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diff --git a/75696-0.txt b/75696-0.txt new file mode 100644 index 0000000..0d304db --- /dev/null +++ b/75696-0.txt @@ -0,0 +1,39181 @@ + +*** START OF THE PROJECT GUTENBERG EBOOK 75696 *** + + + + + + Transcriber’s Note + Italic text displayed as: _italic_ + Bold text displayed as: =bold= + + + + + THE PRACTICE OF + OSTEOPATHY + + [Illustration] + + CARL PHILIP McCONNELL + + President American Osteopathic Association, 1904-05. Formerly of the + Faculty American School of Osteopathy. Member of the Faculty + Chicago College of Osteopathy + + CHARLES CLAYTON TEALL + + President American Osteopathic Association, 1902-03. Dean of the Faculty + and Professor of Practice and Clinical Osteopathy American School + of Osteopathy. Editor Journal of Osteopathy + + FOURTH EDITION + + Rewritten in collaboration with osteopathic specialists of note + with much new and original matter + + + 1920 + JOURNAL PRINTING CO. + KIRKSVILLE, MO. + + + + + COPYRIGHT 1920 + CARL PHILIP MCCONNELL AND CHARLES CLAYTON TEALL + + + + + DEDICATED + TO THE MEMORY + OF + ANDREW TAYLOR STILL + + + + + FIRST EDITION 1899 + SECOND EDITION 1902 + THIRD EDITION 1906 + FOURTH EDITION 1920 + + + + +PREFACE TO THE FOURTH EDITION + + +A science is said to be known by its literature and, if that be true, +Osteopathy is backward for there are few available books on the subject +for the student and investigator although there is a vast amount of +unclassified journalistic matter. A pretentious start was made and, +for a time, it appeared that we should have texts on all subjects for +the teaching of Osteopathy but, for reasons not necessary to give +here, these books did not live although their value and need was never +questioned. + +The third edition of the Practice of Osteopathy was exhausted very soon +after publication and there have been insistent calls for a fourth +which is now presented with the hope that it will find as friendly +a reception as was accorded the previous editions. Close attention +to current literature has been given and reports from experienced +practitioners in the field has been sought and this material made +use of wherever possible. Besides this, certain sections have been +written by specialists in their several lines whose signed articles +we confidently present. The subject of osteopathic practice has been +handled to avoid undue optimism in the light of experience but, also, +not to lose sight of the fact that osteopathy won its way by performing +the so-called impossible in a multitude of cases. Therefore, it has +been thought best not to draw a hard and fast line on our limitations. + +The border line between osteopathy and surgery has been demonstrated +as well as can be done on paper without the actual patient in hand. +Medical literature has been called upon to give its store of knowledge +wherever our needs have appeared and all osteopathic prints have, also, +given from their accumulated wisdom and experience. + +The authors acknowledge, with thanks, this information from the many +writers for osteopathic journals who have created a great fund of +knowledge on osteopathic subjects and particularly those who have +contributed special sections. + + CARL PHILIP MCCONNELL. + CHARLES CLAYTON TEALL. + + 1920. + + “Osteopathy is not so much a question of books as it is of + intelligence. A successful osteopath is in all cases, or should be, a + person of individuality with a mechanical eye behind all motions or + efforts to readjust any part of the body to its original normality, + because unguided force is dangerous, often doing harm and failing to + give relief that should be the reward of well directed skill.”—A. T. + STILL. + + + + +LIST OF CONTRIBUTORS + + +RAYMOND W. BAILEY, D. O. + + Former member of the faculty, Philadelphia College of Osteopathy. + + (_Defective Children_) + + +EDGAR S. COMSTOCK, D. O. + + Professor of Principles of Osteopathy, and of Respiratory and + Infectious Diseases, Chicago College of Osteopathy. + + (_Infectious Diseases_) + + +J. DEASON, M.S., Ph. G., D. O. + + Professor of Rhinology, Laryngology and Otology, Chicago College of + Osteopathy. + + (_Ear, Nose and Throat_) + + +L. VAN HORN GERDINE, A. M., M. D., D. O. + + Neurologist, Still-Hildreth Sanatorium. + + (_Mental Diseases_) + + +A. G. HILDRETH, D. O. + + Superintendent, Still-Hildreth Sanatorium. + + (_Mental Diseases_) + + +H. S. HAIN, D. O. + + Professor of Orthopedics, American School of Osteopathy, Orthopedic + Surgeon, A. S. O. Hospitals. + + (_Deformities_) + + +EARL R. HOSKINS, Sc. B., D. O. + + Professor of Clinical Osteopathy, X-Radiance and Diagnosis, Chicago + College of Osteopathy. + + (_Diseases of the Blood_) + + +CHARLES J. MUTTART, D. O. + + Professor of Diagnosis and Technique and of Gastroenterology, + Philadelphia College of Osteopathy. + + (_Diseases of the Stomach_) + + +GEORGE M. MCCOLE, D. O. + + Osteopathic Practitioner and Writer. + + (_Influenza_) + + +CHARLES C. REID, M. D., D. O. + + President, Denver Polyclinic and Post-Graduate College. + + (_Ophthalmology_) + + +GEORGE A. STILL, M. S., M. D., D. O. + + Professor of Surgery, American School of Osteopathy, Surgeon in Chief, + A. S. O. Hospitals. + + (_Post-Operative Treatment_) + + + + +TABLE OF CONTENTS + + + PART I. + + INTRODUCTION 17 + + OSTEOPATHIC ETIOLOGY AND PATHOLOGY 24 + + Osteopathic lesion; Etiological factors; Osseous lesion; Muscular + lesion; Ligamentous lesion; Visceral lesion; Composite lesion; + Pathology; Spinal lesions; Proof. + + OSTEOPATHIC DIAGNOSIS AND PROGNOSIS 38 + + The Spine; Examination; Vertebræ; Position in examination; Neck, + Head and Face, Atlas, Axis, Skull, Third Cervical, Muscles of the + Neck, Temporo-Maxillary Articulation, Scalp, Ribs, Clavicle, Sternum, + Dorso-Lumbar, Thorax, Abdomen, Gall Bladder, Spleen, Stomach, + Intestines, Kidneys, Lumbar, Pelvis, Coccyx, Arms, Legs. + + OSTEOPATHIC PROGNOSIS 56 + + OSTEOPATHIC TECHNIQUE 60 + + Sense of touch, Definite principles, General treatment, Position, Neck, + Head, Ribs, Dorsal, Lumbar, Abdomen, Pelvis, Legs, Arms, How often to + treat, Length of treatment, Over-treatment, Misapplied treatment. + + OSTEOPATHIC CENTERS, STIMULATION, INHIBITION, READJUSTMENT, + VASOMOTOR AND SENSORY NERVES 88 + + SPINAL CURVATURE 96 + + POTT’S DISEASE 102 + + SPRAINS 104 + + FLAT FOOT 112 + + FRACTURES 115 + + POSTURAL DEFECTS 120 + + Round Shoulders, Painful Shoulders, Pendulous Abdomen, Postural + Curvature of the Spinal Column. + + PROLAPSED ORGANS 133 + + Prolapsed and Dilated Stomach, Prolapsed Kidney, Liver Prolapse, + Prolapsed Intestines, Prolapsed Uterus, Ovarian Displacements. + + SKIN DISEASES 147 + + Eczema, Herpes Simplex, Herpes Zoster, Urticaria, Acne. + + ANIMAL PARASITES 151 + + Tape Worm, Round Worm, Pin Worm, Hook Worm, Trichiniasis, Filaria. + + HEMORRHAGES 160 + + Epistaxis, Hemoptysis, Hematemesis, Intestinal Hemorrhage, + Hematuria, Uterine Hemorrhage. + + HICCOUGHS 165 + + VARICOSE VEINS 166 + + PHLEBITIS 168 + + THE RECTUM 169 + + Local Treatment, Proctitis, Hemorrhoids, Rectal Conditions. + + GENITO-URINARY 175 + + Prostate Gland, Acute Prostatitis, Chronic Prostatitis, Seminal + Vesicles, Varicocele, Impotency. + + HEAT STROKE 180 + + DEPARTMENT OF OPHTHALMOLOGY 183 + + Examination of the Eye, Ciliospinal Center, Somatic Reflexes, + Accommodation in the Eye, The Ophthalmoscope, Diseases of the Eye, + Neuralgia, Diseases of the Eyelids, Lachrymal Apparatus, Conjunctiva, + Ophthalmia Neonatorum, Trachoma, Phlyctenular Conjunctivitis, Vernal + Conjunctivitis, Diseases of the Cornea, Examination, Ulcer, Xerosis, + Keratitis Neuropatalytica, Pannus, Phlyctenular Keratitis, Interstitial + Keratitis, Diseases of the Iris and Ciliary Body, Diseases of the + Choroid, Glaucoma, Diseases of the Lens, Cataract, Diseases of the + Retina, Optic Neuritis, Optic Atrophy, Asthenopia. + + DISEASES OF THE EAR, NOSE AND THROAT 236 + + Examination, Diseases of the Auditory Meatus, Diseases of the Middle + Ear, Acute Mastoiditis, Chronic Mastoiditis, Otitis Media, Catarrhal + Deafness, Normal Hearing, Diseases of the Middle Ear, Diseases of + the Nose, Rhinitis, Hay Fever, Sinuitis, Epistaxis, Diseases of the + Nasopharynx, Adenoids, Diseases of the Oropharynx, Tonsillitis, + Tonsillectomy, Quinsy. + + MENTAL DISEASES 282 + + Dementia Praecox, Delirium, Confusion and Stupor, Manic Depressive + Psychosis, Involutional Psychosis, Senile Dementia. + + DEFECTIVE CHILDREN 303 + + Tendencies, Amentia, Treatment. + + POST-OPERATIVE TREATMENT 312 + + Vomiting, Backache and Headache, Neuritis, Phlebitis, Nephritis, + Pleurisy, Pneumonia. + + + PART II. + + INFECTIOUS DISEASES + Fever 325 + Typhoid Fever 329 + Typhus Fever 344 + Malarial Fever 347 + Septicemia 355 + Pyemia 356 + Dengue 356 + Cerebrospinal Meningitis 358 + Diphtheria 362 + Dysentery 368 + Acute Ileocolitis 368 + Amebic Dysentery 370 + Chronic Dysentery 371 + Erysipelas 372 + Yellow Fever 374 + Tetanus 377 + Simple Continued Fever 379 + Tuberculosis 380 + Influenza 399 + + ACUTE ERUPTIVE FEVERS 412 + Smallpox 413 + Varioloid 420 + Vaccination 424 + Scarlet Fever 428 + Measles 437 + Rubella 444 + Varicella 446 + Mumps 449 + Whooping Cough 452 + + CONSTITUTIONAL DISEASES + Rheumatic Fever 457 + Chronic Articular Rheumatism 460 + Arthritis Deformans 462 + Muscular Rheumatism 465 + Gout 467 + Diabetes Mellitus 470 + Diabetes Insipidus 476 + Rickets 478 + Obesity 480 + Scurvy 481 + Infantile Scurvy 482 + Purpura 483 + Hemophilia 484 + + DISEASES OF THE DIGESTIVE SYSTEM + Stomatitis 487 + Catarrhal Stomatitis 487 + Aphthous Stomatitis 488 + Ulcerative Stomatitis 488 + Parasitic Stomatitis 489 + + Diseases of the Gastro-intestinal Tract + Applied Anatomy 490 + Acute Gastritis 502 + Chronic Gastritis 505 + Gastric Neuroses 510 + Gastric and Duodenal Ulcer 513 + Dilatation of the Stomach 517 + Gastroptosis and Enteroptosis 521 + + Diseases of the Intestines + Acute Diarrhea 523 + Chronic Diarrhea and Mucous Colitis 526 + Diarrhea in Children 529 + Acute Dyspeptic Diarrhea 529 + Cholera Infantum 531 + Acute Enterocolitis 532 + Cholera Morbus 533 + Intestinal Colic 535 + Constipation 537 + Intestinal Obstruction 541 + Hernia 547 + Appendicitis 547 + + Diseases of the Liver and Bile Duct + Hyperemia of the Liver 554 + Simple Catarrhal Jaundice 555 + Cholecystitis 557 + Jaundice 558 + Cirrhosis of the Liver 560 + Fatty Liver 562 + Amyloid Liver 562 + Gall-stones 563 + + Diseases of the Spleen + Splenitis 567 + + DISEASES OF THE RESPIRATORY TRACT + Acute Laryngitis 569 + Chronic Catarrhal Laryngitis 570 + Laryngismus Stridulus 572 + Spasmodic Laryngitis 573 + Tuberculous Laryngitis 575 + Syphilitic Laryngitis 577 + Edematous Laryngitis 577 + + Diseases of the Bronchi + Acute Bronchitis 579 + Chronic Bronchitis 582 + Fibrinous Bronchitis 585 + Bronchiectasis 587 + Bronchial Asthma 589 + + Diseases of the Lungs + Emphysema 592 + Acute Lobar Pneumonia 597 + Bronchopneumonia 605 + Chronic Interstitial Pneumonia 609 + Congestion of the Lungs 610 + Edema of the Lungs 611 + + Diseases of the Pleura + Pleurisy 611 + Acute Pleurisy 612 + Serofibrinous Pleurisy 612 + Chronic Pleurisy 615 + + DISEASES OF THE URINARY SYSTEM + Diseases of the Kidneys + Renal Hyperemia 617 + Acute Parenchymatous Nephritis 618 + Chronic Parenchymatous Nephritis 621 + Interstitial Nephritis 624 + Amyloid Kidney 626 + Pyelitis 627 + Uremia 628 + Renal Calculus 631 + + Diseases of the Bladder + Cystitis 635 + + DISEASES OF THE CIRCULATORY SYSTEM + + Diseases of the Pericardium + Pericarditis 638 + Endocarditis 641 + Chronic Endocarditis 645 + Hypertrophy of the Heart 655 + Dilatation of the Heart 657 + Myocarditis 659 + Degeneration of the Heart Muscle 661 + Neuroses of the Heart 662 + Angina Pectoris 666 + + Diseases of the Arteries + Arteriosclerosis 669 + + DISEASES OF THE BLOOD + General Consideration 671 + The Anemias 672 + Costogenic Anemia 674 + Chlorosis 676 + Pernicious Anemia 678 + The Leucemias 680 + Splenomedullary Leucemia 681 + Lymphatic Leucemia 682 + Hodgkin’s Disease 684 + + DISEASES OF THE THYROID GLAND + Congestion 686 + Inflammation of the Thyroid 686 + Simple Goiter 687 + Exophthalmic Goiter 690 + Myxedema 697 + Cretinism 698 + + DISEASES OF THE PARATHYROID GLAND + Tetany 699 + Diseases of the Thymus 702 + Diseases of the Adrenal Glands 703 + Addison’s Disease 704 + + DISEASES OF THE NERVOUS SYSTEM + + Diseases of the Nerves + Neuritis 706 + Neuralgia 710 + + Diseases of the Cranial Nerves + Olfactory 715 + Optic 715 + Motor Oculi 716 + Patheticus 716 + Trigeminus 717 + Facial 717 + Auditory 718 + Glosso-Pharyngeal 718 + Pneumogastric 718 + Spinal Accessory 719 + Hypoglossal 719 + + Diseases of the Spinal Nerves + Cervical Nerves 719 + Phrenic Nerve 720 + Brachial Plexus 721 + Dorsal Nerves 721 + Lumbar Nerves 722 + Sacral Nerves 722 + + GENERAL AND FUNCTIONAL DISEASES + Paralysis Agitans 723 + Acute Chorea 725 + Choreiform Affections 727 + Infantile Convulsions 728 + Epilepsy 729 + Migraine 736 + Occupation Neurosis 738 + Hysteria 740 + Neurasthenia 744 + + DISEASES OF THE SPINAL CORD + Acute Myelitis 748 + Poliomyelitis 750 + Acute Ascending Paralysis 753 + Locomotor Ataxia 754 + Friedreich’s Ataxia 759 + Spastic Paraplegia 760 + Ataxic Paraplegia 761 + Syringomyelia 761 + Amyotrophic Lateral Sclerosis 763 + Progressive Muscular Atrophy 764 + Bulbar Paralysis 765 + + ORTHOPEDIC SURGERY + Scoliosis 767 + Functional Curvature 773 + Organic Curvature 774 + Congenital Dislocation of the Hip 778 + Talipes 784 + Pott’s Disease 788 + Hip-Joint Disease 791 + Tuberculosis of the Knee Joint 793 + The Plaster Cast Bandage 795 + Index 799 + + + + +PART FIRST + + + + +INTRODUCTION + + +What Hippocrates was to the Allopath, what Hahnemann was to the +Homeopath, Andrew Taylor Still is to the Osteopath, and it is safe to +say that when another century shall have rolled away, his fame will be +equal to that of either. That he is a maker of history, even the most +skeptical will admit. His teachings are revolutionary but are borne out +in fact, and on that as a foundation, is built the superstructure of +the young therapeutic giant—Osteopathy. + +It would be of great interest to trace the history of the first +inception of the thought that drugs were not only unnecessary but +harmful, then view the struggle to grasp something tangible to take +their place, then see the development of the idea that the human body +has within it all that is needed for its upbuilding and repair until he +came to this fundamental: “The power of the artery must be absolute, +universal and unobstructed or disease will result. The moment of its +disturbance means the period when disease begins to sow the seeds of +destruction in the human body; and in no case can it be done without +a broken or suspended current of arterial blood,” capped by the +epoch-making discovery of the cause for this interrupted flow of the +blood stream—the theory of obstruction by anatomical displacement. It +is the only theory of the etiology of disease that will stand the test +of science and its acceptance and practice means a revolution in the +field of therapeutics. + +As it is, he sets the exact date, June 22, 1874, when the light dawned +and he saw the outline of his great philosophy—Osteopathy. Then came +the years of adversity and struggle. With the eye of a prophet he saw +the future of that philosophy, and with the firmness of a Spartan +has defended it since birth. It must be a separate, distinct system. +Outside the fact that it was to heal the sick and was founded on a +knowledge of anatomy and physiology it had nothing in common with +existing schools, and if it were ever to grow it must be alone, for +his brother practitioners would have none of it and if left to their +tender mercies it would have “died a-borning.” Even had it been taken +up the result would have been the same for they would never have fully +developed it. And so through the lean, terrible years he struggled, +buoyed by the faith of a discoverer, urged on by love of this child of +his brain, fanatical in his determination to win. And win he did for it +was vouchsafed to him in his vigorous old age to sit on his hearthstone +and see the results of his work, his struggle and his faith. It is +something to know that his fame has circled the earth, to be honored +and sung by millions; a boon not accorded many a sage or philosopher. +Not only has the public accepted it but the medical profession is +making tardy but forced recognition of certain cardinal principles of +osteopathy by using them, but, of course, without credit. + +Osteopathy has been defined as “that science or system of healing +which emphasizes, (a) the diagnosis of disease by physical methods +with the view of discovering, not the symptoms but the cause of +disease in connection with misplacements of tissue, obstruction of +the fluids and interference with the forces of the organism; (b) +the treatment of disease by scientific manipulations in connection +with which the operating physician mechanically uses and applies the +inherent resources of the organism to overcome disease and establish +health, either by removing or correcting mechanical disorders and thus +permitting nature to recuperate the diseased parts, or by producing and +establishing antitoxic and antiseptic conditions to counteract toxic +and septic conditions of the organism or its parts; (c) the application +of mechanical and operative surgery in setting fractures or dislocated +bones, repairing lacerations and removing abnormal tissue growths or +tissue elements when these become dangerous to organic life.”[1] In +a word, osteopathy is adjustment and the osteopath is an anatomical +engineer who knows what is wrong and has the ability to correct it. +Dr. Still changed diagnosis from guess work to fact and on it his fame +may well stand, for when the cause of the disease was found, treatment +was easy. He has ever emphasized the necessity of thorough examination +and correct diagnosis. All treatment must be based on the definite, +specific object to accomplish certain definite, specific things. + +“Osteopathy would expound and apply the true philosophy of +manipulation. While the hands are used, it is not this alone and +chiefly that distinguishes its method of operation, but the idea and +purpose that lie behind manipulation.”[2] + +All manipulators are not osteopaths any more than all butchers are +surgeons. The need for deep study of the subject is apparent from this +characteristic statement of Dr. Still’s: “Osteopathy is a science; not +what we know of it, but the subject we are working is deep as eternity. +We know but little of it. I have worked and worried here in Kirksville +for twenty-two long years, and I intend to study for twenty-three +thousand years yet.”[3] This brings us to the point of the relations of +osteopathy with other manipulative forms of treatment. They are not +many, for Gerdine,[4] in closing a long article on the “Physiological +Effects of Mechanical Therapeutics” says: “I have striven to show that +in no way is Osteopathy similar to massage either in theory or practice +if Osteopathy is conceived of, according to its founder, Dr. A. T. +Still, as a system of healing in which a definite lesion in form of a +bony displacement is the causative factor and a removal of the same, +the curative factor in disease.” + +The fact that use is made of the hands to the extent it is by both +osteopaths and masseurs or Swedish movement operators gives rise to the +mistaken idea of similarity in treatment. + +“The essential distinction,” says G. D. Hulett, “between Osteopathy and +all other systems of healing based on manipulation, clusters around +the etiology of disease. While these other systems, as indicated at +least by their practice, look at disease from a peripheral standpoint, +osteopathy views it from a central standpoint.”[5] + +Massage is a small branch of manipulative therapeutics, but conceding +that it is perfect and scientific it can only resemble osteopathic +treatment in one ramification of osteopathic practice, viz: relaxation +of muscles. + +The fact that massage is often employed by osteopaths in connection +with their work shows the limitations of that form of treatment. Says +McConnell[6]: “In the human body, as in any delicate, complicated +mechanism, there is mechanism within mechanism; and, in order to +obtain certain mechanical effects, many times there is required a +series of complicated movements, all of which bear a ratio one to the +other according to the energy utilized and the mechanical principle +involved.” No other form of manual treatment takes this principle of +mechanics into consideration. It is possible, as Gerdine points out, +for an undeveloped osteopath to practice massage under another name. +That the two should be confounded before the public is due to his +ignorance and not from any fault of the system. Massage is a valuable +aid in the treatment of disease but it is not Osteopathy. + +“In the bright lexicon of osteopathy there is no such word as rub[7].” + +Osteopathy in its relation with medicine has little in common. +From the beginning, its founder realized their paths should run +divergently, so the first step, its teaching, must be considered from +a different viewpoint. To quote from an address by Teall[8]: “But +to adequately teach osteopathy a vast amount of original work must +be done. Anatomy is anatomy but there is a vast difference in its +application. Physiology must be taught to mean something more than an +interesting phenomenon. Pathology has an unfilled gap between cause +and effect which must be bridged. The post-mortem has a great story +to tell but an osteopath must tell it. A slide of degenerated tissue +under the microscope is of interest, but why the degeneration? It is +described at length by the authorities, but the reason for the causes +and morbific changes are not carried out. Obstetrics along strictly +natural and physiological lines insuring both mother and babe against +injury; gynecology, minus the knife and plus common sense; all these, +and more must be put into shape to teach the osteopathic student. The +archives of osteopathy were empty ten years ago. There was no precedent +to follow and the ideas in teaching which had prevailed for centuries +dominated. All this is changed. The colleges teach the science along +strictly osteopathic lines, making the application of the truths which +have escaped the notice of centuries of investigation.” + +All schools recognize the wonderful recuperative power of nature, as +this from the introduction of a standard allopathic text book will +show[9]: “There is no scientific dogma better established than this: +that the living organism is in itself adequate to the cure of all its +curable disorders. This natural law sustains the medical skeptic in +his infidelity, enables the homeopath to report his sugar cures, and +helps all physicians out of more close places than they are generally +willing to acknowledge.” But at times, as all will agree, nature is not +able to overcome its maladies and assistance is needed. Here, again, is +a divergence as to the method and character of that assistance. There +is no system so trivial or absurd which cannot point to its cures, but +a school of medicine should have a settled system with established +methods of procedure. This is not true of any school employing drugs as +its principal therapy. In the President’s annual address at Cleveland +he says[10]: “The observant reader of the progressive medical press +is struck at once by the unsettled condition in the field of modern +therapeutics. The trend is emphatically away from drugs. But, in +the effort to get away from medicine, the medical investigator has +wandered far afield, cutting loose from nature and resorting to the +artificial.” It is the last paragraph of the extract quoted which +particularly emphasizes the point of divergence, natural _versus_ +unnatural methods. It must be understood at once that the osteopath +admits the reality of drug action for “there is no doubt that the +pharmacopeia records many drugs whose action is rapid and effective so +far as securing activity or decrease of secretion is concerned, but the +element of danger, i. e., their destructive power is great. Oftentimes +their power does not stop at the point desired or limit its effect +to the therapeutic action sought[11].” This point of unreliability +of the drug is emphasized by the following from recognized medical +authority[12]: “We give drugs for two purposes: (1) To restore health +directly by removing the sum of the conditions which constitute +disease. Here we act empirically with no definite knowledge—often +indeed with little idea of the action of our drugs, but on the ground +that in our hands or in the hands of others they have restored health +in like cases. (2) To influence one or more of the several tissues +and organs which are in an abnormal state so as to restore them to or +toward the normal; with the hope that if we succeed in our purpose +recovery will take place. The purpose we effect by means of the +influence which the chemical properties or drugs exert on the structure +and function of the several tissues and organs. Minute information, +therefore, of the nature of drugs and their action is essential for +their proper employment.” Osteopathy brings into action the latent +or stagnant forces of nature by specific methods which are usually +reliable. Naturally there being such a wide difference in theory of +the cause of disease it would be also shown in diagnosis as well as +treatment. The most striking points to the layman in medical procedure +are: first, wide difference in the system of diagnosis and in its +findings by physicians of the same school; second, the great variance +in remedies employed by different physicians of the same school for the +same disease. + +Osteopathic diagnosis is so physical in its character, depending upon +actual conditions found and not upon the subjective symptoms alone, +that the same patient examined by a number of experienced osteopaths +will be given the same diagnosis, and he will also be able to detect +in each the same effort to correct in all their technique. All the +methods of physical diagnosis are used plus the distinctive osteopathic +procedure. Results wherever used bear out the effectiveness of the +system. + +The osteopath must and does consider the necessity of surgery, but +his effort is always to prevent the operation if possible. There can +be no doubt that surgery is carried to extremes and there is a strong +sentiment growing that much of it is unnecessary. Says Homer Wakefield, +M. D.[13]: “It is to the everlasting disgrace and mortification of +the medical man that the wealthy classes who are continually under +the observation and direction of eminent men, in dietary, and all +life habits, in health as well as in sickness, are not only the very +ones who develop appendicitis and most largely go to operation, but +are almost exclusively those who attain to this distinction.” The +operations of today are wonderful and the surgeon shows great skill and +genius in their performance, but great as he is in these matters how +infinitely greater is the man who can prevent them. The need of the +osteopath today is to be trained to recognize surgical conditions and +neither allow surgery unnecessarily nor make the more terrible error of +not acting soon enough. Where surgery is a necessity there is always +an etiological factor to be considered. The cause of the manifestation +not always being removed what is to prevent a recurrence or serious +sequela in spite of the operation? “The specialist ... if he has wit +enough to read the lesson presented to him, that it is not sufficient +to remove an ovarian tumor, e. g., and that if nothing is said at the +same time or subsequently as to the causes which induced it, a positive +damage may be done to the woman, who may, therefore, while considering +herself cured, proceed to manufacture one on the other side, or may +find herself in a few years suffering from cancer in the stump of the +previous one[14].” And so the combination of osteopathy with surgery +may be necessary that the cause shall be removed. Osteopathic treatment +before operations in reducing congestions and inflammations, also in +toning the nervous system, is particularly efficacious while the after +treatment gives gratifying results. In fact, the two go hand in hand +when conservatism rules both. + +That diet should receive particular attention from the osteopath is not +strange, for his veneration of nature peculiarly fits him to realize +the necessity of correct feeding. Probably no subject is more discussed +or presents a wider range of opinion than diet. There is overfeeding +and underfeeding; long intervals and short between feedings. There is +the no breakfast and no supper plan, mixed diet and the vegetarian, +uncooked foods, and one exclusively of milk, anything you want so long +as you are hungry but chew it well, etc., ad. lib. All are represented +by osteopaths in their following as they are from other professions, +but probably this would more nearly represent the views of them as +a school. In health, first, most people eat too much and do not +thoroughly masticate and insalivate. This applies to all stations of +society. Second, meat forms too large an item in the daily dietary. +Third, there is not enough variety and the ration is not well balanced +as to elements. Fourth, not enough care is used in preparation of +foods. In illness, first, the stopping, complete or partial, of food +until the system can take care of it; second, the giving of easily +digested foods. The man who avoids violent extremes in diet as well +as in other habits of life will usually last longest. It is to be +hoped that some rational system can be evolved on which all factions +may agree, for the present confusion of authorities is bewildering. +The osteopath gives attention to hygiene, sanitation, exercise, +environment, mental attitude, etc., as they may affect the welfare of +his patient. + +Osteopathy can cure all curable diseases, for the same forces which +will overcome one malady will overcome another when set in motion. +Forces that produce a diseased condition will it normalized restore the +established type. + + +FOOTNOTES: + +[1] Littlejohn, (J. M.)—Journal of the Science of Osteopathy. + +[2] Encyclopedia Americana. + +[3] Booth—History of Osteopathy. + +[4] Journal of Osteopathy, May, 1905. + +[5] Principles of Osteopathy, p. 190. + +[6] Journal of the Science of Osteopathy, Dec. 15, 1900. + +[7] Osteopathic Calendar, 1900. + +[8] Reported, Portland, (Me.), Advertiser, Feb. 27, 1905. + +[9] Potter’s Materia Medica. + +[10] Teall—Journal of the American Osteopathic Association, Aug., 1903. + +[11] Tasker—Principles of Osteopathy, p. 110. + +[12] Allbutt’s System of Medicine. + +[13] Cyclopædia of Practical Medicine, June, 1906. + +[14] Rabagliati—Air, Food and Exercise, p. 129. + + + + +OSTEOPATHIC ETIOLOGY AND PATHOLOGY + + +Osteopathic Etiology + +Osteopathic etiology and pathology constitutes the most interesting +chapter of osteopathic science. The primal divergence of the +osteopathic schools from previous systems is to be found in the +osteopathic interpretation of disease causes and processes, and not in +osteopathic therapy as some may think. Osteopathy makes claim to an +independent school because it possesses a distinct etiology, pathology, +diagnosis and treatment. Thus osteopathic practice is not a mere +method, but instead a system, a school, a science. + +At no period of medical history have physicians of the older schools +felt more keenly the futility of medical methods and the lack of an +all-embracing principle of medicine than at the present. A recent +writer[15] who claims to have discovered a principle that encompasses +the entire field of medicine, says: “We found, we may say, that the +backbone of medicine was the absent factor, and that if the patient +labors of so many great minds had not proven as useful in the +development of practical medicine as they should, it was because they +lacked such a fundamental framework to afford a fixed _nidus_ for each +discovery, wherein its true relation to other discoveries would at once +become evident.” + +Since the conception of osteopathy its fundamental framework has not +changed one iota as to principle, although the application of the +principle has been greatly elaborated. When Dr. Still proclaimed that +“the rule of the artery is supreme” he gave utterance to a basic +physiological truth. But when he demonstrated that osseous and other +anatamo-mechanical lesions disturbed the artery and caused disease, and +that readjustment of the anatomical cured the disorder, thus allowing +the physiological to potentiate and revealing that the living body +contains all the attributes of a vital and physical mechanism, did his +teaching contain the germ of a comprehensive philosophy; this gave +osteopathic science a “backbone” with a consequent fixed _nidus_ for +all existing facts and future discoveries. And thus, it should always +be emphasized that mechanical readjustment of the component parts of +the vital body is the eternal keynote of the osteopathic school of +healing. + +=The Osteopathic Lesion.=—Broadly speaking a lesion is “any morbid +alteration in a tissue whether attended by a recognizable structural +change or not; but especially a change in which the continuity of some +of the tissue elements is broken in upon.[16]” There are several kinds +of lesions expressing the tissue involved, character of degeneration, +locality of same, etc. But upon analyzing the medley of arbitrarily +defined lesions the fact will be evident that much of medical etiology +and pathology has not been logically and consistently sifted and +arranged; and moreover, it will be found the =cause of causes= of many +diseases is unknown. + +Herein, arises the great significance of the osteopathic lesion, for +the lesion alters the very governing and controlling tissues of the +body, viz., the nervous tissue and the vascular channels. Hulett[17] +defined the osteopathic lesion as “any structural perversion which +by pressure produces or maintains functional disorder.” The constant +maintenance of the structural perversion will, also, cause organic +disease, although it is granted that functional disorder must +necessarily result prior to any organic change. + +The osteopathic conception of a lesion, functional and organic disorder +caused by pressure from disturbed structures, does not bring us into an +absolute new field. Medical literature of all ages contains references +to diseases caused by pressure of tissues on nerves, blood vessels, or +other channels. But the osteopathic idea is an absolutely new one in +the application of this principle universally. It simplifies and makes +uniform the arbitrariness of present semeiology. + +Thus the osteopathic idea that many diseases originate, primarily, +from anatomically malaligned, malpositioned, or malrelated tissues +causing a blockage of vital processes, immediate or remote, is a theory +inclusive of disturbances to all tissues. This principle is fundamental +and is supported by the physiological truth that uninterrupted vital +channels preserve health; moreover clinical and experimental data, as +will be shown later, substantiate this fundamental. It at once places +interpretation of a lesion in an entirely new light from preconceived +concepts, and is analogous to and co-extensive with etiology and +pathology. + +=Etiological Factors.=—The osteopath believes in the potency of +inherited and environmental influences. There can be no question that +a few diseases and certain disease tendencies may be inherited, the +principle feature, however, from the standpoint of heredity is, various +organs and tissues have less vital resistance. These should not be +confounded with congenital weaknesses and diathetic tendencies. + +Environmental influences are very important factors. One’s +surroundings and daily habits in the home, shop, or office count +for much in the aggregate. Food, drink, air, rest, sleep, clothing, +exercise, mental attitude, etc., are all factors in the sum total of +health, and consequently ill health may be traceable to their abuse. +In fact, all hygienic and sanitary measures are duly considered by the +osteopath. Various abuses, over use, and disuse of the functions will +certainly be followed by physiological discord. + +The germ theory contains much truth, but in the very large percentage +of cases where the micro-organism is a factor its significance is +only of secondary consideration. Immunity and resistance comprise an +important part of the health problem, of which the intact anatomical is +of first consideration. Usually the micro-organism plays the role of an +exciting and determining factor; before it can multiply and grow there +must be a field that is first nutritionally disturbed. Nutrition of the +tissue is the one great point always to be considered. The constitution +of an individual is the pivot about which predisposing, environmental, +and exciting factors of disease center. Health represents the integrity +of the artery as well as a maintenance of that master tissue, the +nervous system, and anything that produces or influences, directly or +indirectly, a disturbance of physiological functioning borders on the +pathological. + +Hence the osteopath recognizes many of the common medical causes of +disease, but reserves the privilege of rearranging their relative +positions, for the osteopathic cause of disease greatly modifies their +value. + +=Osteopathic Etiology= distinctively emphasizes structural derangements +and perversions. Of =first= importance, owing to static requirements, +is the =osseous lesion=. This lesion is represented by any abnormal +change of position or relation of the many bony constituents of the +body. The framework of the body is subject to not only any and every +physical violence of any mechanism, but moreover being the corporeal +foundation of a vital mechanism is subject to both direct and indirect +biochemic changes and influences. + +Thus the osseous lesion is caused (a) by traumatism, e. g., strains, +falls, blows, etc.; (b) indirectly by atmospheric changes, over and +violent exercise, the slumped posture, debilitating habits, etc., +through the media of muscle changes and imbalance; (c) by nutritional +effects disturbing the elements of bony tissue; (d) by ligamentous +change such as thickening of a capsular ligament; (e) by infections; +(f) compensatorily and reflexly through the media of body distortions +and muscular irritability or debility, e. g., an innominate lesion +may be compensatory to a lumbar curvature, dietetic errors may cause +dorsal muscular irritation and contraction produce a constant osseous +lesion which in turn may result in chronic indigestion. + +The pathological changes in the osseous lesion are commonly one of +structural derangement, deviation or complete displacement. The +vertebral segments are of primary consideration owing to their +important relations to the spinal nerves, spinal cord centers and +sympathetics; the ribs owing to the close sympathetic and spinal +nervous relations; and then other osseous tissues, as the innominata, +clavicles, etc., depending upon their importance to contiguous vessels, +nerves and organs. It should always be remembered and emphasized +that mechanical changes of the anatomical structures is the primary +essential in osteopathic etiology; this is the one great inception of +pathological variations from the distinctively osteopathic conception, +which the osseous lesion typifies. Consequently the osseous lesion +factor is actually a luxation (complete, or partial, even to a very +slight degree), or malalignment of the bony constituents, which by +virtue of their physical malposition impinge or irritate contiguous +tissues. The essential test is the functional one, movement. The degree +of involvement may be one of many gradations ranging from a slight +malposition or impaction to a marked deviation or firm anchorage. + +=Second= in importance from the static requirement of support is the +=muscular lesion= though from the standpoints of movement and dynamics +it is often of the first consideration etiologically. Many interosseous +lesions are the result of spastic involvement of deep seated spinal +muscles, of fibrotic changes and of tensions and weaknesses that either +establish a rigidness of the segments, compromising nervous stimulus or +vascular channel, or produce an imbalance of muscular tone and tension. +In the latter instance some type of sidebending-rotation osseous +lesion occurs, commonly anchored within the physiologic movements of +the spine. The muscular lesion may be an actual dislocation of either +muscle or tendon, but rarely. Commonly it is a contracted, or tensed, +or contractured muscle. The muscle, also, may be diseased either from +primary or secondary causes through nutritional and infectious sources +and thus be an etiological feature. + +The muscular lesion is caused, (a) by direct or indirect violence the +same as the osseous lesion; (b) by atmospheric influences; (c) by +slumped posture, debilitating habits and various errors of living; (d) +infections; (e) by reflex irritations; (f) by compensatory changes; +(g) by disease causing hypertrophy or atrophy; and, (h) secondary to +osseous lesions, being the result of impingement to the muscles’ +nervous control. The tensed or stretched muscle may result from a +separation of the points of origin and insertion. + +Herein the fundamental osteopathic concept is the resulting affection +due to the physical encroachment, directly or indirectly, of the muscle +tissue upon vascular channel or nerve fibre, or the effect upon the +movement or alignment of the osseous tissue. + +Muscular contractions, displacements, and tensions play a most +important part in acute disorders, although muscular lesions that +are secondary to other lesions are usually taken into account when +treatment is given. Muscular lesions affect, (a) blood and lymph +vessels; (b) nerve fibres. Muscular contractions, especially, impede +mechanically the return of the venous blood to the heart. The lesions +to the nerves may be manifested in innumerable ways, depending upon the +location of the muscle and the function and distribution of the nerve +affected. + +Then there is the relaxed, overstretched, and atonied muscle. This +condition results as a secondary effect to mechanical strains, these +being so severe and constant as to cause direct stretching and possibly +tearing of the muscle fibres. This should be distinguished from the +exhausted or debilitated muscle, e. g., as found in neurasthenia and +anemia. + +Diagnostically there are, (a) contractions of more or less area, due to +atmospherical changes; (b) the deeply seated contractions involving a +very small area, caused by vertebral and rib lesions; (c) contractions +due to reflex disturbances; (d) contractions caused by postural effects +and deformities; (e) contractions from spasms of the blood vessels as a +result of nervous irritations; (f) contractions due to toxicity of the +blood. All of these characteristic muscular lesions give a direct hint +as to both etiology and prognosis. + +=Third=, the =ligamentous lesion=, as a lesion _per se_, is usually of +secondary importance to the osseous lesion. In chronic cases affections +of the capsular ligament and muscular fibrosis commonly maintain +malalignment or rigidness. There are two features that should be noted +in particular when considering this lesion; first, thickenings and +adhesions; and, second, relaxations. + +The tone and integrity of the ligaments cannot but be of vital concern +to the stability, suppleness, and adaptability of the bony framework in +all physical movements. No matter how slight the osseous lesion may be +the ligament must of necessity be involved. The osseous derangements +are either a source of irritation to the ligamentous tissue, resulting +in congestion and inflammation and hence thickening and adhesions, +or else the ligaments are so strained and tensed that in time atony +may occur. Probably, in a fair percentage of atonied cases the first +disturbance to the ligament is one of irritation and congestion, and +from long continued involvement irritation is supplanted by debility. + +Consequently the primary consideration of the ligamentous lesion from +the etiological standpoint is the character of the tissue (ligament) +changes. This, also, gives us a direct hint that is of the utmost +value in prognosis. The independent displacement of a ligament is +rare, thus ligamentous lesions from the viewpoint of purely physical +displacements are secondary to if not an actual part of the osseous +lesion. Ligaments, when displaced or tensed, readily impinge or +irritate contiguous tissues, but the original cause of the structural +perversion is commonly either the osseous or muscular lesion. Hence, +whatever factors enter into the production of these lesions will at +least indirectly produce the ligamentous lesion. + +=Fourth=, the =visceral lesion= is frequently overlooked as being of +much moment as an osteopathic lesion. Visceral displacements acting +as a source of functional and organic annoyance on the physical plane +(structural perversion which produces and maintains pressure) alone are +not in the least uncommon. + +Any or all of the abdominal viscera, or even the organs of the thorax, +may be displaced (physically) pathologically. Actual displacement of +the viscus is a prolific source of distinct disorders and many obscure +symptoms. True it is the organs are most frequently displaced from +indirect causes, but nevertheless the actual physical malposition is in +turn a primary cause of still another train of symptoms and diseases. + +Visceral lesions are caused by, (a) vertebral lesions; (b) postural +defects; (c) direct violence; (d) nutritional disorders; (e) +childbirth; (f) unhygienic measures (tight lacing, heavy skirts, etc.); +(g) congenital weakness. + +From the displaced heart due to valvular and debilitating influences +to the displaced liver, the stomach, the kidneys, the intestines, the +ovaries, and the uterus, may arise a source of direct or indirect +irritations, a train of apparent or masked symptoms, or a group of +nutritional disturbances that include an extremely important chapter +in etiology. Moreover not only may one organ alone be involved but +several may be displaced or prolapsed as a whole as in splanchnoptosis; +and even these in turn may be the direct cause of further organic +displacements as the abdominal viscera prolapsing upon the pelvic +organs. Here is a very fruitful field for the diagnostician, for to +separate cause from effect requires keen perception, an acute sense of +touch, and above all, most careful weighing of all the factors that +enter into the maze. + +=Fifth=, the =composite lesion= is not always recognized as an +extremely important osteopathic factor. By composite lesion is meant a +structural lesion that primarily includes the osseous, muscular, and +ligamentous tissues as a whole. This may be termed a lesion _en bloc_ +or _en masse_. + +Composite lesions are of exceedingly frequent occurrence. Indeed, many +composite lesions are overlooked and instead of treating the _en bloc_ +disturbance as a consistent whole the component factors are treated +separately with no concern or attention to the whole. + +Postural defects are excellent types of the composite lesion. The +various curvatures, the tilted pelvis, etc., are representative of the +composite lesion. Etiologically, pathologically, diagnostically, and +therapeutically the contour of the spine and ribs, the relation of +the innominata to the sacrum and spine, and the symmetry of the body +generally should be recognized and appreciated. The relation of the +part to the whole and of the whole to the part are of vital etiological +concern. An incipient curvature may be easily overlooked, a pendulous +abdomen neglected, and a slipped innominatum passed unnoticed wherein +as a result the entire vertebral column is malaligned in relation to +the physiological curves or to the perpendicular line of gravity. + +Frequently attempts are made to correct individual lesions when +attention should be directed to the composite lesion and _vice versa_, +e. g., a displaced rib is usually dependent upon a corresponding +vertebral lesion, and thus the transverse plane or section of the body +should be considered as a whole. A single lesion may be dependent +upon a composite lesion or a composite lesion dependent upon one or +more single lesions. A slipped innominatum or a disordered hip joint +may bring about a strain to a greater or less section of the spinal +column, or a twisted vertebra may cause a curvature, whereas on the +other hand postural defects may cause a strain at its maximum focal +point resulting in over-stretching and relaxing of ligaments so that +an osseous lesion results, or a spinal curvature cause an innominatum +displacement. Thus there is a constant establishing of equilibrium, +physically and physiologically, through the medium of compensation, +but at some phase of the change there are apt to be pathological +phenomena resulting, and very frequently physiological harmony is +not reestablished but instead irritation, debility and other disease +symptoms are constant effects until relieved. + +Consequently osteopathic etiology is many sided and complicated. To +know whether an osseous, ligamentous, muscular, visceral, or composite +lesion is primary or secondary, compensatory, reflex, predisposing, or +exciting, requires a command of theoretical knowledge backed by much +actual clinical experience. + +In noting the above distinctive osteopathic etiologic features the +student should not lose sight of the constitutional status of the +patient which may be modified by inherited, congenital, diathetic, and +environmental influences, all of which go to make up the predisposition +of the individual and have an important relation to osteopathic +factors. Then it should be recalled that disease processes may be of +insidious progress, and the products and effects of pathologic changes +accumulative. + + +Osteopathic Pathology + +In the etiologic study the osteopathic characteristics have been +designated structural maladjustment, although at the same time not +losing sight of the angle that the body is not only a physical +mechanism but also a vital organism. Structural perversions +characterize the osteopathic distinction when dealing with the +physical body, and remembering the vital or biochemic mechanism, +mental attitude, diet, hygiene, etc., are not forgotten. To retain or +attain health, thorough appreciation of both the physical and vital +mechanisms should be kept in view, for there is both an independent and +dependent interaction on the part of each. The living body being an +entity premises a system of therapeutics both physical and vital, that +acts in direct accord and harmony with physical laws and physiological +functioning. + +Osteopathic pathology deals with the distinctive osteopathic lesion as +a factor in production and maintenance of disease. Then the province +of pathology is, first, to determine whether the lesion is in reality +an etiologic factor; second, the immediate character of the lesion +disturbance; and, third, how organic life becomes involved. + +Inspection, palpation, clinical results, dissection and laboratory +experimentation include the methods employed to prove that the lesion +is of practical consequence. That the lesion is an etiological +factor can be known only through clinical and experimental proof; +the immediate character of the lesion disturbance can be determined +by dissection; and how organic life becomes involved requires the +summation of histological, physiological and pathological data. + +The following outline assumes that the reader is familiar with anatomy, +physiology and pathology. Osteopathic pathology does not add to +medical pathology an absolutely new pathology in all of the present +known numerous details, but instead interprets much of clinical +pathology anew, and furthermore it presents absolutely new data that +is exclusive, but germane to the present general medical and surgical +fields. + +Nervous tissue and arterial blood are the master tissues, the +controlling and governing factors in health, and disturbances of these +tissues are necessarily the cause of ill health. The rule of the artery +and the control of the nerve must continue uninterruptedly in order +that physiological functioning remains intact. The body should be +looked upon as a being complete, no more or less, each tissue and organ +essential to the whole and the organism as a whole essential to every +part. This is fundamental and germane to a living structure, and hence +disturbance to the governing and controlling tissues, the nerves and +vascular channels, must necessarily cause a break in the concatenation +and disease must logically follow. + +Thus in the osteopathic pathology we look to those influences that +primarily disturb the nerve or artery, study the disease process or +extension from inception to effect and from primary lesion to morbid +results, and note action and interaction of tissue upon organ and organ +upon organ. + +That all parts of the body are in intimate and dependent relations each +with the other through the media of the nervous and endocrine systems +is a well known fact based upon histological and physiological grounds. +The neurone being the physiological unit implies that any disturbance +to the cell quickly disturbs any or all of its processes. It may be +said that “nervous tissue is dependent for its integrity upon two +things, blood supply and trophic influences. The nerve cell is solely +dependent on a proper supply of blood, and dies when this is withdrawn. +But the nerve fiber is more dependent on the trophic influence of the +cell of which it is a prolongation. It dies when cut off from the cell +but it can get along for a time with but little direct blood supply. On +the other hand, if the nerve fiber is injured it reacts on the cell, +leading to a partial but curable degeneration of the cell body.”[18] +Here is the immediate pathologic key to many diseases. Whatever cuts +off or obstructs the artery leading to the cell is a primary etiologic +factor; this then leads to degeneration of protoplasmic processes and +axone. It should be carefully noted that if the obstructed blood vessel +is one to the nerve fiber only the resultant partial injury to the cell +is curable. + +“When an axone degenerates the retrogressive process involves not only +the main axone, but also its terminals, together with the collaterals +belonging to it with their terminals.”[19] This is an exceedingly +important link in the explanation of osteopathic pathology, that +distant organs may be affected by the osteopathic lesion. Moreover, +“degenerations of a secondary character may occur in those systems of +neurones which are more or less dependent upon the peripheral sensory +neurone system for their impulses.”[20] This is equally true with the +central motor neurone, or any neurone. It shows how far-reaching a +degenerative process and its effects may be. It further makes clear +that nerve intactness is directly and absolutely dependent upon a +normal circulation, and that it is self-evident any blockage either to +blood vessels or to neurones will vitally affect those tissues that +govern and control the life processes of the body. The integrative +action of the nervous system is one of the outstanding facts of +physiology. + +The above is presented so the student may see how osteopathic spinal +lesions, if deeply seated and effective enough, can involve remote +tissues and organs. No one will doubt that fractures and complete +dislocations of the spinal column will seriously affect visceral life, +or a prolapsed kidney will be a cause of nutritive disturbance, or a +displaced uterus the cause of ovarian congestion, or a dislocated hip +the cause of atrophy of the leg muscles, but it has remained for the +osteopath to offer proof that slight misplacements of the vertebræ or +ribs, incipient curvatures, postural defects, slight deformities, and +unsymmetrical bodies are of sufficient etiological importance on the +physical plane to affect neurone integrity and obstruct artery courses, +and thus organic life. + +The question at once arises, what is the immediate or direct effect +upon blood vessel or nerve of the osseous, ligamentous, muscular, +visceral or composite lesion? The osseous lesion will be taken as +a type. The direct effect is usually one of hyperemia or ischemia, +generally the former, for as physiologists and clinicians observe +irritation commonly precedes debility. In the vertebral and rib lesions +there may be direct pressure upon the spinal nerve at its spinal +foramen exit or on the sympathetic chain directly contiguous to the +heads of the ribs. This causes congestion, inflammation, ecchymosis, +and degeneration of the nerve fiber, followed by macroscopic and +microscopic changes as connective tissue proliferations, arterial +scleroses, etc. Or, as seems probable in experimental work, the +inception of the pathology may be frequently the result of blockage to +nervous stimuli, which when maintained affects the efferent vasomotor, +secretory, trophic and other fibers so that circulation and nutrition +are definitely involved. + +Thus the cells so sensitive to altered vascular changes are directly +and remotely affected, and disease characteristics dependent upon +structure and function of tissue, and degree of irritant are evident. +This can vary, in degree only, with the muscular lesion that involves +collateral spinal cord circulation, the visceral lesion that irritates +sympathetic life, or the composite lesion that deforms or perverts +structure en masse. + +But is the physical noxa as potent an etiologic factor as the chemical +or bacteriologic? Adami[21] informs us whether an irritant is physical, +bacterial or chemical, no satisfactory distinction can be founded on +the duration of the irritation; that a local irritation of the nervous +system may lead apart from “direct reflex action, to changes of nervous +origin, in the region of the injury and in the reflexes affecting +associated regions, the higher centers; and through them the system +at large, may become affected by paths that it is not always easy to +trace.” Again he says that “centrifugal impulses alone, apart from any +local injury, may originate a succession of phenomena of inflammation +in a part.” And “in all probability a nervous and central origin must +be ascribed to some, at least, of the sympathetic inflammations seen +to occur in areas supplied by the other branches of a nerve supplying +a part primarily inflamed; and again in areas supplied from the same +region of the brain or cord as the inflamed organ.” Other inflammatory +changes, of course, may occur independently of centrifugal nervous +influences, and the vessels react independently of central influences. + +This, then, presents a situation postulated thus: + +1. The body follows definite structural relations and is influenced by +mechanical arrangements in its morphology. + +2. The integrity of tissue depends upon structural freedom of nutritive +courses. + +3. The above predicates a structural etiology as exact and precise as +structural relations are important to nutrition. + +What proof, then, of the foregoing have we to offer? + +First, the =clinical proof=. Clinical results have been obtained in +tens of thousands of cases that include disease of various types +and lesions, and of all sections and organs of the body. The art of +osteopathy has been perfected in many of its details, based upon actual +experience and splendid results. The cure of the patient is paramount +to all other consideration, and whereas the osteopathic school has +been shown a superior system it logically follows on _a priori_ +grounds that relief and cure of suffering is of the first and final +importance.[22] + +Were it not for clinical results no new system of therapeutics could +withstand criticism and calumny and finally triumph and be publicly, +legislatively, and scientifically recognized. + +Second, the =autopsy proof=. Many dissections have been made and +autopsies held with the view of discovering the character and the +potency of the osteopathic lesion. This very important work has borne +out the osteopathic theory of disease. Vertebral and rib displacements +have been noted, corresponding ligamentous tissues thickened, +associated nerve tracts and vascular channels disturbed, and finally +the related organ found diseased.[23] + +Third, the =experimental proof=. Experimental proof appeals, logically, +to the scientific mind. This proof[24] is being gradually developed. + +Experimental investigation has been successfully carried out upon +numerous animals. The experiments conclusively prove that not only +spinal inhibitory and stimulatory manipulations (mechanical) are +productive of immediate physiological changes in the viscera, but that +the structural anatomical lesion or noxa is an important factor in +the etiologic field. Pathological changes in several organs directly +follow the artificially produced vertebral and rib lesions, showing +beyond doubt the reality and effectiveness of the osteopathic lesion. +This emphasizes the point that centrifugal impulses originate an +inflammation in a previously healthy and uninjured tissue or viscus. +And as “inflammatory phenomena may be sympathetically developed in +regions innervated from the same area in the brain or spinal cord” +it remains to prove the actuality of vertebral and rib lesions, i. +e., structural perversions really affect contiguous nerve courses +and vascular channels; and this has been demonstrated in laboratory +experiments and at the autopsy. Consequently the vertebral, rib, or +other lesion may be an important etiologic factor either to the nerve +strand from cord or brain to viscus or from viscus to cord or brain. + +Dr. Still says in his Autobiography that “all nerves depend wholly on +the arterial system for their qualities, such as sensation, nutrition +and motion, even though by the law of reciprocity they furnish force, +nutrition and sensation to the artery itself.” It matters little in +this outline whether obstruction to nervous integrity is by way of +an impinged artery or by direct pressure, or both, or otherwise, +for the primary consideration is the noting that the osteopathic +lesion is a real and potent factor of disease. Sajous[25] informs +us that “a neurone is directly connected with the circulation (via +neuroglia-fibril) by one or more of its dendrites, which serve as +channels for blood plasma,” that a neurone receives its nutrition +directly from the general circulation, and that from the axone the +blood passes into a lymph space connected with a vein. Thus in reality +a part of the circulatory system is that of the entire cerebrospinal +system. + +The student is referred to the various publications of the Research +Institute and Deason’s Physiology for experimental data confirming the +validity of the osteopathic theory, although it should be emphasized +that clinical evidence is quite conclusive. Malalignment injuries of +the vertebral articulations, for example, ranging from imbalance of +muscular tension to infections, is certain to result in some type of +rotation and sidebending of the segments to an extent that apposition +is compromised and abnormal anchorage supervenes. There are many +factors of the pathology: muscular tension and fibrosis; damaged +ligaments, particularly the capsular; interference of nervous stimuli, +blockage of impulse directly and reflexly as shown by pathologic +involvement in cord centers and sympathetic ganglia, and in certain +cases direct obstruction of nerve fibers as revealed by Wallerian +degeneration; involvement of circulation as shown by damage to +blood-vessels, local edema and local acidosis, and effect upon local +tissue respiration and drainage. Through a combination of these various +factors circulation, nervous equilibrium and chemism of related parts +are involved, both anatomical and physiologic balance is upset, and +resistance of corresponding viscera affected. Reciprocal innervation +and the axone reflex are also disturbed, all of which are important +predisposing causes that disturb resistance of tissues and organs, +upset their correlated mechanisms and render active various possible +infections and toxins that otherwise a normal circulation, nervous and +endocrine systems, and oxygen supply would rapidly and successfully +combat and restore the organism to normal. Thus from the practitioner’s +standpoint there are three points to always keep in mind: readjustment +of the lesion; correction of the forces, habits, environment, etc. that +produce the lesion; and hygienic attention of the body after lesion +adjustment in order that normal condition may be maintained. A thorough +study of the physiologic movements of the spine is a prerequisite +to an understanding of the various possible abnormal appositions, +though it should be appreciated that these movements are not consonant +or applicable to many abnormal conditions. Pathology reveals many +gradations and combinations not found in normal conditions. Frequently +the key of a successful technique rests upon an understanding of the +individual make up of the interosseous lesion. + +It has not been the purpose of this section to go into details but +rather to follow logically an outline of osteopathic etiology and +pathology. The various details will be found in the osteopathic works +on Principles as well as in the experimental articles referred to. It +should be understood that the osteopath believes thoroughly in _vis +medicatrix naturae_ whether the indications are for stimulation or +inhibition or for the basic readjustment. Generally speaking, however, +therapeutic philosophy resolves itself (ultimately) into the principle +that a cure depends upon giving an impetus to impaired, habitual and +latent forces, which in the osteopathic field implies fundamentally +adjustive manipulation whereby the resultant impetus or physiological +stimulus is initiated. + +In a word, osteopathy premises that the body is a vital and physical +mechanism subject to derangements, structural alterations, and +functional changes, as results of violence on the mechanical plane, +as well as disturbances on the psychic and biochemic planes. Hence, +osteopathic philosophy is inclusive of preventive, palliative and +curative measure. + + +FOOTNOTES: + +[15] Sajous—The Internal Secretions and the Principles of Medicine. + +[16] Foster—Medical Dictionary. + +[17] Hulett—Principles of Osteopathy. + +[18] Dana—Text Book of Nervous Diseases. + +[19] Barker—Reference Hand Book of the Medical Sciences. + +[20] Delafield & Prudden—Hand Book of Pathological Anatomy and +Histology. + +[21] Adami—Inflammation, Allbutt’s System of Medicine. + +[22] See Case Reports, American Osteopathic Association. + +[23] Clark—Applied Anatomy. + +[24] McConnell—Numerous articles Journal A. O. A. 1905-19, Bulletins +Research Institute; Deason, Bulletins Research Institute, Deason’s +Physiology; Burns’ Osteop. World, Aug. 1905; Basic Sciences, Bulletins +Research Institute; Pearce, Osteopathic Physician, Nov. 1905. + +[25] Sajous—Internal Secretions and the Principles of Medicine. + + + + +OSTEOPATHIC DIAGNOSIS AND PROGNOSIS + + +Osteopathic Diagnosis + +In osteopathic diagnosis the spine is the first and greatest object +of interest, for on the result of its examination will depend the +treatment to be given which is in turn hoped to bring about recovery. + +As it is the structure on which rests the weight of the body the +practiced eye is able to detect at a glance, by the poise and gait +of the patient, if there is an abnormal condition affecting any +considerable area of the spinal column. It is well to observe these +points, especially in the female, before having them prepare for +examination, as it will often give a clue to sources of trouble through +faulty carriage, improper dress, particularly corset and shoes. Slight +changes of gait, unnoticed by the patient may be of great aid in +determining the beginning of disease in the spinal cord. + +No osteopath is justified in accepting a patient who will not permit +every examination deemed necessary, as remote and obscure lesions are +frequently the cause of disease, so preparation of the patient for the +first scrutiny is of importance. This cannot be made with the patient +fully clothed, as visual observation is second only to the touch in +making one’s deductions. Neither can palpation be made through more +than one thickness of clothing with accuracy, and examination next +to the skin is always preferable. This need in no way ever cause +complaint, for with the use of a loose fitting short kimono, with all +outer clothing removed except the knit undergarment, and with skirt +bands loosed, a complete survey of the whole dorsum from occiput to +coccyx can be had without the slightest unnecessary exposure. It is +well to remember that the patient has come for help and the osteopath +is not justified in sacrificing thoroughness for any exaggerated +feelings of modesty. With tact and care in the use of the garments the +most sensitive ones need feel no hesitation in coming for treatment. + +A complete history of the case should be taken before the examination +begins, former methods of treatment, symptoms, environment, etc., as +it will aid in the final conclusions. It is well to have blanks for +keeping records of all cases. + +Probably the most comfortable manner to begin physical examination is +to seat the patient on a table squarely with hands placed upon the +knees, then raise the garment and expose the whole back. Begin by +noting the texture of the skin, if it is clear, pigmented, blotched, +or has eruptions. Try the capillary reflex by pinching or stroking +quickly with the finger tips or the blunt end of a pencil. Find if it +is moist or dry and also outline the areas of changed temperature, if +any. Then observe the general contour of the spine with the patient +sitting upright, to find how near it is to the normal body curve. + +Occasionally having the patient alternately sit and stand will, by +comparison, throw light upon the condition. With the patient bending +forward place the hands on the crest of the ilia and see if they are of +equal height. + +Occupation may result in over development of one side or there may be +congenital asymmetry[26]. Note position of the scapulæ and habit of +posture in sitting and standing. + +Before taking up the subject of a critical examination of each vertebra +there are certain points it will be well to consider. It is easy to +know instantly, without counting, the number of the vertebra causing +the lesion if these landmarks are remembered: First, the spine of the +third dorsal is on a level with the spine of the scapula. Second, the +spine of the seventh dorsal is on a level with the inferior angle of +the scapula. Third, the spine of the last dorsal is on a level with the +head of the last rib. It will save much time for the busy osteopath to +have these well in mind. + +The =pathognomonic symptoms= of the osteopathic lesion are: (a) +maladjustment; (b) contracted muscles; (c) tenderness; (d) limited +movement. To these might be added changes in local temperature and +disturbance of function, but the former is not constant and the +latter may be remote. Here the primary lesion is considered, for an +osteopathic lesion may be, also, secondary or compensatory. Forbes +speaks of compensatory changes as being an important diagnostic sign. + +Diagnosis of the position of a vertebra is sometimes difficult to the +beginner from its having longer or shorter spines than normal. Horsley +speaks of the occasional congenital absence of a spinous process. +They may be bent laterally, upward or downward and thus have all the +appearances of a marked displacement, while occasionally the body +itself seems much at fault. These present what might be termed normal +abnormalities and make it necessary for the osteopath to be very sure +of his diagnosis before attempting to correct what is not abnormal, for +disappointment, at least, and injury, perhaps, may follow. + +To avoid mistake, carefully palpate the transverse processes and +determine if they are at right angles with the adjoining normal spine. +In the cervical and lumbar vertebræ it is possible to reach the tips of +the transverse processes, and on moderate pressure, if a lesion exists, +pain will be elicited. Further, where tenderness is associated with +other diagnostic points it can be safely assumed that a lesion exists, +and by outlining the suspected vertebra with the finger and localizing +the sensitive spot one can be sure of the point of greatest irritation +and the character of the displacement. Associated also with these signs +will probably be evidence of congestion, such as thickened tissues, +contracted muscles, etc. + +After having examined the condition of the spinal column thoroughly by +inspection, begin at the first dorsal and examine the spinal column +down to the sacrum. Place the middle and ring fingers over the spinous +processes and stand directly back of the patient and draw the flat +surfaces of these two fingers over the spinous processes from the upper +dorsal to the sacrum in such a manner that the spines of the vertebræ +pass tightly between the two fingers, thus leaving a red streak where +the cutaneous vessels press upon the spines of the vertebræ. In this +manner slight deviations of the vertebræ laterally can be noted with +the greatest accuracy by observing the red line. When a vertebra +or a section of vertebræ are too posterior a heavy red streak is +noticed and when a vertebra or vertebræ are anterior the streak is +not so noticeable. Thus when suspicious points are noticed a special +examination of the localized point can be given. This examination +simply takes into consideration the contour and superficial condition +of disordered portions of the spinal column. In a few cases such an +examination will not be necessary, for the symptoms and signs of the +disease will be so clearly manifested that one’s attention will be +called directly to the cause. Still, great care should be taken in the +majority of cases, as the osteopath finds causes of disease remote from +the seat of complaint. We must always bear in mind the significance of +reflex stimuli and sympathetic radiation. + +In making a critical and exhaustive diagnosis of the spinal condition +after the foregoing general examination has been made, it will be best +to have the patient lie on the side upon the operating table. When the +patient is in this position a more thorough examination can be made, +as then the spinal muscles are not contracted unless abnormally so, +for when a person is in the upright position muscles are continually +contracting first on one side and then on the other, as one of their +functions is to act as a support in keeping the spinal column erect. +The patient lying on his side, the physician should then stand in front +of him and reach over upon the back and make a thorough examination of +the affected portions of the spinal column, chiefly through the dorsal +and lumbar regions. + +Consideration should be given the contraction of the muscles along the +back, chiefly the deeper layers of muscles. It may even be necessary +to relax some of the muscles before a thorough examination of the +vertebræ can be made. From a pathological point of view too much stress +should not be put upon the contracted state of the muscles; although +in a number of instances the contracted muscles may be the primary +cause of the patient’s trouble; especially so when the affection is +due to atmospheric and other changes. Contraction of the muscles may +be secondary to the lesions presented in the bony frame work. For +instance, a dislocated vertebra may be the cause of an irritation to +the innervation of certain muscles along the spinal column and thus +cause them to contract. Still, we must not lose sight of the importance +of the contracted muscles from a diagnostic point of view. They are +oftentimes prominent signs that a lesion exists in the immediate region +and are thus faithful guides in locating the cause of diseases. + +In closing the general consideration of the spinal column it is +well to emphasize the importance of training the faculties to grasp +at a glance the story told by the back as a region, instinctively +placing the proper value on each physical sign and weaving them into +a composite whole so that the patient’s condition stands out a vivid +picture on the osteopath’s mind. When this is accomplished the more +detailed observations are but incidental. Relative to the examination +of the spinal column Clark[27] says: “To the osteopathic physician, +the most important part of the human body is the spinal column. By its +changes in contour and condition the various visceral diseases can be +diagnosed, in most cases. I believe that every disease is characterized +by extreme changes or signs, and I further believe that every chronic +visceral disorder is manifest by changes in the spinal column that can +be, by the practical eye and touch, readily interpreted. In short, +there are various signs along the spinal column that point out the +weakened or diseased parts of the body. This method of diagnosing +disease, that is by noting these spinal changes, is distinctly +osteopathic, and I believe the time will come when it will become such +an exact science that the character of the spinal change or lesion is +diagnostic not only of the viscus affected, but the way it is affected.” + +Regional examinations and diagnosis will now be taken up. + +=Neck, Head and Face.