; gastric mucus present; slow course.

“ULCER OF THE STOMACH.—Hyperchlohydria present, but not invariably so; severe pain in the epigastrium with intervals free from pain when stomach is empty; local tenderness which is circumscribed; dorsal pain; hematemesis, or occult blood in the stool or gastric contents; microscopic pus; no mucus; patient has appearance of suffering; no true cachexia.

“CANCER OF THE STOMACH.—Age usually over forty-five; rapid course; free hydrochloric acid usually markedly diminished or absent; lactic acid present; pain generally continuous, but not so acute as in ulcer; Boas-Oppler bacillus; cachexia; tumor on physical examination; small amount of visible or occult blood; hematemesis much less than ulcer; foul odor to vomitus at times present.

“ACHYLIA GASTRICA.—Slow course; scarcely any gastric juice; acidity very low or entirely absent; absence of pepsin and rennin; usually no mucus or lactic acid.

“These differential considerations apply to typic cases, and the observer must be on the qui vive for various gradations and modifications of these clinical pictures.”

=Prognosis.=—The outcome of chronic gastritis depends upon our ability to locate and remove every factor in the etiology, the willingness of the patient to cooperate and the patience and resourcefulness of the physician. At best the progress is slow and one must expect temporary setbacks usually due to failure of the patient to carry out instructions.

=Treatment.=—The most successful treatment is prophylactic, but until the public has been educated up to this form of economy we must begin with conditions as we find them.

First get the patient’s confidence by making an intelligent examination, a scientific diagnosis, and a reliable prognosis based upon your findings. All lesions, bony, ligamentous, muscular and psychic must be intelligently and carefully removed.

Specific lesions which would directly or reflexly interfere with the nerve and blood to the stomach must be corrected.

The rigidness commonly found in the vertebræ and ribs of the splanchnic area must be overcome first by specific adjustment, and the normal flexibility maintained by teaching the patient proper exercises for the purpose. This should include deep breathing with the spine flexed to the limit, and the ribs fixed, by the patient reaching around as far as possible and grasping the ribs as described by Dr. Harry Forbes. This will tend to overcome the flat dorsal so characteristic in all gastro-intestinal conditions.

Direct manipulation over the stomach has no particular value and may be even harmful.

Inasmuch as nausea and vomiting and excessive gas formation are only the result of hypersecretion we cannot expect to give more than temporary relief except by methods which remove causes. Much comfort may be given by inhibition in the splanchnic area. In severe cases it may be necessary at times to wash out the fermenting, irritating mass by gastric lavage. Outdoor life, frequent vacations and change of occupation are often of decided benefit.

=Diet.=—Indiscretions of diet must be avoided and this cannot be too positively impressed upon the patient. It is always best to make a list of foods to be taken for breakfast, lunch and dinner and insist that no other foods be taken without further instruction.

Just what these foods shall be depends upon the gastric secretions as shown by gastric analysis. They should always be nutritious and given in quantities sufficient to maintain nutrition.

The stomach should have rest and yet is expected to do its part in the process of digestion. All foods must be given in a finely divided form and well masticated to spare the stomach the mechanical effort of grinding.

In hyperacid gastritis all foods of an irritating nature must be positively prohibited. The classical breakfast of grapefruit, oatmeal, ham and eggs and coffee will not do. Starchy foods must be reduced owing to their tendency to ferment in the presence of highly acid juice and the delay in the stomach due to the high acidity.

In subacid gastritis advantage must be taken of the fact that carbohydrates digest well and proteins do not.

=Diet for Hyperacid Gastritis.=—Before breakfast: Wash the stomach with warm water and an ounce of Phillips Milk of Magnesia, allowing the water to remain in the stomach 20 minutes or a half hour, lying down and turning from side to side on the face in order that the water and magnesia may be brought in contact with all parts of the stomach.

For breakfast: Prunes, allowed to simmer for four hours, without boiling, and put through a colander, to remove the skins. Soft cereals, such as farina, cream of wheat, or wheatlet, thoroughly cooked, and served with middle heavy cream, no sugar. Two eggs, soft boiled, or poached. Zweiback, thoroughly masticated, with a liberal quantity of butter. Cocoa (Phillips).

Luncheon: Puree of peas, beans or lentils, made with cream. Asparagus, green peas, boiled rice, spinach chopped very fine, creamed carrots, boiled onions, baked potato, well done. Chicken, boiled lamb or beef, ground; oysters in any form but fried; fresh fish. Desserts: Choice of junket, cornstarch, custard, rice pudding, floating island, gelatine or tapioca.

Evening meal: Same as luncheon except substituting eggs for meat.

Cup of hot water before luncheon and dinner.

If patient requires quick building up give milk between meals and at bed-time.

Gastric Neuroses

Gastric neuroses include =motor=, =sensory= and =secretory= derangements. Though the sensory disturbance is often the most marked, still motor and secretory symptoms are usually present. In other words there is commonly a complex of the different forms.

Where gastric neuroses can be positively diagnosed, by a process of elimination, there is no more plausible explanation than that of the spinal lesion. The success of osteopathic physicians in treating so-called “stomach trouble” proves conclusively the superiority of the osteopathic method. A note of warning should be sounded, however, for as diagnostic methods have become more exact it is found that many cases which were formerly diagnosed as neuroses prove to be referred from some organic change, such as infected gall bladder, appendix, tube or ovary, tonsil, tooth or sinus. It has been proven that many cases of sensory and secretory disturbances have entirely cleared up when these causes have been removed. Though infection may play an important role, still in some instances, especially gall bladder, duodenum and appendix, the gastric neurosis may be simply due to a nervous reflex.

Gastroptosis, atony, and in many cases splanchnoptosis, has been found to be the underlying cause of many hitherto unaccountable gastro-intestinal symptoms.

Gastric crisis of locomotor ataxia if not properly diagnosed by the finding of the other well known symptoms may give us much trouble and discouragement.

Ulcer and cancer have quite characteristic symptoms, yet it is well known that they are often treated as neuroses in the early stages, much to the detriment of the patient, especially if the case proves to be cancer.

In the =sensory= disturbances, which are probably the most common, hyperesthesia and =neuralgia= are the special features. In the former a feeling of weight, fullness and burning are complained of, which are frequently manifestations of a neurotic temperament. In fact, hysteria and neurasthenia are very often basic conditions. The same is true in gastrodynia, where the pain starts in the pit of the stomach and extends around the lower chest and ribs. There may be other neurotic symptoms such as excessive hunger and a constant desire for food. Menstrual irregularities, the menopause, worry, constipation, and anemia are important factors. Special care should be taken that there is no organic disorder of the gastro-intestinal tract or of the nervous system.

The =motor= neuroses comprise a variety of derangements. Excitation of the motor functions of the stomach, as a direct result of irritated nerves or of reflex stimuli, are not uncommon. Owing to this the food may not remain in the stomach long enough or the stomach activity may be too pronounced. There may be also more or less rapid vomiting of the food, without any particular strain. Other motor neuroses may be spasms of either the cardiac or pyloric sphincters, and in a few instances there may be atony of the stomach walls. Although these conditions may be of a neurotic character, still great care should be taken that some organic disease is not basic.

The =secretory= derangements consist of hyperacidity, supersecretion, and lessened amount of acid secretion or achylia gastrica. Many of these cases are associated with hysteria and neurasthenia, though in achylia gastrica, cancer may be the cause. Hyperacidity may be associated with ulcer. Pelvic diseases, nervous reflexes from the gastro-intestinal tract, constipation, and anemia are to be considered as possible etiological factors.

=Diagnosis.=—These cases require the most painstaking inquiry into the history, the most complete physical examination, and all findings carefully checked up by laboratory tests.

Inquiry will often show that all symptoms subside when on a vacation with a change of scene and climate.

Lockwood gives the following rules for arriving at a diagnosis of “nervous indigestion.”

“(1) A diagnosis of nervous indigestion should not be made in the presence of more than 30 c. c. of fluid in the fasting stomach, the fluid giving a strong reaction for hydrochloric acid. Hypersecretion is generally an expression of pyloric stenosis, organic or spasmodic, and this is due to an organic cause.

“(2) A diagnosis of nervous indigestion should not be made in the presence of persistent hyperacidity accompanied by epigastric pain. Nervous hyperchlorhydria may occur, but is not accompanied by either pyrosis or pain. The association of either of these latter symptoms should suggest an organic origin for the complaint.

“(3) Achylia gastrica may be of nervous origin, but this is not probable when serious motor error is in evidence. Achylia with food-stagnation is strongly suggestive of cancer of the stomach.

“(4) Achylia gastrica, accompanied by pain or vomiting, indicates an underlying organic cause.

“(5) The diagnosis of nervous indigestion should not be made when recognizable food remains are repeatedly found in the fasting stomach. Under the influence of fear, nervous shock, or vicissitudes of temperament the motor functions may be temporarily interfered with, but this would not be the case permanently.

“(6) The diagnosis of nervous indigestion should not be made when epigastric distress or pain occurs regularly at a definite time after eating. The very fact of this disturbance coming on at a definite time argues against a neurosis.

“(7) The diagnosis of nervous indigestion should not be made when one symptom alone persists, without other evidences of nervous instability. The presence of one definite symptom in itself presupposes an organic cause.

“(8) The physician should be on the qui vive for drug addictions, for these habitues can sometimes present a syndrome of symptoms that will puzzle the most experienced.

“(9) The diagnosis of nervous indigestion should not be made in persons over forty or forty-five, in whom indigestion is a new symptom. Such patients are usually developing a serious systemic or malignant disorder.

“(10) Finally, digestive nervous neuroses and organic disease may be concomitant, and the presence of either need not exclude the other.”

=Treatment.=—First get the patient’s confidence by making a most complete examination. This desirable beginning is usually hastened by the osteopathic physician, when after a few treatments symptoms are greatly relieved. Correct all lesions wherever found, particularly those anatomically connected with the stomach. When the symptoms are sensory relief can always be given by inhibition over the splanchnic area. Occasionally the ensiform process and the lower costal cartilages are lesioned.

=Diet.=—When hyperchlorhydria is the chief symptom foods must be selected which bind acidity or those which lessen its secretion, such as milk, eggs, cream cheese, fats such as butter, cream, olive oil, boiled or broiled fresh fish, =boiled= beef or lamb run through a grinder, oysters in any form but fried, white meat of chicken, vegetable puree made with cream or milk (no meat stock), gelatine, custard, junket or =sponge cake=.

Many neurotic patients are under-nourished through fear of food. They must be positively assured that if the food is well chosen and carefully masticated there need be no fear of discomfort. Care should be taken that the patient is not constipated.

Some cases can only be reached by a “rest cure” of four to six weeks, which together with the treatment outlined above will prove most satisfactory.

In all cases guard against worry and overfatigue. Build up the general health as rapidly as possible. Outdoor life, sufficient sleep, frequent vacations, and change of scene are specially beneficial.

Gastric and Duodenal Ulcer

Statistics show that peptic ulcer is far more prevalent than is supposed by the casual observer. “In the combined statistics of 59,450 autopsies of various series evidence of healed or unhealed ulcer were observed in 4.4 per cent.” (Bassler.)

The reason for this is that peptic ulcer may present very definite symptoms which are readily interpreted or they may be so atypical as to make definite diagnosis impossible. Like all gastro-intestinal diseases, many of the symptoms are easily confused with so-called indigestion or “stomach trouble.”

=Etiology.=—One characteristic of gastric and duodenal ulcer is that it only occurs where the mucous membrane is subject to the influence of hydrochloric acid and pepsin; lower end of esophagus, stomach and first part of duodenum.

Similar ulcers are often found in the sigmoid and rectum where the feces often become acid due to bacterial action, or on account of slow movement, hydrochloric acid and pepsin which may have escaped neutralization in the duodenum may attack the mucosa.

For the part played by spinal and rib lesions on the glandular layer of the stomach, the reader is referred to a previous discussion of the lesion.

Probable secondary causes of gastric ulcer are: (1) Embolism of an artery (gastric arteries are terminal). These emboli are supposed to be caused by toxic and infectious agencies which enter the circulation, as sometimes occurs in pyemia and large burns of the skin.

(2) While hydrochloric acid associated with pepsin seems to be an important factor, it is doubtful whether it can attack the mucosa without there being a previous abrasion or other injury. It is said that a normal secretion of mucus is nature’s protection against self digestion.

The swallowing of substances of a coarse or irritating nature or those chemically corrosive or at extremely high temperature may so injure the mucous membrane as to permit an attack by HCl and pepsin.

Certain occupations seem to predispose to gastric ulcer, such as cobblers, or others who in their work press various objects against the stomach.

Sharp blows over the stomach have been followed by acute ulcer. A frequently associated condition is gastroptosis, which seems to be explained on the basis of narrowing of the blood vessels and their more ready occlusion. Probably sagging of the duodenum is an important predisposing factor.

Anemia and chlorosis should not be overlooked as predisposing causes. And tuberculosis and syphilis are possible associated disorders.

Of all the theories advanced, the lowering of vitality, due to lesions of the splanchnics and vagus nerves remains the most logical.

=Symptoms.=—The most characteristic symptom is pain, which in a typical case comes on at a regular time after taking food. It may be a half hour, an hour or two hours, and in the case of duodenal ulcer may be as late as four hours. The distance beyond the cardia at which the ulcer is located seems to govern the time; also the time at which the secretion of hydrochloric acid reaches its height, which varies in different individuals.

The pain is due to free acidity (that which is not combined with the food) irritating the raw surface of the ulcer. Pain is often increased or lessened by posture. If turning on the left side gives relief the ulcer is probably at the pylorus; if worse when standing than reclining the ulcer is probably on the greater curvature.

The pain is usually localized by the patient, and pressure at the given spot increases the pain. In many cases there is referred pain in the region of the 9th, 10th and 11th ribs on the left side.

At the height of pain vomiting may occur, due probably to pylorospasm resulting from high acidity. Vomiting always gives relief. The taking of protein food or alkali will usually relieve the pain of ulcer, (hunger pain). Ulcer patients are usually well nourished owing to the habit of relieving themselves by eating, or they may be thin due to their fear of food.

In acute ulcer frank blood may show in the vomit, and may be the first indication of trouble, whereas in the chronic type it may be occult, or occult blood may be found in the feces. The hemorrhage of ulcer, unlike that of cancer, is not constant.

=Diagnosis.=—Diagnosis of duodenal ulcer, as distinguished from gastric, is made by finding the tender spot to the right and below the pylorus, the pain coming on three or four hours after taking food, and the finding of blood in the feces (tarry stool) and not in the stomach contents. Repeated examinations may be necessary owing to the fact that hemorrhage is not constant.

The large percentage of stomach ulcers are near the pylorus, and of the duodenal ulcers the ascending portion is the area almost invariably involved.

Ulcer is differentiated from functional disorders by a history of real pain as distinguished from the vague disturbances of sensation often called pain by neurotic patients. Also its regular appearance in relation to food. The pain of “gastralgia” has no regular habit and is not influenced by food.

Referred pain from cholecystitis, chronic appendicitis, etc. has no relation to food and is not relieved by food or alkalies.

Ulcer is to be distinguished from cancer by the age of the patient (in cancer usually over 40) with a previously good gastric history, except in cases where cancer has been grafted on to a chronic ulcer. In these cases a careful inquiry will bring out a characteristic ulcer history up to a certain time, when all symptoms change; pain becomes constant; is not relieved by food or alkali; vomit becomes dark in color and has a characteristic odor, appetite fails, and signs of cachexia set in.

Gastric ulcer should be suspected in all cases of persistent gastric symptoms which are not readily relieved by treatment and regulation of diet, and in which there is found high acidity and continuous hypersecretion not accompanied by mucus.

The X-ray and gastric analysis should never be neglected in suspected cases, keeping in mind the possible injury from the tube in case of recent hemorrhage.

=Treatment.=—Osteopathic treatment of gastric ulcer will be almost uniformly successful if we will analyze all of the factors entering into the problem.

It is obvious that in order to heal the ulcer we must remove all factors which interfere in any way with nutrition. Then give the stomach as near absolute rest as possible while at the same time building up the nutrition by a generous but well chosen diet.

When acute hemorrhage has recently occurred, complete rest in bed with a trained nurse in attendance is the first indication. Complete rest of the stomach, all nourishment being given by nutrient enema. An ice bag is to be placed over the stomach, and removed every three or four hours to allow surface circulation to react. Warm applications should not be used while there is any marked bleeding.

During this period no effort on the part of the patient should be permitted, and no manipulative treatment which would tend to increase blood pressure should be given.

After all evidence of hemorrhage has ceased for ten days, or at once in case of chronic ulcer, we may carefully correct all spinal or rib lesions in the splanchnic area especially the 6th dorsal, or cervical lesions affecting the pneumogastric. Pain and pylorospasm may be relieved by steady pressure at the 4th and 5th dorsal on the right side.

After spinal lesions have been corrected without unduly irritating the stomach, careful relaxing treatment should be given with the patient on the back, keeping in mind that all exertion will tend to irritate the ulcer.

If special care is observed, frequently definite relief may be given by placing patient in knee-chest position and gently raising the lower portion of duodenum where it lies alongside of ascending 3rd and colon, 4th lumbar.

During this period a hot water bag or a thermal pad should be kept over the stomach night and day.

In certain cases of perforation in a few obstinate conditions, and in a few where mechanical obstruction is marked, surgery may be indicated.

The following diet will be found best during the first week:

7 A. M. A half glass of cooked milk, with the leathery substance which rises on the top removed, and the yolk of one egg stirred into it and sweetened, if desired; taken luke warm or cool, but never ice cold. This amount to be increased on the second day to three-fourths of a glass, and on the third to a full glass, which is to be continued for a week. If the milk produces diarrhea, add two tablespoonfuls of lime water to each portion.

9 A. M. A saucerful of gelatine (Knox’s or Crystal Rock) with 2 tablespoonfuls of cream and a teaspoonful of sugar.

12 M. A half to full glass of milk prepared as above.

3 P. M. A saucerful of gelatine, with cream (medium) and sugar as at 9 A. M.

6 P. M. A half to whole glass of milk, as before, with one egg stirred in and sweetened. The egg yolks at 7 A. M. and 6 P. M. are to be increased until six are taken daily at the end of the week.

8 P. M. A half to a full glass of milk.

The whites of the eggs are to be stirred up in the water in the proportion of a white to a glass of water, 4 teaspoonfuls of sugar to be added to every glass, this to be taken by the patient only when thirsty. If the bowels do not move, no laxative can be taken, but an injection of warm water or a little soap may be employed. If much discomfort is produced by the food, a hot compress must be laid over the stomach or above the navel.

During the second week the diet should remain much the same except for the addition of one or two pieces of Zweiback three times a day.

During the third week, if pain and blood in the feces are lessening, we may add soft, well cooked cereal like cream of wheat, cocoa, puree of split pea made with cream.

Fifth week add minced chicken, coddled egg, =boiled= beef or lamb put through a meat grinder, soft vegetables such as chopped spinach, squash and mashed or baked potatoes with liberal quantities of butter.

During and after the sixth week we may add all vegetables which can be served in puree form, fresh fish, oysters, apple sauce, inside of a baked apple, prune whip, custard junket, corn starch pudding.

At this time also if all goes well the patient may sit up in bed and gradually move about, being careful to avoid all sudden movements which would put a strain on the epigastric region.

If necessary we may also increase our manipulative treatment at this time.

The patient must be warned against the use of any article of diet which will be chemically or mechanically irritating to the stomach, for a period of months, and an examination of feces should be made from time to time to make sure of no return of hemorrhage.

Dilatation of the Stomach

A dilated stomach is a stretched stomach having increased capacity, due to nervo-muscular atony or to pyloric obstruction. Every stomach which is not retracted when empty is a dilated stomach. A dilated stomach may occur either as an acute or as a chronic condition, but it is to be distinguished from temporary distention and a normally large stomach.

=Osteopathic Etiology= and =Pathology=.—The nervo-muscular atony causing dilatation may be due to obstructive lesions in the stomach splanchnics, or to a general debility of the spine in the dorsal region (usually a kyphosis), or to continued overeating and improper food causing a stasis and fermentation. It may also be due to overdrinking and various diseases, as phthisis, liver and lung diseases, anemia, chlorosis, acute fevers and kidney diseases, causing more or less of a general nervo-muscular atony. Dilatation may result from a mechanical obstruction, or narrowing of the pylorus or the duodenum, by a cicatricial contraction of an ulcer; by hypertrophic thickening due to various diseases, by adhesions and tumors. Occasionally the pyloric obstruction is congenital. A floating kidney may fall upon the horizontal portion of the duodenum and thus mechanically obstruct the passage of food from the stomach, which consequently dilates. Tight lacing might prevent the liver, when congested, from passing in front of the kidney, thus luxating the kidney. Dilatation of the stomach occurs at all ages, although most frequently in middle aged persons.

=Pathologically=, the muscular coat is thinner and paler than normal, with more or less atrophy of the glandular tissues and an increase in capacity of the stomach. When obstruction exists at the pylorus, hypertrophy of the muscular coat may occur.

=Symptoms.=—The symptoms are those of the disease causing the dilatation plus those of persistent chronic catarrh. The patient complains of a sense of fullness in the epigastric region and there is flatulency, eructations and vomiting. The cavity of the stomach being much enlarged, great quantities which are usually considerably decomposed are vomited each day or two. There is often lessened acidity of the vomited mass, though in some cases it is increased. Passage of the food from the stomach to the intestine is delayed and the bowels are constipated, the fecal matter being dry and hard. The urine may be scanty and the skin dry. Anemia, debility and emaciation are always present to a greater or less extent, and on account of the absorption of poisonous matter drowsiness may occur.

=Physical Signs.=—=Inspection.=—In some cases the outline of the distended stomach can be plainly seen. There is prominence of the epigastric region, the tumefaction being at the pyloric end of the stomach. =Palpation.=—The resistance upon manipulation of a dilated stomach is like that of an air cushion. If the patient is made to drink a half tumbler of water, bimanual palpation will cause a splashing sound to be heard along the circumference of the stomach at its lowest point; and by moving the water about by changing the position of the patient, the outline of the stomach can be made. If the sound is not heard at the first manipulation, it must not be concluded that the stomach is normal for the stomach may be so dilated and flabby that it falls behind the abdominal wall like an apron. =Percussion.=—The note is tympanitic over the greater part of the stomach until the lower curvature is reached when the sound is dull (due to the liquid contents of the stomach), followed by a tympanic sound again when the intestines are reached. When percussion is made the patient should always be in a standing position if possible.

When there is =pyloric obstruction= a tumor usually presents itself, and vomiting is more severe and peristalsis more active than when the dilatation is due to atony of the walls of the stomach from an obstructed innervation.

=Diagnosis.=—This is usually easy if due care is taken in making the examination. Goetz has shown by the use of his spinegraphometer that in cases of visceral prolapse the spine is commonly posterior in the dorso-lumbar region. The X-ray is of value in determining the size and function of the organ.

=Prognosis.=—In a case of nervo-muscular atony the prognosis is favorable. If due to a malignant disease recovery is usually impossible. In hypertrophy of the pylorus or the duodenum, recovery is probable by means of surgical interference.

=Treatment.=—When the dilatation is due to atony of the muscular walls of the stomach from obstructed innervation at the spinal column, treatment is usually successful. Attention should be given to the condition of the spinal column in the splanchnic region (fourth dorsal to twelfth dorsal), the spine being usually posterior. A thorough and persistent course of treatment must be given, not only to restore the normal activity of the nerves to the muscular coat and glands of the stomach, but to build up and restore strength in the weakened spinal column. Lesions in the spinal column, even higher than the fourth dorsal, may affect the innervation of the stomach. There are cases where lesions have been found at the fifth, sixth and seventh cervicals that interfere considerably with the action of the stomach, causing nausea, flatulency, eructations, and even vomiting. Such an affection may be through the fibers of the splanchnic nerves or through fibers of the vagi nerves.

The vagi nerves have an important bearing upon gastric dilatation as paralysis of the gastric branches of the vagi arrests the peristalsis of the stomach and thus tends to favor retention of food within its cavity. The stomach in such cases becomes enlarged, mainly by the weight of the food and the presence of gases due to decomposition of the retained food. Thus lesions may be found higher than the lower cervicals and cause obstruction and paralysis of the fibers of the vagi to the stomach.

Direct stimulation over the stomach in the form of thorough manipulation of the stomach walls causes contraction of the muscular fibers of the stomach, mainly the circular fibers. This treatment, with additional treatment of the splanchnic and the vagi nerves, will tend to build up the weakened plexuses of the stomach. Much time can be saved by putting the patient to bed and treating him every day for several weeks. When the stomach is dilated or dilated and prolapsed, to any extent, it usually requires three to five months treatment at least; this time can be shortened one-half by keeping the patient in bed, treating the spine three times a week, and the abdomen every day. Light food at frequent intervals, upper thoracic breathing, and frequent drawing up and in of the abdomen should be required. The patient may also manipulate his own abdomen twice a day to advantage; teach him to manipulate, draw and pull it upward. There is no danger of too frequent treatment as long as there is no bruising of the parts; this, however, does not apply to the spine. It is not an uncommon thing to correct a dilated stomach or a dilated and prolapsed stomach that is an inch and a half or two inches below the umbilicus. Care must be taken in all cases that other viscera are not prolapsed. It is a common experience to find enteroptosis, which can usually be readily functionally corrected, with the stomach ptosis. But where the kidney, or possibly both, is much prolapsed only fair results can be secured until the kidney is replaced and kept there, and if necessary by surgical means. Also, note whether the liver is enlarged. (See special article on Prolapsed Organs).

When the disease is due to cancer and various growths of the pylorus or the duodenum, nothing can be done but palliate. Such cases require surgical attention. In all cases it is necessary that care and preoccupation of the patient should be removed. Baths, changes of air, a carefully regulated diet and caution in the use of liquids will be of great aid to the general health of the patient, and thus the weakened nervous system will be indirectly but greatly benefited. Too great care cannot be taken of the patient, as there is created in the organism a special aptitude for the tissues to become inflamed and thus weaknesses at various parts of the body may occur. Phthisis, typhoid fever and various diseases are apt to follow dilatation of the stomach, as the nutritive and resistive process of the body are impaired.

The meals should be taken regularly and with great care, the patient not eating too quickly nor too much. Solids should be used but little; the artificially digested foods, such as peptonized milk and beef peptonoids, probably being the best. Beef juice and scraped beef are excellent foods, as they are easily digested. Fatty and starchy foods should be avoided.

Washing out the stomach is useful, but it should not be indiscriminately employed. Lavage will not be necessary in all cases of mechanical obstruction. It relieves the distention, by removing the weight and the fermenting and decomposing material.

In =acute dilatation=, which may be due to prolonged diseases, general anesthesia, injuries of the spine, and to narrowing of the duodenum, vomiting, pain and collapse occur. Empty the stomach, and place patient in knee-chest position. Reach beneath the duodenum and raise this part of bowel. Start well down, as low as third or fourth lumbar. If this does not give quick relief stand patient on his head.

Gastroptosis and Enteroptosis[74]

(GLENARD’S DISEASE)

=Definition.=—A displacement of the stomach and intestines.

=Osteopathic Etiology= and =Pathology=.—A weakened, debilitated spine is the common cause. A slight posterior curvature is a frequent occurrence. A debilitated spine impairs the innervation to the abdominal viscera and to the muscles of the abdomen. Many cases are of congenital origin due to lack of complete development and weakness of the supporting tissues. Other causes are muscular strain, repeated pregnancies, tight lacing and malnutrition. A downward displacement of the floating ribs, and a consequent prolapse of, and atony of the diaphragm, is an important cause.

=Prolapses= of the stomach and intestines are of frequent occurrence in both sexes, and very common in women. It is a condition oftentimes overlooked, and when recognized, little has been done in the way of a cure. It is the cause of much disturbance, not only to the stomach and intestines, but to the various abdominal viscera and to the pelvic organs, and it is the cause of a large percentage of prolapses of the uterus, (excluding lacerations from childbirth) for not only is the great suspensory ligament of the uterus (the peritoneum) prolapsed as a consequence, but all of the abdominal viscera and the parietes of the abdomen are also prolapsed and crowded down into the pelvis. The small or large intestine or the stomach may be prolapsed singly. This is frequently the case with the transverse portion of the colon, which may be elongated and tortuous and prolapsed nearly to the symphysis pubis. Prolapse of the liver, spleen and kidneys may occur singly or with a general displacement of all the organs.

=Symptoms.=—The abdominal walls are weak, oftentimes flabby. The viscera of the abdomen do not have normal resistance upon manipulation. The spinal column presents lesions. There is dyspepsia, flatulency, constipation, abdominal pains and various neurasthenic symptoms.

=Diagnosis.=—Is readily made by the lack of tone to the abdominal walls and viscera and the general debility of the patient. Inflation of the stomach with air will determine between gastroptosis and dilatation. The X-ray is of special value in determining position, function, spasms, kinks, etc. of the digestive tube. There are innumerable gradations and phases of this condition.

=Treatment.=—To remove the cause is of primary importance. This is to be followed by treatment of the spinal column, correcting its various derangements and improving the innervation to the atonied viscera and abdominal parietes. Direct treatment over the abdomen helps to give tone to both the viscera and abdominal muscles. In many cases the treatment will have to be a prolonged one in order that the tissues may regain their normal condition. Usually a treatment from two months to a year, or possibly more, is required. Exercises and manipulations that tone the tissues, correct the posture, and raise the chest, diaphragm, abdominal and pelvic viscera, and release spasms, kinks, and adhesions, are indicated. The diet of the patient should be nutritious, and sufficient in emaciated cases to increase his weight if possible. A supporting bandage will often give some relief. A few cases will require surgery.

Particular attention should be given to the colon, duodenum and diaphragm.

Relative to the treatment of gastroptosis and enteroptosis, W. E. Harris writes as follows: “I first set to work trying to correct the spinal irregularities; coupled with this I give deep and careful manipulation of the gastric and intestinal walls—treating my patient two or more times per week for a period of one to three years. A lesser period is not long enough to bring the desired result in such cases. I also instruct the patient to knead his own bowels, which I prescribe as a necessary proceeding, and to be performed twice daily on retiring and before rising. Of equal importance with the osteopathic treatment, come local, specific abdominal exercises. These are to be of the resistive type, and must also be taken for the general musculature. I have my patient retract the abdominal walls and voluntarily draw the abdominal contents towards the diaphragm, in regular series. These exercises must be faithfully performed and continued after the treatment has ceased in order to be of real value. I do not find our treatment, without the hearty cooperation of the patient in doing his exercises conscientiously, to be sufficient in itself. Have the patient avoid overloading the digestive tract. Use concentrated foods, in small quantities, i. e., only sufficient to sustain strength, twice daily and without taking fluids at meal times. Of course water, in small quantities and at frequent intervals, may be taken between meals. To summarize—First, corrective treatment. Second, resistive exercises. Third, attention to diet.” (See Dilatation of the Stomach.)

DISEASES OF THE INTESTINES[75]

Acute Diarrhea

=Definition.=—A diffuse inflammation involving the entire intestinal tract to a greater or less degree. Usually the seat of disease is found in the small intestine and the upper part of the large bowel.

=Osteopathic Etiology= and =Pathology=.—Acute diarrhea may be caused by overeating, drinking impure water, unripe fruits, and poisons produced in decomposed and fermented milk and other articles of food. This sometimes takes place in perfectly harmless substances in an inexplicable manner. Milk and ice cream may produce intestinal catarrh. Dr. Still often referred to the harm resulting from iced drinks. Changes in the weather, tending to weaken the system, often cause diarrhea; hot weather favors this, although a chilling of the system by a sudden fall in the temperature may produce the disorder. Dr. Still was of the opinion that sitting on the cold ground (a common habit of children) is a frequent source of intestinal derangements. Changes in the quantity and quality of the secretions also induce the disorder; thus the bile, if in too great a quantity, increases the peristalsis to such a degree that diarrhea is produced; if diminished, it favors the fermentation and decomposition of the food. Pancreatic diseases may be a cause of diarrhea. Infectious diseases, through their specific poisons, such as cholera, dysentery and typhoid fever; inflammation, extending into the bowels from adjacent parts; inflammation caused by peritonitis and intestinal obstructions, as invagination and hernia; hyperemia, secondary to diseases of the liver, heart and lungs; cachectic states met with in Addison’s disease; the last stages of Bright’s disease; cancer and marked anemia are all among the causes of diarrhea.

As in constipation, diarrhea is oftentimes simply a symptom of various disorders; still, it may be the only symptom manifested. Lesions are found in various regions of the body, but chiefly in the lower dorsal and lumbar vertebræ and the lower ribs at either side. Also lesions may be found to the vagi, thus increasing the peristalsis or affecting the blood supply of the intestines. The lesions to the splanchnics may involve the motor, vasomotor or secretory fibers to the intestines. Oftentimes the innervation to the liver is disturbed, affecting the secretion of the bile. The left side of the spinal column is involved more often that the right side, by vertebral, rib and muscular lesions.

=Nervous Diarrhea= frequently follows fright and other causes of nervous excitement, and is often found in hysterical women. There is simply an increase in the peristalsis and secretion of the bowel, due to a vasomotor paresis of the intestinal vessels, producing an outflow of the serum.

The intestinal condition is one of hyperemia. The secretory glands are frequently inflamed. In decided cases the mucous membrane may be red and injected, but more often it is pale and covered with a layer of mucus. Sometimes the solitary follicles are considerably enlarged. These enlargements may become filled with pus, forming abscesses which rupture, leaving an ulcer. Peyer’s patches may also be involved.

=Symptoms.=—The diarrhea is the important, and often the only, symptom of enteritis; the stools are frequent, varying from two or three to fifteen or more a day; they are thin and watery, varying in color according to the amount of bile they contain. They are usually of a yellowish or greenish color. They contain undigested food, mucus, columnar epithelium and mucous cells, micro-organisms and triple phosphate. The reaction of the discharge is either acid or neutral. There are colicky pains in the abdomen, rumbling noises or borborygmi, intense thirst, dry and coated tongue, with loss of appetite, and, rarely, a fever. When fever is pronounced care should be taken that some infectious disease is not the cause. =Chronic catarrhal diarrhea= may follow the acute form. If the stools contain much undigested food the inflammation is in the upper bowel; if thin, watery and containing mucus, the lower bowel is involved. In prolonged cases the general health is affected. Definite tender areas along the spine and deep muscular contractions are invariably important etiologic and diagnostic clues.

=Diagnosis.=—This is ordinarily made easy by giving attention to the above symptoms. In distinguishing as to whether the large or small intestines are involved the following is important: In catarrh of the =small intestines=, diarrhea is not so well marked; there is much undigested food, but very little mucus; and there is usually pain of a colicky nature in the middle or inferior part of the abdomen. When the =large intestine= is involved there may be no pain; when present, it is intense and usually in the upper and lateral parts of the abdomen; there are borborygmi and thin, soupy stools, mixed with much mucus. If the lower portion of the bowel is involved there may be marked tenesmus, with marked contraction of the muscles over the sacral foramina.

=Duodenitis= is often associated with acute gastritis. Placing the patient in the knee-chest position one may be able to palpate the duodenum. If the inflammation involves the bile duct, there is jaundice; in these cases the urine may be bile-stained.

=Prognosis.=—Commonly favorable if early and prompt treatment is employed; though it should be remembered that some infections, or constitutional disease, or intestinal ulcer may be an underlying cause.

=Treatment.=—Many cases of acute diarrhea will recover by restricting the diet, with rest. Where improper food and water are the causes, an entire change of diet should be considered. Withdrawal of all food and the substitution of boiled milk will be of great aid. The bowels should never be confined if there is reason to suspect that all irritating matters have not been removed; and when fermentation and irritation exist in the lower bowel, an enema will often be beneficial. The spinal column should be examined, especially on the left side, from the fifth dorsal down to the coccyx. The vertebræ may become displaced and cause diarrhea, by derangement of the vasomotor nerves.

Either an increased blood supply through the intestines, or an affection of the motor nerves will produce an increased peristalsis. An active condition of Meissner’s plexuses may be produced sympathetically, resulting in increased secretion of intestinal juice and thus in diarrhea. The ribs may become displaced and be a source of irritation to the nerves of the intestines. The muscles of the spine are apt to become contracted by colds, injuries, strains, etc., and stimulate or inhibit the action of certain centers in the cord and produce disordered intestines. Conversely the muscles of the back may be thrown into a contracted condition by irritating substances in the bowels acting as a stimulus to the centers in the cord, and thus reflexly to the muscles. Trouble may arise in the colon and rectum by lumbar lesions, the slipping of an innominate, a dislocated coccyx, or contracted muscles over the sacrum. In a word, thorough inhibition, relaxing contracted muscles and correcting abnormal vertebræ and ribs are the osteopathic essentials of treatment for diarrhea. Inhibition of the lower dorsal and lumbar is very effective; it dilates the mesenteric vessels by way of vasomotor fibers, and thus controls secretions and lessens peristalsis. This has been clearly proven in the osteopathic experimental work of Burns and Pearce.

Hot fomentations over the dorsal and lumbar spine will frequently, through the nervous reciprocal relationship, be of decided value.

Direct treatment over the mesenteric circulation, i. e., through the abdomen anteriorly, will be helpful in some cases. It relaxes tissues, removes irritations and frees the circulation generally about the mesenteric vessels and intestines. When giving this treatment one should be certain of the underlying pathology. The liver should be kept active. Treatment of the vagus nerves is important, as they help to control the blood supply and the motor nerve force through the intestines. Daily hot baths and increased activity of the skin and kidneys are beneficial.

Chronic Diarrhea, and Mucous Colitis

=Definition.=—A chronic inflammation of the mucous membrane of more or less of the large intestines. There may be ulceration.

=Osteopathic Etiology= and =Pathology=.—Chronic diarrhea may be the result of repeated attacks of the acute form or may be caused by cancer, tuberculosis, Bright’s disease, typhus fever, disease of the liver, organic disease of the heart and lungs, obstructions to portal circulation or impactions of any nature that occasion passive congestion. Frequently cases of long standing are due to chronic lesions of the lower ribs or lower dorsal or lumbar vertebræ. The lesions of the lower ribs usually consist of downward displacement of the ribs, affecting the innervation to the intestines directly, or possibly dragging the diaphragm downward to such an extent as to interfere with the blood and lymph vessels as they pass through it, thus causing congestion of the intestines by obstruction to the lumen of the vessels.

In many cases the =pathological changes= are simply those of the acute form. In more pronounced cases the mucous membrane becomes a brownish red, livid gray or slate color; this discoloration being due to hyperemia and blood extravasation. The mucous coat is also swollen and thickened. Atrophy of the mucous membrane, and in some cases of all the coats, with destruction of the glands, may be a result of the chronic form. Ulcerative changes occur chiefly in the lower part of the ileum and colon; these may be follicular or there may be large ulcers and considerable areas of ulceration.

=Symptoms.=—Constipation and diarrhea frequently alternate; the stools are thin, mixed with a large amount of slimy mucus; the small intestine is most frequently involved, and the patient complains of pain in the umbilical region; there is distention of the bowels with gas; the health gradually declines; there is great pallor, and the patient becomes emaciated, gloomy and irritable.

=Mucous Colitis= is a chronic form of colitis, characterized by paroxysms of severe pain and the discharge of large masses of mucus, forming gray translucent casts, which are not fibrinous but mucoid in character. This disease occurs usually in women of nervous type, but is occasionally seen in men and children. When there is no underlying organic disease, it is probably largely a secretion neurosis. Mental emotions and worry, sometimes errors in diet, or dyspepsia bring on the attack. Overfatigue is often an exciting factor. The nutrition is generally well maintained, but in other cases there may be a gradual emaciation and ultimate death. This is undoubtedly one of the most persistent and troublesome diseases that one will meet; still the osteopath can do much for these cases and not infrequently bring about a cure. But the treatment must be consistent and persistent.

Mucous colitis is not hard to diagnose, although many cases are treated for simple indigestion. It is needless to say that a correct diagnosis is paramount. In these cases there is almost invariably some visceral prolapse, which undoubtedly is the underlying cause, by favoring venous congestion of the bowels. The liver is usually congested; this alone may cause the venous stagnation, but more often it is simply due to the common cause. Back of the visceral prolapse and congestion will almost invariably be found a posterior dorso-lumbar curvature; still there may be a scoliosis or single lesions only, and a downward displacement and constriction of the floating ribs.

The =treatment= requires most persistent and careful work for at least three months, and probably six to nine months. Correction of the spine and floating ribs should be of first consideration; then intelligent treatment over the abdomen, by raising and toning the bowels, not only the bowels as a whole, but especially in the ileo-cecal, hepatic flexure, transverse colon, splenic flexure, sigmoid flexure, and rectal regions. The direct treatment should be cautiously given when there are indications of ulceration.

Have the patient help himself by manipulating his bowels night and morning, drawing the abdomen up and in, and by thoracic breathing. Prescribe plenty of drinking water and reduce starchy and saccharine food to a minimum. Again emphasis is placed upon the necessity of persistent treatment, two and three times per week, for several months. The mucus is hard to remove. It is tenacious and frequently causes colicky pains.

To the student Von Noorden’s[76] monograph on this subject is especially instructive. He notes that almost without exception the patients suffer for some weeks or months prior to the development of colica mucosa from obstinate constipation. For acute attacks, among other things, he advises rest in bed, hot applications, and high water injections. He believes in massage of the large intestine (particularly of the sigmoid flexure), in cases of atonic constipation and also in spastic constipation, provided the patient has a diet that leaves a large residue. “A coarse, laxative diet of Graham bread, leguminous plants, including the husks, vegetables containing much cellulose; fruit with small seeds and thick skins, like currants, gooseberries, grapes; besides, large quantities of fat, particularly butter and bacon.”

=Diagnosis.=—Diagnosis is always easy. The presence of blood, pus, or fragments of tissue in the stool point to ulceration. Ulcers in the rectum, and as high as the sigmoid flexure, will be recognized by examination with the speculum.

=Prognosis.=—Osteopathy has undoubtedly changed the prognosis of other treatment. Many cases can be cured and most other cases greatly benefited. The deep seated ulcerations may cause circumscribed peritonitis, or even abscess, and the prognosis becomes grave as these complications arise.

=Treatment.=—As diarrhea may be caused by lesions anywhere from the sixth dorsal to the coccyx, a most thorough examination is necessary. On the one hand, diarrhea may be due to a marked lateral or posterior spinal curvature, which is plainly seen upon inspection, but on the other hand, it may be due to a slight twist or deviation from normal of a vertebra which would require considerable osteopathic ability to exactly locate. Diarrhea may result from subluxation in the lower costal region, one or more of the three lower ribs on either side being involved. Record of one case, in particular, of chronic diarrhea is of interest as it was due to a rib dislocation. It was the case of a man fifty years of age, who had suffered from chronic diarrhea, several stools a day, for over thirty years. He was completely cured in one treatment by correcting the dislocation of the vertebral end of the tenth rib on the left side. This case is cited to impress upon the student the necessity of precise diagnosis and treatment. Rarely will diseases be cured by a single treatment, but when such happens it exemplifies the potency of the osteopathic lesion. Treatment on the left side is usually more effective in diarrhea than treatment on the right side. When diarrhea is a symptom of some constitutional disturbance, correction of dorsal, lumbar and rib lesions, with thorough inhibition, careful dieting and rest, will commonly suffice provided the primary disease is intelligently looked after.

=Chronic lesions= of the vagi nerves may exist and produce chronic diarrhea in the same manner as in acute diarrhea. Rest and a liquid diet, preferably boiled milk and albumin water, will be a helpful treatment; the diet requirement is to have a minimum amount of waste, so that the residue will cause the least possible irritation. Beef peptonoids with the milk will be a nutritious addition to the diet, and change of air and surroundings may be an aid to a more speedy cure. The skin and kidneys should be kept in a healthy condition and, if necessary, the bowels thoroughly emptied by injections.

Diarrhea of Children

Three forms of diarrhea are recognized in children: Acute dyspeptic diarrhea, cholera infantum, acute enterocolitis.

Acute Dyspeptic Diarrhea

This disease is most frequently due to errors in diet; the mother’s milk may be altered in quantity or quality from taking improper food; the child may be over-nursed, or the foods given in place of the mother’s milk are at fault. Too often a filthy bottle is the cause. The predisposing causes are dentition and extreme heat; and these, combined with constitutional weakness, bad hygiene and a weak spine, diminish the resisting power of the infant. Hence, in artificially fed children of the poorer classes, this disease is very prevalent.

=Pathologically=, there is catarrhal swelling of the mucosa of both the small and large intestines. The amount of mucus is increased, and there is more or less involvement of all the lymphoid tissue. The submucous membrane is often infiltrated. If there is much inflammation ulcers may occur.

=Symptoms.=—The child may seem to be in its usual health, with slight restlessness at night and an increased number of stools. This restlessness may be due to nausea and colicky pain. The stools are copious and offensive, containing undigested food and curds. In children over two years old these attacks may follow the eating of unripe food or drinking tainted milk. In other cases the onset may be sudden with vomiting, purging, and griping pains. The fever may rise rapidly to 103 or 104 degrees or more, sometimes followed by convulsions. The stools become more numerous—there may be twenty in the twenty-four hours—gray or green in color, and sometimes containing much mucus, rarely blood.

=Diagnosis.=—The sudden onset and the character of the stools, which never have a watery, serous character, distinguish this from cholera infantum. And the small amount of mucus which the stools contain distinguishes them from those of ileo-colitis. This form often precedes the onset of specific fevers.

=Prognosis.=—Among the better classes this is generally favorable, but among the weak, half-starved children of the poor it is often unfavorable, especially in hot weather.

=Treatment.=—The child should be clad warmly, kept absolutely clean and given a change of diet and air if possible, with frequent baths. Sterilized milk should be given at regular intervals; or if the diarrhea continues, beef juice and egg albumin instead. The bowels should be thoroughly cleansed by injections. The spine should be thoroughly treated through the lower dorsal and lumbar regions, and if the abdomen is not sensitive, a light treatment to the bowels directly will aid recovery. Frequently it will be found that the muscles of the neck and upper dorsals are considerably contracted, especially where the child has fever and is very restless.

For =acute intestinal indigestion= Ruhrah gives the following dietetic treatment: “Withhold all food for the first twenty-four hours, except a little albumin water. This is best given in small doses at not too great intervals. Plain boiled water may be used instead. Very weak tea to which a little red wine has been added may be given if the child is weak. On the second day the albumin or barley water may be given with the addition of weak strained broth, and on the third day malted milk may be added to the list. After four or five days cow’s milk diluted and boiled or peptonized may be tried. It is best mixed with a farinaceous gruel or with malted milk to start with. It may be given every other feeding for a day or two if it agrees, and the former feeding gradually resumed.

“In nursing infants withhold the breast twenty-four hours and feed as above. After that the breast may be given once for a few minutes and the feeding pieced out with albumin- or barley water. If it agrees the breast may be given for three or four feedings, every other feeding followed by albumin- or barley water. On the following day the breast may be given at each feeding. The time of nursing should be increased gradually until the child is back on its old schedule.”

Cholera Infantum

=Definition.=—An acute, catarrhal inflammation of the mucous membrane of the stomach and intestines, with some disturbance of the sympathetic ganglia. This is a disease of childhood during the first dentition.

=Etiology= and =Pathology=.—Probably due to the poisonous products of decomposing and fermenting foods acting upon the system. The predisposing causes are hot weather, dentition, bad hygiene, the previous presence of some slight dyspeptic derangement, dyspeptic diarrhea, and enterocolitis.

The =pathological= changes are similar to the morbid anatomy of catarrhal gastritis and enteritis. The serous discharges and rapid collapse are due to the intense irritation of the sympathetic system. The kidneys and liver may become involved, and bronchopneumonia is a possible complication.

=Symptoms.=—The disease is of sudden onset, setting in with severe vomiting, which is increased by giving food or drink. The stools are copious and frequent, at first containing some offensive fecal matter, and later becoming watery, and odorless. There is decided fever, reaching as high as 105 degrees. The pulse is rapid and feeble, ranging from 130 to 160. Prostration, pinched features, hollow eyes, depressed fontanelles and loss of weight are characteristic symptoms. The tongue is coated at first, but soon becomes dry and red, and thirst is intense. Even at this time a reaction may set in, but more commonly death results with symptoms of collapse and high temperature. In other cases there are restlessness, convulsions and coma. As there is no cerebral lesion, this condition is probably due to toxic agents absorbed from the intestines.

=Diagnosis.=—This is not difficult, as the toxic symptoms, the severe vomiting, the profuse watery discharge, rapid emaciation and prostration, and the hyperpyrexia are significant.

=Prognosis.=—Grave, even with the most favorable surroundings, although in numerous instances osteopaths have successfully treated this disorder. Much depends upon the promptness of treatment.

=Treatment.=—A change of air, complete rest, removal of all foods for a short time, and absolute cleanliness are of great importance. Thorough treatment should be given along the entire spine, particularly to the splanchnics of the stomach and the intestines, and to the vagi nerves in the cervical region. Frequent bathing with cool water, or better still, wrapping the child in cold, wet sheets, will reduce the hyperpyrexia.

Thorough cleansing of the stomach and intestines with warm water occasionally gives excellent results. In =collapse= the use of a hot bath is indicated, followed by wrapping the child warmly in blankets and placing him in a horizontal position. The food of the child should consist of peptonized milk, raw beef juice, diluted egg albumin, barley water and chicken broth. Nourishment should be given gradually, and =only= after the intense symptoms have subsided.

Acute Enterocolitis

In enterocolitis the ileum and colon are chiefly affected, especially the lymphatic glands or lymph follicles.

=Osteopathic Etiology= and =Pathology=.—Warm weather, the artificial feeding of children, dentition and bad hygiene are predisposing causes. The disease usually occurs between the ages of six and eighteen months, but it is not infrequent in the third or fourth year. This disease is not confined to the warm weather, but may set in at any season of the year. Previous light attacks of diarrhea are often a predisposing factor. Lesions in the spine occur from the eleventh dorsal to the fourth lumbar.

The mucous membrane is congested and swollen, and the solitary follicles and Peyer’s patches are swollen and often ulcerated. The changes may end here or the ulcers enlarge and extend into the muscular coat with the separation of a slough. There may be infiltration and thicking into the submucous and muscular coats, followed by induration of the tissue, producing abnormal rigidity.

=Symptoms.=—The disease may be a sequel of dyspeptic diarrhea or cholera infantum. The temperature increases and the stools change in character, being at first yellow, and later green. They contain traces of blood and mucus. Vomiting may be present, but is not a constant symptom. The abdomen is distended and tender along the course of the colon. The disease may abate here, recovery from the condition being slow; or the symptoms may increase in severity with persistent, small, painful stools, mainly of blood and mucus, tenesmus, and with scanty urine. The child grows pale and emaciated, and assumes a senile appearance. These cases last five or six weeks, death being preceded by coma and convulsions; though a few recover. Relapses are not uncommon and should be guarded against. =Ulcerative and membranous= forms may occur. Pneumonia and nephritis are possible complications.

=Diagnosis.=—=Enterocolitis= is distinguished from dyspeptic diarrhea by the greater severity, more fever, greater prostration, the stools containing more mucus and even blood, and by the greater pain and suffering. =Cholera infantum= may be recognized by the abrupt onset, very high fever, constant vomiting, and early collapse. If typhoid fever seems a possibility, the Widal test should be used.

=Prognosis.=—Grave; recovery follows prompt treatment with favorable surroundings.

=Treatment.=—Attention should be given to the condition of the spine from the eleventh dorsal to the fifth lumbar. An inhibitory relaxing treatment over the sacral foramina will lessen the tenesmus. When the ileum and colon are involved, disorder is usually present at the third and fourth lumbar vertebræ, although the lesion may be higher. Relaxation of all muscles in this region and correction of the vertebral lesions are essential.

Irrigation of the bowels once a day with a pint of cold water is very beneficial and even pieces of ice may be introduced into the rectum. Fresh, pure air, rest and cleanliness, with a restricted diet and daily warm baths are important. In a word, hygienic and dietetic treatment similar to that for acute diarrhea should be employed.

In all forms of diarrheal diseases in children much depends upon previous =osteopathic= attention, =diet=, =hygiene=, and =environment=.

Cholera Morbus

=Definition.=—An acute, gastro-intestinal catarrh of sudden onset, characterized by violent abdominal pains, incessant vomiting and purging.

=Etiology= and =Pathology=.—This disease greatly resembles Asiatic cholera; so much so that one seems justified in suspecting that cholera morbus, like true cholera, is due to a specific organism. No single bacillus has yet been designated as the specific germ, although one has been recognized resembling very much the common bacillus of true cholera. Until this has been fully decided, cholera morbus must be regarded as severe inflammation of the mucous membrane of the stomach and intestines, due to some poison generated from the improper food, which seems to be the cause of the disease, such as indigestible fruits, cabbage and cucumbers. It is most prevalent in hot weather, but is also caused by exposure to cold and damp. The condition of the mucous lining of the intestines is the same as in acute diarrhea. In fatal cases of cholera morbus there is the same shrunken, ashy appearance of the skin that characterizes cholera.

=Symptoms.=—The onset is sudden, with intense cramps in the epigastrium and frequently in the lower limbs; nausea; vomiting, and purging of bilious material, which later becomes almost like water, and in severe cases the discharge becomes serous, finally resembling the rice water discharges of true cholera. There are also intense thirst, moderate fever, rapid emaciation and loss of strength; the surface becomes cold and covered with clammy sweat; the pulse is frequent and feeble. The patient becomes restless and anxious.

=Diagnosis.=—=Asiatic Cholera.=—There is no way of distinguishing between Asiatic cholera and cholera morbus, except by examination of the discharges for the bacillus. Similar attacks are produced in poisoning by arsenic, corrosive sublimate and certain fungi, and are only discriminated from it by clinical history and cause.

=Prognosis.=—In the majority of cases the prognosis is favorable, death rarely occurring. The duration is from twenty-four to forty-eight hours.

=Treatment.=—A strong inhibitory treatment to the gastro-intestinal nerves is at once demanded. This relaxes the muscles of stomach and intestines, dilates the blood-vessels and lessens peristalsis. The treatment should be kept up until relief is given. In some cases, gentle treatment over the stomach and intestines quiets the distress. Inhibition at the occiput gives relief, especially to the nausea and vomiting. Hot applications should be applied to dorsal and lumbar spine.

The vomiting is relieved principally at the fourth and fifth dorsal vertebræ on the right side near the angle of the ribs. Cold carbonated water and pieces of ice swallowed are useful. The diet must be regulated, the further after treatment being symptomatic. Clear the bowel by warm enema if any irritating matter is still present.

Inasmuch as food passes through the small intestine in 4 to 6 hours, and requires 20 hours to pass through the colon, the colon should be emptied by high irrigation in all acute intestinal disorders.

Intestinal Colic

This is a painful spasmodic contraction of the muscular layer of the intestines.

=Osteopathic Etiology.=—Lesions of the splanchnics derange the intestinal nervous mechanism, with a consequent upsetting of circulatory equalization and chemical function of the intestines. Thus irritations and obstructions of the reflex arc predispose to lowered resistance, congestions, and disturbed chemism. Indigestible food, flatulency and impaction of feces oftentimes produce intestinal colic. Exposure to cold and emotional upsets may be factors. Foreign bodies, intestinal worms, abnormal amounts of bile discharged into the intestines, and reflex causes from diseases, as from the ovaries, uterus, liver, kidneys, etc., will produce the disorder; also lead poisoning, syphilis, rheumatism, locomotor ataxia, chronic malaria and hysteria.

Kerley says: “Children who take too much milk, too strong milk, or who take milk too frequently are the usual subjects of colic. Probably the most frequent cause of colic is indigestion of the proteid of the milk; either the proteid is in excess or the child has poor proteid capacity. Not a few cases of colic are due secondarily to defective bowel action.”

=Symptoms.=—Severe paroxysms of pain, centering around the navel and diffused throughout the entire abdomen. The pain is of a piercing, cutting and twisting nature, relieved upon pressure. The abdomen is distended and the patient restless and continually changing his position. The attacks alternate with periods of complete quietude. In severe attacks the features may be pinched and the surface cold, with feeble pulse, vomiting and tense abdominal walls, all indicating incipient collapse. The duration of the attack is from a few minutes to several hours, eased at intervals and usually ending by a discharge of flatus.