=—To make a thorough diagnosis of the condition of +the cervical vertebræ probably requires more skill and a more acute +sense of touch than of any other region of the body. The irregularities +and variations of the cervical vertebræ, the numerous muscles and the +passage of many vessels through the neck are very liable to mislead one. + +One may examine the cervical vertebræ by having the patient either +lying down or in a sitting posture. The former position is preferable, +as then the muscles of the neck are passive, and besides it is much +easier to relax the muscles if such should be necessary. Also one has +better control of the field of examination. + +It is undoubtedly best for the student when learning to examine the +cervical vertebræ to first examine along the base of the skull the +condition of the occipital muscles (after the patient has assumed the +dorsal position upon the treating table) for any contractions; for if +disorder exists in the upper five cervical vertebræ the condition will +be manifested by contraction of muscular fibres along the base of the +occipital bone. The muscles of the occiput are supplied by fibres from +the posterior branches of the upper five pairs of spinal nerves, and if +lesions exist to these upper nerves a contracted state of more or less +extent of the occipital muscles will occur, no matter how slight the +lesion. Thus the examiner after locating contracted fibres under the +occiput has a direct clue to lesions existing somewhere in the upper +five cervical vertebræ. After locating these contracted fibres of the +occipital region and then still keeping the finger upon the contracted +muscular fibres and following them downward until the contractions +are lost and seem to enter the spinal cord, one has then located the +exact point of disorder that is causing the irritation to the muscular +fibres involved, and most probably the cause of the affection from +which the patient is suffering, i. e., provided one has reason to +suspect the trouble is in the cervical vertebræ. Simply follow the +contracted muscular fibre downward until it seems to enter the spinal +cord and there one will find a lesion. After the osteopath has become +expert in diagnosis this will not be necessary unless he has to make +a very fine diagnosis or unless he is examining a stout neck where it +is hard to examine through the heavy muscles. With this method one has +a firm, flat, broad surface to work on (the occipital bone) making it +very easy first to locate contracted muscles and second to trace the +course of contracted muscles and thus find the disorder. Otherwise the +beginner is apt to get confused by trying to examine the condition of +the cervical vertebræ. Later, when a student becomes more expert such a +procedure will rarely be necessary only in cases that require special +work in the examination. + +When the point of disorder has been located the diagnosis as to +the exact character of the maladjustment has to be determined. The +abnormal position of the vertebra, tenderness at the point involved, +local contracted muscles, and limited motion are the four diagnostic +points, although the temperature of the affected part as compared with +the general cutaneous temperature and the state of the local vascular +channels (blood and lymphatics) will occasionally be of aid. + +Owing to the irregularity of the spinous processes of the cervical +vertebræ in regard to their length, great care has to be taken in the +examination. Probably there is no other region of the body that will +tax the patience of the osteopathic student so much in his practical +work as making a diagnosis of disorders in the cervical spine. It +requires patient and persistent work to become a fair diagnostician of +the cervical region, and it will take much experience to become expert +in both the examination and treatment. + +One can depend that lateral deviations of the spinous processes are +abnormal in most instances. Placing the finger upon the spinous +processes of two consecutive vertebras the student can readily tell +whether or not there is any lateral displacement; but telling as to +other features is impossible as the spinous processes vary greatly in +length. When a vertebra is lateral, a slightly twisted condition will +be felt by the finger when placed upon and between the two spinous +processes. + +To elicit the various degrees and combinations of rotation and +sidebending one should depend upon the symmetry of the transverse +processes. Reaching anterior to the sternocleidomastoid muscle, or +better still, pushing the cleido muscles forward and reaching posterior +to them upon the transverse processes, a very fair examination can then +be given the vertebras. When the vertebras are deranged, especially +anteriorly or posteriorly, that is the apposition of the articular +facets, a slight elevation will be felt, possibly not any larger +than a very small pea, either the anterior or posterior aspects of +the transverse processes, depending upon which way the vertebræ are +deranged. Remember that accompanying this slight elevation will be +degrees of sensitiveness of the vertebra at the point deranged. In +cases where the vertebra is lateral a slight eminence will be noted +along the outside of the process. Commonly disordered vertebræ are +not entirely deranged in one direction but are oftentimes slightly +rotated, so we may find them dislocated antero-laterally or in various +combinations of sidebending-rotation. Several consecutive vertebras +may be deranged in like manner of direction; this condition is chiefly +found in pathological curves of the spinal column. Probably the most +common general lesion is a strained condition of several consecutive +vertebræ, each one being nearly intact but all of them as a whole +somewhat strained or twisted. Thus there are many pathological states +to take into consideration, although it is not surprising to the +osteopath when he realizes that many of our pains and aches are due to +anatomical derangement. Frequently bending the head strongly forward +and downward, or downward pressure with slight rotation will produce +pain at the point of lesion. + +Subdislocations of the =atlas= are probably among the most common +lesions presented to the osteopath. Owing to the articulation of the +atlas and occipital bone being an anatomically weak point and the +neck muscles being exposed constantly to atmospheric changes, besides +the articulation between the head and neck receiving the brunt of +many jars, falls and strains, the atlas is especially susceptible to +derangements. On account of the intimate relation of the atlas to the +superior cervical ganglion of the sympathetic and to the vertebral +blood vessels it is certainly very necessary that the atlas should +be well taken care of. No other tissue maintains such a significant +position in relation to the blood and nerve supply to and from the +brain. To diagnose correctly the position of an atlas and to be able to +correct it is undoubtedly one of the most essential achievements of the +practitioner of osteopathy. + +The most common disorders of the atlas are anterior and lateral +displacements. Next in order come “rotary” lesions of the atlas, i. e., +where the atlas has been deranged diagonally or simply twisted. It may +also be luxated anteriorly and laterally, or posteriorly and laterally, +etc. A posterior derangement of the atlas is comparatively a rare +disorder, although owing to the many lesions that are found in atlases +one has, during the course of a year’s practice, several to correct. +The atlas may occasionally be slightly tipped laterally, anteriorly, or +posteriorly, and in a few cases it may be somewhat impacted against the +occipital bone. Many times when the atlas is displaced the axis is also +deranged on account of the close relation between the atlas and axis by +the odontoid process of the axis. + +To examine the atlas the patient may be either in the sitting or dorsal +posture; it matters but little which position is taken. Possibly the +dorsal position is better, as then the neck muscles are more relaxed +and if necessary an examination of the cervical spine, below the atlas, +can easily be made. + +By placing the middle finger of either hand on the transverse processes +of the atlas when the patient is in the sitting posture, or the thumbs +on the transverse processes when the patient is in the dorsal posture +and comparing the two sides, undue prominence of one side or the +other can easily be noted. Remember the transverse processes of the +atlas are slightly above and posterior to the angle of the inferior +maxilla. Always, in examining one side of the patient, compare it +with the other; it may save considerable embarrassment. One side may +seem abnormal when by comparing it with the other side, both sides +may be found the same and still be normal. With the fingers still +on the transverse processes note the distance between the process +and angle of the jaw, besides take into consideration the tenderness +of the locality, and, also, what is of essential importance in all +interosseous lesions, its articular range of movements. There should +be room enough (approximately) to just comfortably wedge the end of +a medium sized middle finger between the transverse process of the +atlas and the angle of the inferior maxilla when both are normal. Thus +with the fingers on the transverse processes an expert will be able to +readily determine whether or not an atlas is lateral or anterior. If +an atlas is posterior the distance between the angles of the jaw and +the transverse process will be increased, besides the atlas will be +quite prominent posteriorly. In conjunction with the abnormality of the +tissues (prominence or depression of the bone and state of the muscles) +the sensitiveness of the locality is extremely significant. + +Outside of displacements of the atlas, a lesion between the =axis= +and =third cervical= is most common; following next in frequency are +lesions of the =skull= and =atlas=. By that is meant where all the +cervical vertebræ are intact as far as their individual relation is +concerned, but the skull is forward, backward or lateral upon the +spinal column. This condition occurs quite frequently. To determine +its condition the same methods are employed as in diagnosing a +deranged atlas; for if the dislocations exist between the atlas and +skull the same diagnostic points are presented as far as the skull is +concerned as when the atlas, or atlas and axis, are dislocated from +the occipital bone or from the axis or third cervical. Following the +preceding examinations, additional examination will have to be made to +see whether or not the atlas is intact with the vertebræ below. If the +atlas is found to be intact with the vertebræ below and lesions are +presented between the atlas and the skull, then the disorder must be +between the atlas and the skull and nowhere else. Occasionally there +are cases where the skull is so far posterior upon the spinal column +that the angles of the jaw strike against the transverse processes of +the atlas when the jaw is opened widely. + +Derangement of the =muscles= of the anterior and lateral regions of +the =neck= are common. Especially are contractions of the muscles on +either side of the larynx liable to occur. In examining the cervical +region do not pay too much attention to the superficial muscles, +but examine carefully the deeper muscles. It is from these that +impingements of nerves and constrictions of vessels are likely to take +place in the contracted fibres. Also, imbalance of muscular tension +may be the source of the resulting malalignment. In examining for +contracted muscles do not gouge into the muscle nor grasp the muscle +roughly, but bear down lightly (inhibitory) upon the muscles and then +gradually exert firmer pressure. By carefully and firmly exerting +pressure over muscular areas the deep muscles can then be felt beneath +the superficial ones. Otherwise when the muscles are manipulated +severely the superficial ones will contract to such an extent that the +deeper ones cannot be felt. The muscles contracting on either side +of the larynx tend to draw the larynx downward and thus there may +arise a source of irritation. The various muscles contracting in the +antero-lateral region of the neck are very often the source of chronic +irritations of the pharynx or throat. The omo-hyoid muscle may become +contracted and cause slight traction on the hyoid bone and thus produce +an irritating cough. To examine the muscles of the neck thoroughly it +is best to have the patient flat upon the back, for then all the normal +muscles are relaxed. + +Lesions quite frequently occur in the =temporo-inferior maxillary= +articulation. The lesion may be either unilateral or bilateral, more +commonly the former. The disorder usually consists of a relaxation of +the muscles and ligaments about the articulation which allows a slight +but perceptible dropping of the inferior maxilla on the side involved. +In other cases there may be presented a spasticity of tissue, while in +still others some degree of joint infection may be found. Lesions of +this articulation particularly impinge upon fibres of the fifth cranial +nerve. The points of diagnosis are clicking and tenderness at the +articulation. These two points are the symptoms of which the patient +complains; those noticed by the osteopath are a slight deviation of the +jaw to one side or the other when the jaw is opened and a flinching +of the patient due to tenderness when pressure is exerted over the +articulation of the jaw. When the physician places his fingers around +the jaw, anterior to the angles, and the thumbs over the bridge of the +nose, having patient open the mouth, at the same time exerting pressure +with the fingers and thumb, a sharp click may be elicited by the return +of the jaw into its articulation. + +In disease of the =scalp= the condition of the muscles of the scalp +should be taken into consideration. The muscles are usually found +contracted. The contraction of the muscles is generally due, as well +as the disease of the scalp, to derangement existing in the posterior +branches of the upper five pairs of the cervical spinal nerves. + +In the =neck=, anteriorly the =hyoid= is the only bone to consider. It +is easily palpated by standing at the head of the table and with the +second finger of each hand outline both ends to ascertain its relation +with the thyroid cartilage. Note carefully any contracted tissue or +glandular enlargements which might cause undue tension. The tilting +of either end of the hyoid from these contractions is productive of +much throat irritation. At the same time the =larynx= may be examined. +It may be prolapsed, causing irritation of the laryngeal group of +nerves. The =thyroid= and =cervical= glands should be palpated for +enlargements, and all the muscles and ligaments for contractions. +Externally the =tonsil= may be felt by deep pressure in front of the +angle of the inferior maxilla. + +=The Ribs.=—Under the osteopathic diagnosis of the ribs will be +included the examination of the clavicle and sternum. To be able +to diagnose intelligently, the position of the ribs in detail is +very necessary to the osteopath. Many of the diseases of the heart +and lungs, besides a large number of the diseases of the digestive +tract, may be traced to a deranged rib; also, occasionally diseases +of different regions of the head and neck may be due to dislocated +ribs. In making a thorough examination of the ribs each rib should be +carefully noted as to its position. The ribs may be examined when the +patient is sitting up; but it is better to have the patient flat upon +the back and especially so if the floating ribs are to be carefully +examined, because the muscular tissues of the side if contracted will +interfere with the diagnosis. In many instances the rib lesion is +secondary to a vertebral subluxation. + +An expert osteopathic diagnostician will be able to detect at once +by a single passage of the hands down over the ribs if there are any +disorders of them. In passing the flat of the hand, especially the flat +part of the fingers over the ribs, carefully observe if the intercostal +spaces are too narrow or too wide, and if any of the ribs are unduly +prominent or depressed. If an intercostal space is too narrow it shows +that the ribs on either side of the intercostal space are too close +together. Then the question arises, which one of the ribs is crowding +upon the intercostal space, or whether both of the ribs are crowded +together. Usually when the sternal end of the rib is displaced upward, +the involved rib is prominent and when displaced downward the rib is +depressed. Thus it is commonly easy to diagnose which is the involved +rib. Besides finding an abnormal position of the rib there will be more +or less tenderness over the rib. Finding a rib prominent or depressed +and tender is generally quite conclusive that the rib is displaced. +Then the range of movement as expressed through the sense of resistance +is a helpful guide in diagnosis. + +If a =typical rib= is placed upon a flat surface and one end of it +is depressed the other end will be elevated and _vice versa_. This +peculiarity holds true as well when the ribs (typical) are dislocated +in the living body. If the anterior end is elevated the posterior +end is commonly depressed and _vice versa_. Care should be taken in +examining the first rib and the false ribs, for in these ribs this +peculiarity is not found. + +As a whole a very complete diagnosis can be made of the condition of +the ribs by examining the anterior part of the thorax, although it is +always best to examine along the angles of the ribs if for nothing more +than to confirm the diagnosis made at the sternal ends. Still it must +be remembered that the preceding only holds good when the entire rib is +dislocated. Many times simply one end of the rib is deranged and the +other end is practically intact. + +Besides careful examination of the sternal end of the rib, attention +should be paid to the condition of the costal cartilages. The costal +cartilages may become deranged at either the articulation with the +rib or with the sternum. The same rule holds good when the costal +cartilages are dislocated as when the ribs are dislocated, i. e., when +the cartilages are prominent, they are usually displaced upward and +when depressed the cartilage is displaced downward toward its neighbor. + +One is apt to think that a rib is only dislocated at its vertebral +end. Although lesions of the vertebral end are generally of greater +significance as far as the etiological factors are concerned, still +the sternal end of the rib must not be overlooked. In examining the +vertebral end of a rib attention should be paid the angles of the +ribs, for at the angles a better opportunity for examination is given +on account of the prominence. It will be necessary in many cases to +find out whether or not the vertebral end of the rib is lying between +the transverse processes instead of in front of them. In many severe +lesions of the ribs the vertebral end of the rib is dislocated upward +or downward from the transverse process of the vertebra and lies +between the transverse processes of the vertebræ above and below +its attachment. This certainly requires considerable skill in the +diagnosis, for oftentimes the point to be found is barely an eighth +of an inch in diameter. It is usually best before making such a close +examination to relax the tissues well over the field of examination. + +The =ribs= as a whole may be too transverse or too oblique upon one +side. This is chiefly found in pathological curves of the spine, but +still such conditions may exist where there are severely contracted +muscles, especially in some cases of paralysis. Thus the contour of +the ribs must be taken into consideration by comparing one side with +the other. + +In examining the =first rib= an examination somewhat different from +the other ribs should be given. It is best to have the patient assume +a sitting posture; then place the middle fingers of each hand upon the +first ribs near their centers and compare one with the other. Also note +the difference of the spaces between the ribs and clavicles. Generally +the first rib is dislocated upward, rarely downward. Besides finding an +abnormal prominence or depression of the rib at its center considerable +tenderness will be noticed. Examinations of this region are every day +experiences with the osteopath. + +When diagnosing the position of the =floating ribs= it is best to +have the patient lie flat upon the back with the thighs flexed upon +the abdomen, so that the tissues about the lower ribs may be entirely +relaxed. Then by placing the flat of the fingers carefully over the +ribs the outline and position of them can be easily discerned. The +floating ribs are oftentimes found deranged and are the source of a +great deal of suffering through the iliac regions. These ribs may +become dislocated from the vertebral ends and drop down obliquely +toward the iliac crest, or else the free end may become locked beneath +the rib above. Occasionally both ends of the rib drop down quite +perceptibly and consequently is the cause of considerable distress. In +such instances the rib is depressed inward so that the normal contour +of the lower thorax is lost. + +An examination of the =clavicle= should be carefully made. Always +compare the clavicle with its fellow and examine thoroughly its +articulation with the sternum as well as at the acromial prominence. +Often the sternal end of the clavicle is slightly dislocated +posteriorly to the sternum; although it may become completely luxated. +The acromial end may be dislocated upward or downward. + +In examining the =sternum= special attention should be given the +articulation of the manubrium and gladiolus. This is due to the +crowding anteriorly of the articulation of the sternal parts. Normally +until well along in adult life there should be some movement here due +to its membranous attachment. Occasionally the ensiform cartilage +is turned inward, producing a tender point, but this rarely occurs. +Also the articulation of the cartilages in the region of the eighth, +ninth, and tenth ribs may be found considerably deranged, causing local +tenderness and even stomach trouble. + +=Dorsal= and =Lumbar Spinal Region=.—With the patient sitting on the +table abnormal deviations can be readily noted. There may be lateral +swerves, from muscular weakness, or unilateral tension, involving +the whole spine or less, or a reversal of natural curves, i. e., the +spine depressed anteriorly between the shoulders and posteriorly +in the lumbar making the straight spine. There may be, also, an +exaggerated normal curve in the dorsal region producing a kyphosis with +a compensatory lordosis in the lumbar region sufficiently great to +change its relations with the pelvis. By the method previously given, +now outline the spinal column for lateral and bilateral scoliosis. +These, frequently, are at their incipiency, and to the casual observer +would pass unnoticed. It is well to make an outline of the spine +before beginning treatment, and at times following, that progress +may be observed. A simple method is lead tape which can be had from +any plumber shop and can be molded to the deformity and traced on +paper together with date of examination. H. F. Goetz has perfected +an appliance for outlining and recording these deviations. Observe +well the ligaments, as well as extent of joint movement, under deep +palpation; from irritation they may become thickened and more or less +fill the spaces about the spines and transverse processes, causing a +rigid, smooth spine. + +To make a detailed examination the patient should be stretched out on +one side upon a treating table, although the general examination may +be sufficient. Then, standing in front of the patient and reaching +over him, a most careful diagnosis can be made. Do not stand back of +the patient as the flat of the fingers can not be used to advantage +in outlining the different vertebræ. The various contracted muscles +that may be found along the spinal column will be of valuable aid +in locating derangements of the vertebræ and vertebral ends of the +ribs. By using contracted muscles along the spinal column as a guide +for locating lesions, reference to the large superficial muscles is +not made, but to the small areas of contracted fibres of the deep +muscles. It is the deep muscles that become more or less contracted, +and even fibrotic, when lesions of the vertebræ and ribs exist. The +superficial muscles are generally contracted by atmospheric changes, +slumped postures, wrong habits, etc., and are not generally the result +of disorders in the osseous system. The preceding points in regard to +contracted muscles cannot be too carefully observed for there is a +tendency among many osteopaths to treat the contracted deep muscles +as primary lesions in nearly every case. Remember that if they are +not due to the motor nerve fibres of the muscles being irritated by +the spinal lesion, or to a reflex stimulus, or to a compensatory +change, that although the muscular tension may be the inception of +the almost certain interosseous lesion, still the leverages secured +through bony adjusting are very essential not only in correcting the +osseous malposition but in loosening and releasing fibrous muscles and +thickened ligaments. + +=Thorax.=—Examination of the thorax as a region has been largely +gone over in speaking of the ribs and their sternal attachment, +cartilages, sternum and the clavicles, but its appearance as a whole +should be carefully noted for it will be a valuable aid in diagnosis. +Deviations from the normal, such as the emphysematous or barrel-shaped +chest in asthmatic affections, or chronic cough, or accompanying +kyphosis, the flat chest and its association with phthisis, the +rachitic, etc., should be considered. Spinal deformities are reflected +in the thorax by marked changes in contour, such as elevations and +depressions corresponding to the spinal changes. These result in marked +interference with the thoracic organs and in young subjects are of +particular interest. Rib changes are frequently the result of vertebral +deviations. + +=Abdomen.=—The position for examination of the abdominal viscera is +usually with the patient supine, head slightly elevated, knees drawn up +partially and supported to relieve any muscular strain, and with the +hands at the sides. In this position complete relaxation is obtained. +Observe any enlargements from gas, fluid, or tumor, muscular changes, +color, etc. The patient may, also, be placed upon the side, and in the +knee-chest position for further verification of the diagnosis. Where +the abdominal wall is much relaxed, or there is a pendulous abdomen +with enteroptosis, there will be found a change of relations of the +viscera by these different positions, allowing them to be palpated in +another position. When there is marked tenderness it is often possible +to go deeper with less discomfort with the patient in the knee-chest +position. The Trendelenburg position may also be utilized. Where +ascites is suspected palpation should be made with the patient in +various positions in order to note changes of location of the fluid. +Frequently much can be learned by inspection with the patient standing. +Clues to visceral disturbance can often be had by tracing the nerve +connection from the spinal lesions to the suspected part. + +In examining the =liver= care must be taken that any gouging or severe +bruising of the organ does not take place. The liver can be outlined +by percussion and also by palpation of its lower and inner borders +Congestions, atrophy, enlargement or hardening should be noted, also +any change in position. + +A rather complete examination can be given the =biliary tract= from the +=gall-bladder= to the =duodenal orifice= of the =biliary duct=. By a +careful inhibitory pressure over the duct the outline of the tract can +be discerned providing the patient is not too stout. When the tract +is swollen considerable tenderness will be present. The patient will +complain of a stabbing or piercing pain upon pressure and manipulation +if the duct is inflamed. + +Usually the tenderness is greatest nearer the =duodenal orifice=. The +duodenal orifice is about one and one-half inches diagonally downward +to the right from the umbilicus. In cases of impacted =gall-stones= the +osteopath as a rule has very little trouble in locating the stone. + +The =spleen= may be percussed and when in a markedly enlarged condition +its lower border can be palpated. Great care must be used in the latter +condition as there is danger of rupture. + +In examining the =stomach= the usual methods of inspection, palpation, +percussion, analysis of the contents, etc., are employed. + +Palpation and manipulation over the =intestines= are practiced a great +deal by the osteopath in various intestinal diseases. By his educated +sense of touch he is usually able to locate at once any =impactions= of +=fecal matter=. Such impactions are generally found in the ilio-cecal +and sigmoid regions. In the various acute =obstructions= from +invagination, tumors, twists, adhesions, spasticity, knots, etc., many +times one is able to readily locate the seat of the disturbance. There +is one point to specially emphasize; that is, do not overlook prolapsed +regions of the intestines; such occur frequently and are a source of +considerable distress, especially constipation. Simple manipulation +will never do much good, neither will spinal treatment or injections, +as a rule. A specific treatment must be given and, that is, after +locating the exact point of prolapse, to reach carefully beneath the +fold and replace it. + +In emaciated subjects the =kidneys= can be readily located, and in +a few instances when they are diseased one can feel the contracted +tissues about them. Be very careful not to injure the =capsule= about +the kidney. Do not punch or gouge them in the least; but locate the +kidneys by a careful inhibitory palpation. + +=Lumbar and Pelvis.=—The intimate relation between the lumbar spine +and pelvis make a consideration of them as a region necessary. Outside +of ordinary curvatures involving both the dorsal and lumbar regions +there are certain conditions which involve but one structure and +require careful differential diagnosis to determine whether the lumbar +or pelvis is at fault. In the former the fifth vertebra is a weak +point and is most frequently at fault. The deviations are usually a +sidebending and frequently accompanied with some rotation. Occasionally +a malstructure of the lower lumbar or pathologically relaxed ligaments +will approximate the spines and be misleading as to the real condition. +A rotation or lateral tilting of the fifth lumbar may have the effect +of elevating the crest of the ilium so that the innominatum would +appear involved. There will be a difference in the length of the legs, +angles of feet when patient is lying on the back, anterior spines out +of line and tenderness of the muscles attached near them. However, +other diagnostic points of innominate lesions, i. e., tenderness of +symphysis and sacro-iliac articulation, and prominence of the posterior +spine, will be lacking. Marked deviation of other lumbar vertebræ may +produce practically the same effect, but the lesion will be so apparent +that there will be no doubt as to the cause. + +To be able to diagnose accurately and intelligently the pelvic region +requires nearly as much skill as in examining the cervical region. +The pelvic bones are liable to many subdislocations, especially in +the female. However, it should be remembered that many apparent +innominate lesions are secondary or compensatory changes due to lumbar +lesions. The pelvis as a whole may be tipped anteriorly or posteriorly +upon the spinal column. It also may be twisted or rotated laterally +upon the spinal column. The most common lesions are subluxations of +an innominatum forward, backward, upward, or downward, or various +combinations of these displacements, such as a tipping forward and +downward of an innominatum, or a tipping backward and upward, but these +combinations do not always exist in the manner given. As a rule when +the ilium is anterior, the ischium posterior, then the innominatum as a +whole is downward; when the ilium is posterior, the ischium anterior, +then the innominatum as a whole is upward. This is only a rule, there +are exceptions to it; for in some few cases when the ilium is anterior, +the ischium posterior, the innominatum may be higher, and when the +ilium is posterior and the ischium anterior the innominatum may be +lower. + +To be able to diagnose such derangements will require skill and +practice; still there are symptoms and signs that are characteristic +of such disorders. In examining the pelvic bones have the patient flat +upon the back at first. Be sure he is flat upon the back for a very +slight variation may make considerable difference in the relation of +the pelvic bones, one to the other, so far as the diagnostic points +are concerned. Then go to the feet of the patient and grasp the ankles +firmly, rotate laterally both legs, first to one side and then to the +other, as well as pull and push both limbs slightly, and then bring the +heels together directly in the median fine of the body and compare the +length of the limbs at the heels. If there is any disorder whatever +in one innominatum, and the thigh muscles have been relaxed thoroughly +by the preceding movements and the heels are brought together in the +median line of the body, a difference in the length of the limbs +will readily be observed at the inner malleoli or the heels. For if +the ilium is forward the ischium must be backward and as a rule the +innominatum is thrown downward, thus causing an apparent lengthening of +the limb which will be noticed by comparing the heels; if the ilium is +backward the ischium must be forward and as a rule the innominatum is +then upward, causing an apparent shortening of the limb on the affected +side. A very slight variation in the pelvis will make considerable +difference in an apparent lengthening or shortening of the limbs. Such +conditions are generally met with several times a day by osteopaths. +The object of the lateral rotary movement and the pushing and pulling +of the limbs is to make sure that all the thigh muscles are thoroughly +relaxed, for it is a very easy matter for contracted muscles in one +thigh to produce an apparent shortening of the limb. Also be very +careful in comparing the length of the two limbs at the heels where +they come together that they are exactly in the median line of the +body, for if they should be to one side or the other, however slightly, +there would be an apparent lengthening of the outer limb as compared +with the limb near the median line. While the patient remains flat +upon the back it is a good plan to compare the anterior spines of the +ilia. It may be readily noticed that one is higher or more depressed +than the other, which will help to confirm the diagnosis. It is a +good plan also to have the patient sit up squarely upon the table and +compare the crests and posterior spines of the ilia; thus one may be +seen to be higher than the other. Then, also, note the angles of the +feet when patient is supine; an everted foot usually means that the +limb is shorter due to the tilted pelvis; the opposite is commonly true +when the foot is inverted. However, this is not an absolute rule. Care +should be taken in differential diagnosis of possible old fracture of +leg, of infantile paralysis, of asymmetry, etc. + +There are =three diagnostic points= exclusive of all other signs that +are quite conclusive when coupled with the preceding examination. If +an innominatum is dislocated or subdislocated there will be tenderness +over the symphysis pubis on the side affected, tenderness over the +ilio-sacral articulation on the side affected, and tenderness along +the crest of ilium where the abdominal muscles are attached. When +tenderness is found at these three points it is quite conclusive that +the innominatum is deranged, for at the symphysis pubis and ilio-sacral +articulation tenderness must exist if the innominatum is disturbed, +and by a change in the crest of the ilium the abdominal parietes +will be affected, provided they are not too much debilitated. Marked +tenderness of the external cutaneous nerve as it passes over the crest +of the ilium below the anterior spine will be noticed on the unaffected +side (Dr. Still). There will be, on rectal examination, marked tension +of the tissues on the affected side. Possibly the patient may complain +of pain exclusively in one side along the pelvis and limb which will be +a leading symptom telling which side is affected. + +=Additional diagnostic= signs will be rigidity of muscles along the +ilio-sacral articulation and abnormal prominence or depression of the +ilium at its articulation with the sacrum, depending upon which way the +innominatum has slipped. Considerable deviation of the pubic bones may +be noticed. The pubic bone on the side affected may be either thrown +upward or downward. + +Radiographs have repeatedly revealed subluxations of the innominate +bones in many instances. This is certainly quite conclusive in +confirmation of the osteopathic ideas in regard to the pelvic bones +becoming dislocated. + +=Sacrum.=—Examination of the sacrum is best made with the patient lying +on the side, with the osteopath standing in front and with the hand +palpate its posterior surface. In the sitting posture its relation with +both innominates can be determined. It is displaced posteriorly but +seldom, the most frequent being anterior, downward, and a combination +of the two. In the anterior conditions tenderness at the sacro-iliac +articulations is a good point, but it must not be confounded with an +innominate lesion. The downward displacement is shown by comparison +with the lower lumbar vertebræ. Observe the relation between the two, +as a change in contour of the spine will also change the angle of the +sacrum and _vice versa_. + +=Coccyx.=—With the patient and operator in same position as for the +sacral examination outline the coccyx, as to first, =contour=; second, +=rigidity=; third, =sensitiveness=. If abnormalities are detected go +to the other side of the table and with a well lubricated index finger +palpate its anterior surface. Changed contour, displacements, and +old fractures can be readily determined. The most common deviation +is anterior at its union with the sacrum. The lateral form generally +resulting from muscular contraction is next, with posterior but +seldom. “If the lower part of the sacrum is rotated backward, the +sacro-coccygeal articulation or angle is affected or becomes more +acute, since the tip of the coccyx is not displaced, but held in +position by structures attached to it. If the sacrum is displaced +downward the effect is about the same. Often this sort of sacral lesion +is mistaken for an anterior luxation of the coccyx.”[28] Remember +that normally there should be some movement of the coccyx. It has a +fibro-membranous articulation. + +=Uterine=, =ovarian= and =rectal= examinations are largely of the same +nature as those given by other practitioners, although osteopaths find +that oftentimes other practitioners are mistaken in regard to the +etiology of many diseases to which these organs are subject. + +=Arms= and =Legs=.—There is comparatively little that is exclusively +osteopathic in regard to the diagnosis of disorders of the arms and +legs. One important feature that the osteopath finds in examining the +arms and legs is that many of the disorders supposed to originate +in the affected member are found to be caused from vertebral or rib +dislocations. Innominate and lumbar lesions are particularly fruitful +sources of trouble in the legs and feet. Always carefully examine the +spine in the region of innervation to the arms and legs when they are +affected. The shoulder and hip joints, as well as all joints, are +subject to partial dislocations. Many times when pain or other symptoms +are presented in the arms or legs the trouble is at the shoulder or +hip joint or in the spinal column. There are two regions that are +very apt to be overlooked in the examinations of the arms and legs +and they are the elbow joint and the fibula. The small bones of the +=ankle= and =wrist= as well as of the foot and hand are subject to many +dislocations which are easily discerned upon examination and often +overlooked. Special emphasis should be given in regard to many supposed +diseases of the knee joints which are really caused by lesions in the +spine or at the hip joint. + + +Osteopathic Prognosis + +Everyone is of the opinion that to forecast the probable result of a +disease is one of the most difficult problems the physician has to +meet. To state the duration, course, and termination of an attack of +disease as presented by its nature and symptoms implies an accurate +knowledge of both disease processes and changes, and an insight into +the individual’s idiosyncrasies backed by ripe clinical experience. +And after each of these factors has been carefully considered to +balance one against the other, nothing short of superhuman knowledge +may present a sufficient insight in order to render an accurate +prognosis. A prognosis represents the culmination of one’s learning, +an understanding of disease characteristics, and an insight into +temperament. + +C. M. T. Hulett[29] says: “Only when we can know all the conditions, +causative and sequential, with their possible complications and +terminations, together with a full history of therapeutic results in +a large number of similar cases, and carefully analyzing and weighing +these various elements, are we prepared to really make a prognosis.” +Nettie H. Bolles[30] writes as follows: “The prognosis depends upon +the cause of the disease, the possibility of removing the cause, or +the likelihood of recurrence of causes, and the chances of avoiding +such recurrence. The circumstances to modify the outlook are various +and deserve careful consideration.” It is not the purpose here to +go into the many essential details, for that would mean an outline +and forecast of all disease processes, and the effect of numerous +extenuating circumstances. The medical profession have been gathering +data for these three thousand years and prognosis with them is still +inaccurate and incomplete. Osteopathic science will add just so much to +the accuracy of prognosis as the sum total of the knowledge displayed +in the fields of osteopathic etiology, diagnosis, pathology and +therapeutics. Suffice it to give here a few salient practical hints as +noted in the osteopathic treating room and at the bedside. + +Osteopathically it may be said that prognosis depends, first, upon the +true conception of osteopathy; second, upon the relative value of all +factors pertaining to health and disease; and, third, upon the skill +(technique and native ability) of the osteopath. The first and second +being granted, the third includes a remarkably practical and pregnant +field, for in no school does the physician get into as close touch +and understanding of the actual condition of the patient’s disorder +as in the osteopathic. Although the fundamentals and principles of +the osteopathic conception of diseases are really broad, liberal, +and all-inclusive, still owing to the fact that each individual (and +thus each disease) is more or less a law unto himself should there +not be absolute tables and prescriptions to be governed by; remember, +however, this does not imply our fundamentals are not basic or our +principles are not truths, but rather the application and execution of +the same are as varied as the individual’s constitution, temperament, +and disease. Herein rests the really difficult practical consideration +of etiology, pathology, diagnosis, treatment, and prognosis. In other +words, if the diagnosis and treatment are accurate the result rests +entirely with the patient. + +First, too much emphasis cannot be placed upon the fact that prognosis +is dependent upon the osteopath—his education, training, ability, +experience, and technique. One’s fitness is most important. And fitness +and personality complement each other. An osteopath may know theory and +still not be practical; still one cannot be practical unless he knows +theory. + +Second, osteopathic treatment frequently changes the usual course of +acute disease. It is well known that many diseases have a certain +regular course in their history. Many times the osteopath will be able +to abort, lessen the severity, or cut short the ailment, thus changing +the recognized symptoms and termination. + +Third, the knack of treatment, or knowing how to treat, not only one +region of the body but all regions, not only one temperament but all +temperaments. + +Fourth, the preparatory treatment before correcting the lesion. +Prevention, palliation, or cure, and thus prognosis, may be dependent +upon a necessary preparatory treatment. Here is where a study of the +patient’s temperament is very essential. + +Fifth, a prolonged treatment may defeat one’s purpose. As a rule a +comparatively short, thoroughly indicated, specific treatment is best. + +Sixth, much, relative to prognosis, can be told by the tone of the +vertebral ligaments. When a lesion corrects too easily or does not +remain well in place it shows a lack of tonicity on the part of the +ligaments and muscles. Improvement is in direct ration to the increase +of tonicity. + +Seventh, special care should be taken with the irritable spine. This +spine commonly precedes the debilitated spine. Unless precaution is +taken to apply inhibition before treating specifically a cure may be +prevented or at least the disorder prolonged. + +Eighth, relaxation of muscles is not always essential, although +the lack of it may prevent the correction of primary lesions. The +relaxation should be carried out with care in order that all shock and +irritation may be kept at a minimum. + +Ninth, needless stretching, traction, extending, rotation, and snapping +of the neck is not only useless but may be positively dangerous. +Rarely is it necessary to go through the above “movements” as many are +accustomed to do. + +Tenth, it may be necessary, but not always, to give as additional +treatment, after the anatomical defect has been specifically treated, a +certain amount of stretching and moulding of the parts. + +Eleventh, owing to the close personal relations of physician and +patient, personality has a powerful influence on prognosis. + +Twelfth, too much emphasis cannot be placed upon the uselessness and +injurious effects of over and misapplied treatment. + +All of the above have a positive bearing on prognosis. The osteopath +should study his technique well. He will find that it gradually changes +and improves from year to year. In a word, as he gains in experience +he will become more skillful by giving careful attention to the +development of the sense of touch, by noting the resistance of the +tissues, and a score of details that are very hard to describe but the +sum total of which determines and indicates the successful osteopath. + +Another practical point that bears upon prognosis as well as upon the +health of the osteopath is the manner of giving treatment. First, the +height of the treating table should correspond to the height of the +practitioner. The table should be made for the practitioner and not the +practitioner fitted and warped according to a certain table. Second, +give part of the treatments on a treating stool. Here there is greater +freedom of movement on the part of the patient, hence greater and more +effective leverage can be obtained. Suit your treatment to the patient, +not your patient to the treatment. Third, make your weight count for +energy expended in the treatment. As soon as one set of muscles become +tired substitute another set, e. g., the back muscles and the arms, the +arms and the hands. Fourth, whenever possible substitute the weight of +the patient for expended energy. Fifth, when lifting keep the spinal +column straight; do the bending of the body at the knees. Hence a +better treatment and a more favorable prognosis, and besides that new +occupation neurosis, the “=osteopathic back=,” will be materially +lessened in both severity and frequency. + + +FOOTNOTES: + +[26] See Tubby, Deformities. + +[27] Clark’s Applied Anatomy, p. 334. + +[28] Clark’s Applied Anatomy, p. 331. + +[29] Prognosis—Journal of the American Osteopathic Association, Jan., +1906. + +[30] Prognosis—Journal of the American Osteopathic Association, Nov., +1902. + + + + +OSTEOPATHIC TECHNIQUE + + +The technique of treatment is, in a sense, a personal factor, for it is +a well known fact no two osteopaths treat just alike. Nevertheless, the +principles of technique are constant and universally applicable, and he +who applies them with specificity manifestly secures the best results, +and exhibits a technique that is finished and characteristically +osteopathic. General manipulations are not essentially osteopathic, +although by employing them a few definite results may be obtained; +still such technique should not be classed as distinctive osteopathic +therapy. Every case is a law unto itself and must be studied +individually in order to be able to understand it perfectly. So much +depends upon the ability of the osteopath in the treating of a case, +that in order to meet the indications intelligently he must have +command of the various anatomical details of the body, not only in his +mind but upon his finger tips.[31] + +The =sense of touch= should be very acutely developed and this requires +months of persistent, practical experience. A carefully educated sense +of touch is the keynote to both osteopathic diagnosis and operative +technique. From the very nature of the osteopathic conception—the +physical body viewed as a mechanism whose disordered or diseased +conditions demand anatomical readjustment—it is imperative that a +delicate and educated sense of touch be acquired in order to logically +and successfully apply its tenets. Proficiency means not only being +able to note certain small physical irregularities, and various +degrees and areas of muscular contractions, and variations in body +temperature, but the extent and state of vital resistance, that is, +tissue condition, and the feeling of organic resistance, e. g., the +heart, lungs, liver. These are the special features wherein osteopathic +fingers detect disease causes and traces. To know the difference +between normal and abnormal structural deviations and distortions, as +well as organic changes, requires an accurate, detailed knowledge of +anatomy and pathology with a systematic daily education of the sense of +touch; but to realize, appreciate and know by tissue resistance feeling +that nutritional condition is improving requires much more practical +experience. + +Thus two very practical points should be taught to and thoroughly +impressed upon every osteopathic student: First, =the sense of +resistance of the tissues=. This gives us an absolute clue to the +vitality of the patient. As has been stated, there is a vast difference +between the feel, the sense of resistance, of normal and abnormal +tissues; for instance, a normal muscle and a contractured muscle, a +normal liver and a congested liver, a normal intestine and a prolapsed +intestine and these differences comprise innumerable gradations. + +Second, =the receptivity of the patient to treatment=. This is +dependent upon the vitality of the tissues. The sense of resistance +to touch gives us an important diagnostic clue; the receptivity of +the patient to treatment tells us much as to prognosis. After a few +treatments the receptiveness will be positive or negative; that is, +the patient is, or is not, responding to treatment. Consequently the +receptivity of the patient usually tells much as to the state of +nutrition. + +Definite principles should be followed when applying the technique, for +the osteopathic lesion is a “structural perversion,” thus indicating +mechanical readjustment for its correction. The time is coming when the +technique will be taught graphically and mathematically. This would +not be a difficult thing to do, and it could not but prove invaluable +aid to the student. He can then the more readily and comprehensively +grasp the principles involved. To resolve and illustrate manipulative +readjustment to and by the principles of mechanics would add +considerable to osteopathic development. For example, how nicely +the correction of certain innominata maladjustments illustrates the +principle of the wheel and axle. Vertebral and rib displacements when +readjusted make application of the principles of the simple machines. +We are gradually approaching a more comprehensive understanding of +the physiologic movements of the spine and of the etiologic role +of muscle tension. This is part of the foundation work. Great care +must be exercised in correlating this data with the individual case, +for in therapy we are dealing with abnormalities—not alone normal +physiologic changes. If our distinctive dynamics and therapeutics were +taught in this manner the average osteopath would be more specific and +comprehensive in his work and as a consequence more scientific. And +consequently the principles involved in each and every case would stand +out clearly. Hence diagnosis would be more exact, routine pommeling +discarded, and better all around technique executed. + +Two general rules are applicable to all dislocations, whether partial +or complete: 1. Exaggerate or increase the dislocation. This is to +relax the tissues about the dislocated articulation and to disengage +the articular points that have become locked. 2. Reduce the dislocation +by retracing the path along which the parts were dislocated. Hence to +=correct= a =lesion=, for example, a vertebral lesion: (1) Exaggerate +the lesion. (2) Place the fingers of the hand that are not employed in +exaggerating the lesion over the extended portion of the lesion. (3) +Extend the region that is flexed when the lesion was exaggerated. (4) +When the lesion is being extended produce traction and slight rotation +of the region. (5) At the same time extension, traction and rotation is +being produced push in upon the extended portion of the lesion. To this +might be added for sake of clearness and greater assurance of success: +(a) Be positive the focal point absolutely corresponds to the lesion, +or else most if not all of your effort will be useless. (b) Just before +reaching the maximum of exaggeration have your fingers correctly placed +for the readjustment, and at the very moment of maximum exaggeration or +just a fraction of a second prior begin to correct or readjust, or else +you will lose the vantage gained and the operation will probably be a +failure. (c) The general traction and rotation are to aid in unlocking +the lesion, not to readjust as some may think. Inhibiting and releasing +the soft tissues, such as spasms, contractions and contractures of +muscles, and stretching thickened and adherent ligaments is very +important preliminary work. Then, next to securing exact leverages +an essential point is to maintain the release or exaggeration until +the readjusting step is incepted. In other words, coordination of all +factors is the desideratum. The lack of this is the cause of many +failures. Hot fomentations frequently assist in relaxing irritable and +spastic soft tissues. This, however, is but a preliminary measure. All +rough handling, needless snapping of parts, and excessive rotation +and stretching are not only apt to tighten the lesion more, shock the +system and irritate the parts, but it may be absolutely dangerous. + +It should not be forgotten that the osteopath includes many measures +in his treatment of various diseases, as nursing, dieting, hygiene, +sanitation, hydrotherapy, antidotes, antiseptics, etc., and does +not depend upon readjustive manipulation alone, although correcting +disordered anatomical structures and perversions are paramount in the +treatment. + +=The General Treatment.=—A general treatment but accentuates the +ignorance, in a majority of cases, of many so-termed osteopaths. It is +a deplorable fact that there is a tendency among some osteopaths to +give general treatments in every case presented. The only explanation +of such a procedure that one can think of is a lack of conception as to +what osteopathy really is. To give a general treatment in every case is +not only actually detrimental to the patient but it is the height of +folly on the osteopath’s part, for it gets him into a slovenly habit of +procedure from both scientific and curative points of view, besides +giving the outside world an impression that osteopathy is but little +different from massage and Swedish movements instead of skillful, +mechanical engineering of the human body. But a “general treatment” is +not to be confused with definite attention to be a series of more or +less interrelated lesions. The essential point is to normalize the body +when and where distinctly indicated and after a skillful manner. + +A general treatment, broadly speaking, should be given only under +three conditions: (1) Constitutional diseases that are to be treated +symptomatically. (2) Certain anemic cases. (3) When one is ignorant of +the real cause of the disease. Each of these conditions is self-evident +why a general treatment should be given. A fourth might be added, for +those individuals who think they are not getting value received unless +they are treated from head to foot. Such patients are usually ignorant +of the philosophy of osteopathy and it is the osteopath’s duty to teach +them differently. + +The general treatment consists in stretching the spinal column from +the atlas to the coccyx and relaxing all contracted muscles along both +sides of the spinal column, besides giving special treatment to the +cervical region, between the scapulæ, the splanchnics and internal and +external rotation of the legs. It is no wonder that fake osteopaths +do cure a case occasionally. They are quite certain to correct some +disorder by pulling and hauling a patient around in such a manner. +Still on the other hand they are very likely to do injury to the +patient. Those who claim that no injury can come from osteopathic +treatment are mistaken. One can injure a person by treatment if he +is not careful. It does not stand to reason that the most delicately +constructed mechanism should stand any amount of manipulation and +misdirected force that may be given it. + +=Positions of the Patient and Physician in Treating.=—The position +of the patient when a treatment is given depends altogether upon the +affection to be treated. Probably about one-half of the cases can be +treated to advantage upon a table, the remainder sitting on a stool. +Many osteopaths treat nearly all their patients upon a table. It is +much better to change back and forth, because to correct a certain +disorder may be hard upon the table, but will be comparatively easy +when the patient is on a stool, and _vice versa_. Besides, constantly +changing back and forth rests a physician greatly. + +Learn to treat in various positions, because it will be impossible +to have all cases assume a certain position when being treated; and +especially in treating acute cases one is obliged to suit his treatment +to the patient and not the patient to the treatment. There is also a +tendency for one to get into slovenly habits of treating when patients +are all placed practically in one position, and certainly one cannot +treat all cases in one position to equal advantage. Also learn to treat +as well with one hand as the other. Many times one will be in such +positions that equal use of either hand will be required. Carefully +educate the sense of touch in both hands. + +Another point should receive consideration: learn to shift the strength +exerted in treating from one set of muscles to others. For example, +when one is standing for a long time he will continually shift his +weight from one limb to the other. In the same manner in treating use +the strength of the hands awhile, then the arms, then the muscles of +the back, then the weight of the body, etc.; all in such a manner that +there is a constant change by utilizing certain groups of muscles for +the same work, as well as utilizing the weight of the body of both +physician and patient to advantage. It rests a physician greatly and +thus allows him to perform a maximum amount of work with a minimum +amount of strength and labor. + +It is frequently an advantage to the physician to treat upon the nude +skin, thus preventing the fingers from becoming tender. Gowns can be +easily made that open down the back so that the patient does not have +to disrobe. + +=The Neck and Head.=—In the treatment of the neck the patient may +assume the sitting posture or lie flat upon the back. The latter is +preferable, as then one has complete control of the neck and head. +Absolute control of a part is always necessary and when this is secured +the dangers are reduced to a minimum, provided always that reasonable +discretion as to the amount of strength, is used. Before correcting +the various deviations of the cervical vertebræ it is usually best to +thoroughly relax all the muscles, superficial and deep, about the field +of operation. In relaxing muscles three methods may be employed. The +muscle may be firmly grasped and manipulated until relaxed, or a firm +pressure may be exerted upon the muscle and thus inhibit its nerve +force until the muscle relaxes, or the muscle may be longitudinally +stretched. The second method is comparatively slow and is usually +given in acute cases where the patients are so weak and exhausted that +they cannot stand any severe manipulation. This method, however, has +certain advantages when employed as a preparatory step in interosseous +adjustments, though steady traction accompanied with slight rotation, +if precisely localized, has many advocates. + +In relaxing muscles by manipulation, grasp firmly the belly of the +muscle and draw outward on the muscle several times until it relaxes. +If the patient is sitting, place one hand upon the head of the patient +or about the chin in such a manner that complete control of the head is +maintained throughout the procedure; then with the fingers of the other +hand upon the contracted muscular fibres a manipulating or kneading of +the muscle can be given. It is best to flex the neck and head to the +side where the contracted muscles are, so that a better hold of the +muscle may be maintained; then by a series of flexions and extensions +with manipulation of the contracted muscles outward, results can be +readily obtained. When the patient is lying on the back the physician +may stand to one side of the patient’s head and with one hand on the +forehead of the patient and the other hand around the opposite side +of the neck, a rotary motion of the head and neck, which is equal to +flexion and extension in the sitting posture, may be given by the hand +on the frontal region while the other hand relaxes the muscles; or the +osteopath may stand at the head of the patient and with either hand +on the side of the head and neck of the patient a series of rotary +movements of the head and neck may be given with manipulation of first +one side of the neck and then the other; the hands and fingers being +placed in such a manner that when the fingers of one hand are relaxing +the muscles on its side the other hand is executing the movements of +the head and neck, each hand continually alternating in the work. This +latter method requires some practice in order to do the work readily +and successfully, for quite a variety of movements are required. + +In the former method after one has worked on one side he is obliged to +change to the other side and go through the same process. Movements may +also be given to stretch the contracted muscles, thus overcoming the +contraction and producing relaxation of the muscles. + +After having relaxed the muscles over the field of operation, +correcting the vertebræ will generally be easier to accomplish. In +readjusting an atlas it matters but little whether the patient is +sitting up or lying down. A firm hold of the atlas can be gotten in +either instance. In correcting the middle and lower cervical vertebræ +it is best to place the patient upon the back. + +In correcting dislocations, as heretofore suggested, two general rules +should be followed: (1) Exaggerate or increase the dislocation. This is +to relax the tissues about the dislocated articulation and to disengage +the articular points that have become locked. (2) Reduce the lesion +by retracing the path along which the parts were dislocated. One can +readily see that a dislocated ball and socket joint could be reduced +only by the dislocated bone retracing the path by which it left its +socket, for the capsular ligament would at once prevent its returning +to the socket by any path other than that taken when dislocated. This +applies to all dislocations to a greater or less extent. + +After locating the exact position of the abnormal vertebra the first +rule is applied, i. e., exaggerating the lesion by flexing the head +in the opposite direction to which the vertebra is dislocated. +Then with one or two fingers placed firmly upon the side of the +vertebra in the direction dislocated, so that when the proper time +comes the vertebra may be pushed or slightly rotated back into its +normal position, with the other hand produce flexion of the neck, +so that the angle of flexion is exactly over the involved vertebra; +next produce slight traction, so as to be sure that the articular +points will be disengaged; and then with rotation and extension of +the head to a normal or upright posture, at the same time pushing +in on the disordered vertebra, are the movements to be executed in +reducing a dislocated vertebra. It takes considerable practice to +be able to correct a vertebra and to know when it is corrected. The +amount of force applied varies greatly in different cases. Cases of +recent subdislocation require but little force unless there is marked +spasticity of tissue, while in long standing cases many times the +amount of force required is about all that one wishes to exert. As a +rule in many chronic cases it is better to give a series of preparatory +treatments in order to reduce muscle fibrosis and thickening of +capsular ligament. Remember that often it is a slight rotary movement +or twist given that aids the most in executing rule second. No matter +to what position a vertebra is rotated or side-bent the principles +applied are the same in each case. + +Be very careful when flexing, extending or rotating the neck that too +much strain is not brought to bear upon the ligaments. Some osteopaths +seem to take delight in rotating and flexing the neck to a great +degree. It is a dangerous procedure and moreover does not accomplish +anything in particular. It should be kept in mind that osteopathic +treatment is scientific and not a number of general movements of +various regions of the body. Locate the lesions exactly and then a +specific treatment can be given in every instance. To illustrate +the treatment according to the preceding rules we will assume that +a certain cervical vertebra is anterior, say the fourth cervical. +This means that there is an interosseous lesion between the fourth +and fifth. The inferior articular processes and facets of the fourth +have slipped upward and forward on the opposing facets of the fifth. +First, hyperextend the head in such a manner that the fulcrum comes +exactly over the displaced articulating planes, thus throwing the +fourth vertebra still more anterior, or in other words, exaggerating +the lesion or increasing the space anteriorly between the fourth and +fifth cervicals, so that when the head is flexed forward and pressure +is exerted upon the anterior part of the vertebra (body or transverse +process) the vertebra will have room and release enough to occupy its +normal position. Second, when the head is hyperextended place a finger +anterior to the transverse process of the dislocated vertebra and with +the other hand around the head, that is producing the hyperextension, +throw the head forward with slight traction and rotation and at the +same time push posteriorly quite strongly upon the dislocated vertebra. +Follow out the same principles in all cases, no matter in which way the +vertebræ are deranged. + +There are several methods of applying the underlying principles of +adjustment. Relaxation and leverages may be secured in various ways. +Preciseness, expeditiousness and skillfulness can be attained only by +considerable personal experience. + +In cases where the lesion is between the skull and atlas have the +patient sit on a stool with the back part of his head against your +chest, and reach around the head with one hand under the chin; then +with the other hand around the transverse processes of three or four +upper cervical vertebræ pull the spinal column toward the median line, +while at the same time lifting up on the skull with the other hand and +throwing the skull toward the median line. The object of lifting up on +the skull is to relax and disengage the articulations, by inhibition, +traction and rotation, between the occipital bone and atlas. This is +one method applicable to the various lesions of the occiput, which are +of frequent occurrence. + +In treating the =pharynx=, =tonsils= and =larynx=, outside of +correcting spinal lesions, an anterior treatment to these organs is +very effective. Examine the deep muscles beneath the angle of the +jaw when the pharynx and tonsils are involved; and when the larynx +is affected note the condition of the muscles on either side of the +larynx. After locating deeply seated contracted muscles in the region +of the angle of the inferior maxilla place the fingers over the +contracted tissues, and then by a downward, inward sweeping motion +toward the median line the muscles may be readily relaxed. When +treating the larynx relax the tissues on both sides by an upward, +inward movement. These treatments are very effectual when applied +directly to the disordered tissues. + +Attention should also be given to the lymphatics. In simple infections +treat the glands very lightly but attempt to break down the surrounding +edematous barrier. Release all the tissues down to and including +clavicles, first ribs and pectoral and axillary regions. + +To treat slight lesions of the =inferior maxillary= articulation, +stand at the head of the patient when he is lying down and hook the +fingers about the jaw just in front of the angles, and with the thumbs +over the bridge of the nose have the patient open the mouth while +considerable force is exerted against his effort. This reduces any +slight dislocation of the inferior maxilla. When the jaw is completely +dislocated place a piece of wood or hard substance between the molars +and exert pressure upward and backward on the chin. If the dislocation +is bilateral work on one side at a time. + +The object of treatment to the =face= is to stimulate or inhibit +points of the fifth nerve that come near the surface (see neuralgia of +fifth nerve). While the patient is lying flat upon the back carefully +stimulate these various points, especially the supraorbital and nasal, +with a downward and outward movement, or inhibit as indicated. + +In treating the =scalp= relax the muscles over the scalp thoroughly. +This is secondary treatment to correcting the innervation to the scalp +at the upper four or five cervical vertebræ. + +In cases of pharyngitis, tonsillitis, croup, hay fever, etc., an +effective local treatment may be given through the =mouth= upon the +soft and hard palate. Introducing a finger into the mouth clear back +upon the roof of the soft palate, and with a downward and backward +sweeping movement from the median line on either side toward the +tonsils, considerable relief can be given the patient. This treatment +relaxes the tissues, relieves the congestion, and gives a stimulating +treatment to the local nerves. A treatment of the same nature may be +given over the hard palate to affect the palatine nerves, especially in +hay fever, when the itching of the palate and sneezing are extreme. In +cases of young children it is best to protect the finger by wrapping a +piece of cloth around it. + +An osteopath should never give a manipulation or movement unless he +understands why. Just as soon as one gives general imitating movements, +from that moment his work is not that of a scientific osteopath, but +of a Swedish movement curist and masseur and a poor one at that. The +osteopath’s work is to locate the anatomical derangement and correct +it, as a mechanic would adjust any disordered mechanism. General +treatment amounts largely to naught, although in some few instances it +is of benefit. + +To give a detailed description of the treatment of all lesions that may +be found in the cervical vertebræ would be impossible in this sketch; +only a general survey of the work can be given. Each case calls for +special treatment, but the same general principles are applicable in +each case. If there is any one thing that should be eliminated from +osteopathic treatment it is those mechanical routine movements of +rotating, flexing, extending, and various Swedish-movement-massage-like +manipulations that certain osteopaths give in each and every case. It +shows that they are imitators and do not have a correct conception +of osteopathic therapeutics. True it is, that routine movements will +have stimulating and other effects upon the system. But does the body +require such treatment? Is it lack of exercise on the part of the +patient? If it is, then let the patient exercise himself. You do not +want to lower yourself to be a mere “engine wiper,” or an exerciser. +If it is not the lack of exercise and the system is in need of certain +treatment, then seek the cause and apply a specific treatment. Do not +hide behind generalities. + +=The Ribs.=—In correcting dislocated ribs many methods may be employed, +but all are subject to the same principles as given under the treatment +of the neck and head. + +One of the best methods to correct typical ribs is to have the patient +upon the side with the side of the affected ribs upward. Find out +exactly the nature of the dislocation, i. e., what is the relation +of the dislocated rib to the other tissues. Note whether the rib is +upward, downward, inward or forward, locate exactly the dislocated +rib. Then, while standing back of the patient, place your fingers upon +both ends of the rib. Place your fingers in such a manner that when +the proper time in the procedure arrives, all that will be necessary +will be to push the ends of the rib into their articulations. For +instance, if the rib is raised anteriorly and lowered posteriorly, +you will place the fingers on the sternal end, above the affected +rib and the fingers on the vertebral end, below the rib, so that +when the rib has been released from its abnormal position it may be +slipped into normal position. After having placed the fingers in the +exact position necessary, have an assistant take the arm and draw it +obliquely across the face, while at the same time the patient takes a +forced inhalation. The object of drawing the arm across the face and +the deep inhalation is to exaggerate the lesion—to draw the ribs out +of their locked position—so that the fingers upon either end of the +rib may push the rib into normal position. Drawing upon the arm raises +all the upper ribs as well as the dislocated typical rib, principally +by the use of the serratus magnus; also inhalation has an effect to +throw the rib outward and upward and thus away from its articulation. +Thus after the lesion has been increased sufficiently to loosen the rib +from its abnormal position, the arm is relaxed, the patient exhales, +and the fingers upon the ends of the rib correct the dislocation. This +treatment is used to the greatest advantage when there is a dislocation +of a typical rib; it can be given while the patient is lying down or +sitting up, although the former position is preferable. + +An excellent method, when the =sternal end= of the rib is dislocated +is to have the patient sit upon a stool with his back toward the +physician; then by placing the knee in the back (while standing up, or +easier still for the physician to sit upon an operating table back of +the patient) over the vertebral end of the rib so that the rib may be +held rigid posteriorly, reach around with one hand over the dislocated +end of the rib and place the fingers upon the rib in the direction +dislocated; so that when the rib is sufficiently released from its +abnormal position it can be readily pushed into place; then with the +other hand under the axilla of the arm on the affected side, pull up +and back on the shoulder, so that the rib may be pulled away from its +sternal articulation; and at the same time have the patient take a +deep inhalation so as to aid in throwing the rib outward, upward and +away from its sternal attachment; then when the end of the rib has +been released sufficiently, relax the hold underneath the axilla, have +the patient exhale, and slip the rib into its normal position by the +fingers over the end of the rib. This is an excellent method. It is +easy to give and does the work admirably. + +Practically the same procedure may be gone through when the =vertebral +end= is dislocated, by changing your position to the front of the +patient, but there is danger of the knee slipping off from the sternum +during the operation and injuring the ribs. Several other treatments +may be given to correct dislocations of the vertebral ends of the ribs. +For example, while the patient remains sitting the osteopath stands +in front of the patient and reaches around both sides upon the angle +of the ribs; then with an outward and upward movement of the fingers +upon the angle of the ribs, they are pulled away from their locked +position and allowed to slip into normal articulation. This treatment +is applicable only when the ribs are dislocated downward, but it is one +of the best treatments for such cases. + +Another method oftentimes employed in correcting dislocations of the +vertebral end of the ribs is to have the patient lie flat upon the +side with the affected side upward; then by flexing the arm on the +forearm and placing the elbow against the chest or abdomen reach over +the patient upon the angle of the dislocated rib and pull it away +from the vertebra; when it is pulled away from the spinal column +sufficiently, push upward or downward on the angle of the ribs, as the +case may demand. The elbow placed against you gives complete control +of the patient and aids, by your weight, in throwing the rib upward or +downward. + +A treatment somewhat like the preceding one which is commonly employed, +is to reach underneath the patient’s upper arm, when he is lying upon +his side, with the arm extended upward across the face; then by placing +the fingers of the hand underneath the patient’s arm over the angles +of the affected rib or ribs and reinforcing the hand by the fingers of +the other hand an upward, outward and rotary movement can be given the +ribs, which pulls them out of their abnormal position and allows them +to return to their normal articulations. + +An effectual treatment to spread and raise the upper ribs is to have +the patient flat upon the back, and with the fingers of one hand +underneath the angles of the ribs and the other hand upon the elbow +of the patient’s arm of the same side throw the patient’s arm across +the chest transversely and bear down upon the elbow, at the same time +spring upward and outward on the angles of the ribs with the other +hand. By throwing the arm across the chest and bearing down upon the +elbow a strong leverage can be obtained upon the upper ribs, especially +those between the scapulæ. This treatment is very efficacious in +certain lung and heart diseases. + +Still another method of adjusting ribs is to have the patient flat on +his face upon an operating table with the arms hanging down on both +sides of the table and a small pillow or folded blanket beneath the +upper part of the chest; then standing beside the table, or better +still, with one foot upon a low stool and the knee of the other limb +upon the table in such a manner that one is directly over the patient’s +dorsal region one is then in a position to have full control of the +vertebral end of the ribs. If the ends of the ribs are displaced +downward, placing the thumbs over the angles of the ribs and pushing +upward and outward on the angles, the ribs can be very readily crowded +into position. If the ribs, especially between the scapulæ, are +dislocated in any direction, they may be quite readily corrected by +placing the hand over the shoulder posteriorly and throwing it outward +and upward and away from the spinal column in such a manner that the +ribs are pulled away from the abnormal position; then upon relaxing the +hold upon the shoulder with the one hand, the fingers of the unemployed +hand may push upward or downward, as the occasion requires, on the +angles of the affected side so that the ribs may be slipped into place. + +Many times one is obliged to treat the ribs of one side as a whole. In +such instances the ribs are almost invariably thrown downward except +on one side of scoliosis of the dorsal region. Several methods may be +employed to raise the ribs. Probably the best method is to have the +patient upon the side and with one hand upon the angles of the ribs and +the other hand holding the wrist of the upper arm of the patient, an +upward lifting movement is given both upon the angles of the ribs and +upon the arm of the patient while the patient inhales. The work upon +the angles of the ribs is to raise the ribs directly; the work upon +the arm is to raise the ribs indirectly, principally by the use of the +serratus magnus. Another effective treatment is to have the patient +upon the back and with one hand over the anterior ends of the ribs and +the other hand over the angles of the ribs an upward movement is given +them by springing the ends of the ribs toward each other and by strong +inhalation on the part of the patient. This treatment is most effective +where the false ribs are at fault and especially in case of hemiplegia. +While the patient is upon the back an assistant may take hold of +the arm and draw it upward over the head of the patient, producing +considerable additional upward tendency of the ribs, and the physician +giving the same treatment of the ends of the ribs as before; or the +physician may take an arm in one hand and raise it above the head of +the patient and with his other hand around the angles of the ribs, and +the patient inhaling deeply, the ribs may be raised. + +A treatment used a great deal in raising the ribs as a whole is to have +the patient sit upon a stool, and reaching around the patient from the +front, place the fingers upon the angles of the ribs and raise them +upward on both sides at the same time. This treatment can also be given +by standing behind the patient and reaching around upon the anterior +ends of the ribs and lifting upward while the patient aids you by deep +inhalation. Remember that many times the ribs are drawn downward by +contraction of the muscles, due to atmospherical changes and slumped +postures. One should begin at the upper ribs in all treatments where +the ribs are to be raised, as a whole, and work downward. + +To correct the =first= and the =floating ribs= a different treatment +has to be given than the foregoing. + +An =upward displacement= is the most common lesion of the =first rib=. +To correct such a dislocation, have the patient sit upon a stool and +with one hand pull the head to the opposite side in order that the +lesion may be exaggerated by traction of the lateral muscles of the +neck (principally the scaleni) upon the rib; this disengages the rib +from its abnormal position; then with the fingers of the other hand +upon a point midway of the ends of the rib, exert a downward pressure +at the moment the extended head is relaxed describing a short arc. But +don’t relax head until readjusting pressure is exerted upon rib. If the +patient is unable to sit up, and it is not best to give the foregoing +treatment, have the patient flat upon the back, with one hand take hold +of the arm on the affected side and pull down and out upon the shoulder +so that the rib may be somewhat drawn away from its articulation and +released from its position; then with the fingers of the other hand +upon the center of the rib, or its highest point, press downward +when the hold upon the arm is being relaxed. Correction of an upper +displacement of the first rib is an every day occurrence. =Downward +dislocation of the first rib=, is rare. To reduce this dislocation, +place the thumb beneath the vertebral end of the rib, and with the +other hand lift up strongly on the shoulder from beneath the axilla, at +the same time exerting pressure upward with the thumb on the end of the +rib. + +The =floating ribs= may be dislocated obliquely downward, or the free +end of the rib may be caught underneath the end of the rib above. In +either case, in order to correct the displacement, place the patient +upon the back with the thigh on the affected side flexed upon the +abdomen so that the tissues about the field of operation are relaxed; +then bear down carefully but firmly over the free end of the rib +with the fingers until one finger can be hooked underneath the end +of the rib; then with the other hand over the vertebral end of the +rib, have the patient take a deep breath, at the same time springing +the ends of the rib toward each other, thus relaxing the rib from its +locked position; then have the patient exhale quickly and at the same +time spring the rib into its normal position. It oftentimes requires +repeated trials, especially in stout persons, and quite often the +operation is painful to the patient. It is necessary that one should +understand this operation thoroughly, as it is one of the most common +treatments in osteopathic practice. The floating ribs are very liable +to dislocations and may be the cause of many pains in the side, +disturbances of the vessels as they pass through the diaphragm and +inflammation in the iliac region. A palliative treatment may be given +the floating ribs by having the patient lie flat either on the back or +on the side; then place the hand near the vertebral end of the ribs and +raise them upward while the patient takes a deep breath. + +Treatment of lesions between the =manubrium= and =gladiolus= are best +given by placing the patient with the face downward upon the operating +table, and having the articulation of the manubrium and gladiolus +just over the edge of the table. An assistant should hold the patient +firmly upon the table while hyperextension or flexion, as the case may +require, with traction, is exerted upon the head, neck and shoulders, +and manipulation of the articular points is given to reduce the +dislocation. The same principles are employed here as in correcting +lesions elsewhere. + +Correction of the =cartilages along the sternum= is very easily +accomplished by having the patient sit upon a stool and the osteopath +standing behind the patient places a knee in the back; then reaching +around with one hand over the cartilages and the other hand underneath +the axilla, execute the same movement as given in correcting +dislocations of the sternal ends of the ribs. + +A treatment sometimes used to release a depressed condition of the +=cartilages= of the =false ribs= is to stand behind the patient while +he sits upon a stool and reach around him with fingers underneath the +cartilages and raise them upward as he inhales. By having the patient +take a deep breath and then exhale quickly while the fingers are over +the cartilages a much better grasp of them can be obtained. This +treatment should be carefully given, as there is danger of tearing the +cartilages loose from the ribs. + +=The Dorsal and Lumbar Spinal Regions.=—Here, as in other regions of +the body, before an attempt is made to correct the vertebræ the muscles +should be thoroughly relaxed. One of the easiest methods to relax the +muscles is to have the patient lie upon the side, and then by standing +in front of the patient and reaching over him with the fingers upon the +contracted muscles an upward and outward rotary manipulation is given; +or the patient may sit upon a stool while the physician stands in front +with the arms around the patient and the fingers over the contracted +muscles manipulating them upward and outward. Another very easy method +is to stand behind the patient while he sits upon a stool and place +a thumb over the contracted fibres, with the other hand underneath +the axilla lifting the shoulder upward and backward so as to favor a +relaxation of the muscles, while the thumb manipulates them. + +In relaxing the =muscles= of the =lumbar region= have the patient on +the side upon the table; then flex the thighs upon the abdomen with +your weight against the knees so as to control all movements of the +patient; reach over the patient with the fingers upon the contracted +tissues and manipulate them outward and upward on either side until +they are relaxed. A method sometimes employed to relax the muscles of +the dorsal, lumbar and sacral regions is to place the patient flat +on his face upon the table; then by pushing up on the muscles from +above downward with the flat of the hand they are easily relaxed. This +treatment should be especially given when the patient’s muscles are +contracted by atmospherical changes and from standing in one position +for a long time. When the muscles of the back are contracting they draw +downward and many times draw the ribs with them, as well as tensing +the tissues over the sacral foramina and obstructing or irritating +the sacral nerves. By using the modern table longitudinally relaxing, +or stretching, the lumbar and dorsal musculature saves considerable +strength and effort of the physician. + +To correct =vertebral lesions= of the =dorsal region= the same rules +should be followed as in treating lesions of the cervical vertebræ. +Treatments may be given with almost equal ease whether the patient is +lying on the side or sitting up. + +To illustrate the treatment of the dorsal region when the patient +is lying down, assume that there exists a lateral lesion, combined +rotation and sidebending, between two vertebræ; if the lesion is below +the seventh dorsal use the legs as a lever, and if the lesion is above +the seventh dorsal use the head and neck as the lever. Have the patient +lie upon the side toward which the lesion is pronounced, either reach +under the neck or around the limbs with one hand, and with the other +hand upon the lesion bend the head and neck or the thighs in such a +manner that the angle of the flexion is directly over the break in +the spinal column; this is to exaggerate the lesion; then by lightly +lifting up on the neck or limbs and with a slight rotation of this +lever the flexed parts should be extended, at the same time exerting +pressure with the hand over the lesion in such a manner that the +vertebra is pushed forward toward its normal position. + +Practically, the same treatment is given when a patient is sitting +up, with the exception, of course, that the limbs cannot be used as +levers. Lesions of the dorsal region or even the lumbar region can be +corrected while the patient is sitting up. By this method considerable +lifting is done away with. In fact, the weight of the patient can be +used to great advantage by substituting it for one’s strength. No +matter in what direction the lesion is, the physician reaches around +the patient’s shoulders so that he just holds the weight of the patient +from falling to one side or the other; thus with one hand manipulating +the lesion the other arm is around the patient guiding the weight of +the body in flexion, rotation and extension. It is not always necessary +to lift up on the patient but just let the weight of the patient act +as strength applied to the power arm. Always make it a point when +working upon dislocated vertebræ in any region that just as soon as +one has obtained a slight movement in the lesion =do not attempt= +to correct it any more for the time being. A slight movement toward +the right direction may be all that is necessary to relieve the ill +effects of the lesion. In fact it might be impossible to get the lesion +anatomically correct as the shape of the vertebra may have conformed in +a greater or less extent to its abnormal position. + +An excellent method to correct the various combinations of rotation and +sidebending of the third to ninth dorsals is to have the patient sit up +with the physician either sitting or standing, depending upon height +of seat, back of the patient. Have the patient lean back until head is +supported upon shoulder of physician, and the anterior and posterior +musculature of torso, abdomen and pelvis are thoroughly relaxed. Reach +around the patient’s chest with one arm, the hand of which is placed +beneath the axilla. The thenar eminence of the other hand is placed +upon the posteriorly prominent transverse process of the lesioned +segment. Then with careful hyperextension, traction, and rotation and, +sidebending of the torso, the anchorage is released, care being taken +that localization is exact; this moment of coordination is accompanied +with a thrust of the thenar eminence upon the transverse process. +Relaxation, leverages and thrust must be precise and thoroughly +coordinated. + +To reduce vertebræ that are =deviated anteriorly= in the dorsal region, +especially between the scapulæ, is often a hard matter. A satisfactory +method is to stand behind the patient, while he is sitting upon a +stool, and reach around both sides of him upon the sternal ends of the +ribs corresponding to the anterior vertebræ; then have the patient +relax with the head upon the chest, and at the same time take a full +inhalation while pressure is exerted posteriorly upon the sternal ends +of the ribs. The object of this method is to pull back the rigid ribs +(the lungs being filled with air) which are attached to the anterior +surfaces of the transverse processes of the vertebræ, and thus upon the +anterior vertebræ pushing them posteriorly; all of the muscles of the +body being quite passive and the head relaxed on the body, a separation +of the vertebræ is accomplished, thus favoring a crowding posteriorly +of the subdislocated vertebræ. + +To correct =vertebræ= of the =lumbar region= is on the whole much +easier than in the dorsal region. Here the legs can be used as levers +to great advantage. By the same method of flexion, rotation, and +extension, as employed in the dorsal region when the patient is lying +on the side, the result can generally be obtained. + +Sidebending is the most common single lesion of the lumbar vertebræ, +though there may be some rotation at the lumbo-sacral juncture. +Occasionally malformation is found at the fifth. To correct the lumbar +lesions the following method is often used: place the patient upon the +side of the rotation or sidebending with knees flexed, buttocks well +back and entire spinal column straight. Next bring torso and head, +with spine straight, well forward to edge of table. Then with hand +upon ilium tilt it slightly forward, and with other hand upon shoulder +rotate entire spine, including head, so that spine is locked and the +point of localization exactly corresponds to the lesions. This brings +the spine back to nearly a straight position. Next, after a moment +or two of tension-relaxation, either thrust back upon the shoulder +or forward upon the ilium. Again exactly coordinating localization, +relaxation and leverages is the key of the method. + +=The Abdomen.=—Direct treatment of the abdomen is given in many +diseases of its organs. The patient should lie flat upon the back, the +legs flexed upon the thighs and the thighs flexed upon the abdomen, so +that the abdominal muscles will be thoroughly relaxed; and then the +various organs of the abdomen can usually be manipulated with ease. +Remember that in many diseases of the abdominal viscera the treatment +of the splanchnics and vagi will be the primary treatment rather than +direct abdominal treatments. + +In treating the =liver= directly, the ribs over the liver should be +raised and separated, and the lower border of the liver manipulated +directly, as considerable therapeutic results can be obtained, +particularly when the liver is congested and enlarged. Manipulation +of the =bile ducts= is very essential in many liver diseases. The +treatment relieves congestion of the ducts and removes any collections +of mucus in the ducts due to the congestion, as well as freeing +obstructed flow of bile. The manipulation should be a deep, downward +one, directly over the path of the ducts (from about the cartilage of +the ninth rib to the duodenal orifice of the biliary tract, the latter +being about one and one-half inches diagonally downward and to the +right of the umbilicus). Be very careful when first manipulating, and +bear down lightly over the duct so that the structures superficial to +it may be relaxed as the duct is deep below the surface of the abdomen. +Usually the gall-gladder can be emptied by light pressure over the +skin above the cartilages of the eighth, ninth and tenth ribs. The +light manipulation acts, probably, by way of the spinal segment, as a +stimulus to the dilators of the sphincters of the gall-bladder. Very +likely through reciprocal innervation relaxing the sphincter of the +bile duct will contract fibres of the gall bladder. + +Manipulation of the =stomach= has considerable effect in strengthening +its circular fibres and toning up the coats in general. In cases of +gas formation, the gas in some instances may by manipulating over the +stomach, be forced through the cardiac or pyloric orifices. + +Direct treatment over the =spleen= by raising the eighth, ninth, tenth +and eleventh ribs of the left side is effectual in congestion and +enlargement of the organ. + +In thin subjects the =kidneys= can be treated directly by pressing +down carefully but deeply over the kidneys, and lightly crowding them +upward and outward. This treatment also has some effect in relieving +contracted tissues about the renal vessels and kidneys. + +Treatment to the =intestines= through the abdomen is an effective +treatment. In the various obstructions to the intestines, constipation, +etc., the direct work is essential. Treatment of the intestines is to +correct any abnormal position that they may have assumed, to relieve +constrictions of the gut caused by contracted tissues, to relieve +impactions and adhesions, to increase peristalsis and to tone up the +intestinal coats in general. The treatment consists in a manipulation +of the intestines, especially in the right and left iliac fossæ, and +the pelvic colon, ascending colon and duodenum, as impactions and +prolapses of the gut are more liable to occur at these points than in +any other locality. In manipulating the intestines, work for a definite +purpose and not give a general kneading treatment unless the walls of +the abdomen and the coats of the intestines are weakened; in the latter +case the spinal treatment is the primary one. In treating over the +iliac region, draw upward and inward on the folds of the gut. It is +claimed by some authorities that nerves pass from the cutaneous surface +of the abdomen directly to the intestine by way of the peritoneum; +if such is the case, manipulation of the abdominal walls would have +direct effect upon these nerve fibres. The abdomen may be treated when +the patient is sitting up, but the treatment is not satisfactory. (See +Prolapsed Organs). + +=The Pelvis.=—The treatment of the pelvis is easy, but the difficult +work is in making a diagnosis of the position of the pelvic bones. +The pelvis is especially apt to become deranged by jars and falls. +Some of the most successful osteopathic results have been obtained in +correcting the pelvic region. + +To relax the muscles over the pelvis, the patient should be on the side +or upon the face; then relax the muscles by manipulating them upward, +chiefly those over the sacral foramina. It is a good rule to adjust the +lumbar first owing to release secured to the nerves supplying pelvic +muscles and also to the fact that many pelvic distortions are secondary +or compensatory to lumbar lesions. The easiest method to correct the +innominata is to have the patient lie upon his side; then by standing +in front of the patient slip one hand between the thighs and grasp +around the tuberosity of the ischium, and with the other hand upon the +crest of the ilium, the innominatum can be moved upward or downward +and forward or backward (wheel and axle principle). Simply pulling or +pushing upon these two points in whatever direction necessary is all +that is required providing the soft tissues are thoroughly relaxed. By +having the patient flat upon the back practically the same treatment +can be given, but not to so great an advantage. In cases where the +ilium is posterior and the ischium anterior, the physician may stand +back of the patient, while he is lying upon his side, and place one +knee against the sacrum and with one hand upon the ilium, with the +other take hold of the ankle of the affected side (the involved side +being uppermost in all cases where the patient is lying upon his side); +pressure can be exerted upon the ilium and the limb pulled backward, +thus correcting the derangement. This treatment should be avoided as +much as possible, as there is considerable danger of pulling back too +severely and injuring the patient; the lever is long and the amount of +force exerted upon it cannot be judged precisely. + +Another method is, with the patient on the back, flex and evert the +knee to the side so the side of the foot lies flat on the table. Grasp +the ankle with one hand and with the other on the crest of the ilium +of the opposite side then, by pushing down firmly on the knee the +articulation is gaped and at the same time the operator pushes with his +body against the knee with a sharp thrust. This may have to be repeated +a few times before the articulation is released and if one is keen he +will easily detect the slight concussion carried down the femur as +the adjustment takes place. This will correct a forward and downward +innominate. For an upward and backward one, place the patient in +exactly the same position and go through the same motions except that +the knee is pulled toward the operator. If the desired “chug” is not +felt and adjustment is not definite, the leg may be pulled down rather +smartly by the ankle to a parallel with the other. This is a technique +that is easy, both for the patient and operator, and will correct any +but the most stubborn. + +In the case of a greatly relaxed and atonic condition of the ligaments +of the pelvis much trouble is experienced, often, in making the +adjustment permanent. Many suggestions have been made and most of them +useless but, probably the use of a belt of non-elastic webbing about +two inches in width buckled tightly around the pelvis just below the +anterior spines will do as much as anything and is a procedure well to +follow in all such cases. Where there is a pendulous abdomen a support +in the shape of a simple belt which should be so fitted as to act as +a sling will transfer the weight of the abdominal viscera from the +muscles, already stretched and atonic, to the belt and put the burden +over the sacrum. This prevents the pulling of the innominatum in lesion +again. Overcorrection is suggested as a means on the ground that it +sets up irritation and induces fibrous ankylosis and for the same +reason W. W. Howard places his patient prone and with thumb works the +ligaments associated with the joint until they are thoroughly inflamed. +The patient is then put in bed a few days and after the inflammation +has cleared up the ligaments will be found to have shortened. + +To correct a rotary lesion between the pelvis and fifth lumbar the +patient should be placed upon the side, and with the body held firmly, +the pelvis can be forced backward or forward as the occasion demands. +(See Coccyx). + +=The Legs.=—The origin of many symptoms manifested in the legs, as in +the arms, are due to spinal lesions corresponding to the region of +innervation to the affected tissues. The derangements of the pelvic +bones are a frequent source of symptoms that are referred to the legs +and feet. The osteopath finds that a slight dislocation of the hip +may occur which is especially likely to affect the knee. This partial +dislocation is apt to be an upward-posterior one; the head of the +femur resting in the upper and posterior part of the acetabulum. Many +diseases of the legs and feet are due to local displacement of the +bones. The method of treatment is the same as given in surgical works. +(See Sprains). + +A general treatment of the legs and thighs is oftentimes necessary; +it consists of flexing the thighs quite firmly upon the abdomen, and +executing thorough external and internal rotary movements of the thighs +and legs. In a few cases both limbs are flexed strongly at the same +time upon the abdomen. After giving these movements manipulation over +the saphenous opening and beneath the popliteal space is performed. +This general treatment tends to increase the circulation of the entire +limb and to relax thoroughly all contracted fibres. + +=The Arms.=—In treating the arms, care has to be taken that the +affection is not due to spinal derangements; otherwise the arms are +manipulated according to the disorder. Complete dislocations of the +shoulder comes under the province of surgery. Many times the osteopath +locates slight or incomplete dislocations of the shoulder. Partial +dislocations of the shoulder are generally anterior. (See Sprains). + +In cases where pain exists in the shoulder or arm, outside of locating +the cause in the shoulder joint, the affection may be due to fibres +contracting over the coracoid process, or a dislocation of the second +or third rib, and in some instances the clavicle is deranged. Special +care should be given to a possible bursitis and tendo-synovitis. +Occasionally muscular fibres may slip out of the bicipital groove. +Dislocations of the bones of the arm are treated according to surgical +methods. The pains and various troublesome symptoms that may be +manifested in the fingers or the hands are oftentimes caused by slight +dislocations of the elbow, shoulder, ribs, or vertebræ, as low as the +sixth to eighth dorsals. + +=The coccyx.=—The coccyx, owing to its exposed position and rather +unstable attachment, is subject to many injuries; more indeed than come +to notice. Its injury results in many local and general disturbances +owing to its close relation to the sympathetics. Successful treatment +of deviations often bring startling results. They may be divided into +=fractures= and =displacements=. + +In =complete= or =partial= fracture of the coccyx, as well as in +dislocation, if the patient can be seen with reasonable promptness +after the accident much can be done for relief of the pain and the +prognosis is good for complete recovery. + +Examination should be made externally and internally and after the +condition is diagnosed about the same procedure is indicated for any of +the conditions. With the patient on the left side introduce the right +index finger, well lubricated, into the rectum and carefully relax all +tissue within reach of the tip. If there are spasms of the coccygeal +muscles, inhibition of the anterior nerves will quiet them. When this +has been done place the left index finger externally along the body of +the coccyx and holding it firmly both within and without release it +longitudinally and then adjust. After this has been done it is well to +hold it there until all danger of returning spasm, which might displace +it again, is over, when the finger can be withdrawn. + +The pain following will depend on the severity of the injury, but will +keep up more or less constantly for several days. When severe, relief +is often given by introducing the finger and relaxing contracted tissue +which is pulling it from its position. Hot water bags placed next to +the part will be of benefit. The bowels should be kept confined for +forty-eight hours if possible in cases of fracture. Watch carefully the +progress of union that the bones are _in situ_ so there will not be +deformity. + +In diagnosing the first injury be sure that there is no splitting +of the first segment or splinters which may require surgical +interference. In old cases of fracture where there is complete bony +ankylosis it is not justifiable to attempt any change, but where there +is motion and a fibrous union, after preparatory treatments about one +week apart, it can usually be replaced. Look well to any muscular +contractions which might interfere with it. Force must never be used +nor any attempt to replace until it has been first released from its +articular attachment. In the various forms of =displacement= the same +technique applies as in fractures, or the finger and thumb of one hand +may be used, the tip of the finger internally at the sacro-coccygeal +articulation and the thumb externally at the same point. Complete +control of the part is secured in this manner. Great care must always +be used in treatment of any displacement of the coccyx. Contractions +of its muscular attachments will often cause deviations in contour. +Removal of the irritation and relaxation will allow it to assume its +normal position. + +=The sacrum.=—Adjustments of the sacrum as distinguished from the +ilium in strictly innominate lesions are not many. When posterior with +the patient on a stool the knee of the osteopath coveted by a pillow +and placed against the sacrum and both hands grasping the anterior +borders of the ilia, strong traction will move it into position. In a +downward displacement with the aid of an assistant from behind holding +the crests of the ilia firmly as the patient sits on the table, the +osteopath in front clasping both arms about the patient and with a +rocking motion from side disengages the sacrum and at the same time +lifts it into position. + +For anterior displacements use the technique described in replacing +upward and backward innominate dislocation first right side and then +left, which will result in correcting the lesion. + +The preceding osteopathic technique includes a few of the treatments +given by the osteopath. Although many osteopaths use methods not +given here, those outlined are sufficient for illustrative purposes. +A point which cannot be too thoroughly impressed upon the student is +that osteopathic treatment is in reality =constructive= work, that is, +readjustive, not only in detail, but in viewing the body structure +as a whole. Detailed readjustment is an essential, still do not lose +sight of the relation of the part to the whole. In our distinctive +work anatomical construction is the basis of physiological function, +although physiological stimulus is essential to anatomical development. + +=How often to treat.=—How often to treat a case depends entirely upon +the nature of the disease from which the patient is suffering. Just +as in giving drugs the frequency of treatment is entirely dependent +upon the seat of the disease and its severity. Acute cases require a +thorough treatment at least once daily, and many times in severe cases +the treatment has to be repeated several times daily. In subacute and +chronic cases, as a rule, treatment should not be given as often as in +acute cases; possibly once a day, but usually alternate days is better. +In office practice cases are commonly treated two or three times +weekly. Still it is better not to treat some cases oftener than once a +week. + +There is more danger in treating too often and too long than in +not treating often enough. The distinctive work of an osteopath is +to correct disordered anatomical structures; and when a certain +derangement has been corrected the tissues should have rest and plenty +of time for repair. When treatments are given often, it simply keeps +the tissues in an irritated state and nature does not have time to +heal the diseased tissues. Always make it a point at each treatment to +correct some definite lesion, and when the work is accomplished let +the parts alone until the tissues have recovered as much as possible +from the effects of the previous treatment before another treatment is +attempted. The reason why some cases do not get cured under osteopathic +treatment is simply because the osteopath keeps the diseased tissues in +an aggravated state by the constant treatment so that they do not have +the least chance to heal; the physician is thus adding irritation to +the disease. + +It is only by experience that one can tell how often to treat. Each +case is a special study; what would be quite sufficient for a certain +individual with a given disease would not be at all suitable for a +second individual with the same disease. As in drugs what is suitable +for one person would not be adapted to another, because the make up +of each individual is entirely different; but here the parallelism +diverges, for in drugs there is a foreign agent introduced into the +system, while in osteopathic treatment the curative agent is entirely +harmonious with the idiosyncrasies of the individual. It is for this +reason that experience in practice is so essential. + +Most cases should not be treated, as a rule, after a meal unless the +patient is suffering from some digestive disturbance; for treating +other regions of the body outside of the digestive tract causes more or +less stimulation of the parts treated and thereby draws blood away from +the organs of digestion. Cases of disordered brain circulation, where +the patient is unable to rest or sleep at night, should be treated at +about their retiring time so that the circulation of the body may be +equalized, thus giving the patient undisturbed rest. + +To show in a practical way the methods of experienced osteopaths in +this matter G. J. Helmer[32] is quoted: “I submit the following table +to illustrate the frequency of treatment in one hundred cases taken +from my practice: one case three times per week, sixty-three cases +two times per week, twenty-two cases one time per week, nine cases +once every two weeks, five cases once every four weeks. Comparing +the present with the past, I find I am lengthening the time between +treatments with much better results.” + +Another very practical side of the question and one which will be +greatly appreciated by the patient, is the lessened cost for the same +result in the less frequent treatments, as well as the saving in time. +With the loss in going to the office, rest after treatment, not to +mention possible wait while there, three times weekly represents more +time than the average person can well spare and not infrequently will +deter him from continuing. More especially is this true of those coming +from a distance. + +=Length of Treatment and Overtreatment.=—Naturally the length of +treatment depends upon the case at issue and nothing more. There is no +reason why any two cases should be treated for the same length of time +unless they present identical lesions and then the personal equation +of the two might present such a wide difference of aspect as to forbid +such a proceeding. + +The question of time has no place in the matter, save that it must not +exceed physiological limits and be sufficient for the needs of the +case. The patient should understand at once that it is to accomplish +a specific purpose that the treatment is given, just as definite as a +surgical or dental operation, and when the work is done it is time to +stop. He would hardly be attracted to the dentist who guaranteed to use +forty-five minutes in extracting a tooth. Good judgment is required in +this as in all matters pertaining to osteopathy. There is a generally +expressed opinion among the older osteopaths, based on experience, +that: first, a short specific treatment is productive of best results +and, second, treatments given under high tension when quick work is +necessary are most satisfactory. Long treatments are debilitating and +over stimulation amounts to inhibition. Further, in a long treatment +it is necessary to go over the whole body, thus dispersing the vital +forces (which have been stimulated for healing and upbuilding the +pathological area) to parts not involved, thus defeating the very +purposes intended. Dr. Still always advocated and gave the short, +specific treatment. + +The point always to be considered is the individual characteristics of +the patient, and effects of the first treatment should be carefully +observed. After a patient has been under treatment for any considerable +time it is well to give him a vacation from treatment, and it is +remarkable what improvement will be shown at times by such a measure +and how seldom he will lose ground. Dr. Still presented this subject +vividly as follows: “To treat the spine more than once or twice a week +and thereby irritate the spinal cord, will cause the vital assimilation +to be perverted and become death producing by effecting an absorption +of the living molecules of life before they are fully matured and +while they are in the cellular system, lying immediately under the +lymphatics. If you will allow yourself to think for a moment of the +possible irritation of the spinal cord and what effect it will have on +the uterus, for example, you will realize that I have told you a truth. +Many of your patients are well six months before they are discharged. +They continue treatment because they are weak, and they are weak +because you keep them so by irritating the spinal cord.” It is not a +rare experience for a patient to leave apparently with little or no +improvement only to report a complete recovery a little later. + +=Misapplied Treatment.=—Probably in spinal treatment more risks are +taken than in any other region of the body. To us as a school it is +by far the most important and interesting area we have to treat, +consequently it is not surprising that various general treatments +and methods have been devised with the idea of getting quicker and +easier results. Herein lies the danger outside of mistaken diagnosis, +for short cut treatments can never take the place of time and skill. +Technically speaking, if one thoroughly understands the philosophy of +osteopathy and is conversant with the underlying principles of its +therapeutics, there is absolutely no danger of even the slightest +injury. It is the one who takes chances by not properly diagnosing +and by not being cautious enough with delicate persons when applying +his treatments that is apt to overstrain some tissue or organ and +otherwise do bodily harm. Of the treatments considered dangerous not +one of them is without merit if judiciously applied, but unfortunately +in many cases they are in general and indiscriminate use. It is well +to remember that we are moving structures which have never been +moved before and that time enough has not elapsed to observe what +the ultimate result may be. Again, in adjusting a subluxation of the +spine do not forget that the force necessary for that adjustment, if +misapplied, is sufficient to produce a lesion, and there is no doubt +that this has happened. Your patient’s interests are above everything +and must never be sacrificed for any reason whatever, so if at any +time there is uncertainty always give the patient the benefit of the +doubt. On the other hand the osteopath must have the courage of his +convictions and fortunately when these are coupled with good judgment +the results are all that could be desired. The following should be used +with great caution if used at all: + +First, =Indiscriminate stretching= of the spinal column with the aid of +an assistant. It is not good osteopathy although there are some cases +where it may be beneficial. While not specially dangerous, generally, +in delicate patients, elderly people, arteriosclerotic conditions, and +in some stages of Pott’s disease it is absolutely contraindicated. +Moreover in most spinal cases except impacted vertebræ and symmetrical +curvatures the stretching of the vertebral ligaments locks the lesion +firmer. + +Second, =Extreme rotating= of the cervical region. This cannot be +considered good treatment in any case with the exception of the +muscle stretching. On the contrary it is dangerous; first, it is not +osteopathy for it is not specific; second, the nervous shock is severe, +an important consideration in delicate people; third, the cervical +ligaments become stretched and the vertebræ are easily displaced, while +damage to a diseased vertebra, an aneurism or in arteriosclerosis would +be irreparable. No other region of the body should have greater care in +treatment than the neck. + +Third, =Hyperextension= of the spine with the patient on his face. This +treatment is rarely indicated. In fact, it is barbarous and a relic of +an early day. Possibly more cases have been injured by this treatment +than all others combined. + +Fourth, =Rough separating= of the vertebræ and ribs while the patient +is on his face. This is a most excellent treatment in many cases, but +great judgment is necessary. Delicate patients, heart disease, and +necrosed vertebræ and ribs should be carefully excluded. + +Fifth, =Innominate adjustments= such as placing the patient on the +side and putting the knee against the sacrum while grasping the leg +at the knee. Or, the placing of the patient face down with one hand +on the sacrum and the other holding the knee. In both these there is +a tremendous leverage and in the latter the strain is at the lumbar +rather than where needed. There are other unnecessarily risky methods +for this operation, while it is easy to perform in most cases and +without danger. + +Sixth, =Abdominal treatment= gives wonderful results when intelligently +applied, but it may be productive of great harm in conditions of +tumors, malignancy, and pus formations. + +=Misapplied treatment= is always dangerous, no matter to what part of +the body given, and it is proof of wrong diagnosis when given. As a +rule treatment is given without proper diagnosis in such cases, so a +misapplied treatment has two interpretations—first, ignorance; second, +laziness. In the former lies the greater danger for ignorance coupled +with force and lack of skill is an appalling combination. + +Cases are frequently reported where tumors have passed from the vagina, +rectum, nose, etc., the osteopath thinking it was the result of good +treatment, without considering that it was simply the breaking of a +long pedicle with great danger from hemorrhage. The greatest care +should be exercised in treating cases where aneurism, osteomalacia, +and arteriosclerosis are present, also in the leg treatment of tabes +dorsalis and in the weak, thin ribs of elderly people and those with a +gouty or rheumatic diathesis. Imagine treating an abscess directly, yet +it has been done, as have varicose veins with the terrible danger of +rupture and embolism. Aneurisms have been ruptured in the same way. + +One could go on indefinitely with this subject, but to sum up: if the +osteopath is not familiar with the feel of the living anatomy in its +giving and resisting under treatment both in health and disease and +does not know his osteopathy, nothing can prevent him doing harm. A +successful practitioner means an understanding of pathology, then +experience plus common sense. + + +FOOTNOTES: + +[31] See Ashmore’s Osteopathic Mechanics. + +[32] Journal of the American Osteopathic Association, Dec., 1903. + + + + +OSTEOPATHIC CENTERS + + +“Osteopathic spinal centers” was a term commonly used in the early +period of osteopathic development. From the facts, first, that +a few centers have been actually determined in the cord, viz., +genito-urinary, vasomotor, etc.; second, that the innervation from +the spinal segment to various thoracic, abdominal and pelvic viscera +correspond with a considerable degree of accuracy to certain vertebral +sections, and third, displacements of tissues of the spinal column +affect viscus integrity, depending upon the locality of the structural +perversion as to the organ involved and is a clinical observation of +great import, arose the misnomer “osteopathic centers.” For one to ask +what “centers” should be “treated” in this or that disease shows a +lack of the conception of osteopathy as if he asked what “movements” +to give when “treating” a certain disorder. It is as unosteopathic, as +it is unscientific, broadly speaking, to suppose osteopathic technique +implies the application of movements to certain nerve centers. + + +Osteopathic Stimulation + +“Osteopathic stimulation” is another term loosely used without +extensive clinical experience to support it. Mechanical stimulation +is frequently utilized in the physiological laboratory. But to employ +it extensively and comprehensively in the treating room or at the +bedside the therapeutic potency of it will be found wanting; that is, +to employ it to the exclusion of that most important basic treatment, +readjustment, is a great mistake. + +Clinically, the pathologically slowed heart may be stimulated by a +stimulus to the cervical sympathies, the gall-bladder emptied by a +stimulus near the costal cartilages of the ninth and tenth ribs (this +is probably via the spinal segments), etc. Normally, these organs and +others may be temporarily stimulated. Experimentally, Burns[33] of +Los Angeles and Pearce[34] of San Francisco have shown the potency +of osteopathic mechanical stimulation. For example, stimulation +(mechanical) in the middle and lower dorsal regions irritates and +increases peristaltic action and vaso-constriction in the stomach and +intestines. + + +Osteopathic Inhibition + +Likewise the term “osteopathic inhibition” has not always been +scientifically employed. Mechanical inhibition is probably used less +frequently than stimulation but still it is of more importance. +Probably the true interpretation of considerable of so-termed +stimulatory and inhibitory efforts, is simply one of normalization of +tissues, physiologic equilibrium resulting from such changes. + +Clinically, to relax contracted muscles by inhibition, to relieve +neuralgia by impinging nerve courses, to relax the cardiac orifice +of the stomach by pressure at the ninth or tenth dorsal vertebra on +the left side, etc., are excellent examples of the therapeutic value +of inhibition. Experimentally Pearce and Burns produced the opposite +results to that of stimulation. Inhibition in the middle and lower +dorsal region caused relaxation of the muscles of both the stomach and +intestines, decreased peristalsis, and caused dilatation of the blood +vessels. + +The employment of stimulation and inhibition rounds out to a certain +extent our therapeutics, that is, makes it more practical and specific. +We should not, however, over-rate the relative value of stimulatory and +inhibitory treatment as compared with the readjustive treatment. Not +but what the former is of considerable practical importance, but the +point to be emphasized is that it gives a scientific demonstration of +how pathological effects result, if long continued, from the various +osteopathic lesions. In a word, it shows the physiological process +from cause to effect, or rather a step in the beginning pathological +(perverted physiological) in many disturbances. + +Therapeutically, all will agree with Cherry[35] that “stimulation +and inhibition should be employed in all forms of acute disease as +palliative measures until such time as the primary lesion may be +removed.” + +As a preparation for adjustment of any bony lesion there is no +question but that simple inhibition for a brief time in the area will +bring about relaxation of soft tissues in a much more satisfactory +manner than the usual massage like method. McPherson, Montreal, has +developed a technique of sacral pressure which he uses exclusively in +his practice. Without going into the merits of his theory there is no +doubt that inhibition at the second and third sacral will bring about +relaxation of the muscles of the lower trunk in a most gratifying +manner. Another thing, if there is difficulty in introducing the finger +in making either a vaginal or rectal examination, a minute’s pressure +at these points will, in most cases, cause the sphincter to relax so as +to cause no discomfort to the patient. This pressure will, also, have a +great effect on the hypogastric plexus and the pelvic organs. + + +Osteopathic Readjustment + +Readjustment or adjustment is many times particularly emphasized in +this work as the key to osteopathic therapeutics. + +If the theory of readjustment can not stand the most searching tests +of science osteopathy will have to be relegated to a most subservient +place, on a par with massage, Swedish movements, and various medical +gymnastics. Consequently the readjustment theory is again referred to, +and especially so when the subjects of osteopathic centers, stimulation +and inhibition are outlined. + +No doubt many stimulatory (so-called) and general treatments exert +their greatest influence by inadvertently readjusting tissues. Then +how much more effective would the readjustment treatment be if applied +intelligently. In certain acute disorders, e. g., “colds,” immediate +relief is often obtained by relaxing muscles through either stimulation +or inhibition; in reality the final result, as far as the muscle +is concerned, is one of readjustment. Likewise in stretching and +rotation of tissues and sections of the body the effect may either be +stimulatory or inhibitory, and still it may be, also, readjustive. + +After all has been said the ultimate physiological effect of any +of these treatments, if of any therapeutic value, must be one of +stimulation to a part or to the body generally. But there is a vast +difference between physiological stimulation and the one method of +obtaining the same termed mechanical stimulation. It is not the purpose +here to enter into anything like an exhaustive survey of stimulation +and inhibition but simply to outline a few practical hints on the +relative values. Everyone is aware that overstimulation is equal +to inhibition, and even applying it to very delicate subjects the +therapeutic end we may wish to obtain may be lost and as a consequence +the patient exhausted; whereas at the same time readjustment possibly +could have been employed and real permanent effects secured. + +So we should whenever possible utilize the basic principle of our +therapeutics, readjustment, for this represents in the majority of +cases, first, permanent results; second, a saving of much time, and +third, less exhaustion on the part of both patient and physician. + +McConnell[36] has shown in his series of laboratory experiments on +animals the reality and potency of the readjustment fundamental. +The effect of malaligned vertebræ and ribs upon contiguous vascular +channels and nervous tissues, not only affects immediate skeletal +muscles by simple contractions but even produces interstitial myositis. +Through narrowing of the intervertebral foramina and tension upon the +fibrous tissue anchoring the spinal nerve in its exit, and through +pressure and strain on the sympathetics in contact with the heads of +the ribs, which are secured there by the parietal layer of the pleura, +organs in corresponding cavities become diseased. Some of the diseases +produced in the series of experiments were catarrhal and parenchymatous +changes in the stomach and intestines, congestion of the liver and +spleen, acute nephritis, goitre, inflammation of the lymphatics, edema +of the cornea, and degenerations of nervous tissues. Still too much +emphasis should not be placed upon the narrowing of the foramen for +certain pathologic changes are shown to be due to other conditions than +Wallerian. + +The osteopath, as stated, may inadvertently correct osteopathic +lesions. _Vis medicatrix naturae_ undoubtedly corrects many osteopathic +lesions; this is evident from the fact that many bodily strains, +sprains, and injuries are overcome naturally or involuntarily, that +is, without any voluntary assistance from an osteopath. On the other +hand all osteopathic lesions are not due to outside influences or +forces, e. g., in pneumonia the severely contracted dorsal muscles +often partially dislocate the vertebral ends of the ribs and thus +increase the seriousness of the disease; and this is true in many acute +conditions wherein visceral changes will reflexly contract spinal +muscles and also through these contractions produce osseous lesions. +Here is where osteopathic treatment in acute diseases will not only +correct the primary lesion but also these secondary ones and thus +abort, or shorten, or lessen severity, or prevent complications of +the disease. But it should always be borne in mind that when certain +disease processes occur it will take a definite time at best for +curative changes to predominate. In other words pathological changes +are just as real and potent as physiological facts or anatomical data +and the character of the same should always be considered. + +Consequently in readjustment work a distinctive etiology and pathology +has to be taken into account. The color, contour (whether the lesion is +simply a local one or there is a composite or group lesion), condition +(irritation, debility, contractions, and tenderness), and movement of +the several regions, and the spine as a whole should be noted. And +the student should always keep in mind that the osseous vertebral +lesion may be, (a) a twist between two vertebræ (this generally means +a rotation of one section of the spine on another section), (b) +malalignment of several vertebræ (the composite or group lesion), or +(c) the impacted or strained lesion, (this is a lesion that Clark +attaches considerable significance to, wherein there is injury to the +articular surfaces and ligaments without osseous derangement, followed +by exudation and other inflammatory products, limited motion, etc.). + + +VasoMotor Nerves + +It is extremely important that the osteopath should be thoroughly +conversant with the regions where he may affect the vasomotor nerves to +various tissues and organs. Many anatomical derangements undoubtedly +involve the vasomotor nerves, and it is therefore necessary to know +where they may be affected. The following table is taken mostly from +the physiology of Landois and Stirling, but many of the statements have +been noted at various times; it is, therefore, impossible to give full +credit.[37] + +The vasomotor center is in the medulla, consequently the osteopath +gives cervical treatment to influence this center. Treatment of the +upper cervical region has undoubtedly a marked effect in tending to +equalize the vascular system of the body, when it is disturbed. + +=Head.=—The cervical sympathetic for the same side of the face, eye, +ear, salivary glands, tongue, etc., and possibly the brain. Lesions +are found in all the tissues about the cervical region, but usually in +the vertebræ, which influence these nerves. Deep contracted muscles +oftentimes involve them. The spinal vaso-constrictors for the vessels +of the head are from the first five or six thoracics. Many lesions are +located in the upper five or six dorsal vertebræ, or corresponding +ribs, that have apparently a direct influence upon the vessels of the +head. Not only congestive headache and congestion of the brain tissues +are influenced by lesions in this region, but disease of the eye, ear +and face occasionally arise from such derangements. It is always best +when the head, neck or even the arms are involved, to examine carefully +this region. Vaso-dilator fibres for the face and mouth are found from +the second to the fifth dorsals; these fibres unite almost entirely +with the trigeminus, and pass from the superior cervical ganglion of +the sympathetic, to the ganglion of Gasser. This fact is of great +importance to the osteopath, for oftentimes when inflammation of the +face and mouth occurs, lesions may be located along the upper dorsal +vertebræ or ribs, or in the deeply contracted muscles of this region. +Observation revealed in several cases of erysipelas that the causative +lesion was located in the upper dorsal region; and the cases were cured +by correcting these lesions, thus showing that probably the vasomotor +nerves were the seat of the trouble. Other dilator fibres arise +apparently in the trigeminus, for stimulation of this nerve between the +brain and Gasser’s ganglion causes dilatation of the vessels of the +face. The lingual and glosso-pharyngeal nerves are the dilators of the +lingual vessels. The sympathetic and hypo glossal are the constrictors; +these arise in the sympathetic and reach the nerves by way of the +superior cervical ganglion. Stimulation of the cervical sympathetic +causes constriction of the retinal vessels. This point is extremely +interesting to the osteopath, because diseases of the retina and optic +nerve are oftentimes due to subluxated cervical vertebræ, usually the +atlas or third cervical. The retinal fibres leave the sympathetic at +the superior cervical ganglion and pass along the communicating ramus +to the ganglion of Gasser, from whence they reach the eye through the +ophthalmic branch of the fifth nerve, the gray root of the ophthalmic, +the ganglion and the ciliary nerves. Almost all the fibres to the +anterior part of the eye are found in the fifth nerve; this, also, +is another important point for the osteopath’s consideration. Cases +of conjunctivitis, keratitis, corneal astigmatism and diseases about +the eyelids and tear ducts are usually caused by lesions to the fifth +nerve, due to a deranged atlas or third cervical. The vaso-dilators +for the anterior part of the eye, and also dilating fibres to the +iris may be affected at the first and second dorsals. This point is +also taken advantage of by the osteopath, for lesions of these fibres +occur oftentimes at the upper dorsal. It is claimed that important +fibres that aid in the control of the metabolism of the retina, may be +affected at the fourth and fifth dorsals. + +=Lungs.=—Reflex constriction by stimulation of the intercostals, +central end of the sciatic, abdominal pneumogastric and abdominal +sympathetic. There is not a rich vasomotor supply.[38] The essential +feature to the osteopath is that the vaso-constrictors to the lungs +and bronchial tubes are very likely to be interfered with by rib +and vertebral dislocations, from the second to the seventh dorsals, +inclusive, but chiefly at the third, fourth and fifth. The heaviest +innervation being from the third, fourth and fifth spaces, probably +explains why asthma is often due to a dislocation of the third, fourth +or fifth rib. + +=Heart.=—First to fifth thoracic via ganglion stellatum and inferior +cervical ganglion. Vasomotor fibres to the coronary arteries are found +in the vagi. + +=Intestines.=—Sympathetic, chiefly through the splanchnic nerves. +Vaso-constrictors of the jejunum from the fifth dorsal down, for the +ileum slightly lower and for the colon still lower. There are none +below the second lumbar. Dilators are present in the same sheath, but +more abundant in the last three dorsals and the upper two lumbars; all +probably end in the solar and renal plexuses. + +=Receptaculum Chyli.=—Stimulation of the splanclinics causes dilatation. + +=Liver.=—The splanchnics chiefly on the right side. The vagus contains +vaso-dilators. There are also fibres from the inferior cervical ganglia +of the sympathetic. + +=Kidneys.=—Vasomotor nerves from the sixth dorsal to the second lumbar, +but principally from the ninth to twelfth dorsals, inclusive. In the +large majority of kidney diseases, lesions are found from the tenth +to the twelfth dorsals. Stimulation of the sciatic centers causes +contraction. There are also fibres from the superior cervical ganglion. + +=Spleen.=—Vasomotor fibres are in the splanchnics, third dorsal to +third lumbar, principally, on the left side. There are some fibres +direct from the brain. Stimulation of the vagi contracts the spleen. + +=Portal System.=—Fifth to ninth dorsal. + +=Generative Organs.=—For Fallopian tubes, uterus, vagina, vas deferens +and seminal vesicles, vasomotor fibres are found in the lower dorsal, +and the second, third, fourth and fifth lumbar nerves, principally. + +=Coccyx and Immediate Region.=—Third lumbar down. + +=Back Muscles.=—Dorsal Posterior branches of the lumbar nerves and +intercostal nerves. These nerves arise from the gray ramus of the +corresponding sympathetic ganglia. + +=Arm.=—From the brachial plexus, the sympathetic, inferior cervical +ganglion and first thoracic ganglion, and sometimes lower. + +=Leg.=—Second dorsal down, the sciatic and crural nerves, and the +abdominal sympathetics. + + +Sensory Nerves + +Inhibition of various regions along the spinal column is frequently +given by the osteopath to lessen pain. It is only a temporary or +palliative treatment, but many times gives great relief. One should +inhibit usually over tender points and contracted muscles. These +(tender points and contracted muscles) are signs to the osteopath that +disturbances exist at these points. The following table is taken from +Quain, which is Head’s classification: + +=Heart.=—First, second and third dorsals. + +=Lungs.=—First, second, third, fourth and fifth dorsals. + +=Stomach.=—Sixth, seventh, eighth and ninth dorsals. Cardiac end from +sixth and seventh. Pyloric end from ninth. + +=Intestines.=—(a) Down to upper part of rectum, ninth, tenth, eleventh +and twelfth dorsals. (b) Rectum, second, third and fourth sacrals. + +=Liver and Gall-bladder.=—Sixth, seventh, eighth, ninth and tenth +dorsals. + +=Kidney and Ureter.=—Tenth, eleventh and twelfth dorsals. Upper part +of ureter, tenth dorsal. At lower end of ureter, first lumbar tends to +appear. + +=Bladder.=—(a) Mucous membrane and neck of bladder; (first) second, +third and fourth sacrals; (b) over distension and ineffectual +contraction, eleventh and twelfth dorsals, and first lumbar. + +=Prostate.=—Tenth, eleventh (twelfth) dorsals. First, second and third +sacrals, and fifth lumbar. + +=Epididymis.=—Eleventh and twelfth dorsals and first lumbar. + +=Testis.=—Tenth dorsal. + +=Ovary.=—Tenth dorsal. + +=Appendages, etc.=—Eleventh and twelfth dorsals, first lumbar. + +=Uterus.=—(a) In contraction, tenth, eleventh and twelfth dorsals, and +first lumbar. (b) Os uteri; (first) second, third and fourth sacrals +(fifth lumbar very rarely). + +Other points are used by the osteopath to relieve pain of certain +regions, for such the reader is referred to the article on neuralgia; +besides many tender points are found along the spine by the osteopath, +where inhibition gives relief to the patient, provided such points have +a connection with the case in question. + +Hot fomentations if property applied, through reciprocal relationship +of the nervous system, are of value in relieving pain, releasing +spastic musculature and normalizing visceral function. Frequently, +in both acute and chronic cases, this is an excellent preparatory +measure, to be followed by careful adjustment. It will be recalled +that the functional test, movement of a vertebral lesion is of primary +consideration.[39] + + +FOOTNOTES: + +[33] Burns—Partial Report of Experiments upon Visceral Reflexes. The +Osteopathic World, Aug., 1905. + +[34] Pearce—Some Laboratory Demonstrations of Osteopathic Principles. +The Osteopathic Physician, Nov., 1905. + +[35] Stimulation—Leslie E. Cherry, Journal of the American Osteopathic +Association, Feb., 1905. + +[36] McConnell—The Osteopathic Lesion,—Journal of the American +Osteopathic Association. + +[37] See also Gaskell, The Involuntary Nervous System; Pattenger, +Symptoms of Visceral Disease; Mackenzie, Symptoms and Their +Interpretation. + +[38] MacLeod, Physiology and Biochemistry in Modern Medicine. + +[39] See Luciani, Human Physiology, Vol. III; MacLeod, Physiology and +Biochemistry in Modern Medicine. + + + + +PATHOLOGICAL SPINAL CURVATURES + + +SPINAL CURVATURES + +Any deviation of two or more consecutive vertebræ from the normal +curves of the spinal column is usually termed by the osteopath a +pathological curvature. Of the common pathological curvatures of the +spinal column there are found: (1) scoliosis or lateral curvature, (2) +kyphosis, or excurvation, an antero-posterior curve with the convexity +backward, and, (3) lordosis, or incurvation, an antero-posterior curve +with the convexity forward. + +=Osteopathic Etiology.=—Of primary importance in the causation of +pathological curvatures of the spinal column, are injuries to the +spine, such as strains, falls, blows, and various physical forces, +acting directly or indirectly, as injuries to the chest, pelvis and +limbs. The osteopath in his daily work finds more curvatures, as well +as acute and chronic diseases, resulting from some simple injury to the +spine, as a slip, strain or twist, than from any other cause. The dire +effects of any violence to the spinal column cannot be overestimated. + +Among =predisposing causes= may be mentioned, continued ill health, +general weakness, rapid growth, rachitis, tuberculosis, etc. Any +habitual one-sided position may result in a curvature. An injury to the +chest, adhesions from pleuritis, chronic liver disease, obliquity of +the pelvis producing unequal length of the legs, carrying heavy weights +on one side, and various morbid growths of the chest and abdomen, may +all produce curvatures. Many cases are found in school children who +are growing rapidly, and whose muscular strength and development do +not keep pace with their growth. Unilateral atrophy of the muscles, +due to central changes or overuse, may be the cause of deviations of +the spinal column. Sacro-iliac disease in some instances is a potent +factor. Thus there may be a great variety of causes productive of the +incipiency, and the spine being strained or irritated at a single point +and in a certain way gradually develops a curvature. Every spinal and +innominate lesion should be considered as a potential cause for a +curvature. + +=Scoliosis.=—This is the most common spinal deformity and is +characterized by lateral deviation from the median line. In most +cases the curve is to the right in the upper dorsal region, with a +compensatory curve in the opposite direction in the lumbar region. The +curve being to the right in the majority of cases, is probably due to +the fact that most people are right-handed. + +=Morbid Anatomy.