=Differential Diagnosis.=—In =lead colic= the history, the slate-colored skin, blue line on the gums, sweetish metallic taste, constipation, slow pulse, retracted abdominal walls, and lead in the urine will designate this disease. =Biliary colic= presents pain in the hepatic region, radiating to the back and right shoulder; also jaundice, calculi in the stools and bile in the urine. Tenderness over the gall bladder is important. =Nephritic colic= is accompanied by pain radiating down one or both ureters to the inner side of the thigh, with retraction of testicle of side affected, or the labia, and blood, mucus, pus or calculi in the urine. In =uterine colic= there is dysmenorrhea and pain in the pelvis. In =ovarian colic= there is extreme pain upon pressure over the ovaries, and hysteria. =Abdominal aneurism= presents tumor, pulsation, bruit. In =inflammatory= and =ulcerative= disorders of the abdomen there is tenderness upon pressure, and fever. The pain of acute appendicitis is at first general, centering in the right iliac fossa in about 24 hours. The X-ray may be of definite aid in renal and biliary conditions and various disorders, such as intestinal adhesions, angulations, etc.

=Treatment.=—Relief of pain is the first indication and is best accomplished by strong inhibition in the splanchnic region, which relaxes the spasm of the intestinal muscles, by normalizing the reflex arc. If disorders of the spinal column are located, it is of primary importance that they be corrected. In cases of irritation of the intestinal mucous membrane, a contraction of muscles of the spine will be found according to the area of the intestines involved, e. g., irritation of the mucous coat of the jejunum causes contraction of the muscles at the tenth and eleventh dorsals. It is a viscero-motor, viscerosensory or viscerotrophic reflex sign. On the other hand, a lesion at the tenth and eleventh dorsals may produce colic or other disorders of the jejunum. The portion of the bowel affected, therefore, can be often told by noticing the places of muscular contraction along the spinal column. Generally the jejunum and ileum are the portions of the bowel affected in intestinal colic. The pain can frequently be controlled if in the jejunum, at the tenth and eleventh dorsals; if in the ileum, at the twelfth dorsal; if in the ileo-cecal region, including the vermiform appendix, at first to third lumbar; if in the colon, at the third to the fifth lumbar; and if in the rectum, over the sacral and coccygeal nerves. Occasionally the duodenum and jejunum are reached by nerves as high as the fifth dorsal (usually vasomotor nerves, not sensory), and the other portions of the bowel lower, according to their respective positions. The relief is given by way of the splanchnics and sympathetics to the mucous (sensory) coat of the intestines, although inhibition relaxes intestinal muscles (motor nerves) and dilates blood-vessels (vasomotor nerves). Though precisely localized inhibition is of decided value, still if normal alignment, through adjustment, can be secured results are usually quicker and more satisfactory.

Anterior treatment to the abdomen helps to relieve the contracted fascia of the mesentery, with a consequent freeing of the circulation. It aids peristalsis of the intestines and expulsion of the irritating material. This probably produces considerable effect by way of the axone reflex. Direct treatment to the abdomen for the peristalsis relieves also constipation, impactions and the enteralgia, the latter principally by firm pressure. Peristalsis is also increased by stimulation of the vagi and inhibition of the splanchnics. The latter treatment, of course, is not given to relieve pain directly, but to facilitate the removal of irritating substances if such are the source of trouble. If this does not produce a movement of the bowels promptly, a warm enema will assist greatly. The cecum and sigmoid should not be overlooked.

=Flatulency= can be relieved by direct pressure upon the solar plexus, which apparently removes obstructions to the abdominal nervous system (particularly the nerves of the digestive glands, as fermentation and flatulency are due to a disproportionate secretion of digestive juices) and thus the gaseous formations are absorbed. Additional treatment to the lower dorsal vertebræ and lower ribs to relieve nerve lesions and increasing both thoracic and abdominal circulation may be indicated.

As stated in the etiology of intestinal colic, the splanchnic nerves contain not only sensitive fibers, but motor and vasomotor fibers as well. The same is true of the vagi nerves; they exert upon the intestines not alone a motor influence, but also a blood control; consequently, our work in a certain region can be for more than one purpose. Hot applications to the abdomen may be of benefit. And hot fomentations to the spine for 20 or 30 minutes (affecting reciprocal innervation) is often of great benefit. The diet should always be regulated for a few days at least.

Constipation[77]

=Constipation= is an unnatural retention of feces from any cause. The following causes are frequently met with: A deficiency of the bile or other secretions that aid peristalsis; many acute and chronic diseases which lessen the secretions and impair peristalsis, such as anemia, hysteria, chronic affections of the liver, stomach and intestines and acute fevers; certain drugs and strong purgatives; strictures; concentrated food; sedentary habits, overfatigue and neglect of the calls of nature. Atony of the colon may be caused by chronic disease of the mucosa and by general disease causing debility. There may be weakness of the abdominal muscles, due to obesity and the distention of frequent pregnancies, or obstructions, such as displaced uterus, pregnancy, prolapsed cecum, sigmoid or rectum, and displaced coccyx. Constipation is really a symptom, in most cases, of some disease; many times it is about the only symptom observed. One has to take into consideration the many causes that would produce constipation when the treatment of a case is undertaken. A disordered structure may be found in almost any region of a body, which would bear directly or indirectly in the causation of constipation.

Irregular habits often bring on the most obstinate cases of constipation in later life. There may also be local causes, such as disturbances of the normal secretions, impairment of intestinal walls, due to inflammation, and mechanical obstructions caused by tumors, intussusception, twists, etc. Constipation in infants is usually caused by errors in diet, but may be congenital.

In all obstinate cases the X-ray should be employed in diagnosis.

In the majority of cases lesions will be found in the vertebræ of the lower dorsal and lumbar regions, or in the lower ribs of either side. The lesions may affect the vascular supply and innervation of the intestines directly, or the lesion may cause the constipation by affecting some other digestive organ first. Lesions to the vagi affecting the peristalsis of the intestines are common.

The usual =symptoms= are frequent stools, debility, lassitude, headache, loss of appetite, anemia, furred tongue and fetid breath. Serious symptoms may result in long continued cases, such as piles, ulceration of the colon, perforation, enteritis and occlusion. The fecal mass may become channeled and diarrhea may occur from the irritation. In long standing cases of constipation, if the patient suddenly develops diarrhea the rectum should be well examined to see if there are impacted feces present. Neuralgia of the sacral nerves may also be caused by impacted feces in the sigmoid flexure.

=Treatment.=—Naturally, owing to the numerous etiological factors, each case is a special study and the treatment is necessarily varied. Many cases will present slight impaction of the bowels, a sluggish liver, spinal lesions and so on, which simply require a specific treatment and all the symptoms will be removed. On the other hand, constipation may be due to prolonged ill health and thus require a careful, systematic treatment, not only of the bowels, but of the entire system. Of primary importance in these cases is regulation of the diet, plenty of exercise, sufficient sleep, and regularity in going to stool at a fixed hour each day. The effect of attention to the latter point, in some instances, will be sufficient to perform a cure. Too much cannot be said in regard to the beneficial effect of systematic habits.

Lesions may be found in the spinal column producing constipation from about the fifth dorsal to the coccyx, although principally the lower three dorsal and upper two lumbar vertebræ are at fault. Constipation may be caused by defects at any point in the intestines, and consequently the sections of the spinal column sending nerves through the intervertebral foramina to the several sections of the bowels should be examined. At any point from the fifth dorsal to the coccyx, certain vasomotor, motor and secretory nerves of the intestines may be affected by various lesions. The vasomotor nerves keep up the vascular tone of the bowels, the motor nerves the peristaltic action and the secretory nerves attend to the intestinal juices. In constipation, disorders of the spinal column are generally found on the right side. There is no good reason offered as to why this is so.[78] In those cases where the liver is impaired, the answer might be because most of the nerves to the liver are on the right side, but the right side is just as often affected when the lesions are in the lumbar region and the nerve supply to the hepatic region intact. Dr. Still considered the fifth dorsal of importance.

The =vagi nerves= have important bearing upon the motor apparatus of the intestines. Lesions in the upper cervical, involving intestinal fibers of the vagi, occur occasionally. Stimulation of these fibers increases the peristalsis of the intestines. Mechanical stimulation of the mid and lower dorsal region, as shown by osteopathic experiments, increases peristaltic action and vaso-constriction in the stomach and intestines.

The value of =direct treatment= over the intestines from the duodenum to the rectum in most cases of constipation cannot be overestimated. It aids peristaltic action, removes impactions, stretches adhesions, strengthens weakened muscles of the intestines and abdomen, and in general gives tone to all of the abdominal organs. The treatment should not be given in a hap-hazard manner, but each effort should be for a definite purpose. Care should be taken not to bruise the intestines or other organs, as by gouging or severe punching; the flat surface and the palms of the hands should be used. This means that the part of the bowel involved should be treated intelligently, the osteopath reaching underneath the section and the patient drawing the bowels up and in. Obstructions and impactions of the gut, especially at the ileo-cecal and sigmoid regions, should be carefully corrected. At all angles of the gut, impactions and prolapses may occur.

J. H. Sullivan[79] makes the following observation concerning severe, deep abdominal treatment: “I have noted that this often resulted in the reverse of good effects. In constipation, naturally then, I am chary about treating abdominally, confining my work principally to the biliary regions, the ileo-cecal and left iliac regions and have attained good results when a promiscuous working of the abdomen had not so resulted.” This emphasizes the point that specific treatment is as much indicated for the abdomen as it is for the spine.

Frequently there will be found a spastic condition of the pelvic colon, often associated with congestion and adhesions. This probably sets up a reversed peristalsis. Treatment by inhibitory relaxation, with patient in knee-chest position, and adjustment of lumbar and innominate lesions, is indicated.

Direct treatment to the liver and biliary ducts is necessary in many cases, as the bile secretion is often defective; thus a slowness or inactivity of the liver and bile ducts might cause costiveness.

Some cases result from anesthesia of the rectum, due to pressure of the fecal matter collecting in the rectum. Simple dilatation of the rectal sphincters and a stimulating treatment through the sacral nerves will bring about a healthy activity of these parts. Occasionally the coccyx becomes displaced and produces paresis of the rectal nerves; or a displaced uterus or a tumor may produce the same result.

The use of =proper food= is essential. Coarse food leaves a great amount of residue, and on the other hand, dainty food leaves but little residue, both causing costiveness. As a rule increase the amount of fruit and vegetables. The patient should drink considerable water, and the time is of importance. Have a glass of cool, not iced, water taken on arising and if breakfast is delayed sufficiently, another in half an hour. Most people do not drink enough water. Unless contraindicated eight or ten glasses daily should be insisted upon. An enema[80] occasionally is indicated and is a great aid when used, particularly in cases of paralysis of the intestines and in impactions. Correct breathing and out door life are beneficial.

=Treatment of the Constipation of Infants.=—Repeated small enemata at a fixed hour each day will often be satisfactory but be certain that the tissue is not irritated. Two ounces of tepid water at a time should be injected. Careful spinal treatment and massage to the abdomen will be useful, as will slight dilation of the anus, which is usually done with the little finger, but in obstinate cases a soap stick may be used. When there has been continued straining at the stool, the sigmoid and rectum will often be found prolapsed, causing a mechanical obstruction. With the finger well lubricated this can be corrected and often is all that is needed. These directions, with care in the foods, are usually sufficient in any case not congenital. In chronic constipation Ruhrah outlines dietetic treatment as follows: “In infants see that they get sufficient fat and protein; well cooked and sweetened oatmeal gruel is useful. Orange juice, baked apple, or prune juice taken on an empty stomach is of service. Olive oil, the malted foods, or malt extracts are useful. In older children fresh fruits, vegetables, and oatmeal porridge are of value. Graham bread, dates, figs, and prunes may be used.”

Intestinal Obstruction

(ILEUS)

This is due to a sudden or gradual closure of the intestinal canal at any point. Closure of the gut may be caused by strangulation, intussusception, twists and knots, abnormal contents, strictures, tumors, kinks, spastic states, adhesions, etc.

=Strangulation.=—This is the most frequent cause of acute obstruction of the bowels. There may be stricture of the bowels due to inflammatory processes producing bands or adhesions, or due to the adhesion of a bowel to an abdominal wound; a vitelline remnant, as a blood vessel, may remain and act as a strangulating cord, or in Meckel’s diverticulum one end may be attached to a mesentery or abdominal wall and thus form a ring through which the gut may pass and become strangulated.

Strangulation may take place through the foramen of Winslow or the foramen ovale, or between the pedicle of a tumor and the abdominal wall.

Peritoneal pouches, mesenteric and omental slits, adherent appendix or Fallopian tubes and diaphragmatic hernia may be other causes. An internal strangulation (hernia) may take place in the crural or inguinal canal, in the umbilicus, in the sacro-sciatic notch or in the opening through which the infra-pubic vessels pass. In strangulation there is a constriction of a portion of the bowel causing an arrest of the circulation of blood at that point, and more or less stoppage of fecal matter of the intestine.

In ninety per cent of cases the strangulated part is in the lower abdomen and sixty-seven per cent occur in the right iliac fossa, according to Fitz.

=Intussusception or Invagination.=—Intussusception is a slipping of a part of the intestine into another part immediately below it, as the slipping of a part of a finger of a glove or a coat sleeve into another part. The portion involved may be anywhere from half an inch to a foot or more in length. This produces compression and inflammation of the intestine, and obstruction to the intestinal contents. It occurs principally in children and is more common in males.

Spasms of the intestinal muscles and perverted peristalsis are probably the most common causes. One part of the bowel may be dilated and an adjacent portion contracted, thus allowing an invagination. Diarrhea, habitual constipation and intestinal polypi are important exciting causes. Invaginations oftentimes occur just before death, probably due to irregular peristalsis.

Following engorgement and inflammation of the invaginated portion, a tumor is usually present, and lymph is exuded which may cause the layers of gut to adhere, so that the invaginated portion is firmly held. Necrosis and sloughing are then likely to take place.

Intussusception varies according to location and is named according to the part of the bowel involved. There are commonly recognized (1) Ileo-colic, when the ileo-cecal valve enters the colon. (2) Enteric, of the small intestines. (3) Colic, of the large intestine. (4) Colico-rectal, of the colon and rectum. (5) Rectal, of the rectum.

=Twists= and =Knots=.—These occur more frequently in males, usually between the ages of thirty and forty. In nearly all cases the twist is axial, accompanied by relaxed and lengthened mesentery. One portion of the bowel may be twisted about another, or a loop of bowel twisted upon its long axis. A bowel being impacted or overdistended by feces and gas, is quite likely to roll on its axis or knot and become dislocated, its weight and inactivity thus producing compression and obstruction of the bowels. The volvulus commonly occurs in the large intestine, at the sigmoid flexure and in the ileo-cecal and cecal regions. It occasionally occurs in the small intestine.

=Abnormal Contents.=—Obstructions may be caused by gall-stones, enteroliths, lumbricoid worms, certain medicines (such as magnesia and bismuth), fruit stones, coins, needles, pins, buttons, etc., and fecal matter. Foreign bodies usually lodge in the ileo-cecal region and in the small intestine, while fecal impactions occur in the large intestine, more frequently in the lower part. Females are more subject to it than males.

Its causes are many and are similar to those of constipation. Spinal lesions are very frequent, probably causing paresis or paralysis of a segment of the bowel; or all the forces that maintain a normal activity of the intestines may become impaired. Hemmeter[81] says it is “more frequently the result of defective innervation of the intestine.”

=Impactions= are frequently met with and are easily overlooked under any diagnosis which does not include thorough palpation of the abdominal viscera. The impaction may be so large as to produce dilation of the bowel. The obstructive mass becomes very hard and dry and perhaps channeled, allowing some material to pass until, finally a large piece of fecal matter will obstruct the passage completely. In =diagnosis= it must not be confused with neoplasms, tumors, etc. Impactions may occur at any point of the colon and the weight so drags the bowel out of position as to be misleading. The principal points are the ileo-cecal region, sigmoid flexure, and rectum. Tenderness is usually present, as may be diarrhea which must not be taken as evidence that the bowel is clear. Impaction gives rise to many reflex symptoms and is often the real cause of many mistaken conditions.

Too much cannot be said on the importance of a thorough examination of colon and its connections, which should be routine of every examination as the large bowel is impacted much more often than suspected and may be the seat of many reflex and direct disturbances. The heart may be affected by weight upon the vessels, gastric disturbances and signs of auto-intoxication from absorption may appear.

Dilatation of the sigmoid flexure, especially when it is congenitally long, may even be so great as to crowd up and interfere with the liver and diaphragm; in these cases the coats of the intestines are usually hypertrophied.

=Strictures and Tumors.=—These usually occur in adults, more frequently in women and generally involve the large intestine and lower part of the abdomen, most of them occurring in the left iliac fossa. They frequently result in chronic obstruction. Occasionally, a stricture may be spastic, due to vertebral lesions, that is severe enough to cause complete blockage of intestinal contents. These are usually of the pelvic colon. There are cases where the opposite condition, paralysis of a section, generally of the small intestine, occurs. This may be due to injuries to the bowel, or to damage of the blood supply, or to derangement of the innervation.

Scar tissue, following ulceration of the bowel; tumors of various kinds; and congenital defects, are possible sources of intestinal obstruction.

=Symptoms.=—=Acute Obstruction.=—There is constipation, nausea, vomiting, and pain. The pain is of a colicky nature and may come on abruptly. After the contents of the stomach have been vomited, the material becomes colored with bile, and finally stercoraceous vomiting occurs. Observing the contents vomited (gastric, bile-stained, and fecal) will greatly aid in the diagnosis. The contents of the bowel, below the obstruction, may be emptied or complete constipation may remain. All the symptoms, as a rule, rapidly grow more pronounced. The pain is more severe; tenderness occurs over the abdomen in limited areas; there is slight tympany; the eyes are sunken; the skin is cold and clammy; the pulse is quickened and feeble; there is rapid increase of leucocytes; the urine highly colored; the tongue is dry and there is incessant thirst; tenesmus and tumor may be marked, and fever occasionally occurs. The above condition may continue from three days to a week, when collapse and death may occur, if relief is not obtained.

=Chronic Obstruction.=—In fecal impactions constipation of long standing is commonly observed. In some cases the fecal mass has become channeled, allowing the bowels to remain open; the patient possibly not knowing that there is any trouble. In fact, diarrhea may be present, due to irritation above the impaction. Finally, however, obstruction occurs; the breath is offensive, the appetite is poor, the abdomen swells, and there is fullness and weight within the abdomen, accompanied by pain and vomiting. Upon examination before complete closure, the fecal impactions can easily be felt through the abdomen externally. The tumor is a yielding mass. It has been mistaken for an enlarged liver or gall-bladder, a kidney, or a tumor of the stomach or duodenum. Other symptoms may be present as hiccough, jaundice, tenesmus, tumultuous peristalsis, local peristalsis, local peritonitis and collapse. In stricture caused by cicatrices that may have been formed years before, complete obstruction takes place. Transient attacks often occur. Usually the general health is greatly impaired long before complete occlusion.

=Diagnosis.=—A diagnosis can usually be made by careful, thorough examination through the abdominal wall, in connection with the symptoms, and the physical signs. The region of intestinal trouble is manifested by contracted muscles at certain points along the spinal column, corresponding with the particular portion of the bowel involved, as indicated under intestinal colic. Examining the patient in the knee-chest position will often give a better opportunity to locate and outline the obstruction. Rectal and vaginal examinations should not be neglected. Intestinal obstruction may be confounded with tumors, hernia, intestinal colic, enteritis, peritonitis, hepatic colic and renal colic. =Peritonitis= may be differentiated by the history, the early fever, diffused tenderness and absence of fecal vomiting. When =invagination= occurs, besides the symptoms of obstruction, the age, tenesmus, bloody discharges and the sausage-shaped tumor in the line of the colon, will be diagnostic. In =stricture=, the history, gradual onset, and ribbon-like and bloody stools will distinguish that disorder. In =tumors= the gradual onset, age, bloody discharges, and cachexia will be important symptoms. X-ray diagnosis may be of value in certain cases.

=Treatment.=—Treatment of the bowels directly is required, and each case must depend for its relief upon the ingenuity of the osteopath. Rules to be followed cannot be given, as cases vary in manner of involvement and in location, consequently the correction of the disorder depends as much upon the ability of the osteopath as does the determination of the diagnosis. Taxis is the method commonly used in relieving intestinal obstructions, though other methods may be employed.

In =invagination=, raising the buttocks and lowering the chest, with thorough injection of oil or tepid soapsuds, or an inflation of the colon with air, may give relief. In addition to thorough but cautious manipulation of the bowels as in =impaction=, irrigation of the lower bowel with warm water, soapsuds, or glycerine and water, will usually be of material aid. In =strangulation=, high injections of warm water, and assuming the knee-elbow or lateral position, may straighten out the acute obstruction. =Twists= and =knots= are best relieved by direct treatment, although injections may be of aid. =Kinks= of the pelvic colon, ileum, and duodenum are best treated with the patient in the knee-chest position. =Tumors= and =strictures= will require, sooner or later, surgical interference in most cases, but to treat as in impaction will be effective for a short time at least. If there is no indication of immediate =relief within three days, surgical interference should be instituted=. Besides the ordinary treatment for the nausea and vomiting, washing out the stomach will help allay such disorder, quiet the peristalsis and relieve the abdominal distention and pressure above the seat of obstruction. Strong thorough treatment of the spinal nerves to the stomach and intestines will be of great help in lessening pain, establishing normal peristaltic action and in suppressing inflammation. The vagi also should be treated for perverted peristalsis. Hot fomentations will be of service. The nutrition of the patient is best retained by rectal injections of food.

=Spastic= states, particularly of the pelvic colon, frequently cause constipation of various degrees of chronicity. Reaching beneath the spastic area and inhibiting and raising (knee-chest position) the parts will often give marked relief.

=Adhesions= can often be stretched sufficiently to restore normal function of the bowels.

Treatment of =impactions= and =abnormal contents= requires an additional word. The first step is to free the colon of the fecal mass. The enema is of great assistance in this, for cases of long standing present a hard, dry mass, often adherent, and the mucous membrane is sensitive from inflammation. Much abdominal treatment must not be given until the mass is softened by water. When in the sigmoid or rectum it may, if not dislodged by repeated enemata, have to be removed by a colon spoon, perhaps under anesthesia. Impaction of the small intestine is rare and out of reach of the enema, although if taken as hot as can be borne, it will exert considerable influence high up. In these tendencies and in constipation, when the bowel must be kept open before treatment has produced much effect, there should be an effort made to break up any cathartic habit which may be formed. The enema is a most valuable aid, but it must be given correctly. The patient should be instructed that a fountain syringe is preferable, and that it must never be taken standing. This merely fills and distends the rectum, or lower sigmoid at the best, and is passed without any or with very little effect. Lying on the right side is a very good position, as is also on the back with hips elevated, but the knee and chest is best in most cases. The water should be a little above body temperature and can be saponified or used clear. The effect will be about the same. The tube should be perfectly smooth and well lubricated and introduction must be made with care so as not to bruise or irritate. The water, having been allowed to run to expel the air, may be now started and will separate the mucous folds and allow easy penetration. The rubber tube should be held between the thumb and finger, so the flow can be stopped as soon as it meets an obstruction. When this is passed the flow can begin again and continue until the required amount (from one to two quarts for an adult), has been taken, or until the feeling of distention becomes too great. By following this method, much of the distress and colicky pains which sometimes accompany an enema, may be avoided. Water should be held for some minutes, to allow softening of the fecal mass. In many impactions it is important to get the water into the ascending colon. For that purpose nothing is better than a Coles sigmoid irrigator. This is shaped somewhat like the letter S and is about a foot long from tip to tip. Its introduction is not difficult, but care must be used. Place the patient on the right side and stand in front, having the bag suspended near. Introduce the tube and with slow, gentle pressure let it follow the course of the bowel. When the splenic flexure is reached, it will stop, but by letting a little water flow, the bowel will distend and it will pass. When in the full length, the end will be near the median line and in the transverse colon. Now let the water flow slowly, stopping frequently, and with one hand gently lift and work the abdomen. This will both soften the contents and aid the water in reaching the farthest point. It is not well to give more than a quart the first time, as there is apt to be some prostration. The tube also has the mechanical effect of raising and replacing the sigmoid, descending colon and splenic flexure. When there is lack of tone to the bowel or when very little stimulus is needed, a half pint of cold water taken in the morning, will often act quickly. Appliances which force the water into the bowel when the patient is sitting, are not recommended, as they tend to stretch the muscular coat by pressure from lifting a column of water.

=Hernia.=—There are several methods of replacing a hernia. The first endeavor, in every instance, must be to reduce it, whether it be strangulated, incarcerated or simply protruded. One of the easiest and commonest methods is to place the patient on his back, the buttocks elevated, the legs flexed upon the thighs, the thighs flexed upon the abdomen, and the limb on the affected side slightly rotated inward, so that the columns of the ring about the hernia may be relaxed. After the hernia is protruded a little more, so that its contents may be emptied readily, a gentle pressure with the thumb and finger is made upon the upper part of the tumor, when the rest will follow. A gurgling noise is heard upon reduction. Cases that cannot be reduced and are causing acute obstruction of the intestines, should be treated surgically. Incomplete hernia, which does not show externally, may be present and cause severe reflex symptoms. Considerable attention has been given to this by some investigators. The patient is placed in the Trendelenburg position and the bowel lifted out of the fossa. If any signs of hernia are present a well fitting truss will often cause it to heal. Exercises, in a few instances, will be beneficial.

Appendicitis

=Appendicitis= is an inflammation of the appendix vermiformis. In a few cases the cecum and surrounding tissues are involved (typhlitis, perityphlitis). The vasomotor nerve supply comes from the lower three dorsals and upper two lumbars. The sensory nerves make their exit from the three lower dorsals. Appendicitis is nearly always predisposed by injury to the innervation of the vermiform appendix and immediate region, vertebral derangements or subdislocations from the tenth dorsal to the third lumbar. The vermiform appendix is a peculiarly constructed organ, and its function has not been determined with positiveness. It undoubtedly has a function and possibly a very useful one. Sir William Macewen[82] does not share in the general belief that the appendix is without function, but protests against its indiscriminate removal, believing it has a powerful influence over the function of the colon. “Yet thousands have been operated and show no ill effect.” This is in keeping with the ideas of Dr. Still, who always maintained that the appendix is of importance to the human economy. Although the organ has been found in various localities of the abdomen, this fact and others do not necessarily indicate that it is a functionless relic. It is richly supplied with lymphatic and blood-vessels and has a peristaltic action peculiar to itself. When the organ is in perfect condition, foreign material probably would not find a lodging point in it, on account of its peristalsis. Dr. Still[83] suggests that the appendix has a sphincter, also the power to contract, dilate or shorten, should any foreign substance enter, and he worked with this idea in view with uniform success. The truth of this theory has been proved by Abrams[84] who has demonstrated by the aid of the fluoroscope that peristalsis of the appendix can be stimulated by percussion at the 10th dorsal and it made to empty and fill itself. Abrams makes use of this fact in the treatment of catarrhal appendicitis. Appendicitis may also be caused by fecal impactions and foreign bodies in the bowel contiguous to the appendix. In these cases there is usually an impaired innervation from the spine, due to vertebral and lower rib lesions, resulting in a weakened muscular coat and catarrhal congestion of the mucosa. In a word, prolapse of the bowel at this point is a predisposing common cause. In various instances abrasions of the coats of the tube occur, or the innervation or vascular supply is impaired, and pathogenic bacteria, as bacilli coli communis, streptococci pyogenes, staphylococci pyogenes aureus, typhoid bacilli, tubercle bacilli and others, find a favorable lodging point and determine the nature of the disease. Injuries to the spinal column and displacements of the vertebræ in the lower dorsal and lumbar regions, straining and lifting, tight lacing, torsion of the appendix, traumatism, impaction of feces, concretions and foreign bodies, acute indigestion, indigestible food, overeating, exposure to wet and cold, and infectious diseases (as typhoid fever, tuberculosis and influenza), are all in the list of causes of appendicitis.

=Pathologically=, in most cases the inflammation is catarrhal. This includes many of the mild attacks. The mucosa is inflamed similarly to catarrhal processes elsewhere, although the inflammation may rapidly spread to the deeper structures unless immediately cared for. The inflammation may be so severe that the lumen becomes closed. This is termed =obliterating appendicitis=. When this occurs the attack may cease and danger from subsequent attacks are at an end, but inflammation may go on to purulent involvement and even to =ulceration=, =gangrene= and =perforation= or =peritonitis=. An =abscess= may be within or without the appendix. =Adhesions= are likely to form about the mass.

=Symptoms.=—A sudden, violent pain in the abdomen, usually localized in the right iliac region, although at first this pain may be general. The point of greatest tenderness is detected over McBurney’s point—a point at the intersection of a line between the umbilicus and the anterior iliac spine, with a second drawn along the outer edge of the right rectus muscle. The patient usually lies on the back with the right leg drawn up. The severity of pain is not indicative of the seriousness. If the pain ceases suddenly, it is commonly a serious indication. There is usually fever at the onset, the temperature being from 100 to 102 or even 104 degrees F., and very rarely preceded by a chill. In favorable cases the temperature gradually falls, reaching normal in from five to seven days. If recovery has not begun by this time an abscess is probably forming. If =suppuration= takes place the temperature continues with but slight fall, although in some cases there is a rise, or it may become almost normal. Pain in the right iliac fossa, without fever, rarely points to an acute attack of appendicitis. Vomiting and nausea are more or less frequent, and more commonly present in the event of perforation or rupture of an abscess. In favorable cases vomiting rarely lasts beyond the second day. In the majority of cases constipation is present from the beginning of the attack, due to paralysis of the bowels. There may be diarrhea, particularly in children.

“=Urine= is febrile in character with large quantities of indican. The =blood= shows leucocytosis. A leucocyte count of 20,000 is high and indicates an acute appendicitis, with pus, gangrene or peritonitis.”

On =inspection= of the abdomen at the onset of the attack, the sides look alike, but on =palpation= there is rigidity of the rectus abdominis muscle and the other muscles overlying the seat of inflammation. The whole abdomen may be slightly distended. In the majority of cases there is a progressive development of a hard swelling or tumor in the right iliac fossa. These tumors vary in size, but are usually oval and the size of a hen’s egg, and generally situated a little above Poupart’s ligament. =Fluctuation= of the tumor is indicative of suppuration. There is often great irritability of the bladder and frequent micturition. A sudden fall in the temperature often indicates that a perforation has taken place, or that a small abscess has ruptured into the intestines. In favorable cases the temperature falls at the end of the third or fourth day, the pain lessens, the tongue becomes clearer and the bowels are moved. If the tumor persists, the patient is very liable to have a =recurrence= of the condition.

Rapid growth of the tumor and aggravation of the several symptoms point to suppuration, especially =extreme tenderness= over the point of inflammation. If the appendicitis goes on to suppuration, there is danger of rupture into the peritoneum. In a few cases the abscess may rupture into the bowel, in which case the patient recovers. Other terminations are lumbar abscess, hepatic abscess and perinephritic abscess. Death may be caused by septicemia or pylephlebitis. These events may be delayed a variable length of time, depending upon the extent and strength of the adhesions that form about the abscess. “The gravity of the appendix disease lies in the fact that from the very outset the peritoneum may be infected; the initial symptoms of pain, with nausea and vomiting, fever, and local tenderness, present in all cases, may indicate a widespread infection of this membrane.” (Osler). He also says local signs are not so trustworthy as the general symptoms.

There is liability to =relapse in appendicitis=. The attacks may recur for years at different intervals. In some cases these intervals are very short. In some cases perfect recovery may take place after repeated attacks.

=Diagnosis.=—In many cases the diagnosis is easy, but other cases require careful study and close observation. Sudden pain becoming localized, tenderness and rigidity in the right iliac region are three symptoms that together almost positively indicate appendicitis. The leucocyte count is of particular value. A =pseudo-appendicitis=, with all symptoms of true appendicitis in the initial stage, may be caused by the downward dislocation of the twelfth rib on the right side, and occasionally the eleventh rib on the same side. The rib lies obliquely downward toward the crest of the ilium. In a few cases the obliquity of the lower rib is so great as to very nearly touch the ilium. The dislocated rib may produce severe irritation, pain, tenderness, rigidity, and even inflammation, of the abdominal muscles. The patient nearly always complains of the pain being deeply seated, thus possibly confusing one. In =typhoid= there is a gradual development of the fever, characteristic temperature curve, enlargement of the spleen, epistaxis and diarrhea. The Widal test should be made. The absence of fever and intermittent pain in the abdomen, with complete constipation, fecal vomiting, general distention of the abdomen, bloody stools and marked tenesmus would determine =intestinal obstruction=. In =tubal disease= a gradual onset, a more dull and constant pain, the history, and pelvic examination will usually differentiate this disorder from appendicitis. Kelly[85] gives these points in differential diagnosis, between acute salpingitis and appendicitis: “In the former it will usually be found that there has been a yellowish vaginal discharge for some period before the attack. The local pain and tenderness, usually located deeper in the pelvis, is most intense on palpation in the region of Poupart’s ligament. On vaginal examination exquisite tenderness is felt on either side of the uterus.” In =biliary colic= the pain is higher along the biliary ducts and gall-bladder, extending even as high as the shoulder, and jaundice is generally present. In =renal colic= the pain extends along the ureters down to the inner side of thigh and testicle, and back into lumbar region. There is absence of fever and rigidity. The pain in =perinephritic abscess= is downward into groin, as in nephritic colic, and there is tenderness of the lumbar region. Exploratory incision may be necessary.

=Prognosis.=—Naturally, the prognosis depends upon the character of the appendicitis, but on the whole the prognosis is favorable. A large proportion of cases recover. Surgical operations are many times deferred until too late; undoubtedly on account of the uncertainty of the condition. Still, on the other hand, many serious cases recover under the proper treatment when an operation seemed almost absolutely necessary; all going to prove the fact that very much depends upon diagnosis of the true condition. The statement that there is “no medical treatment for appendicitis,” seems rather broad in view of the report of the medical inspector[86] of the French Army in Algeria. Out of 668 patients suffering from appendicitis, 188 were operated upon and 23 died, while 408 were treated medically and only three died. He concluded that a meat diet tended to increase the number of cases. “It is exceedingly common and the prognosis is, on the whole favorable. Tafft, of Copenhagen, found adhesions in the neighborhood of the appendix in 35 percent, of all bodies subjected to post-mortem examinations[87].

=Treatment.=—Confine the patient in bed at once. Cases have undoubtedly been lost by not enforcing this point. Attempts should be made to correct the disordered condition of the dorsal and lumbar regions. Thorough and careful treatment should be given at this point, and in most instances the pain can be relieved by correction of the disordered vertebræ. If the case is seen at the beginning of the attack, careful manipulation that especially lifts the cecum and surrounding structures and local application of ice are indicated. However, great care should be exercised here, for some of the most severe cases show no induration. Temperature, pulse, and blood picture are invaluable as guides. When the case is advanced, extreme care should be used in manipulating over the swollen and inflamed region. Hot applications will be helpful in such instances.

When due to fecal impaction and foreign bodies, thorough, direct, elevating treatment over the involved region, and high rectal injections are indicated. This applies to the onset, for if the disease has progressed to the point where pus may be present, the =bowel= must be =absolutely= at =rest=. Do not give or allow to be given purgatives at any stage of the disease. When =sure= that =there is no pus=, direct, careful work over the cecum and appendix is allowed and is of value. It should be a lifting of the colon and relaxing of nearby tissues, to promote the circulation. Treatment of the spine is necessary in all cases, to relieve pain, to correct the nerve and vascular supply, and to increase peristalsis so as to remove irritating bodies from the vermiform appendix. “Colitis follows appendectomy more frequently than any other abdominal operation. The explanation for this is that the appendicitis is seldom localized in the appendix but is complicated by colitis, or rather the colitis is complicated by the appendicitis. In such cases, removal of the appendix aggravates rather than alleviates. A conclusion to be drawn is, to carefully palpate the colon in all appendicitis cases and reserve diagnosis, prognosis and advising of an operation until it can be definitely determined as to the location, extent and degree of the disease. The formation of pus is an indication requiring immediate evacuation.

“If good surgical advantages are available and the case begins with considerable virulence and a surgeon can be had within the first twenty four hours, it is in all probability best to operate; but if the case begins slowly or no good hospital advantages are available, or if the case is not seen until some forty-eight hours have elapsed after the onset, in all probability it is strictly an osteopathic case and should not be touched by surgery. Some advocate in all instances to wait until pus is formed before operative procedure is resorted to. This is a rather dangerous attitude to take, for I have seen hundreds of cases operated and have operated upon a great many myself and I have never seen a case die unless it was a pus case.”—S. L. TAYLOR.[88]

The case should be most carefully watched, and a surgeon should be promptly called for consultation if the occasion demands it in the least; and if thought advisable, operation should be resorted to before too late. Do not assume too much responsibility in these cases. The patient should be nourished on a restricted diet of milk and animal broths. Asa Willard[89] strongly recommends no food by mouth, as it is bound to set up peristalsis and cause increased irritation. He sustains the strength by rectal feeding. This view is held by other authorities, even to withholding water when the inflammation is at its height. Tasker confirms the advisability of restricted feeding and advises resting the bowel even to the point of discontinuance of food. The course of the attack is usually so short that there is no danger of starvation and little loss of strength results. This point is a highly important one in cases of any degree of severity.

In =chronic cases= of a fibrotic character, no pus, carefully lifting the parts and loosening adhesions in addition to spinal adjustment will often restore normal circulation. These conditions aside from the local disorder frequently cause hyperchloridia and other digestive disturbances.

Diseases of the Liver and Bile Duct

Primary diseases of the liver will invariably present osteopathic lesions from the fourth or fifth dorsals to the eleventh or twelfth. The ribs on the right side are commonly involved. These lesions probably disturb the liver by way of the vasomotor fibers. Displacements of the duodenum, of the hepatic flexure and transverse section of the colon and displacements of the right kidney are frequent sources of liver disorders. Care should be taken in differentiating primary from secondary diseases, for naturally the relative importance of the various factors in treatment will vary. In many secondary diseases there will be found predisposing osteopathic lesions, and these secondary disorders and degenerations can at least be palliated and occasionally the degeneration retarded or stopped by persistent osteopathic treatment, diet, and hygienic measures.

Hyperemia of the Liver

This is an abnormal fullness of the blood-vessels of the liver, followed by an enlargement of that organ. It is active when there is abnormal pressure in the portal veins (afferent vessels); passive when there is excessive pressure in the sublobular veins (efferent vessels).

=Osteopathic Etiology= and =Pathology.=—=Active hyperemia= is usually due to indiscretions in diet. After each meal a physiological hyperemia of the liver occurs, which is greatly increased by habitually overeating and overdrinking. This condition may lead to functional disturbance and possibly to organic change. Traumatism and lesions of the vertebræ and ribs, irritating vasomotor nerves, are important. Habitual constipation, malaria, heat, and arrested menstrual epoch, and infectious fevers are also causes of the active form. Enteroptosis is not a rare cause.

=Passive hyperemia= is due to obstructions of the efferent circulation. Valvular heart disease is the most common cause. Lung diseases, as emphysema or cirrhosis; obstruction to the vena cava or interference with the flow of blood through the liver; and diseases of the pleura, are among the causes.

Most cases of congestion of the liver present lesions to the vasomotor nerves of the liver, fifth to ninth dorsal. Especially are the ribs over the liver apt to become displaced and affect the organ.

=Pathologically=, the liver is enlarged and engorged with blood. The appearance of the organ depends upon the duration of the hyperemia. In passive hyperemia the central portion of the lobule and the area of the hepatic vein are deeply colored. The periphery and the area of the portal vein are pale. This alternation of the dark and light color gives rise to the nutmeg liver, which is so noticeable upon section. In cases of long standing, atrophy of the liver cells and overgrowth of connective tissue result.

=Symptoms.=—=Active Hyperemia.=—Dull aching and a sense of fullness in the right hypochondrium, aching of the limbs, coated tongue, nausea, vomiting, constipation, highly colored urine, and slight jaundice.

In =passive hyperemia= the symptoms are the same, but less marked. The onset is gradual and the liver may attain considerable size. In severe cases following tricuspid regurgitation the liver may pulsate. In severe cases dropsy takes place.

=Diagnosis.=—Active hyperemia is occasionally confounded with catarrhal jaundice. Usually congestion of the liver is easily diagnosed.

=Prognosis.=—In active hyperemia the prognosis is good, unless repeated attacks lead to atrophic degeneration. In passive hyperemia the prognosis depends entirely upon the cause.

=Treatment.=—=Active hyperemia.=—The treatment consists of measures which tend to diminish the congestion, principally a thorough, direct manipulation over the liver by raising and spreading the ribs. Careful and thorough treatment to the dorsal splanchnics of the liver is also indicated. The substitution of a scanty for a heavy diet is essential. The foods given should be such as are easily digested, as milk and broths; fats and sugars are to be avoided.

In =passive hyperemia= the treatment consists of correcting the disorder causing it. Often heart diseases are the cause. A thorough depletion of the bowels will aid largely in relieving ascites that may follow passive congestion (See ascites).

In liver congestions it is well to pay attention to the intestinal condition in order that the circulatory mechanism here may be thoroughly coordinated with the hepatic.

Simple Catarrhal Jaundice

=Definition.=—Jaundice due to inflammation of the terminal portion of the common duct, not the result of impacted gall-stone. The disease probably starts as a catarrhal inflammation of the stomach and upper portion of the small intestine. The bile is retained and absorbed.

=Osteopathic Etiology= and =Pathology=.—A frequent predisposing cause is the subdislocation of the tenth rib on the right side, thus interfering with the innervation to the bile ducts, and causing congestion of the mucous membrane of the common duct; although lesions above and below this point may occur. Extension of gastro-duodenitis into the common duct is a common source of the inflammation. Sagging of the duodenum will disturb the bile-duct through its being a portion of the duodeno-hepatic ligament. Duodenal catarrh usually follows errors in diet, exposure, malaria, Bright’s disease, portal obstruction and chronic heart disease. Infectious fevers, as pneumonia and typhoid fever, and emotional disturbances are among the causes. Catarrhal jaundice may occur in epidemic form.

=Pathologically=, the duodenal end of the duct is most commonly involved. The mucous membrane is swollen and the orifice fills with mucus. The inflammation may involve the common and cystic ducts and even the hepatic. The liver is enlarged and the gall-bladder distended.

=Symptoms.=—The only symptom present may be simply the jaundice. There is always tenderness upon pressure over the ducts. The patient many times complains of a stabbing pain when pressure is exerted over the duodenal opening. Usually the course of the bile duct can readily be felt upon deep pressure, owing to the tumefaction. Accompanying this condition may be general malaise, loss of appetite, nausea, vomiting, constipation or irregular action of the bowels, pains in the back and limbs and a slight fever.

=Diagnosis.=—Where jaundice is present without pain, it generally indicates catarrhal jaundice. The absence of emaciation or of evidences of cancer or cirrhosis usually makes the diagnosis easy. Good general nutrition and a negative physical examination favor simple jaundice as to the diagnosis.

=Prognosis.=—The prognosis of catarrhal jaundice is favorable, unless accompanied with infectious diseases or hypertrophic cirrhosis. When diseases are associated with jaundice the danger is usually from the disease. The duration of the disease is generally given as from two to eight weeks, but osteopathic treatment generally lessens that time at least one-half.

=Treatment.=—The treatment is directed toward relieving the inflammation of the bile ducts and increasing the flow of the bile into the intestines. Great relief to the patient will be experienced from thorough treatment over the bile ducts, especially at the duodenal end. Press slowly but firmly over the region of the ducts, then execute a downward motion with firm pressure over the course. This performance should be repeated several times, until the tenderness in this region is almost or entirely relieved. The idea of this treatment is, =first=, to slowly but firmly bear down upon the abdominal muscles over the congested tissues, so as to relax the tissues and get as close to the ducts as possible, and =second=, with the downward movements to reduce the congestion of the ducts and at the same time to remove any mucus or other material from the orifice, thus allowing a freer flow of bile. It will be recalled that the normal flow of bile is under very low pressure. Care should be taken not to gouge or dig into the tissues with the ends of the fingers, but to use the flat surface of the fingers. Any gouging or severe treatment will not allow one to accomplish his purpose, owing to the stimulus or irritation it would give the abdominal muscles and thus cause them to contract; and furthermore, it would more or less bruise the parts. An inhibitory treatment should be given along the spine on the side affected to help relax the abdominal muscles before this treatment is administered. In all circulatory disturbances of the bile-duct and other hepatic tissues lift the duodenum at about the second lumbar where it lies beside the ascending colon. This tends to release portal vein, hepatic artery and bile-duct, the duodeno-hepatic ligament.

=Direct treatment= is given to the liver by more or less kneading or working the organ and also by raising and spreading the ribs. This treatment is to stimulate the activity of the liver. Reaching under the cartilages of the eighth and ninth ribs on the right side and bearing inward and downward will empty the gall-bladder and thus be of aid in relieving the tension in the biliary passages. It is probably a stimulus to these cutaneous fibers that causes a relaxation of the sphincter muscles of the gall-bladder and thus allows it to empty. Stimulation of the tenth nerve contracts the gall-bladder. Then it should also be noted that work over the duodenal end of the bile-duct relaxes the orifice while through reciprocal relationship the fibers of the gall-bladder contract. When all of the muscles of the hepatic region have been carefully relaxed and softened, a thorough examination can then be made of the vertebræ and ribs that might embarrass the innervation or vascular supply of the liver. Lesions of the vertebræ and ribs affecting the liver may occur from the sixth to the eleventh dorsal. Lesions to the vagus and phrenic nerves may occasionally involve the organ.

Irrigation of the large bowel with cold water may be employed. The cold excites peristalsis of the gall-bladder and ducts. Drinking freely of water will be helpful. A non-stimulating diet should be given. The stomach may not be in a condition to bear solid food; and furthermore, food on entering the duodenum will increase the local inflammation of the common bile duct. Give diluted milk, buttermilk, light meat-broths, clam-broth, egg albumin and pressed beef juice. After the pain, vomiting and fever subside, the diet can be gradually increased.

Cholecystitis

=Cholecystitis= is an inflammation of the gall-bladder caused by infection. Stagnation of bile due to obstruction (especially gall-stones) of the bile ducts, or a slowing of the bile flow owing to deranged innervation from osteopathic lesions or sagging bowel, are predisposing factors. Fibrotic changes in the appendix are fairly common sources that derange the nervous reflexes of the biliary function. The disorder may be associated with specific fevers.

Exciting factors are the colon bacilli, streptococci, staphylococci, typhoid bacilli, and pneumococci.

=Symptoms.=—The gall-bladder feels hard and full. There is inflammation and thickening of the mucous membrane, with considerable increase of mucus. Owing to the infection there may be ulceration and suppuration, with possible perforation and peritonitis. When the inflammation extends outside of the bladder there are usually adhesions.

The onset is commonly sudden, with pain and tenderness in the right hypochondrium. Great care should be taken in deciding the location of the inflammation, for the pain and tenderness may be over the stomach, or along the duodenum or ascending colon as low as the cecum. Nausea, fever, constipation, and possibly jaundice, are other symptoms.

=Treatment.=—Exercise special care in treating these cases. Although in many instances the inflammation will rapidly subside, still owing to suppuration there is danger of aggravating the condition. It is better, in doubtful cases, to confine the treatment to spinal work, and to influence drainage by placing the patient in knee-chest position and carefully raise cecum, ascending colon and duodenum. Rest, restricted diet, plenty of water, and hot fomentations will be beneficial. In severe cases surgical interference is indicated.

Jaundice

(ICTERUS)

=Jaundice= is a symptom and not a disease. It consists of the discoloration of the skin and other tissues by material derived from the bile. The discoloration may vary from a mere paleness to a yellow or brown olive hue.

=Toxic= jaundice occurs in acute yellow atrophy, pernicious anemia, pyemia, specific fevers, and the action of poisons.

=Obstruction= by foreign bodies as gall-stones and parasites are important causes. Inflammation and swelling of the biliary ducts and duodenum are common causes as well as stricture of the duct by tumors and various growths, either internal or external, to the biliary ducts. In some instances pressure from without by the pancreas, stomach, kidneys, enlarged glands, fecal matter, a pregnant uterus, etc., has been the cause. Irritations and obstructions of the splanchnic nerves, due to lesions in the lower dorsal vertebræ and the ribs from the sixth to the eleventh, will often markedly affect the liver. Also lesions at these points may predispose to inflammation and tumefaction of the bile ducts.

=Symptoms.=—Besides the discoloration of the skin, there is itching of the skin, on account of bile pigment deposits; even eruptions may occur. The mucous membranes are often colored and a constant symptom is the bright yellow discoloration of the sclerotic coat of the eye. The secretions are colored. It may be first noticed in the urine. The perspiration is colored, rarely the saliva and tears. There is frequent sweating.

As very little bile passes into the intestine, the feces are pale and gray, and sticky. The bowels are generally constipated, but diarrhea may occur, owing to decomposition resulting from absence of the normal ingredients. Other symptoms may be associated with the gastro-intestinal derangements, as nausea, fetid breath and loss of appetite. A slow pulse may occur, due probably to some stimulating effect on the inhibitory action of the vagus nerve. Lesions are often found at the atlas and axis, affecting the vagus. Pain back of the right scapula is a symptom of liver trouble; it has been suggested that it is due to a stimulus passing up the vagus to the spinal accessory, and thence to the trapezius muscle.

Various cerebral symptoms may be present, as great depression, irritability, headache and vertigo. In severe cases there may be delirium and coma.

In =hemolytic= and =toxic jaundice= the destruction of blood is due to some toxic agent. The feces are not clay colored and the urine is less stained with bile. The general symptoms may be very severe depending upon the underlying cause.

=Diagnosis.=—To mistake for jaundice the dirty yellowish discoloration of the skin commonly termed sallowness is an error often made. This condition indicates malaria, uterine disease or general ill health. Very likely it is an anemia and is readily diagnosed from the jaundice as the secretions and conjunctiva are not stained. Addison’s disease somewhat resembles jaundice, but the feces are normal, the urine and sclerotic coat are not colored, but exposed portions of the body and flexures of the joints are deeply stained.

=Prognosis.=—Depends entirely on the cause producing it. Ordinary cases run from two to six weeks, while others may not recover for several months. Jaundice from impaction of the bile ducts may be manifest for only a few days. Toxic form may terminate fatally, owing to the disease causing it. The extent of resorption of bile and destruction of red blood cells in the liver varies to a considerable degree.

=Treatment.=—The treatment for the different forms resulting secondarily will be found under the diseases causing them. A simple icterus, caused by disturbance through the innervation of the liver and bile ducts directly, can be relieved readily by thorough treatment of the liver and bile ducts as described under catarrhal jaundice. Carefully raise the intestines if they are prolapsed, especially the colon and duodenum.

Cirrhosis of the Liver

This is a chronic disease of the liver, characterized by hyperplasia of the connective tissue with destruction of the liver cells, resulting in the organ becoming hard and usually small.

=Etiology.=—The disease usually occurs in the male sex and in middle life. When occurring in children, it is commonly of the syphilitic form, though it may be due to other infections. The abuse of spirituous liquors is a common cause. It follows chronic diseases, such as syphilis, long continued malarial intoxication, gout and tuberculosis. Passive congestion, due to chronic heart and lung disease, causes some cases. A few cases are caused by inflammation of the bile ducts, due to infection and obstructing calculi; others to a stimulating diet, while some cases are inexplicable.

=Pathologically=, the =first stage= is hyperplasia of the connective tissue and consequent enlargement of the organ. As this increases the connective tissue destroys immense numbers of the hepatic cells, owing to the pressure. Often the enlargement is accompanied by tenderness. In the =later stage= the overgrowth of imperfectly developed tissue seems to contract the hepatic cells that still remain, causing atrophy and degeneration of most of them, and thus reducing the size of the organ, which is followed by sclerosis. The portal and hepatic circulations are greatly obstructed. An occasional form is termed =hypertrophic sclerosis= in which sclerosis is found while the organ continues enlarged.

There are two common and well defined varieties, atrophic cirrhosis and hypertrophic cirrhosis; other forms (rare) are met with.

=Atrophic cirrhosis= is the common form, and is usually due to alcoholic excess. The surface of the liver is rough and uneven in addition to its hardness and reduction in size. It may also be greatly deformed and covered with granulations (“hob-nails”). The normal weight is four or five pounds, but it may be so reduced as to weigh no more than one pound or a pound and one-half. Sometimes there is =fatty infiltration=, which enlarges the liver to such an extent that the contraction is not noticed. There is an overgrowth of the connective tissue, which contracts and constricts the branches of the portal vein, causes atrophy and degeneration of the hepatic cells, and even sometimes obliterates the bile ducts. The new connective tissue is well supplied with blood-vessels from the hepatic artery, thus aiding greatly in the growth.

In the =hypertrophic form=, as well as in the atrophic cirrhosis, there is an overgrowth of connective tissue, but in the hypertrophic form the new form of tissue exhibits no disposition to contract. The enlargement of the organ is largely due to hyperemia. As the tissue does not contract there is no pressure on the portal vein and atrophy is prevented. There is early jaundice (which is a characteristic symptom) owing to obstruction of the biliary channels. The surface is smooth and its color is greenish yellow.

=Symptoms.=—=Atrophic Form.=—There may be practically no symptoms. As there is obstruction of the portal circulation, there may be congestion of the stomach and intestines, resulting in chronic gastric or intestinal catarrh having the following symptoms—anorexia, distress after eating, distention, constipation and coated tongue. Owing to the anastomotic communication between the portal and caval circulations, as the portal circulation becomes more obstructed, the superficial abdominal veins become greatly distended. Hemorrhoids occur, owing to the communication of the superior hemorrhoidal, which is a branch of the portal vein through the inferior middle hemorrhoids, with the hypogastric vein and the vena cava; hence hemorrhoids are a characteristic symptom. There is enlargement of the spleen and hemorrhage from the stomach or bowels. Edema of the legs and ascites are due to engorgement of the portal system. Ascites is much more common than edema of the legs. There may be slight jaundice, although this is a rare symptom in atrophic cirrhosis. There is always decided emaciation. On examination there is a diminished area of hepatic dullness, while the splenic dullness is enlarged. It is often impossible to outline these organs, as the abdominal distention prevents it. The urine is scanty, high colored and often loaded with urates, but seldom bile-stained.

In the =hypertrophic form= slight jaundice appears at the onset, which gradually deepens until it is intense and persistent. Occasionally there is fever. The disease as a rule is decidedly chronic, though acute symptoms may develop at any period. The urine is often bile-stained, but of normal quantity. On examination the liver is large, smooth and round and can be felt below the ribs. The spleen is greatly enlarged.

=Diagnosis.=—In =atropic cirrhosis=.—With ascites without dropsy elsewhere, history of alcoholism, hemorrhage from stomach or bowels and reduction in size of liver, the diagnosis is absolute.

=Hypertrophic cirrhosis.=—In =cancer= of the liver the patient is advanced in years, has no splenic enlargement, and more commonly ascites is present; while in hypertrophic cirrhosis there is chronic biliary obstruction, the liver is only moderately enlarged and hard, marked jaundice, with causes leading to or evidence of hepatic obstruction. This form of cirrhosis is also to be differentiated from =amyloid liver= and =echinococcus cyst=.

=Prognosis.=—Unfavorable, although in some cases the disease can be arrested during the early stage, provided the habits are regulated and treatment is continuous and persistent. Death usually occurs from one to two years after appearance of dropsy. Ascites is difficult to contend with.

=Treatment.=—If the disease is recognized at the beginning and persistent treatment given to the liver, the chances are that atrophy of the cells and connective tissue formation will not take place. But ordinarily cases of cirrhosis are incurable. The most that can be done is to reestablish a compensatory circulation in the liver. Otherwise it would be no more unreasonable to say that one could cure a chronic valvular lesion of the heart. The patient should live a quiet outdoor life. Alcoholic drinking should be stopped. The diet should be light and nutritious, preferably a milk diet. The bowels should be kept open, the skin active and the kidneys closely watched.

Fatty Liver

In fatty infiltration there is no loss of function. The fat infiltrates the cell, crowding aside the protoplasm. This is largely a normal process, though fatty degeneration may be associated.

In fatty degeneration the cell loses its structure and is changed into fatty tissue. Chronic intoxication from infectious diseases, such as phthisis puerperal fever, typhoid fever, pneumonia and syphilis are the principal causes. Alcoholism and phosphorous poisoning are other causes.