=—The vertebræ in the region involved are rotated so +that their spinous processes point toward the concavity of the lateral +curve. The bodies of the vertebræ on the side next to the concavity +are thinner, due to absorption; the intervertebral discs are made thin +on the same side by pressure and absorption. The ribs are considerably +distorted, depressed on the concave side and prominent on the convex +side. The ligaments on the concave side are contracted, and stretched +on the convex side. The muscles on the concave side are more or less +contracted, and on the convex side they are stretched, causing atrophy +and fatty infiltration of their tissues. + +=Kyphosis.=—This may be a slight posterior curve really amounting to +nothing, or it may be a very grave pathological condition as in Pott’s +disease. Therefore it is very necessary that one should make a most +careful diagnosis (see Pott’s disease). + +The most common =causes= of kyphosis are Pott’s disease, rachitis, +occupation, general weakness, rheumatism and old age. + +In Pott’s disease, the posterior curve is characterized by a sharp +angle, and by the spine being very rigid. This, taken in conjunction +with the history and other symptoms should be sufficient to enable one +to make a diagnosis. Radiographic examination should be made. + +The condition of round shoulders, which in time produces marked +kyphosis, is rarely a habit as it is usually termed. In nearly every +case it indicates either a weakness of the back muscles or, what is +more apt to be the cause, a strained posterior condition of the dorsal +vertebræ, commonly of the lower dorsal region. + +=Morbid Anatomy.=—In mild cases there is simply a relaxation of the +ligaments of the vertebræ and a separation of the laminæ and spinous +processes. In severe forms there may be absorption of the anterior +portion of the intervertebral discs and the bodies of the vertebræ +(Pott’s disease). + +=Lordosis.=—This may be a congenital condition, especially when +occurring in the lumbar region. Anterior curves of the spine are +generally found in the lumbar or cervical regions, but occasionally +occur in the dorsal region, causing the spinal column to be more +or less straight, and thus weakening the individual. This curve is +commonly compensatory to kyphosis, hip-joint disease and congenital +dislocations of the hip. + +=Treatment= of =Spinal Curvatures=.—The treatment of pathological +curves of the spinal column, by osteopathic methods, has been highly +satisfactory to both osteopath and patient. The success of the +osteopath in these cases has been due to his comprehensive and exact +knowledge of each vertebra, and of the spinal column in general. He +recognizes curvatures that the ordinary practitioner, and it is safe +to say the orthopaedic specialist, would not even notice or recognize. +On account of the highly developed sense of touch of the osteopath, +he is capable of detecting the slightest deviation of one vertebra +from another, and of the spine in general from the normal. Thus by +the uniqueness and peculiarity of his work he is capable, not only of +discovering a curvature, but also of reducing a curve when found. + +The work consists of, first, relaxing any muscles that may have become +rigid over the seat of the curve. Then follows a treatment to each +vertebra involved, by attempting to replace it, and treatment to +the curve in general by springing it toward its normal position. At +each treatment effort should be made to accomplish something toward +correcting the spine; too many treatments are given in a “general” +way, and being unspecialized amount to nothing. One must become +familiar with the exact location of each vertebra involved, to attempt +a correction of a curvature intelligently. Upon this one point it is +impossible to speak too strongly, for a great many treatments have been +wasted and improvement of cases retarded by not paying enough attention +to the details of the diagnosis, either from pure slothfulness or from +an imperfect conception of osteopathy. Corrective exercises are always +of value in addition to treatment. + +These remarks refer to incipient and certain moderate curvatures. +In other cases radical measures (Abbott) should be employed if age +and conditions permit. Remember, however, that the practitioner in +his daily work of adjusting the many combinations of rotation and +sidebending lesions corrects innumerable actual and impending curves. + +=Lateral curvature= in the dorsal region is undoubtedly the hardest +to correct on account of the ribs, which complicate the condition. +A marked curve in the dorsal region is sure to be accompanied by a +dislocation of the vertebral end of one or more ribs. Treat each +distinct lesion separately, follow by general stretching, replacing and +molding of the tissues. A good method to stretch tissues and adjust +a moderate lateral curve is to utilize the swing, or in lieu of this +have the patient stand just at arm’s length from the wall with concave +side toward the wall with straight arm at right angles and palm resting +against the wall. Stand in front of patient whose feet are firmly on +the floor and reach around with both hands upon the spine. As the +patient sidebends toward the wall it tends to correct the deformity, so +if the operator coordinates his adjustment with that lateral movement +of the patient, precise fulcra can be obtained and a certain, definite +correction secured. The significance rests with the stretching of +tissues and the definite fulcra obtained, thereby securing a maximum +sidebending and rotation toward correction. + +The =dislocation= of an =innominate= sometimes complicates matters, but +is a simple point to remedy, and should not be overlooked. + +The correction of a curvature presents a special study to the +osteopath, whether it be scoliosis, kyphosis or lordosis, and special +rules cannot be laid down for treatment. Cases of rare occurrence are +what might be termed “symmetrical” curves; i. e., no vertebra presents +separately a marked lesion, the column on the whole being simply bowed. +Such cases can be treated by springing back the spinal column, and by +the use of methodical exercises. Unfortunately most curvatures are +characterized by various lesions between the vertebræ, and thus each +lesion requires special work. + +In simple curves the use of braces, jackets, and the various mechanical +appliances are of very little use to the osteopath, in fact, more +harmful on the whole, than beneficial. Naturally they would apply to +a “symmetrical” curve, or where the patient is too weak to sit or +walk, but they can be of very little use to the average patient, in +place of correct osteopathic treatment. Mechanical appliances confine +the movements of the patient, interfere with the development of the +muscles, and impinge to a greater or less extent the spinal nerves. +Due attention to hygienic surroundings and diet are certainly of aid. +Proper exercises and occupation for the sufferer should be advised. +Special care should be taken in examining (radiographic) for infectious +lesions (arthritis). + +=Straight Spine= is a term used particularly by osteopaths for a +condition seldom recognized by orthopedic surgeons. The following +is from H. W. Forbes[40]: Straight spine is “a departure from the +normal in the conformation of the chest; characterized anatomically +by bilateral diminution in size, decrease in the antero-posterior +diameter, relative increase in the transverse diameter and flattening +of the anterior and posterior walls; characterized clinically by +diminution of respiratory capacity, lowered lung and heart resistance, +impaired general nutrition and predisposition to neurosis. + +“Of the many possible manipulations that may be used to lift and +overcome the morbid bend of the ribs I will attempt the description of +but one. + +“Relax the musculature of the back and chest. Rotate, flex and extend +the dorsal spine. Examine all the ribs on each side and loosen any that +do not move freely. Having done this, the patient is prepared for the +specific treatment. Have the patient sit on a stool and lean forward +on a table. Have him separate the elbows, flex the forearms, place one +hand over the other and his forehead on the hands. Tell him to relax +all the muscles of the shoulders and arms and to breathe deeply without +using the muscles. After a few trials he is able to fully expand his +chest without contracting the muscles connecting the upper extremity +with the trunk. The physician then takes a position at side (either +side) of the patient and places the weight of his trunk on the ribs of +the side he is on, a little external to their angles. He passes his +arms around the patient’s body; the arms passing across the front of +the chest are carried around far enough to allow the hand to be placed +on the ribs just external to their angles. The other hand is placed +on the top of this one. In this position the physician’s body on one +side, and his hands on the opposite, occupy similar positions. The +patient is now told to inspire deeply and at the same time to relax +the shoulder muscles, as before instructed. As the chest expands drop +the weight of the trunk on one side and make pressure forward (forward +meaning toward the anterior surface of patient’s body) with the hands +on the other side. This lifts the ribs to a greater extent than the +patient unassisted could lift them. At the end of inspiration and +during the first third of expiration the chest is compressed laterally. +The compressing force, if applied correctly, will fix the ribs in a +position of less obliquity and will also correct the increased lateral +bending of them. The dorsal spine becomes more convex posteriorly +at the moment of lateral compression of the thorax, if correctly +made. Great force should not be used at the beginning. Repeat the +manipulation five to twenty times each treatment. Give treatment three +times a week. A similar movement may be given on the table. + +“The greater number of flat chests in patients under thirty years +of age may be corrected. If the patient is above thirty, although +complete correction may not always be accomplished, the results are +satisfactory. Two to six months treatment is required.” + +=A “typhoid spine”= comes as a sequel to typhoid fever. There is +constant pain, tenderness along the lumbar region and rise of +temperature. The pain is generally increased when the spine is moved +forward or sidewise. Such a condition is clearly understood by the +osteopath. There are always found distinct vertebral lesions along +the region that is tender on pressure. In fact these very lesions may +have been the predisposing cause of the attack of typhoid fever. +The treatment is rest and the indicated manipulation to correct the +derangements. It is of great interest to note that where the typhoid +patient is treated osteopathically the condition just described seldom +results. Observations by C. M. T. Hulett confirm this statement. + +The =Neurotic Spine= may be the result of injury but the subject is +usually of a nervous, neurasthenic type. It occurs from the age of +puberty to adult, much more often in females than males. + +The patient has dull pain in the back of the neck or in the lumbar or +sacral region, complains of a constant tired feeling and often of a +sharp neuralgic pain in certain parts of the spine. Generally there is +a drooping posture in the upper dorsal with shoulders thrown forward, +which is a sign of weakness. There is extreme tenderness along the +spine and usually the pain is confined to the sensitive places. + +Treatment consists of a constitutional toning up, and increasing +muscular strength through judicious exercise. The posterior curve may +be pushed toward the median line by laying the patient on the face; +also with the knee in the back and the flat of both hands on the +sternal ends raise the ribs; or by the arms making use of the pectoral +muscles accomplish the same result. Deep breathing is also effective. +Relief can usually be given and a cure will depend upon the patient’s +general condition. + +The =Hysterical Spine= is usually considered the same as the neurotic +spine, but there are many cases which have the sensitive spine without +being hysterical. There is more deformity usually present, particularly +in the lumbar region. Probably there will be a history of some injury. + +The treatment is to correct the curvature and build up the general +health. These conditions are stubborn and progress is slow. In both the +neurotic and hysterical spines the ligaments of certain areas will be +found atonied and relaxed. This is especially noticed upon attempting +to spring a group of vertebræ when all of a sudden the section relaxes. +In either of these spines the lesions will irritate or obstruct nervous +courses, produce venous stagnation or arterial starvation, and disturb +lymph channels. H. F. Goetz has observed that in functional nervous +diseases the dorsal spine is flat, while in visceral displacement the +dorso-lumbar spine is posterior. + +The =Spine of the Aged= wherein is found stooped shoulders and a +rigid spinal structure, can be distinctly improved by slow, cautious +traction. This tones weakened muscles, releases contractures, separates +the compressed intervertebral discs, and definitely tones the viscera. +Careful work is imperative. + + +FOOTNOTES: + +[40] Journal of the American Osteopathic Association. + + + + +POTT’S DISEASE + + +An article on Pott’s disease does not really come within the province +of a practice of medicine. Still it will be acceptable to the +practitioners and students of osteopathy, as one of the objects of +osteopathic work is to improve, not only medical and obstetrical +practice, but also surgical practice, and besides the osteopath will +have many cases of spondylitis to treat. “Pott’s disease, or caries +of vertebral bodies, was first described by Percival Pott in 1779. It +consists of a destructive ostitis affecting the spongy tissue of one +or more of the bodies of the vertebræ. The ostitis is tuberculous, and +is similar in character to tubercular ostitis seen in the epiphysis +of the long bones. Owing to the superincumbent weight of the head +and shoulders pressing upon the carious vertebral bodies, the spine +and trunk become peculiarly and characteristically distorted. The +morbid process is limited, as a rule, to the bodies; the transverse, +articular, and spinous processes are rarely primarily affected.” (Park). + +The first consideration in the =treatment= of Pott’s disease is rest. +If the disease is a progressive one, rest in bed in the recumbent +position is necessary. Naturally, the object of the treatment is to +secure resolution of the tubercular ostitis as soon as possible. To +do this, careful manipulative treatment should be applied to the +diseased vertebræ. The treatment must not be harsh, for there would +be danger of greater irritation to the parts, and possibly infected +particles from the destroyed tissue might gain entrance to the vascular +system. The osteopath must be extremely careful how he manipulates +the spinal column in Pott’s disease. The object of the manipulation +is not primarily to overcome the deformity, as some may think such an +act possible, but to separate the vertebræ enough to allow a freedom +of the circulation, and to remove impingements of the nerve tissue. +It is impossible to overcome the deformity to any extent when part +of the body of the vertebra is destroyed; but if one could treat the +case at the incipiency, most probably deformity would be prevented. +There is another danger in treating cases too severely, and that is +causing exhaustion of the patient. Treat the spinal column not only +to separate each articulation slightly, but to carefully crowd the +diseased vertebræ toward their normal position. When the disease is +in the dorsal region, considerable attention has to be paid to the +ribs, as they are invariably involved when the spinal curvature is +great. Hence it is necessary to treat each rib separately, and try to +correct them at least, and remove any obstruction to nerve fibres or +vessels that may be found. One of the strongest arguments against the +indiscriminate use of braces, jackets and various mechanical appliances +in spinal deformities, is that they tend to straighten the spine, by +simply crowding the vertebræ and ribs as a whole into place, besides +interfering with the cutaneous circulation. The osteopath should +realize that each vertebra and rib has to receive special treatment, +in order to correct the spinal column, and that mechanically exerting +pressure upon all the vertebræ at one time tends to lock the vertebræ +and ribs all the more securely. It is like trying to correct a certain +subdislocation of the cervical vertebræ by pulling and twisting the +neck instead of applying specific treatment—the lesion is all the more +firmly fastened. Young, in his Surgery, makes this observation: “Like +chronic abscess or chronic bone disease, this affection has its origin +in the fact that the tissues of the anterior parts of the bodies of +the vertebræ have been partly deprived of their nutrition because of +luxated ribs or subluxated or twisted vertebræ.” + +After the tissue destruction has been limited, and the deformity +corrected as much as can be, an ankylosis should be secured if +possible. Promotion of ankylosis depends altogether upon the preceding +treatment—rest and an improved nutrition of the parts. A truss or +brace, if correctly applied, is often beneficial in such cases. The +treatment of spinal abscesses is entirely in accordance with surgical +treatment. + +In all cases the general health of the patient has to be well taken +care of. The osteopath must not be over zealous for quick results. +It takes many months to perform a cure; however, there is always +a tendency toward a cure. Treatment of the spinal muscles and of +the limbs, and pure air, sunlight, massage and good food are very +necessary. + + + + +SPRAINS AND FRACTURES + + +SPRAINS + +The osteopath is often called upon to treat sprains of various +sections of the body as well as to relieve after effects of fractures +and restore function to the part. The osteopathic treatment is very +effectual; therefore, an outline of the purpose and method is given. + +Sprain is defined by Dorland as “the wrenching of a joint with partial +rupture or other injury of its attachments, and without luxation of +bones.” From an osteopathic viewpoint the above definition is not +fully explanatory, for there is in most cases a partial luxation of +the bones. The most common cause of a sprain becoming chronic is the +presence of partial bony displacements. Rupture of tissues may be the +cause of a chronic state but is not nearly so frequent as the bony +dislocation. In most sprains, the wrenching causes a displacement +of the bony tissues, which may or may not return to normal position +and relation. The function of the muscles is not primarily to hold +the bones in place; this is left to the ligaments, so when a wrench +of a joint is so severe as to cause rupture of muscles or tearing of +ligaments, partial luxation of the bones is almost certain to follow; +and even where such damage does not occur a change in the relation of +the bones is a frequent occurrence. + +Unless a sprain can be seen very early it may be difficult to detect +just what has happened; whether it rests with a rupture of the areolar +and connective tissues, a displaced cartilage, tendon, or bone, a torn +ligament, or ruptured muscle. Hemorrhage and swelling take place so +rapidly that no time should be lost in critically examining the joint. +When in doubt as to the structural disturbances, particularly in acute +cases if there is a possibility of a fracture, and in chronic cases any +supposition that tubercular involvement is present, have a radiographic +examination. + +There is comparatively little to be found in medical literature +relative to the =pathology= of sprains. Probably Moullin in his +excellent monograph on Sprains has given as good an outline as can be +found[41]. He says that “generally speaking, the tissues on one side +of a joint are overstretched and torn; those on the other compressed +and crushed together; but there is always so much twisting, and such +a difference in the strength and power of resistance of various +structures, that unless the part is examined with the greatest care it +is almost impossible to say what actually has given way.” Hemorrhage +due to torn vessels is the cause of most of the swelling within the +first few hours. Later on, there is considerable lymph mixed with the +blood. There is not only extravasation of blood into the surrounding +tissues but also into the synovial wall and cavity. This causes +considerable irritation and pain owing to the roughening of the +membrane, and the joint becomes inflexible. And if the joint or any +strained tissue is kept too long at rest the mass becomes organized and +is the cause of much discomfort and annoyance. + +Similar changes may occur in the bursæ due to the extravasated blood. +Strong ligaments may be torn across, but not frequently. The tear +is usually a separation from the bone. Occasionally interosseous +ligaments, as for instance in the knee, may be injured. + +The muscles may be severely torn, but more often they are “hurt by +their own sudden and spasmodic effort at recovery than by anything +else.” In a few cases the tendons and muscles will be found bruised, +lacerated, and dislocated. + +The veins occasionally rupture and thus results more or less effusion, +so that rigidity and edema may persist for a long time. The bones are +very frequently damaged. This may be a simple bruising of the tissue +but more often, as osteopathic diagnosis shows, there is partial +displacement of the bony structure. + +A point of great importance that every experienced osteopath will +agree to is the following from Moullin: “Diseases of the spine, hip, +and other joints in children may be due, in great measure, to some +constitutional taint, though it is open to question whether the +influence of this is not overrated; but it is quite certain that the +immediate starting point in nine cases out of ten is some chance +sprain, often so slight as scarcely to have been noticed at the time.” + +Before treating a sprain there are one or two points the osteopath +should carefully note: first, that there is no complicative fracture; +second, in children that there is not an epiphysial separation; and, +third, note peculiarities of a constitutional character that would +complicate matters. Whatever is done, always give the patient the +benefit of the doubt. + +If the patient can be seen early, before swelling has reached the +maximum, many times a very quick cure can be secured. Do not at +once put the part at rest and apply cold, but examine the sprain +most carefully and thoroughly and readjust first of all any bony +defects; then replace the softer tissues if displaced, and next relax +contractions; follow this by light massage and passive movements to +reduce and combat hemorrhage and swelling. This treatment alone in +a fair percentage of cases will be all that is necessary provided +frequent subsequent treatments of massage and passive movements are +continued to reduce and counteract inflammation and to prevent rigidity +and stiffness of the softer tissues. Where the osteopathic treatment is +distinctly indicated is in the readjustive manipulation. This is the +reason why the treatment is so efficacious, and the patient is cured in +a fraction of the usual time, and few sprains result in complications +and become chronic. In sprains that have become chronic there will +be found almost invariably some osseous tissue slightly displaced. +After correcting this, apply careful and thorough manipulation and +massage and movements to break up adhesions, to remove effusions and +extravasations, to relax muscles, and to promote normal circulation. +Care should be taken that there are no displaced cartilages, ligaments, +tendons, or muscles. + +It is well to keep in mind that the osteopathic readjustive +manipulation is not an exercise or movement, but definite, specific +correction of the tissues anatomically. Do not treat the displacement +by any general “pommelling,” but apply the mechanical principles +indicated as in any dislocation. This will mean much to the patient in +more ways than one, and especially so should the sprain be so severe +and complicated as to demand anesthesia for correction. + +There is no objection to the employment of cold and heat; in fact, both +are beneficial. Cold to prevent extravasation and swelling, and heat to +remove and relieve the same, is a sound and practical method. But do +not apply a wet bandage. Pouring cold water over the sprain is the best +method; even better than immersing the part. An ice bag is another good +way to apply cold. When the skin begins to look blanched and dull the +maximum amount of benefit has been secured. Heat at the very first may +be employed instead of cold, for it has a tendency to prevent bleeding +and inflammation, but the temperature of the application must be hot as +can be borne or else the desired effect will not be obtained. Later on +to relieve pain and rigidity, and to relax the muscles so that a better +circulation will be secured, moderate heat will be beneficial. Then the +application of heat and cold alternately will be of service, employed +as a douche for a tonic effect, when the part is weak, inactive, +and powerless after the elapse of several days. It should always be +remembered that the employment of heat and cold is only of temporary +benefit, so if used too long opposite effects to those desired will +result. + +Bandaging the sprain may be helpful, but not always. Great care should +be taken as to how pressure is applied. Bandaging from periphery +toward the trunk, seeing that the bandage is smooth, and padding all +depressions so that the bandage does not touch bony prominences only, +are necessary. Unless the bandage is applied so that an even pressure +is secured, the material used not too warm, and the bandage attended to +each day, the effectiveness will amount to but little. + +Next, do not make the mistake of resting the injured joint too much. +The function of a joint is movement, and it has been observed that +prolonged rest of a healthy joint may result in rigidity, stiffness, +and distension of the soft part, and even serious organic changes +in the ligaments, synovial membrane, and cartilages have occurred. +Consequently continued passive movements should be kept up from the +inception of the injury, although it must not be carried to extremes +so that inflammation, hemorrhage, or laceration will be aggravated. +Moullin says: “As a rule, passive movement may be commenced from the +second day with the certainty of preventing adhesions, and without +the least fear.” Osteopathically, with due attention to readjustive +manipulation, and care as to correct position and rest, passive motion +will be allowable usually from the first day. + +There is much corroborative evidence in current medical literature that +bears in a general way upon part of the foregoing. The International +Text Book of Surgery says: “Massage should begin early, in order to +avoid, as far as possible, weakness of the muscles, and to ensure +security to the position of the joints by the retention of a proper +tone in them;” besides, early movement tends to reduce the effusion +into the tendon sheaths around the articulation, which in some cases, +particularly the ankle and wrist, may be a very prominent feature. The +Reference Hand Book of the Medical Sciences voices the same opinion; +and Mumford is referred to as follows: “Immobilization for more than +a few days, as under the older methods, is objectionable because +adhesions are apt to form, thus causing impairment of function, and +because when there is a =tubercular taint=, proper conditions for a +localized tuberculosis are established.” Among other statements Holder +Sneve in the Journal of the American Medical Association of June 1, +1901, says: “Immobilization of muscles is not rest. On the contrary, +in all sprains the muscles should have passive exercise the first few +hours and days, and active exercise after that. In the majority of +cases active exercise should be instituted from the beginning. The +plaster cast should not be used at all, even in cases where we have a +fracture, unless it be impossible to maintain a proper position of the +joint.”[42] + +Again quotation is made from Moullin. These quotations are taken +from the chapters on Manipulation and Massage. It will be observed +he makes a distinction between the two methods. And the osteopath +should carefully keep in mind not only the difference between the two, +but beyond these the more fundamental treatment, readjustment. The +characteristic feature of osteopathy is anatomical readjustment, and +this in sprains should be supplemented by massage (superficial work), +and also manipulation (deep and more or less forcible work) in order to +remove stiffness, rigidity, and fibrous ankylosis. + +The following is relative to forcible manipulation: “Manipulation +is much more useful than division; it can be employed for such a +variety of purposes. In the early stages it prevents the occurrence of +stiffness or the formation of adhesions. Later, when the swelling and +heat have disappeared, it is no less successful in restoring freedom +and ease of movement, and afterward, when all mechanical obstructions +have been cleared away by its use, it is one of the most effectual +methods known for bringing back the circulation and nutrition of the +part, and giving again to the muscles and nerves the energy which has +so long been wanting.... + +“To carry this out effectively two things are needed beyond all others. +The one is a sense of touch so delicate that it can appreciate the +least resistance or irregularity of movement; the other an accurate +knowledge, not merely of the ordinary anatomy of the part, but of +the different degrees of tension that fall on the ligaments in every +position of the limb. + +“Each joint requires a different kind of manipulation according to its +construction.... + +“There should be no jerking. The movements must be vigorous and +forcible, but perfectly smooth; and they must be carried out +thoroughly, the joint being moved to its full extent in all directions +that are natural to it. Each kind of action should be combined +successively with the rest, one by one, so that the tension may fall in +turn upon all the different parts of the capsule. + +“Movements which are especially restricted or painful, of course +require most attention, but the others, though they may not be affected +to the same extent, are not to be neglected. It sometimes happens if +these are dealt with first, that a considerable proportion of the main +obstruction is cleared away, as it were, by side attacks, so that when +its turn comes it yields more readily than it otherwise would. + +“Recent slight adhesions give away at once without a sound, though the +sensation is generally conveyed to the hand. When they are older the +noise may be as loud and clear as when a bone is broken.... + +“The after treatment of these cases (cases where there has been +tearing and breaking of adhesions) should be in all respects the same +as that of a recent sprain, only if passive motion at an early date +is advisable to prevent the occurrence of stiffness in the one, it is +absolutely necessary in the other.” + +The following pertains to massage of sprains: “Massage, in the strict +sense of the term, is a great deal more efficacious, especially with +older sprains. Its action is not limited to the skin and superficial +structures. These undergo immense changes, it is true; they become +softer and finer while under manipulation; their strength and +elasticity increase, the extreme tenderness diminishes, and the natural +appearance and texture return. The surface loses its dry, harsh +character and becomes warm and moist again; the livid bluish color +gives away to a brighter hue, and the deeper layers of fibrous tissue +yield and stretch, so that the hide-bound, shrunken condition that is +often present after long disuse gradually passes off. But the good +effect is not by any means limited to, or even most conspicuously shown +by, this. When properly carried out, massage exerts a simultaneous +influence on muscles, nerves, and vessels; in fact, on all the tissues +within its reach. + +“The circulation is the first thing to feel its power. It has already +been explained how, after prolonged rest, the blood, as it were, lies +almost stagnant in the tissues, slowly circulating through them, and +neither giving them sufficient for their nutrition, nor removing from +them the waste products of their action. This is changed at once. The +life of the part is quickened. The veins and absorbents are emptied +first, and the fluid they contain driven out into the heart, which +fills more rapidly, and contracts more vigorously and firmly. Then +the pressure falls in the smaller vessels, and the tiny irregular +spaces, full of lymph, which extend in all directions through the +tissues. These, in their turn, are compressed and mechanically emptied, +their contents being driven on into the empty vessels, from which any +backward flow is prevented by the valves. The circulation becomes more +rapid; nutrition is carried on with greater energy, and the actual +amount of the blood in the tissues at any one time so much increased +that they become full and soft to the touch and regain the even and +rounded contour of active health.... + +“It is most essential to commence as gradually and as gently as +possible, working on the deeper tissues only after the more superficial +ones have become thoroughly accustomed, and have been unloaded of their +surplus fluid. The skin, the soft subcutaneous tissue, the muscles, +and the deeper layers, must all be worked in turn. Nor should the +manipulation be confined to the injured part. In a sprain of any +standing, the whole of the limb is affected more or less. It is usually +better to devote attention first to the parts nearer the trunk than to +deal with those around the injured area, and only afterward, when the +circulation is thoroughly reestablished, to manipulate the joint itself. + +“The tendency is to make the sittings last too long. Deep manipulation +itself rarely requires more than =five minutes=; but in dealing with +a recent injury it may be advisable to spend a longer time than this +over the friction and other preparatory measures, so that a quarter +of an hour soon passes by. When the tenderness is very great, and the +amount of swelling excessive, much longer than this may be necessary, +but short, frequently repeated sittings are of greater benefit than one +long one. A skillful operator, too, will often effect more in a few +minutes than an ordinary rubber will in as many sittings.” + +A summary of the general treatments of sprains would be as follows: + +1. Readjustment of parts and removal of obstructions. Osteopathy is +especially adapted in these cases, for two of the primal therapeutic +factors in all cases from an osteopathic viewpoint are to readjust the +anatomical and to remove obstructions. One should constantly keep in +mind, “a temporary displacement followed immediately by a return to +place, constitutes a sprain.” The osteopath often finds that a perfect +returning does not take place, and even remote lesions may affect a +joint. + +2. Manipulation, and massage of soft tissues, to restore circulation +and to prevent and remove debris from rupture of vessels and +inflammatory products. + +3. The employment of cold, heat and pressure, and a certain amount of +rest. + +4. Anatomical readjustment and manipulation in chronic cases to break +up adhesions, remove exudates, overcome the organized products of +inflammation, and cure synovitis. + +5. Movements both passive and active to stimulate and exercise +functions of the joint. + +=The Spinal Column.=—The osteopath is especially cognizant of the +fact that many sprains occur to the spinal column. These may affect a +single joint, or more or less of a section may be involved. The bones, +ligaments, tendons, muscles, or spinal cord may be found injured. Even +distant organs, through involvement of the circulation to the cord, or +through irritation or impingement of spinal nerves and sympathetics, +are frequently disordered. It is not necessary to go into detailed +description, for the points bearing upon this will be found under +Osteopathic Diagnosis, Etiology, and Technique, and the general +description will, also, apply. Readjustment, strapping, heat, massage, +manipulation, ironing, stretching of muscles, fomentation, etc., have +their place. There is no doubt that sprains, strains, and blows to the +spinal column are the cause of many spinal disorders and consequent +visceral disturbances. + +=The Ribs.=—Sprains of the vertebral ends frequently occur, resulting +in a partial luxation, stretching of ligaments, contraction of muscles, +and exudative formation in the joint structures, which often is the +cause of irritation to the sympathetic nerves. The costal cartilages +are frequently strained, and may so irritate the intercostal nerve as +to cause considerable pain both locally and reflexly. The treatment is +essentially one of replacement, and relaxation of the softer tissues. +Adhesive strips to limit movement due to respiration may be helpful. + +=The Innominata.=—Sprains of the innominata are also commonly met +with. Besides being a source of discomfort to the patient they are +an important cause of pelvic disorders and leg affections. Partial +displacements are the rule, the correction of which gives quick relief. +Where there is considerable spasm of muscles, examine carefully the +lumbar alignment. In chronic cases fibrosis of muscles and adhesions +may complicate matters. + +=The Hip Joint.=—Sprains involving the hip joint may be readily +corrected, and again may be the exciting cause of serious involvement. +Previous tubercular disease can be aggravated in this manner, or +syphilitic changes in the joint disturbed. Care should be taken +that there are no complicating displacements of the innominata or +irritations to the spinal nerves. Possibly the hip may be so strained +as to cause a twist of the femur in the socket and thus simulate a +partial dislocation; this, in fact, would probably be termed a partial +dislocation. Strain of one set of muscles about the hip joint is +somewhat rare, and spinal lesions may disturb the innervation to one +set of muscles. In cases of =intracapsular fracture= considerable can +be done by careful massage and manipulation after union has taken +place, to secure greater freedom of movement and strength of the limb. +Likewise in =hip-joint disease=, after the disease is healed, massage +and manipulation will be very beneficial. Care must be taken if the +treatment causes spasticity of the muscles; this shows the treatment is +irritative and should be stopped until the spasticity has ceased. Where +the limb is shortened from either hip-joint disease or intracapsular +fracture apparent lengthening may be secured by careful abductive and +hyperextensive stretching. + +=The Knee.=—The knee is the most complicated joint, and sprains are +apt to be very serious. The usual treatment for sprains is employed. +Occasionally the semilunar cartilages are displaced and may be a +source of difficulty in diagnosis; likewise injuries to the patellar +tendon and lateral ligaments. Another joint frequently overlooked is +the innominate. In a number of knee cases that terminate in chronic +synovitis there will be found a displacement of the innominate that +is preventing recovery. A villous synovitis may arise in strains from +faulty posture, especially in the obese. Injury to the hip-joint, also, +may cause strain or irritation at the knee. Occasionally tender points +about the knee, especially at the inner side, are due to irritation at +the hip, or possibly from the spine. Referred pain of the knee joint is +of frequent occurrence. + +=The Ankle and Foot.=—The ankle is often sprained. One should examine +carefully for a possible fracture of the malleolus, and for fracture of +the tibia. There may be a dislocation of the fibula, also a separating +of the tibia and fibula at the ankle. The common bony displacement +takes place between the astragalus and os calcis. Then the cuboid is +frequently displaced, and occasionally the navicular. The treatment +should first of all be directed to correction of the osseous lesions. +The arch of the instep may be weakened from the ligamentous strain and +be an immediate step in the production of =flat foot=. Teall is of the +opinion that lumbar and innominate displacement are common predisposing +causes. Faulty position of the foot in walking may be an underlying +factor. + +=Bunions= result from a malposition of the joint. =Morton’s disease= +due to a pinching of the metatarsal nerve will often yield to +osteopathic treatment alone. There is generally displacement of the +metatarsal bone. A pad worn directly under the painful point will be of +benefit. In many of the local neuralgias, some anatomical displacement +will be found as the exciting cause. =Hammer-toe= if not complicated +with gout, rheumatism, etc., will yield to treatment if kept at +persistently, otherwise surgical interference will be necessary. + +Likewise various deformities of the foot and resulting neuralgias +may be traced to local sprains, ill-fitting shoes, or anatomical +maladjustments higher up of such a character as to affect the pedal +circulation. + + +Flat Foot + +Flat foot or weak foot is one of the common disorders that the +osteopath is constantly called upon to treat. In the first place +the patient should be taught to walk correctly. The feet should be +parallel in walking so that the weakened muscles may be developed and +strengthened. This will be difficult at first, but recovery depends +upon this important point. In addition to this, special exercises, like +turning the toes under and tip toe exercises, should be persisted in +for a few minutes two or three times daily. Upon the other hand, do +not overdo the exercises but always carry them to a point of fatigue. +These two features, walking correctly and exercising, are essential +complementary measures to the adjusting treatment. In conjunction +with the above, the Scotch douche at the end of the day will prove of +considerable benefit. + +In the technique work, first make certain that there are no innominate +or spinal lesions that bear upon the circulation and innervation of the +feet. Then frequently faulty walking is due to these lesions. + +In recent cases, simply remolding the arches of the foot will be all +that is necessary, providing correct walking and foot exercising is +maintained. But in the more chronic cases considerable adjusting and +remolding of the tissues, bones, ligaments, muscles and fascia, are +demanded. Perfect apposition between the astragalus and navicular +bones, the highest point of the longitudinal arch, should be first +secured. Attention should also be given the other articulating +structures down to the metatarsal bones. This reestablishes the arch +and overcomes the everted tendency. Considerable repeated force is +often demanded to release the fibrotic tissues, but it is the important +part of this technique. + +With the patient on the table, supine, place your thumb firmly at the +articulation of the navicular and astragalus. Then with the other hand +around the metatarsals to be used as a lever in extending, rotating +and inverting the foot with the fulcrum at the thumb of the first +hand, spring, thrust and adjust the arch. This requires considerable +strength and exactness of application. The tissues must give freely +before the result can be secured. This is often painful to the patient +but should be continued and repeated to the furthest point of motion +until recovery is complete. Treat as often as the condition permits. +Substituting the crotch of the thumb and forefinger or the knee for the +thumb will give added advantage. Follow this with thorough springing of +the plantar tissues by thumb and fingers. + +If this is kept up with suitable exercises and correct walking, and +proper shoes (Munson last), excellent results will be obtained in the +great majority of cases. Same pair of shoes should not be worn two days +in succession. + +Many times the anterior arch is involved, jointly or separately. +Persistent adjusting and remolding of the arch tissues will secure +satisfactory results unless the bones are markedly deformed and the +weight of the body is relatively too great. In this disorder, aside +from paying special attention to the metatarsal articulations, the +great toe requires a particular technique. For this grasp the toe +firmly, exert traction until the tissue gives slightly and rotate it +inward, toward the median line of the body, on its longitudinal axis. +Have the patient frequently turn the toes under, or attempt to do it +until the exercise can be easily accomplished. + +Do not employ arch supporters except in hopeless cases. They simply +splint the foot and thus further weaken the foot muscles. If the above +methods are persistently followed to the point of actual adjustment, +accompanied by releasing of fibrous tissue and actual strengthening +of muscles through exercise, a very large percentage of cases will +recover. In a few cases adhesive strips will be of benefit. + +=The Shoulder.=—Exclusive of muscular and other strains there may be a +partial dislocation. In these cases the acromial end of the clavicle is +frequently dislocated, and owing to a general lack of muscular tone may +be very hard to keep in place. The lower and inner part of the capsule +is often affected, so that freedom of function is lacking and there is +considerable pain. This is due to the thinness of the capsule and the +large amount of soft tissue, so that when the arm hangs at the side the +tissue is thrown into folds; and being very vascular is easily injured, +so that the vascular lymph readily organizes and the part becomes stiff +and unyielding. It requires patient, laborious treatment to break up +and absorb this fibrous tissue. Then the long tendon of the biceps in +some shoulder sprains is dislocated, but rarely. In shoulder injuries, +examine also, the upper ribs. + +=The Elbow.=—The elbow is another complicated joint. One should be +careful that there is no fracture, and in children that there is not +=epiphysial separation=. Extending, flexing, pronating and supinating +the arm will aid much in the diagnosis. Examine well the rotation of +the radius at the elbow joint, and be positive that the olecranon +process drops normally into its fossa at the end of the humerus. + +=The Wrist and Hand.=—The wrist is another joint commonly sprained. +Here, also, care should be taken that a fracture does not exist. +Colle’s fracture is frequent. The bursal and tendon sheaths are usually +markedly involved. The scaphoid and semilunar are apt to be displaced; +also, the os magnum and the unciform. + +Sprains of the =fingers= are often met with. Outside of strains to the +muscles, ligaments, and other tissues the joint is apt to be somewhat +impacted. Traction will correct the latter. Care should be taken that a +fracture is not present. =Dupuytren’s contraction= occurs from sprains +or injuries, as the result of contraction of the fascia. The ring and +index fingers are members usually affected. In some cases the affection +will be found in both hands (symmetrical), and a spinal lesion will +be the predisposing factor. Treatment every day, by straightening the +fingers and stretching the tissue will at least retard the deformity, +but in a number of cases surgery will have to be resorted to. + +A =ganglion= or “weeping sinew” is a swelling in connection with the +tendon sheath. It presents a round, firm outline, usually upon the back +of the wrist. There is generally found a displacement of one or more +of the wrist bones. If treatment of the joint and tendon sheath does +not remove the ganglion, surgery may be utilized. =Trigger-finger= is +a rare disorder. There is usually a history of local strain, which +probably resulted in some thickening of the tendon. Manipulation and +passive motion if continued will generally give relief. + + +Fractures + +Immobilization and rest have been the paramount points with most +physicians in the treatment of fractures and sprains. They have claimed +that a sprain should be manipulated but rarely, much less a fractured +bone. Rest, quiet, and fixation of an injured joint or bone have been +rules that should not be violated under any consideration. In cases +of sprain the great cry has been to let the joint alone for fear of +spreading a possible =tubercular infection=. It is well to recall +Mumford’s statement that if immobilization is too long continued, +should there be a tubercular taint, proper conditions for a localized +tuberculosis is established. And still a word of caution here, that an +osteopath should not be over zealous and should carefully weigh all +possible factors, both local and constitutional, may not be amiss. In +previous tubercular, syphilitic, and other diseased states discretion +should be employed. + +Reducing rest and immobilization to a minimum means much to the +patient, not only in the loss of valuable time but in annoying and +serious after effects. Many cases of sprains and fractures come to +the osteopath. In sprains that have become chronic through too much +rest of the part and improper treatment, almost invariably there is +found displacements of bone and adhesions that should never have +existed; then has followed organized exudates and chronic synovitis. In +fractures and even in complete dislocations the osteopath continually +observes that too much rest has been given the part, resulting in +unnecessary adhesions, contractions, atrophy of muscles, and impairment +of function. Treatment almost always cures the condition, or at least +materially relieves. How much better if the proper treatment had been +first instituted and thus a large percentage of cases prevented from +becoming chronic. + +Of particular interest to the osteopath is the paper prepared by +Eisendrath on “Early Massage and Movements in the Treatment of +Fractures and Sprains,” and the discussion that followed before the +Chicago Medical Society. The Illinois Medical Journal, December, 1903, +contains a report. + +Eisendrath said in part: “The former routine of immobilizing all +fractures and the adjacent joints for a period of four to six weeks +must, I feel, be subject to slight modification in the light of recent +experience, and it shall be the aim of this paper to show what these +changes are. When we are called to a case of fracture, it should be +one’s first duty after its reduction to consider how can I best aid +the patient in recovering the usefulness of his or her limbs? Can we +shorten the long convalescence with its resultant loss of valuable +time and earning capacity? How can we most rapidly restore to the limb +its normal joint functions and prevent an atrophy of muscles and an +ankylosis which will require many months to overcome?... + +“The use of massage and of active and passive movements in the +treatment of fractures and of severe sprains has been gradually +gaining in the number of its advocates through the writings of +Lucas-Championniere of Paris. We owe him a great debt for calling the +attention of the profession to the employment of these methods in order +to prevent atrophy and ankylosis as well as to promote healing.... + +“Before taking up my subject in detail permit me to recall a few +salient points in the surgical pathology of fracture. Soon after the +injury the blood clot around and between the ends of the fragments is +absorbed and replaced by a jelly-like mass of young connective tissue +cells called the callus. It corresponds to the solder which the plumber +places over the ends of two pipes he desires to join. Bone begins to +form at the periphery of the callus about the tenth day and advances +toward the center rapidly, forming a ring of bone around the ends +of the fragments so that by the end of the third week there is but +slight abnormal motion at the point of fracture (exception to this is +the femur). This entirely disappears by the end of the fourth week, +especially in young people, and the union is firm. In the case of the +femur it requires six or eight weeks. The greater the displacement +of the ends of the fragment, the larger the callus and the slower the +healing of the fracture. + +“During these changes (callus formation) the muscles which supply +the immobilized joints atrophy and the circulation in the skin and +neighboring tissues is sluggish, resulting in swelling, etc., of the +limb. The enforced rest causes more or less fluid to accumulate in +the tendon sheaths and joints. This becomes organized and results +in fibrous ankylosis of the joints and great impediment to the free +action of the tendons within their sheaths. It is this atrophy, fibrous +ankylosis and tenovaginitis which interfere with the restoration of the +normal functions of the limb.... + +“Can we decrease the amount of wasting of muscles and control the +stiffness of joints and tendons after fractures? + +“It is the belief of the writer, based on a large experience, that the +earlier use of massage, active and passive motions, will to a great +extent eliminate the above conditions, which retard convalescence and +in some cases cause permanent disability. + +“Massage of an injured limb increases the amount of blood supplied to +it, promotes the absorption of the swelling and prevents atrophy of +muscles. In the case of a joint injury the exudate rapidly disappears +and the articular surfaces can be again approximated so that movement +is facilitated. By the cautious use of active and passive movements, +either with or without the aid of apparatus, the normal functions of a +joint can be rapidly restored.... + +“The active and passive movements of the limbs can be carried out +immediately after the massage, but should only be permitted for +a period of =five minutes= at first and the time then gradually +increased. When a severe sprain, say the elbow or ankle, is first +massaged, the pain seems to be almost unbearable, but this discomfort +as well as the swelling rapidly disappears, and it is surprising to +those who have never applied this treatment how quickly the normal +function of the joint reappears. The same applies to the synovitis +which accompanies fractures in close proximity or even into joints.” + +The relief given these cases by massage, movements and manipulations +by the osteopath is a daily experience, and results to him are not +surprising. Then in addition to what the surgeon would do, the +osteopath applies his principles of careful detail readjustment. + +Eisendrath continues his paper by referring to the principal varieties +of fractures and giving the treatment for each. He says that if correct +treatment is carried out with proper massage and movements in fractures +of one or both bones of the leg, the patient will be at work in six or +seven weeks instead of three or four months, that in Colle’s fracture +some surgeons do not employ a splint, and that in fractures of the +olecranon, massage from the first week on is of the greatest use. This +part is very interesting but space forbids giving it. + +He then concludes his article with citation of several very interesting +cases of fractures and severe sprains. These cases are exceptionally +interesting to the osteopath, but still the same good treatment and +results are duplicated every day in the osteopathic school. + +The doctor’s contraindications to the use of early massage in fractures +or sprains are the following: + +“1. Tendency to displacement of fragments in oblique fractures. Under +such conditions it is best not to begin either massage or movements +until the union is firm (fourth to fifth week). + +“2. In compound fractures until the wound is healed. + +“3. Whenever the condition of the skin is such as to permit of +infection; for example, the presence of blebs, or extensive abrasions. + +“4. The presence of fragments which project but do not penetrate the +skin.” + +His conclusions are: + +“1. Massage, active and passive motions prevent atrophy of muscles, +tenovaginitis and ankylosis so frequently accompanying and following +fractures, especially those close to the shoulder, elbow, wrist, knee +and ankle joints. + +“2. They give far better results than complete immobilization in the +majority of fractures.” + +In the discussion that followed Henrotin said that for some time, “I +have never put a restraining apparatus of any kind, nor have I used any +lotions on any sprain, no matter how severe.... + +“It has taken many years to bring this subject before the profession. +It is a method that is absolutely effective as regards sprains and some +forms of fractures. I have treated several hundred such cases with the +greatest success.” He also said that, “In treating an inflamed joint +it is improper to use a restraining apparatus of any kind. I consider +that the plaster cast is the bane of all inflamed joints unless there +is a =specific form of infection=, a traumatic condition.” Neither does +he believe that an inflamed joint should be put at rest. He says the +patient is a good judge as to the amount of quiet the joint needs. He +has treated Colle’s fractures and fractured clavicles without bandages +or apparatus. + +To sum up, the osteopathic procedure in the treatment of fractures +would be as follows: + +1. Immobilization in those cases especially demanding it, from the +character of the fracture, until formation assures solid and firm union. + +2. Manipulation and massage and movements of parts at an early period, +compatible with the above, to render soft tissues pliable, to remove +stiffness and adhesions, to restore a normal circulation, and to +exercise and function the parts. + +3. In cases of laceration of soft tissues, abrasions, etc., great care +should be taken so as not to infect the parts. + +4. Great care should be taken where fracture is compound, and where +fragments exist. + +5. In all cases, both acute and chronic, critically examine for slight +anatomical deviations locally and remotely. + +In dislocations the fundamentals of the above are applicable. Do not +let chronic stiffness, or rigidity, adhesions, or synovitis supervene +if possible to prevent. + +An important consideration in all cases of sprains, fractures, and +dislocations that become chronic is the probable effect upon dependent +tissues by way of nerve impairment and vascular obstruction; for +examples, the sprained back may readily impair organic life, the +fractured elbow prevent use of the arm, the injured leg predispose +to flat foot. (See J. B. Littlejohn—Osteopathic Surgery, including +Treatment of Fractures, Journal of the American Osteopathic +Association, Nov., 1905.) + + +FOOTNOTES: + +[41] See also Jones’ latest work, Injuries to Joints. + +[42] See also Wharton Hood, Sprains and Fractures. + + + + +POSTURAL DEFECTS + + +A postural defect is any abnormal position, congenital or acquired, +of the body, assumed in sitting, standing or walking. This leads to a +symmetrical development, causes structural changes, and as a sequel, +disturbance of function and organic life results. + +Defects in posture are of very common occurrence. A perfect posture, in +fact, is somewhat rare. Considerable is being accomplished, especially +of late years, by the laity through various physical methods and +exercises to correct the many defects of position in sitting, standing +and walking. The originators of the many so-termed systems of exercises +have gone so far as to even advertise to cure various diseases of the +body as well as attempting to improve the normal tissues and structure. + +Exercises, undoubtedly, have their place, particularly in the life of +those of sedentary habits. Most of us do not exercise enough, neither +do we as a rule get enough fresh air and pure water. But there are many +defects of the anatomical that mere gymnastics can not adjust. And +there are still other defects that gymnastics may decidedly aggravate. +In these cases the mechanism of the body has become so deranged and +disturbed that nothing short of actual readjustment can be effective. + +In the consideration of postural defects there are a few points that +should be particularly emphasized. First, these defects may not only be +the result of laziness or carelessness, but of more frequent occurrence +is some previous strain or injury to the spinal column or other parts +of the body framework. Some defect of position or symmetry of the body +may easily follow as a result. Here gymnastic work may reduce the +defect to a minimum, but rarely can the compensatory forces of nature +entirely obliterate the structural disorder, unless assisted by actual, +specific readjustment. Second, in the examination and treatment of the +patient due attention should be given the symmetry and figure of the +body as a whole so that relation of the part to the whole and _vice +versa_ may be rightly proportioned. Remember that the spinal column +is only one part of the body outline, thus one should consider the +transverse section of the body in relation to the spinal column and +not the spinal column alone. In a word, correction of postural defects +implies both structural rearrangement and molding of the contour. Do +not make the mistake, for example, when correcting a deformity that +involves the chest, of paying attention to the spine alone, but take +into consideration the thorax as a whole of which the spine is only a +part. + + +Round Shoulders + +=Round Shoulders= are a defective posture with which everyone is +familiar. How many children have escaped the parents’ criticism to +sit, stand, and walk erect? And not a few of the afflicted have not +succeeded after persistently doing their best. + +Round shoulders or stoop shoulders are commonly attributed to +indifference. Probably a few cases are due simply to laziness and +indifference, and others may be carelessness, and usually when they +arrive at an age where pride of their physical demeanor and powers +enters as a life factor, the child soon overcomes the postural +weakness. With still others the correct, persistent physical training, +as exemplified in military schools, will readjust the defect. But there +is a class, and by far the largest, where round shoulders are a very +real and active weakness of the physical body. And the weakness is not +primarily in the shoulders as nearly everyone thinks. The stoop is a +result. The origin is in the lower dorsal spinal column. Here will be +found a posterior curvature that involves nearly the entire dorsal and +lumbar areas. This is the real, the original cause of the larger number +of round shoulders. + +This backward curve of the spinal column, instead of the forward curve +as it should normally be at the waist, obliterates the brace or truss +of the spinal column that is so essential in maintaining an erect +posture of the shoulders. It allows the individual to “fall into his +stomach,” to drop the shoulders, and as a consequence the chest cavity +is depressed. The spine is one continuous backward bow, and when he +does try to sit straight, and it is always with a constant effort, the +normal, the physiological curves of the spine are not apparent. + +First, then, there is a spinal weakness in the region of the +innervation to the digestive organs. Indigestion of various forms +is a common accompaniment. Second, there is lessened lung and heart +capacity. The ribs are depressed, interfering with perfect aeration and +elimination on the part of the lungs and with normal activity and tone +of the heart muscles. Phthisis is predisposed. Is it any wonder the +child’s blood is impoverished and anemia results from the insufficient +aeration and poor digestion and assimilation? Costogenic anemia may +also be a result. And, third, the shoulders are “round” from the spinal +weakness and flattened chest, really an effect; but while the most +noticeable, it is the least serious. + +It is evident from careful observation and study of these cases that +the treatment resolves itself into the treatment of a posterior spinal +curvature. Shoulder braces, steel braces and jackets, and casts have +very little place, if any, although there may be diseased bone of such +character and severity that a cast will be necessary; this, however, +would refer to treatment of Pott’s disease and similar conditions. + +Hence, the =treatment= is, first to replace and readjust the malaligned +vertebræ. There must be an actual physical manipulation in order to +correct the vertebræ at fault. This is the essential, and by far the +primal, treatment for the key to the truss or brace that holds and +retains the body in an erect position is then replaced. + +Second, raising the depressed ribs. Remember the depressed ribs are +dependent upon the spinal condition. The thorax should be treated as a +comprehensive whole, not the spinal column alone. + +Third, exercises are a valuable aid. The individual’s part is as +necessary, in a way, as the physician’s, for in order to accomplish +the maximum there should be consistent and appreciative work on the +part of the patient. Holding the shoulders back, the head erect and +the chin in, drawing the abdomen in and up, all with deep breathing +by the use of the chest muscles, the patient will be able to retain +the correction obtained during treatments. “Setting up” exercises are +helpful. Developing the muscles of forced expiration is excellent. Thus +the patient must be conscious of the work required of him and act in +concert with the physician. Minute instruction on the requirements of +each case is demanded. + +Good food, pure water, and fresh air are necessary, particularly in the +anemic. Right living and correct environment are always in order. + + +Painful Shoulders + +Under this heading may come a variety of conditions affecting one or +both shoulders causing much distress and, at times, total disability. +The conditions may be the result of direct injury to the joint, +systemic, or from spinal lesions. Anatomically the shoulder offers +frequent opportunity to injury as it has the greatest range of motion +of any joint, is least secure in its articulation, and is most +vulnerable from location. Once the shoulder has been dislocated it +is rarely back to normal functioning again as this injury tears the +capsular ligament and stretches the structures in relation. Many times +there is only a =subluxation= in which the head of the humerus is +driven upwards in the fossa, usually from a fall or blow on the point +of the elbow. As a rule, after such an accident, the only thing done +is to rest the joint and apply a liniment and, after a time, begin +the use of the arm. It is, however, painful and to save himself, the +patient each time restricts movement until he reaches a point where he +is unable to dress without assistance. It is then found that normal +motion is reduced fully one-half and even this will be accompanied +by pain on movement and in bed. A radiograph will, usually, show the +condition. Articular crepitus and fibrous adhesions are present while +the adjoining structures have undergone changes so that a reduction is +impossible without certain preparation. Very often a trivial cause will +disable a joint; a sudden movement which finds the muscles about the +shoulder unprepared and the resulting lesion is so slight as to, often, +defy detection. At first there will be swelling and pain but, in time, +it settles down to a limited motion with more or less distress. + +=Bursitis.=—This is a condition in which the subdeltoid bursa is +involved or where there have been a number of bursæ formed from +overuse of the joint. One authority reports as many as twenty-five +in a shoulder. There may be, also, tenosynovitis primarily or from +extension. These conditions may not be easily diagnosed at first. + +=Brachial neuritis= (chronic) beginning with or without an acute attack +is usually from a cervical lesion involving the brachial plexus but +most frequently it is the 5th and 6th cervicals at the origin of the +circumflex nerve. From this the deltoid is particularly affected and +its contraction leads to pressure on the nerve and subsequent partial +or complete paralysis. Brachial neuritis is found in an increasing +number of osteopathic practicians and is the result of overwork of the +arms and to strain of the upper dorsals and lower cervicals. There are +contractions of structures about the joint constantly limiting motion +and pain when a strain is put on them. + +Many methods for the treatment of the conditions described have +been employed, all involving the same principle but none of them +systematized. C. H. Spencer has worked out a technique which, while +originally intended for bursitis, has been found well adapted to all +conditions described. It gives a stretching of all structures and +gradually breaks up adhesions, both in the joint and in the tendon +sheaths, so there is no resulting irritation which could easily result +if suddenly done. His technique is[43]: + +“First: The patient on the side, the affected shoulder up; operator +facing the patient, places one hand on the top of the shoulder, does +nothing more than fixing it; with the hand grasping the forearm above +the wrist, push the elbow backward, the arm parallel to and almost in +contact with the body, then pull forward in the same plane. Second: +Elevate the elbow with the hands of the operator in the same position +as before, carry the elbow in as wide a circle as possible. Third: +With the hands still in the same position, extend the forearm with +traction; carry it as high in front of the patient as possible. The +foregoing are designed to relieve the congestion about the shoulder, +bring pressure to bear on the subdeltoid bursa and moderate traction on +the supraspinatus, infraspinatus, subscapularis, teres minor and major, +latissimus dorsi and the tendon of the biceps. These manipulations +will be all that is possible in the more aggravated cases for some +considerable period of time. As the tenderness subsides, the second +group may be cautiously started, the hands in the same position as +above noted, with the arm extended as nearly as possible at right +angles with the body, carry the arm in as wide a circle as the pain +will permit. Again, with the arm flexed at the elbow, one hand of the +operator on the point of the shoulder and the forearm of the patient +across the forearm of the operator, the other hand of the operator +resting on the point of the patient’s elbow, push down toward the +middle line of the body and carry the elbow toward the head. Then flex +the arm and place the back of the hand behind the patient, flexing the +shoulder in front with one hand grasping the point of the elbow and +pull forward. This group of movements accomplishes with greater force +the same ends obtained in the previous, and the first in this group +is the most effective in overcoming swelling of the subdeltoid bursa. +Direct manipulation of the muscle masses and this bursa is desirable +from the first.” It will be noticed in all these movements that the +joint is protected by one hand of the operator while the other is +grasping the arm of the patient. This is desirable as it makes the +technique absolutely safe. An additional treatment will be found very +effective, especially where the deltoid is involved. With the patient +on the well side, facing the operator, locate the quadrilateral space +which is bounded by the subscapularis above, the teres minor below +and the long head of the biceps medially and the surgical neck of the +humerus externally, and the circumflex nerve can be easily palpated +along with the artery. If these structures are stretched and the +deltoid lifted from the shoulder it will be found to free the action of +both nerve and artery, one supplying the joint with nutrition and the +other innervating it. + +Certain conditions for which these movements are contraindicated arise +and the following differential points by H. Glasscock are well to +remember[44]: =“Rheumatism=: Fever in the joint, with redness, swelling +and other joints involved. =Tuberculosis=: Daily temperature and other +tubercular foci. =Neuritis=: Pain in the neck and shoulder muscles, +also near insertion of deltoid and in the forearm, particularly +musculo spiral. Pain worse at night. No pain on movement. No swelling. +=Bursitis=: No pain in neck. Pain in anterior and posterior part of +joint and on motion. Pain near insertion of deltoid. Arm held close +to the body, motionless. =Infection=: Chill, limited motion, severe +pain with temperature. =Dislocation=: Deformity with preternatural +mobility. =Dislocation= of =acromio-clavicular= joint: Tenderness over +articulation. Arm cannot be raised beyond right angle with the body, +but elbow may be brought across the chest with external rotation of +arm and raised perpendicular with the body without pain.” The infected +joint should never be manipulated and all conditions showing swelling, +redness and pain on touch should be viewed with suspicion. Remember +that all other conditions will almost invariably have vertebral +lesions, primary or secondary and a permanent result will depend upon +their correction. + + +The Prominent Hip + +A hip that is prominent and larger than its fellow is of frequent +occurrence. It may not be necessarily conducive to a defect in +posture, but it often is. The female is more frequently afflicted with +this anatomical irregularity than the male. In the first place, the +female pelvis is not so stable and rugged as the male pelvis, i. e., +a mechanical wrench or fall will more easily displace the relative +position of the tissues in the female. Then, in the second place, the +dress of the woman accentuates irregularities of the figure, so that +possibly in some instances the defect, from a diseased or deformed +point of view, is more apparent than real. But of still more importance +is the fact that many cases of a prominent hip are due to a lateral +curvature of the lumbar spinal column. Lumbar curvatures are of common +occurrence in the woman; first, the spinal column is not so strong as +in man, simply on account of the physique not being so robust; second, +modern dress constricts the waist by the use of corsets and many +waist bands, and the weight of heavy skirts upon the waist, hips and +abdomen; and, third, severe strains from childbirth. Care should be +taken that there is no congenital abnormalities of the lumbar spine, or +that congenital asymmetry of one-half of body, or trunk or leg is not +present. + +Thus the principal =cause= of a prominent hip is the lateral lumbar +curvature. This, through compensatory action, renders the hip on the +concave side prominent and high, while the hip on the convex side is +depressed and less pronounced in appearance. Dressmakers and tailors +are all too familiar with this feature of the irregularly outlined +figure, and, consequently, have to resort to “padding” to round +out the symmetry of the body. The mere irregularity of the figure, +unfortunately, is by far the less serious part of the defect. Many +ailments and diseases can be readily and directly traced to this. Not +that the prominent hip itself necessarily always plays a leading part, +but rather the lumbar curvature is the cause of very much suffering +and misery. To enumerate the many disorders that arise from malaligned +lumbar vertebræ may be unnecessary but a few will be given. A point to +be emphasized is that the prominent hip often plays the role of a sign +or symptom, or an effect, that an ailment or disease may be elsewhere. + +In the female one of the most common causes, if not the most common +cause by far, of disorders of menstruation, whether painful, profuse, +or irregular, is irritation or obstruction of the lumbar spinal +nerves due to lumbar curvatures. It is well known the lumbar spinal +nerves control, to a large extent, the pelvic organs; consequently +the osteopath pays particular attention to this area. Then certain +intestinal disorders, such as appendicitis, typhoid fever, dysentery, +rectal diseases, owe their origin to predisposing lesions here; also, +bladder ailments, and sexual diseases of men, and many affections of +the legs, as sciatica, varicose veins, etc. + +In a number of instances the prominent hip will be due to a displaced +innominatum. Then a lumbar curvature will result as a compensatory +condition. This reverses the compensatory act as heretofore referred +to; the prominent hip, in this instance, is the cause and not the +effect. To diagnose which is cause and which is effect will frequently +require considerable technical knowledge and experience. The slipped +innominatum then produces symptoms and disorders directly from its +changed anatomical relations; the points of diagnosis are given in the +chapter on Diagnosis. The prominent hip can easily be detected when the +subject sits down upon an even, firm surface, or stands up, and the +one side is compared with the other. In some cases where the prominent +hip is due to a lumbar curvature, and the prominence is a secondary +feature, the legs will be found uneven in length, but not always, for +the lumbar curvature may straighten out when the patient lies flat upon +the back. To diagnose the cause from effect and to differentiate the +maze of signs and symptoms that may be present is not always easy even +for the skilled practitioner. + +The =correction= of a prominent hip is not ordinarily a difficult +matter. In the cases where lumbar vertebræ are principally at +fault, and these include the greater number, the problem is one of +correcting the spinal curvature. Lumbar curvatures are the easiest of +any of the curvatures to correct, for one is not hampered by the rib +articulations, and the lumbar section presents an area where a leverage +can readily be obtained. Where the innominatum is primarily at fault it +is simply a matter of readjusting this, with probably some attention +to the lumbar region. Care should be taken that the prominent hip is +not caused by a tubercular sacro-iliac disease, by hip-joint disease, +by a dislocated hip, or by an overlapping of thigh or leg bones from +fracture. + +Standing erect will, of course, be a valuable help, for standing with +the weight on one foot will tend to make the hip on that side more +prominent. But generally the reason why one favors a certain side is +because the other side is weaker; a weak back, a slipped innominatum, +or an injured leg are common causes. There are many cases where the +skirts will have to be considerably altered after the hips have been +made symmetrical. + + +Pendulous Abdomen + +The =pendulous abdomen= is another defect that is all too common. A +great many people have prominent abdomens because they do not stand +properly, but a pendulous or prominent abdomen is not necessarily +synonymous with a stout abdomen. They attempt to stand erect by +drawing the shoulders back and extending the abdomen. If they would +hold the head erect and the chin in, with the shoulders back and the +chest forward, and draw the abdomen inward and upward, their figures +and physiques would undergo shortly a wonderful transformation. These +directions also apply to pregnant women. Drawing the abdomen upward and +inward will at first require considerable effort. It certainly will not +be an involuntary act for the first few days. + +The sagging of the abdomen not only causes an unsightly appearance +but results in great relaxation of the abdominal muscles, interferes +with digestive functions, displaces the pelvic organs, and weakens the +action of the lungs and heart. + +The laxity of the abdominal muscles allows the abdominal organs—the +intestines, stomach, kidneys, etc.