Amyloid Liver

There is infiltration into the tissues of the liver, of the so-called amyloid substance. The infiltration begins in the blood-vessels, the hepatic artery first, then the central zone or periphery, and finally all structures of the liver. This disorder should be viewed as a disturbance of metabolism.

=Etiology= and =Pathology=.—This condition is usually found in cases of prolonged suppuration, especially associated with tubercular disease of the bones as in hip-disease, syphilis, rickets, malaria, cancer and leukemia. It is believed by some to be the result of microbic invasion, especially the tubercle bacillus and staphylococcus. Lesions are frequently found from the fifth to the tenth dorsal vertebræ, which probably act as predisposing factors.

The liver is considerably enlarged and rounded. It is pale or waxy in appearance and is doughy in consistency. On section it is anemic and whitish, partly due to infiltration into the walls of the blood-vessels narrowing the lumen. The amyloid changes may be circumscribed and in some cases fatty infiltration is present.

=Symptoms.=—There are no characteristic symptoms except the enlargement of the liver, although the complexion may be waxy and there may be some gastro-intestinal disturbances. Pain is absent, although occasionally there is a dragging sensation, due to the weight of the organ. Jaundice is not present, but the stools may become light colored, owing to a diminished secretion of bile. The urine may be increased in amount and contain some albumin if amyloid occur in the kidneys. Emaciation and anemia are present and ascites seldom occurs. Amyloid changes involve the spleen, kidneys, intestines and other organs.

=Diagnosis.=—The organ being large, hard and smooth, with absence of jaundice and ascites, the presence of albuminuria and an enlarged spleen and with the history of the case, mistakes are not likely to be made.

=Prognosis.=—Depends upon the cause. The progress may be rapid or slow.

=Treatment.=—Careful attention to the primary disturbing factor and direct treatment to the liver will, in some instances, reduce the size of the organ. Nitrogenous food and hygienic measures should be instituted. The vasomotor nerves of the portal system (fifth to last dorsal) should be treated thoroughly.

Gall-Stones

=Gall-stones= are concretions that originate in the gall-bladder and occasionally in the hepatic ducts. “The primary formation of gall-stones is itself largely dependent upon =stagnation= of bile, such as may arise in the gall-bladder if an intermittent or incomplete closure of the cystic duct be brought about by such things as tight lacing, pregnancy, or even unequal sagging of the abdominal viscera.”—MacCallum. The stone is largely composed of cholesterin, and may form without any inflammation of the gall-bladder, owing probably to the stagnation affecting the bile salts so that the cholesterin is precipitated instead of being held in solution.

More often there is inflammation of the wall of the gall-bladder due to micro-organisms. This causes an exudate from which is derived the calcium. The calcium with bilirubin is deposited in layers on the stone which give it the various colors of yellow, brown or green.

A rare type is one formed in the hepatic ducts, which is soft, green, and composed of calcium bilirubin concretions.

The stones “contain a great deal of organic material derived from desquamated epithelial cells and coagulated albuminous matter, as well as pigment.” The colon bacilli, staphylococci, streptococci, typhoid bacilli, and pneumococci are the bacteria most frequently found. A =cholecystitis= may be a predisposing factor or it may be secondary to the concretion.

=Osteopathic Etiology= and =Pathology=.—This is a disease of middle life and is more frequently found in women. Sedentary habits and constipation combined with overeating, are other important factors. It is found in stout subjects who are particularly fond of starchy and saccharine food. Catarrhal jaundice is a predisposing factor. Depressing mental influences may predispose. The thicker the bile the more likely it is to deposit. Dr. Still’s theory is that lesions of the ribs on the left side from the sixth to the tenth dorsal are factors in the formation of the stones as they interfere with pancreatic secretions. No matter how it comes about, the fact is that in all cases of gall-stones the osteopath finds lesions to the eighth, ninth and tenth ribs on the left side, as well as lesions from the fifth or sixth to the tenth dorsal, deranging innervation to the liver and bile ducts. It is possible that lesions over the spleen probably interfere with the activities of the spleen and thus in some manner this organ does not properly elaborate the blood before it passes to the liver. Sagging of the duodenum may, through tension on the duodeno-hepatic ligament, interfere with the flow of bile. This would cause derangement of the nervous reciprocal relationship between opening at duodenal orifice and gall-bladder. In carcinoma of the liver and stomach, gall-stones are said to be frequent.

The stone itself is a brownish object, nearly spherical, faceted and in some instances polygonal in shape, varying in size from a pea to a hen’s egg.

The stones are found anywhere in the biliary tract from the duodenal orifice to the ramification of the bile vessels. Usually there is more or less of an accumulation in the gall-bladder. At any point the stone may produce ulceration and suppuration. Perforation may occur into the peritoneal cavity or adjacent organs.

=Symptoms.=—Gall-stones may be in the gall-bladder for years without giving rise to any symptoms. Their presence is made known only by their expulsion from the gall-bladder. If they lodge in the duct in transit from the gall-bladder to the duodenum =biliary colic= is produced, which is the characteristic symptom of an impacted gall-stone. Small stones may pass into the intestine without producing symptoms. The pain is very sudden, piercing and excruciating in the region of the gall-bladder, when a stone attempts to pass. The pain radiates through the abdomen, right chest and shoulder, and the patient writhes in agony and occasionally faints. Downing[90] emphasizes the point that when a patient comes in with a history of repeated attacks of biliary colic and no stone found in the stools one should at once suspect that one of considerable size obstructs the common duct.

There is always tenderness in the biliary region with more or less contraction of the abdominal muscles. Nausea, vomiting and sweating are usually present, followed by a weak pulse, cool skin and pale and anxious face. Fever is soon present and a chill is common. The paroxysms continue as long as the stone remains lodged, which may be from an hour to several days. There are remissions of pain, entire relief being given as soon as the stone reaches the duodenum. Jaundice usually follows a prolonged attack. The liver is sometimes enlarged. The spleen is enlarged. Should the stone become impacted, ulcerative perforation, with consequent peritonitis and shock, follows.

=Diagnosis.=—The diagnosis is conclusive when the gall-stones are found in the stools or when they can be felt in the gall-bladder. All the above symptoms are characteristic. If a patient complains of severe pain radiating from the hepatic region, and nausea and vomiting are present, subsiding suddenly with a slight jaundice, the disease should hardly be mistaken.

Tenderness over the gall-bladder frequently indicates infection or gall-stones or both. Radiographic examination may be of aid.

=Nephritic colic= should never be confounded with hepatic colic as in the former the pains start in the lumbar region and radiate downward into the groin, the testicle and the inside of the thigh. In =appendicitis=, jaundice and bile-stained urine are not found. A =pseudo-biliary colic= is occasionally found in nervous individuals especially when the eleventh and twelfth ribs (or ribs as high as the seventh) on the right side are displaced downward.

=Prognosis.=—Is usually favorable. Ulceration, perforation, and suppuration may prove fatal, although much depends upon surgical interference.

=Treatment.=—During the attack of =biliary colic=, the osteopath should usually be able to readily locate the position of the gall-stone in its transit from the gall-bladder. He should usually proceed at once to aid the stone in its downward passage by careful manipulation over the duct. Still this treatment should be given with great caution, for if there is suppuration or ulceration, perforation and resultant peritonitis may occur.

Usually one will not have much difficulty in dislodging the stone and relieving the sufferer in a few minutes. The recumbent position, with the thighs flexed on the abdomen, is the position assumed for treatment, and if the muscles in the hepatic region are very tense and rigid, interfering with locating the gall-stone, an inhibitory treatment to the posterior spinal nerves supplying the contracted muscles will aid one materially. An inhibitory treatment of the nerves of the biliary tract (the ninth and tenth dorsals), may be a helpful measure in dilating the duct. Also, hot application over the affected area and to the dorso-lumbar region will aid.

During remissions two or three treatments per week should be given to correct the lesions at the eighth, ninth, tenth and eleventh segments. Give particular attention to any enteroptosis that may be found. Average cases should not require more than two or three months’ treatment. Hildreth, who has had many cases, is much opposed to operation as his experience has been that where there is not complete obstruction the correction of lesions will prevent further formation of stones. While he finds the trouble ranges from the third to the eighth dorsal, still, as a rule, it is between the fifth and sixth that best results are obtained. Probably if the treatment is a rightly directed one the stones already formed may be disintegrated. Willard[91] reports 393 cases.

Permanently impacted gall-stones require surgical treatment. Prophylactic treatment, as a regulated diet, daily exercise and a discontinuance of excesses, should be strongly urged. The patient should not be allowed any fatty or saccharine food. Water freely taken will be of aid.

Diseases of the Spleen

Diseases of the spleen are usually secondary to other disorders. The following osteopathic treatment under Splenitis will, in addition to the probably primary disturbance, be applicable to active and passive splenic hyperemia and amyloid degeneration of the spleen. Surgical and other measures are to be employed when indicated.

Owing to the role that the spleen plays in infections, the osteopath pays considerable attention to stimulating the organ through its spinal innervation in these cases.

Splenitis

In acute =splenitis= there is generally a blocking up of the smaller splenic arteries by fibrous coagula (hemorrhagic infarct), which have formed in the left ventricle of the heart in consequence of endocarditis. Malarial infections, septicemia, typhus and acute exanthematous fevers may cause coagula formation in the splenic veins. Injuries to the vertebræ or ribs on the left side over the spleen (ninth to eleventh ribs inclusive) are occasionally the predisposing cause of primary inflammation of the spleen. Following the formation of abscesses the entire organ may suppurate; it may produce pyemia, or it may burst and the pus be discharged into the peritoneal sac, causing peritonitis, or into the pleura, stomach or colon. =Chronic splenitis= is induced by passive congestion, leukocythemia and splenic anemia.

=Symptoms.=—Tenderness and enlargement of the spleen are the principal symptoms. The organ may be twice its normal size, but in a few cases the tumefaction is so insignificant that it can hardly be found on percussion. Dull pain generally exists if the enveloping membrane or adjacent organs are involved, the pain being increased upon percussion and deep inspiration. In a few cases the pain radiates to the left shoulder and if the peritoneal covering is involved, a sharp pain will be present. Fever and rigor follow if suppuration has taken place, and peritonitis follows in case of rupture or perforation. Marked hypertrophy and chronic inflammation may cause cough, nausea, vomiting and dyspnea.

=Treatment.=—In the treatment of both the disease producing splenitis, and of primary splenitis, a thorough treatment of the spine, eighth to the eleventh dorsal, is necessary. The nerves (vasomotor) to the spleen are from the left splanchnics, consequently treatment of the left side is more effectual. Particular attention should be given the ribs over the spleen—the ninth, tenth and eleventh—as disorders of these ribs are a common cause of splenic disturbances. Careful and fairly firm treatment is always indicated, care being taken not to add irritation to an already inflamed organ, and especially beware that force is not used where there is danger of rupture. Stimulation of the tenth nerve contracts the spleen. In cases of suppurative splenitis the direct treatment should not be given.

Stimulating treatment over the spleen, as over the liver and kidneys, gives tone to the strong elastic capsule surrounding it, so that direct manipulation over these organs, coupled with the power of the strong elastic capsule and highly elastic tissue of the inner organ, will greatly aid in lessening the engorgement and hyperemia. In a few cases where the spleen is involved, lesions are found in the upper cervical which affect the right pneumogastric nerve and thus impair the normal activity of the gland.

FOOTNOTES:

[74] See special article, Prolapsed Organs, Part I.

[75] The student will receive many helpful suggestions by reading Macleod, Physiology and Biochemistry in Modern Medicine; Cannon, The Mechanical Factors of Digestion; Carlson, The Control of Hunger in Health and Disease; Gaskell, The Involuntary Nervous System; Pottenger, Symptoms of Nervous Disease.

[76] Von Noorden, Colitis, 1904.

[77] See Philosophy and Mechanical Principles of Osteopathy, p. 190.

[78] There are several possible suggestions. (1) Developmental (See Mayo, Relation of the Development of the Gastro-intestinal Tract to Abdominal Surgery. Jour. A. M. A. Feb. 7, 1920). (2) Owing to the appendix, cecum, ascending colon, duodenum, and biliary tract being frequently disordered. (3) Imbalance of muscular tension, owing to the muscles of the right side being often the better developed. Muscular lesions and lymphatic involvement of the cervical region seem to occur oftener on the right side than on the left.

[79] Journal of Osteopathy, May, 1900.

[80] For points on enema, see treatment under Intestinal Obstruction.

[81] Diseases of the Intestines, Vol. I, p. 240.

[82] The Lancet, (London,) Oct., 1904.

[83] Philosophy of Osteopathy, p. 226.

[84] Medical Record.

[85] The Vermiform Appendix and Its Diseases, p. 711.

[86] Dr. Chauvel, 1902.

[87] Rose and Carless.

[88] Clinical Osteopathy.

[89] Journal of the American Osteopathic Association, Dec, 1902.

[90] Journal of American Osteopathic Association, March, 1905.

[91] Journal of American Osteopathic Association, March, 1905.

DISEASES OF THE RESPIRATORY SYSTEM

DISEASES OF THE LARYNX[92]

Acute Catarrhal Laryngitis

=Definition.=—An acute, catarrhal inflammation of the mucous membrane of the larynx. This may be ushered in as an independent disease or it may be associated with inflammation of the upper respiratory passages.

=Osteopathic Etiology= and =Pathology.=—One of the principal causes of acute catarrhal laryngitis is exposure to cold and dampness, which contracts the muscles of the neck region, especially about the larynx. Lesions in the upper and middle cervical vertebræ are important predisposing causes. Occasionally the first rib becomes luxated, causing a greater or less congestion of the laryngeal mucous membrane by contracting the lower antero-lateral muscles of the neck, and affecting lymphatic drainage. Improper placing of tone, as well as too constant use of the voice in speaking and singing, are common causes. Inhalation of irritating gases or dust, and mechanical injuries to the larynx are occasional causes. The disease may be associated with certain infectious diseases, as measles, diphtheria, influenza and whooping cough.

=Pathologically=, the mucous membrane is intensely reddened and inflamed; this inflammation involves both the true and false vocal cords and may extend into the trachea and about the epiglottis. The membrane is covered slightly with mucous secretion. In rare instances edema of the glottis may occur. The muscular contraction about the larynx impedes blood and lymphatic drainage and thus induces congestion. The contraction may be so severe as to slightly prolapse the organ. The vertebral lesions impinge upon or affect vasomotor fibers and thus bring about congestion.

=Symptoms=.—There is hoarseness and cough with a sensation of tickling in the larynx; these are the most constant symptoms. The cough is dry and the voice altered. At first the voice is husky, but some attempts at speaking are attended with more or less pain and finally the voice may be entirely lost. Deglutition is painful. At first the expectoration is scanty, but later it becomes mucopurulent. There is rarely much fever. When there is considerable edema, dyspnea and asphyxia are prominent features.

=Prognosis.=—Simple catarrhal laryngitis never terminates fatally. When there is dyspnea or asphyxia indicating edema of the larynx, the prognosis is grave. The attack usually lasts from one week to ten days, but this can be materially shortened by careful osteopathic treatment. In severe infections it may be two or three weeks before the larynx returns to its former condition.

=Treatment.=—In a few cases confinement of the patient to his room, and possibly the bed, will be necessary; especially should the larynx have rest from phonation, and the taking of food of an irritating character should be avoided. Smoking is to be prohibited. The room should be at an even temperature, from 70 to 75 degrees F., and the atmosphere saturated with moisture by the generation of steam.

The tissues in the cervical region about the cervical sympathetic and vagi nerves should be carefully adjusted. The deep posterior muscles of the cervical spine are to be relaxed and direct treatment given over and about the larynx. Relaxing tissues and raising the larynx will be very effectual in relieving the =huskiness= of the voice and in controlling the congestion and inflammation of the laryngeal mucosa. Besides the treatment of the vagi nerves at the atlas and their course down the lateral and anterior portion of the neck, the superior laryngeal may be treated at the upper portion of the great cornu of the hyoid bone and the inferior laryngeal at the inner side of the cleido muscle near its sternal attachment. Adjust the tissues along the course of the external carotid and subclavian arteries, chiefly the first rib for the latter. Give careful treatment to the internal jugular and innominate veins. Correct any tissues that may impinge upon the lymphatics of the mucous and submucous coats of the larynx where they are drained into the deep cervical glands. Release any immobility of the upper chest, relax the pectoral, auxiliary and upper dorsal muscles, and adjust the first four or five dorsal vertebræ.

Prompt action of the skin, freedom of the bowels, placing the feet in a hot bath and continued local hot packs, or even an ice-bag in severe cases, will be of special value at the onset; but due attention should be given these throughout the entire course. The fever is easily aborted by the cervical treatment and proper attention to the bowels and sweat glands.

Chronic Catarrhal Laryngitis

=Definition.=—A chronic, catarrhal inflammation of the mucous membrane of the larynx.

=Osteopathic Etiology= and =Pathology=.—The causes of chronic laryngitis may be numerous, but lesions of the cervical vertebræ are the most common. The contractured cervical muscles, especially the deep vertebral ones, are usually the result of corresponding osseous deviations.

Other causes given under the acute form, as overuse and abuse of the voice, inhalation of irritating substances, excessive use of tobacco and alcoholic drinks, tumors, etc., are important etiological factors. Thus irritations inducing acute attacks, if repeated, will result in chronic catarrh.

The =pathological= changes as revealed by the laryngoscope are swelling of the mucous membrane, occasional superficial erosions, and rarely ulceration.

=Symptoms.=—The voice is usually hoarse and rough, being due to a thickening of the vocal organs. In severe cases the voice may be lost. There is fatigue and pain after slight use of the voice, a sense of tickling in the larynx which produces a desire to cough, and expectorations of viscid mucus and mucopus.

=Prognosis.=—The prognosis is sometimes unfavorable, although many cases are cured.

=Treatment.=—The patient must learn to take care of himself properly. He should avoid overheated rooms and the use of tobacco and alcohol, and the throat should not be protected too much. It is a good plan to bathe the neck every morning and night with cold water. He should avoid loud speaking; the sound should be expelled by the abdominal muscles and diaphragm and not by the muscles of the throat. Examine the upper air passages carefully for any obstructions and infections that might exist which are a source of irritation to the larynx.

Special attention should be given to the atlas, axis and third cervical. Lesions lower down the spine may be found, for other laryngeal nerve fibers, other than those from the superior cervical ganglion, may be at fault. Palpate the =hyoid= to see if it is tilted by contracted muscles, as will often be the case.

=Aphonia= is commonly caused by a dislocated atlas. The aphonia may also be caused by swelling of the vocal cords and tissues about them and by serous effusions of the laryngeal muscles. The larynx may be prolapsed slightly and if raised quickly relieved. Difficult breathing and hoarseness are occasionally very troublesome symptoms. The former is due to an inability of the glottis to dilate, on account of swelling of the mucous membrane of the diseased parts and from drying of the secretions on them, thus increasing the obstruction (this is sometimes termed pseudocroup) but expiration is easy, the stridor is from the inspiration; the latter is due to a collection of mucus on the vocal cords or the cords may become relaxed, swollen or roughened.

Another annoying symptom sometimes presented is pain on deglutition, which is due to swelling of the mucous membrane of the upper laryngeal passages and the epiglottis. In all of these annoying symptoms, persistent, thorough, direct treatment of the larynx is of value. On the whole, careful, continued treatment of the cervical innervation and vascular supply of the larynx, as in the acute form, is indicated.

In all laryngeal disorders, if condition permits, hyperextend the neck while the patient is lying supine and thoroughly relax the soft tissues about the organ and then carefully raise it.

Laryngismus Stridulus

(Spasm of the Glottis)

=Definition.=—A spasm of the muscles of the larynx that are supplied by the inferior or recurrent laryngeal nerves. This is commonly not excited by an inflammatory condition, but it is usually a purely nervous condition.

=Osteopathic Etiology= and =Pathology=.—Spasm of the glottis is usually found in children with =enlarged tonsils and adenoids=. It has been observed that rickets and syphilis are probably frequent underlying causes. The spasm is occasionally associated with tetany. The nervous factor is the immediate and important consideration. Cervical lesions, both vertebral and muscular, are invariably found. Then nasopharyngeal and tracheal disorders and reflex digestive disturbance are exciting causes. An elongated uvula or a deranged hyoid bone will occasionally be exciting factors. Subluxation of the upper two or three ribs and of the clavicle may also be exciting factors.

The affection is usually found in children under five years of age. All cases are not of a distinct nervous type, for slight acute catarrhal laryngitis may be present.

=Symptoms.=—There is a sudden onset and the spasm may occur on waking from sleep, but it may come on either in the night or day. The disease starts with a sudden arrest of breathing, the child struggles for breath; there are tonic muscular spasms and the face becomes congested in a few seconds. This is followed by sudden relaxation of the spasm and the air is drawn through the glottis with a shrill, crowing sound. Several spasms may occur in a day or they may be weeks apart. Death rarely occurs.

=Diagnosis.=—The absence of fever, cough and hoarseness and its distinctly intermittent nature will differentiate it from croup. Should there be any question of diagnosis a bacteriological examination is advisable.

=Prognosis.=—The prognosis is almost always favorable. In very young children death from suffocation may occur, but rarely.

=Treatment.=—The treatment should be applied either centrally or peripherally, depending altogether upon the location of the irritation. If the irritation is of central origin, that is, through the innervation from the brain and spine, a correction of the superior and inferior laryngeal nerves is necessary; if the stridor is due to peripherial irritations, a correction of the end-plates (muscles) over and about the larynx is required in order that the spasms be relieved.

Thorough treatment should be applied to the upper part of the chest and diaphragm, chiefly the phrenic nerves at the third, fourth and fifth cervicals and over the eighth, ninth and tenth ribs anteriorly, in order that the spasms may be prevented from extending to the intercostal muscles and the diaphragm.

Placing the patient in a hot bath will be of service in some cases when the spasms are severe. Alternating hot and cold packs about the throat are of service. The air of the room should always be kept moist. Care should be taken that the trouble is not due to gastro-intestinal disorders or to dentition. Keep the child upon a fluid diet of milk, meat broths and egg albumin.

In the more severe cases the well known osteopathic method of relaxing and inhibiting the soft palate and contiguous tissues will stop the spasm.

Spasmodic Laryngitis

(False Croup)

=Definition.=—A catarrhal inflammation of the mucous membrane of the larynx with spasm of the glottis.

=Osteopathic Etiology= and =Pathology=.—This affection is practically the same as laryngismus stridulus associated with catarrhal inflammation of the mucous membrane. It is a disease of young children. Derangements of the innervation and blood supply to the laryngeal mucous membrane and muscles of the larynx are found in the same locality as noted under acute catarrhal laryngitis and laryngismus stridulus. There is acute catarrh causing a croupy cough, and difficult breathing due to spasm of the glottis.

=Symptoms.=—These attacks generally occur during the night, the child being suddenly awakened by severe paroxysms of suffocating and a dry, hard cough, associated with evidences of dyspnea. In half an hour or an hour or two the coughing ceases, perspiration follows and the child falls asleep. If proper treatment is not given, these attacks may occur for several successive nights, the child appearing almost or quite well during the day.

=Diagnosis.=—The symptoms are so characteristic that the diagnosis is easy. In all instances the prognosis is favorable.

=Treatment.=—The catarrhal inflammation of the mucous membrane of the larynx should be treated in the same manner as simple inflammation of the laryngeal mucosa, i. e., thorough treatment of the cervical spine and direct treatment over the larynx.

During the paroxysm, if the patient cannot be relieved very shortly by the cervical treatment, he should be placed in a hot bath of a temperature from 98 to 110 degrees F. This will, in the majority of cases, relieve the attack. In addition a hot compress may be placed about the throat. Producing emesis by irritating the fauces with the finger is necessary in a number of cases in order that the secretions in the laryngeal region may be ejected, thus relieving suffocation and labored breathing. Also, an overloaded stomach which is causing an irritation, should be emptied at once by vomiting. The bowels should be kept well open in all cases. Occasionally the epiglottis becomes wedged in the chink of the glottis. Such a condition requires an introduction of a finger into the fauces to release the disorder.

Care should be taken, especially following an attack, that the child is not exposed to cold or rapid changes of temperature, so as to avoid repetition of the spasms.

=Coughing.=—Coughing, not only in spasmodic laryngitis, but also in various diseases where coughing is a prominent symptom, is a most irritating and annoying feature. The osteopath is many times called upon to relieve the cough, whether it is due to slight irritation of a nerve fiber alone or is a symptom of a serious chronic disease. The coughing center is located in the medulla oblongata; the afferent nerves are sensory branches of the vagus; the efferent nerve fibers are found in the nerves of expiration and in those that close the glottis. Consequently, coughing may be caused by stimuli to various sensory nerves, various cutaneous areas (chiefly the upper part of the body), mucous membrane of the respiratory and digestive tracts, the mammae, liver, spleen, ovaries, uterus, kidneys, etc. Perhaps the most common cause of cough is contraction of some of the muscles of the neck, irritating sensory fibers. Contraction of the omo-hyoid muscle may produce an irritating cough by causing traction on the hyoid bone. In a few cases the larynx may prolapse to some extent and thus be a source of irritation. Lesions of the spinal cord between the seventh and eighth dorsal, also at various points above in the dorsal vertebræ and in the ribs (especially at the second and third ribs), are very apt to produce a cough. Impaction of the sigmoid flexure is oftentimes accompanied by coughing. Enlargement of the heart may cause pressure upon the respiratory tract directly and cause a deep, dull cough. Foreign bodies in the external meatus of the ear are occasionally a source of irritation which is accompanied by coughing. Thus there are innumerable sources of stimuli that may produce coughing. In all cases it is necessary to make a careful diagnosis as to whether it is an irritation to some fiber that can be corrected at once or whether it is a symptom of a disease that can only be relieved by the cure of the disease. In local congestions the cold pack will often be of service.

Tuberculous Laryngitis

=Definition.=—An inflammation of the laryngeal tissues of tuberculous origin.

=Osteopathic Etiology= and =Pathology=.—Tuberculosis of the larynx is commonly secondary to pulmonary tuberculosis. In a few cases the laryngeal invasion may be of primary origin. In either instance there will be found a disturbed innervation or altered blood supply of the larynx that predisposes to the multiplication and growth of the bacilli. The osteopathic lesions are similar to those found in other involvements of the larynx.

=Pathologically=, the mucous membrane is inflamed and swollen, and exhibits scattered tubercles, which are usually about the blood-vessels. The tubercles cluster, caseate and leave shallow, irregular ulcers. There is thickening of the mucosa about the ulcer, and the ulcer is generally covered by a grayish exudate. They may erode the true vocal cords, often destroying them completely. The ulcers slowly involve the tissues in all directions, causing perichondritis with necrosis of the cartilages. The mucous membrane of the pharynx, esophagus, fauces, and tonsils may be involved, and the epiglottis may be completely destroyed.

This disorder, strictly, should be discussed under pulmonary tuberculosis for, as heretofore stated, it is generally a secondary affection; the larynx being invaded by the tubercular bacilli in the sputum arising from the bronchial tubes and lungs. The bacilli in inspired air may primarily invade the laryngeal mucosa. However, in either case the circulation of the mucosa is not normal and osteopathic correction of the same is effective.

=Symptoms.=—Huskiness of the voice, followed by hoarseness, and in advanced stages aphonia, are prominent symptoms. A hacking cough is usually present and the patient complains of pain in the throat, particularly on coughing, swallowing or speaking. The loss of voice, painful speaking or whispering are quite characteristic. When the ulceration of the tissues of the larynx has progressed to a later stage, dysphagia, suffocation and distressing paroxysms of cough occur.

=Diagnosis.=—Is not difficult, as pulmonary phthisis is usually associated with it. Examination of the sputum for the specific bacilli will be conclusive.

=Prognosis.=—The prognosis is not of the best at any time. On the whole, it is unfavorable.

=Treatment.=—In this disease osteopathic treatment has been quite effectual. Cases of primary origin are more successfully treated than when of secondary cause, although one will be surprised many times at the results obtained when the disorder is not primary. The treatment must necessarily be both constitutional and local. Care of the general health as to hygiene and diet is absolutely necessary. The food must be nutritious and non-irritating. Scraped beef, raw oysters, raw eggs, soups and gruel are required. In cases where difficulty of deglutition occurs, it may be largely overcome if the patient hangs his head over the side of the bed and sucks through a tube liquid nourishment placed in a dish upon the floor.

The local treatment required is careful, persistent work over the larynx and adjacent tissues. The treatment is given to increase the blood supply to the diseased tissues so that healing may take place, and that the bacteria may be deprived of the conditions favorable to their activity. Treatment along the cervical spine and upper dorsal will aid in correcting the vasomotor disorders that exist. Local application of hot water will assist in relieving the pain. When pulmonary phthisis exists, attention and correction of it is important; in fact, is of primary consideration in laryngeal affection.

Syphilitic Laryngitis

=Etiology.=—This disease is of frequent occurrence, due to inherited syphilis, or to the secondary or tertiary stages of the acquired form.

=Symptoms.=—There is a hoarseness of the voice, a hacking cough, difficulty in swallowing and the various symptoms of catarrhal laryngitis. The secondary form may present superficial, whitish ulcers on the cords or ventricular bands, while in a tertiary stage the lesions are extensive and serious. Deep ulcers with raised edges are present, gummata develop on the submucous coat of the epiglottis and there may be necrosis and exfoliation of the cartilages. Deformity is produced by the cicatrices following the healing of the ulcers and sclerosis of the gummata. Edema of the larynx may suddenly prove fatal.

=Diagnosis.=—The history of the case, the presence of other symptoms of the disease, the deep, symmetrical ulcers, the absence of tuberculosis elsewhere and the absence of marked pain, will usually make a diagnosis easy.

=Prognosis.=—Is somewhat favorable, more so at least than the tubercular form of laryngitis. There is great danger of deformity and permanent impairment of the voice.

=Treatment.=—The treatment should be both constitutional and local. Active measures must be taken to rid the system of the virus of syphilis, and thorough, direct treatment should be applied to the larynx and to its innervation. If the cicatricial stenosis has progressed so far that there is little hope from manipulative treatment, tracheotomy or gradual dilatation should be performed. The ulcerated portion is always to be kept clean.

Edematous Laryngitis

=Definition.=—An acute inflammation of the mucous membrane of the larynx with infiltration of serous fluid into the submucous tissue.

=Etiology.=—This is a very serious affection. It may occur in connection with acute laryngitis, though rarely, and occasionally with chronic diseases of the larynx, as tuberculosis and syphilis. It may be a complication of some acute infectious disease like diphtheria, scarlet fever, or erysipelas of the face. It sometimes occurs suddenly in the course of Bright’s disease. Lesions as in acute laryngitis are predisposing factors.

=Pathologically=, there is marked swelling of the epiglottis. The swelling can very easily be felt with the fingers. The mucous membrane is tense and changed in color. There is infiltration of a serous or sero-purulent fluid into the loose connective tissue of the larynx. The arytenoepiglottic folds are greatly involved, and they may be swollen to such a degree that they almost meet.

=Symptoms.=—Extreme dyspnea and stridulous respiration. Hoarseness of the voice and later aphonia. There is a feeling of intense oppression or suffocation. Evidence of dyspnea, anxious face, blue lips, protruding eyes and retraction of the base of the chest occur. The sternocleidomastoid muscle is very prominent.

=Diagnosis.=—This is not difficult. The history of the case, laryngoscopic examination, and the swollen epiglottis which can be easily felt with the fingers make diagnosis easy.

=Prognosis.=—Generally unfavorable. At any time it is extremely grave, but with prompt and vigorous treatment recovery is possible.

The duration varies from a few hours to several days.

=Treatment.=—One must attend strictly and carefully to the laryngeal innervation, as in acute catarrhal laryngitis. Obstruction to the superior or inferior thyroid, facial, internal jugular or innominata will cause tumefaction and edema of the larynx and adjacent tissues. Also, enlargement of the lymphatics about the larynx and salivary glands may produce edema of the laryngeal region; consequently, particular care should be taken of the various tissues about these vessels and of the innervation from the cervical spine, so the veins are not obstructed or the lymphatic channels disordered, so that infiltration of the tissues may be further prevented.

The most prominent symptom is laryngeal dyspnea and this depends altogether upon the swelling of the soft parts. If the swelling is great and the disorder cannot be removed, suffocation will follow. In such cases, besides giving direct treatment over the larynx, introducing a finger into the mouth, and reaching clear back under the roof of the soft palate, with a firm, downward, outward and sweeping movement on either side, relax the soft tissues. The persistent use of small pellets of ice, held far back in the mouth, will be found very beneficial; also, application of the ice-bag, provided the edema is of inflammatory origin.

If one is not able to control the rapid infiltration of the larynx and glottis when such cases arise, tracheotomy or intubation should be performed at once. When edematous laryngitis is due to diseases of the heart, lungs and kidneys, treatment of the primary disease should be given in addition to the local treatment.

FOOTNOTES:

[92] For diseases of the nose see Deason, Part 1, Page 257.

DISEASES OF THE BRONCHI

Acute Bronchitis

=Definition.=—A catarrhal inflammation of part or whole of the mucous membrane of the larynx, trachea and bronchial tubes, or it may extend into the capillary tubes. This is bilateral, affecting more or less the bronchial tree in both lungs.

=Osteopathic Etiology= and =Pathology=.—The most common cause of acute bronchitis is “catching cold.” It is more prevalent in the winter, and it often succeeds an ordinary cold in the head, coryza or laryngitis, the inflammation extending downward from the upper air passages. A case of acute bronchitis always presents a contracted condition of the muscles on either side of the spine in the upper dorsal region. The contracted muscles may extend as far down as the middle dorsal or as high as the entire cervical. Occasionally, the ribs posteriorly are drawn downward by the extreme contraction of the muscles, and the upper anterior part of the chest may be somewhat constricted and limited in its movements by the tensed muscles. Thus, in a few cases the ribs and upper dorsal vertebræ are actually subdislocated by the extreme contraction of the muscles. The principal points affected are the second, third, fourth and fifth dorsal regions. In a few instances cervical lesions disturbing the vagus and resulting in motor weakness of the tubes, will be noted. The osteopathic control of the bronchial vasomotor nerves is in this region (dorsal).

The disease is also associated with measles and it is usually a symptom of influenza. One attack predisposes to another. It affects either sex and especially children and the old, in whom it most frequently involves the smaller bronchi. In adult life it involves the larger bronchi. Micro-organisms, particularly the pneumococcus, influenza bacillus, and micrococcus catarrhalis, act as exciting causes.

=Pathologically=, the mucous membrane of the portion of the trachea and bronchi that are implicated become reddened, congested and more or less covered with a tough mucus mingled with epithelial cells. The hyperemia is most marked about the mucous glands. Some of the smaller bronchial tubes are dilated. In severe cases there is desquamation of the ciliated epithelium, swelling and edema of the submucosa, and infiltration of the tissues with leucocytes. The affection involves chiefly the vasomotor nerves. In cases on the verge of chronicity, look well to the diet; especially lessen in amount the starchy and saccharine foods.

=Symptoms.=—The onset of acute bronchitis is accompanied by the symptoms of a common “cold.” In the beginning the cough is hard and dry without expectoration; but later it is looser, the secretion becoming mucopurulent and abundant and finally purulent. The scanty sputum is at first glairy and mucoid, while later it becomes more abundant and mucopurulent and contains pus cells and desquamated epithelium. When the bronchial inflammation becomes fully established, there is a feeling of tightness and rawness beneath the sternum and a sensation of oppression in the chest, due to swelling of the mucous membrane and the presence of secretions which cause stenosis of the bronchial lumina. There is a slight fever, rarely exceeding 101 degrees F. The disease lasts from four or five days to three weeks. There is either a complete recovery or chronic bronchitis is developed.

=Physical Signs.=—There may be no physical signs in slight attacks of acute bronchitis of the larger tubes. In severer cases the physical signs are well marked. =Inspection= may recognize increased frequency of breathing, and when the smaller tubes are involved there is dyspnea. =Palpation.=—The bronchial fremitus may often be felt, providing there is sufficient narrowing of the breathing tubes. =Percussion.=—Sounds are normal as long as the bronchitis is uncomplicated. =Auscultation.=—In the early stage piping, sibilant rales may be heard on both sides. These rales are inconstant and appear and disappear with coughing. There may be harshness of breathing added to these. When resolution sets in, the rales change and become mucous and bubbling in quality. Vocal resonance in bronchitis is normal, unless complications occur.

=Diagnosis.=—This is generally easy. The absence of dullness and blowing breathing and the bronchial character of the cough and expectoration are usually sufficient to distinguish it from pneumonia and pleurisy. If the physical signs are noticed carefully, the diagnosis is rendered easy and positive in all cases.

=Prognosis.=—In the very young and the very old, the prognosis is unfavorable, but in a previously healthy adult the most that can happen to a case of acute bronchitis is to become chronic. Recovery is the rule; even in the aged and feeble death is rare. If osteopathic treatment can be instituted from the inception, the disease will probably be aborted. The treatment almost invariably lessens the severity and duration of an attack. For capillary bronchitis see Bronchopneumonia.

=Treatment.=—Complete rest in a warm bed, and a hot foot bath would cure a large majority of cases in a day or two if the patient would only submit to such treatment. Most of them wish to be around and out doors and very likely attending to their usual work, so that a cure in some cases is hard to perform. They are very liable to take more “cold” and in a few cases it will take great effort to prevent the bronchitis from becoming chronic. One thorough treatment per day will usually be sufficient.

The hyperemic condition of the bronchial tubes is due to a vasomotor disturbance, generally caused by a severe contraction of the muscles of the back in the region of the first to fourth dorsal; although the vasomotor nerves to the mucous membrane of the bronchial tubes may be affected anywhere from the first to the seventh dorsal inclusive. Contraction of the muscles over the anterior part of the chest corresponding to these regions and caused by the same influences (chiefly atmospherical changes) is of quite common occurrence. In the majority of cases the contraction of the chest and back muscles is so severe that the ribs are partly displaced by the tension and thus is added a complication to the disorder, and from this complication chronic bronchitis is liable to occur. The ribs or even vertebræ to the corresponding region oftentimes remain partly dislocated and are a source of continued and permanent irritation to the innervation of the bronchial tubes. So it is always necessary in treating any form of bronchitis to see at each treatment that the ribs and vertebræ from the first dorsal to the seventh dorsal, inclusive, are anatomically correct.

As has been stated, the disordered muscles or ribs may be affected anteriorly as well as posteriorly; consequently, the treatment applied is a thorough relaxation of the chest and back muscles and the correction of the ribs and vertebræ in order that the vasomotor disturbance of the bronchial mucosa may be corrected and the inflammation relieved. An excellent method to release the immobilized anterior upper chest is to place patient flat upon his back with pillow beneath upper dorsal. This hyperextends spine, enlarges spinal foramina, and tends to elevate ribs. Then by use of arms as levers, moderate inspiration, and employment of one hand over anterior end of ribs they may be easily released and raised. This treatment effects circulation, innervation, lymph tissue, and rib bone marrow.

In addition to the dorsal spinal nerves, and the sympathetic, the vagi are to be considered in the treatment of bronchitis, as all of these nerves, sympathetic, spinal, and vagi, go to make up the anterior and posterior pulmonary plexuses from which the bronchial mucosa receives its innervation. The veins particularly involved in passive hyperemia of the bronchial tubes are the superior intercostal and azygos major; so raise and spread the ribs to give greater freedom to these blood-vessels.

“The blood flow may be diverted from the bronchi to the abdomen by a slow, deep, inhibitive treatment over it, including pressure over the solar and hypogastric plexuses.” (Hazzard).

The excretory organs and the diet of the patient should be attended to. Especially in children, the diet had best be a fluid one, as milk, egg albumin, meat broths and meat juice. For those who are subject to the disease an outdoor life is best.

Chronic Bronchitis

=Definition.=—A chronic inflammation of the mucous membrane of the large and middle sized bronchial tubes.

=Osteopathic Etiology= and =Pathology=.—Chronic bronchitis may be either primary or secondary. The primary form is the result of exposure to wet and cold or to the daily inhalation of irritating vapors or dust. This form is rare, the affection being almost always a secondary one, and is most commonly met with in chronic lung affections, heart disease, gout or renal disease. It may be caused by any disease which favors congestion of the air tubes by obstruction of the circulation; especially mitral diseases and Bright’s disease. It is also caused by chronic alcoholism and may be the result of repeated attacks of the acute form. Chronic vertebral and rib lesions are found from the first to the seventh dorsal, inclusive. Elderly people are often subject to the disorder.

=Pathologically=, the lesions of chronic bronchitis present great variation, as to both their nature and extent. In some cases the mucous membrane is atrophied, so that some of the elastic fibers are noticeable. The epithelial layer is in great part missing. The muscular coat and mucous glands are atrophied.

In certain cases the mucous membrane of the bronchi is thickened, and there may be ulceration. In long standing bronchitis, there is frequently dilation of the tubes (bronchiectasis) and emphysema.

=Symptoms.=—Pain is rarely present; there is merely a feeling of constriction beneath the sternum. The cough varies with the weather and season and there is often an absence of the cough during the summer. It is apt to be worse at night than in the morning, and is frequently paroxysmal. There is rarely any fever. As a rule, there is free expectoration of mucopurulent or distinctly purulent matter. Sometimes it is abundant, seromucous in character, and again there are severe cases of dry cough in which there is almost no expectoration. Unless associated with other diseases, the general health suffers but little, if at all. The appetite, as a rule, is good and the body weight is well maintained.

=Physical Signs.=—=Inspection.=—There is considerable immobility of the chest and if emphysema is present there is distension. =Percussion= is clear, and hyperresonant in emphysema. =Auscultation.=—The expiration is prolonged and forcible. This is associated with sonorous and sibilant rales and moist rales of all sizes.

=Special Varieties.=—Bronchorrhea, dry catarrh, putrid bronchitis or fetid bronchitis.

=Bronchorrhea.=—In this form there may be an excessive bronchial secretion. This may be liquid and watery, but more frequently it is purulent, thin and containing greenish masses; or again it may be thick. Dilation of the tubes and fetid bronchitis may be developed.

=Fetid Bronchitis.=—Fetid expectoration is associated with gangrene of the lungs, abscesses, bronchiectasis, decomposition of matter within phthisical cavities, or empyema with perforation of the lungs; or it may occur independently. There is considerable expectoration that is thin and offensive. When =putrefactive changes= take place during the course of chronic bronchitis, as a rule, the following symptoms immediately appear: fever, which may be septic; increase of cough; pain in the side, and sometimes a chill. There is increased prostration. The symptoms may abate followed by the usual course of bronchitis.

=Dry Catarrh.=—The cough is distressing and paroxysmal. It is usually associated with emphysema and is a very troublesome form.

=Diagnosis.=—This is not usually difficult. Phthisis—the absence of fever, of hemorrhage, of tubercle bacillus and the signs of localized consolidation (usually at one or other apex) will serve to distinguish between the two.

=Prognosis.=—Recovery is not always accomplished. The diseases being generally a secondary affection, the prognosis must depend upon the primary condition. The danger from development of emphysema, bronchiectasis and dilatation of the right ventricle must be thought of. Frequently cures will be obtained, even in old persons. Care must be taken that there are no serious organic lesions. Deep treatment to readjust the upper and middle dorsals is most essential.

=Treatment.=—In the first place there must be a careful regulation of the hygiene of the patient. The diet should be a nutritious one, care being taken to give food that is easily digested. A liberal diet can easily be selected from the various meats, vegetables, cereals, fruits, soups, broths, eggs and milk. The clothing should be carefully selected. Flannel should be worn next the skin the year around, care being taken that the sufferer is not too warmly clad. Due attention should be given to bathing, exercising, etc. The patient should be out in the open air a great deal, but be careful that it is not too stormy. The air of the room should be kept at an even temperature and not subject to abrupt changes. Two or three treatments per week will be required, and when the condition is considerably aggravated, do not hesitate to treat oftener, but be careful not to unduly irritate the lesions.

Lesions will be found to the ribs and vertebræ from the first to the seventh dorsal inclusive. Many cases present lesions in the vertebræ from the second to fourth, usually of a lateral nature. Other lesions of frequent occurrence are displacements of both vertebræ and ribs. Correcting these deviations relieves the chronic inflammation of the tubes. Also in those cases where dilatation of the bronchial tubes occurs, the obstruction to the motor fibers is to be removed by the correction of the vertebræ and by removing obstruction to fibers of the pneumogastric; the fibers of the latter supplying the transverse muscles of the bronchial tubes.

It generally requires a considerable course of treatment for the cure of chronic bronchitis, and one of the hardest things to contend with in the treatment is the likelihood of the patient “catching cold.” When a fresh cold gets thoroughly started, it is almost impossible to prevent the disease from extending down the bronchial tubes, as the innervation is less rich in the smaller tubes.

Hazzard says: “The obese should be taught the habit of deep respiration, as should all persons subject to the attacks of the disease. This measure, together with the daily cold sponge or shower bath, is a great aid in overcoming the chronic tendency.”

Those cases that are due to cardiac or nephritic diseases require the treatment of the primary disease in addition to a light bronchial treatment.

A lesion between the gladiolus and manubrium of the sternum may be found, but it is of rare occurrence in these cases. The upper portion of the sternum may be held very rigidly and slightly underneath the middle portion of the sternum; or at the point of articulation of the two portions a distinct ridge may be found, caused by the articular ends being pushed anteriorly. Probably such lesions affect the innervation to the bronchial tubes and lung tissues. Associated with this condition the upper chest is considerably immobilized, affecting the lymph and rib bone marrow function. Examine the first ribs and clavicles carefully. Changes of climate are often beneficial.

Fibrinous Bronchitis

=Definition.=—A rare, acute or chronic inflammatory disease of the bronchi, in which a fibrinous mould of the bronchus and its branches is formed. These are expelled in paroxysms of cough and dyspnea. The casts block the bronchial tubes. When these moulds are large or medium sized, they are generally hollow, while those of the smaller bronchi are solid.

=Etiology= and =Pathology=.—The causes are unknown. Young men, between the twentieth and fortieth years, are the usual subjects; but the disease may occur at any period of life. Lesions occur as in other forms of bronchitis. The attack occurs most frequently in the spring months. In some cases there seems to be some hereditary influence. Chronic pulmonary diseases, like phthisis, emphysema and pleurisy, are occasionally predisposing causes. It is sometimes associated with skin diseases, such as herpes, impetigo and pemphigus.

The =pathology= is not known. The masses that are expelled are usually round and mixed with blood and mucus. The casts are more dense, but the membrane is identical with that of croupous exudates. This affection, however, is limited to certain bronchial tubes and recurs at stated or irregular intervals, sometimes for a period of several years. There is loss of epithelium in the affected bronchi and the submucous tissue is often swollen and infiltrated with serum.

=Symptoms.=—Acute cases are rare. The attacks may set in with rigor, high fever, pain in the side, soreness, severe paroxysms of cough and sometimes a slight hemoptysis. The symptoms are those of an ordinary acute bronchitis, but of severer character; aggravated cough and dyspnea and fatal termination are not uncommon. Death occasionally results from suffocation. There may be but one attack without any recurrence, but in the chronic form the paroxysms recur at irregular intervals, though they are less severe than in the acute form.

The disease may last for ten or even twenty years, the attacks recurring weekly, or a period of a year or more may intervene. The onset is marked by bronchial symptoms with or without fever. The cough soon becomes distressing and paroxysmal in character. The sputum may be blood-stained and occasionally there is profuse hemorrhage. The expectoration is in the form of ball-like masses which, when unraveled are found to be moulds of the bronchi. They may be hollow and laminated or quite solid. When examined under the microscope they are seen to consist of a fibrillated membrane in which are imbedded leucocytes, mucus, corpuscles, fat drops and epithelial cells. Leyden’s crystals and Curschmann’s spirals are occasionally found.

=Physical signs= are usually those of bronchitis. The weakened or suppressed breath sounds in the affected territory may occasionally be determined. There is sometimes a diminished expansion or even retraction of the chest wall over the affected area. There is no dullness on percussion, unless the portions of the lung supplied by the affected tubes collapse. After dislodgement of the casts, the normal respiratory murmur returns.

=Diagnosis.=—The fibrinous casts alone are sufficient for a positive diagnosis.

=Prognosis.=—Generally favorable. In uncomplicated cases there is rarely any danger, even though there may be severe paroxysms of cough and dyspnea. In fatal cases the lesions of associated or preceding affections have been found, such as chronic pleurisy, pneumonia and phthisis. Although this is a rare disease, cases have been treated with success by osteopathic means. If uncomplicated there should be a fair chance for a cure, depending, of course, upon the constitutional condition and the permanency of the lesions.

=Treatment.=—The treatment is largely that of acute bronchitis. The disorder is more extensive than in acute bronchitis, consequently severe subluxations of the ribs and vertebræ of the upper and middle dorsals occur, besides extensive muscular contractions of the chest and neck. The fibrinous casts are somewhat of the same nature of membranous exudates elsewhere, therefore the treatment should be directed to a correction of the hyperemia of the mucous membrane of the bronchial tubes, thus loosening and disorganizing the exudate. The vagi nerves supply a part of the innervation to the bronchial tubes and lungs. Any disorder to them should be corrected when diseases of the bronchial tubes and lungs exist. They contain motor fibers to these organs, and to the bronchial tubes they supply, principally the transverse fibers. In bronchitis of various forms, marked effect can be secured by close attention and treatment to the inferior laryngeal nerve. This is best treated at the inner side of the lower portion of the sternocleido muscle.

The different forms of bronchitis illustrate the point so often noted in osteopathic etiology and pathology, that the various affections of the same region should not be studied so much as types of several diseases or disease entities as different degrees of involvement, depending on the severity of the causative lesion, the function of the nerves disturbed, and the character of the tissues. It is straining a point to diagnose and classify many diseases according to signs and symptoms instead of studying the process from central causes, for, at best, peripheral manifestations, micro-organisms, etc., are really incidental to the importance of the primary source of disturbed nutrition. Consequently, the same treatment, if scientific, is frequently indicated for all of the disorders that may affect a given locality. After all has been said and done, the therapy as well as the pathology, must hinge upon the fundamental—uninterrupted blood channels and nerve courses are essential to health. Whether a disease is of primary or secondary origin, or whether or not it presents different symptoms in various types, the above basic principle is invariably applicable. This simplifies etiology, pathology and treatment and furnishes a backbone to theory and practice, and some day rational medicine will adopt it.

Bronchiectasis

=Bronchiectasis= is a dilatation of a part or the whole of the bronchial tube. As a rule this affection is a secondary one, the most common cause being chronic bronchitis. The inflammation weakens the bronchial walls so that they are unable to resist the strain that is put upon them during violent paroxysms of coughing. After dilatation has once commenced, the weight of the secretion which accumulates tends to further distend the weakened walls and the elasticity, becoming impaired, is finally lost. Dilatation of the bronchi is also associated with emphysema, compression of a bronchus, aneurism or mediastinal tumor, bronchopneumonia, measles and whooping cough in children, and also traction associated with fibroid induration. Hence the bronchial dilatation is especially associated with bronchitis, interstitial pneumonia, and sometimes chronic pleurisy. It is rarely a congenital effect in such cases. It is commonly unilateral. The lesions presented to the osteopath are largely like those found in chronic bronchitis, i. e., derangement of the upper four or five dorsal vertebræ and ribs, and lesions of the cervical vertebræ involving the vagi. These lesions obstruct the nerve force to the bronchial tubes and thus cause the dilatation.

=Pathologically=, the dilatation is usually either cylindrical or saccular, which may occur in the same lung. The entire bronchial tree may be converted into a series of sacs opening into each other. These have smooth, shining walls in the most dependent parts which are sometimes ulcerated. In extreme conditions the dilatations may form large cysts immediately beneath the pleura; as a rule, the lung tissue lying between the sacculi becomes cirrhotic. =Partial dilatation= is more common. The bronchial mucous membrane is involved with an occasional narrowing of the lumen. The narrowings are most commonly cylindrical, sometimes saccular.

In all forms there is decided change in the bronchial wall. In the large dilatations, the epithelium is changed. The elastic and muscular layers are thin and atrophied. These dilatations frequently contain fetid secretions and when these secretions are retained, the lining membrane becomes ulcerated.

=Symptoms.=—There is always cough, which occurs in severe paroxysms. In some cases a change of position will cause a paroxysm of coughing—very likely due to the emptying of the contents of a dilated tube into a normal one. The sputum is mucopurulent and is greenish brown in color, is fluid, and has a sour, or more frequently, a fetid odor. On standing, it separates into three layers; the upper is frothy and thin, the middle mucoid, and the lower is a thick sediment of cells and granular debris. Microscopically, the sediment consists of pus corpuscles, fatty acid crystals which are arranged in the form of bundles, and sometimes red blood discs and hematoidin crystals. Elastic fibers may be found if ulcers are present.

=Physical Signs.=—When distinctly present, they are those of a cavity in the lungs. When chronic pleurisy and interstitial pneumonia are associated, there may be retraction of the chest wall. The percussion resonance is impaired. On auscultation, bronchial, or even amphoric, breathing is heard occasionally with metallic rales.

=Diagnosis.=—In a number of cases this was formerly impossible, where the X-ray is now proving of great assistance. History, paroxysmal cough, characteristic copious sputum and an absence of tubercle bacilli with little impairment of the general health will serve to distinguish bronchiectasis from pulmonary tuberculosis. Circumscribed empyema which has ruptured into the lung may simulate bronchiectasis. This is of a much more sudden onset, has a history of previous pleurisy, the health is gradually impaired, and there is thoracic oppression and dyspnea on the slightest exertion.

=Prognosis.=—Is generally unfavorable. However this largely depends upon the cause.

=Treatment.=—Largely the same as in chronic bronchitis. Severe lesions are found in the dorsal vertebræ about the region of the third, fourth and fifth, and many times lesions of the pneumogastric at the upper cervical vertebræ are also found. The lesions are much of the same nature as those of bronchitis, but, as a rule, there is a much deeper or more extensive lesion. These lesions weaken the motor innervation to the muscular coats of the bronchial tubes, and in many instances the extensive lesions involve the vasomotor nerves controlling the blood supply to the bronchial tubes. In most cases marked lesions of the ribs on either side will be found, usually in the region corresponding to the affected vertebræ.

The position of the patient is important; the head should be low in sleeping. In certain fetid cases surgery should be considered.

Care should be taken as to the hygienic surroundings of the patient. The diet should be carefully regulated and nutritious, as in chronic bronchitis.

Bronchial Asthma

=Bronchial= or =spasmodic asthma= is a chronic affection, characterized by a paroxysmal dyspnea due to a spasmodic contraction of the muscles of the bronchial tubes or to swelling of their mucous membrane.

=Osteopathic Etiology= and =Pathology.=—The majority of lesions causing bronchial asthma are from the second to the seventh dorsal region, inclusive, either in the ribs posteriorly or anteriorly, or in the vertebræ. These lesions involve vasomotor nerves to the bronchioles which produce the narrowing of the tubes and thus cause the dyspnea. Usually the lesion is at the third, fourth or fifth rib on the right side, although, as stated, a lesion may be found above or below this point at the anterior or posterior ends of the ribs or in the vertebræ corresponding to the same region. Probably lesions are found more on the right side, because most people are right-handed; these muscles being better developed would tend, when contracted, to draw the ribs from their articulation. The third, fourth and fifth ribs are usually found involved because it is the region of greatest vasomotor innervation to the bronchial tubes.

In a number of cases there will be found a posterior curvature of the dorso-lumbar region; and accompanying this condition will be catarrh and dilatation of the stomach, congestion of the liver, and, perhaps, intestinal indigestion and constipation. Careful attention should be given to the digestive organs.

Lesions involving the pneumogastric at the atlas and axis are fairly frequent. These irritate fibers of the pneumogastric to the muscles of the bronchioles and thus produce narrowing of the tubes and consequently the paroxysms. Other points to note are the costal cartilages and hyoid bone, and probably, in a few instances, lesions to the phrenic.

Attacks may be induced reflexly by various excitants, as dust, diseases of the upper respiratory tract, etc., but the lesions to the vasomotor and motor nerves are the predisposing causes. Laughlin[93] says: “It is questionable whether reflex causes alone are sufficient to produce genuine asthma without the existence of specific lesions affecting the direct nerve connections of the part involved.” No doubt a neurotic tendency is often a predisposing factor. Overeating, and particularly certain foods will frequently excite an attack.

=Pathologically=, true asthma is a pure neurosis. There is more or less chronic inflammation of the bronchial tubes, shown by injection and thickening of the bronchial mucosa in the majority of cases. There may be found the morbid states peculiar to chronic bronchitis and emphysema. Whether the constriction of the tubes is due to spasms of the bronchial muscles or to swelling of the mucosa, or to both, the primary, predisposing and irritating influences are common to both. These are vertebral and rib lesions affecting the spinal nerves at their exit and the sympathetic chain along the head of the ribs; irritating lesions to the vagi, constricting pulmonary vessels, and to the cervical sympathetics, causing disturbance of the same, would be factors in the pathological chain. Reflex irritations may be found in various regions, but the principal osseous lesions, according to Dr. Still, are on the right side from the second to the sixth dorsal.

=Symptoms.=—The attack may come on at any time, but usually it comes on in the night during sleep. The onset may be sudden or the attack may be preceded by premonitory sensations, such as tightness in the chest, flatulence, sneezing, chilliness and a copious discharge of pale urine. Nervous symptoms, headache, vertigo, neuralgia, and an anxious, nervous, restless feeling may precede the attack. There is a sense of oppression and anxiety, followed by dyspnea. Soon the respiratory efforts become violent, the patient is obliged to sit up or runs to the window for air. The shoulders are raised, the hands are placed upon something firm to keep the shoulders fixed so that the accessory muscles of respiration can be brought into play. The contracted tubes resist the entrance of air. Expiration is prolonged and wheezy. In severe cases the face becomes pale, the skin is covered with perspiration, the extremities are cold, the lips, finger tips and eyelids are livid, owing to defective oxygenation of the blood. The pulse is small and quick and the temperature is normal or subnormal. The attack may terminate suddenly, sometimes with a spell of coughing; this is especially so of severe cases, as the cough is generally absent in brief paroxysms.

The =cough= is at first very tight and dry and accompanied by a tough, scanty expectoration which is expelled with great difficulty. The =sputum= contains rounded masses of matter, the so-called “pearls” of Lænnec. Microscopically, they are found to be of a spiral structure, containing cells derived from the bronchial mucous membrane and fatty degenerated pus cells. A second form is contained in the inside of the coiled spiral of mucin, a filament of great clearness and translucency, that is most probably composed of transformed mucin. Curschmann’s spirals are found in the early stages of the attack and for a time these were supposed, by their irritation, to excite the paroxysms. Their spiral form is unexplained. Curschmann believes that these spirals are found in the finer bronchioles and to be a product of bronchiolitis.

=Physical Signs.=—=Inspection= shows enlargement of the chest which is fixed and barrel-shaped. The breathing is labored and the chest moves but slightly. The diaphragm is lowered and fixed. =Percussion= yields hyperresonance, especially in cases which have had repeated attacks or when the asthma is associated with emphysema. =Auscultation.=—With inspiration and expiration are heard sonorous sibilant rales which are more marked on expiration. As the secretion increases, which is later in the attack, the rale becomes moist. The attack lasts for a variable period, rarely less than an hour. In severe attacks the paroxysms recur for three or four nights or more with spontaneous remissions during the day. In some cases the relief seems to be absolute, but in the majority of cases there is more or less oppression and cough for a day or two, sometimes for many days.

=Diagnosis.=—The physical signs, examination of the sputum and the history of the case makes the diagnosis easy.

=Prognosis.=—It is not a fatal disease and only dangerous when complications arise. Under osteopathic treatment the prognosis is usually favorable, unless there are serious complications, as this is a disease that osteopathy has treated with signal success. In long standing cases emphysema invariably develops.

=Treatment.=—Asthma, unless complicated with bronchial and lung diseases, is usually readily relieved during the paroxysms. Cases of many years’ standing have been cured in a few treatments. It should be borne in mind that asthma is a respiratory neurosis.

To relieve an attack the osteopath should locate the lesion and, if possible, correct it. Oium[94], in the acute attack, standing at the head of his patient inserts the tips of both thumbs well under the angles of the jaw and then brings direct pressure on both vagi as they pass over the transverse processes of the axis. Pressure must be brief and let up to be applied again. Immediate relief is given in many cases. Adjust upper three cervicals if found deranged.

If the muscles are so severely contracted that it is impossible to make out the nature of the lesion, then strong inhibition, with an upward, outward movement over the angles of the ribs involved, will be sufficient. The object to be gained in every case is to relieve pressure or irritation to the vasomotor or motor nerves, so that the narrowed tubes may be relaxed. Strong inhibition, such as placing the knee in the patient’s back, at the same time pulling on the shoulders, will have temporary effect, but it is always best to reduce the lesion if possible. In severe cases dilatation of the rectum may relieve the paroxysm, and in a few instances it will be necessary to treat the uterus locally.

During the interval between the attacks is the time to remedy the disease. Then one is able to locate exactly the position of the disturbed tissues that are causing the paroxysms and apply treatment in the regions given under etiology. Many cases of asthma are cured in from one to three months’ treatment. One treatment a week is sufficient, provided one is able each time to accomplish something toward a correction of the lesion and that the patient does not suffer during the meantime. Too frequent treatments may simply act as an irritant to the nervous lesions.

Attention should always be given to the diet and hygiene. Gastric digestion should be complete before retiring or it may induce an attack. Complications are treated according to the disease. Examine the upper respiratory tract, the digestive tract, and the pelvic organs when there is reason to believe the paroxysm may be induced reflexly. Laughlin sums up the treatment as follows: (1) Removal of specific lesion; (2) removal of exciting causes; (3) removal of reflex causes; and, (4) treatment of the patient to improve the condition of the general nervous system.

FOOTNOTES:

[93] Laughlin—Asthma—Journal of the American Osteopathic Association, Oct., 1914.

[94] Journal A. O. A. 1918.

DISEASES OF THE LUNGS

Emphysema

Used in a general way, emphysema is a term which implies the presence of air in the interstitial tissue, but when applied to the lungs there are two applications of the term, having widely different significations, viz: Interlobular or interstitial emphysema and vesicular emphysema.

=Interlobular Emphysema.=—This is caused by rupture of air vesicles, deep in the lung structure, the air escaping into the interlobular connective tissue. It is not a very serious condition, rarely produces symptoms and affords no physical signs. It usually results from violent acts of coughing in which the expiratory strain is very great, as in whooping cough and in bronchial asthma; also, from wounds of the lung.

The air bubbles escape into the interlobular septa and are sometimes seen like little rows of beads outlining the lobules. The pleura may become detached and larger vesicles may form. In rare cases the rupture may take place at the root of the lung and the air passes along the trachea into the subcutaneous tissue of the neck and chest wall, which gives rise to a very peculiar and distinctive crepitation upon palpation. Rarely there is rupture of the superficial vesicles, producing pneumothorax.

=Vesicular Emphysema.=—Dilatation of the infundibular passages and alveoli or an increase in their size either symmetrical, involving both lungs, or localized. Vesicular emphysema is divided into compensatory, hypertrophic and atrophic forms.

=Compensatory.=—This occurs when a region of the lung has been disabled from any cause and does not expand fully during inspiration; the healthy portion of the lung must then distend and do vicarious work or the chest wall will sink in to occupy the space. This happens with portions of healthy lungs in the neighborhood of tubercular areas and cicatrices, areas of collapsed lung or parts prevented from expansion by pleuritic adhesions (in this case the compensatory emphysema is chiefly at the anterior margins of the lungs). As a rule this distention is physiologic and beneficial, the alveolar walls being simply stretched. Later they may atrophy, the air cells becoming fused.

=Hypertrophic Emphysema.=—This is enlargement of the lung, due to dilatation of the air vesicles and atrophy of the walls.

=Osteopathic Etiology= and =Pathology=.—An important predisposing cause of emphysema is often found to be due to derangements of the tissues, usually vertebræ and ribs, which affect the innervation to the lung tissues. Such lesions are found in the vagi and spinal dorsal nerves. The atlas may be involved, but it is generally the ribs and dorsal vertebræ. Distinction should be made between cause and effect in the skeletal changes. No doubt in many instances a vicious circle is thus established. Congenital weakness of the lung tissues, probably due to non-development of the elastic tissue, is a predisposing factor. This disease has a markedly hereditary character and frequently starts early in life. The heightened pressure within the air cells upon an already weakened lung tissue produces emphysema. Hence, the obstinate cough of chronic bronchitis and expiratory straining of asthma are sometimes the immediate cause. In all attacks of severe coughing or straining efforts, the glottis is closed and the air is forced into the upper part of the lungs, forcibly expanding them, and here is where emphysema is found to be most advanced. This disease is also found in players of wind instruments, in glass blowers and in those whose occupation necessitates heavy lifting or straining.

=Pathologically=, the thorax is barrel-shaped. The lungs are enlarged and do not collapse when the thorax is opened, as they have lost their elasticity. The organs are pale, soft and downy to the feeling and pit on pressure. Enlarged air vesicles may readily be seen beneath the pleura. Microscopically, there are seen atrophy of the vesicular walls and a diminished amount of elastic tissue. There is more or less obliteration of the capillaries, and the epithelium of the air cells undergoes a fatty change. There is usually chronic inflammation of the bronchial tubes, which may be roughened and thickened. The diaphragm is lowered and the subjacent viscera are displaced. The most important morbid changes are found in the heart, the right chamber being dilated and hypertrophied. This is caused by the increased tension in the pulmonary artery, which is enlarged and the seat of atheromatous degeneration. In long standing cases the hypertrophy is general. Changes in the liver, kidneys and other viscera are those associated with prolonged venous engorgement.

=Symptoms.=—The onset of the disease is usually gradual. The first symptom to be noticed is the shortness of breath. In rare cases it may exhibit a more acute development, as after whooping cough, and then the first symptom will be dyspnea. In some cases this persists all the time, while in moderate emphysema the dyspnea is noticed only on slight exertion, such as going up-stairs, running or walking rapidly. The lungs are always filled with air which is charged with carbon dioxid and does not change, as the patient is constantly making ineffectual efforts to draw in air. The inspiration is shortened and the expiration is greatly prolonged and is often harsh and wheezy. The pulse-rate is accelerated; the temperature is usually normal. Cyanosis is a characteristic symptom in well established cases and is of an extreme grade not seen in any other affection. Bronchitis is frequently found in combination, especially in winter. In this case there will be the symptoms of the associated bronchitis, cough, expectoration and sometimes oppression. As the patient advances in age and there are successive attacks of bronchitis, the condition gets worse. In advanced cases, the result of cardiac failures, there may be venous engorgement, dropsy and effusions into the serous sacs.

=Physical Signs.=—=Inspection.=—There is a marked change in the shape of the thorax. The chest is rounded with increased circumference, giving the characteristic barrel-shaped chest. The sternum bulges, as do also the costal cartilages. The intercostal spaces are wide, especially in the hypochondriac region, and narrow above. The clavicles and muscles of the neck stand out with great prominence and the neck itself seems to be shortened on account of the elevation of the thorax and sternum. The curve of the spine is increased and there is a winged condition of the scapulæ. These changes give the patient a stooping posture. The chest does not expand, but is raised up by the scaleni and sternocleidomastoid muscles which stand out prominently and are hypertrophied. The heart’s apex beat is invisible and there is usually marked epigastric pulsation. On =palpation=, vocal fremitus is found diminished, but not absent; the apex beat is rarely felt. There is distinct shock over the ensiform cartilage. This is due to the displacement of the heart and engorgement of the right ventricle. There is marked pulsation in the epigastrium. On =percussion= there is sometimes increased resonance, almost amounting to tympany. The upper level of hepatic dullness is depressed. The heart dullness may be obliterated and the upper limit of splenic dullness may also be lowered. The =percussion= note is greatly extended. =Auscultation= reveals that the inspiration is short and feeble while there is prolonged expiration, the normal ratio being reversed. In associated bronchitis rales are frequently heard.

=Diagnosis.=—Unless complicated the diagnosis is generally easily made. The enlargement of the thorax, with dyspnea and hyperresonance and a prolonged expiration will differentiate emphysema from =chronic bronchitis=. =Pneumothorax= is of sudden development while emphysema is of slow development. Pneumothorax is usually unilateral, and it gives a tympanitic percussion note. In auscultation there is amphoric breathing and metallic tinkling and absence of any vesicular murmur.

=Prognosis.=—The disease is rarely fatal, although death may result from heart failure, dropsy or pneumonia. Thorough and persistent treatment will generally relieve the primary condition. The disease, as a rule, runs a long course but does not necessarily shorten life.

=Atrophic emphysema= is a senile change.

=Treatment.=—In cases of recent occurrence one may be able to build up the altered lung tissue by treatment of the innervation to the lung structure, viz.: the vasomotor nerves from the second to the seventh dorsal, the vagi, and the cervical and dorsal sympathetics. When a number of air vesicles have been converted into one sac, it is impossible to restore the altered lung structure and a treatment to relieve the symptoms and to prevent the further progress of the disease is indicated. In all cases treatment should be applied to correct any vertebræ or ribs of the upper dorsal region that may be displaced, and to raise and spread the ribs so that the lung structure may be better nourished and strengthened and that the aeration of the blood will be more perfect. Treatment of the vagi nerves is important, as their physiological action on the lungs is to increase their movement.

The general health of the patient is an important consideration and everything should be done to promote as healthy a condition as possible. The digestion should be carefully looked after and everything done to restore a normal state of the blood. A change of climate may prove beneficial.

Strengthening the cardiac action will be of service in relieving any dropsical tendency that might occur on account of obstruction to the pulmonary circulation. If bronchitis or asthma occurs, their respective treatments are indicated. A general treatment of the splanchnic and lung vascular areas should be given to prevent any disturbance in the circulation which might cause congestion of the liver, congestion of the hemorrhoidal veins, or catarrh of the stomach and bowels.

“Free evacuation of the bowels and measures to relieve any flatulent distention are very needful in cases of emphysema to take off from the diaphragm any pressure from below, and to allow it to descend as freely as possible. With this view also the food should be concentrated, nourishing, and not bulky.”[95]

It is a good plan to instruct the nurse or attendant to aid inspiration by raising the arms strongly above the head during inspiration and to compress the chest during expiration so as to coincide with natural breathing, which will render the aeration of the blood greater and increase the elasticity of the vesicles.

Acute Lobar Pneumonia

(CROUPOUS PNEUMONIA)

This is an acute, infectious disease wherein various vertebral, rib and muscular lesions predispose to a lowered nutritive state of the parenchyma of the lung, permitting the invasion of the diplococcus pneumoniæ, with consequent local inflammation and pronounced constitutional disturbances, chill, extreme prostration and fever, which terminates abruptly by crisis. Secondary infective processes are frequent.

In describing a typical case of pneumonia it is considered as a self-limiting disease. By osteopathic treatment it is often aborted or, at least, its course much shortened. In such a case it is not typical pneumonia and could not be described as such.

=Osteopathic Etiology= and =Pathology=.—Pneumonia occurs more often in the young up to the sixth year and in the aged. It is more frequent during the winter and spring months. “Colds,” exposure and wetting are predisposing influences that lower resistance. Climate exerts little predisposing influence. Males are, on the whole, more frequently attacked. Pneumonia may follow injuries of the chest. Various derangements of the ribs and vertebræ are always found in pneumonia; such derangements correspond with the regions of vasomotor, motor and trophic fibers of the lungs, viz., second to seventh dorsal, inclusive, and the upper cervical vertebræ, the latter region affecting the vagi. The muscles of the chest region are always severed contracted. These various disorders produce a lowered vitality of the bronchial and lung tissues, thus favoring the existence of the micrococcus lanceolatus. Unhygienic surroundings, alcoholism, any or all habits that tend to depress the nervous system, or lowered vitality from some pre-existent disease, like diabetes, Bright’s disease, organic heart affection or one of the infectious fevers, favor its development. One attack undoubtedly predisposes to another and repeated attacks may occur in the same individual. The exciting cause is the invasion of the lung by pathogenic bacteria, especially by diplococcus pneumoniæ. Pneumococci are frequently found in the throat and mouth of the healthy.

=Pathologically=, the lung in croupous pneumonia exhibits three distinct stages—congestion, red hepatization and gray hepatization. In the =stage= of =engorgement= the tissue is red in color, firm and solid and less crepitant than the healthy lung. The cut surface is bathed in blood and stained serum. Microscopic examination shows the capillaries to be dilated and tortuous. The alveolar epithelium is swollen and the air cells filled with a variable number of red corpuscles, detached alveolar cells and a few leucocytes. During the =stage= of =red hepatization= the tissue is solid. It is reddish brown in color and of a dry, mottled appearance. It is very friable and does not crepitate, as the affected portion is airless. Its weight and specific gravity are increased so that it sinks in water. The torn surface presents a granular appearance, there being fibrinous plugs in the air cells. On microscopic examination the air spaces are found filled with coagulated fibrin. The tissue contains red blood-corpuscles and pus cells and the walls of the air cells are infiltrated. In sections properly treated the diplococcus is detected, and in some cases also the streptococcus and staphylococcus. In the =stage= of =gray hepatization=, the lung is still dense and heavy, but the surface is moister and softer, while the lung tissue is even more friable and the red color gives place to a mottled gray. The exudate loses its granular character and a yellowish white purulent liquid flows from a cut surface. Microscopically, the air cells are filled with leucocytes, while the red corpuscles and fibrin filaments have disappeared. The stage of gray hepatization is the stage of beginning =resolution=. The exudate is softened. The cell elements are disintegrated and absorbed by the lymphatics and largely eliminated through the kidneys. In unfavorable cases the consolidated lung may become infiltrated with pus, and abscesses occur. In some instances the tissue is gangrenous, or it may become the seat of fibroid induration. These, however, are rare.

=Symptoms.=—The disease begins abruptly, usually with a severe chill, lasting from half an hour to an hour, the fever rising rapidly. There is a sharp pain in the side, the skin becomes harsh and dry, the face is flushed, the eyes are bright and the expression anxious. A short, dry, painful cough soon develops. The expectoration presents a characteristic, rusty or blood tinged appearance and is extremely tenacious. The temperature rises rapidly, frequently to 104 or 105 degrees F., and continues high for from five to ten days and generally terminates by crisis. The pulse is full, but the pulse-respiration ratio is not maintained. There is marked dyspnea, the respirations ranging from forty to fifty per minute. There are many fine rales. Headache, gastro-intestinal disturbances, sleeplessness, epistaxis, rarely delirium except in drunkards, may also be present.

The symptoms given are those of a typical case of pneumonia, but all are subject to modification. The onset may be gradual and the chill absent. In all cases, and especially drunkards, the temperature may not be high, while the pulse is often feeble and rapid instead of full and strong, and the physical signs may not make their appearance until the second or third day.

=Special Symptoms.=—The =fever= rises abruptly in the initial chill, the temperature reaching 104 or 105 degrees F., and is continuous with a variation of a degree or two. The fever terminates by =crisis= after having continued from five to nine days. The temperature commonly falls during the night and is accompanied by a profuse perspiration. The temperature may fall from five to eight degrees in eight to twelve hours. There is a wide range here depending upon promptness and skillfulness of treatment, the reaction of the tissues, and previous health. Early treatment is invaluable in modifying the course of the disease.

The =sputum= at first is mucoid and frothy. About the second day it becomes of a characteristic color, quite copious and consisting of a frothy, fluid mucus, containing small viscid masses. It is very viscid and glutinous, in some cases almost from the onset. In old and previously weak persons, there may be no expectoration. Under the microscope the sputum is seen to contain red blood-corpuscles, leucocytes, alveolar epithelium, the micrococcus lanceolatus as well as other micro-organisms, pus corpuscles and small fibrinous casts. A stabbing =pain= is a common early symptom, as well as a dry, short =cough=. The =urine= is febrile, scanty and high colored. Urea and uric acid are increased. A trace of albumin is often present, and there may be symptoms of acute nephritis. =Herpes= is common. The nasolabial herpes appear from the second to the fifth day, and they may occur upon the cheek, genitals and also upon mucosa of the tongue. It is supposed to indicate a favorable prognosis. There is redness of the cheek, usually on the affected side. The mucous membrane of the mouth is dry. The tongue is white and furred. Anorexia and thirst are present. The patient is usually constipated, but diarrhea may occur. Vomiting is common. The spleen is usually enlarged, but the liver is not perceptibly increased in size, unless there is extreme engorgement of the right heart. The =pulse= is bounding. The average pulse-rate is from 100 to 108 per minute. In consolidation the left ventricle receives a lessened amount of blood and the pulse may become small. In the aged and debilitated, a small, weak and rapid pulse may be present. The =heart sounds= are loud and clear, and in favorable cases the pulmonary second sound is accentuated, owing to the increased tension in the pulmonary vessels. Upon distension of the right side of the heart and partial failure of the right ventricle, the second sound becomes less distinct which is a very unfavorable symptom, for very much depends upon the strength of the right ventricle in pneumonia. The =blood= usually exhibits leucocytosis which disappears with the crisis. In malignant pneumonia this is absent and its continued absence is an unfavorable sign. The proportion of fibrin is also greatly increased. The diplococci can rarely be seen. Headache is common as an initial symptom and may be persistent. The disease is often ushered in by convulsions, especially in children; consciousness is usually retained throughout the whole attack, even in severe cases, though in some cases there is delirium. In drunkards delirium tremens may be present from the onset. In these cases the patient often wanders about until the preliminary excitement gives way to coma.

=Physical Signs.=—=Stage= of =Congestion.=—Diminished expansion, the movements of the affected side are defective, the face is flushed and the patient lies on the affected side. Tactile fremitus is slightly increased. There may be tympany over the involved area from diminished intrapulmonary tension. In the latter part of this stage there is impairment of resonance. Fine crepitant rales are heard at the end of forced inspiration. Great care has to be taken in examination when there is deep seated consolidation.

=Stage= of =Red Hepatization=.—The breathing is markedly abnormal. Very little or no expansive motion of the chest over the affected region. Vocal fremitus is markedly exaggerated. The skin is hot and dry and the pulse frequent. Dullness over the affected parts with an increased sense of resistance is present. There is high-pitched, prolonged, bronchial breathing when the lung becomes solidified. When the larger bronchi are completely filled with exudate, tubular breathing is absent. Crepitant rales may also be heard.

=Stage= of =Gray Hepatization=.—Largely the same physical signs are repeated in this stage as in the second. The normal manner of breathing returns, as does also the normal expansive movement of the affected side. Crepitant rales reappear. The temperature of the skin is lessened, breathing changes from bronchial to vesicular and bronchial resonance continues for some time.

=Complications.=—=Pleurisy= is the most frequent complication. Pneumonia on one side and pleurisy on the other is possible. The pain is more acute and localized. The respiration is greatly affected and the usual signs of effusion are present. Empyema may be a complication. =Pericarditis= is more common in the pneumonia of children. Though usually plastic it may be serofibrinous, but rarely the fluid is purulent. There is increased dyspnea, the pulse becomes weaker, and the heart sounds are gradually suppressed. =Endocarditis= is a comparatively frequent complication. It is more liable to attack patients with old valvular disease and to affect the left heart. The physical signs are sometimes absent and even when present are liable to be very deceptive. It may, however, be suspected in cases where the fever is protracted; when septic manifestations, such as chills, sweats or irregular temperature, develop; when embolic symptoms appear, or when a rough, diastolic murmur develops. =Meningitis= is a complication that comes on at the height of the fever. This complication is rarely recognized unless the basilar meninges are involved. It is frequently associated with ulcerated endocarditis. Cerebral embolism causing hemiplegia has been observed. Other possible complications are neuritis, arthritis, nephritis, parotitis and various digestive disorders.

=Diagnosis.=—A typical case of pneumonia is easily recognized. The abrupt onset with rigor, the rapidly developed fever, the sputum, physical signs and abnormal pulse-respiration ratio, as a rule make the diagnosis easy. Frequent examination of the lungs should be made in Bright’s disease, diabetes, organic affections of the heart, cancer and alcoholism, as all these affections are liable to become complicated with acute pneumonia. =Pleurisy= is often confounded with pneumonia. The resemblance between friction sounds and crepitant rales is often very close. In pleurisy vocal resonance and vocal fremitus are diminished; there is no “rusty” sputum; the percussion dullness may change with the posture of the patient, and the breathing is distant and weak. A typhoid state may be mistaken for typhoid fever. Hypostasis occurs late in typhoid fever while dullness sets in early in pneumonia. The history of the onset will be of aid, as pneumonia as a complication sets in late in the disease. The Widal test will be of value. =Acute phthisis= may begin with a chill and may resemble pneumonia very closely, especially the physical signs. Examination of the sputum will show the bacilli of tuberculosis. The X-ray will often be of aid as a diagnostic measure.

=Prognosis.=—This largely depends upon the previous health of the patient. At the extremes of life the prognosis is much more unfavorable. It is especially fatal in drunkards. By competent osteopathic treatment the mortality rate may be materially lessened and this disease, dreaded by both physician and patient, need not seem so fearful. The death rate from pneumonia during the past few years has been appalling. In New York and Chicago nearly one-eighth of the deaths the year around are due to pneumonia, and during certain months of the year twenty-seven or eight per cent. of all deaths are due to this disease. Drug medication is notoriously unreliable, the most competent physicians freely admitting that they are practically powerless to stay the ravages. Given a patient with a fair constitution, osteopathic treatment will offer reasonable hope to the sufferer. There is no question that osteopathy merits much commendation in the treatment of pneumonia. Many severe cases have been cured and many more have undoubtedly been aborted. The treatment is directly applicable and specifically indicated, and coupled with good nursing and hygiene, the mortality rate of the old schools is being markedly lessened.

=Treatment.=—The treatment of pneumonia must be both constitutional and local. By this is meant that the systemic strength and vigor must be maintained in addition to treatment of the chief lesion of the disease, which is located in the lungs.

During the various stages of the disease, the treatment should be directed to the nerves of direct innervation that control the capillaries, and to the vasomotor nerves of the pulmonary circulation, in order that the hyperemic and inflamed state of the pulmonary capillaries and adjacent tissues may be lessened and the circulatory system equalized. The disordered tissues that should be corrected in order that the centers of the spinal cord and the nerves that influence the function and structure of the lungs may be relieved, are: contraction of the thoracic and dorsal muscles, subluxations of the ribs and dorsal vertebræ from the second to the seventh, inclusive, and the upper cervical vertebræ that may become disordered and impinge upon the vagi nerves. However, owing to the fact that the vasomotors are not especially abundant here, all increased chest mobility and deep breathing and abdominal aid will materially assist the circulation. Also, carefully treat the middle and inferior cervical regions for the lymphatics of the lungs. Each of these regions should be carefully examined and thoroughly treated whenever found involved. The specific micro-organisms that influence the course of pneumonia are naturally very important factors; but observing and improving the general health, and establishing an unobstructed circulation through the diseased lung tissues will hasten the crisis by favoring a rapid formation of antidotal substances to neutralize the poisonous substance produced by the micrococcus lanceolatus. Healthy tissues, which occur only where there is uninterrupted freedom of vascular supply and nerve force, are obtained by correction of any and all anatomical disorders. This will rapidly decrease any lethal tendency in the patient and often abort the disorder so that all that is needed is sufficient time for nature to heal the diseased tissues. The principal predisposing cause of many specific diseases, is some disorder of the anatomical tissues that interferes with normal physiological functions; and the determining of the different types of disease is often due to the location of the lesion and the character of the micro-organism involved in each disease. What is necessary in many cases is a correction of the mechanical predisposing condition and the exciting and determining influences will be rendered inactive.

The importance of close attention to both vagi can not be overestimated. Any obstruction above or below the origin of the superior laryngeal nerve is followed by loss of motor power of the lungs, thus causing difficult and labored breathing. The lungs become surcharged with blood, because the air pressure in the lungs is low and the thorax is distended. This condition is followed by serous exudation. Thus obstruction of the vagi may be one factor in the cause of pneumonia. Obstruction of the vagi below the origin of the recurrent laryngeal nerves affects the lower and middle lobes of the lungs, and produces also a catarrhal inflammation of the upper lobes. The recurrent laryngeal nerves may be obstructed by dilatation of the aorta or subclavian artery as they wind about them; also by dislocations of the first and second ribs, which may affect the nerves not only directly, but by causing an obstruction to the subclavian vessels with a consequent disturbance of the aorta and the heart. The recurrent laryngeal nerves may be treated directly at the inner lower part of the sternomastoid.

One of the chief objects of the treatment should be to prevent =heart failure= and to lessen the pulse-respiration ratio. The average pulse-rate in typical cases is from 100 to 110 per minute and when it exceeds this to any extent, say 120, there is cause for alarm. At first the pulse is full and bounding, later it is small on account of a lessened amount of blood reaching the left ventricle and systemic circulation, owing to the extensive consolidation. In treating heart failure particular attention should be paid to the condition of the ribs on the left side over the region of the heart, the second to the fifth, inclusive. A correction of any disturbance to the inhibitory nerves of the heart, (the vagi) and the accelerator fibers of the heart (the cervical sympathetic) should be made. This means close attention to probable derangements of the vertebræ from atlas to first dorsal. General treatment of the entire system will relieve the heart of some work and favor an equalization of the vascular system. Also by the use of hydrotherapy the maintenance of the heart’s action may be accomplished. Cold compresses, and not warm ones, should be used, as the latter relax the vessel walls, producing more or less paresis of the vessels, while the former stimulate the vaso-dilators, producing dilatation and tone of the vessels, thereby causing a vigorous increase in the flow of blood. This relieves the heart by increasing the cutaneous circulation, besides increasing arterial tension. The right heart is indirectly aided by the increase of the tension in the general vascular system, and the vessels of the pulmonary circulation have more force expended upon them and a greater contraction of their vessels occurs on account of the dilatation of the cutaneous vessels. The temperature of the water used should be 60 degrees F., and the compress applied for thirty minutes or as long as necessary.

Attention to the abdominal area and diaphragm will have a definite effect upon the circulation and elimination. It is beneficial in its influence upon lungs and heart and in combatting toxemia. Carefully graduated deep breathing is of distinct benefit.

In addition to the fever treatment in the cervical and dorsal regions, the gradually cooled tub-bath will be of aid. The temperature at first should be ninety degrees F. and then gradually cooled to eighty degrees F. The duration should not be over ten or fifteen minutes. Care should be taken that the patient does not exert himself. He should be lifted in and out of the baths. These baths also have a marked effect upon the respiratory and nervous centers. The ice-bag over the chest and spine has a beneficial influence; still, with feeble children be exceedingly careful when applying or using cold methods.

=During all stages of the disease=, the best possible care should be taken of the patient. See the patient frequently, probably twice a day or oftener. Each time thoroughly relax the dorsal muscles and readjust the ribs, for as every osteopath of experience will note (and Dr. Still particularly emphasizes) the contracted muscles frequently and continually displace the ribs. The treatment should not be prolonged to a point of overfatigue, but a definite reaction of tissues should be secured but no further.

Carefully raise all the ribs and moderately hyperextend the spine. Release the cervical, pectoral and axillary lymphatics, and stimulate spleen and liver.

Experience has shown that the first treatment is of the greatest importance and if the osteopath will control the predominant symptoms at that time the result will be much simplified. For that reason it is best not to leave the patient until the chest pain, fever, high pulse or whatever may be present, are well in hand, although it may mean a long visit with fairly frequent treatments. Treat the conditions existing and wait; then treat again and the result will more than repay. There is always more than a chance of aborting the disease, but the first treatment is often the crucial test. F. E. Moore and many others report numerous cases treated without a fatality and the average duration of the disease not exceeding five days. The apartment should be well aired and a temperature of 65 degrees F. maintained. In the very young the temperature should be higher. The diet is exceedingly important. Give a liquid, light and nutritious one, a milk diet being preferable. Otherwise give meat juice, broths, egg albumin and whey. Avoid starchy and saccharine foods, and give plenty of water. Good nursing and complete rest of body and mind, with careful attention to the activity of the bowels, kidneys and skin, will indirectly aid the clogged up lung fascia to perform its function and hasten an early recovery from the disease. In epidemic forms be particularly vigilant in the employment of antiseptics.

Bronchopneumonia

(CATARRHAL PNEUMONIA)

=Definition.=—An inflammation of the minute bronchi and air vesicles. The affection begins with an inflammation of the capillary bronchi, which extends to the air vesicles. The micrococcus lanceolatus, streptococcus pyogenes, influenza bacillus, and staphylococcus aureus et albus are the principal exciting micro-organisms.

=Osteopathic Etiology= and =Pathology=.—The disease is most prevalent among the very young and the old, and may be either primary or secondary. It may occur as a sequence or in association with measles, diphtheria, whooping cough and scarlet fever. Exposure to cold, impure air, rickets and diarrhea are marked predisposing causes in children. In the old, debilitating affections and chronic diseases are predisposing causes. Bronchopneumonia occurs sometimes as a complication in smallpox, erysipelas, typhoid fever and influenza. The principal lesions found upon examination are subdislocated ribs affecting the pulmonary vasomotor nerves. The third, fourth and fifth ribs are especially apt to be subdislocated. The muscles throughout the thoracic region are generally severely contracted.

Another group of cases, the so-called =aspiration or deglutition pneumonia=, are caused by the inhalation of food particles or other substances. A lessened sensitiveness of the larynx (as in comatose states) may allow small particles of food to reach the smaller bronchi and produce inflammation, which may even cause suppuration and sometimes gangrene. Cases are liable to occur after operations about the nose and mouth. It is often secondary to carcinoma of the larynx and esophagus and after tracheotomy and glosso-pharyngeal palsy. A serious form of bronchopneumonia is caused by the =tubercle bacillus=.

=Pathologically=, both lungs are usually involved and become heavy. On the pleural surfaces, especially at the base, sunken purplish or slaty patches are noticed, representing collapsed lung tissue. On section small, projecting portions of consolidation are seen, separated from each other by uninflamed and collapsed tissue. The section of lung tissue is of a dark reddish color. The terminal bronchi are filled with tenacious, purulent material. Microscopically, the terminal bronchi and air cells are filled with a plug of exudation composed of leucocytes and desquamated epithelium. The walls of the bronchi are swollen and contain many leucocytes.

=Symptoms.=—The symptoms are frequently marked by those of the primary affection. The onset may be either abrupt or gradual. The child becomes feverish; there is increased frequency in respiration and there is an aggravated cough. The temperature rises to 102 or 104 degrees F.; respiration may rise as high as 60 or 80. The cough is hard, distressing, frequently painful and accompanied by a mucopurulent expectoration. The pulse is greatly accelerated—120 to 180 per minute. As the disease advances, signs of deficient aeration of the blood are noticed. At first there is a pale and anxious expression of the face, the lips are blue and the child makes strenuous efforts to breathe. The blood soon becomes highly charged with carbon dioxide and, by its benumbing influence upon the nerve centers, sensibility is reduced and the cough and suffering subside. The face becomes livid and death may occur within twenty-four hours from paralysis of the heart.

At the beginning of the attack dullness is absent and subcrepitant and sibilant rales are present. Areas of consolidation soon become manifested. There is slight impairment of resonance and the breathing is harsh. Upon inspection there is, in grave cases, retraction of the sternum due to defective expansion.

=Diagnosis.=—This is usually easy, developing as it generally does in the course or at the conclusion of another disease, with a gradual onset as a rule, and irregular fever and a long duration, besides usually occurring in children under five. If the areas of consolidation are large, involving the greater part of a lobe, it is sometimes very difficult to distinguish bronchial pneumonia from lobar pneumonia. =Lobar pneumonia=, when occurring in children, is usually between the ages of five and fifteen. The onset is abrupt in a child of good health; it resolves rapidly; there is rusty colored sputum and continued fever falling by crisis. =Tuberculous bronchopneumonia= is very hard to differentiate from simple bronchopneumonia. A great many cases can be correctly diagnosed only after the lapse of considerable time. The presence of signs of softening, considerable disease of the apices, and examination of the sputum, or in the case of a child, of the vomited matter, would diagnose this form. If elastic fibers and tubercle bacilli are found in the sputum or vomited matter, the diagnosis is at once decided in favor of tuberculous bronchopneumonia. X-ray diagnosis should be considered.

=Prognosis.=—The prognosis depends on the cause. In children that are previously weak and debilitated the disease is very fatal. When the disease follows measles and whooping cough, the fatality is not so great. In adults the prognosis is about the same as in the croupous form. The deglutition variety is apt to be fatal.

=Treatment.=—A great deal can be done to prevent the disease, by careful attention to debilitated children in keeping them warm and protected at all times. There is usually a preexisting bronchitis. In measles and whooping cough and during convalescence, the child should be well taken care of.

A thorough, persistent treatment, but not to a point of overfatigue, of the dorsal vasomotor nerves posteriorly should be given. Gentle work over the cervical and axillary lymphatics to free the edematous barrier, correction of the tensed scaleni and deranged first ribs and clavicles, and stimulation of spleen and liver, with sufficient general treatment to start reaction, will be effective. Derangements to the third, fourth and fifth dorsal nerves are most likely to be found; the principal vasomotor innervation to the bronchials and air vesicles is from this region. Treatment over the chest anteriorly is of great aid, especially an upward and outward manipulation to release the ribs should be given. Attention should be given the vagi nerves to increase the activity of the lungs as well as for the effect gained upon the circular fibers of the bronchi. Care should be taken, that the first rib is not impinging upon the first thoracic ganglion, or interfering with lymphatic drainage.

Ice-bags over the chest are helpful. The chest should be protected from changes in temperature by a jacket of cotton batting. The diet should consist of milk, egg albumin and broths. Keep the temperature at about 70 degrees F. and the air of the room moist and free from draughts. When the fever is high, sponging or the wet pack is helpful. The bowels from the beginning of the attack should be carefully watched.

There is danger of a =failing heart=; this is generally associated with mucous rales and cyanosis. Douching alternately with hot and cold water will usually excite coughing and overcome the difficulty. The gradually cooled bath will have a marked effect in reducing the temperature, quieting the nervous symptoms, increasing the respiratory power and promoting sleep.

Raise and carefully stimulate the abdominal viscera, and elevate the diaphragm. This is effective in both cyanosis and toxemia.

In the first stage of pneumonia, Hazzard[96] says, “There is better opportunity to correct the specific lesion, as the patient’s strength will allow of such treatment. The work is also aided by the fact that the alveoli are still open, and lung action, stimulated by treatment, may become a valuable aid in dispelling the engorgement.” This is a most valuable suggestion, but be exceedingly careful in subsequent treatments not to treat too hard and thus lame and bruise the patient.

Series I, II, III, and V of the American Osteopathic Association Case Reports present several interesting cases of pneumonia which typify the importance of immediate and direct correction of the osteopathic lesions.

Herman[97] cites an interesting case of delayed resolution, due to a depressed condition of all the ribs on the affected side with marked luxation of the eighth. The lesion at the eighth was the cause of a prolonged attack of hiccoughs which prevented resolution. It is pointed out that there is an abundant intercostal nerve supply to the diaphragm from the eighth and ninth intercostals. C. E. Achorn instances an autopsy of patient dying of pneumonia, where a bony ankylosis was found at the second dorsal; this lesion was probably an important predisposing factor.

Broadly speaking, one should keep in mind the following: First, early treatment will frequently abort what would ultimately be pneumonia—still, in the preceding it is not these cases that are especially referred to, but those following the course of a typical pneumonic process; second, both specific and general treatment prior to the crisis will materially lessen the severity of the disease; third, the crisis corresponds to beginning resolution (during resolution expectoration and liquefaction and absorption of the exudate are paramount features) and must be met promptly and vigorously, special attention being paid to the heart; and, fourth, during convalescence, good, general attention and care of patient as to treatment, hygiene, diet, and climate, are important.

Chronic Interstitial Pneumonia

(FIBROID INDURATION)

=Definition.=—A chronic, inflammatory disease of the lungs, characterized by an overgrowth of fibrous or connective tissue.

=Etiology.=—With few exceptions chronic affections of the lungs cause more or less fibroid overgrowth. This is especially frequent after bronchial pneumonia and pulmonary tuberculosis. It is also excited by abscesses, hydatids, syphilis, emphysema, sarcoma and old fibrinous pleurisy. It may also be caused by compression, by aneurism or neoplasms. It may arise as a primary affection, due to the inhalation of irritating dusts (stone dust, coal dust and metal dust). There will be found deeply seated osseous lesions of the upper and middle dorsal region and corresponding ribs, and frequently of the cervical vertebræ.

=Pathologically=, as it involves limited or extensive areas, it is recognized as =local= or =diffuse=. It is a unilateral affection. The involved portion is shrunken and on section it is found to be tough, firm, of a greenish color and containing an overgrowth of fibrous tissue. If it affects the left side the heart may be displaced. The unaffected lung is usually enlarged (compensatory emphysema). There is hypertrophy of the right ventricle of the heart.

=Symptoms.=—There is a chronic cough, which varies greatly in its severity; moderate dyspnea, and a variable expectoration. There is no fever and the general health of the patient may be preserved for a number of years. The expectoration is generally copious, muco- or sero-purulent, rarely fetid. There is retraction of the affected side, displacement of the apex beat and lateral curvature of the spinal column. The unaffected side is enlarged. The intercostal spaces disappear, the ribs sometimes even overlapping. The tactile fremitus is generally increased, but if the pleural membrane is thickened the fremitus may be decreased. There is generally impairment of resonance. A tympanitic or amphoric note may be heard over a dilated bronchus. On the sound side the percussion note is generally hyperresonant. The breathing sounds may be feeble. They may be bronchial or cavernous, but rather amphoric. Late in the disease cardiac murmurs are not uncommon.

=Diagnosis.=—This is never difficult. It is mainly to be distinguished from =fibroid phthisis=. In the latter both lungs are involved and there is fever and bacilli are found in the sputum. An X-ray examination should be made.

=Prognosis.=—The disease is exceedingly chronic and may last for many years. Death may result from gradual failure of the right heart, hemorrhage or from intercurrent attacks of acute pneumonia involving the other lung.

=Treatment.=—Little can be done for this condition. Intercurrent bronchitis may be somewhat relieved by the treatment for chronic bronchitis. The patient should dwell in a mild climate. Hygienic surroundings and nutritious food are indicated. Something can be done by attempting to correct the condition of the ribs and vertebræ, but this measure, from the nature of the disease, is generally palliative at best.

Congestion of the Lungs

=Congestion of the lungs= may be active, passive or hypostatic. The two former have particular osteopathic significance, owing to the lesions involved.

=Active congestion= may result from violent physical exertion, excessive alcoholic indulgence, inhalation of hot air or as a symptom in pneumonia and other pulmonary affections. There is dyspnea and cough with rusty expectoration of a frothy nature. There may be absence of fever. But generally a slight chill followed by moderate fever, pain in side, and cough are the principal symptoms. On percussion, the note is dull with increased tactile fremitus and bilateral involvement.

=Prognosis= is good under osteopathic treatment, but it must be promptly met as it is usually a symptom of another disease.

=Treatment= is the same as in the beginning of pneumonia.

=Passive congestion=, when not hypostatic, is mechanical and due to an impeded return of blood to the left heart from mitral stenosis, or regurgitation, dilatation of the right ventricle and cerebral disease. The lungs are large with distended pulmonary vessels with venous blood in the air spaces. There is dyspnea and cough, with blood-streaked, frothy expectorations.

The =treatment= is primarily of the condition causing the congestion, but in addition the upper ribs should be raised and thorough treatment of the abdomen and elevating the diaphragm are beneficial.

=Hypostatic congestion= results from a weakened heart in exhaustion, infection or old age; also from continued dorsal decubitus. Rheumatic fever, tuberculosis and other constitutional diseases, as well as organic growths, may predispose. The condition gives rise to a mild form of lobar pneumonia. =Symptoms= are not well defined and often are not recognized. There may be slight dullness, increased fremitus, moist rales and other signs of a venous engorgement.

In =treatment= the first move is to change position of the patient and then look after any underlying cause. Osteopathically, follow treatment of pneumonia. In all cases of circulatory involvement of the lungs, treatment to relax muscles or to adjust vertebræ and rib lesions to the vasomotor nerves of the lungs is very efficacious. Landois (1904) says: “Irritation of sensory nerves, particularly if intense and long continued, causes a dilatation of the vessels in the areas innervated by them.”

Edema of the Lungs

There are two forms of =edema=, collateral and general, which follow an intense congestion with transudation of serum into the air vesicles and interstitial tissue. The =collateral form= is localized and usually appears in connection with pneumonia, pulmonary infarction or abscess. In =general edema= the base of the lung is involved to a greater extent, but the whole structure is affected and hydrothorax is generally present. The =cause= of edema is not well understood, but may result from a long line of constitutional diseases. The =symptoms= are dyspnea, cough with copious, blood-streaked sputum which is expelled with difficulty. There may be fever in the inflammatory type with weak, increased pulse. Dullness over the affected area, broncho-vesicular breathing and small liquid rales are audible. The =diagnosis= must largely be made upon the bilateral dullness at the base of each lung and physical signs noted above. X-ray examination will usually be of value. =Prognosis= depends on the condition causing the edema and treatment should be directed to correcting it. Frequently edema is a terminal affection. This should be followed by osteopathic treatment to free the lungs of the effusion as outlined under pneumonia, especially relaxation of the upper dorsal and cervical muscles, separation of the upper ribs and stimulation of the heart.

FOOTNOTES:

[95] Yeo—A Manual of Medical Treatment or Clinical Therapeutics, Vol. 1, p. 597.

[96] Hazzard—Practice of Osteopathy p. 91.

[97] Herman—An Unusual Feature in a Case of Pneumonia—Journal of the American Osteopathic Association, July 1906. (This refers to lobar pneumonia.)

DISEASES OF THE PLEURA

Pleurisy

=Definition.=—An inflammation of one or both pleural membranes.

=Varieties.=—Etiologically, it may be divided into primary and secondary pleurisy; also, into acute and chronic pleurisy. Anatomically, the cases may be divided into dry pleurisy and pleurisy with effusion (serofibrinous, purulent, hemorrhagic).

Acute Pleurisy

(FIBRINOUS OR PLASTIC PLEURISY)

The affection may be primary or secondary. As an independent affection it is rare. It may follow exposure to wet and cold or it may be due to mechanical injury. The disease may set in with pain in the side, slight fever and the friction sound of pleurisy may be present. These symptoms last a few days and then disappear and no exudation occurs. The pleural surfaces become more or less united.

As a secondary process, dry =plastic pleurisy= arises from extension of the inflammation in acute or chronic diseases of the lung, especially pneumonia. Abscesses, gangrene and cancers are also causes. It sometimes occurs in acute articular rheumatism, and in a large number of cases is associated with =tuberculosis=. This condition may be a complication in chronic Bright’s disease and in chronic alcoholism.

In the =fibrinous form of pleurisy= the serum is scant and the membrane is covered with a sheathing of lymph, which finally organizes and adhesion takes place between the opposing surfaces.

Serofibrinous Pleurisy

This form is known as pleurisy with effusion. There is little lymph, the exudate being mainly composed of serum.

=Osteopathic Etiology and Pathology.=—Many cases rapidly follow exposure to cold, wet or an injury to the thorax. Exposure to cold is considered a mere predisposing agent, permitting the action of various micro-organisms. The large majority of cases are due to =tuberculous= infection of the pleura.

The osteopath finds that important predisposing causes of pleurisy are injury to the chest wall, ribs and vertebræ, and exposure to cold, causing contraction of the thoracic muscles. These injuries and strains throughout the chest result in an interference with the intercostal and phrenic nerves, and also with the intercostal and internal mammary arteries; consequently, there is produced a lowered vitality of the pleural tissues, which permits the attack of the micro-organisms. It may be secondary to rheumatism, Bright’s disease, cancer and cirrhosis of the liver.

=Pathologically=, there is an abundant exudation of serum. Fibrin is found on the pleura, and is rarely abundant in the serous fluid in the form of flocculi. The fluid is straw colored as a rule. It varies greatly in quantity from one-half to four litres. Microscopically, there are found leucocytes, red blood-corpuscles, shreds of fibrin and occasionally cholesterin, uric acid and sugar. The composition of the fluid resembles blood serum, and is rich in albumin.

Various displacements of the adjacent organs are caused by the effusion. The lung is more or less compressed into the back part of the pleural sac. The heart is displaced. The diaphragm may be crowded downward. On the right side this lowers the liver; on the left it displaces the stomach, transverse colon and sometimes the spleen.

=Symptoms.=—The onset may be abrupt with a chill, severe pain in the side and fever. With few exceptions the disease comes on insidiously, pain in the side being the first symptom. The pain is sharp and cutting and is aggravated by breathing or coughing. There is moderate fever, the temperature ranging from 102 to 103 degrees F. Dyspnea may be present at the onset. This is due to the fever and pleuritic pain. When the fluid is effused slowly, dyspnea may be absent except on exertion. It is most marked when the effusion has developed rapidly. As the effusion accumulates and the inflamed surfaces separate, the pain diminishes and, as a rule, soon disappears.

=Physical Signs.=—Immobility and bulging of the affected side, depending on the amount of exudation. The intercostal spaces are obliterated. The apex beat of the heart is displaced. Upon =palpation= the limited movement of the chest is more accurately determined. Tactile fremitus is largely diminished. The position of the heart’s impulse can be readily located by palpation. Displacements of the liver and spleen can be felt through the abdominal walls. At first the =percussion= notes are impaired and later there is dullness which gradually rises as the fluid increases. The upper line of dullness is not horizontal when the patient is in the erect posture, but is higher behind than in front. Above the effusion in the sub-clavicular region, percussion gives a tympanitic note, the so-called Skoda’s resonance. In moderate effusions the level of dullness often changes with the position of the patient. Early in the disease a friction rub can usually be heard. As the fluid accumulates, the breath sounds become weak, distant and may have a tubular or bronchial quality. Vocal resonance is usually lessened. There may be bronchophony, or it may manifest a nasal or metallic quality, resembling somewhat the bleating of a goat (Lænnec’s egophony). X-ray examination should be made.

=Duration.=—The course is extremely variable. The fever is due to inflammation and may last for two or three weeks, when it may subside. The cough and pain disappear and the effusion, which is usually slight in these cases, may be absorbed quickly. In cases where the effusion is poured out rapidly it may be absorbed just as quickly. In cases where the effusion is poured out slowly or where the effusion reaches as high as the fourth rib, recovery is usually slower. Large effusions may persist without change for months and finally the case may become subacute or chronic. This is particularly true of tuberculous cases.

=Prognosis.=—This depends largely upon the cause; on the whole, prognosis is favorable. Death is a rare termination of serofibrinous effusion; death may, however, occur suddenly without sufficient lesions to explain the cause. The exudate may become purulent.

Treatment of Acute Pleurisy

An early treatment and rest in bed with a liquid diet are the measures to be employed at the beginning of the attack. Pay particular attention to any primary disease and to the general health. Rarely is there any difficulty in locating certain predisposing causes of the disturbance. Then often a rib or corresponding vertebra is badly subdislocated over the seat of the disease. The sympathetic and phrenic nerves are involved through the intercostal and phrenic nerves. A careful examination of the side of the affected chest should be made, as there may be more or less obstruction of the intercostals and the internal mammary arteries from their branching of the aorta and subclavian vessels. A dislocation of the first or second rib may affect the subclavian vessels and their branches markedly; although all the upper ribs and the thoracic muscles should be examined carefully for derangements which would affect these blood-vessels and produce an exudation. Ice-bags upon the chest, as in pneumonia, may be used. Limiting the movements of the chest with a bandage or adhesive strips will give considerable relief.

When the effusion has taken place, carefully raising and spreading the ribs with attention to special points of involvement, will at times cause absorption of the fluid. The daily amount of liquid food should be greatly lessened with a view of depleting the blood serum from various tissues; thus the serum collecting in the pleura, which is a lymph space, will also be absorbed. Treatment of the bowels, kidneys and skin, so that they may be rendered active, will aid in the depletion of the blood serum.

It may be necessary in some cases to aspirate, especially if other methods fail and if the effusion is large. The points of operation are in the mid-axillary line at the sixth interspace or at the angle of the scapula at the eighth interspace. In puncturing, the needle should be held close to the margin of the upper rib so as to avoid the intercostal artery. Withdraw the fluid slowly and if faintness is produced, desist.

Empyema should be treated surgically. Simply tapping is rarely sufficient. A free incision, as in abscess, and thorough drainage should be made. Care must be taken that the drainage tube is large enough.

“In cases of pleurisy the axilla and the inner arm may be tender and painful; this is due to the pleuritic inflammation being carried by the way of the ‘nerve of Wrisburg.’

“The pleuritic pain in the costal muscles compels restricted movement of the ribs and also limits the respiratory function of the diaphragm. These painful cramps and stitches are independent of the pain arising alone from the inflamed pleural surface, and the diminution of the respiratory movements is due to a particularly contractured state of the muscles of the chest as is demonstrated by the fact that the patient can not draw a long breath; hence one may reasonably conclude that nature has so distributed nerves to the pleura as to enable that serous membrane to control the muscles which create movements of the adjacent costal surfaces and thus insure its quietude during the stages of inflammation or repair.” (Ranney).

Chronic Pleurisy

=Definition.=—Chronic inflammation of the pleural layers. There are two forms, exudative and dry or plastic pleurisies.

=Chronic Pleurisy with Effusion.=—This may follow an acute serofibrinous type. Some cases develop very slowly. In most cases in children, the fluid changes to pus early in the disease. The fluid may remain for months without changing to a purulent character. In such cases the character and physical signs do not differ from those in acute serofibrinous pleurisy.

=Chronic Dry Pleurisy.=—These cases originate in two ways:

=First=, this may succeed pleural effusion when the fluid portion of the exudate is absorbed and the pleural layers are opposed. They are separated only by fibrinous elements that become organized into firm connective tissue. This process goes on at the base, principally, which, if it follows the acute form, produces but slight flattening, but if it succeeds the chronic form or empyema, the extent of retraction and flattening will be marked. Calcification may occur in these firm, fibrous membranes and occasionally little pouches of fluid are found between the false bands.

=Second=, a large number of cases are dry from the onset. This condition may follow directly =acute plastic pleurisy=. It may be of =tuberculous= origin or it may set in without any acute symptoms. No matter how slight the plastic exudate may be, it invariably tends to become organized, thus producing adhesion of the layers. This is undoubtedly the result when the pleurisy is primary or secondary. The adhesions are generally circumscribed. When the adhesions are of tuberculous origin they may be locally confined to one pleura or they may be bilateral. In these cases both the parietal and costal layers are thickened, and embodied in the thickened pleura are found firm fibrin masses and small tubercles.

Occasionally, vasomotor symptoms arise in chronic pleurisy, especially in cases of tuberculous origin, and are probably due to the involvement of the first thoracic ganglion. These almost invariably mean that there is a displacement of the first, second, or third rib. Unilateral flushing or sweating of the face or dilatation of the pupil are frequently noticeable.

=Symptoms.=—Definite symptoms are rarely present. In some cases the physical signs are quite pronounced, while, on the other hand, they may be entirely negative. In mild cases there may be slight immobility of the affected side with feeble breath sounds. In other cases there may be very full chest expansion while the breath sounds are feeble. In a large number of instances the physical signs are quite distinct. There is displacement of the viscera, retraction of the chest walls, curvature of the spinal column and dropping of the shoulders. There are feeble breathing and creaking, leathery friction sounds. Dullness is found at the base.

=Treatment.=—The treatment of chronic pleurisy is largely that of acute pleurisy. Gymnastic and methodical breathing exercises should be employed in helping to correct the thoracic walls. Care must be taken not to injure the chest and pleura if adhesions have formed. Surgical work may be necessary in some cases.

The vasomotor symptoms that are sometimes manifested in chronic pleurisy and are claimed to be due to involvement of the first thoracic ganglion, are an interesting feature to the osteopath. Such cases would probably present to the osteopath a marked lesion of the upper dorsal vertebræ or the second or third rib. These vasomotor symptoms are also found in pleurisy associated with tuberculosis of the apex of the lung.

The osteopath frequently treats these cases and he should be cautious about over-treating or straining the chest wall. The adhesions are persistent and often there is more or less pain, so care must be exercised when attempting to structurally readjust. Do not expect to completely relieve every case, but nevertheless there are few cases but that can be benefited. Occasionally the pain alone is due simply to pleurodynia.

DISEASES OF THE URINARY SYSTEM

Diseases of the Kidneys

(RENAL HYPEREMIA)

=Definition.=—An increase in the amount of blood to the vessels of the kidney. It is active hyperemia when there is arterial congestion, passive hyperemia when there is venous congestion.

=Osteopathic Etiology and Pathology.=—Active hyperemia may be caused by injuries to the renal splanchnics, especially the tenth to twelfth dorsal segments; injuries over and to the kidneys; exposure to cold when the body is very warm; poison given, as diuretics; eruptive fevers and pregnancy, or follow genito-urinary operations. Passive hyperemia may be caused by obstructive diseases of the general circulation, as chronic heart, lung and liver diseases, or by pressure on the renal veins by tumors, growths and the pregnant uterus. Thrombosis of the renal veins may produce passive hyperemia, but rarely.