—to displace downward. This tends to +indigestion, constipation, inactivity of the liver, etc., and causes +a score of reflex symptoms. The organs become simply weakened from a +lack of proper tone. This is a frequent cause of nervous prostration. +Also it is one of the common causes of prolapsed and displaced pelvic +organs, because the abdominal organs sag down upon them and the pelvic +organs thus receive the brunt of the gravitative effect. Internal local +treatment of the pelvic organs can only be a makeshift in these cases. +The lungs and heart are weakened because the abdominal organs are +dragging on the chest, the lungs can not aerate the blood freely owing +to the abdominal weight and to the blood being obstructed in passing +from the abdominal organs through the liver to the heart and lungs. The +heart is handicapped in its work through lessened chest capacity and +obstructed circulation. Just “suck” up the abdominal organs and see how +much easier it is to expand the chest and to breathe. + +There are other causes for a pendulous abdomen, such as a weakened +spinal nerve supply to the abdominal muscles and organs. The weakened +nerve supply may cause a loss of tone to the abdominal organs +themselves, so that certain organs, as the stomach and intestines, +become dilated and prolapsed; to the ligaments, and to the tissues and +organs as a whole so that they become gravitated. + +Through childbirth muscular fibres of the abdominal walls often +rupture, leaving scars and a relaxed condition. Actual ruptures, +hernia, of the abdominal muscles occur and cause a pendulous abdomen. +Then there are cases of obesity where the pendulous abdomen is a +symptom. + +Much can be done with all of these conditions through osteopathic +work; the patient must also help himself. The center of gravity of +the body must be changed, and kept changed; correct posture and a +constant effort will accomplish considerable. The “setting up” military +exercises are excellent. Even in some cases of obesity the abdominal +prominence can be markedly lessened by careful exercising and keeping +the abdomen drawn in so that the abdominal muscles, the diaphragm, and +the chest may be strengthened. For the relaxed, flabby abdomen, self +manipulation of the weak muscles when lying on the back will materially +aid. + + +Postural Curvatures of the Spinal Column + +Undoubtedly, the great percentage of postural defects, or slumped +states, are dependent, directly or indirectly, upon weaknesses in the +spinal column. As was seen, round shoulders, the prominent hip, or +the pendulous abdomen, are often initiated by spinal deviations and +deformities, so naturally spinal column curvatures are a most fruitful +source of direct defects of posture. + +It is somewhat uncommon to find an anatomically true spinal column, +although this does not preclude that one’s posture is defective, for +often through pride and effort one may consciously overcome a defective +posture. + +It is the purpose here to offer a few suggestions relative to the +development of a greater symmetry of the body. Nearly every one is +more or less interested in physical exercises and development. And +especially to those of sedentary habits do means and methods of +exercise appeal. Curiously enough, in a way, nearly every layman looks +upon defects in posture, symmetry and stature as an effect arising +from lack of, or improper, exercise. He seems to be imbued with the +idea that the body in most instances is practically permanent in +construction and when irregularities in figure occur certain exercises +will correct the defect. Thus have individuals been prone to look upon +osteopathy as a method of passive exercises. Osteopaths should believe +most thoroughly in exercising, personal hygiene, etc., but the idea of +osteopathic manipulation is primarily one of anatomical reconstruction, +and not muscular development alone. The work of the osteopath is +to readjust or to re-mold the body framework and the many tissues +that clothe it so that normality of function may predominate. The +manipulation is not routinism but mechanical rebuilding of the tissues +so that perfect freedom of vital forces may be forthcoming. + +The spinal column presents the most frequent as well as many +extremely interesting phases for re-correcting work. The number of +abnormalities as to contour to which it is subject are many and varied. +Emphasis should be placed upon possible congenital abnormalities and +developmental defects as sources of certain derangements. Any variation +or combination of variations with the normal or physiological curves +constitutes an abnormality or pathological curve. And as a consequence +defective posture, unless thoroughly compensated, is readily initiated. +Not only may the normal curves be exaggerated, lessened, eliminated or +reversed, but lateral and rotary curvatures are of frequent occurrence. + +Curvatures involving the cervical region to the extent of producing +noticeable defects of posture are principally lateral deviations of +several vertebræ. Wry-neck is probably the most noticeable disturbance. +The head and neck being drawn and slightly twisted to one side is a +defect that is both noticeable and painful. Another common source +of postural affection is an exaggerated forward curving of the neck +vertebræ. This produces a stooped appearance of the neck. + +The dorsal vertebræ are often curved backward too far. This produces +roundness with too decided a fullness of the upper back and shoulders. +The chest may be somewhat flattened as a secondary effect but not +necessarily so. Neither are the shoulders what may be termed “round +shoulders,” still such a condition may occur, for “round shoulders” +are more often caused by a backward swerve of the column at the waist +line. There is often a shortening of the anterior structures which pull +the point of the shoulders forward. Forcing them backward will aid in +correcting the fault. The dorsal vertebræ may be forward from what is +termed a “straight” spine; this results in an exaggerated “braced” back +position. Then lateral curvatures of the dorsal spine are common, which +in time may develop into a rotary curvature; that is, the vertebræ are +actually rotated on their axes. Lateral curvatures of the dorsal spine +are slow and difficult to correct, for the ribs complicate matters very +materially. Then, also, the vertebræ are apt to be deformed. + +Curvatures of the lumbar spine, whether posterior, lateral or anterior, +are common. Both dorsal and lumbar curvatures, as any one can readily +see, are extremely common sources of postural defects. Erect positions +of the body are maintained through the support of the dorsal and lumbar +vertebræ. Stooped shoulders, one shoulder lower than its fellow, +sitting humped over, sitting on the sacrum instead of squarely on the +buttocks, the prominent hip, standing first on one foot and then on +the other in order to rest the back, and the many allied variations of +incorrect postures are largely dependent on the condition of the lumbar +and dorsal spines. + +It is not to be supposed that the above defects are the only ailments +and disturbances that spinal curvatures cause, for, indeed, the +defective posture may be by far a minor consideration. Disorders of +body functions and affection of organic life itself are very often +traced to the malaligned vertebræ. + +The =causes= of spinal curvatures are many, but without question one +of the most common causes is mechanical wrenching or twisting of +the column from falls, jars, etc. Often the strain or sprain of the +sections are readjusted through the inherent powers of the body, but +there is a point where _vis medicatrix naturae_ requires extraneous +help to correct the perversion; and, naturally, such aid, by virtue of +the cause of the disturbance, should be physical force mechanically +applied. Other causes of spinal curvatures are contractions of muscles +on one side of the column or paralysis of the muscles on one side; +in either instance, muscular action is greater on one side than the +other, which easily results in a curvature. This imbalance of muscular +tension, whether due to the above or other sources such as overfatigue +or various deleterious habits, is a prolific source of lesions. And +among still other causes may be noted, bone diseases of the spinal +column, compensatory deformities, and constitutional weakening and +irritating diseases. Also, some occupations predispose to certain +curvatures. + +One can readily see that the =treatment= which is directed specifically +to the cause of the vertebral deviation would be the most scientific. +This is just what osteopathic work implies, direct readjustment of the +sections at fault—not exercises, or routine stretching, or braces; +although these latter methods may in some cases have their place as +secondary aids. Of course exercises are usually physiological and may +be employed, in many instances, as an auxiliary. Care should be taken +to eradicate infectious foci when present. + +Where curvatures are extreme, complicating and deforming the ribs, and +absorbing the bodies of the vertebræ so they become wedge-shaped, and +resulting from abscesses, no one can expect within reason to absolutely +correct the posture. Some aggressive work can be accomplished, but a +perfect symmetry will not be forthcoming. It may be well to emphasize +again that where the ribs are involved the osteopath is not contending +with the deformity of the spinal column alone, but in addition the +entire transverse area of the body. (See also Spinal Curvatures). + +=Conclusion.=—In concluding this rapid survey of a number of postural +defects the principal lesson to be drawn is not one of developing the +physique and thus perfecting a better posture, so much as curtailing +and eliminating insidious beginnings of disease. These little ailments +and deformities, of which postural defects may be the most noticeable, +are so often the inception of more serious disorders. The anatomical +structure being maladjusted, -aligned, or -positioned, easily and +readily leads to consequences that require much time and patience to +overcome. + +Poise of body represents much to every one. Poise or correct posture +coupled with careful and methodical exercise and correct breathing are +material aids in constructive development, as well as in eliminating +disease, for not alone may abdominal, pelvic and thoracic integrity be +benefited, but the upper respiratory tract may be toned. + +The most important goal that osteopathic science and art is striving +for is that of a fully developed and rounded out prophylaxis or +preventive treatment. When the public realizes that the proverbial +ounce of prevention is an established medical reality then it can truly +be said our science has reached its ultimate good. To those who are +familiar with osteopathic theory, facts, and development, it is an +open secret that this school holds the key to successful preventive +treatment. The time is rapidly approaching when the actual lessening +of diseases will be an established fact. Then will be the universal +practice of the layman going periodically to his osteopath to see if +there are any small or insidious beginnings of disorder or disease. + +Not only must the many deleterious habits and errors of the daily +regimen be corrected, but after environmental, physiological and +structural adjustment, in so far as possible, has been attained, a +daily regimen to maintain the normal should be instituted. + + +FOOTNOTES: + +[43] Journal American Osteopathic Association, Jan. 1916. + +[44] Osteopathic Physician, Nov. 1919. + + + + +PROLAPSED ORGANS + + +Prolapse of various organs or tissues are among the very common +ailments that afflict all classes. Prolapse of the stomach, a kidney, +the uterus, or the rectum is a familiar term to every one. But this +condition may also rest with the intestines, the liver, an ovary, or +even the heart. + +Outside of injuries, congenital weaknesses, and so-termed surgical +disorders, there are commonly two constant forces predisposing to +prolapsed organs, viz: gravitation and weakened innervation; the one, +of course, is a constant factor in either health or ill health, the +other is dependent upon acquirement. Here the latter, or acquired +nervous weakness, will especially demand our attention. + +Where tissues are torn or lacerated, or congenital malformations are +present, or tissues are weakened from ulceration and with a resultant +scar tissue, or certain tumors are present, the disorder must be +amenable largely to surgical measures if at all. + +The perpendicular position of the body favors a decided gravitation +of the abdominal and pelvic organs. This gravitative effect being a +constant one, many methods, both surgical and mechanical, have been +devised to hold in approximate and relative position certain organs and +tissues that may be prolapsed. But it is well known that outside of a +certain few instances where surgical measures are clearly indicated the +prevalent use of braces, bandages, supports and the like are usually +poor makeshifts. + +The one great feature in these cases is that tonicity to organs and +supporting muscles and tissues is more or less impaired. The tissue +atony may vary from mere weakness to actual tearing and separating of +the fibres. The indications in the cases about to be described are +to stimulate a lowered nerve supply and to increase a lessened blood +supply; if this can be accomplished, supporting muscles, ligaments and +other tissues will be able to restore the prolapsed organs to normal +positions, thus improving functions and eliminating disease symptoms. + +In discussing the prolapse of the following organs, perhaps it should +be noted here that all of the abdominal organs may be prolapsed as a +whole. The intestines, stomach, liver, kidneys, etc., may actually +prolapse together. This is more apt to occur in persons whose abdominal +walls are thin and flabby. In women pregnancy is a common cause. When +the abdominal organs have gravitated, the pelvic organs, also, are very +likely to be disturbed and displaced; in fact, the pelvic organs are +frequently disordered this way. + + +Prolapse and Dilatation of the Stomach + +Dilatation of the stomach is a much more common and serious affection +than prolapse of the stomach, although usually the two are associated. +Prolapse, or ptosis, of the stomach means simply a downward +displacement of the organ. This is apt to take place in those cases +where all of the abdominal organs have gravitated. There is invariably +some dilatation of the organ as well. + +Weakness of the abdominal walls and of the supports of the stomach +constitute the principal =causes= of the prolapse. Spinal deviations +that impinge or obstruct the nerve strands (or obstruct the blood and +lymph supply to these strands) to the supporting stomach tissues is +the most frequent cause of the ailment. General debilitating diseases, +as anemia, cancer, etc., are indirect causes of weakened organs with +consequent displacements. + +In dilatation of the stomach the condition may be either acute or +chronic. The former is found where immense amounts of food or drink +have been introduced. + +One of the principal causes of chronic dilatation is some obstruction +to the opening from the stomach into the intestine, so that the stomach +contents do not pass readily into the bowel. This leads to chronic +disturbances of the stomach walls, and the food remaining in the +stomach somewhat indefinitely weights down and stretches the walls +of the stomach. The obstruction may be a tumor, or some stricture or +adhesion from scar tissue resulting from ulceration or inflammation. +The treatment of these cases comes within the province of surgical +interference rather than other methods. + +The second important cause of chronic dilatation is muscular weakness +of the walls from poor nerve supply. This is a common cause and +osteopathy is very successful in curing these cases. The splanchnic +nerves are below normal, usually from a slight lateral or posterior +spinal curvature. The nerve force to the walls of the stomach not +being normal causes atony of the muscles and dilatation results. This +nervo-muscular atony, also, results from a chronic catarrh, or from a +general nutritional disorder as tuberculosis or anemia. The treatment +of the former would imply direct correction of nerve and blood supply +with attention to diet; the latter can be cured only through relieving +the nutritional disorder of which the stomach condition is a symptom. + +Dilatation of the stomach is most common in people of middle age or +older. The disease is usually easily diagnosed. The symptoms may +not be indicative of the trouble beyond showing that the stomach is +disturbed. Indigestion, uneasiness, and nausea are common. Vomiting +of large quantities of material from the stomach is likely to occur. +The patient is generally emaciated, the skin is dry, the bowels +constipated, and the urine scanty. + +The =diagnosis=, as a rule, is not hard to make. Through the media +of inspection, palpation and percussion, the careful osteopath will +have little trouble to determine the size of the stomach. Kemp’s[45] +distinction between gastroptosia and dilatation of the stomach is as +follows: “In dilatation the lesser curvature retains its relation +to the diaphragm. The distance between the lesser and the greater +curvature is increased, but the lesser curvature still maintains its +relation to the diaphragm, with the exception that the pyloric end may +extend farther over and somewhat farther down.” Another instructive +point relative to diagnosis the above authors make is the importance +of the splashing sound. Owing to the fact that the stomach in health +closes concentrically about its contents and thus adapts itself to the +volume of ingesta, no splashing sound can be elicited. Three different +degrees of relaxation are diagnosticated as follows: “Splashing sound, +which can be elicited only during the normal period of digestion, means +simple atony; splashing sound produced after the legitimate time of +digestion has expired means motor insufficiency; and splashing sound +produced in the morning, after the night’s fasting, before liquid +or food has been introduced, may mean stagnation, dilatation of the +stomach, as understood by most writers.” (For a more complete outline +see Dilatation of the Stomach. The object of this section is to present +an outline of prolapsed organs as a whole, and to refer especially to +the effectiveness of osteopathic treatment in this condition). + +This is a disease where osteopathy has been particularly successful in +not only relieving distressing symptoms, but in actually curing the +disorder. This refers to the nervo-muscular atony type, for where there +is obstruction due to stricture or tumor of the pylorus, resulting in +stomach dilatation, the treatment, from the very nature of things, must +be largely surgical. Stomachs that have been dilated and prolapsed +several inches have been entirely restored to function and organic +integrity. To =cure= these cases is a matter of stimulating nerve +control and blood supply to the stomach tissues, and, often of greater +importance, removing spinal impingements to the stomach nerve fibers, +thus allowing nature to fully assert herself. In reality, outside of +so-termed surgical cases and other cases where the stomach dilatation +is merely a symptom of general nutritional disorder, the primary +treatment, by far, is the spinal one. Treatment over the stomach +is a decidedly beneficial treatment; it aids materially in toning +both abdominal and stomach muscles; still this is mostly a secondary +treatment. + +Dieting is essential. Careful dieting lessens the tendency to catarrhal +inflammation and reduces the work of the stomach to a minimum. Still, +nourishing food is necessary and the dieting can easily be carried to +an extreme. Liquids should not be taken freely. Fatty and starchy foods +should be eliminated. Give the patient food at short intervals. Various +nutritious meats are excellent. + +In dilatation, and also general abdominal relaxation, daily abdominal +treatments may be indicated. If the relaxation is pronounced, keeping +the patient in bed with thorough spinal treatment two or three times a +week, daily abdominal treatment, having the patient exercise abdominal +parietes by drawing the walls in and up, upper thoracic breathing, +and frequent feeding will accomplish comparatively quick results. The +progress of each case depends very materially upon the general health, +the physical status of other tissues, constitution, inheritance, +environment, age, etc. Some cases will yield in two or three months, +others will require two or three years in order to obtain the greatest +possible benefit. + + +The Prolapsed Kidney + +A =prolapsed kidney= is often termed a floating kidney, or movable +kidney, or dislocated kidney. It is of common occurrence, especially +in thin persons. Some authorities state that one woman out of every +four has a floating kidney. It is more common in women than in men, and +among the working class than other classes. + +The condition is usually an acquired one, following severe strains from +lifting, falls, injuries, etc. It is claimed by some that a floating +kidney arises from congenitally weakened and relaxed tissues about +the kidney, that is, the tissues that keep the kidney normally at +anchorage. Thus a congenital looseness of the kidney would easily be a +predisposing cause whence mechanical violence, repeated pregnancies, +an enlarged liver, or tight lacing would act as an exciting cause. +Undoubtedly in some instances there is a congenital predisposition, +the peritoneal fold attaching the kidney to the spine being loose and +the capsule of fat retaining the kidney being scanty, but osteopathic +experience has amply demonstrated that the tissues anchoring the kidney +may in many case become atonied and relaxed from lower dorsal spinal +lesions. Rarely is a case presented to an osteopath that does not +exhibit two apparently characteristic causative features, viz: spinal +irregularity in the lower dorsal spine, and constriction of the zone +about the waist, i. e., dropping and constricting of the floating ribs. +Furthermore, correction of these lesions will almost invariably lessen +the mobility of the palpable kidney. + +The =symptoms= of a floating kidney are many and variable. The kidney +may be slightly movable or it may be so loose that one can easily +grasp it through the walls of the abdomen. Most of the symptoms are +of a nervous reflex nature. Indigestion, which is likely to be very +persistent, flatulency, heart palpitation, painful menstruation, +irritable bladder, etc., are the most common symptoms. Still, blueness, +depression and morbidness are frequently present. The most distressing +direct disturbance is the feeling of weight in the abdomen, especially +on standing, running or lifting. Sometimes the ureter becomes twisted +and severe pain, colic and even collapse occurs. (Dietl’s crisis.) + +The =diagnosis= of a dislocated kidney is not a particularly difficult +matter. A little experience coupled with a delicate sense of touch +will usually readily detect abnormal mobility of the kidney. A point +to always remember is that the kidney normally descends about one-half +an inch with each inspiration. Care should be taken not to mistake a +floating kidney for a movable spleen, although this is not likely, as +the shape of the spleen is different. + +The =treatment= of a movable kidney under osteopathic measures is +usually successful. In the first place a number of cases require but +little attention, simply toning up the general health, and especially +directing attention to the abdominal walls and organs. There are a +number of cases where the kidney prolapse is incidental to general +abdominal laxness and weakness. In more severe cases, treating the +spine, raising the floating ribs, carefully manipulating over the +abdomen, keeping the bowels open, and lessening liver congestion should +it arise, will suffice; in fact, will remedy a good percentage of the +cases. With others, a well fitting, medium width, elastic bandage with +pad underneath will be beneficial. In these cases the patient should be +taught how to treat the abdominal organs, to manipulate the abdominal +walls, and to replace the prolapsed kidney; particularly after going +to bed this can be done successfully by the patient and will prove a +decided help in obstinate cases. + +=Surgical measures= for fixing the kidney should seldom be resorted +to. If the patient will live a careful life, avoid unduly straining +himself, keep the bowels normal, and have the anatomical lesions +corrected, he will come very near being entirely relieved, if not +absolutely. Surgical measures are not always a success. Surgeons are +not operating for this disorder so often as in past years. (See Movable +Kidney—Diseases of the Kidney.) + + +Liver Prolapse + +This is commonly termed a =floating liver=. There is prolapse of the +organ as well as its being abnormally movable. It is not of frequent +occurrence; women suffer from it much oftener than men. + +Normally, the liver is partially held in place, in the concavity of the +diaphragm, by a number of peritoneal folds. The attachment of these +ligaments is to the spine and the diaphragm; their principal function +is to prevent extended lateral movements. Of greater importance in +supporting the liver in a normal position is the integrity of the +abdominal walls, and the position of the stomach and intestines. If +the abdominal walls are of normal tone the liver is very apt to be in +correct position. And the rest of the abdominal organs, especially +intestines and stomach, act as a cushion support. Often when the liver +is displaced the remaining abdominal organs are, also, out of normal +position and relation to each other; in fact, general prolapse of the +abdominal viscera is a frequent cause of liver prolapse. An additional +support of the liver is a certain cohesion of the liver and diaphragm, +and the elastic traction of the lungs. + +Foremost among the =causes= that predispose to inelastic and atonied +abdominal walls are spinal irregularities, deviations, and curvatures, +which impinge nerve force and obstruct blood supply. These same lesions +weaken ligamentous supports of the liver and lessen tonicity of the +other abdominal organs, so that local or general displacements are +readily forthcoming. Strains, injuries, frequent pregnancies, etc., +also act as causes that weaken the supports of abdominal tissues and +organs. In a word it is very often the pendulous abdomen that is the +immediate cause of a floating liver. + +It is very rare to find the liver displaced to the lower region of the +abdomen. The ptosis is usually somewhat slight. The organ generally +rotates on descent, the right lobe being the lowest portion, owing to +the attachment of a ligament, the ligamentum teres, to the umbilicus. +Probably in some cases there is a congenital tendency to relaxation +of the ligaments, and, thus violent exertions and atonic and flabby +abdominal walls and diaphragm are secondary but important factors. + +The principal =symptom= of a floating liver is a tumor in the right +side, which may be low down. Palpation will usually determine this. +Then the abdominal walls are flabby. Pain and bearing down of the right +side are common. There is apt to be considerable indigestion. Various +reflex symptoms are often present. The floating liver will seem larger +than normal, as the liver is below the costal arch and much of it can +be felt. Percussion will be of value in determining the extent of the +disorder. + +Much can be accomplished by =treatment=, especially where the +displacement is of a lesser degree. Correcting the spinal lesions, +toning up the abdominal walls and diaphragm, and replacing the +displaced organs will be extremely effectual. The abdominal bandage may +be of service. Certainly abdominal exercises will be beneficial. + +A point to remember is, stimulation over the abdomen beneath the right +costal arch will cause the liver to contract and retract. This is of +considerable osteopathic note. The liver will often recede at least a +half an inch. This is a liver reflex (Abrams). + + +Prolapsed Intestines + +=Prolapse= of the =bowels=, as a whole, or, more frequent still, +of a part, is undoubtedly the most common form of organ prolapse. +The intestines are so situated that they readily feel the effect of +gravitative influences, of atonic and anemic states, and of weaknesses +and disorders of other abdominal organs. + +Spinal irregularities come first as potent =causes= of bowel prolapse. +The spinal nerves to the supports of the intestines, to the muscular +coats of the intestines, and to the abdominal walls, are obstructed in +their normal activity, and consequently those tissues to which these +nerves are distributed are affected. Wasting diseases, as anemia, +consumption, cancer and the like predispose to intestinal atony. + +The severe mechanical wrenches, strains, frequent pregnancies, tight +lacing, heavy skirts, large abdominal tumors, obesity, cause more or +less general or local weakness. + +The pendulous abdomen, from wrong or careless posture, and exclusive +of other causes, is a common source of general bowel displacement. +This form of disorder, besides being unsightly, favors abdominal +stoutness. There are a number of instances where simply voluntarily +holding or “sucking” the abdomen into place, until it becomes strong +enough to support itself, has reduced one’s weight by five, ten or +fifteen pounds. These were cases where most of the adipose tissue was +about the abdomen. Thus exercising and toning the abdominal organs +by keeping them in normal position rectified a dormant blood and +lymph circulation, which was followed by absorption of the abdominal +stoutness. + +Congenital weaknesses are to be considered in many cases. The muscular +ligaments may not be developed, the mesenteric attachments may be +too long, and various other abnormalities may result from congenital +disturbances. + +Of particular local interest to the osteopath, outside of the bowels +dislocating as a whole, are: first, the hepatic flexure; second, the +ileo-cecal region; third, the sigmoid flexure; fourth, the rectum; and +fifth, hernias. Each of these sections are of separate interest and +will be considered presently. + +The =symptoms= are extremely variable. Constipation, a feeling of +discomfort in the bowels, nervousness, depression, lassitude and anemia +are frequent. Colicky pains in the intestines, indigestion, hysteria +at times, are also among the symptoms. In reality a great variety of +symptoms may be present. The patient is likely to be emaciated. In some +cases exhaustion is marked. + +=Diagnosis=, as a rule, is not a difficult matter. The various +neurasthenic symptoms in a lean patient with constipation, indigestion, +and stomach and intestinal distress would lead one to suspect +intestinal displacement. The outline or contour of the abdomen will +often reveal the character of the trouble. The atonic, thin and relaxed +walls of the abdomen may readily give view of the displaced organs. +Then careful examination by palpation and percussion will help very +materially in the diagnosis. Radiographic examination is a decidedly +helpful diagnostic method. + +The =hepatic flexure= is frequently prolapsed. The bowel (colon) +ascends from below upward to beneath the costal arch and then angles +sharply into the transverse colon, which extends directly across the +abdomen to the left side. The ligaments that support this flexure +are apt to become weakened or stretched and allow a descent of this +section of the bowel, which is followed by constipation, indigestion, +etc. The ligament especially involved is the colo-hepatic ligament. +The =duodenum= may require attention. This can be raised by getting +beneath it where the organ descends alongside of the ascending colon. +The effect of treatment is to release tension of the duodeno-hepatic +ligament which is closely associated with the portal vein, hepatic +artery and bile-duct. + +The =ileo-cecal region= is an area that readily becomes congested +and catarrhally inflamed, especially from constipation or impaction +at this point. The section often becomes atonic and prolapsed with +resultant clogging of fecal matter. Owing to the close proximity of +the vermiform appendix, appendicitis frequently results from the above +condition. The osteopath can do much in these cases of appendicitis. +Lesions are invariably found in the lumbar vertebræ or the floating +ribs are depressed. + +The =sigmoid flexure= is also frequently prolapsed. The fecal mass +often becomes impacted here, owing to a settling or prolapse of this +part. In some cases the prolapse is so marked that it extends to the +rectum below and drags on the splenic flexure above. + +Lumbar and innominate lesions are the usual causes, although, it seems +in a number of instances, that relaxed walls of the abdomen cause a +“contraction of the diaphragm resulting in kidney displacement and +followed by intestinal prolapse.” The vertebral lesions, probably, +first weaken the muscular coat of the bowel, then, second, the bowel +supports (other than its own inherent tonicity) and the abdominal walls. + +Prolapse of the =rectum= is of such separate importance that it will +be but partly outlined here. As stated above, a source of rectal +displacement arises from the section of the bowel above settling +downward and ultimately causing invagination of one or more coats of +the rectum. Dislocation of the coccyx is a potent cause of rectal +disorders. Lumbar lesions, especially twists between the fourth and +fifth, and fifth and sacrum are common causes of rectal weaknesses. +Slips of the innominata are other causes of prolapse. + +Osteopathy has had marked success in these cases. Cures may result +from a single treatment to readjust the coccygeal displacement or +temporarily relieve excessive physiological activity by dilating the +rectal sphincter, or the treatment may demand a number of months’ +work in correcting general abdominal prolapse. Raising the sigmoid is +effectual. + +A =hernia= is “the protrusion of a loop or knuckle of an organ or +tissue through an abdominal opening.” Two of the common hernias of +the intestines are inguinal and femoral. These conditions are most +often acquired from severe straining, so that a loop of the bowel +protrudes through a weakened and stretched area of the abdominal walls, +though there is reason to suspect that congenital defects are often +predisposing factors. + +Mention of the hernia is here made because, in a way, it is a form +of bowel prolapse; that is, a limited form, and osteopathy contains +certain possibilities for a successful treatment. Hernia has always +been looked upon as purely a surgical disorder; i. e., remediable by +surgical measures only. Where a truss has failed to give relief surgery +has been resorted to. This is true in most instances, but where the +hernia is in the incipiency careful abdominal exercises (this should be +carried out with great care, for severe exercise may produce a hernia +or increase one already existing), massage to the tissues about the +hernia, attention to the bowels, and spinal stimulation corresponding +to the weakened tissue, and avoidance of strains may strengthen the +tissues materially about the hernia. + +Occasionally a loop of the intestine will prolapse into the cul-de-sac +back of the uterus. A heavy dragging pain low down in the center of the +abdomen and constipation or complete obstruction are the pronounced +symptoms. Careful lifting of the loop of bowel by pressure within the +vagina and traction from above with a hand outside, with the patient, +on her back, with buttocks elevated, gives speedy relief. + +The =treatment= of the prolapsed bowels represents those measures that +will replace and keep in position the displaced organs. Naturally, the +spinal and abdominal treatment comes first; this strengthens intestinal +ligaments, tones intestinal muscles, and contracts the abdominal +parietes, and at the same time the bowels are regulated, digestion +and nutrition improved, and the general health built up. In some +cases abdominal supporters will be of value. In a number of instances +attention to chest mobility and diaphragm tonicity will be of value. +Right living, which is represented by proper diet, sufficient outdoor +exercise and regular habits, is invaluable. + +The really specific treatment is to correct spinal, rib and innominate +deviations and abnormalities. But direct local work will be, in many +instances, necessary. General abdominal manipulation is good, but this +should be supplemented by careful local treatment. The hepatic flexure +requires a direct stimulating and replacing treatment. The ileo-cecal +section should be raised, stimulated and emptied of the fecal mass. +Direct upward manipulation of the sigmoid flexure in the left iliac +fossa and of the splenic flexure beneath the left costal arch is +extremely efficacious. Care must be taken not to bruise the parts. +Getting beneath the prolapsed area and gently and intelligently raising +the bowel so that it is emptied, toned up, and vascular congestion +relieved, are the indications. This requires careful work and the +necessity of gentleness can not be emphasized too much. Still in all of +this treatment we should never forget the absolutely essential spinal +readjustment. + +Rectal prolapse requires lacol internal treatment, external tissue +correction, especially of the coccyx, an innominatum or the lumbar +spine, and, of much importance, deep, careful and thorough work over +the sigmoid section. + +Cases of bowel prolapse are every day experiences with the osteopath. +The osteopathic treatment is of great value in these and a successful +issue is very often the result. Cases of pendulous abdomen, of +obstinate constipation, of chronic indigestion, of many nutritional +disorders, of feeling pain, weight or dragging, locally or generally, +in the abdomen, are very apt to be in persons suffering from prolapsed +intestines. + +A number of cases of bowel prolapse are associated with general +prolapse of abdominal organs; that is, displacement of the stomach, +kidneys, liver, spleen, etc. This general condition is termed +enteroptosis or Glenard’s disease. It usually requires several +months to treat it successfully. These patients are neurasthenic, +malnourished, and often hysteriacs. The symptoms from which they +suffer are innumerable. Mechanical weaknesses, lowered vitality, poor +innervation and blood supply, and auto-intoxication are causative +factors. + + +The Prolapsed Uterus + +=Prolapse= of the =uterus= is of common occurrence. The prolapse may be +incomplete or complete; the latter when the organ is presented to the +external world. Of special interest are those affections exclusive of +surgical cases. Ptosis of the abdominal organs upon the pelvic organs +is a common cause of uterine prolapse. The abdominal prolapse crowds +uterine space, congests the uterus, weakens the ligaments, and drives +the uterus downward as a wedge. + +Lumbar spinal curvatures are frequent causes of prolapse, as well as +other displacements of the uterus. In this region vasomotor nerves +to the pelvic organs make their exit, and, consequently congestions, +inflammations, and weaknesses of supports are results. Also, slips of +the innominata disturb the pelvic circulatory balance. Weakness of the +uterine support from below, the vaginal walls and perineum, most often +arises from lacerations at childbirth. Still, the vaginal walls may +become relaxed through other causes. Tumors and extreme congestions are +causes of prolapse. Heavy lifting is quite a frequent source of uterine +displacements. Osteopathy is very successful in uterine prolapses; +that is, any displacement of the uterus not of a surgical character. +Correction of the external causes comes first. Then local treatment +to replace, tone, and relieve congestion, and break up adhesions is +necessary. The external treatment is usually the primary treatment. +Local work is not always necessary. Lacerations and other surgical +indications, of course, require surgery. + + +Ovarian Displacements + +The ovaries may be prolapsed, the left much oftener than the right. +When prolapsed, it drops backward, downward and inward. + +Ovarian congestion, tumor, retroverted or retroflexed uterus, tubal +disease, and pregnancy are among the principal causes. Back of these +congestions, tumors and uterine displacements, are the osteopathic +causes, particularly spinal and rib lesions from the ninth dorsal +downward. Specific lesions at the ninth and tenth dorsals and +corresponding ribs, affecting directly ovarian tissues, and lumbar and +innominate lesions and abdominal prolapse disturbing uterine and tubal +tissues, are the most frequent osteopathic causes. A retroverted or +retroflexed uterus is often found. Uterine displacements bear down upon +the ovary and cause its descent, and also disturb ovarian circulation. + +As has been stated, the left ovary is more apt to be displaced than +the right. This is owing to the absence of a valve in the ovarian vein +on the left side, and also, this vein opens at a right angle into the +renal vein; this anatomical feature easily leads to passive congestion +of the ovary, and thus to diseases of the organ. Then the rectum is +on the left side and large fecal masses are apt to crowd against the +ovary, which tends to its displacement. + +Thus it is readily seen that osteopathic treatment is very applicable +to ovarian displacement unless the indications are surgical. A more +or less constant burning or sharp pain in the ovarian region, with +probably some feeling of weight, profuse and painful menstruation, +depression, irritability, etc., are =diagnostic=. However, a local +examination will reveal the status of the ovarian position and +congestion. + +The same =treatment= as in other organ prolapse is indicated: toning +weakened tissues, relieving congestions, replacing organ, with careful +attention to the bowels and the general health. There are no tissue +disorders of any part of the body wherein osteopathy is more thoroughly +indicated and the results more generally satisfactory than in prolapse. +And especially should it be remembered that in prolapse of various +organs many vague intestinal and pelvic disorders and even ureteral and +bladder disturbances may be traced to bowel dislocations and excessive +kidney mobility in which osteopathic measures are often successful. + +=Conclusion.=—The purpose of this section on Prolapsed Organs has been +to supplement the various articles on Dilatation of the Stomach, +Movable Kidney, etc., with an outline that may include relaxation of +a part or of the whole of the abdominal viscera. The physician is all +too prone to simply note the most offending or conspicuously disturbed +organ instead of carefully analyzing all the features, great and +trivial, that may be either apparent or marked. A general relaxation +of the abdominal and pelvic organs may be found, and a nearly complete +restoration take place under treatment, but still a lacerated perineum +may have to be repaired before a cure is completed. Or it may be in +a general abdominal ptosis that a floating kidney will resist all +measures for restoration, short of surgery, and before much improvement +can be obtained the kidney will have to be stitched into place. An +enlarged liver may crowd the kidney out of place or a transverse colon +may prolapse and drag on contiguous tissues and still the annoying +symptoms be referred elsewhere. Then the primal point of general +relaxation may not be in one organ, but there may be a simultaneous +displacement of several. + +The thorax itself may be distorted from various diseases so that the +chest is narrowed, the diaphragm displaced with consequent descension +of the abdominal organs, and from the latter a displacement of the +pelvic. + +“Far down displacement, marked changes of form, and real +disfigurements of the stomach are found in some cases of kyphosis and +scolio-kyphosis.”[46] The osteopath will not only find this true in +some cases, but in many cases, although he recognizes as causative +factors injuries to the spine causing curvatures and postural defects +as prolific sources of abdominal relaxation. + +“Glenard’s whole theory of splanchnoptosia is based on the relaxation +of the suspensory ligaments of the intestines, especially that of the +transverse colon; and Stiller, the discoverer of the floating tenth +rib, says that splanchnoptosia is a descent of the atonic stomach, of +the colon (especially the transverse portion), of the kidney (the right +or both kidneys), exceptionally of the liver or the spleen. A descent +which has been developed mostly in tender age, in consequence of +general relaxation, especially of the peritoneal suspensory ligaments +in individuals with congenital general dyspeptic neurasthenia, tender +muscles, lean habit, and slender bone structure, manifested in a higher +degree by a floating tenth rib.” Stiller observed that when there is a +floating tenth rib there is a displaced stomach and a floating kidney, +although it is not found in every case, but never missing if the case +is pronounced. The tenth ribs in these cases have only a ligamentous +fastening and are as freely movable as the eleventh and twelfth. + +That abdominal relaxation plays a very important part in many +diseases of the abdominal and pelvic organs, in cardiac and pulmonary +affections, disturbs the circulation in the legs, and is the source +of many reflex affections no one can gainsay. The osteopath should +always pay particular attention to tonic condition of the abdominal +viscera, for relaxation of the suspensory tissues and walls, and atony +and sluggishness of the organs are frequently paramount etiological +factors. And the osteopathic treatment is the remedy par excellence. + + +FOOTNOTES: + +[45] Rose and Kemp—Atonia Gastricia. + +[46] Rose and Kemp—Atonia Gastricia. + + + + +SKIN DISEASES + + +Various skin diseases have been treated osteopathically with varying +success. So much depends upon the cause of the disturbance and its +removal, in skin diseases, that the cure does not rest so much with +the mere treatment, as with the necessary skill in locating the +disturbing factor. One has to be continually on his guard to locate +external irritations and disorders of the digestive and genito-urinary +tracts. A great deal depends upon the avoidance of external influences; +eating nutritious food and having an unobstructed circulation. The +leading object of osteopathic treatment is to free the circulation +and thus promote a healthy and unobstructed flow of blood; in no +other class of diseases is this more essential than in skin diseases. +After the removal of cutaneous irritations and the correction of +internal disorders, the cure of the case depends upon the removal of +constrictions to the cutaneous blood-vessels. The osteopath corrects +the lesions found, relaxes the muscles thoroughly and stimulates the +circulation to the parts involved, and promotes a healthy activity of +all the excretory organs. When the upper part of the body is affected, +lesions are generally found at the atlas and axis, and when the lower +part of the body is affected, lesions at the fifth lumbar are of +common occurrence, although lesions may be located at various points +corresponding with the seat of disturbance. The constant use of hot +baths will be found a helpful measure in many skin diseases. But use +of soap must be considered as too much alkali will neutralize the oil +of the skin and cause undue dryness, but bran may be substituted to +advantage. Cleanliness is necessary but the result sought is, also, +flushing the cutaneous vessels. There are many cases where a specific +vertebral lesion will cause, through the peripheral nerves, a cutaneous +irritation with intense itching and discomfort. This, in turn, produces +an exudate with or without a crust and a condition results which is not +amenable to any local or constitutional treatment but an adjustment of +the lesion will in most cases bring immediate relief. Application of +this principle will aid greatly in treatment of any skin disease. In no +disturbance of health is it more necessary to find the cause than in +skin disease and once found to apply specific treatment. + +=Eczema= is frequently met in osteopathic practice. It is the most +common form of skin disease, comprising nearly one-third of all these +disorders. For a differential diagnosis of the several varieties the +student is referred to special texts. It is well to remember that the +same underlying causes may be basic to the various forms, for several +varieties may occur at the same time or one variety pass into another, +though commonly one form is more prevalent. The limbs, face and +genitalia are the most common sites, though the eruption may occur on +various parts of the body. + +=Etiology= includes a number of factors, constitutional and local. +Dietetic errors, indigestion and faulty elimination comprise the +principal underlying causes, often manifested through absorption of +toxins and leucomains. In fact any disorder of the abdominal viscera, +organic or functional, may be a predisposing factor, likewise various +disorders of the pelvis, tuberculosis, diabetes, anemia, etc. should +be considered. So-called gouty and rheumatic tendencies may be the +constitutional basis. + +The many osteopathic lesions play a very important role in lowering not +only systemic resistance but of local tissue as well. This feature can +not be over-emphasized. + +Then local irritants, mechanical, chemical and thermal, are not to be +neglected. These are usually of secondary importance. Micro-organisms +are probably a complicating factor after the lowered resistance has +been established. Vasomotor neurosis, through constitutional defects, +toxins and the very significant osteopathic lesion, is probably an +essential part of the pathogenesis. + +=Treatment= is usually successful if the various etiologic factors +are eradicated. Early treatment is very important. If the disorder +is of more than local significance change the entire daily regimen +of the patient. Diet, outdoor exercise and sufficient sleep should +be definitely regulated. A certain amount of general treatment to +improve digestion, assimilation and elimination is imperative. An +unbalanced diet and over eating must be corrected. In certain moist +types, eliminating fatty foods will be helpful, while in dry forms the +starches and sugars should be reduced. + +If there is an underlying disease this should be remedied if possible. +Particular attention should be paid to constipation. + +Common sense in diet, rest, change of environment and free elimination, +coupled with due attention to the osteopathic lesions, will cure the +vast majority of cases. The greatest difficulty arises where there +is some underlying disease. The parts should be protected against +irritation such as dirt, cold, soap, and too much water. Meddlesome +local treatment is to be guarded against. A simple application is boric +acid, rice-flour or cornstarch, or where there is much itching add +carbolic acid to the saturated solution of boric acid. Substitute bran +for soap for cleansing purposes. + +=Herpes Simplex=, fever-blister, or “cold sore” comprise two principal +varieties: =herpes facialis= and =herpes genitalis=. The first occurs +upon or near the lips, face, neck or ears. When the herpes is on the +tongue or the mucous membrane within the mouth it is commonly termed +“canker sores.” + +Herpes genitalis is located on the prepuce, glans penis or farther back +upon the penis. In the female the labia majora and minora and vestibule +are the usual locations. Lack of cleanliness, sexual excitement and +adherent prepuce are causative factors, though predisposing factors +such as faulty circulation and disturbed innervation are to be +considered. + +In “cold sores” there is often some gastro-intestinal disturbance, +especially intestinal stasis, cold in the head and other infections +that supply toxins which irritate the nerves. No doubt there are +underlying osteopathic lesions that lower the local nerve resistance or +block the impulses such as vertebral and inferior maxillary lesions. +The predisposing disturbance is probably due to the Gasserian ganglion. + +Cold winds and excessive exposure to the sun’s rays will effect the +tissues over the mental and infraorbital foramina, tensing the muscles +and irritating the nerves at these points. On palpation they will be +found sensitive. Frequent rotary motion by tip of finger over foramina +will open them and allow congestion to drain. + +=Herpes Zoster=, or shingles, is an acute inflammatory disease +characterized by groups of small vesicles, usually along the course of +the intercostal nerves on one side of the body. Before the vesicles +appear there is more or less severe neuralgia. The eruption is +unilateral, very rarely bilateral. The nearby lymphatics are usually +enlarged. + +Though the intercostal nerves are the ones most frequently involved, +still the lumbar, thigh, trifacial and other cutaneous nerves may be +affected. + +The most common lesion is an inflammation of the posterior spinal +ganglion which usually involves the fibers of the entire nerve. +Inflammation of the nerve outside of the ganglion will cause the +disorder. Toxins from various infectious sources are often exciting +causes. Vertebral and rib lesions are always found; and where the +Gasserian ganglion is involved lesions of the inferior maxilla and +upper cervical vertebræ are predisposing factors. Thus osteopathic +lesions from traumatism, cold and wet, and imbalance of muscular +tension are important. Exudates, tumors, pleuritic and pulmonary +affections are to be considered as possible sources. + +=Treatment.=—Adjust vertebral lesions and carefully raise and separate +ribs if intercostals are affected. Look after vertebral origin of any +other nerve or nerves if otherwise. Local application of talcum or +starch or boric acid will generally be sufficient. + +=Urticaria=, hives or nettle rash is a common affection often due to +some derangement of the digestive tract. This may be a mechanical +irritation or of a toxic nature. Every one is familiar with the various +foods that are apt to cause the hives, shell fish, strawberries, +cheese, pork, oatmeal, mushrooms, etc. + +The irritation may be a reflex one from the visceral disturbance; +also, there may be irritation of the pelvic organs that would give +rise to the trouble. It is well known that certain drugs will produce +urticarial eruptions. There are cases where the irritation is simply +local due to the nettle, mosquito bites and wasp stings. + +In chronic cases intestinal stasis, nervous exhaustion and nephritic +diseases are important. + +No doubt osteopathic lesions frequently determine the location of the +wheals. These lesions affect the innervation and thus establish a basis +for the reflex vasomotor effect. This is in the nature of spasm of the +cutaneous vessels quickly followed by dilatation with exudation of +serum. The irritant probably acts on the walls of the blood vessels. + +=Treatment= consists of thoroughly emptying the bowels by warm water +enema, correcting the diet, toning the viscera and adjusting the +osteopathic lesions. Thorough attention to the patient’s environment, +daily habits and occupation are of value. Warm soda baths will relieve +the itching. + +=Acne= is a common skin disorder that is characterized by an +inflammation of the sebaceous glands of the nature of papules, +tubercles or pustules. The face, shoulders, chest and back are the +regions usually involved. It generally, appears about puberty. +Blackheads is the starting point; these are accompanied with greasy +skin and dust, and influenced by micro-organisms and more or less +intestinal disorder. + +The general or systemic health no doubt affects the local disorder, +as in many skin diseases; for various intestinal derangements as +indigestion, constipation, etc.; pelvic and menstrual irregularities; +general ill health; anemia, etc. affect circulatory, glandular and +nervous integrity. Any disturbance of normal elimination is important. + +The =treatment= consists of careful attention to the general health and +to the local innervation of the face or region involved. Measures that +tone the bodily organs such as outdoor life, regular habits, plenty of +sleep and correct diet are important. In some cases the X-ray is of +value. + + + + +ANIMAL PARASITES + + +Tape Worms + +=Varieties.=—Taenia solium; taenia saginata; bothriocephalus latus. + +The larvæ of tape-worms are introduced into the intestinal canal by +food and drink. The parasite reaches adult growth in the intestines. +The larval forms are then found again in the muscles and solid organs. + +=Taenia Solium.=—This is derived from the hog, and is the most common +form in this country. When mature it is from two to four yards in +length. The head is small, about the size of a pin, and provided with +four cup-like suckers surrounded by a double row of hooklets, hence it +is called the armed tape-worm. The head is fastened to the body by a +thread-like neck, and following the neck, the body occurs in segments. +The sexual organs, both male and female, occur in the center of the +broad surface of the segment. The segments are about one millimeter in +length and seven or eight millimeters in breadth. There are thousands +of ova in each mature segment. The worm attains its growth in about +twelve to fifteen weeks, after which time the segments are shed and +passed. For further development the ova must gain entrance to the +stomach of a pig or of man, and passing from the stomach they may reach +the muscles and organs and develop into larvæ or cysticerci. + +=Taenia Saginata.=—This is derived from beef, and is much longer and +larger than the taenia solium. It is from five to six yards in length; +the head is over two millimeters in breadth, is square shaped, and +has four large sucking discs, without hooklets; hence it is called +the unarmed tape-worm, in contra-distinction to the hooked variety. +The segments are thicker and the ova larger, and they are passed and +ingested in the same manner as the taenia solium. + +=Bothriocephalus Latus.=—This is found especially in Europe and is very +long, measuring from eight to ten yards; it is derived from fish, is +not provided with hooklets, but has two lateral grooves. The segments +are short and wide, the sexual organs being on the narrow side of the +segment. + +=Etiology.=—Unhealthy condition of the stomach and intestines is the +predisposing, and uncleanliness an important, factor in the occurrence +of tape-worm. Those eating imperfectly cooked beef, pork, fish or other +meats, and those handling fresh meats, are liable to be affected with +tape-worm. + +When the ovum is taken into the stomach the capsule is dissolved and +the embryo passes into the small intestines, fastening itself into the +mucous membrane, by its hooklets and suckers and grooves. + +=Symptoms.=—Tape-worms occur in the human being at all ages. Oftentimes +symptoms are absent, the expulsion of segments being noticed and thus +the worms accidentally discovered. The tape-worm is seldom dangerous, +but if a worm is known to exist it is always a source of considerable +anxiety on the part of the patient. Severe anemia may result and be +wrongly diagnosed. + +There are dyspeptic symptoms, colicky pains, nausea and occasionally +diarrhea. The appetite is variable, sometimes ravenous. This condition +is followed by loss of flesh and various reflex phenomena, as vertigo, +headache, convulsions, palpitation, choreic movements, itching of the +nose and anus, paralysis, and rarely, insanity. In addition to these +symptoms there may be a wrinkled countenance, sensation of a cold +stream winding itself toward the back immediately after a meal, pain +in various parts of the body and ringing in the ears. The decisive +diagnostic symptom is to find segments of the worm in the stools. + +=Diagnosis.=—Discovery of the ova or segments in the passages of the +bowels is the only proof of the presence of a tape-worm. + +=Prognosis.=—Favorable in all cases. + +=Treatment.=—Prophylactic treatment is necessary. Meats should be +thoroughly cooked so that the larvæ will be destroyed; and all segments +of tape-worms passed in the stools should be burned—by no means should +they be thrown outside or in the water-closet. + +The immediate expulsion of a tape-worm is not a necessity. First of +all the mode of living, and then the general state of health should +be corrected. Tape-worms invariably result from a general state of +unhealthiness, and with improved health and corrected digestive +processes the worms cannot exist, and in a short time will be expelled. +Expulsion of the head is necessary before the case will be cured, for +if the head is not expelled new segments will continue to grow. + +Stimulating the liver to increase the amount of bile, and increasing +the activity of the digestive glands of the stomach and intestines, +by a thorough treatment of the splanchnic region and direct treatment +over the abdomen, will usually be sufficient for the cure of intestinal +parasites. The treatment will probably have to be repeated several +times, in order that the intestines may regain a healthy tone, so that +the parasite will not find favorable conditions for its existence +within the intestines, and that the bile may be secreted in sufficient +quantities to dislodge the worm. + +Hahnemann claimed, “that during a period of comparative health +tape-worms do not inhabit the intestines proper, but rather the +remnants of food and fecal matter contained in the intestines, living +quietly as in a world of their own without the least inconvenience to +the patient and finding their sustenance in the contents of the bowels. +During this state they do not come in contact with intestinal walls, +and remain harmless. But when from any cause a person is attacked by +an acute disease the contents of the bowels become offensive to the +parasite, which in its writhing and distress touches and irritates +the sensitive intestinal lining, thus increasing the complaints of +the patient considerably by a peculiar kind of cramp-like colic. (In +similar manner the human foetus in the womb becomes restless, twists +its body and moves whenever the mother is sick, but floats quietly in +the liquor amnii, without distressing her while she is well.)” This +but harmonizes with the osteopathic theory and practice with regard +to tape-worm, that there is an unhealthy condition of the intestines +which predisposes to the affection, and consequently the cure must be a +correction of such a disordered state. + +During the treatment, if a light diet of milk and broths is given, it +will favor an earlier removal of the parasite, by helping to remove the +mucus in which the head is embedded. If this fails extract of male fern +is suggested. + + +Ascaris Lumbricoides (Round Worm) + +This is the most common parasite, and is found principally in children; +it is also found in cattle and hogs. It is of a yellowish brown color +and in form resembles earth worms. The worm is cylindrical, pointed at +both ends; the female is from seven to twelve inches in length, and +the male from four to eight inches. They are probably introduced into +the stomach by food and drink. They occupy the upper part of the small +intestine, and are usually one or two in number, though they may be +numerous. Occasionally they migrate into the stomach and are ejected +by vomiting, or into the trachea and produce suffocation, or into the +larynx or Eustachian tube, or they may pass downward to the anus, or +into the bile ducts. + +=Symptoms.=—Oftentimes symptoms are absent. There may be dyspepsia, +colicky pains, mucous stools, meteorism, vertigo, fretfulness, +voracious appetite, anemia, sallow complexion, headache, chorea and +convulsions. Other symptoms may be present, as grinding of the teeth +and itching of the nose and anus. Obstruction of the bowels has +occurred. If a worm enters the bile duct obstructive jaundice occurs. A +decisive diagnosis can be given only when the worm is seen. + +=Treatment.=—Particular attention should be paid the liver, for it is +here that we must seek the natural remedy in the form of bile, in order +to eject and cleanse the system from nematodes. + +Modes of improper living should be corrected; cleanliness is essential, +and there should be attention to the general health of the patient. +Thorough correction of all defects of the spinal column in the region +of the splanchnics, and careful direct treatment of the bowels is +indicated. The child may be put to bed and fasted twenty-four hours, +then the liver strongly stimulated to increase flow of bile. + +If the above treatment is not successful oil of wormwood may be +employed. + + +Oxyuris Vermicularis + +(Thread-worm; Pin-worm) + +This small parasite, commonly seen in children, is from three to five +millimeters long in the male and about twenty millimeters in the +female, is blunt at one end and sharp at the other, and occupies the +colon and rectum. They are probably introduced into the intestines in +the ova, by uncooked fruits and vegetables, or by the dirty hands of +mothers and nurses of the infants. They vary greatly in number; migrate +to the rectum where they deposit their eggs, and are often discharged +in the feces, where they appear like pieces of ordinary white thread. + +=Symptoms.=—Loss of appetite, anemia, restlessness and irritability +are marked. The itching becomes intolerable when the worms come down +in the rectum to the anus and within the folds about the anal orifice. +In the female the worms may wander into the vagina where they become +particularly distressing, and thus may produce excessive sexual +excitement and cause nymphomania and masturbation. + +=Treatment.=—Cleanliness of the most scrupulous kind should be demanded +in every instance. Injections of cold salt water (repeated for at least +ten days) and other agents within the rectum will destroy the eggs as +soon as they are deposited, besides relieving the terrible itching. In +obstinate cases use quassia decoction. + +Attention to the general health of the patient and great care of the +intestines and other digestive organs are absolutely necessary. The +spinal treatment to the intestines and other digestive organs, as well +as thorough direct treatment over the abdomen, is indicated. + + +Uncinariasis + +(European hook-worm disease; Miner’s anemia; Ankylostomiasis; Hook-worm +disease) + +This disease results from infection by the hook-worm of any of the +various types. In Europe it is found in Italy, Belgium, Germany, +France and Switzerland. In America it seems to be of Africo-Asiatic +origin but was first discovered in the Southern states and abounds +chiefly in Texas, Florida, Georgia, North and South Carolina as well +as in the West Indies. Infection comes from unprotected feces that are +allowed to be spread where the feet or hands may come in contact as +it is without doubt that the contagion occurs through the skin. One +authority states that hook-worm is rarely found except in cases where +ground itch has occurred within a period of eight years. Negroes harbor +the parasite and transmit it but seem immune to its effects while the +poorer whites are afflicted to a large degree. The worms are carried +from some abrasion of the skin, by the blood to the heart and lungs, +thence to the pharynx and swallowed, thence to the duodenum and jejunum +where they attach themselves to the lining walls. Here they not only +feed upon the blood but develop a toxin. The female worm is about twice +the size of the male, 10 to 18 mm. as against 6 to 11 mm. and there is +slight difference between the old and new world varieties. The head is +provided with four hook shaped teeth which form the attachment to the +intestine and it is very secure. + +=Diagnosis.=—For years the languid, dull, expressionless, lack-luster +of eye and general unambitious characteristics of the inhabitants of +the great sand belt of the United States attracted attention and was +attributed to laziness but the discovery of the hook-worm explained the +cause. Children are stunted in mind and body and have a muddy, dirty +white complexion. + +At the beginning there must be a very considerable colony of the +parasites to cause symptoms but as the disease advances there is a +distention of the abdomen from enlargement of the spleen and liver and +from flatulency. There is palpitation, shortness of breath, cardiac +bruits from the severe anemia while edema of the feet and legs is +rather common. The blood shows a severe secondary anemia with its +coagulation time much increased. Leucocytosis is not common; hemoglobin +is from one-tenth to one-half normal with erythrocytes about half +normal. + +=Treatment.=—The removal of the worms with the least possible harm to +the body is indicated. Thymol is a poison which is not absorbed by the +body, when carefully given, and which is very toxic to the parasite. +The dose varies from eight grains for a child under five years of age, +to forty-five for an adult. Thymol is soluble in fats and in alcohol, +so that for a day or so before the thymol is given, and from one to +four days after, no fats or alcohol should be taken. The best way to +avoid poisoning by thymol is to give the patient charcoal, then no +fats or alcohol is permitted until the treatment is completed. When +the stools become black, the thymol is given on an empty stomach. A +purgative is given a few hours later. Enemas should be used very freely +in order to facilitate the removal of the injured or poisoned worms. +Another dose of charcoal is given, and when the stools are black again, +the patient may return to his ordinary diet. The denial of fats to the +person so thoroughly accustomed to bacon three times a day is a factor +met with difficulty in dealing with patients of the ordinary class with +the disease. (Clinical Osteopathy.) + +=Prophylaxis.