=Pathologically=, in active hyperemia the kidney is swollen and slightly enlarged. Upon removal of the capsule, the kidney is found to be brown and mottled. On section the parts bleed freely, the Malpighian bodies are distended, and microscopical examination shows a cloudy swelling of the renal epithelium. In passive hyperemia the kidney is swollen, hard, firm and of a bluish red color. Later there is an overgrowth of connective tissue and some infiltration between the tubules. The Malpighian bodies occasionally become shriveled and the renal epithelium fatty.

=Symptoms.=—In =active hyperemia= the urine is scanty, of high specific gravity and of high color, containing some albumin and casts. Pain is experienced over the loins, following the course of the ureters, and the bladder is irritable. There are headache, nausea and vomiting. When from infection, fever may be present.

In =passive hyperemia= the symptoms are primarily those caused by the disease producing the disorder. There is weight over the loins and dropsy. The urine is diminished, of high specific gravity, highly colored, albuminous and occasionally shows a few hyaline casts.

=Prognosis.=—=Active hyperemia.=—Usually favorable if it can be treated in time. If prolonged, acute nephritis may develop. =Passive hyperemia.=—Depends on the cause. If the disease is prolonged, it terminates in interstitial nephritis.

=Treatment.=—=Active hyperemia.=—Absolute rest and thorough treatment to the renal splanchnics and treatment over the abdomen to the kidneys directly by carefully raising them. Adjust the lower ribs if found lesioned. Water should be drunk liberally and the patient encouraged to use vapor baths. Favorable hygienic surroundings, warmth and good food are indispensable. Warm applications over the loins are helpful.

=Passive hyperemia=.—The treatment largely depends upon the cause, but too much importance cannot be given to the treating of the vasomotor fibers of the kidneys from the eighth dorsal to the first lumbar. Textbooks state that the vasomotor fibers to the kidneys are from the ninth to the twelfth dorsal vertebræ, inclusive, but osteopathic experience shows we can affect vasomotor fibers slightly higher. Treatment here has a distinct effect on the blood pressure within the glomeruli. The renal epithelium is extremely sensitive to circulatory changes. Even the compression of a renal artery for only a few minutes causes marked disturbances. Hence any irritation or obstruction to the vasomotor innervation of the renal blood-vessels may result in serious conditions. The superior cervical ganglion of the sympathetic and the sciatic center have important bearing on the secretions of the kidney, through vasomotor fibers. Due attention should be paid to the bowels, and the patient required to take plenty of rest and a light diet.

Acute Parenchymatous Nephritis

(ACUTE BRIGHT’S DISEASE)

=Definition.=—An acute, inflammatory process affecting the epithelium of the uriniferous tubules and due to the action of cold or toxic agents upon the kidneys, as well as to injuries to the renal splanchnics; is characterized by certain nervous symptoms with fever, dropsy, and scanty and highly colored urine. This inflammation involves more or less the whole kidney.

=Osteopathic Etiology and Pathology.=—This disease is caused by exposure to cold and wet while the body is warm and perspiring. Excessive use of alcohol may be a factor. May be caused also by infectious diseases, such as scarlet fever, diphtheria, measles, smallpox, acute tuberculosis and others; also by certain specific poisons which are eliminated by the kidneys, as turpentine, chlorate of potash, carbolic acid, phosphorus, ginger, cantharides and oil of mustard; also by pregnancy, as this is supposed to compress the renal veins, or through toxic agents. Syphilis may be an underlying cause. Blows and injuries to the back at the tenth, eleventh and twelfth dorsals are frequently the cause. Lesions are found from the sixth dorsal to the fourth lumbar. The lower three ribs may be at fault, while the innominate and muscular contractions have been found to be pathological factors. Lordosis may be a contributing cause. Loudon places considerable importance on cervical lesions and McConnell believes vasomotor disturbance plays an important causative role in the disease.

=Pathologically=, at times the kidney alteration may be so slight as not to be recognizable by the naked eye, the appearance varying according to the stage and severity of the disease. The kidneys become enlarged, engorged and of a bright red color, and later have a mottled appearance; and when the capsule, which is non-adherent, is stripped off, the kidney is found to be soft and inelastic. In most of the cases in which the disease is due to toxic agents brought to the kidney through the blood-vessels, the glomeruli suffer first. The epithelium of the glomeruli and tubules is the seat of cloudy swelling and, in the later stages, of fatty change and hyaline degeneration. The tubules are clogged by altered cells, leucocytes and blood-corpuscles. In mild cases the interstitial tissue is simply inflamed, but in all cases it becomes more or less mixed with leucocytes and red blood-corpuscles. Osteopathic lesions produced upon animals in the region of the ninth to the twelfth dorsal, resulted in acute nephritis. The autopsy findings were distinctly typical.

=Symptoms.=—The onset is usually sudden, with moderate fever, pain in the back in the lumbar region and over the kidneys and following the ureters. Nausea and vomiting may be present. Dropsy soon appears, beginning with slight swelling or puffiness in the face below the eyes, later showing itself in edema of the abdominal walls and extremities. Uremic symptoms may develop. The urine is characteristic; is diminished in quantity and of high specific gravity; at first the sediment is copious and reddish brown in color, becoming less in amount and of high color. This sediment contains casts of the uriniferous tubules, free blood, epithelial cells, uric acid and urates. There are large quantities of albumin in the urine.

The presence of albuminous matter in the urine, even in large quantities, is not sufficient evidence to warrant a diagnosis of Bright’s disease nor is the amount a guide as to the severity of the case, for grave conditions often show a slight amount (Loudon).[98]

=Diagnosis.=—The general symptoms may be very slight, for the most severe cases may manifest slight edema of the feet, or there may be only the puffiness under the eyes and of the eyelids. In such cases the diagnosis must depend upon examination of the urine. With previous history, suddenness of the attack and character of the urine, ordinarily the diagnosis will be quite easy.

=Prognosis.=—Although this disease is generally grave, the prognosis is favorable and the majority of cases recover under judicious treatment.

=Treatment.=—Cases of acute nephritis require rest, quiet and warmth. Many cases recover under these conditions alone. It is absolutely necessary, however, that these conditions exist no matter what other treatment is used. A thorough treatment to the renal splanchnics cannot be overestimated for it is here (tenth to twelfth dorsal, inclusive) that a majority of the lesions producing acute nephritis occur. Besides correcting the vertebral and rib displacements in this region, a very effective treatment is to have the patient lie flat upon the back and then the osteopath, reaching around the patient with the fingers of one hand on either side near the spines of the lower dorsal vertebræ, raise the patient so that the entire body, except the shoulders and the feet, are lifted clear of the bed. Thus the treatment springs the spine anteriorly and produces a marked effect upon the kidneys through the renal vasomotor nerves. Occasionally lesions in the upper cervical region interfere with the normal activity of the renal nerve fibers passing to the kidneys by way of the superior cervical ganglion of the sympathetics.

Another very effectual treatment for the kidneys is treating them through the abdomen by a careful pressure upon the kidneys through the abdomen on either side of the umbilicus, thus lightly working each kidney outward and upward. This treatment relaxes any tissues about the blood-vessels, nerves and lymphatics to and from the kidneys that may be contracted and thus aids in establishing a normal activity of the involved organs. It also helps in relaxing tissues about the ureters and prevents the clogging up of the latter with debris. Bandel and Stearns report cases in which an impacted colon was an important factor in this particular.

The above means have for their object the direct relief of the congestion of the kidney. This is further aided by keeping the bowels active, which supplements the action of the kidneys, and by increasing the activity of the skin. This also aids in relieving dropsical effusions. The hot pack, in which the patient is wrapped in a wet sheet and then covered by a number of blankets, is an exceedingly good method to relieve the kidneys of some of the work and lessen their congestion, besides arresting uremic intoxication. This can be repeated daily if necessary. Where there is dropsy and scanty urine, the indications are to increase the secreting action of the kidney; besides treatment through the renal splanchnics, which contain the vasomotor nerves of the kidneys, stimulating treatment to the vagi will help to increase the urinary secretion. Hot fomentations, placed directly over the region of the renal splanchnics, is a valuable aid in cases which do not respond quickly to osteopathic stimulation. Treatment of the liver is important. Injections of cold water into the intestines will tend to stimulate the secretion of the kidneys, but this should be used with the greatest caution; in some cases tepid water would be better (see uremia).

The diet of the patient with acute nephritis is important. Give food that is easy of digestion and which contains a minimum amount of nitrogen. The stomach is quite likely to be irritable, consequently food that is adapted to it should be selected. Milk and weak animal broths are undoubtedly the best foods. The return to a solid diet, especially of meat, should be very slow. Suitable adjuvants to the milk diet are rice and farinaceous preparations. Loudon[99] recommends complete withdrawal of all foods for twenty-four to forty-eight hours and the reducing of nitrogenous foods to a minimum; a diet of milk and cream after the fast, followed by cereals and broths, then eggs and fish until albumin disappears from the urine. Alkaline mineral waters are useful to help maintain an alkaline urine, thus tending to withdraw exudates. The patient should be treated daily at first and later on every other day, for case reports show frequent treatments hasten recovery.

For treatment of acute uremia in Bright’s disease, see uremia. Complications should be treated as affections independent of the renal disorder.

Chronic Parenchymatous Nephritis

=Definition.=—A chronic inflammation of the kidney, involving the epithelium, glomeruli and interstitial tissue, characterized by dropsy, increasing anemia, albuminous urine and acute uremia.

=Osteopathic Etiology and Pathology.=—It may be the result of acute nephritis. It follows the same diseases as already mentioned in acute nephritis. More often it follows the same diseases as already mentioned in the acute form, syphilis, tuberculosis, purulent conditions, focal infections (streptococcus), alcohol, scarlatina and pregnancy contributing the greater number. It is more common in the male sex and in early adult life. Habitual exposure to cold and dampness; chronic lesions of the spine, chiefly in the lower dorsal region, are causative factors.

=Pathologically=, the =large white or a yellowish white kidney= is the most common kidney lesion. In this form the kidney is enlarged, often to twice its normal size, is smooth, and the capsule very thin. The tubes, on microscopic examination, are found to be choked with broken down granulated epithelium and fibrinous casts. The capillaries show hyaline changes. The interstitial tissue is increased everywhere, but not to an extreme degree. Catarrhal swelling and hyperemia (to a slight degree) are found in the pelvis of the kidney.

In the =second stage=—that of the =small white kidney=—there is a reduction in the size of the organ, due to the destruction of the renal epithelium and the contraction of the overgrown connective tissue. Some hold that this may be a primary, independent form and not always preceded by the large white kidney. The organ is pale in color, rough and granular, the capsule being thickened and somewhat adherent. There is an accumulation of fatty epithelium in the convoluted tubules, constituting marked areas of fatty degeneration and giving the organ a white or whitish yellow appearance. It is this which gives the name of small granular fatty kidney to this form. There are extensive interstitial changes, degeneration of tubules and destruction of great numbers of the glomeruli.

=Chronic hemorrhagic nephritis= is a variety associated with this stage. The organ is enlarged, and scattered throughout the cortex are found brown hemorrhagic foci due to hemorrhages into and about the tubes. Otherwise the changes are similar with those found in the first form.

=Symptoms.=—It usually begins as a chronic affection and the symptoms slowly become apparent. Failing health and loss of strength, dyspepsia and anemia, waxy appearance with puffiness of the face, dropsy and increased arterial tension with hypertrophy of the left ventricle, gradually make their appearance. Uremic symptoms are common, while dropsy is marked and persistent. Vomiting and sometimes profuse diarrhea occur; in fatal cases there is sometimes found to be ulceration of the colon. The urine, as a rule, is diminished in quantity, is often very scanty, although it is frequently normal in color and appearance. There is an abundance of albumin, heavy sediment, hyaline and granular tube casts, epithelium from the kidneys and pelvis, leukocytes and often red blood-corpuscles. If fatty degeneration takes place, there will be fatty casts and oil globules. In the later stages the urine is abundant, low specific gravity, considerable albumin, and many casts.

=Diagnosis.=—In the inflammatory stage, where there is enlargement of the kidney, extreme pallor, scanty urine, albumin, and tube casts, history of infections, pregnancy, or exposure to cold and wet, and lesions in the lower dorsal region, the diagnosis is clear.

=Prognosis.=—Always give a guarded prognosis; relapses are frequent, but cases have been cured. There is always a tendency for the subchronic forms to become chronic.

=Treatment.=—The treatment requires persistent work, especially over the renal splanchnics, and strict attention on the part of the patient to hygienic principles. The lower dorsal lesions are very apt to be refractory owing to extensive fibrotic changes of the deep muscles and capsular ligaments. But repeated effort will usually secure results. Care should be taken as to exposure to cold and overexertion. The quality of the blood should be improved, as it is anemic and contains various toxic products. Strict attention should be paid to the diet. Iron is largely used for anemic conditions, but this principle we hold to be wrong. It is not more iron that is wanted, but an ability of the system to assimilate the iron which it has. Relative to diuretics von Noorden says: “It would be the greatest paradox to economize the renal work to the utmost in one direction (diet, sweating, etc.) and on the other hand excite them to increased activity by means of the strongest stimulants we possess, (drugs). I regard such prescribing as radically wrong.” The diet should be carefully selected and of minimum amount. The pure milk diet is undoubtedly the best. The use of meat seems to favor uremic convulsions.

The digestive organs should be kept in as good condition as possible, particular attention being paid to the liver and bowels. The use of suitable clothing is important; wool should be worn next to the body. The skin is a powerful adjuvant to kidney elimination, and the suppression of the action of the skin throws extra work on the kidneys. Possibly stimulation of the lung function would aid in the elimination. Rest, with a proper amount of fresh air and outdoor exercise, is essential.

In conditions calling for attention to the skin and bowels the treatment will be the same as in acute parenchymatous nephritis. There is a ganglion on each side of the umbilicus within a radius of an inch that sends fibers to the kidneys (Dr. Still). Just what is the function of these ganglia is unknown. The treatment of the complications is independent of that for the renal trouble. For direct treatment to the kidneys see acute Bright’s disease.

Interstitial Nephritis

=Definition.=—A chronic inflammation of the kidney in which there is reduction in its size due to an extensive destruction of the tubular substance, with an overgrowth, and later a contraction, of the connective tissue elements. Cardio-vascular changes, arteriosclerosis and cardiac hypertrophy are usually associated.

=Osteopathic Etiology and Pathology.=—Osteopathic lesions to the renal splanchnics are important predisposing causes. The disease may follow parenchymatous nephritis; or it may be caused by a continued passive congestion due to valvular heart disease. Gout; cystitis (often following gonorrhea), the inflammation extending up the ureters to the kidney; heredity; old age; long continued worry, anxiety or grief; chronic alcoholism, overeating; syphilis; tuberculosis; focal infections, especially of streptococci; chronic mineral poisoning (as from lead), and alterations in the renal ganglionic centers are causes. It chiefly occurs in males during middle life.

=Pathologically=, both kidneys are involved (although one may be more affected than the other), and reduced in size, often to less than half their normal size. After removing the capsule, which is thickened and adherent, the surface is found to be uneven, or granular and containing small cysts. The kidney is hard, tough and resistant, the color varying from a darkish brown to a yellowish gray. The cortical portion is especially reduced in size. On microscopic examination, the connective tissue appears greatly increased; this contracts, compressing the tubules and blood-vessels, causing their destruction. There is general arterial sclerosis, and the left side of the heart is hypertrophied. There are frequent nasal and retinal hemorrhages, due to the brittleness of the arterial walls which predispose them to rupture; hence, apoplexy is a frequent termination. The ganglionic centers, being interfered with, undergo fatty degeneration and atrophy. There are marked retinal changes—retinitis, fatty degeneration of the retinal tissues and sclerosis of the nerve fiber layers.

=Symptoms.=—The onset is insidious. In most cases the symptoms are latent. The general health is disturbed; there are frequent micturition, gastric disturbances, tense and bounding pulse, hypertrophy of the left ventricle, high blood pressure, disorders of vision, sleeplessness, headache, furred tongue, slight swelling of the feet, dry skin, scurvy and shortness of breath. The urine is increased in quantity, of acid reaction, light in color, low specific gravity, with a small amount of albumin, a few hyaline casts, and some epithelial cells. There is increased thirst and the patient may have to urinate two or three times during the night. There is well marked mucous cloud, slight sediment, and as the disease advances the urine may be diminished, the albumin increased and the casts become more numerous, while occasionally blood cells will be found.

Much importance should be attached to the blood pressure condition.

=Diagnosis.=—The early stages are not always recognizable. Later, while there is high arterial tension, thickening of the arterial walls and marked hypertrophy of the heart, the urine should be examined very carefully both night and morning, as the diagnosis will greatly depend upon the condition of the urine, which is increased in quantity, of low specific gravity, with a trace of albumin, narrow hyaline and pale granular casts, making the diagnosis usually easy.

=Prognosis.=—It is generally incurable, but favorable so far as the power to prolong life is concerned, provided the diagnosis be made early in the case, and the patient lives a quiet life. The case usually terminates with convulsions, coma and death. Apoplexy is frequently associated with chronic nephritis. In all forms of chronic nephritis some intercurrent infectious disease is quite possible, which is apt to be serious owing to the cachectic state.

=Treatment.=—The dietetic and hygienic treatment is the same as in chronic parenchymatous nephritis. The nerve and vascular supply to the kidneys should be treated as in acute parenchymatous nephritis. Freedom from worry and overwork, and if possible change of climate, should be prescribed. Frequent bathing, with friction of the skin, should be insisted upon and the bowels kept regular by a treatment of alkaline water. In all kidney cases special attention should be given the liver. The alkaline water is a good diuretic; besides it flushes the kidneys and helps to remove the debris.

These cases invariably present a rigid spine which should be carefully but thoroughly treated, traction being one of the methods that give comparatively quick and excellent results. Overcoming spinal immobility, correction of the dorsal area, attention to the chest rigidness, and frequently raising the abdominal organs will often considerably reduce the blood pressure.

The accidents and complications which so often endanger the patient, must be treated as they arise.

Amyloid Kidney

=Definition.=—A pathological state of the kidney in which there is a peculiar infiltration into the kidney structure of an albuminoid material of a waxy appearance.

=Etiology and Pathology.=—This is associated with Bright’s disease and other wasting diseases. It is most frequently caused by profuse and long continued suppuration, especially of the bones, by syphilis, tuberculosis, cancer, lead poisoning and gout.

=Pathologically=, the kidney is large and pale, but it may be normal in size or even small, pale and granular. The capsule is not adherent, the surface of the kidney, after removing the capsule, is pale and anemic. On section the cortex is seen to be enlarged. It is homogeneous, anemic, pale, waxy and resisting. On microscopic examination there is found to be an infiltration of a homogeneous or wax-like material. This progresses until all parts of the organ are infiltrated. As the result of this pressure the structures of the kidney undergo an atrophic degeneration, the kidney becoming contracted, smaller, rough and even distorted in shape. The cortex becomes narrowed and the capsule adherent. If a section of an amyloid kidney be stained with a solution of iodine, numerous mahogany red points appear.

=Symptoms.=—There are similar changes in the liver, spleen and often the intestinal canal. There is a profuse, watery diarrhea, due to amyloid changes in the intestinal canal, with loss of flesh and strength, edema of the lower extremities, and ascites. There is an increased flow of pale, watery urine, of low specific gravity; albumin is abundant and usually hyaline, often fatty or finally granular tube casts occur.

=Prognosis.=—As a rule the prognosis is decidedly unfavorable and it must be controlled by the disease with which it is associated.

=Treatment.=—The primary disease demands attention, otherwise the measures of treatment indicated are those of chronic parenchymatous nephritis, with special attention to the general health and surroundings of the patient. Give a generous diet and be persistent with the treatment.

Pyelitis

=Pyelitis= is inflammation of the pelvis of the kidney. When a suppurative inflammation extends into the interstitial tissue of the organ, it produces a condition called pyelonephritis. The inflammation usually starts in the pelvis of the kidney, the infection being carried there either by the circulation or the urinary tract, but it soon involves the rest of the kidney. Pyelitis is usually secondary to some other conditions such as urethritis, cystitis, or ureteritis. “Infection of the kidney rarely takes place through the blood and only when the vital membrane of the kidney is impaired.” It may start from within the organ in the interstitial tissue, caused by infectious embolism or traumatism, or the tubules may become obstructed by concretions.

=Osteopathic Etiology and Pathology.=—Retained decomposed urine due to pressure upon the ureters by tumors or bladder disease; calculus concretion, kinked ureter, displaced kidney, traumatic agencies, as falls, blows, strains, kicks or penetrating wounds; nephritis, pregnancy, cold and wet, are causes. Pyelitis may follow cystitis, the inflammation extending up the ureters to the pelvis of the kidney and thence to the substance of the organ, inducing pyelonephritis. Tuberculosis, focal infections, and intestinal disorders (colon bacillus), are other causes. Lesions from the ninth dorsal to second lumbar or lower, and malnutrition are predisposing factors.

=Pathologically=, the mucous membrane of the pelvis is usually the first affected, the inflammation generally extending from below upward. It is swollen and sometimes visibly congested and of a gray color. The pelvis and calyces are more or less dilated, while the papillæ are flattened. There is a gradual dilatation of the calyces and atrophy of the kidney substance, until the whole organ may be converted into a pus sac. If complete obstruction occurs, the fluid portion may be absorbed and the pus become inspissated and cheesy. The ureter is often dilated. In tuberculous pyelitis the apices of the pyramids are also invaded, the kidney substance is broken down and the result is the same. In the pyelitis caused by cystitis, the infection passes up the tubules or is carried by the lymphatics. The abscesses extend along the pyramids, burst through the papillæ and calyx into the pelvis of the kidney, and thus also the kidney becomes a purulent sac.

=Symptoms.=—Pain and tenderness over the region of the kidney first appear. In a few cases cystitis will be the only symptom. The suppurative stage is marked by high fever and a chill or a succession of chills. The general condition of the patient denotes prolonged suppuration. There is failure of health and more or less wasting and anemia. The urine is characteristic, contains pus, which varies in quantity greatly, and where only one kidney is affected, may be suppressed for a time and there will be a sudden outflow of the pus, due to the breaking of the sac. Blood is also very constant, but hardly ever of sufficient quantity to be seen by the naked eye. The urine is usually diminished in quantity and the color pale; the specific gravity is low on account of the small amount of urea present. The reaction of the urine is acid. Pus and blood render the urine slightly albuminous. Casts from the kidney, and even portions of the kidney, may be present.

=Diagnosis.=—From =nephritis= by the absence of much albumin, tube casts and dropsy. From cystitis, by the history, lumbar pains and acid urine. =In cystitis the urine is always alkaline.= From =perinephritic abscess=, by the absence of edema over the lumbar region. The urine may be normal and there are lumbar pains and hectic fever. In =tuberculous pyelitis= there is a history of tuberculosis in other organs and there are tubercles in the urine. =Malaria= or =typhoid= may be suspected. The X-ray and cystoscope should be employed. An exploratory incision may be necessary.

=Prognosis.=—Depends altogether on the cause and extent of kidney involvement. In simple cases and some tubercular, recovery may occur, although there is a tendency in all cases for the disease to become chronic.

=Treatment.=—Depends upon the cause, but thorough treatment along the lower dorsal, the lumbar and sacral regions will be of considerable benefit in controlling the catarrhal process in the kidney, its pelvis, the ureter and the bladder. If pathology permits, gently raising the kidneys, ureters and neighboring organs, knee-chest position, will materially assist circulation and drainage. Fresh spring waters for diluents and restricting the diet to light food, preferably milk, are indicated. Rest is important and warm applications locally are sometimes helpful. The general health must be carefully watched as there is always considerable drain upon the system. A timely operation may materially lengthen the life in many cases. Attention to the bladder, urethra and prostate is necessary.

Uremia

The name applied to a series of manifestations resulting from the retention of poisonous materials in the blood, which should have been removed by the kidneys. Uremic symptoms may occur any time during an attack of nephritis. In chronic cases it seems likely that extensive destruction of renal tissue is the principal factor that leads to the toxemia. They may also occur when the circulation of the blood in the kidneys is interfered with or the ureters are obstructed. They are not due alone to the urea (which is found to be increased in the blood), but more probably several poisons that are retained in the blood. Traube’s theory is that acute cerebral edema with anemia accounts for the symptoms. Halbert says: “A more recent and more plausible claim is to the effect that a poison is developed in the body as the result of nephritis,” for retention of effete matter or ligation of renal arteries and ureters or impaired renal activity does not fully explain the cause of the stupor, coma, convulsions, sometimes paralysis, and gastro-intestinal disorders.

=Symptoms.=—Loss of appetite, nausea, vomiting, headache and drowsiness are the initial symptoms. Headache is usually at the back of the head and may extend down the neck. The next symptom is coma, alternating with convulsions which may range from only a slight twitching to violent epileptiform spasms. These spasms may occur without the slightest warning and are often followed by blindness which may last for several days. These attacks of coma and convulsions are sometimes ascribed to localized edema of the brain.

Transient paralysis is also due to congestion or edema of the brain and it may be of the cord. There may be mania which comes on abruptly, although the delirium is not at all violent, while profound melancholia may be found. There may be nervous symptoms develop, such as numbness in the hands and fingers, itching of the skin and cramps in the muscles—especially those of calves of the legs. Pulmonary symptoms are sometimes continuous—dyspnea, paroxysmal dyspnea and Cheyne-Stokes’ breathing. These attacks of dyspnea may be as distressing as true asthma. Cheyne-Stokes’ breathing may be present without coma.

Uncontrollable vomiting may set in with great abruptness, followed by hiccough and purging. There may be a catarrhal or diphtheritic inflammation of the colon with diarrhea. The breath has a urinous odor and the tongue is often very foul. The pulse is slow and full, with a temperature below the normal, although during convulsions the pulse may become rapid and the temperature rise. Occasionally there are atypical forms of uremia which may be very confusing and obscure.

=Diagnosis.=—The history, subnormal temperature, the urinous odor of the breath, high arterial tension and increased second sound of the heart will distinguish the condition. Feeling of numbness, palpitation, headache, restlessness, mental wandering are not infrequently early symptoms. The phenolsulphonephthalein test for the secreting power of the kidney, and the examination of the urea in the blood are of great aid in diagnosis.

=Prognosis.=—Extremely grave, but one should always be very careful in his prognosis, for there is a possibility of recovery, even after the most serious symptoms have been manifested.

=Treatment.=—As impermeability of the kidneys produces uremia, by not allowing the various poisons to be eliminated by the renal path as they should be, the treatment must be applied directly to the kidneys. Elimination is demanded and if treatment through the abdomen to the kidneys directly and to the renal splanchnics does not bring about prompt and thorough elimination of the intoxicating properties, the bowels and skin must be made active. The vapor or hot air bath or hot pack should at once be used. An ice-bag to the head will be beneficial. An increase in the quantity of urine may be brought about by the displacement of a part of the mass of blood, which is in relative stagnation in certain parts of the vascular system. Forcing it into the main circulation in order to increase the pressure within the vessels of the kidney, is the treatment indicated. This great stagnant mass of blood is found in the arterial capillaries of the portal system in the liver and splenic tissues and should be manipulated into the general circulation in order to increase the arterial tension of the kidneys and thus favor elimination. The treatment should mainly be applied to the vasomotor nerves of the portal system, from the fifth to the ninth dorsal, and directly over the abdomen, liver and spleen.

The introduction of water, from 110 degrees to 120 degrees, or even 150 degrees, into the colon by means of injections, is useful; warm irrigations increase renal secretion, bowel action and sweating with a decrease of tension. Cold drinks will stimulate the abdominal vessels and induce absorption of a certain quantity of water to still further increase diuresis. Cold irrigation increases blood pressure temporarily, but later it lessens the pressure; it should be used only with great caution. Milk is one of the best drinks to be used. Secretions of the liver must not accumulate. The bile must be expelled so that its toxicity will not be added to the other poisons.

The food of the patient is an important matter. A milk diet is best; avoid meat and nitrogenous foods and any food that leaves much residue. In this way the nutrition of the patient is kept up with a minimum of urea formation and, besides, there will be very little intestinal putrefaction. Emergency measures not mentioned above are repeated high normal salt enemata (two to three pints), the alcohol sweat and venesection (about one pint). When the attack is broken the condition resolves itself into the renal disorder, generally acute Bright’s disease.

This disease illustrates one phase of the uselessness of drugs; for when the impermeability of the kidney has become such that it ceases to have the power of eliminating toxic substances formed by the organism, there is then retained the medicinal substances. The kidney is as impermeable for therapeutic poisons as for the natural poisons and the employment of toxic medicines in such cases has often no other effect than to bring an association of medicinal intoxication with an uremic.

Renal Calculus

=Renal calculi= are concretions formed by precipitation of solids derived from the urine, and are found in the kidney or its pelvis. If large, they are called stones; the smaller masses are known as gravel or sand, according to their size. When the stones attempt to pass through the ureters, it brings on an attack of renal colic; rarely are they voided without this symptom.

=Osteopathic Etiology and Pathology.=—The affection occurs at all ages, more commonly, however, in children and in old people. The male sex is more liable than the female. Sedentary habits, gout and excessive meat eating are predisposing causes. Heredity seems to be a predisposing cause in some families. Inflammation of the pelvis of the kidney, caused by derangement of the ribs and vertebræ of the tenth, eleventh and twelfth dorsals or first lumbar, is an important etiological factor.

=Pathologically=, the chemical varieties are:

(1) =Uric acid and urates= are the most common. The stones are usually smooth or lobulated; are hard and of a reddish color. Usually in these stones, both uric acid and urates are to be found. This material may be passed in the form of sand or large stones. The sediment in the urine may be the nuclei of the stones; as may foreign matters, such as the mucus or desquamated epithelium caused by the inflammation of the pelvis of the kidney, blood clots, or, in fact, any foreign matter that may reach the urinary passages. Individuals passing a small amount of urine, and old people are the principal subjects. “As a consequence of concentration and high acidity of the urine, the uric acid and urates are readily separated in solid form and held together by the albuminous matrix.”

(2) =Phosphatic Calculi= are white in color, soft and mortarlike. They are composed of phosphate of lime, ammonia and magnesium phosphate. These are found more often in the bladder than the kidney. Disease of the bladder is the cause.

(3) =Oxalate of Lime= are a mixture of oxalate of lime and uric acid. They are dark in color, very hard and uneven, with hard, pointed projections. On account of their uneven shape they have been named mulberry calculi. These stones produce great pain as they pass through the ureters.

There are other concretions of rare occurrence.

=Symptoms.=—There is pain in the back in the region of the kidneys with more or less tenderness. The pain may be severe and paroxysmal. There may be bleeding, which is seldom profuse; this will give the urine a smoky hue, but may be present to such a small degree as to be only apparent by the use of the microscope. The stone may obstruct the ureter and cause pyonephrosis or hydronephrosis. Pyelitis of a catarrhal character is common. In pyelitis there may be intermittent fever of several degrees, then sweating. There may or may not be pus in the urine.

=Renal Colic= is caused when the calculus attempts to pass through the ureter so that ureteral spasms result. The stone, however, may become lodged at the entrance to the ureter. There is a sudden onset and great pain which starts in the back, radiating downward into the groin, down the side of the thigh and into the testicle and glans penis. The testicle is often retracted, the face pale, the features pinched, and there is frequently vomiting. There are cold sweats and the pulse is weak. The paroxysm may last only a few minutes or extend over several hours. If uric acid is found, it points to uric acid or oxalate of lime calculi and the urine is acid in reaction. If alkaline phosphatic stones may be suspected, examination of the urine directly after the attack aids greatly in diagnosis, for at other times the urine is usually negative.

=Diagnosis.=—=Biliary Colic.=—The jaundice in biliary colic comes on very soon after the obstruction begins. The stools are without bile and the pain extends from the right hypochondriac region to the upper abdomen and the right shoulder. The urine is negative and a stone may be passed in the stools. =Renal colic= is often =simulated= when the ureter is obstructed from any cause whatever. It may be compressed from a floating kidney or tumor, or obstructed by a clot of blood, fragments of hydatid cysts or plugs of mucus. =Lumbo-abdominal neuralgia=, =intestinal colic=, =and renal tuberculosis= may simulate renal colic. The X-ray plate is of decided value.

=Prognosis.=—As complications may arise, it is best to give a guarded prognosis, but the prognosis is generally favorable. It is a disease that is very apt to recur when strains or falls affect the innervation to the kidney, but many cases have been permanently cured. If the stone is large, its passage along the ureter may prove fatal unless surgical interference is instituted at once, but if it is renal sand it may be easily voided in the urine and thus the prognosis will be favorable.

=Treatment.=—Treatment should be given toward overcoming the cause producing the calculi, which will often be found at the tenth rib. Treat the kidneys thoroughly, both through the renal splanchnics and directly through the abdomen, anteriorly. But direct abdominal treatment should be given very cautiously. Treatment here corrects disorders and seems to release some solvent that acts upon the various forms of calculi and disintegrates the ones already formed and prevents the formation of others. Possibly this solvent is an internal secretion of some gland; possibly like the splenic secretion is to the biliary calculi (Dr. Still.). Dr. Still held that one of the functions of the suprarenal capsule was to prevent the formation of these concretions.

In the =uric acid tendency=, the free use of alkaline mineral waters for the solution of uric acid may be helpful. Much may be done by dieting. The amount of nitrogenous food should be limited, eating a minimum amount of meat and using plenty of milk and vegetables. In the =phosphatic tendency=, diluted drinks freely used are helpful. Meats are indicated. Milk and vegetables should not be used freely as they tend to make the urine alkaline. In all instances care of the general health and avoidance of beer drinking and excessive meat eating are demanded.

During an attack of =renal colic=, when a stone had lodged in a ureter, one may be able, by very careful manipulation, to aid the stone in its progress downward, (somewhat after the manner of manipulating gall-stones), but do not delay surgical measures too long. By inhibiting the nerve force of the spinal nerves along the lumbar and sacral regions (chiefly tenth dorsal and first lumbar), relief may be given. The nerves of the ureters are derived from the inferior mesenteric, spermatic and pelvic plexuses. Employ the hot bath; this may relax the spastic condition. Cloths wrung out of hot water and applied locally are of aid. Occasionally a change of posture will give relief. Even inversion of the patient is sometimes followed by immediate cessation of the pain. The patient may drink freely of hot lemonade or water. An anesthetic may be of aid in the manipulation of a renal calculus in the ureter, as the anesthetic will relax the tissues over the abdomen, making it much easier for one to get near the impacted calculus, but =be cautious=. Morphine may be necessary. During the intervals the patient should lead a quiet life and avoid sudden exertions of any kind. It is important to keep the urine abundant, consequently have the patient drink a large quantity of distilled water. “Renal calculus is brought about by lesions affecting the suprarenal capsule of the kidney, or spinal lesions from the tenth dorsal to the first lumbar, affecting the lower ribs.”

Movable Kidney

This means a distinctly mobile condition of the kidney (almost always acquired, but may be congenital), due to the lax condition of the tissues which support it and to the elongation of the renal vessels which allow the kidney to move in certain directions. Rapid loss of tissue that absorbs the fat surrounding the kidney is a cause. There are almost invariably lesions in the dorso-lumbar region that predispose to an abnormal mobility of the kidney. These lesions undoubtedly weaken the innervation to the surrounding and supporting kidney structures. A posterior spine, with consequent downward and constricting displacement of the floating ribs, is common, although lateral and anterior spines (dorso-lumbar region) may be found. Strains, heavy lifting, and various violent exertions are important exciting factors. Tight lacing, pregnancies, an enlarged liver and gastro— and enteroptosis are also important factors. This condition is found more commonly in women, and undoubtedly is a frequent cause of direct, gastro-intestinal, reflex, and obscure disturbances. There are very different degrees of mobility in different cases. It may be so slight as hardly to be recognized or so great that it can easily be felt by the hand through the abdominal walls, resembling a movable tumor in the abdomen.

=Symptoms.=—Often there are no noticeable symptoms. Sometimes when the displacement and mobility of the kidney are most marked, the reflex symptoms are not noticeable. The right kidney is the one usually affected, on account of its relation to the liver which moves during the respiratory act. Usually there is pain in the lumbar region and the patient experiences a heavy, dragging pain in the abdomen, which especially manifests itself while standing and walking. There may be intercostal neuralgia. Various colicky and other gastro-intestinal pains, and nervous symptoms as neurasthenia, melancholia, hysteria and headache are common. There may be obstinate indigestion, palpitation of the heart, flatulence and cardialgia; also, an irritable bladder, due to pressure. At times the kidney becomes tender and swollen as a result of twisting of the renal vessels or of the ureter (Dietl’s crises), causing engorgement of the organ; this may be associated with agonizing pain and symptoms of collapse. Hydronephrosis may be manifested.

=Diagnosis.=—The shape of the tumor, marked mobility, and lessened resistance on percussion of the renal region will make the diagnosis. The disorder very rarely proves fatal. In doubtful cases utilize the X-ray.

=Treatment.=—Many cases rarely give trouble directly, but may be a source of reflex and obscure symptoms. Attention to the general health of the patient and persistent treatment of the dorso-lumbar region greatly strengthen the relaxed tissues about the kidney and cure a number of cases. Having the patient attempt to replace the organ after he goes to bed will be of value. Treatment of the abdomen to strengthen the walls and lessen any liver congestion and to keep the bowels active is very beneficial. Teach the patient how to stand and walk correctly, especially holding the abdomen in and up. A liberal diet to the point of increasing the weight is worthy of trial. The use of supports is not always satisfactory. Surgical treatment for fixing the kidney is of permanent value, but do not advise operation unless absolutely indicated. (See Prolapsed Organs, Part I).

To =determine the presence of a movable kidney=, it is best to have the patient in the dorsal position, the head slightly lowered and the abdominal walls relaxed by flexing the thighs moderately upon the abdomen. Then with the left hand in the lumbar region behind the eleventh and twelfth ribs, and the right hand in the hypochondriac region, the kidney can usually be detected after full inspiration followed by complete expiration; or, have the patient in a standing posture with the body bent slightly forward and the hands placed upon a table, then perform bimanual palpation; or, perform the manipulation in the knee-elbow position. When in this position (knee-elbow), if the kidney has become dislodged, a resonant note will be obtained by percussion over the normal location of the kidney.

FOOTNOTES:

[98] Journal of the American Osteopathic Association, July, 1904.

[99] Journal of the American Osteopathic Association, Dec., 1904.

DISEASES OF THE BLADDER

Cystitis

=Cystitis= is an inflammation of the mucous membrane of the bladder. Retention of the urine; foreign bodies, such as stones, in the bladder; the use of dirty catheters; exposure to wet and cold; injuries to the bladder and over the pubes; irritations to the sacral nerves; spinal lesions in the dorsal enlargement of the cord; innominate lesions; irritating drugs; enlarged prostate and urethral strictures are the principal causes of cystitis. The disease may be secondary to fevers, infectious diseases and inflammation of adjacent organs. A displaced uterus may produce a chronic irritation of the bladder.

=Pathologically=, there is hyperemia of the mucous membrane of part or of the whole of the bladder, with redness, congestion and edema. The secretion of mucus that covers the mucous membrane is of a dirty gray color. If the congestion is very extensive, a bursting of the capillaries may take place. In a few cases the neck of the bladder and the urethra, where it passes through the prostate, is involved. In chronic cases the mucous membrane becomes thickened and covered with patches of false membrane. The muscular coat of the bladder becomes hypertrophied and the veins tortuous.

=Symptoms.=—The onset may be sudden with rigors and fever, but in many cases a frequent desire to micturate will be the first symptom. This is followed by tenderness and pain over the bladder and contiguous parts, loss of appetite, depression and sleeplessness. Tenesmus of the bladder, caused by a spastic condition of its muscles, and a burning along the urethra are usually present. The urine is alkaline in reaction and contains pus, epithelium and blood.

=Diagnosis.=—The diagnosis is usually easy. =Pyelitis= causes pains in the lumbar region and along the ureters and there is a frequent desire to urinate. The bladder is not subject to spasms and the urine is of an acid or neutral reaction.

=Prognosis.=—In many cases the prognosis is favorable, but in cases of long standing and in hypertrophy of the bladder, prognosis must be guarded.

=Treatment.=—Rest in bed with strict attention to diet is necessary. Milk is the best food and avoid highly seasoned articles and acid foods. The use of plenty of pure water is helpful to dilute the urine, and if necessary the bladder should be washed out carefully. If the case is severe, emptying the bladder several times a day with a catheter will be necessary. Always be careful about the cleansing of the instruments. Warm applications over the pelvic region will be comforting to the patient. Lifting the abdominal viscera from the bladder is of assistance. The patient may be placed in the knee and chest position for this or the usual method employed.

Treatment to the second, third and fourth sacral nerves controls the neck of the bladder, and strong inhibition will generally control the spasms of the sphincter. The fundus of the organ is supplied by sympathetic fibers from the pelvic plexus. Direct treatment over the bladder, if applied carefully, will act on the terminal fibers of the sympathetic. Lesions to the nerves of the sphincter of the bladder oftentimes occur between the fifth lumbar and sacrum, also from a displaced innominate. Such lesions are apt to be found in cases of incontinence of urine. The lesion to the vertebra is usually a lateral one.

Thorough treatment to the genito-urinary center (lower dorsal and upper lumbar) will also be of aid. In males direct treatment of the prostate gland is occasionally important as is also the plexus of nerves at the trigone of the bladder. In =treating= the =prostate gland= introduce a finger into the rectum and work about the base of the gland to relax the tissues, and thus remove obstructions of the vascular, lymphatic and nervous structures to the gland. Do not work too much upon the gland itself (commonly once a week or ten days), as it may irritate, but release surrounding edema. Also treat the innervation at the eleventh and twelfth dorsals, fifth lumbar, and first, second and third sacrals. Spreading the ischii will occasionally be beneficial; this tends to release the anterior commissure where it is attached to the symphysis.

Follow the above with a “general treatment” in order to secure a general systemic reaction. This is of value in all infectious disorders.

It is important in =young boys= to examine the condition of the penis in bladder diseases. The prepuce may become adherent or other irritations may be found that are a source of disturbance to the bladder, or even to the kidneys, on account of the intimate connection of the sympathetic system in this region and the relation of one organ to another.

An =irritable bladder= is usually due to disorders of nearby tissues, especially the urethra, vagina, uterus and rectum.

=Enuresis=, exclusive of paralysis, is frequently due to some local mechanical disturbance. =Nocturnal enuresis= or =bed wetting= is caused by lower dorsal and lumbar lesions (especially the fifth lumbar), displacements of the innominate, or phimosis, hooded clitoris, contracted meatus, highly acid urine, worms, lack of discipline, etc. The patient is usually =neurotic=, which demands attention to the neuromuscular system of the entire body. Care of the general health and habits is important. Constipation may be present.

DISEASES OF THE CIRCULATORY SYSTEM

DISEASES OF THE PERICARDIUM

Pericarditis

=Pericarditis= is an inflammation of the serous membrane covering the heart and its reflection in front over the chest. Primary inflammation of the pericardium is rare. Such cases usually result from cold and exposure or injury or tuberculosis, and are most commonly met with in children.

The exciting causes of =secondary pericarditis= are rheumatism, Bright’s disease, tuberculosis, gout, diabetes, eruptive fevers, various septic conditions and dyscrasia. Pericarditis may result by extension of inflammation from contiguous organs, as the disease may occur in pneumonia, pleuropneumonia, chronic valvular diseases, and ulcerative diseases of the esophagus, bronchi, vertebræ, ribs, stomach, etc.

Displacement of the ribs over the heart and involvement of the corresponding vertebræ predispose to pericarditis, by weakening the innervation of the pericardium and thus disturbing the circulation. Lesions of the cervical region affecting the left phrenic are to be considered. Upper rib lesions may disturb the internal mammary artery and the lymphatics, which have important relationship with the pericardium. The disease may occur at any age. Males are more frequently attacked than females.

The morbid conditions vary with the stage. The stages are (1) acute, plastic, or dry pericarditis; (2) pericarditis with effusion, serofibrinous, hemorrhagic or purulent; (3) absorption or adhesive pericarditis. These different stages or varieties commonly succeed one another, although medical writers place so much importance in them that each is described separately. =Acute pericarditis= is by far the most common and often the inflammation subsides at this point instead of going on to more serious involvement. There is a possibility that in some cases the forms are independent of each other.

The changes are the same as in various serous membranes. Hyperemia and alteration of the epithelium is most marked on the visceral layer. This is followed by an exudation from the hyperemic vessels. There is roughening and loosening of the epithelium and the fibrin is precipitated upon the walls of the pericardium. More or less lymph is exuded and sometimes injected capillaries burst and cause a bloody exudation. From this stage the morbid appearances vary according to the progress of the disease. The disease may undergo resolution and fatty degeneration and absorption of the products in point take place. As the stage of effusion occurs, the parietal and visceral layers of the pericardium are separated by a serofibrinous exudate. This condition may increase until the quantity of the exudation is considerable, or the effusion may become absorbed. Rarely does the exudate become purulent.

Adhesions may be formed between the layers of the pericardium, during the last stage, by bands of various lengths or the layers are more or less separable.

=Symptoms.=—Simple cases may not present any symptoms. Usually a chill or cold feeling at the heart, followed by pains in the cardiac region, ushers in the attack. Fever is commonly present, rarely exceeding 103 degrees F. Tenderness over the heart is noticeable. There is dyspnea and the patient is restless.

In the =effusive stage= the symptoms depend largely upon the amount of diffusion. The pain is sharp and stitch-like. Nausea, vomiting and hiccough sometimes occur. The pulse is irregular and feeble. Insomnia, headache and even delirium may occur. Distention of the veins of the neck may cause dysphagia and a cough may be present, owing to the irritation of the trachea. The recurrent laryngeal nerve may be compressed as it winds about the aorta and thus cause aphonia.

The friction sound is a characteristic physical sign of the first stage. In the effusive stage there may be precordial bulging. The area of dullness is enlarged, the diaphragm and liver may be crowded downward, causing an epigastric bulging. As the effusion increases, the heart sounds become less distinct; the friction is not heard. In the =third stage= there is usually a return to normal, although =adhesions= may form and cause precordial retraction and permanently embarrass the heart’s movements. The young are more subject to permanent disability. Extension of heart impulse, which is undulatory; diastolic shock to hand placed over heart; increased area of dullness; prominent precordia; position of patient does not change apex beat; and when pericardium is adherent to diaphragm a systolic tug is noted over points of attachment, are essential signs and symptoms.

=Diagnosis.=—Pericarditis is frequently overlooked. It is a serious disease and one should be especially careful. In cases of rheumatism the osteopath must always be on his guard. Tonsillitis may be the origin of the infection. Care has to be taken in distinguishing between dilatation and cardiac hypertrophy and pericardial effusion. Hydro-pericardium may be mistaken for pericardial effusion.

To distinguish between endocarditis and pericarditis should not be a difficult task if one understands thoroughly the nature of each disease. A large pericardial effusion may be confounded with a pleural effusion. In doubtful cases utilize the X-ray.

=Prognosis.=—In mild cases of pericarditis the large majority rapidly recover in two to three weeks. In cachectic subjects and where adhesions have formed, the duration is longer. Relapses may occur. The purulent effusions are always serious.

=Treatment.=—Demands prompt and effective measures. Absolute rest mentally and physically, is necessary. Too much stress cannot be laid upon this point, as death has occurred from neglect of this. To quiet the heart’s action is the first necessary requisite, and then give treatment to limit the inflammation. In the early stage relaxing the upper dorsal musculature to control innervation, and raising and freeing all the upper ribs and clavicles to promote lymphatic drainage is effective. In the second stage prevention of cardiac failure and promotion of absorption are the indications to be met. Too much importance cannot be placed upon the point that general strength, good nursing, dieting and free elimination are essential, not only in securing a rapid subsidence of the inflammation, but to prevent further complications.

Raising and separating the ribs over the heart will be of great aid in lessening the inflammation and promoting absorption. In many cases lesions to the ribs on the left side and subdislocations of the vertebræ affecting the vasomotor nerves, the lymphatics and nerves to the heart will be found. The first five ribs and corresponding vertebræ is the region where one may expect to find the lesions. In addition to absolute rest, an inhibiting treatment in the dorsal region between the scapulæ will aid in slowing the heart’s action. Correcting any lesion that may be found to the vagi nerves will also be a help in controlling the heart’s action; besides, most of the vasomotor fibers to the heart are in the vagi. These lesions are usually found at the atlas. One should also examine carefully all the cervical vertebræ for derangements that might affect the cervical sympathetic, especially the superior and middle cervical ganglia. These ganglia are primarily affected from the fifth cervical to the first dorsal. Inhibition for a few minutes between the transverse process of the atlas and the occipital bone to the posterior occipital nerves will be of great aid in controlling the tumultuous action of the heart; also, inhibit in the upper dorsal. The warm bath will quiet the heart, but care should be taken not to weaken the patient. The general treatment has the effect of lessening nervousness and quieting the heart.

The function of the phrenic nerve must be borne in mind when regarding the pericardium. The phrenic is usually primarily affected at the third, fourth and fifth cervicals, and occasionally there are connecting fibers as low as the fourth and fifth dorsals. Ice-bags may be found of value in retarding the progress of the effusion and in lessening the heart’s action. Liquid food, as milk and broths, should be given throughout the disease. If the effusion is very large the services of a surgeon should be secured and tapping performed. If the effusion is of a purulent nature, a free incision should be made with antiseptic precautions.

In chronic cases carefully graduated breathing exercises and moderate stretching of the adherent regions, if pathology permits, should be considered.

Endocarditis

=Endocarditis= is an inflammation of the lining membrane of the heart. The process is usually confined to the valves; the lining of the cavity of the heart may also be affected, especially in severe cases. Three forms are recognized: simple acute endocarditis, ulcerative endocarditis, and chronic endocarditis.

=Simple Acute Endocarditis.=—This form usually results from acute articular rheumatism. Tonsillitis may be associated with endocarditis. It may also be caused by other infectious diseases, especially scarlet fever, but rarely, by typhoid fever, measles, chicken-pox, diphtheria, smallpox and erysipelas. Acute endocarditis is frequently found in chorea. It is also met with in diseases attended with emaciation and general weakness, as cancer, gout, Bright’s disease and diabetes. It is not uncommon in phthisis. Micro-organisms play an exciting part, but back of this the osteopath finds lesions of the heart innervation important predisposing features. Prophylactic osteopathic treatment is a potent factor in preventing endocardial changes in the above diseases. Keeping the muscles relaxed and the osseous tissues intact is of great value.

=Pathologically=, the left side of the heart is most commonly involved. The disease is characterized by the presence of small vegetations on the segments or on the lining membrane of the chambers, although in mild cases there is simply swelling of the valves. The mitral valves are more often affected than the aortic. The vegetations appear, usually, on the auricular surface of the mitral and the ventricular surface of the aortic valves, a little back of the valve edge. Their seat corresponds to the point of maximum contact (Sibson). These growths are liable to be broken off at any time and carried as emboli by the blood current to distant organs, particularly the brain, spleen and kidneys. This is not uncommon in acute endocarditis or chronic valvulitis. In favorable cases the vegetation is ultimately absorbed and the valve is but slightly altered beyond a simple sclerotic thickening. This is often the starting point of sclerotic valvulitis. Osteopathic measures undoubtedly lessen the liability of cardiac involvement, prevent extensive changes and promote absorption of disease products, by lowering heart tension and improving the cardiac nutrition, as well as increasing free elimination of the toxins in the blood.

During the fetal life, the right side of the heart is most commonly involved. The chorda tendinæ are sometimes affected, but rarely alone.

The vegetations are composed of proliferated connective tissue cells. The superficial elements undergo a coagulation-necrosis and fibrin is deposited from the blood. Micro-organisms are found and are the specific agent in causing acute endocarditis.

=Symptoms.=—A large number of cases are latent, the autopsy first disclosing the lesion. In many cases there are slight fever, a frequent, sometimes irregular, pulse, palpitation and dyspnea. There is seldom any pain.

=Physical signs= are very uncertain. They may not be present in mild cases and in those in which the valves are not affected. Usually auscultation furnishes the only indication of endocarditis—a soft, blowing, systolic murmur which is heard most frequently at the apex, as the mitral valves are the ones generally involved. When the aortic valves are affected, the murmur is heard at the second interspace at the right edge of the sternum.

=Diagnosis.=—This depends entirely upon the etiology and physical signs. The greatest danger is in the disease becoming chronic.

=Treatment.=—The patient should be kept as quiet as possible, so that the work required of the heart may be reduced to a minimum. The disturbed circulation can be controlled by careful attention to the vasomotor nerves at the various centers along the spine. Attention should be given the disease that is causing the endocarditis. Keep the patient well protected by flannels and beware of damp rooms and sudden changes of temperature.

Treatment should be given to correct any lesion found in the upper five dorsal vertebræ or ribs and to raise and spread all of these ribs so that the heart’s action will not be unduly disturbed by interferences with its innervation. The vasomotor nerves to the heart’s vessels are found in the vagi nerves, consequently care should be taken that lesions to these nerves do not exist. An inhibitory treatment to the suboccipital nerves acts reflexly on the vasomotor nerves and tends to equalize the general vascular system. This treatment quiets the heart’s action. Ice applied locally is advocated by many practitioners. Flannels should be placed next to the skin and the ice-bag placed over the flannel. This reduces the fever, lessens the pulse-rate and quiets the heart action. The same points are obtained by the inhibitory treatment at the suboccipital region. The ice-bag also relieves pain and oppression. Be very careful in the use of ice when there is much cardiac dilatation. Treatment of the middle and inferior cervical regions may have some effect in controlling the heart’s action. A general treatment to quiet the patient is effective. Do not allow any overexertion. The patient should have nourishing liquid food.

Emery[100] says: “Many of us have been in the habit of saying, just because we hear a decided murmur in the heart region, that the patient has valvular heart trouble; that the patient has organic heart trouble. This is a common error... When there is an anemic condition of the body, apparently the cusps of the valve will be so weakened, and the attachment will be so weakened that the blood will force its way between the valves and back into the heart, causing regurgitation murmur, when as an actual fact there is no deformity and no real disease of the valves, and as soon as the general condition of the anemia is improved, the valve will do its work fully and the murmur entirely cease. So if you have the murmur without the hypertrophied condition, which at once follows such a valvular lesion, you must be guarded in your statements, for if an actual valvular lesion existed, compensation would take place, and it would be the means of corroborating such a valvular condition; if no hypertrophy is found, then we are not justified in definitely stating that a valvular or organic lesion exists, for such a weakened condition as has been mentioned might be the only pathology present, and be the cause of the murmur.”

=Ulcerative or malignant endocarditis.=—This is an acute, infectious or septic disease, characterized locally by necrosis or ulceration of the valve. It is generally a secondary affection to septicemia, pneumonia, erysipelas, scarlet fever and acute rheumatism. Acute endocarditis often precedes the ulcerative variety, the latter being simply an increase in severity of the former.

=Etiology and Pathology.=—It is doubtful if there can be a primary form of ulcerative endocarditis. Chronic valvular defects are the most important predisposing causes. Pneumonia is most frequently, of all the acute diseases, associated with severe endocarditis. It is rare in tuberculosis, diphtheria, typhoid fever and chorea. It occurs in association with erysipelas, gonorrhea and rheumatism. Septicemia, pleurisy, meningitis and puerperal fever are other possible causes of ulcerative endocarditis.

Deep seated lesions, which means firmly anchored lateral flexions and rotations due to fibrotic changes, are important predisposing local factors, while other lesions that disturb blood elaboration and resistance and lessen elimination, are predisposing systemic causes.

=Pathologically=, the lesions are either vegetative, ulcerative or suppurative. The vegetations are composed of granulation tissue, granular and fibrillated fibrin, and colonies of micro-organisms. They become necrotic and break down into ulcers. The ulcerative changes may lead to perforations or produce valvular aneurisms. Of the valves the mitral is the most frequently affected; then the aortic; then the mitral and the aortic together; then the heart walls; then the tricuspid; then the pulmonary. In a few cases the right heart alone is involved. The lesion is not always confined to the valves, but may involve the mural endocardium. The most common organisms found are the pneumococcus, streptococci and staphylococci. The bacillus diphtheriæ, bacillus coli, gonococcus, bacillus anthracis and other organisms have been found. Associated pathological changes include the lesions of the primary disease and the changes due to embolism. The spleen, kidneys, brain, intestines and skin may be the seat of embolism. When found in the lungs, they originate in the right heart.

=Symptoms.=—If in the course of any of the diseases previously named under etiology, chills followed by fever and sweats occur, ulcerative endocarditis should at once be suspected and a thorough examination be made. The general symptoms are high, irregular fever, delirium, sweating, great prostration, rapid pulse, hurried breathing and sometimes jaundice and diarrhea occur.

The occurrence of delirium, coma or hemiplegia points to involvement of the brain; pain in the region of the spleen, with increased dullness on percussion, point to trouble in that organ; hematuria may occur from involvement of the kidneys. More rarely there will be impaired vision from retinal hemorrhage; and there may be suppuration and sometimes gangrene in various locations, depending upon the position of the embolism.

The =septic type= is secondary to suppurating external wounds, puerperal sepsis or acute necrosis. Occasionally gonorrhea is the cause. The symptoms presented are rigors, irregular fever, sweats and exhaustion—the signs of septic infection. The symptoms may resemble a quotidian or a tertian ague. The =typhoid type= is the most common. The characteristic symptoms are irregular temperature, sweating, prostration, delirium, drowsiness, diarrhea, petechial and other rashes, distention of the abdomen and pain in the right iliac region. The heart symptoms may be overlooked, as in the septic type. The =cardiac type= are cases of chronic valvular diseases in which fever, rigors and sweats, and the symptoms of embolism may develop. In the =cerebral= cases the symptoms may simulate meningitis. Acute delirium may be the distinctive symptom. Heart symptoms may be overlooked.

=Physical Signs.=—The heart symptoms may be latent. Even after a careful examination, there may be no murmur present. When murmurs are present it is often difficult to locate them.

=Diagnosis.=—The previous history should be considered and this, together with the symptoms, makes a correct diagnosis possible, even though physical signs are absent. The duration is from a few days to several weeks.

=Treatment.=—The treatment of this form of endocarditis is likely to be of little avail, although in a few cases where the source of infection can be eradicated the condition may be considerably improved and life prolonged. About the same treatment as in simple endocarditis should be followed. Absolute rest is essential and this, coupled with the local treatment of simple endocarditis and a nourishing liquid diet, constitutes the principal treatment.

Chronic Endocarditis

This condition may begin as a chronic inflammation or follow the acute form, which is more often the case. There is a =sclerosis= of the valves which causes deformity, owing to the contractions. The onset is usually insidious.

It is well known that the larger percentage of valvular lesions are the result of either acute or chronic endocarditis. Thus rheumatism stands foremost as a cause of valvular defects. Alcoholism and overeating (through introducing irritating influences into the blood, or by causing rheumatism, gout and allied diseases) are important etiological considerations. Nephritis and syphilis are considered among the causative factors. Infections and senility, when associated with high blood pressure, is a phase not to be overlooked. Chronic endarteritis extending from the aorta to the valves, resulting in thickening and degeneration of the tissue, may be an insidious source of valve disease. This is probably often of syphilitic origin.

A potent cause of special interest to the osteopath (for the reason that his treatment is so effective), is continued =muscular strain= as seen in athletes and laborers. The heart muscle itself may be strained, particularly the valve leaflets and the tissues about the valve, which effect often terminates in valvular leakage. In addition, the orifice of the valve openings may become stretched and distorted through strain superinduced by prolonged exertion, by flabbiness of heart tissue, and by dilatation of the ventricles. In these latter cases it is seen that the leaflets of the valves may remain intact, but still they are unable to stretch completely across the opening.

With the above condition it is readily noted that thickening, curling and adhesions will take place when inflammation attacks the valves and contiguous tissues, and following these, limy infiltration and fatty degeneration may be a consequence.

Predisposing osteopathic lesions as noted in acute endocarditis, are not to be neglected.

=Thickening and hyperplasia= are immediate consequents of connective tissue overgrowth; and especially is chronic endarteritis accompanied with atheromatous and calcareous degeneration. Thickening, at times, is only slight and the function of valves is not impaired.

In curling or =retraction=, there occurs a shrinkage of the hypertrophic or hyperplastic tissues. This condition is very apt to become permanent.

=Adhesions= of the valve leaflets is a self-evident condition. It is well to note here that in acute and chronic endocarditis some part of the fibrous valve ruptures or is lacerated or eroded from strong and rapid heart action; the =laceration= or rupture or erosion always occurs at the point of maximum contact. Thus the eroded surface allows an opportunity for the rheumatic or septic micro-organisms to lodge, multiply and grow, and adhesions result. Carefully applied osteopathic methods are very efficacious in impending acute heart disturbances, and this without doubt is the reason why so many of our rheumatic cases get well without any heart affections. Keeping the heart quieted and slowed prevents the strong and rapid action and thus lessens the probability of lacerations, ruptures and erosions of the valve tissues. General resistance is increased and elimination improved, which have a decided effect in preventing complications.

=Calcification and atheroma=, as has been mentioned, may follow the above diseased processes. The calcification is sometimes so marked as to be of the character of a bony ring.

The question arises here, What effect have =osteopathic lesions= as direct =causative factors= in valvulitis? It appears reasonable that the heart is not exempt from the influences of the vertebral and rib maladjustments. Furthermore, clinical experience has abundantly proven that the heart tissues are affected by these lesions in the same manner as any tissue or organ is affected. Again, osteopathic dissection reveals direct nervous connection from the upper dorsal spinal ganglia to the heart ganglia.

No one will question that the integrity of heart function and life are dependent upon normal coronary artery supply, upon vasomotor equilibrium, and upon motor control. All of these functions are influenced by the status of cervical vertebræ, upper dorsal vertebræ, and rib relations. Just what the pathological affection is when these anatomical parts are disturbed is beyond us until more careful dissection and experimentation have taken place. How cervical and dorsal sympathetics, vasomotor and motor nerves with their spinal connections, vagi and phrenic, are so disturbed as to involve valvular parts and induce inflammation, is a problem for us to investigate. Through analogous reasoning from other organic ailments and through the fact that osteopathic therapeutics corrects heart lesions, we know in a general way that the correction of osteopathic lesions decidedly influences the heart.

Two well known =physiological facts= relative to the heart are: first, the heart increases in size up to adult life, and, second, the heart muscle can actually be increased in size. This latter fact occurs in physical development and training. A heart that is weak and flabby can be increased in strength, tone and size. This helps us to understand how certain strains and distortions of the heart, with consequent valvular lesions, may be corrected through rest, exercise and treatment; somewhat analogous to the correction of an atonic, prolapsed and dilated stomach. Then it also seems probable that disturbed innervation and blood supply to heart areas or to the heart as a whole would predispose to congestions, inflammations and degenerations whereby rheumatism, septic states, etc., and muscular strains would act only as exciting causes, not true causes.

No one is going to expect that thickened, retracted, adhered, or ruptured valves are to be made anatomically correct; but the right treatment will certainly reduce the morbid state to the minimum. Then there are cases where osteopaths have eliminated all murmurs when specialists stated the disease was incurable; showing that it is impossible by signs and symptoms to always diagnose the morbid tissue state. Only the resulting effects of size and of leakage are definitely revealed by auscultation and percussion. Hence there is a class of valvular diseases that can be successfully treated by osteopathic measures, which, if left to terminate under drug medication, will reveal (at post-mortem) the pathological signs of valvular heart disease.

Downward displacement of the =first rib= may interfere directly with the subclavian artery and thus cause constriction of that vessel and a consequent regurgitation; also, cardiac fibers of the recurrent laryngeal nerves may be impinged by a dislocation of this rib. Many lesions which interfere with the right side of the heart occur at the =second= and =third ribs= and lesions of the =third=, =fourth= and =fifth ribs= may interfere with the valves. Lesions of the =corresponding vertebræ= produce the same results as the ribs. These lesions are probably to the sympathetic nerves along the dorsal region. Lesions may be found anywhere along the cervical vertebræ which may involve inhibitory (vagi) fibers or accelerator (sympathetic) fibers to the heart. Also, in some cases the =floating ribs= are dislocated downward and cause a prolapse of the diaphragm, and thus a constriction of the aorta, which may result in regurgitation and valvular disorder.

=Mitral Regurgitation.=—Mitral regurgitation is a leakage of blood from the left ventricle, through the mitral valves, into the left auricle. The opening of the valve may be distorted, or the valve leaflets thickened, rigid, or retracted, thus allowing an escape or reflux of blood from ventricle into auricle. The tendinous cords may also be thickened and adhered, with consequent prevention of free action.

By a forcing back of a portion of the blood from ventricle to auricle at the same time the pulmonic veins are emptying into the auricle, an overdistention of the auricle takes place. The auricle, then, from the extra amount of work required, becomes hypertrophied and dilated. There may be no noticeable symptoms at first. Later on shortness of breath, cough, irregularity of heart’s action, indigestion, liver congestion, and so on, occur.

The =apex beat= is forcible and downward to the left. Of course the area of dullness is to the right and left. There is a =systolic murmur= in the mitral area, which is transmitted to the left axilla.

Every osteopath should understand the mechanism of this most frequent valvular lesion. Following hypertrophy and dilatation of the left auricle, the reflux may be so excessive that a residue remains. The auricle not being able to handle all the =blood=, stasis of the pulmonary vessels takes place, and pulmonary edema and hydrothorax are sequelæ. Then comes dilatation of the right ventricle and back pressure on tricuspid valves and right auricle. The =veins= throughout the body become turgescent, and the liver is apt to be indurated. It should be emphasized, however, that “back pressure” is only an effect commonly due to myocardial degeneration, caused by some infection, of which auricular fibrillation is an important part of the pathology.

Before the breaking down of the left heart compensation, osteopathic methods, as all know, are effective in maintaining balance. Even after the lungs begin to be affected, careful and thorough treatment will result in good, and in cases of general venous sluggishness treatment, particularly to liver, diaphragm, bowels and limbs, will generally materially help in slowing the downward course of the disease.

=Mitral Stenosis.=—In stenosis there is narrowing or constriction of the valve opening. Thus in mitral stenosis the free flow of the blood from left auricle to ventricle is hindered.

The =cusps= are usually thickened, rigid and adhered. The valve opening may be so stenosed as to be but a narrow slit. In all cases stenosis is a =structural defect=. It can occur by strains, as regurgitative effects sometimes result.

The =symptoms= of mitral stenosis are practically the same as those of mitral regurgitation, owing to similar effects upon the circulation.

Under =physical signs= we find the apex-beat is only slightly displaced. Palpation will reveal, near the apex, a rough presystolic thrill. The increased area of dullness is to the right. There is an abruptly terminating, rough, presystolic murmur.

=Aortic Regurgitation.=—Aortic regurgitation is a reflux of blood from aorta to left ventricle, following ventricular systole. This is considered the =most serious= of the valvular diseases. The valve opening is either too large, so the valve leaflets do not fit tightly, or the segments themselves are thickened and retracted. Structural defects of the aortic valves are largely of the same character as in diseases of the mitral valves.

The =regurgitation= first causes dilatation of the left ventricle. This is followed by hypertrophy. If the mitral valve holds intact, no further effects result. But if the mitral valve is diseased or becomes incompetent from the dilated ventricle, the same morbid states follow as was noted under mitral regurgitation.

There is a forcible apex-beat, displaced downward to the left. The increased dullness is to the left. There is a long, loud =diastolic murmur=. The well known “water-hammer” pulse is felt.

=Aortic Stenosis.=—Aortic stenosis indicates a narrowing of the aortic orifice. It is a structural defect. The free flow of blood is obstructed from the left ventricle into the aorta.

Aortic stenosis is much less frequent than regurgitation. Aortic stenosis and regurgitation are very apt to be associated. The beat is commonly forcible, and the increased area of dullness is to the left. There is a systolic murmur, heard best at the right second interspace, which is conducted into both carotid arteries.

=Tricuspid Regurgitation.=—Tricuspid regurgitation is the most common valvular lesion affecting the right heart. It is rare as a primary lesion. The affection may be of a structural character, or functional.

Hypertrophy of the right ventricle occurs after the manner of left ventricle hypertrophy in mitral regurgitation. The sequelæ of venous turgescence follow, also, in the same way as was given under the mitral lesions. Tricuspid regurgitation rarely exists independent of some other cardiac or pulmonary ailments.

The apex-beat is diffused toward the epigastrium. Increased cardiac dullness is toward the right. There is a systolic murmur, which is heard best just above the xiphoid cartilage. The jugular vein pulsates; in severe cases there is pulsation of the liver.

Osteopathic treatment is usually effective in relieving the engorgement of the veins, and particularly in reducing liver congestion.

=Tricuspid Stenosis.=—This affection is said to be the =most rare= of valvular lesions. Thickening, obstruction and adhesions from endocarditis cause the stenosis. As in other lesions of the heart, there is a congenital form. There is presystolic murmur, heard best at the xiphoid cartilage. The pulse is small and weak.

=Pulmonary Regurgitation.=—This is another rare lesion, and is seldom met with in a simple form.

There is forcible pulsation in the epigastrium. Increased cardiac dullness is downward. There is a diastolic murmur, heard most distinctly at the left second intercostal space.

=Pulmonary Stenosis.=—Another rare lesion. The effect of this lesion on the right ventricle is the same as that of aortic stenosis on the left. The congenital lesion is apt to occur with a patulous foramen ovale.

There is a systolic murmur, heard best at the second intercostal space on the left. =Many systolic murmurs= heard over the pulmonary opening =are functional=.

=Combined Valvular Lesions.=—When two or more lesions occur at the same time the terms, combined or associated, are employed. This is a very common occurrence. Two, three or all of the valves may be affected at the same time. =Stenosis= and =regurgitation= at the same orifice is the most common association of any two valvular lesions. When there is a joint affection of two or more valves, the =aortic= and =mitral= are most commonly associated; then mitral and tricuspid; then aortic, mitral and tricuspid.

=Prognosis and Treatment of Valvular Diseases.=—It is impossible to outline with exactness either prognosis or treatment of heart lesions. All will agree that the character of the lesion is the first consideration, and before records of these cases can be of any scientific benefit, we must look well to the nature of the valvular leakage or obstruction and note precisely what effect our therapeutics has. Perhaps of greatest consideration in the matter of prognosis is, to what extent =compensation= has been maintained. We know that compensation may be perfect; that hypertrophy and dilatation may balance the valvular defect so thoroughly that even the patient is not aware of a heart lesion. As soon as compensation begins to fail, when palpitation, irregularity of pulse, dyspnea, edema, etc., appear, we know that our treatment should pass from the realm of the defensive to that of the offensive. Then when compensation fails still more, prognosis and treatment must necessarily be changed according to the increasing gravity.

In our osteopathic work we should never forget that the condition of the lesion may be greatly influenced by environment. Habits, occupation and general daily life may affect the heart ailment for good or bad. Thus in =prognosis= we have =three features= in particular to note: character of heart lesion, extent of systemic involvement, and environment. In the immediate prognosis, the extent of general venous stasis, if any, is of great importance. In other words, the gravity of the complications is of first consideration.

Aortic regurgitation is ranked by heart specialists as the most serious lesion. Aortic stenosis is a grave lesion, but not so serious as aortic regurgitation. It is often stated that the character of the lesion is not of so much consequence as the extent of involvement the lesion has engendered. Mitral stenosis is more grave than mitral regurgitation. Right side heart lesions are usually relative, and, naturally, when the right heart is diseased from extension of the ailment from the left side, the situation is serious.

It should be remembered that a heart normal in size and beating regularly is usually in a fairly healthy condition even if a murmur is present.

In our =treatment= the first point indicated is to improve, if possible, the =integrity= of =heart muscle= and lessen the =valvular defects=, if such can be done. Owing to a dearth of statistics, it is impossible to state to what extent improvement in organic lesions has been accomplished. Very likely if we had statistics and no post-mortem findings, we would still be in the dark as to much of our work. This much is positive: osteopaths have time and again apparently cured grave valvular lesions; cases that eminent specialists diagnosed as absolutely organic lesions. Our practitioners have eliminated the murmurs, reduced the size of the heart, and removed any and all systemic symptoms. These patients are well, have been well for years, and are leading active lives. But were these cases suffering from organic lesions? No doubt there was valvular leakage, hypertrophy and dilatation, but was the valve defect a functional one? In other words, was it due to strain and distortion? In all probability the patients’ days were numbered and post-mortems would have shown grave lesions and quite likely more or less organic changes.

Does it not seem likely that some functional lesions may terminate in organic lesions? Through continued stretching of the valves and their immediate tissues, fatty degeneration may take place; the same as fatty degeneration of the heart muscle, occurring in dilatation of the chambers. If we can remedy functional lesions through specific work upon nerve centers and fibers, why cannot we influence organic lesions and at least reduce the gravity to a minimum? We know functional diseases of the heart, as palpitation, rapid heart, slow heart, etc., can be corrected, and from all indications, functional valvular leakages are generally easily and quickly remedied; it is only a step farther to affect truly organic lesions. The same valves, the same nerves, and the same osteopathic lesions are noted. Then it is only a continuation of the same process from functional disease to organic disease. Indeed, no one is able to draw a line between the two. Probably, as was intimated before, careful osteopathic treatment in rheumatism and other diseases that are apt to predispose to heart affections, will keep the heart so strong functionally and organically that resulting valvular lesions are not nearly so likely to develop. The heart can be treated and controlled as can any tissue or organ. It certainly stands to reason that osteopathic therapeutics is rational in both preventing and curing valvular lesions. The M. D. gives his drugs with the hope of maintaining heart muscle integrity, of lessening a too forceful beat, of increasing waning power, of promoting general circulation, of preventing and lessening complications. We can do the same thing with our methods, even more effectually, and with no probability of harmful effects.

It would appear there are at least two ways in which organic lesions may develop. =First=, as stated above, through =functional distortion=, the normal heart muscle being strained from severe exercise, or a weak, flabby, or disused heart muscle being overtaxed by ordinary exercise. Here it will be seen that in the first instance immediate rest will probably correct the weakness; in the second, rest and general building up of the body if the atonic heart muscle resulted from some debilitating disease. If from local causes correction of the specific osteopathic lesion should be effective.

=Secondly=, through strong and rapid heart action the =valves= are =ruptured= or =lacerated=, always at the point of =maximum contact=, and thus present a favorable surface to micro-organisms.

Owing to the valves being a reduplication of the endocardium, they have no muscles or blood-vessels, so that in =functional leakages=, inflammation does not play a part, hence, a possibility of degeneration occurring from excessive stretching.

The large majority of =osteopathic lesions= are unquestionably found in the upper five dorsal vertebræ and the first five or six ribs on the left side, although cervical lesions, in many instances, play an important secondary, if not the primary, role. These maladjustments affect vasomotor nerves to the heart, that is, to coronary vessels, the dorsal and cervical sympathetics, the vagi, and the phrenic. We are unable to state just how these lesions disturb nerve conductivity; what present anatomy and physiology teach us does not fully explain. Osteopathic dissection must be the means to the end of the explanation. We have many clinical results, but not the physiological knowledge, as yet, to support it.

The dropping down of the first rib, as well as the clavicle, interferes with the large blood-vessels, especially the subclavian, and causes increased resistance of the heart’s action and probably a certain regurgitative effect. This regurgitative effect would also occur in cases of obstruction to the aorta by constriction of the diaphragm from dropping of the floating ribs. To what extent this latter feature has been demonstrated is not known. In valvular diseases it is practical to divide them for treatment into, =first=, where the =lesion= is =compensated=; =second=, where =compensation= is =incomplete=; =third=, where =compensation= is =lost=. With all cases we should give consideration to environment, temperament, habits, food, clothing, exercise, etc. Often these secondary matters are of vital importance, especially when compensation is failing. The Schott method of treatment may be of some avail; this treatment, which is composed of a series of resistant exercises, tends to lessen peripheral resistance, develop heart muscle, and remove heart stasis.

Speaking in general, =hypertrophy= and =dilatation= follow valvular leakage, as a =secondary effect=. It is a compensatory condition, and whenever compensation is failing, there is naturally a breaking down of the structural tissues of the heart; that is, the muscular hypertrophy is losing in integrity. Our primary aim, then, should be to keep up the compensation, which is represented in the hypertrophy, although there are cases that fail rapidly, especially in emphysema and cirrhosis of the lungs. Generally, in hypertrophy and dilatation, there is a =disproportion between= the =amount of work the heart has to do= and its =ability= to do it. One of two things has occurred; there is an increase in peripheral resistance or the volume of blood through the heart is abnormal in quantity[101]. Loudon[102] says: “The treatment of chronic disease of the heart requires a longer time, as a rule, than the same disorder in the acute stage. Some cases cannot be materially helped; a vast majority may be greatly benefited after a thorough trial; while more than we might at first suppose, can be entirely cured. We desire to quote at length from Hare relating to this point. He says: ‘A chronic structural change in the heart resulting from an acute process is not always synonymous with chronic heart disease. Thus, acute endocarditis occasions a variety of changes of the mitral and aortic valves which long may indicate their presence by their characteristic murmurs, and yet in time these may wholly disappear. That many such cases outgrow the valvular trouble, especially mitral lesions, there can now be no doubt. The majority, even of those in whom valvular murmurs permanently continue, do not have their health unfavorably affected for years, and in many of these, the duration of life is not appreciably shortened.’” This statement, from such an author, gives the osteopath great encouragement; for add to those above referred to, which recover in time from all valvular trouble, the many cases of valvular insufficiency, due to dilatation, owing to osteopathic lesions to the trophic nerves, and which may be cured by removing such lesions, we find that quite a percentage of cases are thus disposed of.

“It is doubtless true, also, that the cases above mentioned having valvular thickening and vegetations, could have been cured in quicker time and greater number had osteopathic treatment been given to tone the heart, upbuild the general circulation and increase the activities of the excretory organs. The importance of the lungs is often overlooked in the treatment of cardiac diseases. The osteopath’s ability to expand the chest and increase the capacity of the thorax should be demonstrated in both cardiac and pulmonary troubles. It is said to be a universal law throughout the animal kingdom ‘that muscular power is directly proportional to the amount of oxygen consumed.’ Hence give the power, and have your patient live as much out of doors as practicable. =Exercise= should be =moderate= and always =stopped= short of =fatigue=.”

Treatment of the abdominal organs should not be neglected, for improved circulation here and thorough removal of effete products will influence the heart. Freedom from worry, strains, etc. are essential. Tepid baths are best.

A person may have a valvular leakage and not be aware of it. Probably it is best to inform them, except in certain neurotic individuals. For then they can take special care of themselves, as to overwork, strains and intercurrent infections, and their life and usefulness be greatly prolonged.

When compensation begins to break, certain symptoms are noticed, as heart irregularity, difficult breathing, particularly at night, shortness of breath, and more or less anemia. Later there is disturbance of rhythm, cyanosis, dilatation of heart and dropsy. Frequently, considerable can be accomplished through the upper dorsal treatment, attention to the chest mobility, manipulation of the abdominal organs and diaphragm, and special attention to the diet, rest and some exercise. A light general treatment will assist the labored circulation and improve assimilation, and a change of climate may be of benefit.

Hypertrophy of the Heart

=Hypertrophy= of the heart is an enlargement of the heart, due to an increase in the muscular tissue. It is usually associated with dilatation. The ventricles are more often involved than the auricles, and the left ventricle is more likely to be affected.

=Etiology.=—Valvular disease of the heart causing an obstruction to the outflow of blood, as mitral insufficiency, diseases of the aortic valve; increased intra-vascular pressure, caused by sclerotic changes in the walls of the vessels; contraction of smaller arteries, due to irritation of toxic substances in the blood, as in Bright’s disease. Overeating or drinking and excessive physical exercise would also induce hypertrophy of the left ventricle. Hypertrophy of the right ventricle is caused by valvular lesions on the right side. Lesions of the mitral valve causing an increased resistance in the pulmonary vessels are etiologic factors; also diseases of the pulmonary vessels in the lungs, as in cirrhosis and emphysema. There are conditions affecting the heart, as the use of tea, alcohol and tobacco. Disturbed innervation, as in exophthalmic goiter; derangements of the vertebræ, and ribs corresponding to the upper five dorsals; downward displacements of the floating ribs, causing a prolapse of the diaphragm and a consequent retardation of blood through it to and from the heart, will affect the heart’s action. Simple hypertrophy never occurs in the auricles; it is always accompanied with dilatation. The condition develops in the left auricle in mitral lesions; in the right auricle when there are disturbances of the pulmonary circulation. The tricuspid is rarely affected primarily.

=Pathologically=, the left side of the heart is more commonly enlarged than the right; the ventricles than the auricles. The shape of the heart varies when the left ventricle is hypertrophied, the conical shape being more or less lost; it lies more horizontally and is elongated. When both ventricles are enlarged the heart is round. When the right ventricle is affected, it occupies the largest part of the apex. The increase in the size of the heart is probably due to a numerical increase in the muscle cells. The muscle is firm, of deep red color and cuts with considerable resistance. Normally, the heart weighs from eight to nine ounces. In general hypertrophy it may weigh from fifteen to thirty ounces.

=Symptoms.=—Hypertrophy, being a conservative process or an act of =compensation=, does not necessarily present any symptoms at first. At the beginning there is rarely any pain, but a sense of fullness and discomfort is present. As the hypertrophy increases, the arteries become fuller, the veins less full and the circulation accelerated. In hypertrophy associated with arteriosclerosis the blood pressure is increased, and the pulse full and firm. Epistaxis may be of frequent occurrence and the face congested. Pains occur in the precordial region. There are nervousness, headache, hot flushes, palpitation, cough and vertigo. In hypertrophy of the =left ventricle=, the apex is lower and to the left. The carotids pulsate visibly and the radial pulse is strong and tense. Percussion reveals enlargement to the left and downward. The first sound is louder and prolonged. The aortic second sound is intensified. In hypertrophy of the =right ventricle= the enlargement is to the right edge of the sternum. The second sound in the pulmonary area is increased. The apex-beat is displaced outward. The pulse at the wrist is usually small. Hypertrophy of the =auricles= always occurs with dilatation, which is most common in the left auricle. The physical signs are characteristic. They are caused by diseases of the mitral and tricuspid valves and diseases of the lungs, as emphysema and cirrhosis.

=Diagnosis.=—If a careful examination is made, hypertrophy can hardly be mistaken for any other condition. There may be a resemblance to pericardial effusion, pleuritic effusion, aneurism or mediastinal tumor, when near the heart. The X-ray will be of assistance.

=Prognosis.=—Depends largely upon the cause producing the hypertrophy. Remember that hypertrophy is a compensatory act. The prognosis is more or less unfavorable if resulting from emphysema, Bright’s disease or in old age; also in degeneration of the vessels. In most cases of functional overaction, persistent treatment can usually accomplish considerable.

=Treatment.=—The treatment must be according to the cause of the hypertrophy. There are many etiological factors, consequently the treatment depends upon the influence of these factors. The principal treatment will be found under endocarditis, as valvular diseases are usually caused by endocarditis, and hypertrophy of the heart is a conservative process of nature—an act of compensation secondary to valvular and arterial lesions. The indications are to lessen the force and number of pulsations of the heart and remove the cause if possible.

Dilatation of the Heart

There may be =dilatation= with thickening of the walls, and dilatation with thinning of the walls, or they may be normal. It may be produced by impaired nutrition of the cardiac muscle or increased endocardial tension. More frequently the two conditions act jointly, although they may act singly. Impaired nutrition of the cardiac muscle may diminish the resisting power and thus cause dilatation. Weakening of the cardiac walls may occur in scarlatina, typhoid, typhus, rheumatic fever, etc. It is met with in chlorosis, anemia and leukemia. Increased endocardial tension occurs in sudden, extreme exertions and in valvular diseases. A normal heart through excessive exertion is rarely if ever dilated. The important causes are considered under hypertrophy. Both impaired nutrition and increased endocardial tension are influenced directly by the extent and severity of the osteopathic lesion. This point has been considered under chronic endocarditis.

=Pathologically=, the right side is more commonly affected than the left. In advanced aortic incompetency, all the divisions may be dilated. When one ventricle alone is dilated the septum may be seen to bulge. In extensive dilatation, the auriculo-ventricular rings are often dilated. Other orifices may also be dilated. The condition is often associated with =hypertrophy= and =fatty degeneration=. The muscle may be normal in appearance. The endocardium is often opaque, and roughened in patches. There is degeneration of the ganglia of the heart.

=Symptoms.=—Dilatation causes weakness of the walls of the heart, but as long as the hypertrophied walls can compensate, no symptoms result. When the hypertrophy weakens, greater dilatation occurs and symptoms of venous stasis appear, as dropsy, feeble irregular pulse, dyspnea, cough and scanty urine. In some instances there may be brief precordial distress, faintness or palpitation.

=Physical Signs.=—On =inspection= the apex-beat is diffuse and feeble, or it may not exist. As observed by Walsh, the impulse may be visible and yet not palpable. =Palpation=—the impulse is diffuse, feeble and fluttering. The pulse is small, rapid and irregular, rarely is it slow. =Percussion=—the area of lateral dullness is increased to the right. There is increase in the dullness downward to the sixth interspace and upward to the second rib in many cases. =Auscultation=—the sounds are weak and sharp. The first sound is shorter, lacks its muscular element and becomes more like the second. The sounds are obscured, the cardiac murmurs are present. In many cases the characteristic gallop rhythm is present. When the right heart is chiefly dilated, the true apex-beat cannot be felt, while an impulse may be felt below the xiphoid cartilage, and a wavy impulse is seen in the fourth, fifth and sixth interspaces to the left of the sternum.

=Diagnosis.=—When a clear history can be obtained, together with the characteristic features, the diagnosis can be readily made. =Prognosis= depends upon the cause.

=Treatment.=—The treatment of dilatation is that of valvular heart disease. It is important that the patient should have plenty of rest, suitable food and regulated exercises.

In acute dilatation absolute rest is necessary. Limit the fluid intake, and open the bowels thoroughly. In serious cases, bleeding, a pint or more, should be considered.

Myocarditis

=Myocarditis= is an acute or chronic inflammation of the heart muscle. In many cases where the muscle substance of the heart is diseased, there is no doubt that =osteopathic lesions= are potent underlying factors. The lesions lessen nervous integrity and thus have a direct bearing upon the muscular strength and the likelihood of inflammatory invasion.

=Acute Interstitial Myocarditis.=—This affection is met with in fevers, in connection with endocarditis and pericarditis. Of the infections diphtheria and typhoid are the most frequent. Septic emboli may block the coronary arteries in pyemia, septicemia and malignant endocarditis and cause infarcts in the myocardium with abscess formation. It may be a complication of gonorrhea. Males are affected more often than females.

=Pathologically=, in =acute interstitial myocarditis= the changes take place in the intermuscular connective tissue. This becomes swollen and round-cell infiltration takes place. The muscle substance is pale and soft. =Acute parenchymatous degeneration= is characterized by degeneration of the muscle fibers, which are infiltrated with granules. The cardiac muscle throughout is pale and soft. =Acute suppurative myocarditis= is a rare condition. In this form abscesses occur, which vary in size from a pin’s head to a pea. They vary greatly in number and are usually multiple. They may not cause any disturbance and may not be recognized before death. On the other hand the abscess may rupture into the heart cavities or the pericardium, or it may perforate the intraventricular septum, thus allowing the venous and arterial blood to intermingle. It may cause a cardiac aneurism.

=Symptoms.=—These are very uncertain. If during the course of any of the causal diseases, the pulse suddenly becomes rapid, small and irregular and compressible and palpitation and syncope develop, all of which point to cardiac weakness, myocarditis may be suspected. Signs of venous stasis develop later in the affection. The physical signs are those of dilatation. This is extremely grave. Cases do, however, recover.

=Treatment.=—The treatment is the same as that given under endocarditis and pericarditis. Rest in bed is absolutely necessary. Pay particular attention to the nourishment and to the hygienic surroundings of the patient. Especially attention should be given to the upper dorsal area, both to the muscles and the interosseous lesions, for this influences cardiac muscle innervation and nutrition. Then lesions of the upper cervical are important owing to their relationship to the vagi which control muscular impulses of the heart muscle.

=Chronic Interstitial Myocarditis.=—Among the causes of this form of myocarditis are the excessive use of tobacco or alcohol; gout, rheumatism, malaria, diabetes, chronic nephritis, syphilis and lead poisoning. Acute interstitial myocarditis may lead to the chronic form. This form is “commonly caused by the narrowing of a coronary branch in a process of obliterative endarteritis” (Osler). It may be due to injuries of the anterior and lateral portions of the chest. Unquestionably =osteopathic lesions= of the upper dorsal vertebræ and ribs and cervical region affect the integrity of the heart muscle and predispose to congestion, inflammation and debility of the tissue. Males of middle life are more predisposed to chronic myocarditis.

The =pathological changes= occur most frequently in the left ventricle and the septum, but they may occur in any portion. The patches and streaks that are in the walls are sometimes only seen upon very careful examination. They are of a gray or grayish-white color, and when fibers that have undergone fatty degeneration are intermingled, they have a grayish yellow tint. The condition may be associated with hypertrophy and dilatation. A part of one of the heart cavities may become dilated, producing what is known as cardiac aneurism. There is destruction of the muscular fasciculi with subsequent development of new fibrous tissue. Fatty degeneration is also seen.

=Symptoms.=—Advanced fibroid myocarditis may be present without any symptoms. Slight degrees present no symptoms. The symptoms when present are: a feeble, irregular, slow pulse; attacks of angina pectoris and sometimes arhythmia. The blood pressure is increased. Upon exercising there is more or less pain, cardiac distress and dyspnea. If fatty degeneration is also present the pulse will be quickened and irregular.

=Diagnosis.=—This is often very difficult and it requires careful and persistent study of a case to be able to make a correct diagnosis.

=Prognosis.=—This is grave, though unquestionably a number of cases have been distinctly improved through osteopathic methods. Sudden death is liable to occur at any time from complete obstruction to the coronary arteries, as this condition is associated with sclerosis and narrowing of these arteries or their branches.

=Treatment.=—The treatment of chronic myocarditis is largely included in chronic endocarditis. The cause of the disease should be determined, if possible. Careful treatment to the ribs of the left side, from the first to the sixth, and the corresponding vertebræ, will be of great aid in controlling the disease. The cervical region demands attention, owing to the influence of the vagi on conduction of the heart impulse and to vasomotor effect. Attention should be given to the diet and hygiene of the patient. Outdoor life, bathing of the skin, and careful treatment of the vasomotor nerves will be of great help.

Direct attention to the entire splanchnic region as vasomotor control here materially lessens the work of the heart and assists generally in maintaining the digestive and nutritive functions.

Degeneration of the Heart Muscle

In fatty degeneration, the sarcous substance of the fasciculi is converted into fat. In fatty overgrowths there is an excess of fat in and about the heart.

=Fatty degeneration= is very common and is due to an interference with the nutrition of the cardiac muscles. It is found in the impaired nutrition of old age, of cachectic states, of grave infectious diseases and of wasting diseases. In poisoning by arsenic and phosphorus, intense fatty degeneration is produced. Pericarditis may be associated with changes in the superficial layers of the cardiac muscle. Lesions of the coronary arteries will produce this condition; also impairment of the oxygen-carrying power of the blood. It occurs most frequently in men after forty years of age. The affection may be either general or local. It is most commonly seen in the left ventricle. When the condition is general the heart is dilated, flabby and relaxed. Microscopically, the muscular fasciculi exhibit a loss of nuclei, and oil drops and granules appear in the fibers. The affection may be present without any noticeable symptoms. Slight degrees and localized fatty degeneration are unrecognizable. =Dilatation= must be present to produce =symptoms=. This is apt to occur early. Dyspnea; asthma; cough; angina pectoris; dropsy; slow, weak pulse; palpitation, and toward the end, Cheyne-Stokes breathing may appear. Mental symptoms, such as maniacal delusions, may come on and last for weeks. =Prognosis= depends upon the cause and extent of involvement.

The =treatment= is largely that of dilatation of the heart. An effort must be made to determine the cause, and treatment should be applied accordingly. Considerable can be done in improving the nutrition of the tissues of the heart by hygienic and dietetic measures. Light exercises will often be of aid, but care has to be taken that the exercises do not tax the patient too severely. A general treatment of the body will be a helpful measure in invigorating the system as a whole and toning the cardiac tissues. The diet should be nutritious; largely nitrogenous.

Raising the ribs over the heart and increasing the chest expansion will be of help in cases where there are attacks of dyspnea and angina. Many cases present deep seated lesions in the upper dorsal region. When there are attacks simulating apoplexy, lay the patient flat upon the back with the head slightly elevated.

=Fatty overgrowth= is associated with general =obesity= and sooner or later this infiltration impairs the nutrition of the cardiac muscle and true fatty degeneration results. This form occurs more frequently in men, and between the ages of forty and seventy years. The characteristic changes consist of an increase in the normal fat. The heart may be enclosed in a thick covering of fat. The fat may also be deposited between the fasciculi, sometimes reaching the endocardium. Fatty overgrowth is certain to exist in extreme obesity. No =symptoms= are produced until the muscular fibers weaken so that =dilatation= occurs. The presence of extreme obesity, combined with signs of cardiac weakness, point to fatty overgrowth. The =treatment= of fatty overgrowth of the heart is largely the same as that of obesity. Oertel’s method of lessening the amount of liquids, proteid diet and graduated exercises is effective in cases where heart compensation is intact.

Neuroses of the Heart

=Palpitation= is a more or less rapid action of the heart, of which the patient is conscious. There is usually an irregular or forcible action of the heart, as well as a frequency of the heart-beat. There is generally some local irritation to the cardiac nerves; especially are =lesions= found to the third and fourth ribs, although a lesion may be higher or lower in the dorsals or it may be in the cervical area. Muscular lesions are frequent. These lesions predispose to the disturbances of reflex stimuli, still the general health may be so weakened or the reflex irritation so pronounced that palpitation results independently of predisposing osteopathic lesions. Females are more liable to be affected. The neurotic state is a common source of the disorder. If palpitation is long continued it causes hypertrophy. It often occurs at puberty, during menstruation and at the climacteric period. Anemia, the acute infectious diseases, dyspepsia, disturbances of the ovaries and other pelvic organs are common causes. The abuse of coffee, tea, alcohol, tobacco; diseases of the stomach, overwork, fright, grief, anxiety, and sexual excesses are causative factors. Palpitation may be associated with organic diseases of the heart, but as a rule it is a purely nervous affection.

The patient’s perception of the increased action and force of the heart is the =essential element= in palpitation. The action of the heart varies greatly and at times it may be a mere fluttering which lasts but a few minutes. In severe cases the heart beats violently and the pulse may be rapidly increased and reach 160 or more. The face is usually pale, but may be flushed. The heart’s action is not increased in some cases. The attack generally lasts only a few minutes.

The first consideration in =treatment= is to locate the disturbing factor. Raising the ribs over the heart and lowering the first rib; correcting the clavicle in a few instances, or inhibiting along the upper dorsal region will usually quiet the heart’s action. Stimulation of the vagi nerves, as they pass along the side of the neck, may be all that is necessary; in some cases inhibition of the superior cervical sympathetic or of the middle cervical region, acting on the depressor nerve of the heart, will lessen the tumultuous action of the heart. It will be recalled that either there is irritation of the accelerator nerves of the heart or the vagus is inhibited.

All =reflex disturbances=, as a displaced uterus, indigestion, etc., must be removed before the palpitation can be permanently stopped. Rest and confidence in the treatment are of great importance. A very few cases will require a hot bath and a general treatment and possibly an ice-bag over the heart to quiet the increased activity. In =anemic cases= hygienic measures and a proper diet, coupled with the treatment for anemia, are indicated. If the attack is severe, the patient should rest in a recumbent posture and drink something warm, besides receiving the indicated treatment. When the patient is not a decided neurasthenic a rapid five or ten minute walk will often normalize the heart’s action.

=Tachycardia= is rapid action of the heart and commonly occurs in paroxysms. There are no heart sensations, as in palpitation. Either the sympathetics are stimulated or the vagus inhibited. It is not generally related to lesions of the heart, but is in reality a =disorder= of the =nervous system=. In some instances the condition is physiologic. Nervous strain, in the form of =osteopathic lesions= to the upper dorsal or cervicals irritating the sympathetic, is the most common cause. Emotion, fright and severe exercise are other causes. It is found in neurasthenia, anemia, hysteria and in those using an excessive amount of tobacco, tea and coffee. =Reflex stimuli= from abdominal or pelvic disorder, especially during the climacteric may induce tachycardia. In exophthalmic goitre the sympathetics are overstimulated, and in some instances the vagus inhibited, leading to “heart hurry.” Tumors, hemorrhages, enlarged glands, etc., obstructing the action of the vagus, are a source of rapid heart.

Sudden onset with rapid action of the heart, small weak pulse, headache, flushed face and faintness are common =symptoms=.

The =treatment= is somewhat similar to that outlined under palpitation. Locating the cause is the first essential. Besides removing local osteopathic lesions, inhibition to the cervical and dorsal sympathetics is effective. Raising the ribs over the heart will lessen the pulse-rate.

Rest, diet and general care of the patient may be necessary. Outdoor exercise and cold bathing are beneficial. In a few cases springing the dorsal spine forward, raising the floating ribs, and slight traction of the cervical spine are effective in slowing the heart’s activity. A few cases are very refractory, especially in neurotics.

=Brachycardia=, or slow action of the heart, is the opposite of tachycardia. In a few cases it is physiologic. It usually occurs secondarily, following infectious diseases; accompanying nervous disorders, as hysteria, melancholia and neurasthenia, and is associated with diseases of the digestive organs, pulmonary disorders and toxic effects of coffee, tea, tobacco, and drugs and the toxins of jaundice, diabetes, uremia, etc. Obstructions to the cervical sympathetics and irritations of the vagus, from osteopathic lesions, may be either direct causes in themselves or predisposing factors in the above diseases.

A =slow, weak pulse= is the characteristic symptom. The heart sounds are feeble. When the pulse beat is below sixty per minute it is diagnostic.

In the =treatment= of slow heart, as in the other neuroses of the heart, the cause should be first determined. A stimulating treatment to the cervical sympathetics and inhibition to the pneumogastric will readily relieve many cases, at least temporarily. The lesion may be directly to these nerves and of course removal of the same is essential. Inhibition of the pneumogastric probably affects the activity of the depressor nerve, and stimulation of the cervical sympathetics, besides acting on the accelerator fibers of the heart directly, influences the blood supply of the body and thus increases arterial tension. Stimulation to the upper chest anteriorly and posteriorly, over the cardiac region, will increase the rapidity of the slow heart. Rest and care of the general health is necessary.

=Arhythmia=, or an irregularity of the heart’s action and pulse beat, often due to lesions in the cervical region interfering with the vagi, symis pathetic or vasomotor nerves to the heart. In a number of cases the first, second or third rib on the left side is at fault and a correction of it will relieve the irregularity immediately. It is claimed that there are nerves at the fourth and fifth dorsals that tend to control the rhythm of the heart-beat. Other causes are organic diseases of the heart and nervous system, reflex disturbances, excessive use of tobacco, coffee and tea.

“Normally, the contraction of the heart originates at the sinoauricular node, at the mouth of the superior vena cava, is conducted to the auricle, and thence to the ventricle by way of the auriculo-ventricular bundle (bundle of His or Gaskell’s ridge). Under conditions of abnormal stimulation, contractions may originate in the auriculo-ventricular node in the wall of the right ventricle near the coronary sinus; or in the auriculo-ventricular bundle on the ventricular side of the node; or in the auricular tissue itself.”—Clinical Osteopathy.

Fibers from the right vagus pass to the sinoauricular node, and from the vagus to the auriculo-ventricular bundle. Lesions of the upper three cervicals may readily disturb the vagi through circulatory and chemical sources as well as through the communicating branch of the second spinal nerve. Thus the rhythmic power of the heart, rate and strength, and conductivity of impulse may be readily influenced, which is borne out by clinical experience.

There are several forms of irregular heart action. For a description of same it is probably best to refer the student to special works.[103]

The more common forms are =Sinus= Irregularities, the =Extrasystole=, =Paroxysmal Tachycardia=, =Auricular Fibrillation=, =Auricular Flutter=, and =Heart-block=. =Pulsus Alternans= is a rare form, and is of grave significance when the heart muscle is degenerated. A knowledge of =auricular fibrillation= is of special value, for it is a common form and often indicates a serious condition.

Most of the irregularities are not of special pathological importance, providing the heart muscle is healthy. They are best studied through instrumental means and require considerable experience in order to determine the exact condition.

Frequently, unnecessary worry has been the result in discovering irregularities in the young as well as in otherwise healthy adults. Only when the cardiac muscle is diseased or degenerated through various infections and toxic properties in the blood should they receive unusual attention.

Dorsal and lower cervical lesions that affect the heart by way of the sympathetics no doubt disturb nutrition of the heart tissues. And lesions of the vagi, particularly of the upper three cervicals, will disturb the rhythm, rate, strength, and conductivity of the impulse through auricles and ventricles. In no other organ of the body will the osteopath be better rewarded for careful and painstaking work than in normalizing the stimuli from sympathetic and vagi that influence the heart. Stimulatory and inhibitory efforts will frequently suffice, but in our judgment it is always better to secure interosseous adjustment if possible.

Though a number of individuals with heart irregularities are of a neurotic type, that predisposes to nervous disturbances of various kinds, still it would be an interesting study, especially in cases of children, to note what percentage are the result of upper cervical lesions caused by birth injury.

Angina Pectoris

=Angina pectoris= is characterized by pain in the cardiac region which usually extends to the inner side of the upper arm and forearm. “This region corresponds to the peripheral distribution of the lower cervical nerves (6th and 7th in the arm) and the upper three or four dorsal nerves (in the upper arm and the chest).”[104] Occasionally similar areas of the right side are affected, and in a few there is pain in the lower jaw and back of the ears. “The starting of the pain is usually across the chest, about the level of the third ribs, or as low as the fifth ribs,” although the inception may be anywhere in the left chest or the arm. The duration of the pain is from a few seconds to several minutes; sometimes it may remain for several hours.

Osteopathic lesions are invariably found in the upper dorsal, including ribs, or lower cervical region, which are predisposing factors that tend to exhaust and weaken the cardiac muscle, and disturb the coronary circulation, so that resistance is lowered. Thus toxic agents and infections may readily involve the cardiac tissues. Many cases present more or less arteriosclerosis, which involves the heart and affects its circulation. Inflammation of the root of the aorta from syphilis is a frequent cause. Valvular heart disease and chronic nephritis are other underlying factors. Worry, strenuous living, and continued physical strain are to be considered. There are a group of cases, that are comparatively mild and frequently found in women, that are of toxic origin, due to intestinal stasis as a result of constipation, adhesions, etc. The ileo-cecal section is commonly involved in these instances. Focal infections may be an exciting cause.

The =osteopathic lesions= undoubtedly affect the cardiac innervation, particularly vasomotor and trophic, thus leading to consequent disturbances of cardiac circulation and resulting irritation to the ganglia. Sclerosis and spasm of the coronaries, ischemia, cramping, exhaustion, and degeneration of the heart muscle, and cardiac neuralgia, are various results that may take place.

The =paroxysm= usually begins suddenly, often during exertion or intense mental emotion. The pain is agonizing and of a grip-like character, and there is a feeling of impending death. The intercostal muscles are constricted and there may be a feeling of suffocation. The pains radiate up the neck and down the arm, and may be accompanied by numbness or tingling. There is usually extreme pallor, and the skin is ashen. Sweating is not uncommon, and dyspnea may be present. The attacks occur at intervals, varying from a few days to many years. After the paroxysms there is instant relief.

Other cases may present less severe attacks.

In the =diagnosis= the only condition with which true angina pectoris is liable to be confounded is pseudo-angina pectoris. =Pseudo-angina= or hysterical angina occurs chiefly in women or in neurasthenic men. These cases are often excited by toxemia. The attack usually occurs at night and is unassociated with organic heart disease. There is a feeling of cardiac =distention instead of constriction= as in true angina. There is emotional excitement and the attack lasts one or two hours, which is usually longer than that of true angina. The =prognosis= is unfavorable, although many cases live for a number of years. A few cases have recovered under a thorough course of treatment.

The =treatment= of angina pectoris consists in correcting the disordered upper dorsal vertebræ, the upper left ribs over the heart, and the lower cervicals. Invariably lesions are found in this region and if the treatment is applied to correct these disorders, the attack can frequently be relieved. By following up the treatment during the intervals, a number of cases can be practically cured. A common lesion found is a slight lateral curvature in the upper dorsal region. This curvature is oftentimes great enough to cause a subdislocation of several of the ribs, which certainly complicates the derangement, at least as far as a quick cure is concerned.

=During= the =attack= raise the ribs over the heart at the point of constriction so as to relieve the impinged nerve fibers. Hot drinks are of value. The vagi and phrenic nerves may also be at fault in some cases. The sensory nerves to the heart are from the first, second and third dorsals.

Ice-bags or heat applied locally will be a helpful measure. In cases where there is high arterial tension, an inhibitory treatment to the upper and middle cervical regions will be of special aid, as it relieves this tension by affecting the vasomotor nerves. This treatment will at least overcome the =vasomotor form= of angina pectoris. Hot foot-baths and friction will also be found of value. In many cases under forty or forty-five syphilis is a cause. In cases past middle life there is often organic disease of the circulatory organs.

The patient should at all times avoid any excitement and live a very quiet life. He should take frequent vacations. He should take the best of care of himself and his food should be nutritious. In pseudo-angina the treatment is to relieve the irritation to the nerves affected as well as the underlying affection.

FOOTNOTES:

[100] Journal of the American Osteopathic Association, April, 1906.

[101] Valvular Heart Diseases, A. O. A. Journal, March, 1905.

[102] Journal of Osteopathy, February, 1904.

[103] Mackenzie, Diseases of the Heart; Lewis, Mechanism of the Heart Beat; Macleod, Physiology and Chemistry in Modern Medicine.

[104] Mackenzie, Oxford Medicine, Vol. II.

DISEASES OF THE ARTERIES

Arteriosclerosis

(ATHEROMA)

This is a thickening of the intima of the arteries, due to an inflammatory increase of the connective tissue, associated with more or less fatty degeneration and calcification.

Old age, alcohol, lead, gout, syphilis, rheumatism and other infections, laborious work, overeating, nephritis, and calcareous water tend to produce the condition. =Excessive eating= and =drinking= are common causes of both atheroma and chronic renal diseases and should always be regulated. Physical overwork, chronic intoxications, etc., produce hypertension of the vascular system and thus lead to changes of the vessel walls. A rigid spine is invariably found; this may be a causative factor in itself, or an associated condition. All of the above list of causes are important.

=Pathologically=, the arteries are thickened, tortuous and rigid. The intima may be occupied by rough, calcareous plates. In extreme cases the sub-endothelial tissue undergoes degeneration and breaks down in spots, forming “atheromatous abscesses.” The disease may be =circumscribed= or =diffuse=; in the latter there is a widespread distribution of the affection. Owing to the general effect, the heart, liver and kidneys receive less blood and tend to atrophy. Microscopically, there is found more or less fatty degeneration of the different coats, and an overgrowth of connective tissue in the intima. The arteries most frequently affected are the aorta and coronary.

=Symptoms.=—=Circulatory.=—There is a high tension pulse and accentuation of the second aortic sound. There is also dyspnea, severe pain in the left side, palpitation, pallor, and the left ventricle is hypertrophied. =Cerebral.=—Such symptoms as headache, tinnitus, aphasia, vertigo, syncopal or epileptiform attacks may be present. =Renal.=—There is an increase in the quantity of urine, which is of a pale color and low specific gravity; at times it is albuminous. The disturbance leads to atrophic nephritis. There may be gastro-intestinal symptoms, as constipation, pain, etc., due to hardening of the splanchnic vessels. In some cases the peripheral arteries become obliterated. The veins become hardened.

=Sequelæ= are cardiac dilatation, heart failure, paralysis, apoplexy, fatty heart, aneurism, contracted or senile kidney, angina pectoris, and in extreme cases, gangrene of the extremities.

=Diagnosis.=—The characteristic symptoms are hardened arteries, high tension of the pulse, hypertrophy of the left ventricle and accentuation of the aortic second sound. The average blood pressure is from 160 to 180 mm. of mercury, though it may be considerably higher.

=Prognosis.=—Many cases can be greatly benefited by osteopathic treatment, and at the incipiency the improvement is generally marked. It usually runs a very chronic course.

=Treatment.=—The treatment must necessarily consist, principally, in the removal of such conditions as are producing the degeneration. The rigid spine should be carefully treated by methods (preferably traction) that overcome the contractures and release the intervertebral discs. The dorsal and lumbar areas, and the abdominal organs should receive special attention. Outdoor life and plenty of rest are important. Alcoholism, gout, rheumatism, syphilis, etc., must be remedied before there can be much change in the arteries. Freeliving and all excitement must be stopped. The patient’s cooperation is invaluable. A milk diet is often beneficial. Besides treatment of the primary disease, a general treatment will be of much avail in equalizing and reducing arterial tension. Brunton[105] speaks of cases of atheroma being cured by exercise and manual treatment to the rheumatic joints themselves. One, apparently suffering from senile dementia, was much improved after two years of this treatment applied to the joints, and showed benefit to the cerebral circulation. The bowels and kidneys should be kept active, and the general health of the patient carefully watched. Keeping the skin active by daily baths is an essential factor in the treatment. Very frequently the disease is not only retarded, but improved. In high blood pressure venesection may be of benefit.

FOOTNOTES:

[105] Lectures on the Action of Medicine, p. 343.

DISEASES OF THE BLOOD

BY EARL R. HOSKINS

=General Considerations:=—It has been said that each individual is a part of all the generations which have preceded him. In the same way it might be said that every drop of our blood is a part of every other cell in our bodies. The other tissues are able to maintain their existence only through the ministrations of the blood and in turn the blood derives its own substance from tissues which it supplies. We are accustomed to speak of certain organs as being those of blood formation, yet it is true that every tissue furnishes its quota of blood composition, making up the mass which we call blood.

It is in one way an algebraic sum of good and baneful substances, without which there can be no normal function, and sometimes being of itself a menace as well as an aid to other tissues, as in sepsis. There can be no perverted function of any tissue without there being a direct effect upon the blood. We may not always be able to measure this effect with our present laboratory methods. We may not be able to detect clinically the result of this alteration of the blood stream because of compensatory influences, dilution, phagocytic action, enzymatic action, oxidation, and the intricate processes of excretion. It must also be remembered that normal blood is not of a certain definite chemical or physical composition. It must vary from minute to minute according to the normal metabolic phenomena which make up our succession of events associated with life.

But comparatively little is known about this most important fluid. We have accumulated data regarding morphology and relative numbers of its formed elements and their behavior when sufficient abnormality is present to upset their wonted balance of arrangement. We have an ever widening field of investigation in the blood plasma in which we are constantly being told of newly discovered complexities. Certainly the field of the unknown is big enough to contain our unexplained blood reactions.

It is probable that as our knowledge increases our number of diseases really considered as true blood diseases will decrease and be shown to be the effect of blood passing through certain pathologic tissues of the body. We can measure the number and proportion of formed elements, and the relative efficiency of the erythrocytes by the amount of hemoglobin which they carry. The genesis of the formed elements is to be kept in mind in considering therapy. The erythrocytes and granular cells developing in adult life, principally from the red marrow, leads our attention in decrease or increase of these particular cells to the greatest aggregation of red bone marrow which happens to be in the ribs. The anatomical relation of the ribs to the spine would seem to render them very liable to disturbances of nutrition and nerve control as a result of structural maladjustment and clinically this presumption is verified. Limitation of the motion of the thoracic spine is perforce accompanied by costal inactivity with disuse effects upon the red marrow and eventually upon the relative content of the blood stream.

We can measure the efficiency of the erythrocytes in carrying oxygen to the tissues by measuring the relative amount of hemoglobin which a given volume of blood contains. The actual changes taking place in blood character are often thus sufficiently indicated for us in terms of our present methods of examination, to at least aid in the arrival at a diagnosis. We sometimes have to remember that the adaptation to abnormality may be efficient enough to keep the apparent significance from telling the “whole truth.”

The Anemias

The class of diseases which are referred to as the Anemias are those in which there is an actual, or apparent, decrease in the oxygen carrying element or hemoglobin. This may not be due to an actual decrease in amount of hemoglobin, but rather to a decrease in the ability of the red cells to carry it. This decrease in ability may be due to alteration in the erythrocytes themselves, or to effects of change in the molecular concentration of the plasma in which they are suspended. The plasma may also contain certain poisons probably protied, which may make impossible the efficient carrying of hemoglobin by the erythrocytes.