=—After treatment it is imperative to prevent reinfection +and to do that the most rigorous sanitary measures must be instituted. +All feces must be disposed of and habits of cleanliness in defecation +insisted upon while negroes, who harbor the worm without showing +symptoms, must be looked after as well as the actual victims. Care of +the feet is important and shoes should be worn in infected regions +and all abrasions of the skin protected. Drinking water must be +uncontaminated which presents a problem as wells and springs are +usually unprotected. Absolute and persistent cleanliness is the answer +to the question of prevention. + + +Trichiniasis + +Trichiniasis is a name given to a disease produced by the embryos of +the trichina spiralis. In the adult condition the trichina spiralis +lives in the small intestines. The embryos migrate into the muscles +where they finally become encapsulated. Man is infected by eating +insufficiently cooked pork containing the encapsulated worm, which +is set free during the digestive process. About the third day they +attain their full growth and become sexually mature. Each one +discharges large numbers of embryos. As soon as born the young brood +is carried away from the bowel and invade the muscles through various +channels—principally by means of the blood stream and along the +connective tissue routes. The female trichina may bring forth several +broods of embryos in succession. In nine or ten days after infection +the first brood reaches its destination. They attain to maturity in +about two weeks after entering the muscular tissue. In this process an +interstitial myositis is excited and a fibrous capsule is formed in +four to six weeks. The capsule gradually becomes thicker and finally +calcareous infiltration may take place. + +Thorough cooking destroys the parasite. The disease is most frequent +among the Germans who eat raw ham and sausages. + +=Symptoms.=—These are sometimes absent, especially when only a few are +eaten. If large numbers have been ingested, gastro-intestinal symptoms +develop in the course of a few days. Vomiting, diarrhea, and pain in +the abdomen may be present. + +In from one to two weeks muscular symptoms develop. There is fever, +muscular pain, especially during motion, and the muscles are stiff, +tense and sometimes swollen. When the respiratory muscles are involved +dyspnea is produced, which may prove fatal. Eosinophilia is a helpful +diagnostic point. Edema, especially of the face, is an important +symptom. Profuse sweats, itching and tingling of the skin have been +observed. + +=Diagnosis.=—Epidemics of this disease are more easily diagnosed than +an isolated case. Among the Germans, if cases of apparent typhoid +fever occur after a picnic or other feasting occasion, where raw ham +or sausages have been indulged in, this disease should be suspected. +Examination of the stools and of the muscles will be of aid. The worms +may be discovered in the pork, a portion of which has been eaten by the +patient. + +=Prognosis.=—This depends upon the number of worms ingested. The +prognosis should always be guarded. Early, marked diarrhea is favorable. + +=Treatment.=—Prophylactic treatment is of great importance in +trichiniasis. Inspection of the meat supply, is doing much to prevent +trichiniasis; although the most practical way to prevent the disease is +to thoroughly cook all pork and sausages. The central portions of the +meat should be well cooked. + +In the feeding of hogs care should be taken that they do not receive +any offal, but only milk, grain, vegetables, etc. + +When a person is infected with trichiniasis, thorough and prompt +evacuation of the bowels should be performed at once, so that the +embryos will not have time to pass into the muscles, but will be +ejected from the body. This should be followed by a thorough and +persistent treatment for several days of the liver and intestines; +treat both the liver and intestines directly and through the spine. +The object of this treatment is to render all the digestive juices +active, so that they may dislodge the animal parasite, and to prevent +their passing into the muscles. Also keep the bowels active for several +days. + +When the larval parasites have entered the muscles, a treatment cannot +be applied to affect them directly, but the health of the body should +be maintained if possible, and the severer symptoms, as the muscular +pains, weakness and insomnia combated. Thorough manipulation, massage +and hot baths will be of special aid in relieving the stiffness and +weakness of the muscles. + + +Filaria + +(Filaria Sanguinis-Hominis) + +There are two varieties. One is a thread-like worm with tapering, blunt +ends, appearing in the blood at night, hence called =nocturna=, while +the other is of slightly different form, appearing in the blood only by +day and is called =diurna=. + +The mosquito is the communicating host of the parasite. During the +night, or should the patient sleep during the day, the =nocturna= +appears in the peripheral circulation, while during the other interval +they are probably in the other vessels, particularly the lungs. + +After the mosquito has taken blood from an affected patient it requires +from six to seven days for the metamorphosis of the minute filaria +which are then lodged in the probosis of the mosquito and introduced +into the blood of the next victim. The adult parasite is from three to +four inches long and the thickness of a coarse hair, with clear sexual +distinction. + +=Pathologically= there are no distinct lesions, as the parent worm +must establish one. Lymphatic engorgement may result from plugging of +the thoracic duct or of a large lymphatic with consequent engorgement +which may develop symptoms in the inguinal glands, pelvic and lumbar +lymphatic trunks. As these varicosities develop rupture may occur; if +into the genito-urinary tract chyluria or chylocele may result, or if +in the abdominal cavity chylous ascites. + +Lymphangitis follows a lymph stasis, which later results in +=elephantiasis=. (Barbadoes leg.) + +=Symptoms.=—Elephantiasis affects the legs, but the arms rarely; the +labia of the female and scrotum of the male; occasionally the breasts +and other parts of the body. Fever is present on account of the +lymphangitis, accompanied by rigors and delirium and there is marked +local inflammation. The attack terminates in a pronounced sweat. In +deeper parts there is deep seated pain and signs of sepsis, while +abscesses may develop over the inflamed area. + +The varicose inguinal glands are doughy, soft and painless, with both +sides affected alike. The scrotum is affected by the extension, and at +times the testes. + +=Treatment= is surgical, as the tumors must be removed. Unless the +female worm is also removed this is, however, only palliative. + +Methylene blue is said to be destructive to the filaria and it is +practically harmless to the human body. The only treatment is one that +will aid in building up the general health. + + + + +HEMORRHAGES + + +Nasal Hemorrhage + +(Nose bleed; Epistaxis) + +=Osteopathic Etiology= and =Pathology=.—Traumatism, such as picking +the nose, blows, and surgical operations; straining when coughing; +nasal tumors and ulcerations; lesions of the atlas, or any lesion of +the upper cervical vertebræ, that would interfere with the vasomotor +distribution to the nose and cause local congestion or weakness of the +blood vessels; obstructions to the general circulation; irregularities +or suppression of the menstrual flow may result in nose bleed, as +a vicarious menstruation; suppression of a habitual hemorrhoidal +discharge. + +=Pathologically= the great frequency of nasal hemorrhage is due to the +great vascularity of the nasal mucous membrane. Usually in cases of +spontaneous origin, bleeding is from the region of the septal artery. +Spontaneous bleeding may also occur from posterior hypertrophies or +adenoid vegetations. The blood flowing downward into the fauces, is +expectorated in such cases, and may be mistaken for a hemorrhage from +the lungs. + +=Treatment.=—The position of the individual is important. He should +assume a sitting posture, or as nearly so as possible. Holding the +nostrils tightly, or plugging them with a piece of cotton, will favor +the formation and retention of a clot, so that the hemorrhage may be +controlled. Pressure upon the carotid artery, or upon the facial artery +at the angle of the inferior maxilla, will slow the blood current +and favor the formation of a clot, also pressure on the sides of the +bridge of the nose may influence it. Correcting any lesions that may +exist in the superior cervical region, as derangement of the vertebræ +or contracted muscles, will remove obstructions or irritations to the +vasomotor system of the affected region, and thus equalize the vascular +system. Holding the arms above the head, and the application of ice to +the nose are of aid in some cases. Also, injection of cold or hot water +into the nostrils. In serious and obstinate cases, where other methods +fail, a plugging of the anterior and posterior nares should be resorted +to, using absorbent cotton or gauze. + + +Broncho-pulmonary Hemorrhage + +(Hemoptysis) + +=Osteopathic Etiology= and =Pathology=.—Pulmonary congestion; croupous +pneumonia; tuberculosis; hemorrhagic infarction; ulcers of the larynx, +trachea or bronchi; gangrene of the lung; fibrinous bronchitis, +carcinoma of the lung; lesions of the ribs or vertebræ from the second +to the seventh dorsal inclusive, may cause diseases of the bronchial +tubes or lungs, that result in hemoptysis, or the hemorrhage may be +caused directly by extreme congestion resulting from the disordered +vasomotor nerves; diseases of the heart, such as mitral disease, +causing pulmonary congestion; aneurism of the branches of the pulmonary +artery; vicarious menstruation from deranged menstrual functions; +diseases of the vessel walls, or blood, as scurvy, anemia, hemophilia, +etc. + +=Pathologically= in many cases, the lesions are microscopic, consisting +of ruptured capillaries. In other cases larger vessels may be ruptured, +or are the seat of erosion. Many other lesions may be observed. After +death the bronchial mucosa is occasionally found inflamed and the lung +tissues paler than normal. + +=Diagnosis.=—A differential diagnosis must be made between epistaxis, +hemoptysis and hematemesis. + +In =epistaxis= the blood may flow from the posterior nares into the +pharynx; it causes coughing and a discharge of the blood may occur the +same as in hemoptysis. A careful examination of the nasal region alone +can determine the source of the bleeding. + +In =hemoptysis= the history of the case as to pulmonary or cardiac +diseases is to be considered. There is a feeling of weight and of +uneasiness in the chest. A salty taste and a tickling of the throat +precedes the bleeding. The blood is ejected by coughing and is bright +red, frothy, very little coagula, and is alkaline in reaction. + +In =hematemesis= the history would indicate disease of the stomach, +spleen, liver or heart. Uneasiness, and occasionally nausea and +faintness, precedes the bleeding. The blood is ejected by vomiting, and +is dark, clotted or fluid, mixed with food, and is of acid reaction. +In a few instances the blood due to hemoptysis may be swallowed, and +vomited. + +=Treatment.=—In all these cases of hemoptysis the patient should be +placed in bed and absolute rest demanded. An attempt should at once +be made to correct any lesion that may be found influencing the cause +of the bleeding. Correcting lesions to the vasomotor nerves of the +lungs and bronchial tubes, and equalizing the disturbed vascular area, +may be sufficient in a number of cases. These lesions will be found +principally in the upper dorsal region. In some cases, perhaps, there +is an impairment of the trophic nerves by the same lesions, thus +interfering with the tone of the vessel walls and pulmonary tissues. +The diet should be light, nutritious and non-stimulating. The use of +hot drinks is to be avoided. The rapidity of the heart’s action should +be reduced. This is best performed by thorough treatment of the dorsal +spinal nerves of the left side over the heart, and by inhibition in the +suboccipital region. The ice-bag to the precordia is also helpful. Iced +drinks and the eating of ice is of aid. Stimulation of the systemic +circulation will be of value in helping to relieve the pulmonary +congestion, although the two systems are somewhat independent of each +other. Also, hot foot baths and the evacuation of the bowels may be of +additional value. In cases due to organic disease of the heart, the +mind and body should receive absolute rest, so that the diseased areas +may be strengthened as much as possible; besides a tonic treatment for +the heart’s action is necessary. + +After the hemorrhage has subsided care should be taken that bleeding +does not occur again. All irritations of the respiratory tract should +be avoided. A stimulating diet, tobacco and alcohol should be avoided. +Nutritious food and a moderate amount of exercise is indicated. + + +Hemorrhage of the Stomach + +(Hematemesis) + +=Osteopathic Etiology.=—Injuries to the stomach; local diseases, as +congestion, ulcers and cancer; vicarious menstruation; a mechanical +obstruction to the portal circulation; spinal lesions to the vasomotor +nerves of the stomach; alterations in the blood; perforation of the +stomach walls, involving a blood vessel; disease of some neighboring +organ. + +=Diagnosis.=—A careful examination of the case and of the blood +ejected will be necessary to determine the nature of the cause. The +differential diagnosis as to the source of the blood, whether from the +stomach or lungs, was given under hemoptysis. + +=Treatment.=—Correction of any lesions that may influence the blood +pressure in the region of the stomach, is the first requisite. +Treatment of the splanchnics has the greatest influence upon the +vasomotor nerves to the stomach. Treatment of the vagi nerves and of +the fourth and fifth dorsals, will quiet the violent movements of the +stomach, and thus aid in controlling the hemorrhage. Stimulation of +the cervical sympathetics and heat applied to the feet will tend to +equalize the vascular system, and thus lessen the gastric congestion. +The application of a broad flat ice-bag over the stomach will be of +great value. Keep the patient quiet in bed. Surgical interference may +be necessary. + + +Intestinal Hemorrhage + +=Osteopathic Etiology.=—An obstructed circulation of the blood through +the venaporta, as in diseases of the heart, lungs and liver; lesions of +the vertebræ deranging spinal nerves to the intestinal blood supply; +injuries caused by corroding or cutting substances; mechanical injuries +to the intestines; degeneration or erosions of the blood-vessels from +ulcers of the intestines, as from typhoid fever, typhus, dysentery, +etc.; disordered menstrual or hemorrhoidal discharges. + +=Diagnosis.=—The locality of the intestines affected can be +approximately determined by an examination of the discharged blood. +When the blood comes from the upper part of the intestines, it is +generally dark and mixed with the intestinal contents, which gives it +a tarry appearance. It is generally red and fluid when it comes from +the lower portion of the bowels. If from the stomach, the blood is +thoroughly mixed with fecal matter. Throwing the passage into water, +the water is colored red when it contains blood, and if the contents +contain bile the water is colored green or yellow. Also, noting the +areas of contracted muscles, as in intestinal colic, will aid in the +regional diagnosis. + +=Treatment.=—Absolute rest in all cases is necessary, the patient +remaining as quiet as possible. Food, in severe cases, should not be +given for ten or twelve hours. The bed-pan should be used in caring for +the evacuations. Correction of the lesions along the spinal region, +chiefly of the lower dorsal and lumbar regions, that are impeding the +innervation to the intestines, should be attended to at once. This +treatment tends to relieve any hyperemic condition of the intestinal +mucosa and influences the whole vasomotor area of the mesentery. Direct +treatment of the abdomen in a few cases is of great value to relieve +obstructed and contracted vessels in the mesentery, but in certain +pathological conditions, e. g., typhoid fever, leave the abdomen alone. +Treatment (inhibition) along the spinal column from the sixth dorsal +to the coccyx is helpful in all cases to quiet the peristalsis of the +intestines. In severe cases cold drinks, eating of ice and an ice pack +to the abdomen are of aid. In a few instances surgical measures will be +necessary. + + +Hematuria + +=Osteopathic Etiology.=—Congestion and acute inflammation of the +kidneys, exacerbations of pyelitis, renal calculi, chronic nephritis, +traumatism, tuberculosis, etc.; affections of the urinary tract, as +calculi or lacerations of the ureter; calculi, cystitis, ulcerations, +etc., of the bladder; calculi, gonorrhoea, parasites, etc., of the +urethra; general diseases, chiefly the acute specific fevers and blood +diseases; blows, wounds and traumatic influences, external to the +kidneys; lesions of the renal splanchnics. + +=Diagnosis= of the locality of the hemorrhage in the urinary tract: +In hemorrhage from the =kidney= the blood is thoroughly mixed with +the urine, giving a uniform color. Blood casts and leucocytes are +present. In hemorrhage from the =ureters= the blood is usually molded +in clots which conform to the shape of the ureter. The clots appear +like small dark worms. In hemorrhage from the =bladder= the blood is +not thoroughly mixed with the urine and large clots form upon standing. +In hemorrhage from the =urethra= the blood often discharges without +micturition. When urine is passed the blood precedes the passage of +urine. + +=Treatment.=—Rest is essential. A correction of the lesions to +the renal splanchnics is necessary to control the congestion and +inflammation of the kidneys. When the ureters, bladder or urethra is +involved, attention must be given to the condition of the spinal column +below the renal splanchnics. In all cases the inhibitory treatment to +the lower spinal column and ice to the loins are of value. If surgery +is indicated, do not delay operation. + + +Uterine Hemorrhage + +Most of the causes of uterine hemorrhage come under the subject of +obstetrics; others under menorrhagia and metrorrhagia. Such will be +found in obstetrical and gynecological works. + +=Treatment.=—The patient should assume the dorsal position with the +buttocks raised. If any displacement of the uterus is present or if +there is any foreign material in the uterus, usually such should +be corrected or removed at once. Stimulation of the clitoris is a +most effectual means to control uterine hemorrhage; it contracts the +circular fibres of the uterus. Stimulation of the uterus directly +through the vagina, and over the abdomen, and stimulation of the upper +wall of the vagina, will aid in contracting the uterus. A quick, +unexpected pull of the hair on the mons veneris will have the effect of +closing the capillaries by shock to the nervous control (Dr. Still). +Before closing the os, however, it is well to know that there is no +irritating foreign material within the body of the uterus. Correction +of obstructions of the vasomotor nerves of the uterus through the +splanchnic and lumbar region is important. Compression of the abdominal +aorta, and vaginal injections of hot water may be of aid, as will +also a hot water bag at the lumbar region and ice water bag over +symphysis. In severe cases inversion of the body, if it can be done +with safety, may be performed. Packing the vagina is a method resorted +to occasionally in severe cases. + + +Hiccoughs + +Occasionally there is a case of hiccoughs that has been continuous for +hours or even days and that all efforts have failed to stop. They are +caused by an irritation to the peripheral distribution of the phrenic +nerve from some gastric disturbance or a local irritant acting upon the +center in the medulla. It may follow fright or great emotion and be +associated in persistent form in rheumatism, typhoid fever and other +febrile diseases. It follows abdominal operations at times and is very +distressing. When occurring in elderly people with pneumonia and in +peritonitis with distention it usually marks the end. The same may be +said in case of carcinoma of the stomach and bowels. + +=Treatment.=—Go first to the origin of the phrenic nerve at the third, +fourth and fifth cervical and, if there is a lesion as there will +probably be, adjust it and note results. This will be sufficient in +many cases. Failing, bring direct pressure on the nerve just above +the clavicle and anterior to the sternomastoid muscle and release +the scaleni muscles. After this examine and treat at the fifth and +twelfth dorsals. Correct any lesions but best results will be had from +inhibition at these points. Another method is to stand beside the +patient and insert the fingers of both hands under the costal end of +the ribs and lightly pull. Firm pressure over the solar plexus with +flat of the hand is sometimes beneficial. In hysterical cases, drawing +out the tongue will often be effective and it has been suggested +that standing the patient on the head will stop them in short order. +Tickling the nose to produce violent sneezing is an ancient remedy. +Some one of these will cure the case, as osteopathy has never failed so +far as recorded. + +The stomach should be emptied of all irritating matter to prevent +recurrence. + + + + +VARICOSE VEINS + + +In varicose veins there is a dilatation of the calibre of the veins +and their valves are insufficient. The walls are irregularly thinned, +lengthened and tortuous. + +=Osteopathic Etiology= and =Pathology=.—The =internal saphenous= is +the vein most frequently affected, although any vein throughout the +body may become varicose. Commonly, varicose veins occur in the lower +extremities and occasionally in the arms. + +The =valvular insufficiency= is caused by stretching of the wall +of the vein, thus separating the thin, free edges and leaving an +interspace that allows regurgitation of the blood. The valves becoming +insufficient, the column of blood in the veins has no support against +gravity, and being interrupted in its course does not flow normally +into collateral channels. The walls of the veins become thin, as does +also the adjacent skin, thus increasing the danger of a rupture, either +external or subcutaneous. + +Varicose veins are most frequently found in females, following +uterine enlargements. The condition may be due to any obstruction +or constriction that prevents the free return of blood from the +veins, such as dislocations of the hip, either slight or complete, +dislocations of innominata, contractions of adductor magnus muscle +affecting femoral vein, prolapse of diaphragm obstructing vena +cava, tissue constrictions about the saphenous opening, garters, +and, in fact, anything that might impede the free venous flow. The +tendency to varicose veins increases as age advances, and many cases +are found among people of middle life who have been accustomed to +standing a great deal. Injuries to the pelvis, thigh or leg, lessening +the nutrition to the leg, or injuries to the nerves, as vertebral +dislocations in the lower dorsal or lumbar regions (the fourth lumbar +especially) may be causes of varicose veins. Pregnancy or tumors +in the abdomen or pelvis, causing pressure upon the iliac veins, +are occasionally causes. Distention of the sigmoid flexure, causing +pressure upon the left iliac vein, or distention of the cecum; pressing +upon the right iliac vein, are fruitful sources, as are also diseases +of the heart and lungs. Varicose veins of the upper extremities are due +to occupations requiring overuse of the arms. + +=Complications.=—Varicocele, hemorrhoids, labial varix in the female, +varix over pubes, ulceration and eczema due to disturbances of +nutrition, edema and thrombus. + +=Symptoms.=—=Lower Extremities.=—Cramping pains in the limbs upon +rising. Fullness and heaviness of the limbs. Inspection may reveal +superficial varicose veins near the saphenous opening, upon the +external thigh, in the popliteal space, upon the external leg or behind +the ankles. Edema and congestion of the foot and ankles occur in a few +cases. Pain is quite a prominent symptom, due to pressure upon the +nerve fibres. Eczema and itching are due to disturbed innervation and +blood supply to the skin. Ulceration may occur, due to the bursting of +a vein. + +=Upper Extremities.=—Before the varicosity appears there is usually +pain or a feeling as of a sprain in the involved region of the arm. The +pain is usually confined to a muscle or group of muscles. + +=Treatment.=—The majority of cases are due to disorders about the +pelvis, hip or thigh, and the treatment resolves itself into the +removal of these obstructions or constrictions. Occasionally cases are +caused by partial dislocations of the hip joint, which can be easily +overlooked during a hurried examination. The slipping of an innominatum +is an important factor. Rest in a recumbent position, attention to the +general health, and especial attention to the bowels and liver, are +essential in acute attacks. Occasionally the heart and lungs are at +fault. Treatment twice per week should consist of removing any of the +numerous causes of the condition, and spinal treatment as well; then +the leg should receive special attention. Remember, thrombi may form +and the vein must, under no circumstances, be touched in the treatment. +Begin by carefully rotating the leg to stretch contracted tissue about +the saphenous opening, then separate the tendons of the popliteal space +and follow the course of the vein to the abdomen and relax tissue about +it. Keep patient off the feet as much as possible and elevate the leg +when sitting. + +In rupture of varicose veins the hemorrhage can be arrested by +elevating the limb and applying pressure with the fingers, above and +below the wound, until a compress and bandage can be applied. The +support of the varicose veins by elastic stockings will ease the +pain and prevent edema in many cases, but, as a rule, it is a direct +hindrance to the circulation on account of the necessity of having the +stocking fit closely. Surgical operations are rarely indicated. + + +Phlebitis + +(Phlegmasia alba dolens; milk leg) + +An inflammation of a vein. In the condition described here it is a +puerperal septic inflammation of the femoral vein. About the third +week after confinement there is a swelling of the leg with or without +redness. Great pain accompanies the condition and the temperature +gradually rises to 102°-3°. As understood by osteopaths, this is the +result of a partial closing of the saphenous opening during parturition +so that the venous flow is partly stopped. + +=Treatment= consists in carefully rotating the leg at the hip so +that the fascia lata is spread, opening the lumen of the vein so +the congestion will drain out. There will, also, probably be found +innominate or lumbar lesions which must be adjusted with the result +that almost immediate relief is given as a rule. + + +Chronic Phlebitis + +The chronic form shows considerable inflammation along the line of +the vein marked by tenderness, edema and thickening of tissue. The +entire leg may be more or less involved through circulatory injury. +In these cases will be found definite innominate lesions of a primary +type or the distortion is superinduced by lumbar lesions. A few cases +are quickly cleared up through adjustment that is readily secured. +However, in others, there being considerable thickening of the +sacro-iliac articulating tissues, some time may be required to get +complete adjustment and consequent restoration of femoral circulation. +In addition to this, careful abduction, flexion, hyperextension and +circumduction is indicated. This last technique should be executed with +great care and with due regard to pathology. If Dr. Still’s emphatic +command were followed, that all maternity patients should have both +legs rotated and innominates inspected, there would be no phlebitis +cases, acute or chronic. + + + + +THE RECTUM + + +To treat the rectum intelligently and thoroughly, requires special +knowledge on the part of the osteopath. A speculum should be used in +many cases when making an examination, and all abnormal conditions +carefully inspected with the eye; although much can usually be noted by +the examination with the finger alone. The best position in which to +give an examination and treatment is to have the patient on the side, +with thighs flexed upon the abdomen. In a few cases the patient may +lean over an operating table. + +The =objects= of =rectal treatment= are many—to relieve hemorrhoids, +etc., of the mucous membrane; to correct a dislocated coccyx; to treat +an enlarged prostate gland; to replace a prolapsed rectum; to tone the +lower bowel in cases of constipation; to give reflex stimuli to the +heart and lungs, in cases of fainting, paroxysms, etc.; to relieve +severe pains in the rectum at the time of the menstrual period, and +to relieve congestion, inflammation, contracted tissues, etc., of +local sources; to relax spasms in croup, and to remove tension to the +nervous system in some forms of insomnia. In fact, so many diseases are +affected by reflex irritations from the rectum that its examination +is a necessity in many cases. The phrase “when in doubt treat the +rectum” was coined by a progressive student and there is an element of +truth in it. Surgical assistance to treatment will be considered under +hemorrhoids. + +The principal need of osteopathic internal rectal treatment, is: (1) +To relax all contracted and constricted fibres about the walls of the +rectum and between the sacrum and coccyx. (2) To correct a dislocated +coccyx. (3) To dilate the sphincters thoroughly, in order to relieve +irritations about the sphincters, and to stimulate the sympathetic +nerves. + +Work through the rectum to treat an enlarged prostate gland, to correct +a displaced uterus, and to make a more thorough examination of the +uterine tissues, the Fallopian tubes and the ovaries, is a frequent +occurrence. + +In giving =local treatment=, cleanse the fingers and oil the index +finger; then, after introducing it into the rectum relax the contracted +tissues by an upward sweeping motion on all sides. This treatment +relieves all obstructions to vessels and nerves caused by contracted +fibres, and tones the rectal walls. In prolapsed sigmoid, causing +obstructive constipation, the finger can be used to separate the folds +of mucous membrane and open the lumen of the bowel. Frequently there +will be enough tone to the muscular coat so that the irritation +will set up slight peristalsis and cause the bowel to draw up to a +considerable degree. In children where there is much straining at the +stool, the sigmoid will often be found down and by using the little +finger the same results can be accomplished and much relief given. + +To =dilate= and =stretch= the sphincters thoroughly a speculum or +dilator should be used under anesthesia; still, considerable can +be done by one or two fingers. The sphincter should be thoroughly +stretched in all directions, care being taken when an instrument is +used that too much force is not applied. Secure as much voluntary +relaxation of the sphincter as possible. Inhibition at 2d and 3d sacral +will aid. This treatment is of aid in cases of hemorrhoids and prolapse +of the rectum, in constipation due to the loss of tonicity of the lower +bowels, in tightness of the sphincters, in pain of the rectum, and in +stimulating the heart and lungs. In cases of a prolapsed rectum, due +to irritation about the sphincters, causing tenesmus, this treatment +is of special value, as it gives the sphincter a physiological rest. +Frequency of treatment per rectum must depend entirely on the patient +and disease. It can be given daily in many cases and is frequently so +indicated in acute hemorrhoids, prostatic troubles, etc. + +According to Quain, the sensory nerves to the rectum are from the +second, third and fourth sacrals. Some of the motor fibres of the +circular muscles of the rectum are from the lower dorsal and upper +two lumbar nerves; these pass by the aortic plexus to the inferior +mesenteric ganglion. Associated with these fibres, are the inhibitory +fibres of the longitudinal muscles of the rectum. The sacral nerves +contain motor fibres to the longitudinal muscles, and inhibitory fibres +to the circular muscles of the rectum. In all cases of rectal trouble, +the lower dorsal and upper lumbar vertebræ may be found deranged, and +thus interfere with the rectal nerves. Relaxation of the sacral muscles +over the sacral foramina has a marked effect in relieving =tenesmus=. +In dysentery, where there is a constant desire to defecate, a thorough +upward relaxation of the sacral muscles will give great relief. + +=Proctitis= or inflammation of the rectum is not an uncommon disorder. +The disease has been divided into acute, chronic, gonorrheal, +dysenteric, and diphtheritic. Foreign bodies, impacted feces, cold, +purgatives, prolapse of the sigmoid, and lumbar, coccygeal and +innominate lesions are the most important causative factors. The +=acute= form is more frequently found in older people. The =symptoms= +are tenesmus, frequent evacuations of blood and mucus (possibly pus), +prolapse of the mucous membrane, feeling of fullness, and radiating +pains. The gonorrheal, diphtheritic and dysenteric forms are of rare +occurrence, with the exception that the dysenteric may be somewhat +frequent. The =treatment= is to remove all local irritations, cleanse +the bowels, and put the patient in bed. All irritating foods are to be +prohibited. Use milk, soups, beef juice, soft boiled eggs and similar +foods. Correct all osteopathic lesions; especially will inhibition over +the sacral foramina relieve the tenesmus. Cold water in the rectum and +applied to the anus will be beneficial. If abscesses occur, employ +surgical measures. + +=Prolapse= of the =rectum= is another common rectal disorder. Acute +cases are especially found in children, due to straining at stool. The +sacrum is more straight, and thus violent straining, coughing, etc., +the more readily produces prolapse. Prolapse of the mucous membrane +is the most common, although all of the rectal coats may be involved. +Prolapse of the upper part of the rectum into the lower or invagination +is frequently met with by osteopaths. The sigmoid may prolapse and +also affect the rectum. The =treatment= is to return the mass, using +an anesthetic if necessary. If it is not retained, place straps across +the buttocks. Then with attention to lesions that may be disturbing +and weakening the rectal walls, and thorough local toning treatment, +the prognosis should be favorable. In high rectal prolapse local +attention is necessary as well as deep treatment through the abdominal +walls to the sigmoid and upper rectum. The use of Cole’s irrigator for +high enema will replace and elevate both the upper rectum and sigmoid +and greatly aid in a cure. Regularity of habits and proper food are +essentials. + + +Hemorrhoids + +=Definition.=—A dilated or varicose condition of the plexus of veins +lying in the submucous tissue of the lower part of the rectum. The +dilatation of these hemorrhoidal veins may extend into the adjoining +subcutaneous tissues and mucous membrane, and the perirectal plexus and +adjoining venous plexuses of the bladder, uterus, vagina and sacral +canal may become involved. + +=Osteopathic Etiology= and =Pathology=.—The chief predisposing cause +of piles is man’s erect position and the absence of valves in the +hemorrhoidal veins. Thus a retardation or stagnation of the portal vein +would cause a backward movement of the entire column. It is evident +that such a downward pressure of the blood in the portal system would +dilate and extend the blood vessels, to the very capillaries in the +rectal region. + +This retardation may arise from several causes: obstruction of the +portal vein, from diseases of the liver; diseases of the heart; +obstruction or destruction of the capillaries of the lungs; pressure +from a gravid uterus, tumor, etc.; a general loss of tonicity of the +abdominal walls, as in persons who take but little exercise; the +excessive use of wine, tea and coffee; injuries to the spinal column, +especially in the lumbar, sacral and coccygeal regions; a dislocation +of an innominate bone; lifting; constipation; straining at stool; +carelessness of the calls of nature, etc. Catarrh of the bowels may +cause a congestion of the mucous membrane and consequently piles. +Hereditary influence may be a factor in a few cases. + +Hemorrhoids are divided into two classes, =external= and =internal=. +An =external pile= is one that arises from the margin of the anus +outside of the external sphincter muscle. It differs from the internal +pile from the fact that it is always composed either of skin or +hypertrophied connective tissue, forming a mere cutaneous tag, or else +it is composed of a small cutaneous vein enlarged by a clot of blood. +The =internal hemorrhoids= are composed mostly of enlarged veins and +are connected by hypertrophied connective tissue. They have a free +arterial supply and are covered by the mucous membrane of the rectum. +They are due, usually, to an affection of the middle hemorrhoidal blood +supply, thereby being a part of the visceral vascular system. Internal +hemorrhoids, when protruding, can be returned within the rectum, while +the external ones cannot. The venous turgescence varies in size from +a pea to a walnut. They may be single or may surround the entire anal +opening like a bunch of grapes. + +Repeated attacks of engorgement of the veins involved, will in time +change the mucous membrane or the submucous tissue, and cause catarrhal +swelling of the mucous membrane, or hyperplasia of the connective +tissue. At first the hemorrhoid is usually a blood tumor, but in +chronic cases it is oftentimes made up largely of connective tissue. +Owing to pressure of the varicose veins, atrophy of the mucous and +submucous tissue may occur. The white or slimy hemorrhoids occur when +these roughened parts of the mucous membrane become inflamed and +thickened, resulting in suppuration. + +=Symptoms.=—The symptoms are quite diagnostic and need not be mistaken. +Besides the appearance of tumors, there may be constipation, pain +during stools, indigestion, headache and pain in the back. Hemorrhages +frequently occur, and if suddenly checked, as by cold, other +disturbances may occur, as congestion of the head, lungs, stomach, +liver, kidneys, etc., which may result in hemorrhages from these +organs. Fissures of the anus, contraction of the rectal sphincters and +prolapse of the rectum may occur. Occasionally in old people there is a +varicose state of the veins of the neck of the bladder, and in females, +of the uterus and vagina, which causes hemorrhages of these organs. +The communicating plexus of the spinal canal may be affected, causing +weight, numbness and pain, so as to simulate a lesion of the cord. The +patient may have a hypochondriacal disposition and be disinclined to +work, especially at mental labor. + +=Prognosis.=—Depends upon the predisposing and immediate causes, but a +large majority of cases can be cured. + +=Treatment.=—A thorough examination of the patient should be made, not +only to ascertain the extent of the local trouble, but to understand +thoroughly the general health of the sufferer, especially the state of +the heart, lungs and liver. + +Many cases of hemorrhoids are caused by lesions in the lumbar and +sacral regions, and especially dislocations of the coccyx (usually +anterior) and the innominata. Correcting these lesions will oftentimes +cure the hemorrhoidal disorder. Simple dilatation of the rectum once +a week, in addition to other treatment, is of great aid in curing +hemorrhoids, not a few of the cases being cured by dilatation alone. +It relaxes the tissues about the tumefied vessels. Treatment is rarely +necessary above the second lumbar, (unless there is more or less of a +constitutional disorder) as the superior hemorrhoidal blood vessel of +the inferior mesenteric is given off about opposite the second lumbar. + +In cases where the abdominal walls have become relaxed, a treatment +should be given to strengthen the abdominal muscles and viscera. +Particular attention should be given the liver. Treatment should be +given over the abdominal muscles directly, and also to the spinal +nerves of the same region. The diet should be strictly regulated and +the bowels kept loose, and stimulants, indigestible food, full meals +and too much meat should be avoided. Injection of cold water before +stools is a good prophylactic, and applications of cold water to the +protruding pile will be of some help in relieving the congestion. A +squatting position during defecation will relieve considerable strain. + +=Hemorrhoids= in the =acute state=, within twelve or twenty-four hours +from the engorgement, yield quickly to treatment. The local technique +is to relax the tissues about the tumor, especially above and along +the line of the vein, then with pressure at its base carefully force +out the engorged blood. Follow this up by another treatment the next +day and continue until normal. The vein wall, not being permanently +stretched, will contract and if the irritating cause is found, there +is little danger of return. Remember, in a case like this, the danger +of embolism and be sure a clot has not formed. Cases of hemorrhage at +stool, during or immediately following evacuation, when not from a +bleeding pile, may be of considerable quantity and the source difficult +to locate. It may be due to ulcerations or easily ruptured capillaries +of the mucosa, but the cause will in many cases be found in the +innominata and a reduction of the lesion give relief. + +=Rectal conditions=, associated with piles, and =requiring surgery= +after treatment has failed, are: =hemorrhoids=, which are of such long +standing as to become organized tissue, (these will keep up continual +irritation and cannot be absorbed); =saccules= or pocket, formed by +folds of mucous membrane catching and holding particles of feces, +gradually enlarging and ending with considerable reflex symptoms; +=fistulae=, complete or incomplete, may frequently be healed by +adjusting coccygeal or innominate lesions, but are apt to recur from +the tract not being clean in the center or bottom; =abscesses= in or +about the anus or rectum are usually traced to coccygeal, innominate, +or local interference to circulation; =fissure=, complete dilatation +under anesthesia to insure physiological rest of parts, is probably +the best treatment. It is suggested that a fissure may be healed +by making surgically clean, touching with iodine and coating with +collodium. =Papillae= are small, hard black-capped papules in the lower +rectum, each one involving a nerve terminal and causing much distress. +All these conditions give rise to much discomfort and with surgical +assistance can be cured without much trouble. It is not necessary +to make them a major operation and do uncalled-for things. The less +surgery about the rectal sphincter the better. + +=Care= of the =anus= and =rectum= after operation or successful +treatment is a factor in preventing return. First, there should be +soluble, non-irritating stools, which do not tend to bring about +prolapse from straining. Diet and regularity contribute to this. +Second, absolute cleanliness. This can only be obtained by following +the stool with an enema of four or five ounces of cool water and +immediately passing it. It will bring forth a considerable quantity of +feces which would otherwise have been retained for another twenty-four +hours. This procedure following, as it does, the stool does not in any +way interfere with the normal function or create a habit. The anus +should then be thoroughly washed in cool water and as thoroughly dried. +Dusting with borated talcum powder, starch, etc., will prevent chafing. + + + + +GENITO-URINARY + +THE PROSTATE GLAND + + +This gland is subject to several painful and annoying diseases, +controlling, as it does, the flow of urine and exerting such a +profound influence over the sexual functions. The nerves to the +prostate pass between the gland and the levator ani muscle, and the +secretory branches are from the sacral nerves, while Quain gives the +sensory as from the tenth, eleventh (twelfth) dorsal, first, second +and third sacral and fifth lumbar. Lesions affecting the prostate are +occasionally found at the tenth and eleventh dorsal and fifth lumbar, +while the innominate lesions are common causes of trouble. These should +be corrected, if present, and local treatment given to the gland. +“Massage of the prostate,” says Lydston,[47] “properly performed, is +one of the most valuable advances in genito-urinary therapeutics that +has been developed in many years.” Osteopathic technique is to place +the patient on the side, knees flexed, and standing in front insert +the index finger. Care must be used not to bruise the gland and it +must be touched lightly when sensitive. Relax tissue about the gland, +and, then, from the median line with an outward movement, massage the +surface of each lobe. This influences the blood and nerve supply, while +the pressure will tend to relieve congestion. Length of treatment, as +well as frequency, depends entirely upon conditions. Do not make the +mistake of treating the perineum instead of the gland and do not gouge +it with the finger. Remember it is sensitive tissue. + +=Hypertrophy= is most commonly met with in practice, as twenty per cent +of men past middle life are said to be afflicted. It is probably not a +sequence of old age, but due to chronic, congestive and inflammatory +conditions. Anything which would produce these conditions—spinal +lesions, excessive venery, masturbation, or other more innocent +causes—would in time bring about enlargement. As the length of catheter +life is estimated at six years it is of great importance that the +condition be early recognized, for in advanced stages surgery is the +last resort. In early stages the prognosis is good, either for a +cure or to stop further enlargement, while many enlarged ones at the +catheter stage have been greatly benefited or cured. Treatment of the +gland once per week is usually enough, but in older cases can be given +semi-weekly. Look well to nerve and blood supply. + +=Acute Prostatitis= is a serious and painful inflammation, causing +urinary retention usually. It results from trauma, horseback riding, +over exertion, gonorrhea and its maltreatment, etc. Lower dorsal and +lumbar lesions are frequent. This condition must be closely watched. +Inhibition of the sacral nerves will help control pain and stop any +spasm of the sphincter. Cold applications to the gland externally at +the perineum will aid in reducing inflammation. Local treatment should +at first be given to the adjacent tissues as the gland will be very +sensitive. Later direct massage will be of great benefit. + +=Chronic Prostatitis= may follow an acute attack or it may originate +as a chronic or subacute affection. Frequent micturition and dull +pain, referred to the perineum and rectum, with the local examination, +make diagnosis sure. The spinal lesions should be corrected and the +gland massaged. This will induce absorption, by squeezing out the +inflammatory products and do much toward preventing future hypertrophy. +“Massage is done by the finger. The patient is placed in the knee-elbow +position and massage employed for four minutes daily. The value of +massage in chronic prostatitis is very great, but should be employed +with much caution and never in cases of suppuration.”[48] + +=Prostatorrhea= is often taken for spermatorrhea and any irritation +of anterior sacral nerves would cause undue activity to the secretory +nerves to the gland. This is easily determined. + +=The Seminal Vesicles= can be reached just above the prostate, and if +inflamed and tender or if engorged by inspissated seminal fluid, local +treatment will be of benefit. Frequent massage, daily in some cases, to +the gland and treatment to the sympathetic nerves above the trigone of +the bladder, to the nerve fibres passing along the spermatic cord, and +to the arteries directly, will be of the greatest aid in impotency. + +In =Chronic Gonorrhea=, where the gonococcus has found lodgement in and +about the gland, it can be more readily dislodged by massage than by +any other form of treatment. + +=Retention of urine= from nervous excitement or other minor causes, can +often be overcome by local massage of the prostate. + +=Spastic stricture= can usually be cured by work about the prostate and +its innervation. + + +Varicocele + +A varicose enlargement of the veins of the spermatic cord, epididymis +and testicle. In varicocele the pampiniform plexus is usually enlarged, +but all the veins of the cord may be involved. The swelling gets +smaller under compression or in a horizontal position and enlarges +again on standing erect. It is almost invariably found on the left +side, and the testicle on the affected side is generally smaller and +softer than its fellow. + +The predisposing =causes= are a longer and tortuous spermatic vein on +the left side; the absence of support of the veins from surrounding +muscles; the imperfect valves; the entry of the left spermatic vein +into the renal vein at a right angle, instead of at an acute angle like +the right vein; the more liability of compression of the left spermatic +vein by accumulation of feces in the sigmoid flexure; the lack of +normal exercise of the sexual functions in young, unmarried adults. +Lesions in lower dorsal and upper lumbar affect the condition; the +eleventh dorsal particularly. A lesion at the second lumbar may cause +neuralgia of the testicle with engorgement of the vein. + +The exciting causes are straining during stool, heavy lifting, +excessive sexual indulgence or anything that would determine more blood +to the testicles. Varicocele is similar to the varicose state of the +hemorrhoidal veins and may have like causes. + +The =diagnosis= is easily made. The feeling of the veins between the +fingers like a convolution of earth worms; dull, aching, dragging +sensation, and possibly prostration, weakness and dejectedness of +spirits, are characteristic symptoms. “The condition is devoid of +danger, except that it often begets morbid fears on the part of the +patient, usually the result of suggestion.”[49] + +The =treatment= consists of regulation of the bowels, removal of such +predisposing and exciting causes as may be found, treatment of the +vessels along the spermatic cord, and treatment to the lower dorsal +and lumbar regions. In severe cases a suspensory bandage will give +temporary relief. Surgical interference may be necessary in some cases +in order to effect a cure. + + +Impotency + +Results from treatment in these conditions are particularly gratifying +and offer a great field of activity in this day of sensational medical +advertising. This condition can well be classed under four heads, +Exhaustive, Traumatic, Psychic and Organic. + +=Exhaustive Impotency= is the result of functional abuse, masturbation +in early life, excessive venery, coupled with intemperate use of +alcohol and improper diet without sufficient sleep. It can be +symptomatic in neurasthenia. There is at first irritation of the spinal +centers, which causes exaggerated sexual activity, and later this is +followed by complete or partial loss of function. The first step is +for a radical reform in habits; regulation of the bowels, as they will +likely be constipated; direction of the mind into wholesome channels, +and then skillfully directed spinal treatment. Where there has been +masturbation, look well for sources of irritation to the parts; a +long foreskin or adherent prepuce indicates surgical aid, or there +may be a lesion at the sacrals involving the nervi erigentes or, of +greater importance, the pudic nerve. The innominatum can be at fault +in this. The lower dorsal, ribs and upper lumbar are of importance. +Kraft-Ebing says: “Conditions of absolute impotency are, however, rare, +and are caused =only= by severe vertebral and nervous diseases.” Nerve +irritation undoubtedly is the cause of sexual perversion (outside of +heredity and malformation) so their relief is as necessary to bring +about reform of habits as to effect a cure. Where the general health is +affected constitutional treatment should follow. Motschutkovsky uses +suspension in treating these cases with good results. The effect is to +separate the vertebræ, freeing spinal nerve and blood channels. The +prostate will probably be found in an irritated, sensitive condition, +as well as the seminal vesicles. Treat as outlined under the prostate +gland. Ligation of the dorsal vein of the penis is recommended by some +authorities as tending to aid turgescence of the organ. Prognosis is so +dependent on how well the patient follows directions, age, environment +and general condition that it is hard to give, but as a rule is rather +favorable. + +=Traumatic Impotency= is a strictly osteopathic classification, for +the reason that sexual weakness is often traced to lesions resulting +from remote injuries. These injuries may be to the spine, ribs or +sacrum. The lower spine may be impacted from a fall or the result of +long continued riding on rough streets or the railway. This inhibits +the nerve supply to the extent of often seriously impairing the sexual +functions. If the cord is injured to any extent the results are more +serious. Treatment in these cases has given uniformly good results. It +will always be due to a specific lesion, so the examination must be +thorough. + +=Psychic Impotency= is the form most frequently met with and generally +the most difficult to cure, yet it should not be if the patient’s +confidence can be secured, for in many cases sexual power is but +slightly impaired, but owing to the suggestions given by the medical +advertisers the victim diagnoses his own case as hopeless. “It is not +uncommon that virility returns with the peace of mind.”[50] Observe all +the procedure given and then inspire hope where it can be honestly +given, and if the patient is progressing favorably, other things being +equal, advise early marriage under strict rules of conduct. If already +married, conjugal relations should be most carefully investigated and +the wife taken into your confidence. Her cooperation in correcting very +possible errors in sexual matters, as well as sympathetic aid in easing +the patient’s anxiety and chagrin, will be invaluable. Nothing but +the frankest understanding between all parties is permissible and the +osteopath must be in absolute control. + +=Organic Impotency= is the result of a cortical injury or disease. The +latter is the most common, as it follows tabes dorsalis, paralysis +affecting the lumbar cord, some cases of diabetes, etc. Also, any +congenital malformations or absence of all or part of the organs. +Prognosis in these cases is bad, as cure is seldom possible. + +In no other class of cases will honesty, tact and good judgment count +for so much or the rewards be greater. + + +FOOTNOTES: + +[47] Twentieth Century Practice of Medicine, Vol. XXI. + +[48] C. Kruger, Munch Med. Woch. + +[49] Deaver’s Surgical Anatomy, Vol. II, p. 652. + +[50] Vecki, Sexual Impotence. + + + + +HEAT STROKE + +(Heat Exhaustion: Sunstroke) + + +An affection produced by exposure to excessive heat. Two varieties are +recognized; heat exhaustion and thermic fever. + +=Heat Exhaustion.=—This is caused by prolonged exposure to high +temperatures, combined with physical exertion. Fatigue, overeating, +alcoholic drinking, and poor sanitation predispose. This may occur +without exposure to the direct rays of the sun, the heat being +artificial, or in mid-summer, in close, confined rooms the same result +will be produced. There is vasomotor paralysis, the surface of the body +is usually cool, the temperature may be as low as 95 degrees F., while +the pulse is small and rapid. + +=Sunstroke= or =Thermic Fever=.—This is usually caused by prolonged +work under the direct rays of the sun in a humid, very hot and sultry +atmosphere. This is caused by the action of the heat upon the heart +centers producing a paralysis of those centers. + +=Pathologically=, rigor mortis develops early and is marked. +Putrefactive changes appear early, owing to the high temperature of +the cadaver. The various organs are deeply congested, the venous +engorgement is extreme in the cerebrum. There is rigid contraction of +the left ventricle; while the right is dilated and filled with blood. +The blood is fluid and dark. Parenchymatous changes take place in the +liver and kidneys. + +In heat exhaustion with lowered temperature there is a paralysis of +the vasomotor center in the medulla, and the heat is dissipated more +rapidly than it is produced. In thermic fever the heat regulating +centers become paralyzed by the action of the excessive temperature and +more heat is produced, and less dissipated than normal. + +=Symptoms.=—=Heat Exhaustion.=—This may occur gradually or suddenly +with a severe attack of faintness, pallor, dizziness, headache, +cold perspiration and sometimes blindness as the first symptoms. +Consciousness is rarely entirely lost. In severe cases there is more +permanent collapse. The pulse is rapid and feeble and there is great +restlessness and delirium. Under prompt treatment mild cases may +recover in a few hours, while in extreme cases death may occur almost +at once from heart failure. + +=Thermic Fever.=—In some cases the patient is struck down, becomes +quickly unconscious, and may die within an hour, or death may be +almost instantaneous. In other cases there is pain in the head, +oppression, dizziness, nausea, vomiting and sometimes diarrhea or +frequent micturition. Soon unconsciousness sets in, the face is +flushed, the eyes injected, the breathing labored and there is a +temperature of from 105° to 110° F. The pulse is full and rapid, the +skin hot and dry and the pupils are contracted. There is usually +complete relaxation of the muscles, and in some cases there is +twitching and jactitation. Epileptiform convulsions are rare. In fatal +cases the coma deepens, the pulse becomes feeble, rapid and irregular, +the breathing hurried and shallow and death occurs in a few hours. +Favorable cases are indicated by a fall in the temperature and by the +return of consciousness. In these cases recovery may be complete. In +some cases the patient may never be able to stand even moderate degrees +of temperature, which often produce excitement, headache and pain in +the cervical region. Failure of the memory, and the loss of power to +concentrate the mind are sometimes sequelæ. Meningitis, epilepsy and +insanity are also sequelæ. + +=Diagnosis.=—This presents little difficulty. The history and +circumstances preceding the attack are very important in making the +diagnosis. The diagnosis between heat exhaustion and sunstroke fever +is readily made. In heat exhaustion the temperature is =lowered=, the +pulse is feeble, consciousness is rarely completely lost; in sunstroke +fever the temperature is extremely =high=, there is usually complete +unconsciousness, and the pulse is full and rapid. + +=Prognosis.=—This should be guarded, depending upon the severity of the +case. + +=Treatment.=—In cases of =heat exhaustion= remove the patient to a +shady place and apply water to the face, chest and spine. Thoroughly +treat the upper cervical region, in order to control the impaired +vasomotor centers and nerves. If the temperature is below normal a hot +bath should be given. Keep the heart and lungs stimulated. + +In =sunstroke=, place the patient in a recumbent position and loosen +all constricted clothing, and stimulate the heart’s action. The high +fever is to be met promptly. Place the patient in a bath of water, +to which add ice freely. The patient may also be rubbed with ice, +and ice water enemata may be employed. The muscles of the neck will +be found contracted, probably due to cerebral hyperemia. A thorough +relaxation of these muscles will be of great aid in equalizing the +vascular system. It is a good plan to thoroughly relax all the muscles +along the spinal column for the same purpose. When the temperature +nears normal the baths should be stopped. After the temperature has +been reduced place the patient upon a cot with ice to the head. The +cervical treatment should be repeated as often as necessary. The diet +of the patient should be liquid for a few days. Plenty of water and +stimulation of the kidneys and bowels will be found beneficial. The +sequelæ are to be treated according to the condition. Much can be done +for the sequelæ of heat exhaustion and sunstroke. Lesions will be found +corresponding to the regions involved. Deep contracted muscles are +common. + + + + +DEPARTMENT OF OPHTHALMOLOGY + +By C. C. REID + + +It is the desire to make this discussion on the eye the most useful +possible to the whole profession. Let it be plainly understood that +there is no effort to cover every phase of eye pathology but to +elaborate eye diseases and therapeutics strictly from the standpoint +of osteopathy. There are many very elaborate and extensive text books +and even encyclopediæ written on the eye by the medical profession. +The world of ophthalmic literature is extensive and profound. Just so +are the elaborations on the general field of medicine. Such things as +hereditary influences, congenital deformities, amblyopias, albinism, +coloboma and the field of ophthalmic surgery does not concern us at +the present time in an osteopathic text book. This department is +dedicated to a scientific development of ophthalmic therapeutics along +osteopathic lines of thought. Some things in the therapeutics of the +eye concern all schools alike. For instance, proper cleanliness and +antiseptic precautions in regard to the eye, dietetics, hygiene and +the care of the general health. The same anatomy and many of the same +methods of examination and diagnosis obtain in all schools. It is +the intention to go into the opthhalmic therapeutic field in these +discussions where osteopathy has a different outlook with a definite +distinct reform to offer in the viewpoint of the anatomy, methods of +diagnosis and the system of treatment. + + +How to Examine an Eye + +It has been said that one should be a good general man in order to be a +competent specialist. This is especially true in regard to ophthalmic +therapeutics. Many systemic diseases have eye symptoms and pathology. +The same blood and lymph that nourishes and bathes different parts +of the body, also circulates in the structures of the eye. In the +examination of the eye, heredity, occupation and environment are to be +taken into consideration. Osteopathic lesions may exist from falls, +strains, twists, blows, colds and exposure and impair the integrity +of the metabolic processes of the eye through the nerve connections +and blood supply and lay the foundation for a great variety of eye +diseases. With these lesions existing about the neck and upper dorsal, +it is only required to have some insignificant local irritant to start +symptoms and cause pathology apparently out of all proportion to the +etiology. It is important then that one understand the nerve centers +and reflexes and the osteopathic logic underlying these conditions or +else he must frequently work without a satisfactory explanation of the +etiology and consequently be more or less unscientific in his treatment. + +The eye examination should consist of the case history, the family +history, inspection, osteopathic examination, especially from the +fourth dorsal vertebra to the occiput and especial examination of the +eye by inspection and other methods. + +=1. The Case History.=—Thoroughness of the doctor, or the lack of it, +will be readily displayed at this point. Every little thing, as far +as possible, that has a bearing on the case should be observed and +uncovered in the case history. The physician should want to know every +fact that helps him to better understand his case. Patience in hearing +the history will often be of great assistance. It gives light on the +physical and mental condition of the patient. Much can be gained by +being careful and attentive. Notice carefully what he emphasizes and +what he thinks is the most important. Inquire in regard to headaches, +nervous symptoms, previous eye trouble and past illnesses. Get a +venereal history if present, as many eye diseases are complicated or +caused by syphilis or gonorrhea. + +=2. The Family History.=—Inquire as to blindness in the family and +about the age it occurred, if any. Get a venereal history if possible. + +=3. Inspection.=—Much inspection can go on while the history is being +taken. Observe the countenance, whether there is strabismus or frowning +due to eye strain, photophobia as suggested by the effort to avoid the +light; note symmetry. Look closely at the lashes, lids, conjunctiva, +cornea and iris. Note any scales or crusts on the lids at the root of +the lashes. Turn the lids for further inspection. Note the size and +relation of the eyes. Exophthalmos may be due to an enlarged globe +in high myopia, to Graves’ disease, orbital tumor and paralysis of +the extrinsic muscles, or staphyloma. In blepharospasm there may be a +corneal ulcer or a rupture of the eyeball. An exact examination must +be made at the first visit in order for a diagnosis to institute the +best treatment possible. Study the conjunctival sac for congestions, +hypertrophy, swelling, tumors, foreign bodies, trachoma bodies and +secretions. In all forms of conjunctivitis the congestion is most +marked in the fornix and decreases toward the sclerocorneal junction. +In iritis and cyclitis there is a circumcorneal injection, a pink or +red color radiating from the cornea. Note any corneal pathology in the +way of ulcers or abrasions and foreign bodies. Compare the tension of +the eyes. + +=4. The Osteopathic Examination of the Eye.