The simplest form of anemia is that due to removal of a large percentage of erythrocytes from the body. This condition is fulfilled in acute hemorrhage. If the amount of blood lost does not exceed the amount necessary to maintain circulation, roughly fifty per cent of the total quantity, the fluid portion lost is quickly replaced from the fluids of the body and from material ingested. The formed elements and proteids are less rapidly replaced by a compensatory increase in function of the hematopoietic tissues so that there is a gradual return to the original number and proportion.

A blood cell may be considered as passing through a life cycle of infancy, adolescence, maturity, and senility before it is finally destroyed. If the demand for new cells is not too great it will be met with mature cells. If the call is more urgent, younger and older cells will both be put into the conflict, while in a time of extreme stress all types of cells, from the “school boys” to the “gray-beards”, will have to be utilized to maintain life. So, roughly, we can judge the severity of the anemic process by the reaction which the body makes to it as indicated by the character of the cells in service.

The pigment, hemoglobin, is slowly regenerated even as compared to erythrocytes, so that the color index is usually the last finding to return to normal after a hemorrhage. The leucocytes are usually increased after hemorrhage, probably as a protective mechanism, nature having learned by hard experience that she has less resistance to infection, when there is loss of a considerable quantity of blood.

To be considered, also, is the fact that constantly blood cells are outliving their usefulness—some must be disposed of. The extra function required of these older cells gives the same results as over work upon an old man—hurries his time of demise so that there is a greater percentage than usual to be sent to the salvage shops. The regeneration of blood after hemorrhage depends upon the severity of the loss, the nutrition, upon the treatment given, and indirectly the ability of resistance developed by the patient.

In the chronic anemias we may have either defective development of erythrocytes, or defective function of them, or a relatively too great destruction of these same agents.

A bank account may be depleted either by too small deposits to account for current expense, or by extravagant withdrawals. It is sometimes difficult to determine on which side the fault lies. It seems to be nature’s plan not to subject to active work an erythrocyte until after the nucleus has disappeared, judged by ordinary methods of staining. A sudden call for an increased number of erythrocytes may force the organism to send in some with nuclei, but the circulation does not receive those which have not been standardized, as to shape and staining reaction, unless the crisis is of grave import. Evidence of increased destruction of these cells is shown by broken forms—shadow forms, and by an increased excretion of the pigments derived from the breaking down of hemoglobin, namely bilirubin and urobilin. A great deal of information can be obtained by a study of the other formed elements of the blood.

In general the symptomatology of all the anemias will be that of lessened metabolism because of deficient oxygenation. This is accompanied by imperfect nutrition and general impairment of function. Among the usual results are muscular weakness, malaise, headache, dizziness, anorexia, and cutaneous and membranous pallor, with tendency to local hemorrhages. The heart is often rapid, easily disturbed in rhythm, may possess a hemic or functional murmur, and gives a soft compressible pulse of low pressure. As a compensatory attempt the respiration may be rapid, but is likely to be shallow, and dyspnea results from disproportionately small exertions.

There may be either troublesome constipation, or diarrhea; often there are alternating periods of each. In the severer forms convulsions, coma, delirium, stupor, localized edema of the ankles or eyelids may be seen.

In general the treatment of the secondary anemias will concern the removal of the cause followed by measures tending to increase the decreased element or elements in the blood stream. In the anemia resulting from hemorrhage the thirst which follows is the body’s method of calling for more fluid with which to maintain pressure in the arteries and capillaries sufficient to develop new formed elements to take the place of those lost. If the loss is severe enough to give rise to shock, emergency measures are necessary of introducing into the venous stream an artificial fluid to make up for the fluid part of the blood lost. If the condition can be predicted and a suitable donor obtained, blood transfusion is of greatest advantage to the patient. More often the urgency of the condition will require an artificial fluid to be given in haste. Probably the best so far devised solution is Fischer’s physiological salt solution. In the anemias due to chronic metal poisoning as from lead and mercury, or from systemic poisoning such as syphilis or malaria, or from the retention of metabolic products as in some of the diseases of the kidneys or of the liver, the anemia can only be successfully treated by normalizing its primary cause—as it occurs in the role of a symptom or result, and hence is only indirectly a blood condition.

Costogenic Anemia

(BURNS’ ANEMIA)

Costogenic Anemia is a result of functional disuse-atrophy of the hematopoietic organs, there being an insufficient supply of erythrocytes to meet the demands of the metabolism of the body. It results from insufficient opportunity for nutrition and drainage of the red marrow of the ribs, and gives the clinical picture of an anemia due to too slow production of erythrocytes.

=Etiology.=—The condition is predisposed to by any factor which tends to limit the action and nutrition of the ribs. We are too prone to forget that the function of the ribs is to produce erythrocytes; it is really a matter of secondary importance that they make up part of the thoracic wall. The change from the horizontal to the upright position has tended to a drooping of the whole chest from gravity. The human animal seldom develops the free hinge rib motion as often seen in quadrupeds. The passage of both arterial and venous blood, is not normally free and copious, and as a consequence the tissue supplied functions less efficiently. This function of the red marrow is to produce erythrocytes. Any structural lesion of the dorsal vertebral column, or its costal articulations, which interferes with the free motion of the rib thus interferes directly with the efficient function of these particular ribs. The severity of the condition varies with the number of ribs affected and the impedance to nutrition and drainage.

=Diagnosis.=—The condition may be of gradual onset, and may be associated or coincident with some other condition leading to a loss of tone or opportunity for free rib action. The systemic symptoms are due to a deficient oxygenation of all tissues as a result of the above disuse. The thorax is usually rigid—forced respiration requires unusual effort without proportionate thorax expansion. The type of breathing tends toward diaphragmatic. The quantities of tidal and supplemental air are both markedly decreased. The lack of tissue oxidation renders elimination less active, hence constipation. Gas accumulation, weakness, insomnia, with slightly increased amount of urine, and low in total solids, is the rule.

“The blood itself is rather characteristic. Coagulation time is increased; specific gravity and viscidity diminished; red cell count normal or only slightly diminished; hemoglobin 6 to 10 grams per 100 c. c. of blood (Meischer); 40% to 80% (Dare). The red cells are small, pale, vacuolated, sometimes nucleated. The white cell count is normal, slightly increased or slightly diminished. The hyaline cells are normal, or slightly relatively increased. (These, being formed in lymph nodes, tonsils, etc., are not affected by rib changes.) The mononuclear neutrophiles are relatively increased. The nuclear average of the polymorphonuclear neutrophile is low. Vacuolated and atypical neutrophiles are often found. Basophiles, myelocytes and amphophiles may be found in considerable numbers. Nuclei in all granular forms present evidences of immaturity or degeneration—they may be swollen, vacuolated, extruded, ragged, or with variable staining reaction” (Clinical Osteopathy).

=Treatment.=—The treatment is to obtain a normal function in the inactive tissues. This is done by getting better rib hygiene. Whatever is interfering with rib function and metabolism is to be removed. Breathing exercises are given not only to “ventilate the thorax, but to exercise its walls”. Carefully selected horizontal bar work is often of great value. The diet should be of such nature as to supply material for manufacture of erythrocytes and for loading them with hemoglobin as well. Hence the foods with high chlorophyl or hemoglobin content should be emphasized.

=Prognosis.=—This depends on patient’s desire for improvement of his condition. He can be improved by correction of whatever lesions there may be interfering with his freedom of thoracic motion. He can be benefited by manipulations which adjust the ribs, but his cooperation is essential. Lack of cooperation on the part of the patient, which would tend to increase the mobility and metabolism of the ribs, renders him more liable to any of the intercurrent pulmonary infections, as a result of his deficient thoracic ventilation.

Encourage free thoracic respiration especially when in school, or when under conditions which ordinarily would tend to slovenly habits of breathing.

Chlorosis

(GREEN SICKNESS)

An anemia characterized by great reduction in the amount of hemoglobin. It most frequently occurs in adolescent girls. It seems to be associated with neurotic manifestations and menstrual irregularities.

=Etiology.=—Its cause is not well understood. Poor hygienic conditions may be a factor, but it is a condition found in all stations of life. The age and sex have led to investigation as to probability of lack of an ovarian internal secretion. The reports of workers are contradictory. The name of the condition is derived from the color of the skin, which usually ranges from a pale greenish tint to a slight pallor. Occasionally there is localized vasodilation of the cheeks giving brilliant color. Constipation accompanied by copremia seems to be either a causative factor or result. In many cases it appears to act in the dual role. Fixation of the middle and lower ribs accompanied by osteopathic lesions from the mid to the lower dorsal spine seem to be constant findings. The costal fixation leads to lessened respiratory excursion and resulting diminished oxygenation.

=Diagnosis.=—Chlorosis may be suspected from the color of the skin, perverted appetite, wandering neuralgias, heart palpitation, edematous infiltration, and shallow type respiration, but the diagnosis is not to be made without the aid of the blood count. The striking part of the blood picture is the great reduction in amount of hemoglobin carried by each erythrocyte. There is usually some reduction in the erythrocyte percentage but not in proportion to the decrease in color index.

There are usually many pessary-shaped and shadow erythrocytes. These are of all sizes, but seldom is the condition of such gravity as to cause more than an occasional nucleated red cell, and when found are most likely to be normoblasts. The staining reaction is of wide limits. Cells of all degrees of relative alkalinity are found and often there is a wide variation of staining reaction in the same cell. The number of erythrocytes is usually slightly decreased but not in the proportion that the hemoglobin percentage is, so that the color index is therefore strikingly low. Probably, the average color index for a typical case of chlorosis is 50, with an erythrocyte count of 4,000,000 and a hemoglobin of 40 per cent (Dare.) This drop in color index in chlorosis is far out of proportion to the clinical symptoms which would be expected from a similar reduction resulting from the ordinary causes of secondary anemia. The blood plasma is increased and the specific gravity is lowered, sometimes reduced from 1.055 to about 1.030.

=Treatment.=—The treatment of any malady in which the etiology may be apparently of widely different natures will naturally rationally vary with the apparent cause. If there is copremia, which seems to be a definite causative factor, this should be at once corrected. These patients form the cathartic habit readily, so physical and dietary methods of returning the digestive motility to normal should logically be given first trial. If it is a matter of lessened metabolism as a result of insufficient exercise, or blood oxygenation, outdoor gymnastics and breathing exercises may incite the stimulus to normal erythrocyte hemoglobinization. The diet should be of such nature as to furnish material both for erythrocyte formation and iron in form for ready absorption by them. The organic iron compounds of animal hemoglobin and vegetable chlorophyl are our most common and cheapest as well as most effective sources.

The medical treatment of chlorosis is based on the empiric use of inorganic iron. “The exact method in which iron exerts a favorable influence upon chlorosis still remains unsettled. It is difficult to understand why iron salts in the food which are sufficient for all ordinary needs, are insufficient in chlorosis. It seems most probable that iron cures chlorosis by acting as a stimulant to the =blood forming organs=” (Beifeld, The Basis of Symptoms.)

Clinically, osteopaths are daily obtaining rationally the necessary stimulus to the blood forming organs by removing all impedance from these organs caused by vertebral and costal lesions and by obtaining better digestive and respiratory hygiene.

=Prognosis.=—Recovery is to be expected and its rate will depend upon the thoroughness of the osteopathic work and the patient’s ability to respond to the stimulus. The blood may show chlorotic relapses with concomitant symptoms if in later life secondary anemia develops from hemorrhage, hook-worm infection, or other causes.

Pernicious Anemia

This anemia is of obscure etiology, characterized by progressive destructive hemolysis of the erythrocytes, usually with fatal termination. The cells retain their hemoglobin carrying ability, so that while the hemoglobin is decreased in percentage, the proportionately greater decrease in the number of erythrocytes leads to a marked increase in the color index. The destructive influence upon the red cells may be sufficient to allow only a small percentage of the erythrocytes to appear normal and show the greater number to be deformed, or in various stages of degeneration. Cells which in times of health would have been sent to the “salvage station” are retained to carry an over-load for them of hemoglobin to the needy tissues. Immature nucleated cells of all types are drawn into the battle long before they can be efficient carriers to help supply oxygen to the tissues. Seldom will a secondary anemia be severe enough to produce megaloblasts in the blood stream yet they are a rather constant finding in pernicious anemia. With these cells of irregular carrying capacity and development, anisocytosis and polychromatophilia are expected findings.

=Symptoms.=—The condition must be regarded as a symptom complex or a result of pathologic process or processes. A type of anemia very similar in symptoms and blood findings to the pernicious anemia is produced by the toxins of advanced malignancy, and by at least two forms of intestinal parasites, the ankylostoma duodenale and the bothriocephalus latus. In the true pernicious anemia we have similar results but are not able to locate the primary pathology. There are present synchronously, enormously increased destruction of erythrocytes and enormously increased production of them but we are unable to determine which is primarily at fault. The belief that the cells are more fragile and too easily broken up has led to the removal of the erythrocyte destroying spleen in the hope that destruction would be delayed until regeneration of even imperfect cells would balance the need. Occasionally, the algebraic sum of regeneration and destruction may be apparently balanced and not tell the tremendous amount of pathology both productive and destructive, that the body is going through.

The first symptoms are of easily produced fatigue of all the body, brain, muscles, diminished digestive secretion, and dyspnea. As a result of poor tissue oxygenation, fatty degeneration takes place in the more active organs as the heart, kidneys and liver. There may be extensive degeneration of varying areas of the central nervous system. Some of these areas are due to hemorrhages from the general tendency to breaking down of vessel walls. Often these areas of destruction affect the posterior horns of the spinal cord, and, occasionally, a blood count differentiates between similar symptoms of pernicious anemia and tabes dorsalis. There is seldom any emaciation; usually the patient appears “puffy” with a “pasty” color. There is variable subcutaneous edema. The symptoms being of such wide distribution and character, the patient is usually treated for all sorts of supposed conditions until some one makes a blood count at a time when there is enough disturbance of equilibrium to give the findings of pernicious anemia.

=Treatment.=—The treatment of the form due to intestinal parasites gives striking results on removal of the causative organisms. Some advise treating all cases having these blood findings on the assumption that the presence of these parasites is responsible for the condition. The treatment of the idiopathic form resolves itself into building up the ability of the body to resist disease and the removing of all possible agents for depressing the vitality of the body. Rest in bed coupled with the digestible and assimilable limit of nutrition often gives temporary improvement. Removal of questionable teeth also often aids for a time. Correction of troublesome osteopathic lesions is often accompanied by the same result. The symptomatic osteopathic treatment always makes the patient more comfortable, often gives temporary improvement, and, occasionally, has given a return to normal that has persisted for several years.

=Prognosis.=—It is nearly always possible to obtain transient improvement, but the pernicious anemia patient is usually dead within two years from the time the diagnosis is well established.

The Leucemias

As a result of any inflammatory process, there is a physiological reaction or stimulus leading to an increase in the number of neutrophilic leucocytes found in the peripheral circulation. As long as this increase does not crowd out other cells, red and white, sufficiently to interfere with their ability to function there is nothing but gain to the body of the character of more efficient bacterial destruction. After the need for these cells has passed, their number is decreased by destruction and the lessening of their production, until an equilibrium is reached which will be maintained.

This same process of making and destroying is constantly going on for all of the different classes of cells found in the blood stream. Over-production of any type will lead to actual increase of that sort of cell in circulation, and, if unaccompanied by over-production of other types, will lead to a relative decrease of the other elements.

It is very difficult for the body to furnish normal cells very much in excess, relatively, of the normal number, so that when the stimulus leading to immense over-production is at work immature cells in great numbers are apt to be thrown into the blood stream. As an example, the case of leucocytosis which has a white count of 60,000 is extreme and the patient nearing death, yet it may not show many, if any, abnormal types of cells. A case of myelogenous leucemia with a white count of 60,000 would not be proportionately sick, and would be a mild case—yet the greater part of his white blood content would be made up of cells not found in normal blood. The leucocytosis patient is suffering more from the =cause= of his increase in number of cells, while usually the leucemia patient suffers because =of= the increase of cells. In one, the cause is usually extrinsic, and, in the other, it is intrinsic as far as the blood is concerned.

In general, then, the symptoms of a leucemia parallel in intensity the increase in cells. It takes energy to make these cells—other tissues are made to suffer from lack of this energy. Erythrocytes and white cells cannot occupy the same space at the same time. The increase in white therefore crowds the red cells out of function. Disease in relative and absolute content of erythrocytes decreases the oxygen carrying capacity of the blood stream. Hence, metabolism of the whole body suffers. Often, then, the whole apparent symptomatology of a severe leucemia is that of a secondary anemia.

The primary pathology is of hyperplasia of the particular genetic tissue of the type of cells which are in excess, and is proportionate in amount to the excess developed.

Splenomedullary Leucemia

(MYELOID LEUCEMIA; MYELEMIA)

Myelemia is a disease characterized by an enormous increase in the white cell content with proportionate changes in the spleen, liver, and the blood marrow.

=Etiology.=—It is a disease occurring at all ages, but the majority of cases are recognized in adult males.

Heredity, trauma to the spleen, malaria, syphilis, and rapid repetition of pregnancies seem to be at least exciting factors. A few cases have been reported in which tenth, eleventh, and twelfth rib lesions were definite etiologic factors by pressure.

=Diagnosis.=—The patient goes through a period of vague, indefinite, and wandering symptoms. General malaise, weakness often accompanied by dyspnea, and emaciation similar in many ways to incipient pulmonary tuberculosis, except that the slight temperature changes are not typical. At the same time there may be digestive discomfort of various kinds without typical pathology. Of these early symptoms the most persistent is the =dyspnea= which is a structural result of the increase in size of the spleen. As a direct pressure result of this hyperplasia, there may develop dropsical infiltration of the lower extremities and ascitic accumulation in the abdominal cavity.

With the changes in the blood itself, the blood vessel walls break down more easily, and subcutaneous hemorrhages, epistaxis and hematemesis are common.

In an attempt to destroy the excessive amount of white cells, the liver may become enlarged. But this occurs later and of much less degree than the enormous increase in size of spleen. There may be areas of hemorrhage with resulting softening in the spinal cord. The most likely areas to suffer are the posterior and lateral horns, with resulting paraplegia, spastic or ataxic.

Usually, the course is slow, and the condition is truly chronic. But, occasionally, the rapid increase and succession of symptoms, with concomitant blood changes, change the diagnosis to acute myelogenous leukemia.

The total cell count, red plus white, is diminished, for while there is enormous relative increase of the white cells a greater actual decrease takes place in the reds. This decrease in reds is partially relative from crowding out of erythrocytes by leucocytes, but there is also actual decrease in their formation, so that there is an actual anemia present as well as a leukemia.

In some respects the red cells behave as in chlorosis, each carrying a diminished percentage of hemoglobin, resulting in a low color index. Atypical staining reactions and morphology, together with many fractured forms, are the rule. Normoblasts are common throughout the course of the disease, but megaloblasts seldom appear until near fatal termination.

The changes in the white cells are enormous, both as to numbers and character of cells found. The total white count often exceeds 350,000. This, with the accompanying reduction in number of erythrocytes, leads to a reduction of the ratio between reds and whites to as low as 1 to 5 or 3, or occasionally 1 to 1. There is an actual increase in number of all the white cells with the possible exception of the lymphocytes. In the actual increase of polymorphonuclear neutrophiles and eosinophiles is rendered a sharp relative decrease by the enormous production of myelocytes. Basophiles are usually both relatively and absolutely increased. In a white count of 350,000 it is not unusual to have present 325,000 myelocytes, with 25,000 as the actual number of ordinary leucocytes. There is, therefore, a =mild leucocytosis= coupled with a =violent= leukemia. These two are combined with an =anemia= that varies with the course of the disease.

=Treatment.=—The treatment is largely hygienic, including thorough osteopathic attention to the lower dorsal and costal area. Symptomatic treatment is often followed by temporary improvement both clinically and in the blood picture, but complete recovery seldom takes place. Occasionally, roentgen therapy has given a “cure” lasting several years.

=Prognosis= is not good. These patients are frequently carried away quickly by some oftentimes slight intercurrent infection. Even if carefully guarded from such, the course of the process usually leads to death from exhaustion in two or three years.

Lymphatic Leucemia

Clinically, this is a parallel condition to myelogenous leucemia, except that the hyperplasia of cells occurs in lymphoid tissue, and leads to an enormous over-production of lymphocytes rather than myelocytes. It is more readily divided into acute and chronic forms than myelogenous leucemia from differences in symptomatology.

In the =acute form=, adolescents are usually affected, the condition beginning with tumefaction of the lymph glands, first noted in the cervical region, but usually a general involvement. Dyspnea results from pressure upon trachea and bronchi by the enlarged glands of the mediastinum. There is pyrexia of 103 to 105 degrees, intermittent in character.

The pressure upon nerve trunks and plexuses in the thorax leads to variable anginas distributed not only in regions actually imposed upon but over all sorts of possible reflex paths. The blood vessels of the skin are easily broken down so that slight injuries result in great suggillation. The patient rapidly develops anemia, and later goes into a syndrome similar to the cachexia of malignancy. In fact, the rapid termination and clinical course of acute lymphatic leukemia is parallel to the action of malignancy. Probably the condition will eventually be properly classified as a neoplasm of the blood itself.

The =chronic form= occurs in later life, and, instead of being an abrupt rapid process, is slow, progressive and painless. It has the lymph gland hyperplasia, but the enlargement is so gradual that compensation is established to a remarkable degree. It is usually a generalized process, first noted in the cervical and axillary glands because of their accessibility. Usually both the spleen and liver are enlarged, but this also is a slow and later development.

There may be exacerbations of temperature, but they are not constant or usually severe. Hemorrhages into the skin are not common, but pruritus may be very troublesome.

The patient comes to a physician because of symptoms resulting from his secondary anemia, dyspnea, dyspepsia, and palpitation.

The =diagnosis= cannot be made without the aid of a blood study. The blood picture shows a severe anemia with both the number of erythrocytes and the hemoglobin percentage very much lowered. Of the two findings, the hemoglobin percentage is relatively more decreased, so that the color index is markedly lowered.

In the acute form nucleated reds are common. Just before death these may show various forms and sizes as well as the normoblasts. In the chronic form normoblasts do not appear except as the case grows decidedly worse. As compared to myelogenous leucemia the anemia of lymphatic leukemia is of greater severity.

In the leucocyte count there is great increase in numbers, the greater part being composed of the lymphocytes. The lymphocytes may be either of the large or small variety, and occasionally are found in about equal proportions. In contra-distinction to the myelogenous type, the increased type of cells are of the mononuclear nongranular types. It is not very unusual to find a well advanced case of lymphatic leucemia without abnormal cells in the blood count, the expression of pathology being in the shape of disturbance in number and proportion of cells rather than in development of abnormal types. The actual number of leucocytes does not go as high in proportion to the gravity of the condition in lymphatic leukemia as it does in the myelogenous. In other words, a patient with lymphoid leucemia showing a count of 90,000 leucocytes with 90% of these lymphocytes is a much sicker man than the myelogenous case showing a 350,000 leucocyte count.

Usually there is an actual as well as relative decrease of all the granular types of leucocytes with the polymorphonuclear neutrophiles especially decreased.

The =treatment= is systemic and symptomatic. Recovery is not to be expected, but these unfortunates can be made relatively comfortable and given occasional respite by judicious osteopathic care.

Hodgkin’s Disease

(LYMPHADENOMA; PSEUDO-LEUCEMIA)

In a general way, the several conditions which are clinically leucemia, yet do not possess leukemic blood, can be classified as pseudo-leukemias. We do not definitely know the cause of leucemia as yet and can but little more than speculate on the various etiologic factors of the pseudo-leucemias.

Syphilis, malaria, tuberculosis, and malignancy are all considered as factors, and probably certain cases can be definitely associated with these conditions.

All of this group of pseudo-leucemias are characterized by early swelling of cervical lymph glands, followed by general gland enlargement, and by great destruction of the erythrocytes. There may be metastatic-like growths of lymphoid tissue in other organs. The enlargement of cervical glands usually begins on one side near the angle of the jaw, and most commonly in young male adults. These glands progressively increase in size, first are soft, then later become hard through fibrous proliferation. Each gland tends to increase in size by itself, not to coalesce with its neighbors, so that each separate gland can be palpated. This is more readily done as there is little tendency to fibrous adhesion formation to the overlying skin. These glands are painless throughout the course of the disease, and tend neither to caseate nor to suppurate.

The excised glands show a combined hyperplasia and connective tissue proliferation. In the soft stage of the tumefaction, the lymphoid hyperplasia is in preponderance, while, at the stage of hardening, the fibrous tissue derived from the trabeculae and capsule of the gland is in prominence. There is increase in the size of the spleen, and occasionally of the liver, but these are never as marked as those resulting from leucemia.

The =symptoms= are, first, those due to the glandular enlargement in the order of: dyspnea, hydrothorax, dysphagia, ascites, swelling of the extremities, and jaundice.

The destruction of red cells gives a resulting anemia which goes with and exaggerates the pressure symptoms.

A process of this kind to induce such grave changes over as well protected organs as make up the lymph system, must be virulent enough to set up other symptoms, to be associated with those due to pressure or to anemia. These are usually emaciation (giving greater prominence to glandular tumefaction), cachexia, and the implantation of masses of lymphatic tissue in organs where normally only traces of this tissue exist.

Fever is dependent upon the disturbed thermic metabolism and may be practically absent or subject to wide variations.

The erythrocyte count shows a progressive decrease with a greater proportion of broken down cells and abnormal types as the condition advances. The actual count is usually between 2,000,000 and 3,500,000 per cubic millimeter. The hemoglobin usually reduces in proportion to the erythrocytes, so that there is little change in color index.

The leucocytes are not markedly changed in number (seldom over 10,000), and this is often the =diagnostic= finding between leukemia and the pseudo-leukemias. Hodgkin’s disease usually has a high percentage of lymphocytes, so that there is an actual as well as relative decrease of the granular leucocytes.

The =treatment= is unsatisfactory, and is in the main symptomatic. Roentgen therapy has given temporary improvement, in some cases lasting several years. In general the =prognosis= is hopeless, the end occurring within four years of the time the condition is recognized.

DISEASES OF THE THYROID GLAND

Congestion

Physiological congestions of the thyroid gland are not uncommon during puberty, painful menstruations, pregnancy, and the menopause. The =premenstrual= congestion may persist after the menstrual function has been established, but this is comparatively rare. When the enlargement remains there is more or less hypertrophy, and it should receive appropriate treatment. Upper dorsal and cervical lesions are common. The congestion during =pregnancy= occurs in the majority of cases and seems to be a physiological process, wherein there is more or less hypertrophy and hyperplasia, which probably counteracts the waste products especially caused by this state, or due to the inactivity of the ovary. During =delivery= the gland may rapidly enlarge and remain so for an indefinite time. It seems probable that the straining due to labor may cause lesions of the upper dorsal and neck that will derange the function of the organ. When the enlargement occurs during the =menopause= special care should be taken that the goiter is not malignant.

Other possible causes of congestion are overfatigue, particularly when associated with heavy lifting; tight clothing about the neck; overuse of the voice; and in a few cases it may be discovered in boys at puberty.

The =symptoms= are congestion, the gland being very vascular, either soft or tense, somewhat painful owing to the tension of the capsule, and in persistent cases there may be hypertrophy and hyperplasia. The treatment is the same as given under simple goiter.

Inflammation of the Thyroid

Inflammation of the thyroid is not of frequent occurrence. In the several cases that the authors have seen there was some previous enlargement of the organ, which probably caused a =lowered resistance= of the local tissues. There is almost invariably some infection elsewhere in the body. The exciting causes are usually streptococcus, staphylococcus, or bacillus coli. The inflammation may follow pneumonia, tonsillitis, rheumatism, typhoid, puerpal infections, enteritis, diphtheria, influenza, mumps, etc. Trauma, carrying weights on the head, and cold, may be etiological factors.

Commonly, one lobe is involved, though the entire gland may be affected. There is swelling, the capsule is distended and painful, and small hemorrhages occur which in the case of suppuration form the site of the abscess. The swelling involves the parenchyma and interstitial tissue.

The =onset= is usually sudden with chills, fever, and pain over the glands. The patient keeps the head flexed to release the muscular tension, swallowing is painful, and there is a sense of constriction. A rapid heart may be a prominent symptom. Much depends at this period on the =treatment= given. If the drainage can be freed, by lowering the first ribs and raising the clavicles with attention to the dorsal and cervical innervation, prompt subsidence of the condition commonly takes place. This should be carefully accomplished in order not to bruise the parts.

=Diagnosis= is not difficult as a rule. The symptoms and history of infection will generally suffice. Hemorrhage may occur in a goiter and somewhat simulate inflammation. A possibility of =malignancy= is to be considered.

If the condition does not yield to treatment, surgical interference may be necessary.

=Tuberculosis= and =syphilis= of the thyroid are rare conditions. =Woody thyroiditis= may be mistaken for malignancy. The gland is very fibrous, and when cut has a dry surface. The connective tissue is hardened and crowds upon the parenchyma. This condition is usually found in young men. It develops rapidly, with more or less pain and dyspnea. =Adenocarcinoma=, =carcinoma=, and =sarcoma= are rare diseases[106], still one should be on his guard as to their possibility. They are most apt to occur after forty. A rapid enlargement should be regarded with suspicion.

Simple Goiter

We employ the term simple goiter to designate chronic enlargement of the thyroid gland not due to inflammation, exophthalmic goiter, or malignancy, although the latter conditions are frequently associated with or follow the former. There is usually an enlargement of the gland in cretinism, and occasionally in myxedema, but the functional grade of the gland is far different from that in other diseases of the thyroid.

The disease is very prevalent in certain regions of Europe and Asia, although in the United States it is not so common, except in the environs of the Great Lakes, the District of Columbia, and the Northwest states. The second decade of life, probably owing to adolescent changes, especially in girls, develop the greater number of goiters. It is infrequently congenital, and occasionally a case will develop as early as four or five years of age.

=Etiology.=—Disturbed innervation of the gland unquestionably seems to be the predisposing cause of the deranged secretion and vascular changes, which if continued finally lead to hypertrophy and hyperplasia of the tissues. These lesions are found from the fifth dorsal to the occiput and to the corresponding ribs. They probably involve secretory fibers of the sympathetic that emerge from the upper dorsals, first to fifth inclusive, maximum effect second, third and fourth. “Evidence is presented that the impulses pass to outlying neurones whose cell bodies are located close below the superior cervical ganglion and also in the inferior cervical ganglion.”[107]. In both these ganglia impulses to the thyroid pass from preganglionic fibers to the outlying neurones. This also includes the area of vasomotor[108] innervation of the head and neck.

In a number of cases cervical lesions alone will disturb the thyroid innervation, especially from the second to fourth segments. These may involve the superior cervical sympathetic, owing to its relationship to the rectus capitis anticus major muscle. Then there are afferent association fibers that pass down through the lateral horns and whose connecting fibers emerge via the upper dorsal.

The lymphatic drainage of the thyroid should not be neglected. Lesions of the upper ribs and clavicles are very prone to impede its circulation, and thus predispose to secondary infections.

Infection from septic foci are important secondary factors. This is particularly true of focal infections of the upper respiratory tract and buccal cavity, although infections and toxins from various regions may be exciting factors. Toxemia due to intestinal stasis is not rarely an important consideration.

McCarrison insists that infection from certain waters is the cause of goiter. He finds that boiling the water renders it harmless.

=Pathologically=, the first effect upon the gland is to lessen its iodine content. The circulation is increased, with hyperplasia of the epithelial tissue, and a lessened amount of colloid material. If the condition continues, the alveoli will again become distended with the colloid material so that the epithelial tissue cells are almost flattened. This represents the so-termed =colloid goiter=. The gland, commonly the whole organ, though one side may be involved, is fairly uniform in size. In rare instances, the gland may surround the trachea—the so-termed circular goiter. Hemorrhages may occur, and there may be various alterations and degenerations. When the vessels are much dilated, it is often called a vascular goiter, though the colloid changes are present.

The =nodular goiter= is another form characterized by new formation of gland tissue that is not diffuse but circumscribed. These cases are apt to follow persistent involvement of the gland at puberty. The two forms may occur together, and there may be various combinations and changes. In the nodular goiter there is comparatively little colloid. There are many blood-vessels, and small hemorrhages are frequent. This latter point should be remembered by those who treat over the gland, which at best is a doubtful procedure. Various changes may take place, as local points of =necrosis=, =cystic= formation, and =calcification=, are not uncommon.

=Symptoms.=—The essential feature in goiter is distension of the alveoli and formation of new ones, associated with dilated vessels, and usually degeneration of the colloid. Often the function of the gland is not noticeably disturbed. Usually, it is for the pressure symptoms or the unsightliness, due to the distension, that the patient seeks relief. Pressure upon the windpipe, gullet, or blood-vessels is not rare, and may cause more or less difficulty in breathing or swallowing. Coughing and huskiness may be troublesome. The recurrent nerves and vagus may be compressed. Disturbance of the heart, such as palpitation, tachycardia, and hypertrophy may be caused by the effect of pressure upon the blood-vessels, or to changes in the secretory function of the gland.

=Treatment.=—Adjustment of the upper dorsal and cervical lesions will be followed by recovery in the majority of cases. Dr. Still emphasized the point that the vertebral ends of the first ribs are frequently displaced upward and outward. This lesion is often found in cases following confinement. The effect of the change here is probably to the stellate ganglion, or to the lymphatic drainage of the gland. Treatment over the gland should be cautiously given, if at all. Definite correction of the lesioned vertebræ and ribs will be sufficient, but muscular manipulation and halfway measures are practically useless.

Lesions of the lower spine may be the primary source of a compensatory lesion of the upper dorsal, or they may derange the pelvic organs, or be the predisposing factor of intestinal stasis. Attention to possible focal infections, and thorough elimination, are to be considered. In goitrous regions boiling the water is of value. In obstinate cases the X-ray may be of service, and as a final resort surgery may be employed.

“Marine observed that the amount of iodine is inversely proportional to the degree of hyperplasia of the gland, and when the hyperplastic condition becomes fully developed, scarcely a trace of iodine is contained in the gland. Later, when the hyperplasia gives place to colloid goiter, the iodine increases again, both absolutely and relatively. Moreover, it has been found that if iodine be administered to an animal suffering from hyperplasia, the hyperplastic condition very quickly disappears and the animal becomes normal.”[109]. His viewpoint of the hyperplasia is that an effort is being made to compensate for an “insufficiency due to inability to absorb or assimilate sufficient iodine”, and thus the effect of the administered iodine is to normalize the gland by stimulation.

No one can question that this may be effective under certain conditions, particularly where there is deficient iodide in the water, but it is an essential element of the body. But it does not necessarily follow that because in thyroid disturbance the relationship between thyroid functioning and the substance containing iodine is upset that recovery depends upon furnishing more iodine to the body economy. It may be somewhat parallel to giving iron in anemia, when often the real difficulty is one of assimilation, and not insufficient iron in the alimentary canal. Moreover, case after case of goiter has recovered through osteopathic measures following a most thorough trial of the iodine treatment. It is very obvious that the cause of the goiter rested elsewhere. Dogs are susceptible to thyroid enlargement. Lesioning of the cervical region has resulted in goiter formation, and recovery has followed adjustment of the lesion. And dogs having goiter without experimental lesions have frequently been normalized by adjusting an abnormal cervical spine.

Exophthalmic Goiter

In exophthalmic goiter there is an excess of the thyroid secretion or thyroid autacoid which passes into the circulation, due to hypertrophy or hyperplasia of the secreting cells. The disease is characterized clinically by nervousness and irritability, rapid pulse, flushed and moist skin, tremor, and increased nitrogenous metabolism. A goiter is usually present, but not always noticeable. There is apt to be protrusion of the eyes, especially after the disorder is established, though it may never appear. A disturbed coordination of the muscles of the eyelid, eyeball, and orbit are frequent characteristic symptoms.

=Etiology.=—The essential factor in the cause of this disease is probably osteopathic lesions that irritate the secretory fibers of the thyroid tissue. These lesions are almost invariably found in the upper dorsal, first to fifth, and most often localized at the second-third or third-fourth segments. They are definite interosseous changes, combined rotation and lateral flexion, and are generally very sensitive upon palpation. The constant stimulus thus produced passes through the sympathetic fibers to the cervical ganglia, and thence to thyroid secreting tissue, which through vascular changes and hypertrophy and hyperplasia increases the output of the thyroid hormone.

The sensitiveness of the lesions is probably of more than passing interest. For this actual tenderness is not to be confused with a neurasthenic state, which may be associated with the disease, or even be a source of confusion in the diagnosis. The lesion is of such a distinct character that there is considerable local irritation and congestion. This constant stimulus is a cause of the increased number of impulses carried to the sympathetic, and results in not only an excess of thyroid secretion and the concomitant hypertrophic changes, but also in the rapid removal of the colloid into the circulating blood. This seems to be a very important link in the pathologic chain.

Other underlying lesions may be present, as outlined under simple goiter, and do not require repetition here.

The mechanism of the thyroid gland may be further upset or deranged by various exciting causes, such as focal infections, toxic states, intestinal stasis, and occasionally an enlarged thymus is an important factor. An inherited neuropathic tendency, excessive strain, worry, and mental shocks may have more or less influence in either predisposing or exciting the disorder.

The particular points for the practitioner to remember are that exophthalmic goiter is due to a toxic state, of which there are many gradations, from the excessive secretion of the thyroid gland; that the normal resistance of the gland is lowered through definite lesions of its innervation or circulatory channels, or occasionally of lesions of the other organs of internal secretion which are closely associated; that infections and toxins are often important considerations; and that direct manipulation of the organ may increase the disorder.

=Pathology.=—The enlargement of the thyroid gland is commonly an early symptom, occurring before the nervous, cardiac and exophthalmic manifestations. There are instances where it follows a simple goiter, although Graves’ disease does not seem to be any more prevalent in regions where simple goiter is endemic than elsewhere. In these particular instances intestinal toxemia is often present. There are cases where the gland is very slightly enlarged, containing only small areas of hyperplasia. There is usually very little colloid, though there may be marked exceptions. It should be emphasized that there are various degrees of changes found in the gland though fundamentally of the same order. The blood supply is extensive, and the veins especially are fragile. The alveoli are distorted, due to the increase of epithelial cells. Lymphoid nodules are frequently noted through the glandular tissue.

Research work of unusual interest to the osteopathic physician pertaining to the etiology and pathology of exophthalmic goiter has been carried out at the Mayo Clinic. An examination of cervical sympathetic ganglia removed at operation from such cases and certain animal experimentation has given definite results. The following is a summary of their principal findings:

“Degree of hyperpigmentation, granular degeneration, and reduction in the number of cells was in direct ratio to the continuance of symptoms of hyperthyroidism. The increased amount of perivascular connective tissue generally throughout the gland was similarly in direct ratio to the time during which symptoms of hyperthyroidism had continued.

“Increase of connective tissue in the ganglia from the chronic cases may be interpreted as due to the irritation from inflammation, or as merely a replacement following the destruction of the ganglionic nerve cells.

“Ganglia were intimately connected by firm adhesions to the surrounding tissue.

“There were changes in the outer and middle coats of vessels, and in the nerve fibers. There was an increase of connective tissue throughout the ganglion.

“It appears that definite histologic changes do occur as (a) hyper-chromatization, (b) hyperpigmentation, (c) chromatolysis, and (d) atrophy, or (e) granular degeneration of the nerve cells. All of these are but successive steps in degeneration which, if uninterrupted, proceed to complete destruction of the ganglion cells affected. Not all of the ganglion cells in any of the ganglia examined were so completely destroyed as to render improbable their return to normal under favorable conditions. There is some evidence that in ganglia from cases clinically improved some of the cells have partially or wholly recovered.”[110] They are inclined to the view that local infection in the cervical sympathetic ganglia plays an important part in the etiology.

The above pathologic changes of nerve fibers and ganglia support in many ways the findings noted at the A. T. Still Research Institute, not alone in the cervical region but in other regions of the body, that is, they are changes common to interosseous lesion pathology of various areas of the spine, and thus are predisposing factors that establish lowered resistance of tissue and derangement of function.

An important feature of the pathology is hyperplasia of the thymus. Simmonds finds it enlarged in three out of four cases. MacCallum[111] has found it enlarged in all autopsies that he has seen. The lymphoid structures of the spleen, liver, kidneys, intestines, and bone marrow is increased, while the lymphatic glands of various regions of the body may be enlarged, especially the cervical, bronchial, and axillary. This is probably due to a toxic condition.

Dilatation and hypertrophy of the heart is common, and in advanced cases myocardial degeneration is apt to take place.

=Symptoms.=—The outstanding feature of hyperthyroidism is the excessive secretion of the gland. The symptoms seem to be largely dependent upon the amount thrown into the blood stream; still there is a possibility that there may be a certain perversion of the secretion, though if such exists it has not been discovered. It should be kept in view that in certain instances where the secreting activity of the gland has been markedly curtailed, by surgical means, for instance, even to hypo-functioning there may still exist some of the symptoms of exophthalmic goiter, which goes to show that other factors may be of decided importance. The thymus and other related organs, as well as the sympathetic nerves, are not to be neglected.

Kendall and Plummer (Mayo Clinic) “believe that the location of the active constituent of the thyroid, when it functions, is within the cells not of any particular set of organs or portion of the body, but that it is a constituent of cellular life and activity. Plummer states that the active constituent of the thyroid determines the rate at which any particular cell can produce energy, that is, it establishes the quantum energy which any cell can produce when it is stimulated, either from within itself or from without, so that the thyroid is directly related to the production of energy within the body. He has shown that one-third of one milligram of the active constituent of the thyroid increases the basal metabolic rate one per cent in an adult weighing approximately 150 pounds.” This shows how important the secretion is not only to all related glands but to every cell of the body, and assists in establishing a physiological basis in the correlation of the symptoms of both hyper- and hypo-functioning of the organ.

As a rule the =thyroid= is not greatly =enlarged=. The size, shape, and consistency varies. It may follow a simple goiter. Many of them are soft and yielding, or cystic; others are hard, of a fibrous resistance, or nodular. Probably in the instances where hypertrophy is not discoverable there is hyperplastic tissue scattered through the gland. Or it is possible there may be an intrathoracic thyroid, or =accessory= tissue in other regions, varying from the root of the tongue to the aortic arch, which has become diseased. Generally, both lobes are enlarged, though the derangement may be confined to a portion. Often there is pulsation and a thrill over the gland. Systolic murmurs are frequent. In the early stage of goiter, tenderness is noticeable due to the distension of the capsule.

The =eye symptoms= are: widened palpebral fissure or Dalrymple’s sign; failure of the upper lid to follow the downward movement of the eyeball or V. Graefe’s sign; insufficiency of convergence of the two eyes or Moebius’ sign; exophthalmos, which may be unilateral (in about seventy five percent of the cases); and rareness of involuntary winking, are the principal eye signs.

=Rapid heart= action is an early and important symptom. This is given by all observers as the most constant of all symptoms. Palpitation is often disturbing. The pulse is forcible, especially in the vessels of the neck. There is generally a low blood pressure. The heart is apt to be dilated, and in chronic cases hypertrophy and degeneration are often found.

A =fine tremor=, eight to ten times a second, is an important symptom. This is usually present and is considered one of the cardinal diagnostic points.

Profuse sweating, emaciation, muscular weakness, especially of the legs, vomiting, diarrhea, a feeling of dyspnea, and polyuria are frequent symptoms. Anxiety, apprehension, headache, irritability, and fatigue are often early symptoms, but care should be taken that they are not entirely dependent upon a neurasthenic state.

Pruritus may be a distressing symptom. There may be abnormal pigmentation. Menstrual derangements are common, especially amenorrhea, owing to the anemia. And there may be various sexual disturbances. Exophthalmic goiter occurs oftener in women than in men.

The disease is commonly a chronic one lasting several years, unless the morbid cycle can be broken; still there are cases where it appears very suddenly and runs a rapid course.

McCarrison[112] says: “Our consideration of the morbid changes met with in Graves’ disease will have brought into prominence the fact that they are indicative of toxic action. The lymphocytosis, the lymphatic hyperplasia, the lymphocytic infiltration of the thyroid, the liver and other organs; the chronic toxic inflammatory changes in the thyroid, liver and pancreas; the changes in the muscles, in the nervous system and in the adrenals; all these point to a condition of chronic irritation as the underlying factor in their production, and to the gastro-intestinal tract as the most common source of the toxic irritant.”

=Diagnosis.=—The diagnosis as a rule is not difficult. Difficulty may arise where there is incomplete development of the disorder. Irritation of the sympathetic nerves is of the greatest significance, for the characteristic symptoms are dependent upon this condition. Neurasthenia, hysteria, paralysis agitans, and tobacco poisoning and alcoholism may mislead one. The enlarged and active gland, with murmur in the majority of cases, loss of weight, excessive sweating, diarrhea, tremor, and tachycardia, even without the eye symptoms, are specially significant. The tenderness of the osteopathic lesions is very often noticeable.

=Prognosis.=—A great deal depends upon the cooperation of the patient. Rest and diet are such important features of the treatment, that if the patient is not willing to follow instructions, great difficulty will be encountered in securing satisfactory results. Adjustment of the lesions and elimination of toxins are highly essential, but only in a certain number of cases will this suffice. This, however, will usually lessen the severity of the condition, and the patient gets along fairly well, but this may be far from securing the possible maximum results. The duration of the disease is often from five to twenty years, or even longer. And the patient frequently dies from some intercurrent disease, particularly pneumonia and tuberculosis. Weakness of the heart is the most important cause of death. Severe vomiting and diarrhea may so exhaust the patient that a fatal termination takes place. Surgical interference should not be too long delayed if there is no indication of improvement by other means.

=Treatment.=—Every case requires individual study, owing to the many possible exciting causes, especially those where infections and toxins play so important a role. The four cardinal features of treatment are: adjustment of the osteopathic lesions, rest, diet, and elimination of infectious and metabolic poisons.

=Specific adjustment= of the upper dorsal spine is primarily essential. The work should be definitely and quickly accomplished. Soft tissue manipulations amount to but little except as a preparation for the interosseous adjustment. Do not tire the patient. Often, following exact adjustment a definite lessening of the severe symptoms will be noticed. The activity of the thyroid will be appreciably decreased; the heart’s action slowed; the eye symptoms less noticeable; the tremor lessened; and the strength of the patient improved. Do not treat too often. Once a week is far better than every day. But usually twice a week in the majority of cases will secure the best results. Then later once in two weeks will be the best course to pursue. The tissues are irritable, and require time to establish a physiological balance, that if kept constantly excited by too frequent or too severe manipulation will increase rather than lessen the condition. This, however, does not apply to those cases where a certain amount of general treatment is demanded to improve systemic tone and overcome intestinal stasis, but even here do not unduly tire the patient, and keep away from the thyroid innervation except at stated intervals. There is nothing more important in osteopathic therapy, except definite adjustment, than not over-treating.

The cervical region should be normalized, and the upper ribs and clavicles carefully adjusted. But leave the gland alone, for manipulation over it further stimulates its function and there is a possibility of rupturing its fragile vessels. Normalization of the entire spine is important, owing to its bearing upon interdependent relationship, mechanically and physiologically, and the necessity of correcting all metabolic irregularities.

Both =physical= and =mental rest= are essential. This tends to lessen the excitability of the nerves, conserves the strength, increases the metabolism, improves muscle tone, and rests the heart. At least several extra hours in bed is always best. Lying down two or three hours during the middle of the day will accomplish considerable. In severe cases absolute rest in bed until the disorder is under control is imperative. In mild and moderate cases all excessive fatigue should be avoided. Unless such measures are followed the treatment otherwise may not accomplish anything. Stopping short of fatigue is the rule that must be followed.

The =diet= is important in order that the strength may be increased and harmful foods eliminated. If the carbohydrates in the small intestine are not sufficient, they may decompose into toxic substances that are harmful when absorbed into the circulation. An abundance of green vegetables and fresh fruit is best. Milk, fermented milk, butter milk, butter and cream are allowable. The patient should drink freely of water. Meat should be used sparingly, and avoid tea, coffee, and condiments.

Free elimination and fresh air are also important. It is the aggregate of details that counts so much, particularly in such a toxic and excitable disease as exophthalmic goiter. The neutral bath (95 to 96 degrees) is better than either hot or cold baths. In such a nervous disease as this, suggestion is unquestionably a valuable measure in quieting the nerves and improving the mental viewpoint.

All focal =infections=, such as often found in the throat, nose, and buccal cavity, in the appendix region, gall-bladder, etc., should be eradicated.

If under carefully controlled treatment the patient does not definitely respond within from two weeks to a month, surgical measures should be seriously considered.

Myxedema

Myxedema is a chronic disease due to loss of thyroid function, and characterized by markedly decreased metabolism, trophic disturbances of the skin and subcutaneous tissues, and a cessation of mental development corresponding to the time of the injury of the thyroid.

McCarrison restricts the term “cretinism” to those cases where there is congenital thyroid deficiency. “After the first year of life, when ossification has proceeded to the extent of closure of the fontanelles, the case is only distinguishable from one of cretinism by this fact.” In the =child=, all the functions are depressed, there is a low temperature, the bones do not develop, and the child may become stout. The mental development is retarded, and also the sex organs.

In the =adult= cases there is the same depressed metabolism. The skin is sallow, dry, and increased in thickness. The tongue is enlarged, the lips thick, and the feet and hands considerably changed in size. The nails may be thickened, and the hair falls out. The abdomen is apt to be pendulous. Heavy pads occur below the clavicles and on the chest, neck, abdomen, and sexual organs. Usually the thyroid cannot be palpated. In a few, the gland may be goitrous.

The =mental= faculties are sluggish. The speech is slow, and the voice more or less changed. Physical exertion is an effort, and the patient may have some difficulty in walking. And there is anemia, loss of appetite, and poor digestion. The number and character of symptoms are innumerable, depending upon the extent of thyroid insufficiency, and often upon predisposing and associated disorders. But the essential symptoms are those pertaining to the skin, and the mental apathy. In children the retarded physical and mental growth is the outstanding condition. Development of the disorder is slow.

=Etiology.=—Lesions of the thyroid innervation may cause a lessened function of the gland, for correction of the lesions has been followed by markedly definite improvement in a number of cases. The disorder has followed operation on the gland. In other cases some form of infection, primary or secondary, is probably the cause of the injury and subsequent atrophy. In some instances there is evidently a family tendency. It occurs more frequently in women, and in cold than in hot climates. The menopause seems to be a predisposing factor. Overwork, anxiety, poor nutrition, and conditions that lower tissue resistance, are among the etiological considerations.

In well marked cases the =diagnosis= is easy. In others the disease may be mistaken for nephritis or jaundice. X-ray examination of the ossification centers is of decided value. The =prognosis=, in untreated cases, is considered hopeless, the duration being from four to seven years. The treatment with thyroid extract, or alpha-iodine, has resulted in marked improvement, though in severe cases it must be kept up continuously in order to supply the deficiency.

=Treatment.=—There have been several well marked cases that have responded to the osteopathic treatment. Adjustment of the lesions affecting the gland, and attention to the general health have been the methods administered. The response in a number of children has been most notable. In fact, to such an extent that all faculties and functions were completely recovered. Even in cases where thyroid extract had been administered with comparatively little results, the adjustment of the upper dorsal and cervical lesions, with attention to the diet, elimination, and general hygiene, was followed by normalization.

That the thyroid function when deranged, hyperthyroidism, hypothyroidism, or otherwise, can often be recovered through osteopathic treatment, adds a very important therapeutic measure in the treatment of this gland. But in view of the brilliant results secured in hypothyroidism, through the administration of the thyroid extract, one should not hesitate to use it if improvement is not otherwise forthcoming. Nevertheless, the very important point remains that thyroid extract is only supplying a necessary substance, however essential, to the bodily metabolism, and does not strike at the essential etiology of the disorder.

Cretinism

It should be kept in mind that there are many gradations and alterations in both hyperthyroidism and hypothyroidism, and that a “goiter” may present either picture, partly or wholly, or on the other hand may be normally functioning.

MacCallum says: “Unlike the myxedema cases which occur anywhere and everywhere, regardless of environment or hereditary taint, these people, known as cretins, are found in regions where the condition seems to be endemic or inherent in the environment, and we can usually trace in their parents or ancestors some similar thyroid defect.”

This disease is found in various countries, particularly in certain parts of Switzerland, Austria, and Italy. McCarrison presents an interesting study of 203 cases of Endemic Cretinism found in Himalayan India. He thinks it is due to infection. There are a few cases in North America, probably mostly due to immigration. It is frequently confused with myxedema.

Cretins are of short stature, flat-chested and pot-bellied. The face is broad, low forehead, broad nose, prominent cheeks, thick lips, and large nose. The development of the bones is retarded; the skin is thickened and edematous; the hair is thin, and the nails brittle; the sexual organs as a rule do not develop; and in most cases a goiter, sometimes of huge size, is present. Most of them are stupid and apathetic; others are distinct idiots. Deafness is common.

There are sporadic and endemic cases, but the same underlying cause is probably present. It is claimed that most cases of the former should be classed as congenital myxedema.

Early diagnosis is essential. Removal of the patient from the goiter region, and thyroid substance is the treatment given, though results are not so marked as in myxedema.

FOOTNOTES:

[106] Ewing, Neoplastic Diseases; Grotti, Thyroid and Thymus.

[107] Cannon and Cattell, The Secretory ennervation of the Thyroid Gland, Am. Journal of Physiology, July, 1916.

[108] Gaskell, Involuntary Nervous System.

[109] Macleod, Physiology and Biochemistry in Modern Medicine.

[110] Collected Papers of the Mayo Clinic, 1916, ’17, ’18.

[111] MacCallum, A Text Book of Pathology.

[112] McCarrison, The Thyroid Gland.

DISEASES OF THE PARATHYROID GLANDS

Tetany

The clinical manifestations of the insufficiency of function of the parathyroid glands is well understood. This came about through the study of endemic tetany, and, especially, noting that tetany followed operations when the entire thyroid gland was removed. Considerable experimental work on animals was next in order, until the discovery was made that the thyroid gland and parathyroids are anatomically independent, and that tetany is entirely dependent upon the loss of function of the parathyroid glands. =Operative tetany= is now comparatively rare, since the surgeon is particularly careful not to injure the parathyroids in his operations on goiters, though mild forms may occur through damage of the tissues or extension of inflammatory processes.

There are =other forms= of tetany aside from operative, that occur in both adults and children, but instability and insufficiency of the function of the glands are basic to all cases. This is the common factor, which may be modified by tissue resistance and various hygienic factors.

In tetany there are paroxysmal, and often painful, contractions of the muscles of the extremities. Both sides are affected, and occasionally the spasms may extend to other muscles of the body. This is due to an abnormal excitability of the nervous system. Probably the secretion of the parathyroids have normally a restraining effect upon the nervous impulses, which when removed, or insufficient, or possibly perverted, results in the tonic spasms.

Thus the =predisposing condition= of tetany may be either =acquired= or =congenital=. Children may be born with defective parathyroids. In such instances there is probably a hypoplasia of tissue, which may markedly vary in a series of cases, and give rise to different degrees of tetany. Other factors, nutritional and toxic, would, very likely, be important exciting causes. Hemorrhages and fibrosis have been noted in some cases, that add to the injury of the tissues.

The blood and nerve tissues in tetany show a decreased amount of =calcium=. It is claimed by some that the abnormal excitability of the nervous system is due to the lack of calcium. Noel Paton[113] believes that, though this may bear some relationship, the parathyroids control the metabolism of =guanidine=, and that guanidine intoxication is the cause of the symptoms. Guanidine seems to regulate the tone of the skeletal muscles, and is closely related to urea.

Tetany may occur under many conditions: during pregnancy and nursing, the infectious and nutritional diseases, the diseases of the thyroid and very often gastro-intestinal disorders. There are various exciting causes, such as cold, worry, overfatigue, etc. Alcohol, ergot, morphine, chloroform, and other poisoning may precipitate an attack. But in all these cases the parathyroids are previously damaged.

The blood supply to the glands is from branches supplying the thyroid organ. This intimacy implies that the same sympathetic nerves to the thyroid vessels are in control. Probably there are distinct secretory nerves, as well as vasomotors, that are connected with the upper dorsal and cervical sympathetics. =Lesions= related to the corresponding spinal areas probably affect the integrity of the parathyroid function.

Schafer says: “The parathyroids are amongst the most vascular organs in the body. They are supplied each by a special branch of the inferior thyroid artery. The sinus-like capillaries come into close relationship with the epithelial cells of the gland. The nerves of the parathyroids, like those of the thyroids, pass both to the vessels and to the secreting cells. Some evidence has been adduced which seems to show that the cell-activity is controlled by the nervous system.”

Hence it would seem that in many cases of tetany, aside from those cases due to operative injury and possibly certain congenital instances, =osteopathic lesions= affecting the nerve and vascular supply of the organs may so lessen, or pervert, the secreting cells that tetanic states may supervene, especially where lowered nutrition, toxins, and infections are inciting factors.

=Symptoms.=—The tonic contraction of the muscles may last a few minutes or may persist for several hours, and are usually confined to the hands and feet. The fingers and toes are first affected by the spasm, which extends upward toward elbows and knees. This is commonly preceded by numbness and more or less pain in the parts. Occasionally there is a general ill-feeling, depression, and headache. There may be rise of temperature, and some edema of the affected parts. There are no mental symptoms.

The fingers are partly flexed at the metacarpo-phalangeal joints and rigidly extended at the inter-phalangeal joints, the thumb is markedly adducted and the fingers drawn close together. The wrist may be flexed, and in severe cases the elbows flexed and adducted. When the feet are contracted the toes are drawn together, flexed, and may overlap, and the feet are arched.

=Trousseau’s phenomenon.=—The spasm is increased by pressure over the median or ulnar nerves, or blood-vessels supplying the parts. This may also excite an attack. =Chvostek’s phenomenon.=—Percussion over the facial nerve will cause quick contraction of the muscles innervated. =Erb’s phenomenon.=—The electrical excitability of the motor nerves is markedly increased.

=Diagnosis.=—The characteristic attitude, and the irritability of the motor and sensory nerves, make diagnosis easy. It may be confused with =meningitis=, but in tetany there are no brain symptoms, while in meningitis there are no characteristic signs of tetany. Generally, there is little probability of confusing the disease with =tetanus=, or =hysteria=.

=Treatment.=—Most cases are of a mild type, and recovery is the rule. A great deal depends upon the underlying cause. Malnutrition, if long continued, is a very important factor that may readily predispose to the disorder. Rickets in children is often a basic consideration.

Rest, warm baths, and careful inhibitory relaxation of the tissues materially assist in controlling the spasms. Attention to the thyroid innervation should not be neglected. In indicated cases thyroid feeding may be of assistance. The diet is of special importance, for many cases present some disorder of the gastro-intestinal tract. Meat should not be given. Milk is of great value, owing to its calcium content. The administration of calcium is highly recommended, for reasons stated under etiology.

Diseases of the Thymus

There is little known relative to the functions of the thymus. It is most active during the growth of the body, attaining its greatest weight from the eleventh to fifteenth years, after which it gradually atrophies, though a certain amount of the tissue remains throughout life. There is usually a gradual atrophy of the organ after puberty, associated with increase of connective and adipose tissues. In cases where it does not atrophy, there is often hyperplasia of the entire lymphatic system in the body.

There is some relationship between the thymus and sexual organs, and in experiments where the organ has been removed, ossification is delayed, muscular weakness and tremor occur, there is hyperplasia of the thyroid, parathyroids, and adrenals, and general cachexia, acidosis, and mental deterioration take place.

The inferior thyroid and internal mammary arteries from above, and the pericardiophrenic from below, comprise its arterial supply. The nerve supply is from the sympathetic, vagus, and possibly the phrenic. In cases of exophthalmic goiter there is frequently an associated enlargement of the thymus, which may be shown by the X-ray, due to failure of normal involution or a renewal of growth, that may be definitely influenced by adjustment of the osteopathic lesions.

In some of the acute infections as pneumonia the thymus may atrophy with some fatty degeneration and increase of connective tissue. This also occurs in starvation. If the condition is not of long standing recovery will take place.

In =status lymphaticus= there is hyperplasia of the thymus and enlargement of the lymphoid tissue of the body, and hypoplasia of the cardiovascular system. This is a constitutional defect, so that slight injuries or infections may prove fatal. It is found in some cases that there is hypoplasia of the chromaffin system. Whether this latter condition is primary or secondary has not been settled.

In males the secondary sexual characteristics are not fully developed. The figure resembles the feminine type. The skin is pasty, and the beard is lacking or but little developed. In females the distribution of the hair may be somewhat similar to the male sex, slender limbs and chest, and disturbances of the menstrual function are noticeable.

The thyroid, thymus and lymphatic tissues are usually enlarged, while there is hypoplasia of the adrenals and chromaffin system.

The condition is met with in children who have a weak muscular system, increased adipose tissue, pasty complexion, enlarged tonsils and adenoids, and frequently are anemic. In children where the thymus is enlarged there may be excessive lymphocytosis.

The enlarged thymus may compress the trachea, interfering with breathing so that cyanosis and temporary loss of consciousness occur. Young children may die in the attack, probably due to compression of the trachea or to heart shock. Death in adults has occurred from trifling injuries, shocks, infections, and anesthesia. The underlying cause is probably a constitutional weakness.

=Diagnosis= is made from the clinical signs, percussion of the thymus and the X-ray picture, although these may not be positive. An excessive lymphocytosis is suggestive.

=Treatment= should consist of good general care of the patient, avoidance of injuries and shocks as far as possible, and careful attention to all lesions, especially of the upper chest and neck. By following this plan the child may overcome the condition. X-ray treatment is being employed with success in some cases. Operations have been successful in thymic hyperplasia where it has complicated exophthalmic goiter, and also in serious mechanical pressure in children.

Diseases of the Adrenal Glands

Experimental work supports the view that the cortex and the medulla have separate functions. The =medulla= of the adrenals is part of the chromaffin system, which includes tissue of the same character in the ganglia of the sympathetic, the carotid gland, and the accessory gland called Zuckerkand’s organ. This system is derived from the same cells as the sympathetic nerves. The medulla receives a richer blood supply than any tissue in the body. The secretion of the chromaffin tissue is called adrenalin or epinephrin. The blood receives a continuous supply of the secretion, which acts upon the small blood-vessels and assists in maintaining blood pressure. It also stimulates glandular tissue, and has some effect upon voluntary muscle which tends to counteract fatigue.

The =cortex= of the adrenal glands is of epithelial origin, and is part of the so-called interrenal system, which comprises very small masses of tissue in the sympathetic ganglia. These are located in the hilus of the kidney, broad ligament, inguinal canal, prostate, epididymis, and along the spermatic veins (Baker). The cortex is the chief glandular tissue of the interrenal system. The amount of tissue is not so great after puberty as before. The blood supply of the cortex is not so rich as that of the medulla. Abnormal activity is claimed to be the cause of certain sexual derangements, particularly sexual precocity.

Schafer states that the adrenals are very richly supplied with nerves. Each receives no less than thirty-three nervous filaments (Kolliker), derived in part directly from the splanchnic, in part from the suprarenal plexus, which is itself constituted by branches from the celiac, phrenic, and renal plexuses.

We have noted that in lesions (experimental) of the splanchnics a few cases presented acute pathological changes, congestion with some degeneration of cells, in the adrenals.

Macleod states that of the many functions of the adrenals that which is most directly associated with epinephrin is the production of glucose from glycogen. “When the nervous system is stimulated in such a way as to excite the glycogenolytic process, two effects both operating in the same direction with regard to the glycogenic function are developed: the one, a hypersecretion of epinephrin, which activates the sympathetic nerve endings, the other, the transmission of the nerve impulse to the liver cell.”

Addison’s Disease

This is a rare, chronic disease, more often occurring in men, that is characterized by muscular and vascular weakness, digestive disturbances, and pigmentation. Tuberculosis of the adrenals has been the most constant lesion found. In others, syphilis and atrophy have been noted, while in a few the condition seemed to be functional. It should be remembered that it is possible that lesions elsewhere in the chromaffin system may be the cause in some cases, for all the chromaffin tissues secrete adrenalin.

It is quite likely that in most cases there is some constitutional defect of the chromaffin system which underlies a certain tendency to the disorder. Infections, injuries, physical and mental strains may lower resistance and predispose to the condition.

Osteopathic lesions of the splanchnics may congest the organs, or derange the secretions, or be of such a character that hemorrhages result, or fibrous changes follow, that would definitely incapacitate the cells and lower resistance.

=Pathologically=, the most common change is tuberculosis. Next in importance are atrophy and interstitial inflammation. Cancer of the organs has been noted in a few. The adrenal ganglia, the semilunar ganglia, and the solar plexus are often involved. The thyroid gland may be altered, which, when affected, is usually decreased in size. Brown atrophy of the heart is common.

=Symptoms.=—An insidious onset with muscular weakness, languor, and weak action of the heart are generally the first symptoms. Digestive derangements, such as nausea, hyperacidity, loss of appetite, may occur at the same time, or shortly succeed the general debility. Headache, insomnia, and depression frequently take place. Pigmentation, usually, shortly follows, though there are cases where it is only slightly noted. The disease is very chronic, of several years duration, with periods of intermission. Occasionally, a case runs a very rapid course.

The general weakness is most noticeable. There is low blood pressure. The derangement of the stomach and intestines is characteristic. And the pigmentation, which at first is light yellow later assumes a dark brown color. The pigmentation may be more or less general, but the axillæ, nipples, genitals, the palms of the hands, and the neck, waist or wherever the clothing presses upon the skin, are most pigmented. And pigmentation of the mucous membrane may be noted.

=Diagnosis.=—In typical cases, where there is esthenia, pigmentation, and gastro-intestinal disturbances, the diagnosis is not difficult. Where the clinical picture is incomplete, the diagnosis may be very difficult.

Pigmentation may occur in several other disorders, notably: in bronzed diabetes, abdominal malignancy, tuberculosis of the peritoneum, exophthalmic goiter, pellagra, marked intestinal stasis, stomach ulcer, pernicious anemia, certain skin diseases, etc., so great care has to be taken in atypical cases.

=Treatment.=—General treatment, with special attention to the adrenal innervation, diet, rest, and fresh air will accomplish something. In functional derangements, which are very few, recovery may follow. But owing to the often constitutional defect, the probability of tubercular, syphilitic, and other serious lesions, the prognosis is unfavorable.

FOOTNOTES:

[113] Paton and Finlay, Jour. Exp. Phys., 1917.

DISEASES OF THE NERVOUS SYSTEM

DISEASES OF THE NERVES

Neuritis

=Neuritis= is an inflammation of the nerve fibers. It may be confined to a single nerve, localized; or general, involving a large number of nerves, when it is known as multiple neuritis. Osteopathically, there are =invariably lesions= of the osseous or muscular tissues, that correspond to the nerve fibers involved. The lesion either irritates the nerve directly or disturbs the circulation to the nerve. In those cases where the osteopathic lesion is not the immediate exciting cause, there will be found anatomical irregularities that predispose to the affection.

=Localized neuritis= may be due to: Local osteopathic lesions; Exposure to cold; septic foci; traumatism; and inflammation of contiguous tissues.

=Multiple Neuritis= may be due to: Osteopathic lesions, which are associated with infectious diseases, as in diphtheria, typhoid, scarlet fever, etc.; prolonged strain or exposure; metabolic poisons, as in diabetes, anemia, tuberculosis, cancer, etc.; alcohol, lead, mercury and arsenic poisoning; and =beri-beri=, which is probably due to lack of vitamins, or possibly micro-organisms, or carbonic gas poisoning.

The inflammation may chiefly involve the connective tissue surrounding the nerve—perineuritis—or it may involve the deeper structure—interstitial neuritis. =Parenchymatous neuritis= is really a degeneration, due to excessive or prolonged irritation or pressure which cuts the nerves off from their centers. This is found in deeply seated osteopathic lesions. In experimental osteopathic lesions the first effect is degeneration of the medullary sheath. This is followed by degeneration of the axis cylinder. The local circulation is notably impaired. An acutely inflamed nerve is red and swollen. In =perineuritis= there is an infiltration of the nerve sheath with leucocytes. In the =interstitial form=, lymphoid cells are found between the nerve bundles. In the parenchymatous form, inflammatory signs are wanting. The muscles atrophy. Associated in all these forms the =osteopathic lesion= plays either an exciting or predisposing role, by disturbing nutrition to the tissue and thus setting up inflammation, which may lead to Wallerian degeneration[114].

=Symptoms.—Localized Neuritis.=—In the case of a sensory nerve, there is severe pain following the course of the affected nerve, with tenderness upon pressure. This may be followed by loss of sensibility. Trophic symptoms, such as glossiness of the skin and brittle nails, arise in more chronic cases, while in advanced cases, there is wasting of the muscles. Sweating, herpes, and occasionally effusion into the joints, occur. When a motor nerve is principally affected, muscular power is impaired, motion painful and muscular twitchings will occur. Finally contractions, wasting of the muscles, and even reactions of degeneration, may take place. A rare form is the so-called =ascending neuritis=, in which the inflammation extends upward from the peripheral nerves to the larger nerve trunks, or even the spinal cord, resulting in =myelitis=. This occurs most commonly in traumatic neuritis. The duration is variable. Many acute cases get well in a few days. Other cases may persist for months and even years.

=Multiple Neuritis.=—Inflammation involving several nerves which are affected simultaneously or in rapid succession. =Acute form.=—The attack usually follows overexertion or exposure to cold and wet, with probably some infection. This form is characterized by a chill, followed by a rapid rise in temperature which may reach 103 or 104 degrees F.; headache; pains in the back and limbs. There is weakness of the legs or arms, depending upon region involved, which may be so severe that the muscles atrophy. Sensory symptoms are variable. Most cases recover, though there are instances where the vagi, the nerves to the bladder, rectum, or heart, may be involved.

=Alcoholic Neuritis= results from a moderate amount of alcoholic drinking, continued over a long time. The first symptoms are usually numbness and tingling in the fingers and toes. Loss of power soon becomes marked, first in the lower, and then in the upper, extremities. The extensor muscles are most affected, causing wrist and foot drop. Occasionally there is paraplegia. There are hyperesthesia, tenderness and pain, especially in the legs. The cutaneous reflexes are commonly intact, and the deep reflexes, as a rule, are lost. Delirium is common, and hallucinations or illusions occur.

Neuritis from =lead poisoning= usually present the “wrist drop” and “foot drop”, with colic, and “blue line” on gums.

=Infectious Diseases= neuritis is due to an attack of some infectious disease, and may be local or multiple. It is due to toxic materials absorbed into the blood. It is most common after diphtheria. The symptoms presented are those of neuritis due to any other cause.

=Senile neuritis= is probably due to arteriosclerosis.

=Diagnosis.=—As a rule, the diagnosis is not difficult. In the alcoholic form in some instances, there may be difficulty, and in cases with paralysis, care should be taken. The =prognosis= of neuritis is generally favorable.

=Treatment.=—It is very evident that the successful treatment of neuritis depends upon being able to ascertain the cause. Rest is important in all cases. Rarely has one any difficulty in locating the deranged structures that are predisposing to the attack; and usually correction of these disturbances, which are in the region involved will give considerable relief. If the parts are too sensitive to handle insist on absolute rest and hot fomentations. The affected area should be kept warm and protected. Attention to the diet, and free elimination, are important. Metabolic disorders should be corrected, if possible. Give particular attention to any septic foci. A change of occupation may be necessary in some cases.

In alcoholic cases, the alcohol should be stopped as soon as possible. Passive movements and massage are helpful, but of course bear no comparison to specific osteopathic treatment. Relaxation of muscles along the spinal column and along the course of the nerve will at least give temporary relief.

If contractures and other changes remain after the acute attack, persistent treatment will generally result in recovery. (See also Painful Shoulders, Part I.)

=Sciatica= is usually a neuritis of the sciatic nerve, although all painful affections of the nerve are termed sciatica. In some cases it is a neuralgia when the nerve is swollen and presents an interstitial neuritis.

=Osteopathic Etiology.=—This affection occurs more frequently in males than in females. The usual period for sciatica is from the twentieth to the fiftieth year and the principal causes are =vertebral lesions= of the lower dorsal and lumbar vertebræ, especially lesions to the fourth and fifth lumbar. Occasionally the lesion is a subdislocated innominatum, a downward displacement of a floating rib or a partial dislocation of the femur. Other causes are exposure to cold, contraction of muscles, gout, rheumatism and syphilis. Contraction of the pyriformis muscle may bring direct pressure on the nerve. Focal infections, arthritis of the articular processes of the lower spine, and sacro-iliac and hip-joint disease should not be overlooked. In a few cases there are intrapelvic causes, such as uterine and ovarian tumors, rectal accumulations and the fetal head during labor. Enlarged prostate may be a factor. It is possible for the roughened edges of the sacro-iliac joint, internally, to irritate the sacral plexus as it passes over and thus keep up the pain. This may explain the occasional failure of treatment.

=Symptoms.=—Pain in the nerve along its course is the most constant symptom. The pain is most intense back of the thigh and above the hip-joint. The pain radiates downward through the entire nerve; it is of an annoying character and walking is especially painful. In rare cases there is wasting of the muscles, cramps, herpes and edema. In a few cases the neuritis may extend to the spinal cord.

=Diagnosis.=—The diagnosis of sciatica is usually easy. Care has to be taken in the examination to determine whether the affection is primary or secondary. It is difficult, in some cases, to locate the origin of the disturbance, especially if it is in the lumbar vertebræ, as frequently a very slight deviation of a vertebra will cause the disease; or some focal infection may be difficult to locate; or malformation of the fifth lumbar may be present; or asymmetry of the legs or the body be a factor. Careful palpation, measurements, and the X-ray are of diagnostic importance. =Hip-joint disease= and =sacro-iliac disease= can generally be easily distinguished from this affection. The lightning pains of =tabes= may simulate sciatica, but then there are other well defined symptoms of the disease.

=Treatment.=—Sciatica rarely runs a very long course, though there are cases that last for years. The treatment almost wholly depends upon the cause. If the cause can be determined at once, the probabilities are that severe cases may be relieved by a few treatments. Correction of the vertebræ, to relieve impingements to the nerve fibers as they pass through the intervertebral foramina, usually constitutes the primary treatment. Carefully examine the pelvic organs for disturbances. Occasionally deep treatment over the iliac vessels will be of great help. The innominatum, if deranged, should be corrected and all troubles of the hip-joint that are found must be corrected.

Cases of rheumatism and gout should receive their separate treatments, besides careful manipulations of the affected leg. Rest in bed should be insisted upon; this will usually markedly lessen the duration of the inflammation. Adjustment of the special points found deranged and a thorough treatment, if conditions permit, of the entire leg will be beneficial. Hot fomentations applied along the course of the nerve, and an inhibitory treatment back of the trochanter will at least give temporary relief. Extension of the leg is effective. Placing a patient upon his back and flexing the leg and thigh upon the abdomen, at the same time keeping the leg straight and the foot flexed, is an effectual stretching method. As a rule, sciatica readily responds to osteopathy.

Neuralgia

=Neuralgia= means simply “nerve pain.” The term neuralgia should be restricted to such nerve pains as are not caused by structural changes in the nerves. In cases where the pain is due to organic changes in the nerves, the disease should not be classed as a neuralgia, although it is practically impossible to draw an absolute line between functional and organic disturbances for the one may gradually progress (pathologically) into the other. In neuralgia there is always =disturbance= of the =blood supply= to nervous tissue, which may be of the character of congestive irritation, ischemia or altered states of the blood wherein it contains toxic substances or is below normal quality. It is well known that osteopathic lesions are very common etiological factors.

=Osteopathic Etiology.=—Neuralgia is essentially a disease of adults. It rarely occurs before puberty or late in life. Women are more prone to neuralgia than men and the tendency may sometimes be hereditary. Sufferers from neuralgia often present a peculiar “nervous temperament.”

The exciting causes of neuralgia are impairment of general health; irritations of the nerve fiber or trunk by a displaced bone, ligament or muscle, which may affect the nervous tissue directly by mechanical irritation, or indirectly, by the disturbance of its blood supply, or toxic agents; exposure to cold or damp; overwork and worry; toxic influences of various diseases, as malaria, lead poisoning and alcoholism; irritation from carious teeth, and various septic foci.

=Symptoms.=—Pain, which is spontaneous and paroxysmal, is the most prominent symptom. It may be described as “darting,” “shooting,” “burning,” “stabbing,” “boring,” etc. The pain is usually unilateral, following the course of the sensory nerves, and there are generally tender points along the course of the nerve. Especially are there points of tenderness near the central end of the nerve, where the displaced structures are irritating it. After the pain has continued for some time the skin becomes tender, reddened and swollen. The redness and edema are supposed to be due to vasomotor changes. Muscular spasms, trophic disturbances, skin eruptions, herpes and grayness of the hair are of rare occurrence. The duration of an attack varies from a number of minutes to a few hours.

=Neuralgia of the Fifth Nerve.=—This is by far the most frequent variety of neuralgia, and it is generally due to a displaced =atlas= or =inferior maxilla=. The teeth sinuses, and other possible regions of focal infections should be thoroughly investigated. Anemia and products of metabolism may be underlying factors. All the branches of the fifth nerve are rarely involved. The =ophthalmic division= is most often affected; pain and tenderness being present about the supraorbital notch or foramen, the palpebral branch at the outer part of the eyelid, the nasal branch, and occasionally an ocular pain will be felt within the eyeball. When the =infraorbital branch= is involved, pain and tenderness are principally present at the infraorbital, nasal and malar points. When the =third division= is affected, the chief tender places are the inferior dental, temporal and parietal points. In nearly all cases of neuralgia of the fifth nerve, there is extreme tenderness in the region of the articulation of the atlas and the occipital, particularly the side on which the fifth nerve is involved. This tenderness in a few cases may be found as low as the second or third cervical vertebra. The pain may be so severe as to cause edema along the course of the affected nerve fibers, grayness of the eyebrows and locks of hair chiefly in the temporal region, and convulsive twitching of muscles.

=Tic Douloureux= is a vastly exaggerated neuralgia of the fifth nerve and is supposed to be a primary affection of the Gasserian ganglion. Starting in middle life from no apparent cause it increases in severity until it becomes unbearable and suicide is not an infrequent result.

Many methods to relieve have been tried including destruction of the ganglion but with various results.

Treatment should be the same as in the milder form of neuralgia but it will require critical examination to determine the causes which are liable to be obscure.

=Cervico-Occipital Neuralgia.=—This variety involves the =posterior branches= of the =first four cervical= nerves, affecting the region of the posterior part of the neck and head. The pain may extend as far forward as the parietal eminence and the ear. The chief tender points are about midway between the mastoid process and the spine, between the sternomastoid and trapezius (branches of the cervical plexus), and a point just above the parietal eminence. This form of neuralgia is chiefly due to =subluxation= of the =upper four= or =five cervical= vertebræ irritating the posterior branches of the spinal nerves. A draught of air or exposure to cold are common exciting causes. The pain is of a sharp lancinating nature or else it is heavy and tense. Tuberculosis of the cervical spine may be an underlying cause.

=Cervico-Brachial and Brachial Neuralgia.=—In these forms of neuralgia the pain is referred to the area supplied by the =four lower cervical= and the =first dorsal= nerves. The tender points are in the axilla along the course of the ulnar, the circumflex at the posterior part of the deltoid and points at the lower and posterior part of the neck. The =lesions= exciting this form of neuralgia are usually found in the upper dorsal and upper cervical spines, but they may be as low as the sixth dorsal or as high as the atlas. As far as neuralgia of the ulnar nerve alone is concerned, it can be traced to the seventh and eighth cervical and first dorsal, and the lesion may be found occasionally at the fifth dorsal vertebra or rib. How a lesion as low as the fifth dorsal affects the ulnar nerve, it is hard to say definitely. There may be fibers directly to the ulnar nerve as low as this region, the nerve may be reflexly affected, the vasomotor supply to the ulnar nerve may be disturbed, or possibly the lesion interferes with fibers of the deep layers of the back muscles and thus contraction of muscles for some distance above the lesion would affect the ulnar and other nerves. The scaleni may be affected and involve the plexus. A bursitis may be present (See Painful Shoulders Part I). Focal infections are sometimes factors.

=Trunk Neuralgia.=—This includes dorso-intercostal and lumbo-abdominal neuralgia. The former, =dorso-intercostal= neuralgia, affects the intercostal nerves from the =third= to =ninth dorsal=, and is characterized by pain along the intercostal spaces, or in a few of them. The pain may be bilateral and symmetrical, which usually shows a vertebral lesion. Three points of tenderness are usually noted, viz., near the median line in front, and midway between these two points in the mid-axillary line. The pain is usually dull with acute exacerbations. =Lesions= of the =vertebræ= and =ribs= in the locality affected are by far the principal causes. Cold, exposure, strains, etc., are exciting causes of every day occurrence. When the pain is bilateral and symmetrical the lesion is usually in the vertebra; when unilateral the rib alone may be involved. The most common lesion is a crowding together of the ribs anteriorly at the fifth and sixth interspaces. Carefully exclude a possible tuberculosis of the spine or ribs, aneurism, etc.

The pain of =herpes zoster= is not neuralgic, but neuritic, involving the posterior spinal ganglion. =Pleurodynia=, strictly speaking, is neuralgia of the pleural nerves, and not of the intercostals, but a deranged rib over the region of the pain is commonly the cause of the pleurodynia.

=Lumbo-abdominal= neuralgia involves the posterior branches of the =lumbar nerves=. Tender points are found near the vertebræ, middle of the iliac crest, lower part of the rectus, and in the male occassionally in the scrotum, in the female in the labia. These are often bilateral and are usually of a constricting nature. The ilioscrotal branch is the one most commonly affected.

=Subluxation= of the =vertebræ=, and other lesions, as contracted muscles, are found along the lumbar vertebræ, and even as high as the lower dorsal vertebræ. Also lesions are found at the lumbo-sacral articulation. Pelvic disease is also a cause.

A downward displacement of the =lower ribs=, eleventh and twelfth, is a common disorder and may be the cause of severe neuralgic pains in the region of the iliac fossæ. It may simulate ovarian inflammation, renal colic, or even appendicitis if on the right side. And septic kidney has been wrongly diagnosed from these lesions. In fact it may be a cause of inflammation of the deeper structures, such as the ovary and Fallopian tube.

A subluxation of the vertebræ at the fourth and fifth dorsals may cause severe neuralgic pains in the epigastrium.

=Neuralgia of the Spinal Column.=—According to medical writers this is especially found in weakly women and after concussion of the spine; that it is a troublesome symptom in hysteria, and in many cases it is due to a reflex stimulus from diseased viscera. Most of this is undoubtedly true, but they have not found out the real significance of these neuralgic pains. The various =tender points= along the spinal column are of paramount importance to the osteopath as a =guide= to his =diagnosis=; not only in certain cases, but in nearly every case. The tender points are not due, in nearly every instance, to reflex stimuli from diseased organs, but these tender points are often the result of a local lesion, and are many times the cause of the disorder to the diseased viscus. The neuralgic pains are simply a symptom that a lesion exists in the immediate locality.

=Neuralgia of the Sacral Region and Coccygodynia.=—This form involves the nerves in the sacral and coccygeal regions. The nerves between the bone and the skin are affected. The cause of the pain is generally due to derangement of the articulation of the =lumbar= and =sacrum=, and to severely contracted muscles over the sacral foramina; also to lower lumbar lesions. It may be a reflex from various possible disorders of the organs and tissues of the pelvis. In coccygeal neuralgia, the =coccyx= is commonly displaced in any one of the various displacements that are liable to occur. Special attention should be given to the fibro-articulation of the coccyx, and to the status of the lumbo-sacral and innominata. In adjusting the coccyx, place forefinger in rectum up to proximal end of coccyx, and with thumb externally over the section, exert traction until articulation is released; then adjust.

=Neuralgia of the Legs and Feet.=—This includes the =crural form=, in which the front of the thigh is the seat of the pain; also the form in which tender points are found along the course of the =sciatic= nerve. The latter form is quite a common one, although sciatica is rarely a neuralgia. It is a neuritis and will be found classed under that heading. The tender points presented are the lumbar, sacro-iliac, gluteal, peroneal, maleolar and external plantar. The various neuralgic pains of the legs and feet are generally due to =lesions= of the =lumbar=, =pelvic= and =thigh= regions, and to =weak arches=. =Metatarsalgia= occurs when the fourth metatarso-phalangeal articulation is partially dislocated. Neuralgia in the heel, ball of the foot and toes may be due to local causes or to lesions higher up. Aside from the above care should be taken that there are no toxic factors that may be exciting causes.

=Visceral Neuralgia.=—This is a term applied to neuralgia of the gastro-intestinal tract, the kidneys, and the various pelvic organs.

=Diagnosis and Prognosis of Neuralgia.=—Neuralgia is to be diagnosed chiefly from neuritis, rheumatism, and the effects of severe pressure upon the nerves. In =neuritis= there is oftentimes a symmetrical affection, while in =neuralgia= there is a unilateral distribution and there are many remissions and intermissions and a varying of the pain from one place to another. In severe forms of neuritis, anesthesia succeeds the hyperesthesia of the sensory nerves. In cases of severe pressure upon nerves, the pain is continuous and neuritis will soon be manifested. In =rheumatism= the pain is localized in muscles or groups of muscles and does not follow the course of the nerve. The pain is increased by motion.

The =prognosis= is generally favorable, no matter how severe the attack. The prognosis is influenced only by the age of the patient and the cause.

=Treatment of Neuralgia.=—Consists, first, in the control of the paroxysm and, second, in the removal of its cause. In controlling the paroxysm, frequently one will be able to remove the cause. In a large majority of neuralgias the cause is directly due to a =displaced tissue=, generally a bone or muscle in the locality affected; often all that is necessary in order to perform a cure is to adjust the disordered tissue and the pain will cease. This usually can be done immediately, although there are cases which require several treatments before an adjustment of the parts can be accomplished; besides, in acute cases the involved region will be so tender that an attempt to correct the tissues sufficiently to relieve the paroxysm will be unbearable to the patient. In such instances when the cause cannot be removed at once, firm pressure or inhibition over the involved nerves for a few minutes and local application of hot packs generally disperse the pain for the time being. The rules of hygiene should be observed in all cases.

The best time to =remove= the =cause= of neuralgia is between the attacks when the tissues are not as tender or contracted to such an extent as during the paroxysm. A diagnosis can then be made much more easily, and the tissues adjusted with less pain to the patient.

The details (as to the locality treated) for each form of neuralgia will be found under the discussion of each variety. The general health and diet should be considered. Peterson[115] says: “Morphine is, among the alkaloids, the most frequent cause of insanity. It is a sad commentary on the heedlessness of some medical men, but the family physician is responsible, in almost every case, for the development of the morphine habit and its far-reaching consequences. It should be looked upon as a sin to give a dose of morphine for insomnia or for any pain (such as neuralgia, dysmenorrhea, rheumatism) which is other than extremely severe and transient.”

Diseases of the Cranial Nerves

=Olfactory Nerves.=—This nerve may be affected at various points from its origin to distribution. The disturbances may produce hyperosmia, or anosmia. The lesions may be tumors, injuries to the head and various diseases of the brain, or diseases of the nasal mucous membrane.

The =treatment= of the nerve (beside treating the disease causing the disturbance) is to the cervical region with a view to controlling the blood supply.

=Optic Nerve and Tract.=[116]—The retina, optic nerve, chiasma and optic tract may be affected by various lesions.

The affections of the =retina= are organic or functional. Under organic there is hemorrhage and retinitis. Retinitis may be due to several diseases, as syphilis, Bright’s disease, anemia, etc., Functional includes toxic and hysterical amaurosis, tobacco amblyopia, nyctalopia, hemeralopia and retinal hyperesthesia.

Included in the lesions of the =optic nerve=, are optic neuritis and optic atrophy.

Under lesions of the =chiasma= and =tract= are diseases of the chiasma and unilateral regions of the tract. Lesions of the tract and centers may be found in the tract itself, in the optic thalamus and the tubercula quadrigemina, in the fibers of the optic radiation, in the cuneus, and in the angular gyrus.

A brief summary, only, has been given of the lesions found, it being the idea not to dwell upon symptoms, morbid conditions, etc., but to bring out essential osteopathic features in regard to the cranial nerves. For the various effects of these lesions and points of diagnosis, the reader is referred to the various works on nervous diseases.

=Lesions= peculiar to =osteopathic= practice, that affect the optic nerve and tract, are found chiefly in the upper and middle cervical vertebræ. The disorders to these vertebræ may involve fibers of the optic nerve directly—those that are supposed to originate in the cervical spine; they involve the retina and optic nerve by way of the fifth, as claimed by some; and the above lesions especially affect the blood supply to the optic nerve and tract, either interfering mechanically with the blood-vessels or obstructing and irritating vasomotor nerves. The most common lesions are subdislocations of one or all of the three upper cervical vertebræ. Still, lesions may be located as low as the third or fourth dorsal vertebra, which may influence vasomotor and sympathetic nerves, or the lymphatics. The three or four upper ribs should also receive due consideration.

=Motor Oculi.=—Lesions of the third nerve may affect its center or the course of the nerve. These lesions produce spasms or paralysis.

The only way that we can control the motor oculi is by way of the superior cervical sympathetic; also, it has a connection with the fourth, fifth and sixth nerves, and we can influence it to some extent by direct treatment to the eyeball and orbital muscles. It should be remembered by the osteopath that many of the lesions affecting the cranial nerves, are found upon post-mortem examination, to be the effect of lesions in the spinal region; that many predisposing lesions are the disordered anatomical spinal tissues; as for instance in the third nerve, derangements of the atlas or axis may affect the nerve sympathetically (reflexly), or possibly by direct fibers, and produce the secondary effect—the so-called primary lesions of other schools—at the center or in the course of the nerve.

=Patheticus.=—This nerve may be involved by tumors at its nucleus, or as it passes around the outer surface of the crus into the orbit. Aneurisms or the exudation of meningitis may also compress its fibers. This nerve is purely motor, although it receives a few recurrent sensory fibers from the fifth nerve.

This nerve is controlled osteopathically, principally at the superior cervical sympathetic. It has connections with the sympathetic by way of the cavernous plexus.

=Trigeminus.=—Lesions of this nerve are found in its nucleus and in the pons, and include sclerosis, hemorrhage, disease and injury at the base of the skull, tumors, aneurisms, inflammation of the nerve, and subdislocations of the =upper three cervical= vertebræ, or the inferior maxillary.

This nerve is an extremely important one from an osteopathic point of view, as it has a vasomotor influence over various vessels of the head and face, and secretory fibers to the lachrymal, parotid and submaxillary glands; also, it controls mastication, and to some extent deglutition, and influences hearing (tensor tympanum muscle). Diseases of the nasal mucous membrane and disease of the anterior portion of the eyeballs are largely due to the =vertebral subdislocations= and to derangements to the inferior maxilla. Our principal work upon this nerve is at the upper cervical vertebræ, the inferior maxilla, and the deeply contracted muscles in the upper cervical region. For the facial points of treatment =see neuralgia of the fifth nerve=. This nerve is closely related to the sixth, seventh, eighth, ninth, tenth, eleventh and twelfth nerves. Particular emphasis is given to the importance of treating this nerve in nasal catarrh and in eye diseases of the anterior portion of the eyeball. It contains trophic fibers to the eye, sensory fibers to the sclerotic coat and iris, and vasomotor fibers to the choroid plexus.

=Abducens.=—This nerve is especially liable to be affected by tumors and meningitis. It is controlled osteopathically at the superior cervical sympathetic, being connected with the sympathetic at the cavernous plexus.

=Facial.=—Lesions may occur in the cortical centers of the nerve, the nucleus and the nerve trunk. Paralysis of the facial nerve occasionally occurs (Bell’s paralysis); also facial spasm may occur. This nerve is controlled at the stylomastoid foramen. =Lesions= to the =atlas=, anteriorly or laterally, are commonly found. In the region of the stylomastoid foramen, the nerve communicates with the great auricular of the cervical plexus, the trifacial, the vagi, the glosso-pharyngeal and the carotid plexus of the sympathetic. The facial nerve may be affected directly as it passes above the angle of the jaw.

Nearly every case of =Bell’s paralysis= can be cured by osteopathic treatment. There are usually lesions to the upper two or three cervicals. Correction of the cervical vertebræ and massage of the paralyzed muscles, with care of the general health, will suffice, provided there is not an extensive central lesion. Although the disease may be due to syphilis, meningitis, tumors, etc., the most frequent causes are lesions of the =atlas=, =axis=, and =third cervical= and =exposure= to =cold=. The cold produces a neuritis in the Fallopian canal, and deep treatment beneath the angle of the jaw is effective. The =prognosis= of Bell’s paralysis is favorable.

=Auditory.=—Lesions[117] affecting this nerve may occur anywhere from its cortical center to its distribution in the cochlea and vestibule. Disorders resulting from lesions to this nerve are nervous deafness, auditory hyperesthesia, tinnitus aurium, and Meniere’s[118] disease.

The control of the nerve and the treatment of lesions affecting it, are effected principally at the =first= and =second cervical= vertebræ. The atlas is especially apt to be subdislocated anteriorly or in a rotary manner. The condition of the =upper dorsal= region should also be carefully examined, as vasomotor nerves to the ear may be impinged at this point. The auditory connects with the fifth, sixth and seventh nerves.

=Glosso-Pharyngeal.=—This nerve may be affected by tumors, degenerations, meningitis and various lesions. It is often very hard to determine exactly the pathology, on account of its various connections with other nerves, the vagi, facial, spinal accessory, olfactory and optic nerves.

This nerve is chiefly controlled at its exit at the jugular foramen. Osteopathically, =lesions= of the =cervical= vertebræ and =upper dorsal= vertebræ affect it. The deep muscles of the anterior and lateral regions of the neck and subdislocations of the atlas especially affect the nerve.

=Pneumogastric.=—On account of its extensive distribution, and the importance of its functions this is one of the most important nerves in the body. It distributes fibers to five vital organs—heart, lungs, stomach, liver and intestines—and to other organs of secondary importance. This nerve is associated with deglutition, phonation, respiration, circulation and digestion.

Hemorrhages, softening, etc., may involve the nucleus of the nerve, while the trunk may be impinged by tumors, thickened meninges, aneurism of the vertebral artery and =subdislocation= of the =upper five= or =six cervical= vertebræ, chiefly the atlas.

The nerve is most easily controlled at its exit from the foramen. Inhibition of the suboccipital region, between the mastoid process and transverse process of the atlas, will influence the nerve markedly, probably reflexly; also direct treatment may be given the nerve as it passes along the anterior part of the neck near the trachea. The superior laryngeal branch may be treated below the great cornu of the hyoid bone and attention is particularly called to this in all affections of the throat where coughing is a feature; the inferior laryngeal, at the inner side of the lower part of the sternocleidomastoid muscle. The inferior laryngeal nerve may be affected by dislocation of the first and second ribs, producing pressure upon the nerve as it winds about the subclavian vessel. Fibers of the nerve have been traced to the spinal accessory nerve, as low as the sixth and seventh cervical vertebræ; consequently, lesions to the vagi nerves may occur anywhere in the cervical region.

=Spinal Accessory.=—Lesions of this nerve may cause paralysis or spasms to the structures to which it is distributed. The lesions consist of =subdislocations= of =cervical= vertebræ, chiefly the upper three or four. The nucleus may be involved by wounds, abscesses, caries of the vertebræ, tumors and meningitis. These lesions may also involve fibers of the trunk.

The special points of control of the nerve are at the jugular foramen, the sixth and seventh cervicals and the second, third and fourth cervicals.

=Torticollis= or =Wry-neck= is spasm of the muscles of the neck supplied principally by this nerve. There will be found either derangements of the =middle= or =lower cervical= vertebræ or the muscles are swollen from exposure to cold or from a blow. Sometimes the lesion is in the upper dorsal. The disorder is mainly a neurosis and, unless it has become chronic, the =prognosis= is favorable, and even in chronic cases, often considerable benefit can be obtained.

=Hypoglossal.=—This nerve may be affected by cortical, nuclear and infra-nuclear diseases, as well as by subdislocations of the upper cervical vertebræ. It communicates with the superior cervical ganglion, the vagi, the upper cervical nerves and the gustatory branch of the fifth nerve. We control the nerve at the anterior condyloid foramen and at the superior cervical ganglion.

Diseases of the Spinal Nerves

=Cervical Nerves.=—The =great occipital= nerve may be controlled at a point on the occiput between the mastoid process and the first cervical vertebra. The =small occipital= and the =great auricular= nerves may be controlled at a point just behind the mastoid process. The great auricular nerve and the frontal branch of the trigeminus nerve meet over the parietal protuberance. The preceding points are the places where one may inhibit the nerves and control certain headaches or neuralgic attacks, although subdislocations of the upper cervical vertebræ, or contracted muscles between the atlas and occiput are usually the cause of such disturbances. Adjustment of the lesion will usually correct the disturbance. Carefully exclude possible caries or tumors.

=Treatment= of the upper cervical region, by relaxing muscles and correcting deranged vertebræ, constitutes the principal treatment of an ordinary =headache=. It is best to have the patient flat upon his back and the osteopath stand at the head of the patient, and, first, thoroughly relax these contracted muscles or correct the derangement of the vertebræ; then after the foregoing has been accomplished, give an inhibitory treatment of the suboccipital region. In inhibiting, place the fingers over the contracted and tender tissue; hold tightly for several minutes, or at least until the tissues have thoroughly relaxed. Many times one will be able to detect a slight twitching underneath the fingers, and when such is felt, he knows at once that the headache is relieved. In inhibiting at any point along the spine, seek the contracted fibers and tender points and inhibit exactly over the area. Headaches that are due to a disturbed circulation of the brain, may be relieved by this inhibitory treatment in the suboccipital region. The treatment tends to reestablish a normal circulation to the brain. Although the large vascular areas such as the splanchnic, should, if possible, be normalized. Headaches may also be due to lesions at various points along the spine and ribs, and a correction of such points is necessary in order to cure the affection. A place often found involved is the upper dorsal region. =Reflex headaches= can be cured only by relieving the irritation. The treatment to the head would only be temporary. In headaches of the chronic type it is well to examine the scalp and if not freely movable over occipital region it may be adherent to the skull and cause pressure on the occipital nerves.

Lesions to the =phrenic nerve= usually occur in the region of the third, fourth and fifth cervical vertebræ. The lesion may be due to a deranged vertebra, or to disease of the membrane of the cord, or of the anterior horn of the gray matter (See Hiccoughs).

Paralysis of diaphragm from the phrenic may be single or double. When single it is not very noticeable. When double, respiration must be carried on by the intercostals and accessory muscles. When quiet, the patient may not notice it but on exertion there may be temporary dyspnea. Bronchitis with its constant coughing is a bad complication.

Various disorders of the phrenic nerve are principally treated in the area of the origin of the phrenic nerve. Tumors, aneurism, caries, and neuritis are possible complications.

Lesions to the =brachial plexus= are usually derangements of the cervical or upper dorsal vertebræ. Focal infections should not be overlooked. Direct injuries, contraction of muscles, a deranged clavicle, a cervical rib, or a dislocated shoulder are to be thought of. (See, also, Painful Shoulders, Part I) The X-ray as a diagnostic aid may be invaluable.

In obstructions to the =musculo-cutaneous= nerve, the power to flex the forearm upon the arm is greatly impaired. The lesion is most likely to be found between the fifth and sixth cervical vertebræ.

Clinically, the =median nerve= is of special interest from the fact that atrophy of the muscles of the ball of the thumb, which is pathognomonic of progressive muscular atrophy, may be caused by an affection of this nerve. The lesion is usually from the third to the seventh cervical vertebræ.

Lesions of the =ulnar nerve= may arise between the sixth and seventh cervical vertebræ, but are oftentimes found as low as the fifth dorsal, especially at the fifth rib on the side affected.

Lesions of the =circumflex nerve= may be found in the lower cervical vertebræ, but are commonly caused by dislocations of the humerus and clavicle.

Lesions of the =suprarscapular nerve= occur most frequently from the fifth to sixth cervical vertebræ.

The =posterior thoracic= may be lesioned at the fifth or sixth segments, or by pressure injuries to the serratus magnus.

=Dorsal Nerves.=—The essential osteopathic points of the dorsal nerves have been considered under intercostal neuralgia. It might be stated that the posterior fibers of the sixth and seventh dorsal nerves supply the skin of the pit of the stomach. This is of value, clinically, as severe pains in the epigastric region which may result from impingement of these nerves, are supposed by the patient to be due to stomach disorder.

Diseases of the =liver= may be manifested by =pains= in the region of the right scapula. It has been suggested that the stimulus passes from the liver up the pneumogastric to the spinal accessory and down the spinal accessory to the trapezius muscle and thus causes the “liver pain.”

=Intercostal neuralgia= is more common on the left side of the body. The intercostal veins of the left side empty into the left superior intercostal vein or the left azygos. Thus the blood, to reach the vena cava, is obliged to take a circuitous route and stagnation is more likely to occur than on the other side.

The glandular structure of the =mammary glands= is supplied by intercostal nerves from the third to the sixth interspace. Lesions here will cause various diseases of the breasts and adjustment will cure many of them.

=Lumbar Nerves.=—The lumbar nerves may not only be deranged by various growths, inflammatory processes and abscesses in the abdomen, but by lesions, infections, parturition, and developmental defects of the lumbar vertebræ. Tuberculosis of spine, sacro-iliac and hip joints, is not rare. In doubtful cases utilize the X-ray plate.

Lesions in the region of the =first lumbar= may affect the =iliohypogastric= and =ilio-inguinal= nerves and causes various irritations of the penis, scrotum, labium and thigh. Also, the perineal region may be involved, as well as connecting branches of these nerves to various visceral nerves underneath.

The =genital organs= may be affected by lesions to the =genitocrural= and =external cutaneous= nerves, caused by vertebral lesions of the second and third lumbar vertebræ. The latter nerve may be irritated by pressure underneath Poupart’s ligament.

Lesions at the third and fourth lumbar vertebræ and sacro-iliac articulation may affect the =obturator nerve=.

=Sacral Nerves.=—Lesions to the sacral nerves are especially liable to occur when an innominatum is subdislocated, as that changes the relative position of the femur with the body and causes impingement to the sacral nerves. Contraction of the pelvic and thigh muscles also affect sacral nerves. Other lesions to the sacral nerves may be located at the fifth lumbar and sacrum. It should be remembered that the centers of the sacral nerves are in the lower dorsal and upper lumbar region. Various lesions to the sacral nerves may be caused by pelvic inflammation, compressions by growths, and injuries and contractions of muscles within the pelvis. Sciatica has been described under neuritis.

FOOTNOTES:

[114] See Osteopathic Lesion—Journal of American Osteopathic Association. May, 1906, and Deason’s Physiology.

[115] Nervous and Mental Diseases, p. 622.

[116] See Diseases of the Eye, Part I.

[117] See Ear Section, Part I.

[118] R. D. Emery reports a case of Meniere’s disease as cured. A. O. A. Case Reports, Series IV.

GENERAL AND FUNCTIONAL DISEASES

Paralysis Agitans

(SHAKING PALSY)

=Definition.=—A chronic, nervous disease, characterized by tremors, muscular weakness, muscular rigidity and alterations in the gait.

=Etiology.=—The disease usually commences after forty years of age, but occasionally it occurs from the thirtieth to fortieth years. It is more frequent in males than in females. Heredity seems to have but little influence in the cause of the disease. Among the principal causes are physical injuries, exposure to cold and wet, emotion, worry, alcoholism, sexual excesses and acute diseases. Physical injury, in conjunction with exposure to cold is the best determined cause. Disorder of the vertebræ of the cervical or dorsal regions, or of the upper and middle ribs, can generally be found. Traumatic influences probably affect the nerve centers, causing a disturbed innervation, either by the direct effect of the deranged structures upon the nervous tissues or obstructing nutritive channels to the nervous tissues.

In most cases no changes have been observed in the central nervous system or in the sympathetic ganglia. Some observers have noted induration of the pons, medulla and cord, but these changes may be due to senility or to the indirect consequences of the long disturbance of function. In a few cases, interstitial sclerosis of the peripheral nerves is observed; these are probably secondary changes. Osteopathic experience regards paralysis agitans as an affection of the central nervous system, due to a disordered structure in the locality affected.

=Symptoms.=—The onset is usually gradual, but may come on quite suddenly after exertion. The =initial= symptoms are usually tremor, stiffness or weakness in one hand. In rare cases, at first there may be neuralgic pains, dizziness and symptoms of a rheumatoid nature. The tremor can be controlled by the will at the onset of the disease. The affection gradually extends until an entire side or the upper or lower limbs are involved. At this =advanced stage= of the disease, a peculiar muscular rigidity of the involved region takes place. Muscular weakness comes on at about the same time as the rigidity, and the loss of power varies much in degree. The condition is most marked in the fingers and hands, whence it extends to the arms and legs. It commonly passes from the right arm to the right leg, then to the left arm, and then to the left leg. At this stage the movement between the thumb and fingers is like that of crumbling bread. The writing is greatly affected and in time it is impossible to write. The trembling may be so violent as to prevent sleeping. There is occasionally an intermission of days in the tremor.

On account of the rigidity of the muscles, the patient assumes a characteristic =attitude= and =gait=. The position of the body is that of a tendency to go forward, the head is bent forward, the back curved outward, the arm bent at the elbow and held away from the body, and the knees so close together that they rub in walking. The gait is a “propulsive” one, and when once started in a forward walk, the patient’s gait becomes more and more rapid and he cannot stop until he comes against some object. The expression of the face is stiff and mask-like, the speech slow and monotonous and the voice shrill. The patient is generally restless and troubled with insomnia. The general health is in fairly good condition. Reflexes are usually normal. The intellect is generally retained, although the physical ailment may cause mental depression.

=Diagnosis.=—Is usually easy and can oftentimes be made at a glance. =Disseminated sclerosis= has a tremor, but is shown particularly in voluntary movements. The speech is scanning and the gait ataxic. The disease begins in the lower extremities, the attitude is different from that of paralysis agitans, and there is nystagmus. In =chorea= the movements are general, irregular and more intermittent, and it particularly involves muscles of the face. Also chorea is a disease of children and young adults.

The =tremors= of old age, hysteria, and certain toxic conditions due to tobacco, alcohol, etc. are generally easily diagnosed.

=Prognosis.=—The disease does not necessarily shorten life; the patient oftentimes dies with some intercurrent disease. Improvement usually results from careful, prolonged treatment. Early treatment, of course, will give the most satisfactory results, and occasionally, if taken very early, the case can be cured.

=Treatment.=—A most careful examination of the physical structures of the patient should be made, particular attention being paid to the =cervical= and =dorsal vertebræ=, the upper and middle =ribs= and the =muscles= along the spinal column. All irregularities found should be corrected if possible, and strong, thorough treatment given to the region of innervation of the affected parts. Traction of the rigid areas is of some value. Treatment of the arms and legs will also be of aid. All mental strain and physical exhaustion should be prevented if possible. General =hygienic measures= are to be employed. The life of the patient should be quiet and regular. Bathing, fresh air, massage and outdoor life will aid in improving the general health. =Persistent= treatment will retard the progress and frequently improve the general condition. Simple and hysterical tremor must not be confounded with that of paralysis agitans. E. Ashmore[119] reports an interesting case which shows about what may be expected under treatment.

Acute Chorea

(ST. VITUS DANCE)

=Definition.=—A functional disorder of the nervous system, chiefly affecting children, more than twice as frequent in females as males; characterized by irregular involuntary muscular contractions, often slight mental disturbance, and liability to endocarditis.

=Osteopathic Etiology.=—The disease affects children of all stations, but is more common among the lower classes. The greater number of cases occur before the age of twenty. It sometimes develops during the early months of pregnancy, when it often assumes the maniacal type. Chorea is frequently associated with endocarditis and rheumatism and delayed menstruation. It occasionally follows infectious diseases of childhood, especially scarlet fever. Fright, mental worry, sudden grief and overstudy may bring on an attack. Children of neurotic stock are more susceptible. Heredity plays some part as a predisposing cause. Reflex irritation from worms or from genital irritation has a slight influence upon the disease. Overwork in school is an important factor. =Derangement= of the =anatomical structures=, involving the nervous system along the spinal column, is the most common predisposing cause. Most of the anatomical displacements are found in the cervical vertebræ, although the upper dorsal may be involved.

=Pathologically=, as yet, no constant anatomical lesions have been found. Emboli occur in some cases, but this might be expected, as endocarditis so frequently occurs as an effect and not the cause of chorea. “In cases not rheumatic, the most probable explanation of the symptoms is to be found in vascular changes, having their origin in disturbed nutrition.” (Holt) According to osteopathic theories and investigations, the disease is due to various irritations to the spinal centers and nerves of the affected region. The disordered nerve cells may be the result of direct pressure, hyperemia, anemia, etc., and the action upon the brain centers is possibly a reflex act. Of late acute chorea is regarded by some as an infectious disease.

=Symptoms.=—In the majority of cases the muscular movement is not severe. They are purposeless and the child appears awkward. Restlessness, disturbed rest at night, crying spells, pain in the limbs, headache and irritability, are some of the premonitory symptoms. In =mild cases= one hand, or the hand and face, are involved. Occasionally there is some difficulty in talking. The irregular, jerky movements are characteristic of this disease. The child is anemic, and the muscles are weak. In =severe cases= the movements are general, the power of speech is lost, and the patient is unable to get about. The condition usually occurs after one or more mild attacks, although it may occur primarily. During an attack of chorea, the child’s disposition changes, he becomes irritable, cannot concentrate his mind, memory is affected and hallucinations may occur. The reflexes do not usually differ from the normal. =Maniacal chorea= is most serious, and often proves fatal, although recovery may occur. This form occurs most frequently in pregnant women. Speech is greatly affected and insomnia, fever and maniacal delirium develop. The =duration= is from six to ten weeks, in the average case. Mild cases may recover in a month or less, others last six or more months. There is a tendency of chorea to recur; rheumatism seems to favor this tendency. In children recovery is the rule.

=Diagnosis.=—In the majority of cases chorea is easily diagnosed. The symptoms are generally very characteristic. In a few cases of hysteria there may be difficulty of diagnosis, but history and rhythmical movements will usually differentiate. In =hereditary ataxia= the slow, irregular movements, the scolioses, scanning speech, talipes and the existence of other cases in the family, will differentiate this from chorea. =Cerebral sclerosis= usually occurs in infancy; impaired mentality, exaggerated reflexes, rigidity and chronic course of the disease, are points which render the diagnosis easy.

=Treatment.=—Nearly all cases can be cured.[120] The predisposing causes of chorea, osteopathically, are usually found to be subluxations of the vertebræ or ribs at any point, but particularly in the cervical vertebræ. Chorea is one of the diseases of the nervous system, in which constant morbid changes are not found upon the post-mortem examination. Possibly the reason is because the lesions causing the diseased state are not deeply seated enough to primarily affect motor centers; but are lesions of the spinal column and ribs, affecting simply the nerve fibers reflexly, as they pass through the intervertebral foramina. There will be found well marked lesions, and upon their correction the osteopath finds complete recovery largely depends.

The muscle, or group of muscles, involved, will give a =direct clue= as to where the lesion will probably be found. In nearly all cases, it is in the spinal region of innervation to the affected muscles. Other cases may be due to cerebral lesions, as well as to intestinal and uterine disturbances. Search should be made for possible =reflex= irritation, such as intestinal parasites, adherent prepuce, eye strain, nasal abnormalities, etc.

All cases should be taken from school, carefully guarded from excitement, and placed under the most favorable =hygienic= conditions, with a certain amount of discipline as to self control. The more serious cases should be placed in bed, so that rest will be secured as well as diminished liability to heart complications.

The =diet= must be carefully watched and the bowels attended to regularly. A milk diet during the early stage is highly recommended. Do everything possible to restore the general health. Mild gymnastics, in most cases, will be found of service. Amusement should be given the child, in the open air if possible. In severe cases where the skin is harsh and dry, the hot air bath, providing the strength is good, will give considerable relief from the intensity of the disease. A few cases of acute chorea run into a =chronic form=, but the latter, as a rule, yields to osteopathic treatment.

Choreiform Affections

=Myoclonia= is a sudden contraction of a few muscle fibers, a single muscle or of a group of muscles. A neurotic tendency, infections and toxic conditions are factors. Occasionally epilepsy may be associated with it. Osteopathically there can be but little doubt that the innervation to the muscles involved is interfered with.

The lower extremities are usually first affected and it may be sudden or gradual in appearance. It is progressive and slowly involves the arms and, rarely, the face. Usually the spasms cease during sleep.

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