=—This heading is put +here in order to show what osteopathy has to offer that is distinct +as belonging to our system and not practiced by any other school. +Osteopathic research so far has shown that osteopathic science has much +to offer on etiology and diagnosis and treatment in eye diseases. The +case history, family history and inspection should require but a few +minutes but they are essential to a proper examination and may aid us +in what to expect osteopathically. Weak nerves will cause asthenopia. +A broken arch, an innominate lesion or a slipped axis may cause weak +nerves. The osteopathic eye examination then should consider the whole +mechanism of the body. In case glasses are being worn for asthenopia +they may readily be made unnecessary by osteopathic treatment in +the correction of the lesions and building up the system. Some time +ago some parents sent their daughter to me to have her eyes fitted +for glasses. They stated that she had been to different doctors and +opticians and no one had ever given satisfaction. They said she was all +right every other way if her eyes were properly fitted with glasses. +They did not want her examined or treated otherwise because she would +be well every other way with correct glasses. Her vision was right +eye 5-20, left eye 5-15 or about one fourth vision in each eye. A +plus .87 diopter sphere combined with a plus 3 diopter cylinder in +axis 90 gave her perfectly normal 5-5 vision in each eye. This gave +her perfect satisfaction until she started to school in September, +a couple of months later. Before the end of the first month she was +having trouble with her eyes and was again sent to me by her parents. +Her vision was reduced to 6-15 in each eye with her glasses on. She +wondered and no doubt the parents did, if it was not another case of a +misfit in glasses similar to all her previous experiences. This time I +insisted upon a thorough physical examination against all protest. The +following lesions were discovered: the left innominate was up and back +or tilted posteriorly, first lumbar anterior and to the right, sixth +and first dorsals to the right. The case was not refracted again. I +took particular care the first time and I was quite sure the refractive +error was corrected. It was all explained to the parents and regular +osteopathic treatment was begun. In less than a month practically +every lesion was corrected, her vision returned to normal and she also +was cured of an annoying backache with which she had been bothered +for years. Her nerves were depleted a great deal. She got benefit in +ways that she had not dreamed of. This approach to the eye is not +considered by physicians in general, even the oculists. I have had +about ten special courses in medical colleges and hospitals on the eye, +ear, nose and throat, and I have never heard anything mentioned that +would indicate any ideas of the logic involved in this case. Surely +osteopathy has much to offer in eye troubles that is new and unique. +The osteopathic examination of the eye then should begin with the +feet, going then to the innominates, lumbar, dorsal, ribs and cervical +regions. Oculists are too prone to rely upon crutches (glasses) in the +treatment of asthenopia. + +It is easy for the osteopath to conceive how lesions of the upper +dorsal and cervical regions may occur and disturb the nerve and blood +supply to the eye. This is why asthenopia appears so frequently with +ordinary use of the eyes, even without abuse or refractive errors. + + +The Lumbar Region + +The lumbar region should be carefully examined, especially for any +curvature which might cause a disturbance of the equilibrium above. +Compensatory curves or individual lesions would be the result with a +consequent interference with the integrity of the nervous reflexes to +the eye. + + +The Dorsal Region + +The same may be said of the dorsal region as of the lumbar in regard +to curvatures. There is one individual lesion in this region that very +frequently exists with eye troubles, i. e., the 2nd dorsal vertebra +lateral. Any of the upper four dorsals in lesion may be a causative +factor in predisposing to disease of the eye but it has been my +observation that the 2nd is involved most often. In severe headaches +due to eye strain from refractive error, a good diagnostic symptom is +tenderness and contraction at the 2nd dorsal even when there is no +subluxation. + + +The Cervical Region + +This region should have particular care in search for individual +lesions. It is quite easy to pass over some small cervical lesion that +may be causing serious disturbance, especially if the neck happens to +be fleshy. I have corrected cervical lesions and stopped twitching of +the eyelids (orbicularis palpebrarum) and other muscles about the face. + +The first case I ever saw was twenty-two years ago when I was a junior +at Kirksville. Dr. F. P. Millard, now of Toronto, was a room mate of +mine. He was constantly annoyed by a twitching of an eyelid. I did not +find any lesion for it. We went one day to see Dr. Still at his home +and told him of our difficulty. He said without examination that the +3rd cervical was in lesion. There was a senior student present whom +the “Old Doctor” directed how to use the proper technique. There was +a sharp pop, the vertebra evidently went into right relation, the +twitching stopped. I understand the patient has had very little trouble +since. + +Injuries, exposure and strains to the spine may have antedated an +innominate lesion and caused weak joints, muscular and ligamentous +tension, local inflammations and partial immobilization of joints. +All this would have its modifying effects upon the manifestation of +secondary lesions from the innominate abnormality. This makes the study +of the bony relations very complex and the effect upon the numerous +blood vessels, nerves and other soft tissues still more complicated. + + +The Ciliospinal Center + +Following osteopathic examination and giving proper importance to +lesions below the fourth dorsal vertebra, we must remember a special +significance to be attached to lesions of the =upper dorsal= in +relation to the eye. + +Almost any author on nervous diseases or diagnosis will discuss this +center. Many of us have it not sufficiently impressed, hence I repeat +some known relations. The =ciliospinal= center consists of a nuclear +group of cells in the lateral horn of the last cervical and two upper +dorsal segments of the spinal cord. From this nucleus fibers pass to +the anterior division of the eighth cervical and first and second +dorsal nerves and become the white rami communicantes which are +efferent in their function. These fibers pass to the =inferior cervical +sympathetic ganglion=, thence upward with the sympathetic trunk through +the =middle= and =superior cervical sympathetic ganglia=, along the +carotid plexus to the vessels of the face and eye, to the glands of +that region, to the unstriped muscular fibers of the levator palpebræ +superioris and to the =dilator pupillae muscle=. + +Any strong feeling or emotion (which of course is perceived and +interpreted by the brain cortex) will cause a dilatation of the pupil +of the eye. The cervical sympathetic being cut, dilatation does not +take place. The rami of the cervical, first and second dorsal cut, the +phenomenon stops. It is evident the ciliospinal center is under the +influence of a center or centers in the brain. Bing says “There is even +an idiomotor mydriasis, which may be brought about by a very vivid +mental conception of darkness.” + +It has been noted that paralyzing lesions of the cervical sympathetic, +of the last cervical and two upper dorsal segments of the cord, and of +the anterior roots and rami communicantes of the same, will result in +myosis. + +The efferent rami are also vasomotor, secretory and trophic. It must +necessarily follow that congestive and inflammatory conditions, +secretory perversion of the lachrymal, Meibomian, Zeissian and +perspiratory glands, and disturbance of the normal nutrition of any of +the orbital tissues may result from lesions of the lower cervical and +upper dorsal vertebræ. + +Osteopathically we know that such a lesion may not be sufficient to +be paralytic in its effect, but stimulatory. In this case we may +note a pupil habitually too wide and more or less photophobia from a +superabundance of light. The unstriped muscle fibers in the levator +palpebræ superioris may be unduly contracted making an appearance of a +slightly bulging eyeball when it is only a wide open eye. + +One who has eye strain from a refractive error, overuse of the eyes, or +unbalanced muscles will as a rule have tenderness at some spot in the +region of the =ciliospinal= center. A mechanical lesion at that part of +the spine may or may not exist in such conditions, but I believe the +soreness is there every time. This is one of the diagnostic points in +differentiating =headache= of eye strain from other conditions. + +White rami are only in the dorsal region and to the second lumbar +and from the second, third and fourth sacral. It has been noted +that lesions of the cervical vertebræ do not have as profound +an effect upon the eyes as do lesions of the first three dorsal +vertebræ. The plausible explanation of that is that the cervical +vertebræ have no white rami from their corresponding nerves in the +bulbo-spino-sympathetic-ciliary arc as have the upper dorsal. + +From all the foregoing statements one can readily contemplate the +intricate complexity of our osteopathic problems in relation to the +eye. Combine this logic of the lesions outlined and the ramifications +of the structures with their normal and perverted functions and combine +it with contributing causes, such as infection, exposure, irritants, +etc., and amidst the great diversity we reduce much miscellaneous, +unclassified material to a degree of simplicity. Many otherwise +unexplainable conditions become reasonably clear. + +Dr. Louisa Burns under “The Experimental Demonstration of Osteopathic +Centers” has this to say: + + +“Somatic Reflexes” + +“In the first series of experiments, the electrodes were placed upon +the nasal mucous membrane of animals under anesthesia. The muscles near +the third thoracic vertebra were at once strongly contracted.... + +“The electrodes were then placed upon the conjunctivæ. The muscles near +the second vertebra were then contracted. There were also slight and +inconstant contractions of the cervical muscles.... + +“The electrodes were placed upon the eye ball. The muscular +contractions were sometimes noted near the second thoracic vertebra, +but the reaction was not constant. The cervical muscles were scarcely +contracted at all. + +“The electrodes were placed upon the outer surface of the eye lids. +The facial muscles were contracted very quickly and forcibly, but no +contraction of the muscles of the upper dorsal region were noted.... + +“The =superior cervical ganglion= was exposed to view, and the +electrodes placed upon it. The pupils became greatly dilated, the +conjunctivæ became lighter in color, and the mucous membranes of the +nose and throat were also lightened.... + +“The =Gasserian ganglion= was exposed to view. The ganglion was +stimulated directly. The upper thoracic muscles were very strongly +contracted, and the blood vessels in the area of the distribution of +the fifth nerve were immediately and strongly contracted. Some of the +sympathetic fibers are carried by way of the fifth nerve. In order to +exclude the effect of the direct stimulation of these fibers, the fifth +nerve was cut, and the central end was stimulated by the electrodes. +The muscles of the upper thoracic region were contracted, as before. +The vessels in the area of distribution of the fifth nerve were +contracted after latent period of a minute or so.... + +“The stimulation of the central end of the cut fifth nerve caused +strong muscular contractions in the upper thoracic region, and also +constriction of the vessels in the area of distribution of the fifth. +Direct stimulation of the superior cervical ganglion produced effects +identical with those produced before the mutilation. + +“The spinal cord was cut above and below the superior cervical +ganglion. This cut was made from behind, and the sympathetic chain was +uninjured. The effects noted after both operations were the same, and +can be described as one. + +“The stimulation of any cranial structure failed to cause reflex +contraction of the muscles in the upper dorsal or the cervical region. + +“Stimulation of the cranial structures did not produce any vascular +changes except those which might be referred to the direct effects of +the electricity upon the vessel walls. + +“Direct stimulation of the =superior cervical ganglion= produced the +effects noted before mutilation. + +“Therefore the cervical portion of the spinal cord is an essential +element of the reflex arc by way of which sensory impulses from the +cranial structures are able to affect the condition of the upper +dorsal muscles, and also in the path by which these impulses are able +to affect the size of the blood vessels of the cranial structures +themselves.... + +“Mechanical stimulation of the tissues near the second thoracic spine +was followed by a contraction of the blood vessels of the cranial +mucous membranes and the conjunctivæ, by a dilatation of the pupils, +and an increased secretion of saliva. These effects were practically +invariable.... + +“The superior cervical ganglion was subjected to mechanical stimulation +by the manipulation of the tissues over it. In animals, this maneuver +was followed by dilatation of the pupils and by a contraction of the +cranial vessels, which was soon followed, if the stimulation continued, +by a dilatation which was rather persistent. + +“After the =extirpation= of the =Gasserian ganglion= without the +injury of the sympathetic nerves, the mechanical stimulation of the +tissues near the second and third thoracic vertebræ caused the same +vaso-constriction and =pupilo-dilation= as was observed in the animal +before mutilation. + +“After the destruction of the cervical portion of the sympathetic +chain, and after the extirpation of the Gasserian ganglion in most +animals, the mechanical stimulation of the tissues in the upper dorsal +region did not produce any perceptible effects.... + +“Mechanical stimulation of the tissues near the second and third +thoracic spines caused dilatation of the pupils and contraction of the +vessels of the cranial mucous membranes. + +“Inhibition, or the maintenance of an artificial lesion, caused +dilatation of the vessels of the nasal mucous membranes and of the +conjunctivæ. The eye ball was also somewhat congested. The pupils were +dilated in this case also.” + + +The Nose and Throat in Eye Trouble + +An examination of the eye would not be complete without a careful +inspection of the =nose and throat=. The same nerve and blood supply +that go to the eye is tied up so definitely with the nose and throat +that when there are lesions of the nose and throat the eye is often +affected secondarily. Just recently a case of =dacryocystitis= came +into my office. After I had carefully examined her eye, spine, nose +and throat, she informed me that she had been to three eye specialists +before and not one of them had ever looked at her nose and throat, +not to mention the spine. She had cervical and dorsal lesions, and +=diseased tonsils=. The =inferior turbinate= on the side of the +dacryocystitis was curled out so that it lay against the external +wall of the nose almost if not altogether blocking the entrance of +the =lacrymal duct= to the inferior meatus. This was evidently the +predisposing cause of her dacryocystitis. + +In =neuralgia= of the eye, =blepharitis=, =obscure pain=, +=conjunctivitis= and often deeper troubles you will find a bad +condition of the =nasopharynx=, such as adenoids, vegetations, pus +pockets, adhesions in the fossa of Rosenmuller, contraction of the +soft palate, disturbed relations of the septum and turbinates, sinus +trouble, poor drainage, exostoses and polyps. In eye disease all these +things should be discovered if they are present, in order to get best +results and in order to make a careful diagnosis. + + +Examination of the Eye by Special Methods + +The first thing after the family history, personal history, inspection +of the eye and the osteopathic examination, is to find out how well the +patient can see. To test the acuteness of vision certain test letters +are used. Snellen’s Test Letters are good. The normal eye can read 3-8 +inch letters at twenty feet. The test letters on the cards usually +range in size to be read at 10, 15, 20, 30, 40, 50, 70, 100 and 200 +feet. The most desirable distance is 20 feet. If at the distance of +twenty feet he reads the 3-8 inch letters his acuteness of vision would +be marked 20-20 or normal. Always use the distance between patient +and chart as the numerator of the fraction and the number above the +letters which he reads as the denominator. If he is twenty feet away, +the numerator remains twenty and the denominator changes according to +the line of letters seen on the test cards thus: 20-15, 20-30, 20-70, +or 20-200 may express the vision. If the patient could not see the 200 +feet letters at 20 feet he must be brought nearer, say 10 feet, for him +to see the large letters; his vision would be 10-200. These fractions +representing the acuteness of vision may be expressed in meters. Some +charts have letters numbered that way. + +If the vision is good enough for small objects to be clear, the near +point should be taken. This would show the amount of accommodation of +the eye. This is expressed in diopters. + +A =diopter= is the unit of measurement of the =refractive= power of +lenses. =Lenses= are numbered by their refractive power in diopters. A +lens that has a curvature that will refract parallel rays of light and +bring them to a focus at one meter distance is said to be a one diopter +lens. This unit of measurement for the refractive power of lenses was +proposed by Nagel in 1866. It soon became quite generally used. + +The focal distance of a lens decreases as the strength of a lens +increases. One diopter lens (written 1 D) has a focus of one meter (1 +M) or 100 cm distance. A 2 D lens has a focal distance of ½ M or 50 +cm. A 4 D lens has 25 cm focal distance and a ½ D lens has 100 cm ÷ +½ = 200 cm distance or 2 M. Trial cases have in them lenses varying in +strength from .12 D or .25 D to 20 D of the spheric form. We will not +discuss the trial case here. + + +Accommodation in the Eye + +=Accommodation= in the eye is the ability of the eye to vary its focal +point. When the normal eye (emmetropic) is at rest its focal point is +at infinity so far as parallel rays are concerned. This is called the +far-point or the “=punctum remotum=” (P. R.). + +When the eye looks at letters twenty feet away it scarcely accommodates +at all to get a focus, or so little that it may be disregarded in +ordinary practice. Now if one brings fine print close to the eye he +will find a point so close that it becomes indistinct. This point is +the near-point of focus or the =“punctum proximum”= (P. P.). The range +of accommodation is the difference between the refractive power of the +eye when it is at rest and when the accommodation is exerted to the +utmost, the difference between the P. R. and the P. P. + +If one must accommodate one diopter to get a focus at one meter or +forty inches distance, at thirteen inches or reading distance one must +accommodate at least 3 D in order to see the letters clearly. If 3 D +were the total of his accommodation he could not read at that distance +but a few minutes; because the accommodation could not be held at its +maximum for long at a time. Eye strain with its train of symptoms would +result. Hence it is quite important to find the near-point or punctum +proximum in order to judge in regard to eye strain in an emmetropic +eye. If there is a refractive error, allowance for it must be made +accordingly. + +As a person gets older the accommodation in the eye becomes less +and less until at 45 years of age he can only use 4 to 5 D of +accommodation. This is so close to the amount required for reading +that he has some eye strain. He begins to hold his paper farther away +from him so he requires less accommodation. This condition we call +“old sight” or =presbyopia.= An emmetropic eye at forty-five to fifty +years of age requires a plus glass to make up for some accommodation in +reading. + +Frequently there are latent disturbances of equilibrium of the +extrinsic muscles of the eye. This is =heterophoria.= If it is a +latent convergence it is =esophoria=; if a latent divergence it is +=exophoria=. The latter is more frequent. Hyper- and hypophoria are +used for upward or downward tendencies. Normal muscular balance is +=orthophoria=. + +Cause the patient to fix on an object about thirteen inches away with +both eyes; push a sheet of paper in front of one eye and watch behind +the paper, the eye thus covered. If heterophoria exists the eye will +move slightly from its point of fixation since it no longer sees the +object. In orthophoria it will remain fixed as long as the other eye +sees the object; the innervation to the different muscles is properly +distributed. + +A Maddox rod found in any complete trial case may be placed before one +eye. Have the patient fix on a candle flame, say twenty feet away. +The flame appears drawn out into a luminous line. This line can not +be fused with the candle flame as the other eye sees it if there is +heterophoria. The amount and kind of disturbance is somewhat indicated +by the distance and direction of the luminous line and the flame. The +exact amount can be measured by the use of a prism that will cause them +to fuse. + +Next the patient should be taken to the dark room and a careful +inspection of the anterior segment of the eye should be made with +oblique illumination. First use the unaided eye, then use a lens that +magnifies. The 20 D plus lens from your trial case will suffice for the +magnification. Note the transparency or lack of it in the cornea and +crystalline lens; the depth of the anterior chamber and the appearance +of the pupil and iris. Now we are ready for the ophthalmoscopic +examination. + +=The Ophthalmoscope.=—This is an instrument that commands great +respect. Any one who is interested in eye troubles must have and use +the ophthalmoscope if he expects to be efficient in diagnosis, upon +which, of course, intelligent treatment must forever depend. One must +try and try again in order to become proficient in the use of the +ophthalmoscope. + +A Schematic Eye is of great assistance to a beginner who does not +have clinics or patients on whom to practice. Such an eye with full +directions can be obtained at almost any optical goods store. It will +make the study of ophthalmoscopy easy and interesting. The pupil can +be regulated to any size and the eye can be made short (hyperopic), +long (myopic) or normal (emmetropic) for study. + +The efficient use of the ophthalmoscope makes the diagnosis of internal +diseases of the eye as easy as the diagnosis of external diseases of +the eye. Only some rare conditions will puzzle, and that is true of any +part of the anatomy. + +The ophthalmoscope is a simple instrument; its chief function is to +illuminate the interior of the eye. The value of ophthalmoscopic +findings depends on their correct interpretation by the examiner. + +The ophthalmoscope has a mirror to reflect the light into the eye. It +has two discs on which are mounted convex (plus) and concave (minus) +lenses. The larger disc has seven plus and eight minus lenses. To these +may be added the lenses in the smaller disc making many combinations. + +A drop of a 2% solution of cocaine or homatropine may be used as a +mydriatic where one can not otherwise see clearly the fundus. If no +mydriatic is used a somewhat weak illumination should be employed in +order not to arouse the accommodation to much activity and make the +pupil small. If there is any opacity in the media a strong illumination +should be used. The room should be dark; the darker the better. + +There are two methods of using the ophthalmoscope. The =indirect= and +the =direct= methods. One is more useful at one time and the other at +another time. By the indirect method we view the whole field of the +fundus more readily but less in detail. With the ophthalmoscope before +his eye the examiner’s face is twelve to fifteen inches from that of +the patient. When the “=red reflex=” of the eye is seen a plus 13 or 16 +D lens is interposed near the patient’s eye. This magnifies the field. +The image is inverted. As a rule it is best seen with a +4 D lens in +the aperture of the ophthalmoscope. + +This method is especially more satisfactory in high degrees of myopia +and astigmatism. The =optic disc= is the objective point. One may see +a retinal vessel first; this should be followed to its emergence from +the disc. From this point view all parts of the fundus by having the +patient look in different directions. This is better by the indirect +method than for the examiner to vary his position. + +The direct method of ophthalmoscopy is better for detail work and in +all cases except high degrees of myopia and astigmatism. It is also +better in determining errors of refraction. The patient looks straight +across the room. For a beginner it may be essential to dilate the +pupil, hence the schematic eye as suggested. + +If the examiner has a refractive error, he should wear his own glasses +or correct by throwing in front of his eye proper lenses in the +ophthalmoscope. Face the patient and sit on the side of the eye to be +examined. Use left eye to examine the patient’s left eye and right eye +for the patient’s right. Examiner and patient keep both eyes open. The +examiner may not be able to suppress the image of his other eye and may +have to close it part of the time. Catch the “red reflex” some 15 to 18 +inches away and move close to the patient’s eye. The “red reflex” color +varies with the error of refraction, the transparency of the media, the +degree of pigmentation and the size of the pupil. A blood clot will +make it redder, some exudates will make it gray or yellow. + +The examiner may approach as close as half an inch from the eye to be +examined. Find the optic disc and examine all points of the fundus from +it. Rotate in glasses to correct the patient’s refractive error if he +has any. The strongest plus glass with which the fine retinal vessels +can be clearly seen will represent the =hyperopia= of the eye. This +is true only if the examiner’s accommodation is at rest. The weakest +minus glass with which the fine retinal vessels can be clearly seen +represents the =myopia=. + +=A Normal Fundus.=—The color of the fundus is due to the blood vessels +of the retina and choroid and the connective tissue of the choroid and +sclera. Variation is due to the pigment. In the albino it is light +pink. In the negro it is dark reddish. There are all gradations between +the two. + +The =optic disc= is the end of the optic nerve as it comes into the +eye; it is circular in shape, pink in color, and sharply defined. It is +about 1-16th of an inch in diameter; about 15° to the nasal side of the +pole of the eye and slightly above the horizontal. There may be a dark +=choroidal ring= around the disc or part way around. There may also +be a white ring caused by the sclera. As a rule there is a depression +in the center of the disc out of which the retinal vessels emerge and +spread out over the fundus. + +The =fovea centralis= or point of clearest vision is located two and a +half disc diameters to the temporal side of the disc. Around this is a +circular area of light yellow, the =macula lutea=. + +The subject of ophthalmoscopy has been touched upon somewhat in detail +because of its great importance to the general practitioner. Every +osteopathic physician should know the ophthalmoscope well enough +to recognize the ordinary lesions inside the eye. When we take up +pathological conditions of the eye we will have occasion frequently +to refer to the ophthalmoscopic appearance. Without the use of this +instrument all of our clinical field research on internal diseases of +the eye is valueless. Many have told me they have cured cataract with +osteopathic treatment, some say they have cured specific neuroretinitis +with no sequelæ, others testify to opacities and blindness from +various causes. Invariably we ask if they used the ophthalmoscope in +their diagnosis and with it watched the progress of the case. Almost +invariably the answer is “no, it looked like it,” “the symptoms +indicated it,” or “Dr. so and so, an oculist diagnosed it as such.” +Fellow Osteopaths! we can not base our claims on this kind of data. +With a little study and practice the ophthalmoscope can be mastered. +Not till then can we get reliable statistics on internal diseases of +the eye in our case reports. Osteopathy has much to reveal to us in +this field and for the sake of the science and our patients we appeal +to every one to do the work here set forth. + + +Diseases of the Eye + + +OSTEOPATHIC MANIPULATION FOR EYE DISEASES + +A general correction of lesions should be made in order to give perfect +alignment and equilibrium. Lesions that affect the nerve and blood +supply will be found from the fourth thoracic to the occiput; more +often at the occiput, atlas and axis in the cervical region and the +second and third thoracic in the dorsal region including the ribs. + +Correction of these lesions must have specific attention in every case +of eye disease that shows any tendency to chronicity or in repeated eye +disease and exacerbations. + +A thorough upper spinal treatment to insure good mobility of all joints +and establish freedom of fluids and forces is recommended. + +The =nose=, _throat_ and =sinuses= should be examined for pathology. If +the tonsils and pharynx are not normal the cotted index finger should +be introduced into the mouth until the anterior pillar of the fauces +is reached. A mouth gag may or may not be used. Massage the tonsil +through the anterior pillar then move to the top and press down on +the tonsil with a pumping motion. Repeat this from below the tonsil +and posteriorly. Slip the finger under the soft palate and stretch it +thoroughly. Clean out any adhesions and vegetations in the vault of the +nasopharynx and fossa of Rosenmuller. Stretch the pillars of the fauces +by pressing down on each side at the root of the tongue. + +If the sinuses are diseased they should be drained. If the nose is +diseased and has abundance of secretion, first use irrigation for +cleanliness. + +Manipulation in the nose will be of great benefit in some eye diseases +as pathology there frequently has an important bearing on diseases of +the eye. The nose is often too narrow and contracted. The first inch of +the nose is muscular and cartilaginous; it is of even more importance +to dilate the nose in contractured conditions than it is the sphincters +at the lower end of the rectum. The great benefit derived from rectal +dilatation has been recognized for years. + +In dilating the contracted nose a wide blade nasal speculum may be +used. The cotted and oiled little finger may be used where it is +properly adapted in size. The dilating can be done with practically +no pain and no damage to membranes or other tissues. It should not be +extended beyond the cartilaginous and muscular part. Manipulation of +the turbinates and tissue further back may be done if needed, by the +use of instruments. The Edwards turbinate adjuster instrument (Aloe +Co., St. Louis) or the Ruddy Nasal Third Finger (Sharp and Smith, +Chicago) are the best instruments so far devised for this operation. + +A thorough stretching of the =eyelids=, manipulation of the =eye ball= +and the points of the fifth nerve are indicated in many diseases. + +The lids may be stretched by pulling them from side to side. The cotted +forefinger well oiled (sterile vaseline) may be slipped into the +conjunctival sac back of either lid and with the thumb on the outside +the lid may be massaged or stretched in any direction. The points of +the fifth nerve may readily be influenced at their respective exits +about the orbit. The eye ball and deeper contents of the orbit can be +profoundly treated by pressing the finger into the orbit above, below +and at the sides of the bulb and pushing it in all directions as far +as possible. The Ruddy eye finger instrument was devised for this deep +manipulation of the orbital and bulbar structures. It is of high value. +One finger may be laid on the closed eye and with a tapping motion with +the other hand a vibration or oscillation of the orbital structures may +be had. This is a useful treatment. + +The wise selection and skillful use of these various methods of +treatment for the eye will solve most of our difficulties. + +This short survey of osteopathic methods will aid us in the more +specific discussions to follow. + + +Neuralgia + +A considerable number of people seem to be subject to attacks of pain +in one or both eyes. These attacks of pain come at varying intervals; +in some cases several times a day, in others as far apart as one +or two weeks. The pain will suddenly start almost without warning +and with very little provocation, and last from one to twenty-four +hours. It is very severe and the patient frequently thinks something +terrible is wrong. Something terrible is wrong so far as his comfort +is concerned. But in these cases to which I am referring there is no +organic trouble with the eye. The patient does not need glasses. There +is no sign of inflammation. Vision is not disturbed. Local examination +of the eye with the ophthalmoscope reveals that the fundus of the eye +is normal. There is no symptom connected with the eye except pain, +occasionally accompanied by a slight redness. I have had several cases +in my own practice and my attention has been directed to cases of other +physicians. + +These cases differ from _tic douloureux_ in that there is no muscular +spasm. In fact, motor nerves do not seem to be involved. The +involvement seems to be largely in the =fifth cranial nerve=, usually +the supraorbital, or other smaller branches of the ophthalmic division +of the fifth cranial. Sometimes we note slight dilatation of the pupil +with more or less congestion. This would indicate an involvement of the +sympathetic branch to the eye. + +The lesions discovered in these cases have been a subluxation of the +occiput upon the atlas or an upper cervical lesion and frequently some +involvement at the second dorsal. There has been noted also trouble in +the nasopharynx such as contractures of the muscles of the soft palate +and adhesions in the fossa of Rosenmuller. + +Misplacements of the uterus have also been found in some cases. + + +Treatment + +Nearly all these cases are curable with from one week to six weeks +treatment. Of course the treatment must be intelligently directed after +a correct diagnosis as to the cause. The cause can usually be removed. +One case to which my attention has been directed was that of a woman +about forty years of age who had very severe pains. With all the local +treatment of the eye and otherwise she got practically no results +until she had replacement of the uterus, which brought immediate +relief. Other cases have no trouble on that kind but have lesions of +the cervical region and on correction of these lesions the neuralgia +disappears. Other cases have had the nasopharynx cleaned out by the +finger operation and the stretching of the soft palate which relieved +the neuralgia immediately or in a few days. Numbers of cases have been +to medical physicians and had various eye remedies administered locally +with no permanent benefit. Of course the treatment was administered at +the wrong place. + +The ramifications of the sympathetic and fifth cranial nerves are so +complex and far-reaching that we must keep in mind that one or more of +many causes for the trouble may exist and be quite remote from the seat +of the pain. + + +Diseases of the Eyelids + +Occasional factors are bee stings or insect bites, which completely +occlude the palpebral fissure. We may have some palpebral edema from +lid abscesses, chalazion, hordeolum, dacryocystitis, panophthalmia and +so forth. In =hemorrhagia subdermalis= there is so much spongy tissue +beneath the skin about the eye that the blood extends easily and far. +The red tint will soon change to a reddish blue and then become dark, +what is known as a black eye (ecchymosis). This frequently results +from a blow. The skin is sharply attached around the orbital margin by +tense connective tissue so the area of the hemorrhage is limited to the +region of the orbit. There may be spontaneous rupture of some of the +vessels by hard sneezing or coughing, especially in young children. +In older people it may indicate a fragile condition of the vessels, +arteriosclerosis or some trouble with the kidneys. The diagnosis of the +eye condition is not difficult but the cause of the hemorrhage in that +region might be investigated further. Local treatment is of some value +in these conditions. They may be soothed by cold compresses. In bee +stings and insect bites use an alkaline compress. Manipulation about +the eye and osteopathic treatment of the neck with a view to directing +a better circulation to that region will aid much. + + +Herpes Zoster Ophthalmia + +This affection of the supraorbital branch of the fifth cranial nerve +may extend to the eyelids. It may not go beyond the stage of blistering +and redness with some edema. However, it is possible for it to become +gangrenous and even extend to the conjunctiva and cornea. I had one +case of herpes zoster gangrenosa of this region. There were several +gangrenous spots as large as a dime on the forehead and extending down +in the region of the eyelid. The process extended to some extent on the +cornea and in healing left a condition of irregular astigmatism. + +=Treatment.=—The prognosis in herpes zoster is always favorable under +osteopathic treatment. Lesions of the cervical region will almost +invariably be found interfering with the sympathetic connections of +the fifth cranial nerve causing the trophic disturbance to the region. +Osteopathic treatment applied to these conditions will always hasten +normalization. The affected part might be kept covered with some +soothing lotion to keep the skin soft. + + +Hordeolum + +This is commonly known as a =sty=. It is due to suppuration of the +=glands of Zeiss=. It is a harmless affection but causes pain and +inconvenience. + +=Diagnosis.=—Swelling and pain with a small inflammed nodule in the +palpebral margin is quite diagnostic. + +=Treatment.=—The circulation is obstructed in this region. The effort +should be made to open the circulation before pus has formed. This can +frequently be done and the hordeolum aborted by carefully picking up +the eyelid and rolling the nodule between the fingers. This will cause +some pain but if it is kept up for a moment or two about every hour +through the day with an occasional thorough treatment of the neck the +sty will usually be aborted. If pus forms it should be opened as soon +as it points and then the squeezing and rolling process may be employed +again, which will aid rapidly in the freeing of the circulation. + + +Chalazion + +This is a =Meibomian cyst= in the eyelid. It shows as a circumscribed +swelling on the inner side of the lid. It frequently becomes large +enough to produce some deformity of the lid. A chalazion is movable on +the tarsal cartilage. It is a chronic condition and the cyst may become +as large as a bean. There may be more than one in the same lid. + +=Treatment.=—When a chalazion is small and not of long standing it can +frequently be cured by osteopathic treatment. Introduce the finger into +the conjunctival sac under the lid, and with the thumb externally, +grasp the chalazion between the finger and thumb; roll it thoroughly. +Squeeze and massage it two or three times a week for awhile. This, +combined with a thorough treatment of the neck, will result in a cure. +If at the end of six weeks the condition has not disappeared surgery +should be resorted to. + + +Blepharitis + +This is an inflammation of the eyelid. It is either =acute= or +=chronic= according to the cause. Acute blepharitis may be due to heat +or injury. Chronic blepharitis affects the glands of the lid causing a +perversion of the secretions. There is usually the formation of crusts +and scales. This condition is known as =blepharitis sicca=. In some +cases infection will form little pustules at the roots of the cilia. +There is soreness and aching. There may be photophobia. The nasal +region may be involved. Osseous lesions of the cervical region are +usually present. Refractive errors frequently exist in these cases. +Occupation or environment may expose to dust or wind sufficient to keep +up the irritation. + +=Treatment.=—Change environment. See that there is thorough cleanliness +of the lid. Rub or pick away all scales. Use a bland ointment. Correct +any cervical or upper dorsal lesions. + + +Ptosis + +This is =congenital= or =acquired=. In congenital ptosis operation +seems to be the only treatment. Acquired ptosis is amenable to +treatment frequently. The cause is some lesion interfering with the +passage of proper nerve force to the levator muscle of the lid. The +lesion may be at the origin of the third nerve, at the cortical nucleus +in the sigmoid gyrus or in the trunk of the third nerve, or a lesion +of the muscle itself. Tumor, trauma, syphilis, sclerosis, hemorrhage, +gout or rheumatism, or anything that will produce a peripheral neuritis +are causative factors. Lesions of the cervical and upper dorsal by +reflecting back upon the nerve centers may produce a ptosis. + +=Treatment.=—Remedial measures according to indications. Cases due +to osteopathic lesions as indicated will usually yield readily to +treatment. Where there are other factors treatment must be varied +accordingly. + + +Trichiasis + +This is a condition in which part or all of the eye lashes turn +inward and touch the eye ball, due to cicatricial contractions in +the conjunctiva and tarsus. Many of the cilia are so small in these +conditions that it is very difficult to see them. A loupe or a +magnifying glass must be used in order to discover them. + +=Dystrichiasis= is a condition where the cilia come in irregularly +growing in all directions, some of them turning in toward the eye ball +and causing irritation. + +=Treatment.=—An epilatory should be used to extract all of the wild +hairs. Care should be taken to get out the finest ones as they will +frequently cause irritation if not removed. + + +Entropion and Ectropion + +=Entropion= is a turning in of the eyelid and =ectropion= is a turning +out. These conditions may be spasmodic and temporary. Entropion is more +often due to cicatricial contraction in old blepharitis or trachoma +conditions. In some cases the condition may be corrected by the use +of strips of adhesive plaster. In cicatricial conditions operation is +the rule. Spasmodic ectropion may be corrected sometimes by curing the +conjunctivitis. Bandaging may be resorted to. In paralytic ectropion +osteopathic treatment may serve to produce a complete cure. Operative +procedure should be a last resort. + + +Diseases of the Lachrymal Apparatus Dacryocystitis + +=Dacryocystitis= is an inflammation of the lacrymal sac. It is due +to some lesion in the nose, malposition of the inferior turbinate or +a poor blood and nerve supply to the lacrymal region as determined +by cervical lesions. The sac becomes infected and we have a +=dacryocystoblennorrhea.= Pus and tears are regurgitated into the eye +through the puncta. There is irritation and the conjunctiva may become +infected at any time, also the cornea. It is a dangerous and annoying +affection. + +=Treatment.=—Osteopathic measures have something to offer along this +line. The medical idea seems to be completely surgical in recent years. +The first and only thing to be done surgically is to obliterate the sac +or dissect it out and curette the nasal duct, completely destroying +the apparatus. Lancing does not affect a cure. By treating for a good +nerve and blood supply to that region, the irrigation of the nose and +a thorough squeezing of the sac each time with a view to forcing the +solution in the sac down through the nasal duct into the nose, a cure +may be effected in many cases. If these cases can be gotten before +infection has taken place, in the state of epiphora or the backing up +of the tears into the eye, thorough treatment along the lines just +indicated will in nearly all cases result in a cure. + +Boric acid solution should be used to wash out the sac when pus is +present. The attempt should be made to force it into the nose. Probing +properly done is of value in many cases. These cases should be followed +up with great care. + +Treat the neck thoroughly and spring the inferior maxilla. + + +Diseases of the Conjunctiva Conjunctivitis + +The conjunctiva is a mucous membrane that coats the posterior surface +of the eyelids and the anterior surface of the eyeball. It forms a sac, +which is slit open in front in the line of the palpebral fissure. + +The conjunctiva consists of three parts (1) the conjunctiva tarsi, the +part on the lids; (2) the conjunctiva bulbi, the part on the eyeball, +and (3) the conjunctiva fornicis, the part connecting the first and +second; it is the retrotarsal fold or the region of transition, often +called the fornix. The first part can be seen by everting the lids. It +is adherent to the tarsus. It is covered with a laminated cylindrical +epithelium. The membrane contains an abundance of lymphocytes similar +to adenoid tissue. This increases with every inflammation of the +conjunctiva. This is why =chronic conjunctivitis= often results in +thickened lids. + +The =blood supply= of the conjunctiva of the lids is from the muscular +branches of the ophthalmic artery. The =nerve supply= is from the +ophthalmic division of the 5th cranial and the sympathetic. + +The bulbar conjunctiva continues over the cornea. It is covered +with layers of pavement epithelium. Its blood supply comes from the +posterior conjunctival vessels about the retrotarsal fold, and the +anterior ciliary arteries which accompany the tendons of recti muscles; +these two systems anastomose in the conjunctiva. Conjunctival injection +or congestion shows a superficial net work of larger or smaller vessels +that move with the conjunctiva. The color is scarlet or brick red. +Ciliary injection occurs as a rose-red or pale violet zone around the +cornea, spoken of as peri-or circumcorneal injection. It does not move +with the conjunctiva and occurs more with diseases of the cornea, iris +and ciliary body. + +In the =etiology of conjunctivitis= a great variety of germs are +considered by different writers. Collins and Mayo give a report of +“germs found in normal conjunctiva.” + +Bacillus Xerosis in 94% of normal conjunctivæ; Staphylococcus Albus in +79%; Pneumococcus in 9%; Diplobacillus in 6%; Staphylococcus Aureus in +6%; Streptococcus in 5%. + +If this be true, and I do not doubt their statement, we are practically +compelled to say that these germs at least are only secondary in the +etiology of conjunctivitis. Just at this point osteopathy comes with +its flood of light and makes it easily explainable why some conjunctivæ +become inflamed while others do not, when all have germs present. The +lesion disturbing the integrity of blood supply and nerve force to +the eye is the primary cause while the presence of germs may be the +aggravating cause. The lesion prepares the soil in which the germs +thrive sufficiently to become an irritant. There are all gradations +of this soil preparation. The more fertile the field (i. e. the more +profound the effect of the lesion) the more virulent germ life may +become; the resistance is proportionately less. + +=Conjunctivitis= is =classified= for convenience in study, diagnosis +and treatment as follows: + +(1) Catarrhal, (a) acute, (b) chronic, (c) follicular; (2) gonorrhoeal; +(3) ophthalmia neonatorum; (4) trachoma; (5) diphtheritic; (6) +eczematosa (phlyctenulosa); (7) vernalis; (8) tubercular; (9) +traumatic. This is the clinical classification after Fuch. + + +Treatment of Conjunctivitis + +In order to give the best care in these cases it is quite essential +that both the primary and secondary causes be given attention. Some +good =germicide= or =antiseptic= is to be used with intelligence. This +is in harmony with the great principles of antisepsis and cleanliness +taught by osteopathy from its inception. The use of the microscope in +the =bacteriology= of conjunctivitis aids in more definite diagnosis +and the selection of a proper germicide. For the Koch-Weeks bacillus, +the pneumococcus and the influenza bacillus silver nitrate 1% or a 25% +solution of argyrol is used; for the diplo bacillus (Morax-Axenfeld) +zinc sulphate 1 gr. to the ounce is almost a specific. + +A good way to prepare the zinc prescription would be: + + Boracic acid and water oz. 1. + + Zinc sulphate gr. 1. + +The boric acid and water of course being a saturated solution. Apply +one drop to each eye about four times a day. If one can not have +the use of the microscope to make specific the diagnosis, the zinc +solution may be alternated with the argyrol as the germicide. Ice cold +applications are good in many of these cases. + + +Catarrhal Conjunctivitis + +=Acute=.—mostly affects the conjunctiva of the lids in the light form. +If severe it invades the bulbar conjunctiva. There is redness and +swelling and increased secretion which dries at night upon the edges of +the lids and glues them together. The eyes are better in the morning +and worse toward evening. =Corneal ulcers= and =iritis= may arise as +complications. Chronic inflammation may result. + +=Etiology.=—Textbooks on the eye give =bacteria= as the chief cause; +some scarcely mention anything else. After discussing how the bacteria +get there and multiply, they usually bring in some statement to +indicate that in many cases no bacteria can be found in the secretions +from the conjunctiva. These latter are unaccounted for in the etiology. + +=Catarrhal conjunctivitis= is non-specific in its origin. + +The great science of osteopathy will fill in the missing links to works +otherwise very exhaustive on the eye. + +If the cause is due only to a passing irritant as dust, smoke, pollen +or wind the disturbance may vary from hyperemia only, to a severe +attack of conjunctivitis. Fuch says the majority of cases are produced +by bacteria, but THAT IN NOT A FEW CASES OF CONJUNCTIVAL CATARRH THE +EXAMINATION OF THE SECRETIONS FOR BACTERIA PROVES NEGATIVE. He also +says that the usual course of the disease is from eight to fourteen +days, but NOT INFREQUENTLY THERE REMAINS A CONDITION OF CHRONIC +CATARRH PROTRACTED OVER A LONG TIME; THAT NOT INFREQUENTLY THE NORMAL +CONJUNCTIVAL SAC CONTAINS PATHOGENIC GERMS. + +Some authors divide the =etiology= into (1) specific, (2) non-specific. +The first they account for by irritants due to dust, heat, smoke, +metal, pollen, cold, wind, glare of light, eye strain from overwork of +the eyes, ametropia and chronic alcoholism. The second they account +for by germ life, most often the Morax-Axenfeld diplobacillus or the +Koch-Weeks bacillus, the latter germ being found in the so-called +“pink-eye.” It is contagious. This is one condition for which the zinc +sulphate (½% to 2% solution) is almost a specific. + +No doubt the irritants and the bacteria mentioned, with others, do +cause much of our catarrhal conjunctivitis and that one who fails +to consider properly the local conditions in practice will be sadly +lacking in best results. + +On the other hand many cases, treated for local conditions only by +very competent men who used the best antiseptics and germicides, have +very indifferent results. The acute condition would continue and +gradually become chronic. From observation, study and experience there +are causes aside from local irritants, ametropia, bacteria, syphilis, +rheumatism or measles. There is some disturbance to the integrity of +the =spinociliary sympathetic arc=. In many cases of eye disease note +lesion and tenderness at the upper dorsal, the removal of which will +cause improvement of the eyes. Many cases of eye strain can be relieved +by correction of the first, second or third dorsal, and the use of +glasses made unnecessary. + +Irritation of the eye will cause more or less tension of the muscles at +the second and third dorsal, and stimulation of the tissues near the +second and third dorsal spines will cause dilatation of the pupils and +contraction of vessels of the cranial mucous membranes; which means +vasomotor, secretory and trophic disturbances. + +It follows then that an =osteopathic lesion= at the second or third +dorsal will cause or tend to cause disease of the eye. There may be all +gradations in the effect produced, the lighter being mere tendency, +while again it may be enough to set up profound vasomotor, secretory +and trophic changes in and about the eye. The first effect of the +lesion may be stimulatory, and later, inhibitory. The normal resistance +of the eye would be lowered and naturally, local irritants, bacteria +and ametropia would have a more profound effect. This will explain how +one can develop conjunctivitis in the absence of a local irritant with +no bacteria present, and no eye strain. + +All of these causes, or any number of them, may be acting together, and +each more virulent because of the influence of the other. + +=Lesions= of the =occipito-atlantal= joint or any of the cervical +articulations may cause eye disturbance. There are no efferent +ramicommunicantes in that region and the course of the physical +disturbance must be greater in proportion to the eye trouble produced, +than at the upper dorsal. It is important however to make a close +examination of the entire cervical region in eye trouble. + +What has been said on the osteopathic causes of acute catarrhal +conjunctivitis applies with equal force to chronic and =follicular +concatarrhal conjunctivitis.= + +What has been said on the osteopathic causes of =acute= catarrhal +conjunctivitis applies with even greater force to the =chronic= +form. The great variety of local irritants may account for acute +conjunctivitis, and does in most instances; but in chronic +conjunctivitis local irritants are more often secondary or +incidental while the osteopathic lesion with its effect upon the +=bulbo-spino-sympathetic= ciliary arc is the =fundamental= cause. Of +course some continuous local irritant, e. g., an uncorrected refractive +error, excessive light, heat, dust or germ life in the environment may +cause a chronic conjunctivitis. Other causes may be retracted lids +(lagophthalmus) leaving the eyeballs too prominently exposed; turning +in of the cilia (entropion, trichiasis or dystrichiasis) which impinge +upon and irritate the bulbar conjunctiva. =Chronic blepharitis= may +spread to the palpebral conjunctiva and then the bulbar. Foreign +bodies in the eye, or infarction of Meibomian glands may be causes. +The diplobacillus (Morax-Axenfeld) is the most common germ in chronic +catarrhal conjunctivitis. + +=Symptoms and Course.=—In mild cases the redness is only moderate. +The conjunctiva is smooth and not swollen. Old cases have hypertrophy +with thickening. There was a small girl who came into the office +recently who had the conjunctiva of the lids decidedly swollen with +some hypertrophy. Her eyes were glued shut with pus every morning. Pus +pockets were forming along the follicles of the cilia and on the direct +edge of the lid. Her troubles started a year ago and got gradually +worse. A few osteopathic treatments were given during three months +(she was irregular in coming) and argyrol, 20%, used locally. All pus +and debris were cleared off the lids and conjunctiva each time. The +swelling all left and the thickening became inconsiderable; the eyes +looked almost clear. On pressure there was tenderness at the right side +of the second dorsal. No mechanical lesion was apparent there but in +treatment that region was thoroughly loosened. + +The subjective symptoms are usually worse at night; pain, heaviness of +the lids; feeling of a foreign body in the eye; burning; itching and +dryness in many cases. + +This condition is one of the most frequent of eye diseases in adults; +may be senile catarrh in advanced age. It is frequently complicated +with blepharitis, ectropion, epiphora and ulcerations of the cornea. + +=Treatment.=—The osteopathic treatment depends on the findings in the +osteopathic examination. No case of chronic catarrhal conjunctivitis +should be treated without a thorough examination of the whole spinal, +rib and innominate mechanism. Careful and detailed adjustment should be +made of any lesions that might disturb the ciliary arc, the other nerve +connections, the blood supply or the body equilibrium. + +This does not mean that local treatment of the eye should be neglected +in any way. Any measure that will aid in getting rid of local pathology +as quickly as possible should be ours. Where there is abundant +secretion, silver nitrate 1% to 2% solution put on the conjunctiva +with a brush when the lids are turned, or argyrol 20% to 25% dropped +into the eye are among the best antiseptics for local use. If the +diplobacillus is present zinc sulphate ½% solution is indicated. + +The nose, nasopharynx and pharynx should never be overlooked in this +disease. + + +Follicular Conjunctivitis + +=Follicular conjunctivitis= is of catarrhal origin. It is characterized +by the presence of follicles. There may be only a few or a great many. +If numerous they are often in rows on the palpebral conjunctiva. +Microscopically they show as circumscribed masses of adenoid tissue. In +this they resemble the granules of =trachoma=. Sometimes cases persist +for years with little or no inflammatory symptoms. On account of the +follicles this disease is frequently confused with trachoma. + +We have heard numbers of well meaning conscientious osteopathic +physicians testify to curing cases of trachoma with a short course of +osteopathic treatment with no pathology remaining. We are absolute +believers in the effectiveness of osteopathic treatment and want +to give it full credit for doing all it will; but here we want to +enter a plea to the profession that we need more discrimination and +definiteness in our diagnosis. Technique is being emphasized and we say +Amen! It is proper for us to be thoroughly competent in technique but +diagnosis should be made just as emphatic because scientific technique +depends upon diagnosis for each individual case. + +=Differentiation= of follicular conjunctivitis from trachoma. + +=Follicular conjunctivitis= occurs (1) chiefly in the young; (2) the +follicles are smaller, more sharply limited, project more above the +conjunctiva, are often in rows, and oval in shape; (3) the disease +clears up with no bad after effects often without any treatment and the +tendency is to ultimately get well; (4) it never leads to shrinking of +the conjunctiva, to pannus or other destructive sequelæ; (5) it can +arise without contagion and is not considered contagious although, like +trachoma, it does attack large numbers of people who are confined in a +small place. + +=Trachoma.=—(1) It seldom occurs in children; (2) the follicles are +larger, do not have sharp outlines, are less prominent under the +conjunctiva, are round in shape and never in rows; (3) tends to lead +to more or less pathology and seldom recovers spontaneously; (4) scar +tissue becomes a product of the inflammation in the conjunctiva and +leads to shrinking of the conjunctiva, causing in turn entropion and +trichiasis. Pannus is the sure result of unarrested cases as there is +a tendency to infection of the cornea from the infected conjunctiva +moving over it and remaining in contact; (5) trachoma has been proved +to be contagious. Trachoma bodies which are considered the infective +agent have been isolated. + +The use of atropine in some instances will cause a follicular catarrh +which clears up on stopping the use of the poison. + +Parinauds “Infectious conjunctivitis” has granulations but almost +always occurs in only one eye and is accompanied with constitutional +symptoms. + +=Treatment of Follicular Conjunctivitis.=—The treatment should be +directed against the inflammation. The trophicity of the nerve +terminals to the conjunctiva may be altered by osteopathic lesions. + +Suggestions under chronic catarrhal conjunctivitis apply here. If there +is no inflammation the follicles tend to disappear, leaving no trace +of pathology, hence a few osteopathic treatments of the lids and the +cervical region will hasten normalization. + + +Gonorrheal Conjunctivitis + +This disease is sometimes called =purulent ophthalmia= or =acute +blennorrhea=, It is caused from an infection of the conjunctival sac +with the gonococcus of Neisser. Contact with soiled fingers or linen +may transfer the germ. + +=Symptoms.=—Within 12-48 hours after inoculation the first symptoms of +redness and irritation occur. This is soon followed by much swelling +and tension of the lids and chemosis of the conjunctiva. There is much +pain and a copious discharge of pus coming from beneath the lids. At +first the pus is yellow or yellowish green. + +Later the symptoms begin to subside; there is less tenseness and heat; +the lids can be more readily everted and the discharge ceases after 6 +or 8 weeks. The puckered conjunctiva becomes rough and granular. + +In these cases the =prognosis= is always grave; more so than in +ophthalmia neonatorum. The eye is almost always marred in some way. +One of the great dangers is involvement and destruction of the cornea. +If the cornea becomes hazy soon after symptoms begin it is not a +good omen. =Ulcers= will likely form and then there is a tendency +to puncture the cornea. In mild cases the cornea may escape without +injury. In severe cases it is likely to ulcerate. If it perforates, +the anterior chamber is emptied and the iris prolapses into the +perforation; adhesions take place and there is healing with reformation +partially of the anterior chamber. An adherent leucoma is the result +with practical loss of vision. There may be a bulging of the cornea +known as anterior staphyloma. The iris and ciliary body may become +involved, causing iritis and cyclitis, or the whole inner structures +may be affected making a =panophthalmitis= with =atrophy= of the +eyeball. + +The cornea is affected by the infective material direct or the nutrient +vessels to the cornea at the limbus may be obstructed by the extreme +swelling and pressure. + +=Complications= of arthritis, rhinitis, septicemia and endocarditis +may arise. If there is none of these, at least there is a general +debilitated condition which needs attention. + +=Treatment.=—The treatment should be =local= and =constitutional=, +The diagnosis should be made quickly from the history, symptoms +microscopically, and local cleansing begun at once and followed +diligently. Excessive discharge should be wiped away with cotton. The +conjunctival sac should be thoroughly irrigated every hour or oftener +if necessary to keep it clean. This is to be done day and night. A +saturated solution of boric acid may be used, or corrosive sublimate +one grain to the pint, or permanganate of potassium solution 1-5000. +The irrigation should be followed by the free use of argyrol 25%. This +procedure will keep the eye clean and be the means often of saving the +cornea from destruction and the eye from blindness. + +If there should be ulceration of the cornea a drop of atropine ½% +should be used in the eye often enough to keep the pupil dilated and +the ciliary body at rest. + +Osteopathic physicians no less than other physicians should not +neglect this local, careful, persistent, antiseptic cleansing of the +eye in such cases. The osteopathist can do more. He is not limited +to antisepsis even in this kind of work, however important it might +be. The unaffected eye should be carefully protected. Buller’s shield +should be used. + +The osteopath should give thorough treatments to the neck and the fifth +nerve. + +Supporting treatment to the system according to indications should +be given e. g., bowels, kidneys, nerves, muscles, joints as in +constipation, nephritis, neurosis, rheumatism, arthritis, endocarditis, +septicemia, rhinitis etc. + + +Ophthalmia Neonatorum + +This is an =acute purulent conjunctivitis= in the new-born. Neonatorum +comes from a junction of the Greek word Neos—new, to the Latin word +natus—born; new-born. This disease is the bugbear to the obstetrician. +He must always be on the lookout for it and act promptly in order to +save sight. Every general practician should make a careful study of +this disease if he expects to treat children. + +Sixty to seventy percent of conjunctivitis neonatorum is due to the +infection with the gonococcus of Neisser. It usually comes from a +gonorrheal discharge from the genitals of the mother. The nurse or +anyone who handles the baby might be the agent in the transmission of +the infection. + +The disease is not always of gonorrheal origin. Some cases are due +to the pneumococcus, streptococcus, diplobacillus or one variety of +staphylococci. + +Thus there are two varieties or types of ophthalmia neonatorum; a +severe type which is =gonorrheal= or specific and a mild type which is +non-specific. + +In some states there is a law which requires the use of silver nitrate +in the eyes of all babies at birth. Every baby’s eyes should be +thoroughly washed at birth, with boric acid and where there is the +least suspicion of gonorrhea silver nitrate 1% or argyrol 25% should be +used. A routine use of one of the silver salts would be good practice. + +=Symptoms.=—Gonorrheal cases begin usually the third day after birth, +non-gonorrheal, on the fifth or sixth day. Both eyes are usually +involved, one worse than the other. The lids swell much. There is +chemosis of the conjunctiva which may put the cornea in a pit. The +discharge is abundant. It is yellow or greenish yellow. + +The disease gradually declines and the discharge ceases in six to eight +weeks. The conjunctiva is thickened and looks granular. May be some +cicatricial changes. + +The chief danger is to the cornea, more so if it becomes hazy the first +two days. Corneal lesions seldom occur in non-specific forms. + +If the cornea is involved perforation is likely, with a general +inflammation of the eyeball (panophthalmitis) followed by atrophy +(phthisis bulbi). + +Complications such as rhinitis, meningitis, endocarditis and general +septicemia may occur. + +=Diagnosis= is made from the onset, character, symptoms and course with +the use of the microscope. + +=Prognosis.=—Delayed or improper treatment in these cases will likely +be fatal to sight as sloughing of the cornea will occur. With prompt +and proper care the prognosis is favorable. + +=Treatment.=—Mild cases (non-specific) are treated in the same manner +as simple conjunctivitis. In severe cases (specific) clean the eye +carefully and apply cold compresses of gauze 15 to 20 minutes at a +time every hour or two. Keep the gauze on a block of ice and change +every few minutes. If the cornea is involved heat may prove more +satisfactory. There must be constant removal of the discharge. Wipe +away the excess and irrigate freely with boric acid at least every hour +day and night and more often if necessary. After each washing use a +solution of argyrol 25%. Once a day silver nitrate 1% solution may be +used and washed out with a salt solution. + +If the cornea should ulcerate the treatment need not be altered. + +The attendants should be carefully instructed as to the importance of +the care and the contagious nature of the pus. + +Antisepsis and cleanliness here is more essential, effective and +exclusive than in any other disease of the eye. Wisdom in the use of +antiseptics is a strong point in the armamentarium of every progressive +osteopath. + + +Trachoma + +This disease is known as =granular lids= or =granular conjunctivitis=. +Although the germ has not been discovered, we know this is an +infectious disease. A roughness and hypertrophy of the conjunctiva +develops. There is development of follicles or granulations. Later +these products are absorbed and cicatrization of the tissues follows. + +=Cause.=—Trachoma is found most common in Egypt and Arabia. It spreads +easily in crowded institutions. It is in many instances a mixed +infection with the Morax-Axenfeld bacillus, Koch-Weeks bacillus and the +gonococcus. + +=“Trachoma bodies”= have been discovered which are claimed by some to +be a causative factor in the disease. These small bodies are not found +in all cases however. + +Spinal lesions of the cervical and upper four thoracic vertebræ will +disturb the blood and nerve supply to the eye which will predispose to +the disease should some of the virus or germs of trachoma be present. +In practically all these cases there is tenderness if not an actual +twist at the second and third thoracic. + +=Symptoms.=—A small boy came to our clinics complaining that his +left eye was smaller than the right. No inflammation or swelling +was prominent. The eye looked normal except slightly smaller than +the right. On turning the lid granules in the fornix of that eye +were readily noticed. Trachoma had a good start. The tissues were so +hypertrophied in that region that the eye could not be opened quite +as wide as the other one, hence the impression that that eyeball was +smaller. The granulation often develops so insidiously that the victim +may have the disease for months before he realizes he has a bad eye. +When symptoms appear there may be photophobia, lachrymation, gluing of +the lids from a scanty secretion, pain, and blurring of vision. The +granules are gray, translucent and roundish under the conjunctiva. + +Hypertrophy increases to a certain height when cicatrization and +contraction begin. The duration may be years. The more the hypertrophy +the longer the duration and the greater the contraction. (Note here +that treatment should be directed toward combatting the hypertrophy by +establishing circulation). + +=Sequelæ.= I merely mention the sequelæ here: pannus, ulceration of the +cornea, trichiasis, dystrichiasis, entropion, ectropion, symblepharon, +xerosis, corneal opacities. For the explanation, pathology and +treatment of these sequelæ not covered in this treatise, see any good +works on diseases of the eye as Weeks, Fuchs or De Schweinitz. + +=Treatment of Trachoma.=—In reporting cases of trachoma treated and +cured by osteopathy we should be sure of our diagnosis. + +The treatment is antiseptic, hydrotherapeutical, osteopathic and +operative. A saturated solution of boric acid should be used. Argyrol +20% is good if there is much secretion. Nitrate of silver 2% and copper +sulphate are still used in some cases to advantage as claimed by some +physicians. The osteopath should count on careful cleanliness. + +Hot compresses over the eyes are often very agreeable. + +Operations are often performed for trachoma. The granules are rolled +out with Knapp’s roller forceps, and other methods. + +=Grattage= is practiced with some wonderful results. It is done as +follows: Get some fine sand paper and cut it in strips about one-half +inch wide by three or four inches long. Put it in alcohol in a vessel +for ten to fifteen minutes. Pour off all the alcohol except a few drops +that will cling to the vessel by capillary attraction. Touch a match +to the residue. This will burn just enough to make the sand paper +absolutely sterile without burning the latter. Put the patient under +somnoform. Use a small artery forceps to grasp the edge of the eyelid, +roll the lid back over the artery forceps to expose all granulations +clear to the fornix. Use a protector to the eyeball. Now with the +sandpaper quickly scrape or curette away all of the trachoma bodies and +granulations. Repeat the process on the other eye if it is involved. +Wash out well with a saturated solution of boric acid and bandage +the eyes for a few hours. This will cause considerable swelling and +inflammation. Use cold applications and keep the eyes disinfected. I +have seen some very good results from this method. + +=Osteopathic.=—Following the sand paper operation a thorough treatment +of the cervical and upper dorsal region would add considerably to the +rapidity of the patient’s recovery and sense of well being. General +tonic treatment is of special benefit in nearly all trachoma cases as +they are subnormal in their general health. + +One form of technique which has been used by myself and others +to advantage in these cases is as follows: Sterilize the fingers +carefully, lubricate with vaseline or K. Y. the forefinger of the +right hand. With the left hand raise the upper lid and introduce the +forefinger of the right hand with the thumb above. Catching the lid +between the thumb and finger squeeze and massage the whole structure +clear to the fornix as thoroughly as possible. Repeat the process on +the other eye. + +A technique used by Dr. Edwards of St. Louis is as follows: After +sterilizing and lubricating the forefinger lift the lid and introduce +the finger as far as possible into the orbit pushing the fornix back +into the orbit. This stretches all the tissues around the fornix, +opening up a better conjunctival and palpebral circulation. The +ciliary vessels and nerves are stretched and stimulated. It is rather +surprising to one who has not tried it, how far the finger can be +introduced into the orbit. + +One set of nerves that should be especially studied and considered in +trachomatous conditions is the cere-brobulbo-spino-sympathetic-ciliary +arc. This has already been elaborated. All spinal lesions should be +carefully diagnosed and corrected. + +Dr. T. J. Ruddy’s third finger eye instrument is very useful in these +conditions in restoring normal circulation about the orbit. + +See that the nose and throat are normal. + + +Phlyctenular Conjunctivitis + +By some this disease is considered an =eczema= of the conjunctiva. +This will at least enable us to get an idea of the conjunctival +pathology. What is said of phlyctenular conjunctivitis applies largely +to its corresponding disease of the =cornea-phlyctenular keratitis=. +Scrofulous ophthalmia is applied by some because so many of these +phlyctenular patients have =scrofula=. Herpes conjunctivæ is used as a +name because of the small blisters or blebs that form in the beginning +stage. Little red eminences develop near the limbus (sclerocorneal +junction). They are cone shaped, slightly elevated about the +surrounding tissue. There may be one or several, usually not more than +one or two. After a few days the cone breaks and on top appears a small +gray ulcer. There is further breaking down and the cone disappears +leaving an ulcer on level with the conjunctiva. Vessels are congested +about it. There may often be noted an area of small vessels, fan like +in shape, running from the outer region of the conjunctiva to the ulcer +or phlyctenule. + +=Etiology.=—This is a disease of frequent occurrence in children, +mostly among the poor classes. Such things as eczema, dirt, adenoids, +scrofula, rhinitis, malnutrition, abuse of tea and coffee and +exanthematous disease are mentioned by oculists as causes. I have +no doubt any or all these conditions predispose to phlyctenular +conjunctivitis. + +De Schweinitz in “Diseases of the Eye,” 1916 edition, p. 242, says: +“The exact cause of ocular lesions, or phlyctenular eruption, has not +been determined.” + +I have met Dr. De Schweinitz and heard him lecture on the eye. I +consider him one of the best eye specialists in the country. His +experience and study with the eye dates over many years and his book +has gone through eight editions. He is professor of ophthalmology in +the University of Pennsylvania; Ophthalmic Surgeon to the Philadelphia +Polyclinic Hospital, the Philadelphia General Hospital etc., etc. + +His opinion represents the summary of the investigation of the +ophthalmic profession the world over and through all the past down to +the present time. “The cause of phlyctenular conjunctivitis is not +known.” + +=Bacteriology.=—At times in the ulcers have been found the +staphylococcus pyogenes aureus and albus. They are also found in a +normal conjunctival sac. They could not with logic be taken as a +causative factor; at least they would be only secondary. + +If oculists and other students of the eye all had a good deep +osteopathic vision to throw light upon these problems many causative +factors would take on a new meaning. Such supposed causes as have +been mentioned, e. g. eczema, adenoids, rhinitis and malnutrition may +easily be secondary to the osteopathic lesions. Micro-organisms may be +enabled to act because of trophic and circulatory disturbances to the +conjunctiva through disturbed nerve connections from lesions in the +cervical and upper dorsal regions. Herpes zoster is purely a trophic +nerve disturbance manifestation on the skin as blebs or blisters with +more or less neuritis. Any lesion that would affect the integrity of +the function of the fifth cranial nerve might easily manifest itself as +herpes of the conjunctiva. + +We believe the osteopathic lesion is primary and fundamental in the +causation of most of our phlyctenular conjunctivitis. Of course +insanitation, scrofulous diathesis and the exanthemata play their role. +A good diagnostician should figure out the relative importance. The +history, onset and examination will usually eliminate these conditions. + +=Symptoms.=—Lachrymation, photophobia, blepharospasm and injected +vessels are the chief symptoms. There is pain as well as fear of light. +The child fights examination. + +The attack subsides in ten to fourteen days unless there is +multiplicity of blebs. Some patients have repeated attacks for months +or years. Many of these cases in medical clinics keep coming for months +with repeated attacks. Never leave out careful osteopathic treatment. + +=Prognosis.=—This is favorable for a final cure. If there should be +multiple blebs and frequent recurrence and the cornea is invaded, +the prognosis is not good for perfect sight. The pathology goes deep +enough to affect Bowman’s membrane of the cornea disturbing the +substantia propria. This causes a macular condition of the cornea which +impairs sight. + +=Therapy.=—Diet should be bland; the eyes should be protected from +irritants; yellow oxide ointment should be used in the eye once a day +or 10% argyrol. The ointment is preferred. Moist warm compresses on +the eye are comforting. A boric acid wash in almost all conjunctival +trouble is good. If there is much irritation giving a suspicion of iris +involvement a drop of atropine ½% should be used. The general regimes +of living should be regulated. + +Osteopathic treatment should be directed toward building up the general +health and correcting all lesions, especially that may have a specific +bearing on the eye trouble. Such lesions will be found more often at +the first, second and third thoracic, but may be anywhere from there to +the occiput. + + +Vernal Conjunctivitis + +This disease is known by many as =vernal catarrh= or =spring catarrh= +of the conjunctiva. It is a chronic inflammation which sets up changes +in the conjunctiva and tarsus. This disease may be confused with +trachoma unless one observes closely. There are broad flat papillæ on +the conjunctiva. These papillæ may readily be taken for granulations. +They are larger than the granules in trachoma. They somewhat resemble +the arrangement of cobble stones. The conjunctiva has a bluish-white +filmy appearance called by some, milky shimmer. + +The disease was thought at first to appear only in the spring, +hence the name vernal. Many cases continue through the year with +exacerbations in the spring. It occurs more often in boys. Both eyes +are attacked. It may heal and leave no trace. It may last from four to +twenty years. + +=Causes.=—Almost all works on the eye say the cause is not known. De +Schweinitz says, “Definite information in regard to the cause of this +disease is lacking.” There may be a micro-organism which has not been +discovered. + +I wish to call the attention of the osteopathic profession to the great +fact that there are numbers of diseases of the eye as well as of other +parts of the body about which the medical profession are entirely +“at sea.” This gives valuable ground for scientific research by our +profession. + +My experience with this disease is not sufficient for me to speak with +any positiveness or finality as to its cause. The altered trophic +parts and the very chronic condition existing leads me to the firm +belief that we will ultimately find the cause as a mechanical lesion +affecting the trigeminal or sympathetic (or both) nerve connections. +Glare of light and local irritants act only as secondary causes. Nasal +disease may be associated and act as a cause. + +=Symptoms.=—There is photophobia, some mucus, slight pericorneal +injection, redness of the conjunctiva of both the bulb and lids; that +of the lids is thickened and of dull pale color due to sub-epithelial +hyaline thickening. The fact that there is no pannus, and flat +granulations and recurrence with spring, marks it from trachoma. + +=Prognosis.=—Under medical treatment it is unfavorable; may last twenty +years. Slight opacity of the cornea may develop. + +=Treatment.=—The eyes should be protected with dark glasses. Cold +compresses give some relief. Boric acid is good as a wash. Yellow oxide +of mercury ointment may be of service as an antiseptic and alternative. +If nasal disease exists, it, of course, should be treated according to +indications. Fundamentally the lesions in the spine in the cervical +and upper dorsal regions should be specifically corrected. When enough +cases of vernal catarrh have been observed and treated osteopathically +much light and benefit will be brought to bear upon this obscure and +intractable disease of the conjunctiva. + + +Diseases of the Cornea + +Anatomy + +The cornea with the sclera forms the outer coat or tunic of the eye +ball. The cornea is in front and forms one-sixth of the envelope. +It is a segment of a smaller globe than that of the sclera. It is +about 12 mm. horizontally and 11 mm. in the vertical diameter. Its +thickest part is at its junction with the sclera where it is about +1 mm. This junction is called the limbus. The cornea is inserted +into and rests on the sclera like a watch crystal. The fibers of the +cornea pass continuously into the sclera, however. The normal cornea +is transparent. Most morbid changes of the cornea cause a diminution +in this transparency. In old age a narrow gray line near the corneal +margin makes its appearance. This is known as the =arcus senilis=. +There is a little strip of perfectly clear cornea between the arcus +senilis and the limbus. + +The cornea has five layers. These layers should be noted with care, as +in wounds of the eye, foreign bodies in the cornea and ulcerations, the +results depend much upon which layers are affected. + +1. The =anterior epithelium= consists of pavement cells of several +layers. This layer of the cornea may be damaged or scratched off in +large patches and still it will heal readily leaving no trace of the +injury. + +2. The =anterior elastic lamina= or =Bowman’s membrane= is very thin +and homogeneous; it is just beneath the epithelial layer and forms a +resisting sheath to prevent damage to the next layer. + +3. The =stroma= or =substantia propria=. This layer composes about +nine-tenths of the cornea. It is composed of minute connective tissue +fibers between which lie some stroma cells or corneal corpuscles. Some +of these cells are fixed while others are motile. The motile ones are +the white blood-corpuscles which move about in the lymph passages of +the stroma. They increase in any irritation of the cornea. + +4. =Descemet’s membrane.= This is a tough homogeneous hyaloid membrane +back of the stroma. When the stroma is diseased and breaks down +Descemet’s membrane may be sufficient to prevent a puncture of the +cornea. + +5. The =Endothelial layer= is a single layer of flattened cells which +coat the posterior surface of Descemet’s membrane. + +The margin of the cornea is in relation with three membranes, the +conjunctiva, the sclera and the uvea (iris and ciliary body). In a +disease of the cornea, a conjunctivitis, an iritis or a cyclitis is +easily started. + +The cornea contains no vessels. It is nourished by imbibition. At +the limbus there is a rich network of marginal loops supplied by the +anterior ciliary vessels. From these loops the blood plasma passes into +the stroma of the cornea. + +The nerves of the cornea come from the ciliary nerves and the nerves +of the bulbar conjunctiva. These are from the trigeminus and the +sympathetic. The nerves extend numerously in the stroma passing forward +through Bowman’s membrane into the epithelial layer. This makes the +cornea very sensitive to the touch. + + +Examination of the Cornea + +Note the size and form. Both may be modified by morbid processes. Note +the surface with regard to curvature, evenness and smoothness. In +=keratoconus= the curvature is greatly increased. Noting the reflex +images in the cornea and comparing these with those of a normal cornea +will show any variation in curvature. Also any =unevenness of the +surface= may be noted by the irregularity or distortion of the images. +Uneven spots on the cornea may be =depressions or elevations= from loss +of substance; =wrinkles or collapse= from lowered tension. + +If the smoothness or polish of the cornea is lost it looks like glass +that has been breathed upon or greased. It is lusterless and dull. + +Note also the transparency of the cornea and determine the form, extent +and density of the opacity; whether it is diffuse or in spots; in the +deep or superficial layers. A magnifying glass should be used in the +study of opacities. According to the density of the opacity of the +cornea it is known as a =nebula= or a =nebulous opacity=, a =macula= +or a =leucoma.= The nebula is the least noticeable and the leucoma is +the densest opacity. A leucoma is a condition of complete opacity. The +cornea looks white. + +Defects in the corneal epithelium may be made to show clearly by the +use of a 2% solution of fluorescein which stains them green. + +Note the sensitiveness of the cornea by touching it with the end of +a thread, a little cotton or a shred of paper. The sensitiveness is +diminished or lost in glaucoma and some other diseases. + + +Diseases of the Cornea + +Almost all diseases of the cornea have some form or degree of +inflammation. =Keratitis= is the word generally used for inflammation +of the cornea. In order to aid clearness in discussion there are +various subdivisions of keratitis made by different writers. +Suppurative and non-suppurative are the principal types. In +=suppurative keratitis= there is always some destruction of corneal +tissue which on healing leaves an opacity with partial loss of vision. +Germs gain entrance into the tissues usually from the exterior and some +form of ulceration results. + +The following classification is taken from Fuchs: + +=Suppurative Keratitis.=—(1) Ulcer of the cornea; (2) Serpiginous +ulcer; (3) Keratomalacia or Xerosis; (4) Keratitis neuroparalytica. + +=Non-suppurative Keratitis.=—(A) SUPERFICIAL: (1) Pannus, or keratitis +with blood vessels; (2) Phlyctenular, or keratitis with vesicles. (B) +DEEP: (1) Parenchymatous or interstitial. + +In keratitis there is first an infiltration or the increase of cells +in the substantia propria or the parenchyma of the cornea. This is +the exudate of the inflammation. It causes the cornea to look more +or less dull or cloudy. The disease may clear up at this point or +go on to suppuration. If it clears up it is known as =resorption=. +If the lamellæ of the substantia propria are not destroyed by the +process, resorption takes place with no loss of substance. The exudate +disappears and there is perfect transparency of the cornea again. There +may be slight damage of the stroma preventing perfect transparency. +Resorption of the exudate may not be quite complete which may +become partly organized and left permanently fixed in the cornea. +Cases resorbing without destruction of the stroma are forms of the +non-suppurative keratitis group. + +If the stroma breaks, suppuration occurs. This is the second stage and +is associated with a localized destruction of the cornea. These cases +are known as =suppurative keratitis= or =ulceration of the cornea=. +The disintegration begins in the most anterior layers of the cornea. +A slight depression in the cornea can be noticed. The infiltration is +all about the ulcer, getting less as it is more remote from it. If the +floor and walls of the ulcer are foul with the infiltrate it is known +as a =progressive= ulcer. =Sloughing= may continue to spread the ulcer. + +If the cloudiness around it disappears and the ulcer acquires a smooth +transparent base and edges it is known as a =retrogressive= or clean +ulcer. + +The disintegrated areas of the cornea may be replaced by newly formed +tissue. This is the third stage or that of =cicatrization=. This new +tissue is connective tissue. It is opaque, leaving a permanent opacity. + +=Stages of keratitis=: + +=Suppurative.=—(1) Infiltration; (2) Suppuration and (3) Cicatrization +or Reparation. The suppuration is progressive or retrogressive. + +=Non-suppurative.=—(1) Infiltration; (2) Resorption. + +In the diagnosis of a keratitis one should look at it very carefully. A +loupe which has thick plus sphere lenses will magnify the field and may +be of great assistance in observing closely the condition. + +If the cornea is clouded and dull the trouble is recent and if there +is no loss of substance it is an infiltrate (first stage). If there is +loss of substance it is a progressive ulcer (second stage.) + +If the surface is lustrous but cloudy the trouble is an old one and if +there is loss of substance it is a retrogressive ulcer; if no loss of +substance it is a cicatrix. + +Frequently blood vessels grow in from the margin in ulcerations of the +cornea. This is usually a process of healing of the corneal ulcer. +The advent of the blood vessels is favorable. After healing the blood +vessels gradually disappear. They never entirely disappear from large +cicatrices. + +In some cases new vessels accompany the inflammatory process and like +the exudate are a part of the clinical picture of the disease as in +parenchymatous or interstitial keratitis. Pannus also has vessels. They +are not in the cornea but are in new tissue deposited upon it. + +=Symptoms appearing in keratitis=: + +1. =Ciliary injection= or a red area encircling the cornea. If the +keratitis is severe there will be considerable inflammation of the +conjunctiva which may hide to some extent the ciliary injection. + +2. =Iritis or iridocyclitis= may set in. The iris and ciliary body are +in such intimate relation with the cornea that these structures are +very subject to involvement in any severe keratitis. With iritis would +come danger of =synechiae= or adherence of the iris to the anterior +surface of the lens. + +3. =Hypopyon.=—In suppurative keratitis there is some exudate into the +anterior chamber of the eye. This exudate drops to the bottom of the +chamber and looks like pus had gathered in the bottom of the aqueous. +This condition is called hypopyon. + +4. Other symptoms which are frequently prominent are =diminished +vision=, =pain=, =photophobia=, excessive =lachrymation= and +=blepharospasm=. Edema of the lids and conjunctiva may occur. + +Intelligent treatment of keratitis of course is based upon the exact +conditions present. Great care in diagnosis and treatment should be +exercised. + + +Ulcer of the Cornea + +Inflammation of the cornea sets in from some cause. There is an +infiltrate into the substantia propria. A spot becomes cloudy and the +surface over it becomes dull; at this point the epithelium breaks +down or exfoliates and the loss of substance in the parenchyma is the +beginning of an ulcer. + +=Cause.=—The cause may be constitutional or local. The causes usually +thought of from the medical standpoint may be noted in such books as +“Diseases of the Eye” by De Schweinitz or Weeks. I wish especially +to call attention to the fact that there is frequently a primary and +underlying cause of corneal ulcers not mentioned in any medical texts, +i. e. the osteopathic lesion. By this I mean more than the spinal +lesion although the subluxation lesions that result from the occiput +to the fourth dorsal are of most importance. Any tension or change of +tissue in the cervical region that may interfere with perfect freedom +of circulation of blood to the tracts and centers in the cord, is to be +considered. The osteopath of course should take into consideration all +causes primary and secondary and govern himself accordingly. + +=Symptoms and Course.=—There is a gray area surrounding the ulcer +at first, also the floor is grayish in color. In this condition it +is known as a =progressive= ulcer or a =foul= or =unclean= ulcer. +This cloudiness or gray area may increase in size and the ulcer keep +spreading, or it may go deeper even to perforation of the cornea. + +Some ulcers advance or spread on one side and heal on the opposite +side so that they creep along on the cornea—these are the so-called +=serpiginous ulcers=. + +With corneal ulcers there is irritation, pain, photophobia and +increased lachrymation. There is usually some ciliary injection which +is an indication of involvement of the iris and ciliary body. If +iritis occurs there is contraction of the pupil with slow reaction. +=Hypopyon= may develop. With iritis and the exudate there is likely to +be adhesions between the iris and the lens known as posterior synechia. + +A few corneal ulcers are asthenic and do not have irritative symptoms +and yet are dangerous. + +When the ulcer begins to heal it is called =retrogressive=. Dead +tissue is cast off; other tissue becomes transparent from resorption. +We have a =clean= ulcer. Symptoms disappear and cicatrization begins. +Vessels extend to the ulcers and soon it is leveled up with the corneal +surface. Cicatrization may leave it slightly below the corneal level or +above it. + +If there should be perforation of the cornea from the ulcer there may +be =complications=, e. g. keratocele, loss of aqueous, dislocation +and expulsion of the lens, intra-ocular hemorrhage, flattening of the +cornea, fistula of the cornea, glaucoma, intra-ocular suppuration, +prolapse of the iris into the opening, etc. These complications and +sequelæ that occur occasionally will not be considered here. + +After healing is complete by cicatrization there is opacity of the +cornea in proportion to the depth and size of the ulcer. In months +and years of time there is some clearing of the opacity so that small +superficial opacities may become invisible. + +=Treatment of Corneal Ulcers.=—Most ulcers of the cornea are quite +amenable to proper treatment and the prognosis is favorable. Neglect +or wrong treatment is very dangerous. The treatment is local and +constitutional. Often the ulcer is kept going by unwholesome +constitutional conditions. + +=Local Treatment.=—This varies according to the stage of the ulcer, +whether progressive or retrogressive. In a progressive or foul ulcer if +due to trauma any foreign bodies should be removed. If the ulcer is a +result of pathology of the conjunctiva it is of primary importance to +treat the conjunctival condition. + +In mild cases of ulcer a dressing over the eye with atropine ½% to keep +the pupil dilated is sufficient local treatment. The bandage protects +the eye from bright light and other environment and the atropine puts +the iris and ciliary body at rest preventing complications and giving +nature her best chance to work. + +If the ulcer is rapidly progressive, warm compresses an hour or two a +day are good; iodoform sprinkled on the ulcer or actual cautery may be +used. In the retrogressive stage (clean ulcer) healing has begun and +we desire to get as near as possible a resistant transparent cicatrix. +Yellow oxide ointment is useful at this stage. + +=Osteopathic.=—The local measures just mentioned are not incompatible +with osteopathic theory or practice. They are merely adjunctive in +getting nature’s reaction toward normalization, as also are hot and +cold applications. Osteopathy comes in now in a most important and +fundamental way with the constitutional and specific lesion treatment. +The =bulbo-spino-sympathetic-ciliary arc= has been mentioned and +explained. Through this important nerve connection with the eye, +profound and wholesome effects on the eye may be gotten by osteopathic +treatment. Frequently lesions of the occiput, cervicals and upper +dorsals will affect the integrity of the ocular structures through +disturbances of nerve and blood supply. + +The stomach, bowels, liver and kidneys should be carefully noted +in corneal ulcers. Poor circulation, indigestion, constipation and +auto-intoxication may have an important bearing on the recovery of the +ulcer. + + +Xerosis or Keratomalacia + +This is a disease of the eye in children due to insufficient nutrition +of the cornea. Hereditary influences, depleting diseases and lesions +affecting the trophic nerves to the eye are causes. + +=Treatment= consists of building up the nourishment of the child, +correction of lesions and careful dieting. Hot applications to the +palpebral region helps to bring the blood supply to the eye for local +effects. + + +Keratitis Neuroparalytica + +This disease is due to a paralysis of the 5th cranial nerve. The cornea +becomes slightly cloudy. The epithelium gradually sloughs away. An +ulcer may or may not form. Pain and lachrymation are absent because of +paralysis of the trigeminus. There is usually ciliary injection. + +=Treatment.=—The most important treatment for this unfortunate +condition is manipulation to restore the integrity of the 5th cranial +nerve and the blood supply to the eye. Cervical, spinal, nasal, +nasopharynx treatment should be given. Spring the inferior maxilla. + +A drop of atropine (1%) should be used locally because of the ciliary +injection. Warm compresses used locally will help. The healing usually +leaves some opacity of the cornea. Keep the eye bandaged to protect the +cornea. + + +Pannus + +This form of keratitis is superficial and is characterized by the +formation of blood vessels in the cornea. It is caused by some +irritative influence. Most often it is a complication of trachoma. + +If the irritation can be removed the vascularity gradually recedes, +leaving a clear cornea unless the deeper structures of the cornea have +been involved. + + +Phlyctenular Keratitis + +This disease is an involvement of the cornea with an eczematous process +similar to phlyctenular conjunctivitis. There is more likely to be +ciliary injection and iritis, in which case atropine should be used. +The treatment is the same otherwise as for phlyctenular conjunctivitis. + + +Parenchymatous or Interstitial Keratitis + +This is shown by a diffuse inflammatory infiltration of the substantia +propria of the cornea. Part or whole of the cornea of one or both eyes +may be involved. Very fine blood vessels may invade the deep structures +of the cornea. + +=Cause.=—Syphilis, tuberculosis, rheumatism, diabetes and rachitis are +systemic diseases found back of this trouble. + +=Symptoms.=—Irritation, lachrymation, photophobia with ciliary +injection are the chief symptoms. + +=Treatment= must be local and constitutional. + +Locally atropine should be used. Dark glasses should be worn or the +patient must be kept in a dark room. Treatment to the trigeminal nerve +and tissues of the orbit should be given. + +Constitutional treatment should be spinal with the idea of arousing all +the forces of the body to greater activity. Careful dieting should be +followed according to indications. + +The infiltration and blood vessels will ultimately disappear. Sometimes +enough may remain to cloud the vision. + + +Diseases of the Iris and Ciliary Body + +The iris and ciliary body have the same blood and nerve supply. That +is, they are supplied by the same set of vessels and nerves. For this +reason it is practically impossible to have an iritis absolutely +independent of a cyclitis or some inflammation of the ciliary body. If +the iris is the primary seat of the trouble there are certain symptoms +that may indicate such a state. However, when we are treating the iris +or diagnosing conditions of the iris we must remember that the ciliary +body is very likely more or less involved and may be the primary seat +of the trouble. + +In =iritis= there are some symptoms which are caused from the +hyperemic condition of the eye, such as a slight change in color. The +pupil becomes rather inactive, there is some ciliary injection with +photophobia, lacrymation and pain. In case of an exudate in the iris +there may be thickening, and the exudate in the anterior chamber of the +eye will form a =hypopyon=. Sometimes the small vessels will break and +there will be a little bleeding which will be mixed with the debris in +the bottom of the anterior chamber. This is known as hyphemia. There +are likely to be adhesions between the iris and the anterior capsule +of the lens known as posterior =synechia=. The pupil is more or less +irregular. If atropine is dropped into the eye to dilate the pupil, +parts of the edge of the pupil will be adhered while the other parts +dilate making it very irregular. + +In case of cyclitis there is an exudate from the ciliary body into +the posterior chamber. This may cause a total adherence of the iris +to the crystalline lens. With the ophthalmoscope, opacities in the +vitreous may be noticed. These are exudates. The tension of the eye is +liable to increase a little at first but as the exudates absorb there +is more or less softening. Vision is low. Also in cyclitis there is +ciliary injection, photophobia, lacrymation and pain, similar to that +of iritis. Pressure on the eye ball will reveal a very tender condition +around the sclerocorneal junction or over the area of ciliary injection. + +The causes of iritis, cyclitis or iridocyclitis frequently are systemic +conditions and infection such as syphilis, rheumatism, gonorrhea, +tuberculosis, infectious diseases and metabolic changes, it may be of +traumatic origin or sympathetic. Fuchs says “There are many cases of +iritis for which no cause can be discovered and therefore which cannot +be placed under these causes.” We agree with him and advance the theory +of cervical and upper dorsal lesions or trouble in the sinuses, nose, +nasopharynx or throat. No doubt osteopathy can throw some important +light on the causes of diseases of the iris and ciliary body. The nose +and throat should be examined in all these cases. + +=Treatment.=—Atropine must be used in the sore eye to put the iris +and ciliary body at rest and dilate the pupil to draw it back from +the lens so that adhesions may not form. Warm compresses will give +much comfort. Sweating should be brought about. All fluid should be +reduced to a minimum. Diet should be very moderate and the bowels kept +unusually free. The eye should be protected by dark goggles. Thorough +treatment of the neck and upper dorsal region with attention to the +nose and throat should be given. Constitutional treatment should be +given according to the indications mentioned under causes. If annular +synechia or total posterior synechia form or there is atrophy of the +eyeball operative work may be needed. Also for injuries, tumors, +anomalies and so forth of the iris see the latest medical works on this +subject. + + +Diseases of the Choroid + +The =choroid= is the vascular tunic of the eye. With the iris and +ciliary body it forms the =uvea=. The iris and ciliary body are rich +in nerve terminals and when inflamed; pain is a prominent symptom. The +choroid has no sensory nerve terminals. When it is involved alone; pain +is not present however severe the pathology. Embryologically Descemet’s +membrane is a part of the uvea. When the uveal tract is diseased we +frequently note symptoms of a descemetitis as a turbidity of the +anterior chamber and spots on Descemet’s membrane. When one part of the +uvea is inflamed the tendency is to pass to the other parts because of +the intimate blood supply. + + +Choroiditis + +There are many forms of choroiditis given by writers according to the +clinical picture and the pathology. + +=Symptoms.=—No pain is experienced unless there are complications. +Vision is altered in some degree. The use of the ophthalmoscope may +reveal opacities in the vitreous. Pigmentation spots and exudation may +be noted in the fundus. In disseminated choroiditis spots of exudate +appear in the fundus which go on to atrophy, leaving irregular circular +light patches. + +=Treatment.=—In all forms of choroiditis careful diagnosis of +constitutional conditions should be made and treatment given according +to indications. + +Nasopharynx and orbital treatment as outlined under manipulation for +diseases of the eye should be given. + +Rest and protect the eyes. Secure free elimination. + + +Panophthalmitis + +By injury or otherwise pathogenic germs are introduced into the eye. +The trouble begins as a =suppurative choroiditis= and rapidly spreads +to all the eye structures. The vitreous chamber becomes filled with pus. + +=Symptoms.=—Pain is severe and sight is lost early. The conjunctiva +and lids are much swollen. There is a mucopurulent discharge. The +cornea becomes gray and may slough. In about two weeks the inflammation +subsides and the globe passes into atrophy. + +=Treatment.=—Elimination must be thorough. Spinal treatment for keeping +up strength. Cervical, upper dorsal and nasopharynx treatment for the +eye. Moist hot compresses to the eye. Operation, incision for drainage, +or evisceration may have to be performed. + + +Sympathetic Ophthalmia + +The other eye may become inflamed by the process from the +panophthalmitis passing around through the circulation or the +continuous structures. All symptoms of a general inflammation appear +and vision gradually diminishes. + +=Treatment.=—In panophthalmitis of one eye always watch the other eye +closely. If it becomes irritable or shows any signs of being affected +the diseased eye should be promptly removed, especially if vision is +lost in that eye. If no irritation occurs, continued conservative +treatment of the panophthalmitis may result in a subsidence of the +disease without the well eye becoming affected. + +Sympathetic inflammation rarely develops earlier than a month after +injury to the exciting eye. Sooner than that or even a few minutes +after injury there may be some signs of sympathetic irritation and +the symptoms continue with no evidence except a slight circumcorneal +injection. It should be treated like iritis. A thorough toning of the +system by spinal treatment should be given. Order a limited diet. +Secure free elimination. + + +Glaucoma + +Glaucoma is essentially an increase in the intra-ocular pressure. All +other symptoms of the trouble may be traced to this condition. + +In =Primary Glaucoma= the increase in pressure sets in without any +discoverable antecedent disease of the eye. + +In =Secondary Glaucoma= the increase in pressure is due to some other +disease of the eye. It is a symptom, a complication or accessory and is +confined to the eye diseased. + +Primary glaucoma affects both eyes, but not always at the same time. +Fuchs says primary glaucoma constitutes about 1% of all eye diseases. +It is often mistaken for iritis or iridocyclitis and treated with +atropine which is contraindicated. It may be regarded as beginning +cataract and time lost in expecting it to become ripe. These delays and +wrong treatment have caused much blindness. + +Palpation with the finger or the use of the tonometer may readily +detect any increase in tension. A correct diagnosis must be made early +and proper treatment instituted if vision is to be saved. + +=Primary glaucoma= may or may not have signs of inflammation. If the +tension rises suddenly inflammatory symptoms develop (acute) while if +the increase in tension develops gradually these symptoms are lacking +(simple). + +=Acute primary glaucoma—Symptoms.=—First stage, rise in tension, vision +obscured, sees a colored ring around lights, cornea dull, pupil dilated +and sluggish, some ciliary injection. The attack may clear up for a day +or for weeks. Gradually the symptoms become permanent after repeated +attacks. Second stage, when the attack comes there is much pain, visual +power fails rapidly, may be edema of the lids and chemosis of the +conjunctiva, all symptoms become much exaggerated, the cornea becomes +cloudy. After a violent attack the vision is more or less permanently +damaged. Third stage, after many attacks the optic nerve becomes +excavated and atrophy takes place. + + +Simple Primary Glaucoma + +=Symptoms.=—Tension comes gradually; no inflammatory signs; pupil +somewhat dilated and sluggish, the cornea may look slightly smoky. +With the ophthalmoscope a cupped disc may be noted. There is gradual +diminution of sight, which begins by contraction of the field. + +There are many theories advanced as to the cause of intra-ocular +tension in glaucoma. (Fuchs, Weeks, De Schweinitz). + +=Treatment.=—Eserine is used instead of atropine. The object is to +contract the pupil and draw it away from the side wall of the eye +ball so the sinus (Schlemm’s canal) and the pectinate ligament (the +filtering angle) may become free. The good effect of this is more +marked in inflammatory glaucoma. In simple primary glaucoma miotics do +little good. + +Reports from osteopathic treatment of this condition have been +favorable in a number of cases. Careful manipulation of the structures +of the orbit with the finger or with Dr. Ruddy’s third finger eye +instrument is good in restoring better circulation of the lymph and +blood. Special attention to the venous drainage should be given. Treat +the points of the fifth nerve, the nasopharynx and cervical region, +spring the jaw. Treat second dorsal. + +Have the patient avoid strong emotions or excitement. Keep the bowels +free and use only a very bland diet. + +Iridectomy is considered the best operation in glaucoma. + +In the treatment of secondary glaucoma the other diseases or +complications must be considered in conjunction with the foregoing +treatment. + + +Diseases of the Lens + + +Opacities or Cataract + +=Symptoms.=—Beginning opacities can best be recognized with the +ophthalmoscope. Advance opacities can be seen at a glance with the +naked eye. + +Vision is disturbed according to degree and location of the opacity. +If the opacity is in the center of the lens and the periphery is +transparent they see better when the pupil is dilated. When the +opacities are in the periphery of the lens they see better by day. +Muscæ volitantes and polyopia are present until increasing opacity +closes up all clear areas shutting out these visual perversions. + +There are many clinical varieties of cataracts which may be studied in +works on ophthalmology. + +=Causes.=—Some interference with the nutrition of the lens accounts +for the condition. Heredity is supposed to play a part in some +cataracts. Rickets, convulsions, traumatism, old age, some drugs +(ergot), inflammation of iris, ciliary body and choroid are given +as causes. Cervical and upper dorsal lesions and disease of the +throat, nasopharynx and nose will interfere with perfect circulation +and drainage of the orbit, and may well have much to do with many +idiopathic cataracts. + +=Treatment.=—Many cases have been reported cured by osteopathic +measures. Correct lesions and treat to establish free nerve force +and circulation of blood and lymph to the orbit. Manipulation of the +orbital tissues and mild vibration of the bulb are measures of value. +More hope may be held in symptomatic, toxic, secondary and progressive +cataracts. The process may be stopped and in many cases there is hope +of a clearing. + + +Diseases of the Retina + +The retina lines the back part of the eye ball. It comes forward to the +ora serrata. It consists of ten layers which have been demonstrated +microscopically. One layer of it passes over the ciliary body and back +part of the iris to the pupil. The fibers of the optic nerve spread +out over the retina. The point of entrance of the optic nerve is the +papilla. It is to the inner side of the posterior pole of the eye. The +retinal vessels emanate there. The macula lutea is the yellow sensitive +spot at the posterior pole of the eye. The fovea is the center of +the macula. The rods and cones constitute the external layer of the +retina. This layer is the light perceiving stratum. For vision to be +perfect all the other layers must be perfectly transparent. The visual +purple is a chemical substance in the rods that gives the retina a +purplish-red color. The light shining into the eye forms images which +are converted into nervous stimuli by chemical action of the visual +purple and by physical changes and fibrillations in the rods and cones. + + +Retinitis + +=Symptoms.=—The ophthalmoscope must be used in diagnosis. There is at +first cloudiness of the retina; the outlines of the papilla become +indistinct. We may note light patches of exudates. The vessels are +more tortuous and often there are hemorrhagic spots. Opacities in +the vitreous due to the exudate may be seen. Vision is disturbed in +proportion to the inflammation. Weeks or months are required for +recovery. Atrophy may set in and cause blindness. + +=Cause.=—Many general diseases are found back of this trouble, e. g. +albuminuria, diabetes, leukemia, syphilis, gout and arteriosclerosis. +Idiopathic cases occur with none of these diseases present, which gives +a field for osteopathic research. + +=Treatment= should be directed against the general disease when +present. For local effects treatment should be given to all the centers +and localities that affect the trophism, nerve supply and circulation +to the eye. Protect the eye by dark glass or confinement to a dark room +and complete rest. Keep the bowels free and produce diaphoresis. + + +Optic Neuritis + +This disease when manifest in the eye ball is called papillitis. If +back of the bulb it is =retrobulbar neuritis=. + +=Symptoms of papillitis.=—Pupils are dilated and sight diminishes. The +color of the papilla is altered to a white, reddish or gray and may +show extravasation of blood. The papilla is swollen (choked disc), the +arteries are thin and the veins are engorged. It takes months for the +inflammation to clear. Atrophy is likely to occur. + +=Causes.=—Brain diseases are the most frequent cause, e. g. tumors. +Syphilis, febrile diseases, nutritive disturbances, lead poisoning, +heredity and growths in the orbit are cited as causes. + +=Symptoms of Retrobulbar Neuritis.=—There is little or no change in +the papilla. The diagnosis must be made mostly from the way the vision +is affected. The rule is a central scotoma in the field of vision. The +first colors to disappear are red and green. In the acute form there +is quick disturbance of vision. The eye looks normal outside and shows +practically no change inside. + +=Cause.=—Toxemia, cold, influenza; nasal, nasopharyngeal and sinus +disease (ethmoids), and infectious diseases are causes. Idiopathic +inflammation of the optic nerve is noted by most oculists. Here the +profound effects of spinal lesions upon the eye adds some important +light. + +=Treatment of Papillitis and Retrobulbar Neuritis.=—In each individual +case the treatment requires consideration of the causal factor. There +may be required constitutional treatment in many cases. In others the +cause may be found in the nose, nasopharynx, or spine. Effort should be +made to remove the lesion in each case. Diaphoresis will aid in acute +stages. + + +Atrophy of the Optic Nerve + +There are many causes for this condition such as optic neuritis, +meningitis, acute infectious diseases, locomotor ataxia, +arteriosclerosis, nasal disease, syphilis, traumatism, alcoholism, +exposure, embolism of the central retinal artery, diabetes and +poisoning. Diagnosis must determine the original cause. + +=Treatment.=—I have mentioned conditions in the nose as frequently +accounting for various eye troubles. If these atrophies of the optic +nerve can be gotten early, many of them will be influenced very +favorably by osteopathic treatment. Spinal treatment to direct the +circulation to the area of the orbit at the base of the brain is +beneficial. Regulation of the patient’s diet, habits, methods of living +and so forth is important. Excessive mental strain, excessive sexual +intercourse and stresses of every kind should be prohibited. Special +treatment should then be given according to the causal factors entering +into the case. + + +Eye Strain and Its Reflexes + +For the subject of refraction and refractive errors such as the +different forms of hypermetropia, myopia and astigmatism the reader +is referred to the many excellent works on ophthalmology which cover +these subjects quite thoroughly. They are only used here in the +relation to eye strain and its reflexes. The osteopathic logic here +given should be combined with a reading of the refractive errors in +such works as Fuchs, Weeks, De Schweinitz and others. + + +Asthenopia + +=Eye strain, weak sight or asthenopia= embraces the group of symptoms +dependent upon fatigue of the ciliary muscles or of the extraocular +muscles. + +There are three varieties of asthenopia. (1) Retinal or nervous, (2) +muscular and (3) accommodative. + +The symptoms are headache—frontal, fronto-temporal or fronto-occipital. +It may extend into the neck between the shoulders. Eye balls may be +tender, diplopia at times, may be photophobia, lachrymation, congestion +of the eye, itching and burning of the lids. + +=Accommodative Asthenopia.=—In this form the ciliary muscle is +fatigued. The cause is usually overuse of the eye when hyperopia and +astigmatism exist; sometimes in myopia or presbyopia. + +=Treatment.=—In this form the treatment is the proper fitting of +glasses and improvement of the general health. + +=Muscular Asthenopia= is due to tiring of the extraocular muscles, +usually the internal rectus. This may result in a phoria or a +non-paralytic squint. + +Ametropia may exist but asthenopia may come even in emmetropia due to +overuse of the eye. + +=Treatment.=—Correct ametropia if present, with glasses. Exercise the +weakened muscle. Correct the nerve supply to the weak muscle. Treat +cervical and upper dorsal. Manipulate tissues of the orbit. Spring the +jaw. Correct any nose and throat pathology. + +=Nervous, Neurasthenic or Reflex Asthenopia.=—The cause is supposed to +be some functional disorder, more often found in females. May be due to +too dim or too bright light, overuse of the eyes. Hysteria may follow +ametropia. + +=Treatment.=—Often the treatment is troublesome and the case is very +obstinate according to old school methods. Rest, hygiene, general +health and habits are looked after. The cause must be found or the +treatment cannot be specific. + +These are the different forms of eye strain as ordinarily classified. +Now as we study the reflex symptoms from these and attempt to trace +out the reflexes from an osteopathic point of view, we may find some +more definite causes of these conditions and consequently some methods +of treatment not found in standard text books might naturally suggest +themselves. + +Reflex symptoms that have been traced to eye strain by ophthalmologists +are as follows: + +Constipation, indigestion, heartburn, nausea, vomiting, nervous +attacks, fear of impending calamity, irritability, despondency, +insomnia, restless sleep, epilepsy, nervous twitchings and enuresis. +All these symptoms have been seen to disappear after eye strain was +corrected. There is no absolute way of proving that all these symptoms +have existed because of eye strain. The existence and disappearance +of some of them at the time of treatment for eye strain may be a +coincidence. It is evident that eye strain in varying degrees may +produce a train of symptoms similar to many above mentioned. + +A patient, nervous, anxious, uneasy, and despondent, constipated, +and having some indigestion, showed on examination contractures and +tenderness at the third dorsal. It was found he was suffering from eye +strain from overuse of glasses that were too strong for him. The eyes +were refitted. He was wearing a + + (R)+4.50 D. S. = +.50 cyl. Ax. 180. + (L)+4.50 D. S. = +.50 cyl. Ax. 90 + for close work and a (R)+2.00 D. S. = +.50 cyl. Ax. 180 + (L)+2.50 D. S. = +.25 cyl. Ax. 90 + for distance. The new glasses were—Reading— + (R)+3.00 D. S. = +.25 cyl. Ax. 180 + (L)+3.00 D. S. = +.25 cyl. Ax. 180 + Distance: + (R) + 1.50 D. S. = +.25 cyl. Ax. 180 + (L) + 1.50 D. S. = +.25 cyl. Ax. 180 + +He was fitted two years previously. At that time the stronger glasses +were correct. Eyes change more or less constantly, especially between +the ages thirty-five to fifty-five years. When glasses are fitted, a +weak ciliary muscle after a rest may become stronger and allow weaker +glasses to be worn. + +If a young person is fitted for myopia, in a few years he may discard +his glasses as presbyopia develops. A person fitted correctly, who has +a strong ciliary muscle may not be able for awhile to see as well with +the glasses as without them. After they are worn awhile the ciliary +muscle will cease its efforts to accommodate so much and the glasses +give the desired effect. In some cases the doctor’s reputation to fit +glasses properly may suffer at the hands of such people who sometimes +refuse to take glasses, or after getting them refuse to wear them. + +In the case of the man just mentioned a refitting quieted the nervous +symptoms—he became more cheerful and ceased to worry. Indigestion and +constipation improved. The soreness and contractures were overcome in a +few treatments. + +Now let us ask the question, why is it that eye strain will cause +nausea and vomiting? Also why will indigestion affect the eyes by +causing “spools” in the vision? + +A little osteopathic logic, based as it always is or should be, upon +anatomy and physiology, may throw some light on this subject. No doubt +every one of us has demonstrated many times clinically that indigestion +from overeating will cause soreness and contractures at the third and +fourth dorsal, the nerve center in the spine for the stomach. + +The reflexes between the viscera and the eye are complex and difficult +to follow. In giving the probable course of the nerve reflexes from +the optic nerve to the third nerve Dr. Louisa Burns suggests the +following: “The nerve elements of the retina start the impulse; it +passes over that portion of the optic nerves which enter the anterior +quadrigeminates, the cells of the quadrigeminates where the impulses +are coordinated, then by axons of these cells to the lateral or +viscero-motor nucleus of the third nerve, thence to the cells of the +ciliary ganglion, and by the non-medulated (sympathetic) fibers of +these, the short ciliary nerves to the non-striated muscles concerned, +viz: the ciliary muscle, some fibers of the levator palpebral and the +sphincter of the iris.” + +The third nerve arises in the floor of the aqueduct of Sylvius from +two nuclei; a lateral nucleus which is a viscero-motor group of nerve +cells, and a central nucleus or a somato-motor group of cells. The +somato-motor nucleus supplies all the extrinsic muscles of the eye +except the external rectus and superior oblique which are supplied by +the sixth and fourth respectively. The nasal branch of the ophthalmic +division of the 5th sends fibers to the ciliary muscle. Association +fibers connect the nuclei of the 3rd, 4th, 6th and 7th. The evidence is +in favor of the 10th or pneumogastric having such association fibers. + +We noted four places in the brain to which the optic tracts go before +the radiations reached the center of sight in the occipital lobe. If +we cannot follow all the reflexes through the brain and cord at least +with the facts we have it is not difficult to imagine abnormal impulses +coming over the third nerve from a straining of the ciliary nucleus, +thence over viscero-motor fibers in the lateral horn of the cord, over +the white ramicommunicantes, through the sympathetic ganglia, over the +splanchnics to the stomach, producing abnormal peristalsis, nausea and +vomiting. In turn we would have the somato-motor nerves to the muscles +affected as before described, contraction and congestion of muscles of +the spine. + +When we have patients consult us and describe a train of symptoms +like nausea, vomiting, nervousness, frontal and occipital headache, +we should have eye strain in mind and inquire for lachrymation, +photophobia, itching and burning lids and congestion of the eye. Any +of these things should make us think of testing for ametropia in its +various refractive errors, as well as a careful spinal and a nose and +throat examination. General physical and laboratory diagnosis should +not be neglected. + + +References + + Fuchs’s Text Book of Ophthalmology, Duane. + + Headaches and Eye Disorders of Nasal Origin, Sluder. + + External Diseases of the Eye, Greeff. + + Vol. III Practical Medicine Series: The Eye, Ear, Nose and Throat by + Casey A. Wood, Albert H. Andrews, Geo. E. Shambaugh. + + Diseases of the Eye, Weeks. + + Diseases of the Eye, Ear, Nose and Throat, Posy and Wright. + + Diseases of the Eye, De Schweinitz. + + Diseases of the Eye, May. + + Text Book of Ophthalmology, Roemer and Foster. + + Diseases of the Eye, Jackson. + + Ophthalmic Surgery, Meller. + + + + +DISEASES OF THE EAR, NOSE AND THROAT + +By J. DEASON + + +Diseases of the Ear + +=Methods and Technic of Examination.=—The external ear may be examined +by direct inspection with or without the aid of artificial light. +The external auditory meatus may be examined by means of a simple +conical ear speculum and reflected light from a head mirror. This +method requires considerable practice but efficiency can and should be +attained because it can be used under all conditions and therefore is a +reliable method. + +The Holmes electric auroscope which we use and recommend for examining +the meatus and ear drum, is very efficient but like other electrical +equipment is not always dependable. There are many electrical +equipments for examining the ear, but so far I have found none other +than the one above mentioned that is worth space in an instrument +cabinet. + +To examine the meatus, grasp the pinna and draw it firmly upward and +backward. This tends to straighten the canal so that the aural speculum +may be inserted well into the external canal. It must be remembered +that the auditory canal is always sensitive and while there is really +little danger of doing any harm by exercising ordinary care, the +patient is always afraid of being hurt and one can accomplish better +results by practicing careful technic. + +If the electric auroscope is used, the eye should be placed very close +to the lens and every part of the canal, walls and drum membrane +carefully examined. The Holmes auroscope has a small tube and bulb, +pressure upon which will vary the air pressure in the meatus and cause +the drum to move. This must be done very carefully because in very +thin, atrophic membranes there is some danger of rupturing the drum. + + +Diseases of the Auditory Meatus + +=Inspissated Cerumen=, or hardened ear wax is one of the most common +affections of the meatus. The cause in some cases can be traced to +lesions of the mandible, but in many cases the cause is unknown. + +=Treatment.=—Protect the clothing by means of a towel or rubber neck +piece. By means of a soft rubber ear syringe, wash the canal thoroughly +by forcing warm soap solution into it. I prefer concentrated liquid +castile soap (any good soap will do) diluted about one to four in water +as warm as the patient can bear it. The soap solution is contained in a +pus bowl held tightly against the neck under the ear. There is little +danger of using too much force with the soft rubber syringe. + +In most cases the hardened cerumen will be dislodged by the syringing +only. If this cannot be done, it may be well to discontinue the +treatment until the following day. The solvent action of the soap +solution will further reduce the hardened mass and it usually can be +removed by syringing the following day. This method is preferable in +many cases because patients dislike the pain which usually accompanies +the use of a curet. + +The dull loop curet is the most efficient and safest instrument for +removing hardened cerumen that the syringe may fail to dislodge. This +instrument must be used with great care because the membranes, long +protected by the covering of cerumen are hypersensitive and bleed +easily. + +After removing the cerumen, the canal should be thoroughly dried and +lubricated with some non-irritating lubricant. It is also well to +place a small pledget of absorbent cotton into the external opening to +protect the sensitive membranes from the cold, air and dust. + +In drying the canal I prefer to use a small aluminum applicator, +twisting a small piece of absorbent cotton on the end in such a way as +to cover the tip well, thus making any injury from its use impossible. + + +Atrophic Meatus + +Sensitive or itching ears as the patient commonly describes it, is a +very common disease caused by any atrophic condition of the membranes +of the auditory meati and frequently found in common with auditory or +other cranial nerve deficiency or degeneration. The direct cause of the +irritation is the collection of particles of dry cerumen. + +=Treatment.=—The local treatment consists of syringing with warm +(118° to 120°F) soap solution until all of the scaly cerumen has been +removed. The canal is then dried and lubricated as described above. +Several such treatments may be required after which I prefer the use +of the continuous irrigating ear cup, using salt mixture instead of +the soap. The same salt mixture as is recommended for nose and throat +irrigation is satisfactory. After such irrigations the application of +phenol-glycerine (10% phenol in glycerine) seems to be an efficient +treatment. + +The local treatment must, of course, be accompanied by corrective +treatment to the mandible and upper cervicals. + + +Furunculosis + +There are three acute affections of the ear which may usually be +diagnosed from their points of tenderness or pain. Pain upon moving the +lobe or pinna indicates furunculosis. Pain on pressure posterior to the +angle of the jaw or externally in front of the ear indicates middle +ear infection and pain on pressure over the mastoid region suggests +mastoiditis. + +Probably the most common of the painful diseases of the external meatus +is furunculosis, which is a subcutaneous infection of the lining +membrane of the meatus. The point of swelling may usually be seen but +in some cases the entire canal is closed. + +=Treatment.=—In all cases of occluded pus, drainage must be obtained, +but in the early stages of furunculosis, it is not always possible +to determine the place of “pointing” or the most desirable point +to lance. As soon as the place of “pointing” can be located it is +advisable to lance deeply by means of a curved paracentesis knife. +The parts are thoroughly cleansed and anesthetized by applying phenol +and neutralizing with alcohol. The external parts are first painted +with alcohol to prevent “burning” from any phenol which may be +dropped upon them. A small cotton applicator is used, applying the +concentrated solution of phenol or the crystals (using only a small +amount of phenol) to the affected parts and immediately neutralizing +with alcohol. Care must be observed not to apply any phenol to the drum +membrane and the operator must be sure that the action of the carbolic +acid is completely neutralized by a liberal application of alcohol. + +The knife blade is placed beyond the furuncle, its curved point turned +outward and quickly drawn forward through the furuncle, cutting +deeply. The canal is then packed with a pledget of cotton dipped into +phenol-glycerine. + +If the place of pointing cannot be seen, palliative treatment may +be applied by thoroughly cleaning the meatus, drying and applying a +phenol-glycerine pack. Heat may be applied by means of a therapeutic +lamp. Any electric light bulb or the dry electric pack will do. The +external parts are well lubricated with paraffin oil and the heat +applied continuously or intermittently until the pain is relieved. + + +Infection of the Meatus + +Infections of the meatus are frequently secondary to, or accompanied +by furunculosis. The treatment, therefore, is similar to that of +furunculosis. + +Always try to locate the point of infection, lance or curet, apply +phenol or other chemical germicide, neutralize, dry and pack with +phenol-glycerine. After the point of infection has been thoroughly +drained, cleanliness and protection from dust or further infection is +all that is necessary. + +In all cases of infection of the external meatus, suspect middle ear +abscess as a cause. There may be a pin-point opening through the drum, +from which the infection has originated and is being maintained. + +=Otomycosis= or fungus infection of the auditory meatus is rare. It +usually resembles other infections symptomatically, but often without +pus. A microscopic examination will serve to diagnose the condition. + +The treatment consists of thorough cleansing, drying and the free +application of alcohol. Alcohol is dropped into the ear until the canal +is full and a pledget of cotton applied to retain it. Usually two or +three applications are sufficient to effect a cure. + +=Eczema= of the auricle and meatus is of two types, the squamous or +scaly form and the sclerotic form. Both forms are chronic and may be +readily diagnosed by the appearance. + +=Treatment.=—Some cases are very difficult to cure but we have had +excellent results with the following treatment: Careful adjustment +of cervical and mandibular lesions; thorough treatment of any local +infections of head or neck; direct application of phenol-glycerine, +local cleanliness and protection from irritation. + + +Diseases of the Middle Ear + +Clinically the middle ear consists of the tympanic cavity and its +contents, the Eustachian tube and the mastoid cells. + + +Acute Suppurative Otitis Media + +Acute infections of the middle ear result from acute nasopharyngeal +affections such as colds, influenza, measles, mumps, whooping cough, +etc. Bathing in contaminated water often results in infection to the +middle ear through the Eustachian tube. + +=Diagnosis.=—Earache, pain on pressure under the angle of the jaw and +sudden deafness are the symptoms. (There are also the common febrile +symptoms.) The chief physical signs are: redness and bulging of drum +membrane, and contraction and tenderness of upper cervical muscles. + +=Treatment.=—If the patient is seen before the drum has ruptured it is +seldom necessary to lance the drum if the proper treatment is given +promptly. + +Drainage must be obtained and maintained by catheter aspiration through +the tube irrigation of the nasopharyngeal cavity, irrigation of the +meatus by means of the continuous ear irrigator and application of +dry heat over the affected part. Heat is best applied by means of a +therapeutic lamp. (Any lamp with reflector that will furnish proper +heat is efficient as there is no virtue in colored light.) The skin +surface over the ear, side of face and mastoid region is first well +lubricated with some mineral oil to prevent blistering and the heat is +applied either constantly or intermittently. A pledget of absorbent +cotton dipped into phenol-glycerine is placed in the meatus and forced +loosely against the drum. This should be removed every few hours and a +fresh pledget put in. + +The neck and upper dorsal muscles should be kept relaxed and adjustive +treatment given frequently. + +Under this treatment the pain should be relieved and the bulging of +the drum should disappear in from two to twelve hours. If this is +not accomplished or if the condition grows worse, the drum should be +lanced. See some text on otology for technique. In my experience, very +few cases have required paracentesis. + +It must be remembered that treatment should be continued regularly and +for some time after the pain and other symptoms have been relieved or +a recurrence is probable. Patients should have daily treatment until +the physician is sure that no complication or recurrence is likely to +result. + +If the patient is not seen until after the drum has ruptured, the same +treatment may be applied except the irrigation or syringing of the +meatus. This, in case of ruptured drum, may force pus into the mastoid +cells resulting in mastoiditis. Instead of syringing, the auditory +meatus is cleaned by means of a cotton applicator or by aspirating with +a catheter. At all times drainage through the meatus must be maintained +until the drum begins to heal. + + +Acute Mastoiditis + +Acute mastoiditis results from acute or chronic otitis media. In some +cases the otitis media may have been only a mild attack. + +=Diagnosis.=—There is no one symptom that is positively diagnostic but +a number of signs and symptoms must be considered as follows: + +1. Always suspect mastoid complications in acute otitis media and watch +for this complication daily. Most cases have some mastoid inflammation. + +2. Pain or swelling over mastoid. Pain may not be present, but usually +is, sometimes radiating over temples and eye on affected side. + +3. Tenderness on pressure not always present. May be very marked. +Tenderness extending to tip or above ear means extension of infection. +If persistent tenderness over tips with marked swelling and +discoloration—operation is indicated. + +4. Swelling, not always present, but sometimes very marked. If extreme +swelling and bluish discoloration—usually means operation. + +5. Temperature varies from normal to 104° or 105° F. Temperature of +more than one or two degrees means systemic absorption and suggests +surgical drainage. Streptococcus or staphylococcus infections cause +higher temperatures and require drainage earlier than other infections. + +6. Transillumination not positive, but of some value. Like X-ray, +usually shows dark, because of inflammation, but must rely upon +symptoms, as above. + +7. =Microscopic.=—Stain for pus, bacteria and bone debris. Hematoxylin +stain shows dark bone particles if there is bone disintegration. + +8. =Blood Count.=—If absorption, there will be some variation in +proportions of leucocytes. Any high leucocytosis shows systemic +absorption and the natural attempt to overcome the infection. + +=Non-Surgical Treatment.=—1. Drainage must be maintained from middle +ear through tube or drum or both. Catheter aspiration through tube. +Sometimes gentle inflation to clear the tube, followed by aspiration is +effective. + +2. If drum is ruptured, aspirate middle ear by catheter or by Moore’s +method or both. =This is very important.= If no aspirating machine, use +syringe and pump meatus and tube persistently. Dry meatus and keep well +open. + +3. Patient should be kept in bed if symptoms are marked, with light +diet and bowels well open. + +4. =Heat.=—Apply oil or other lubricant over whole side of face and +head and apply heat by means of “therapeutic” lamp intermittently. +Thirty minutes light on and fifteen minutes light off. The light-heat +(any electric lamp with reflecting shade will do) is much better than +hot water bottle or electric pad or sand bag. The heat must be kept +going day and night if symptoms are marked until the pain has entirely +subsided. Heat is most efficient in the early stages. After symptoms +are well marked, the ice pack is more desirable. + +5. If drum is not ruptured, heat may be applied by means of Deason’s +continuous irrigating cup. Start at 116° F. and gradually increase to +123° F. if patient can bear it. + +=Surgical.=—If drum has not ruptured and symptoms continue, it is best +to make free incision of drum,—keep open and apply (2) above. + +=Indications for Mastoid Operation.=—There are no definite signs, +symptoms or tests that will determine positively when operation should +be done. If the above non-surgical methods are practiced, few cases +will require operation, but many will develop into chronic mastoiditis +and so it is very difficult to decide whether a mastoid operation +should or should not be done. It is best to explain thoroughly the +possible complications to the patient and relatives and request them to +assume responsibility. Mastoid operations are attended by very little +danger when properly done. + +=Signs and Symptoms Suggesting Operation.=—Acute otitis media with +mastoiditis. + +(1) Persistent pain and swelling not relieved by non-surgical treatment. + +(2) Marked protruding of posterior wall or meatus. + +(3) Marked tenderness, swelling and discoloration above ear or over tip +of mastoid. + +These with temperature of more than 102° usually are enough to demand +immediate drainage. + +(4) Any evidence of extension of pus under skin of neck below tip. A +positive indication for drainage. + +(5) Any indications of brain or meningeal involvement such as very +marked and persistent headache, partial or total loss of consciousness, +etc. + +(6) Indications of labyrinthine involvement such as marked vertigo, etc. + +(7) Sudden cessation of discharge means obstructed drainage from middle +ear or from mastoid into middle ear and if drainage cannot be restored +by aspiration, this means operation. + +(8) The whole clinical picture must be carefully considered at all +times. Take no chances. Advise operation before someone else finds it +too late. + + +Chronic Mastoiditis + +=Cause.=—Always from unsuccessfully treated acute form or from chronic +suppurative otitis media. + +=Non-surgical treatment.=—See chronic suppurative otitis media. We have +had a few cases that were seemingly permanently cured by non-surgical +treatment, but believe they are rare. + +=Indications for Operation.=—1. Recurrent exacerbation of acute or +chronic otitis media. + +2. Constant discharge which resists treatment for chronic suppurative +otitis media. + +3. Continued pain or recurrent pain and swelling following acute otitis +media. + +4. Open sinus into mastoid either external or through meatus. + +5. Cholesteatoma. + +6. Symptoms of labyrinthine or brain involvement following acute otitis +media. + +7. Definite evidence of bone disintegration in mastoid. + +As stated above, none of these are definite indications. The whole +group of signs and symptoms are to be considered. + + +Chronic Suppurative Otitis Media + +=Etiology.=—Chronic suppurative otitis media usually results from an +unsuccessfully treated acute otitis media. If in acute otitis media +there has been bone erosion or extensive destruction of the mucous +membrane by a virulent infection, chronic suppuration is likely to +result. A persistent mastoid infection following otitis media is likely +to result in chronic otitis media and this is strong argument for early +mastoid operation. + +1. Otitis media resulting from some virulent infection such as the +recent influenza pandemic or scarlet fever is always more likely to +result in mastoiditis and chronic suppuration of the middle ear. + +2. Such infectious agents as streptococcus, staphylococcus, long-chain +pneumococcus or bacillus influenzæ are likely to result in chronic +suppurations. + +3. Lowered vitality from any cause. + +4. Inefficient drainage from failure to aspirate the Eustachian tube, +delayed perforation or failure to lance drum sufficiently early. + +5. Mastoid necrosis, which maintains drainage into the tympanic cavity. + +6. Abnormal granulations, polypi, etc. in tympanic cavity. + +7. Chronic inflammation with suppuration of the epipharynx or +Eustachian tubes. + +8. Cholesteatoma resulting from perforated drum and growths of +epithelium extending into the middle ear cavity. + +=Diagnosis.=—The diagnosis is easy because nearly every case of +discharging ear without pain is chronic suppurative otitis media. The +determination of the exact nature of the condition present is not only +very important but very difficult. + +Differential diagnosis consists in determining the nature of the +infecting organism and the nature and extent of the pathology. + +1. Direct examination of the external meatus after drying with cotton +applicator usually determines the location and extent of perforation +of the drum and the general nature of the discharge, whether purulent +or mucopurulent. Very rarely one finds a serious discharge which means +a very slight infection or discharge from non-infective inflammation. +The presence of whitish or greyish pus, mucoid and stringy, usually +means pneumococcus infection. Greyish, purulent non-mucoid discharge +usually indicates streptococcus or bacillus influenzæ infection. +Yellow, purulent discharge suggests staphylococcus infection. The +general appearance of the discharge, however, cannot be considered of +important diagnostic value because most chronic suppurations are mixed +infections, because of long exposure to external contamination. + +2. After cleaning the meatus, several smears should be made directly +from the opening in the drum. By staining with methylin blue or gentian +violet, the nature of the bacterial infection can be determined and +this is very important. + +By staining another smear with hematoxylin and washing in water, any +dark irregular particles, bone debris, may be found, which means bone +disintegration. This too, is very important. + +3. Transillumination is sometimes of value. The mastoid may be +transilluminated by placing a good rubber covered transilluminating +lamp over the mastoid and observing the external meatus through an +aural speculum. If the mastoid is free from infection the light will +pass through and illuminate the meatus. + +4. The X-ray plate is, of course, the best means of determining the +nature and extent of mastoid involvement. + +=Treatment.=—This is certainly one of the most difficult diseases of +the ear that one is ever called upon to treat and the physician should +be cautioned against offering a favorable prognosis. Perhaps the most +difficult thing about its treatment that the doctor has to learn is +that practically none of the so-called antiseptic washes do any good, +but on the other hand they often do harm. Certain general principles +are important and the treatment must depend upon the nature and extent +of the infection and pathology present in each case. + +The constitutional treatment consists of everything that will increase +the patient’s general resistance and certainly all lesions of the +cervical, upper dorsal and mandibles must be properly adjusted, but +this is not enough. All spinal lesions that may exert an influence on +metabolism and elimination are of important consideration. The diet, +habits and environment of the patient must be considered. + +A careful examination of the nasopharyngeal tract may reveal some other +focal infection, such as chronic tonsillitis, pharyngitis or sinuitis, +which is maintaining the infection through the Eustachian tube. There +may be a focal or general infection of some other part of the body, +which is reducing resistance or causing a hematogenous infection of the +tympanic cavity or mastoid cells. + +Drainage must be maintained in all cases, both through the Eustachian +tube by catheter aspiration and through the drum by aspirating and +drying. If the perforation in the drum is small or in the middle or +upper part, it should be opened down to the floor so that the contents +may be more easily removed and better drainage established. It is well +first to thoroughly cleanse the meatus and tympanic cavity by syringing +with salt mixture (salt 3 parts, borax 2 parts and soda 1 part, a +teaspoonful to a half pus bowl of water) at from 116° to 118° F. After +syringing, the meatus is carefully dried, and the middle ear cavity +aspirated through the tube and drum opening. The advantage of this +simple treatment is thorough cleanliness and drainage with the minimum +of irritation. This treatment given daily or thrice weekly will often +cure the case. + +Staphylococcus and streptococcus infections usually respond to the +following treatment: After thoroughly cleansing as above, the meatus +and tympanic cavity is syringed with a one to four or one to five +dilution of Dakin-Carrel solution (Hyclorite may be used instead) +followed by aspiration, the fluid being drawn through the tube, thus +preventing reinfection from that source. + +Pneumococcus infections do not respond to either of these methods of +treatment. The pneumococcus, because of its capsule, is not affected by +antiseptics, but on the other hand the irritation of the tissues caused +by their use, only gives the infective agent a better opportunity for +growth. + +In pneumococcus infections we have found the following method +efficient: Thoroughly cleanse the meatus and middle ear cavity by salt +mixture syringing, aspiration and drying. The meatus and tympanic +cavity is then filled with a neutral mineral oil. The oil is also +pumped through the Eustachian tube. It is the purpose to fill the +entire cavity and its openings so thoroughly that no air can enter. +In some cases we have used bismuth paste after the oiling with +excellent results. The pneumococcus is aerobic and if all air can be +kept away for a considerable time, it furnishes an unfavorable culture +environment with little irritation to the membranes. + +=Surgical treatment.=—The presence of bone debris indicates bone +disintegration in the tympanic cavity or mastoid cells. If the mastoid +cells are thus involved there is little chance for direct treatment. +If such cases do not respond in a short time to any of the above +methods of local treatment, ossiculectomy or mastoid operation may be +necessary. Some specialist surgeons claim from 80% to 90% favorable +results from mastoid operation in such cases. + + +Non-Suppurative Otitis Media—Catarrhal Deafness + +Deafness is any impairment of normal hearing and is that symptom next +to pain and chronic discharge that causes the patient to visit the +doctor. If acute diseases of the ear, nose and throat could always be +successfully treated, there would be little trouble from the symptoms +of chronic pathology. It must be understood that catarrhal deafness is +a symptom of chronic otitis media and is, therefore, seldom of recent +origin. + +=Etiology.=—Chronic otitis media is nearly always the result of the +extension of infection through the Eustachian tube and has come +from some acute or chronic nasopharyngeal infection. Chronic colds, +pharyngitis, tonsillitis, sinuitis, etc., resulting in acute or chronic +otitis media either with or without suppuration, constitutes the +beginning of catarrhal deafness. + +=Symptoms.=—There is seldom any pain with this disease. Some cases have +an occasional acute attack with pain and other symptoms of acute otitis +media. + +Deafness, varying with the progress of the pathologic changes, is +always present. The patient in the early stages will seldom admit +that he suffers from deafness and often he is honest because he may +not realize that he cannot hear normally until his otitis media has +progressed to the second or third stage. Most patients, in fact, do +not become alarmed about their hearing until it is too late to restore +normal hearing. For this reason, physicians should be on the lookout +for such conditions and should advise special treatment early. + +The human species in its present environment, depends much less upon +the organs of special sensation than do the animals of the wild, and +they may therefore be very deficient in sight, hearing, smell, etc. +without actually realizing this loss. + +In addition to deafness there are other symptoms such as occasional or +constant fullness or feeling of “stuffiness” as the patients express +it, due to partial or complete occlusion of the Eustachian tubes. +Tinnitus aurium or head noises is very common and often the most +annoying symptom. Autophony, or the loud sound of the patient’s voice +to himself, which often causes him to speak low and indistinctly, +occurs in the later stages. Presbyacusia, or the inability to adjust +the hearing apparatus to variations in pitch, commonly occurs in the +second stage and is evidenced by the fact that the patient does not +hear when more than one person is talking. Paracousis or perverted +phenomena of hearing, such as the better hearing of some persons in a +noisy environment, is a symptom of the third stage of otitis media and +often means an unfavorable prognosis, so far as marked improvement in +hearing is concerned. + +=Pathologic Stages.=—For convenience of discussion we may consider +chronic otitis media in three stages. + +=The First Stage.=—The active pathology is limited to the pharyngeal +portion of the Eustachian tube with some inflammation of the membranes +of the tympanic cavity. Closure of the tube followed by absorption of +the oxygen causes a decreased pressure in the tympanic cavity and thus +a retraction of the drum, decreased movement of the ossicles and a +general decrease in function of all tympanic structures. Deafness in +this stage may be very marked, especially if the Eustachian occlusion +has occurred from some nasopharyngeal acute inflammation. There may +be pain but there is always a characteristic “fullness” and sometimes +dizziness. Deafness in these cases varies with weather changes. If +proper treatment is had in time, the progress of the pathology can be +stopped and every case can be restored to normal hearing. + +=The Second Stage.=—The active pathology has extended throughout the +Eustachian tube causing marked occlusion and some stenosis. There is +further inflammation of the tympanic structures with an increase in +the symptoms of the first stage. The drum membrane is less movable but +there is no fixation of the ossicles. Pressure upon the bulb of the +auroscope causes movement of that part of the drum to which the malleus +is attached. The drum is thicker, more retracted, and less movable +than in the first stage. Presbyacusia is common and often marked, but +there is no paracousis. More than 90% of these cases can be materially +improved and many can be made to hear normally if proper treatment is +given in due time. + +=The Third Stage.=—The active pathology in the third stage consists of +an involvement of the entire mucous membrane lining the Eustachian tube +and tympanic cavity. These membranes are all chronically hypertrophied. +The Eustachian tube, however, is sometimes fairly well open, but the +ossicular attachments are more or less fixed by hypertrophied tissue +and adhesions and the drum is markedly retracted, thickened and usually +very immovable. The deafness is usually quite marked, head noises are +commonly present and often very annoying. Patients usually do not +notice a variation in their hearing from weather changes. Presbyacusia +is present in 80% of cases and their hearing for low tones is much +reduced. + +Unless there is a complicating nerve affection these cases hear well +by telephone, which means that they can also use an electric hearing +instrument to advantage. These cases can never be restored to normal +hearing, but many of them (30% of my cases) can have some improvement +and in most cases I believe the progress of the pathology can be +stopped, and this is always well worth while because their hearing is +likely to be entirely lost if something is not done. + +=Psychologic Stages.=—There are three rather distinct psychologic +stages in catarrhal deafness. The first, the period in which most +patients refuse absolutely to admit that they are deaf even to the +aurist upon whom they call for treatment. They insist that they hear +perfectly if people would only speak distinctly. This is partially +true, because up to the third stage of deafness the voice can be fairly +well heard if people would only articulate clearly. In the second +stage patients admit that they don’t hear well, but insist that they +are going to recover normal hearing and often resort to various kinds +of injurious treatment. In the third stage they give up all hope of +ever regaining their hearing, become morose, and avoid company. These +psychic stages do not always correspond with the pathologic stages +given above. + +=Diagnosis.=—The external auditory meatus, drum membrane and ossicular +chain, constitute the apparatus whose function is that of conduction of +sound waves to the perception apparatus of the inner ear. The function +of the conduction apparatus varies inversely with the progress of +pathologic change in these structures. The perception apparatus, the +structures of the inner ear, are not necessarily affected by middle ear +pathology, but on the other hand, sounds transmitted by bone conduction +not only seem louder but they last longer because the “escape of the +excess” of sound thus transmitted is hindered by deficient conductive +mechanism. This explains why such persons hear well by telephone and +why the tuning fork, whose base is held to the mastoid (provided +there is no nerve affection) may be heard for a greater time than +normal. Likewise the prong of the vibrating tuning fork when held near +the concha is heard for a shorter time than normal, because of the +deficient function of the conduction mechanism. + +Tuning forks are known by their number of vibrations per second, such +as 16, 32, 64, 128, etc. Three or more forks are required to make an +accurate measurement of the conduction and perception functions—a low +fork about a 32, for the low tones, 128 or a 512 for the medium tones +and a 2048 for the high tones. + +A good set of forks should be selected and standardized, i. e., the +normal bone and air conduction of each fork determined by testing it +on a number of persons whose hearing is known to be normal. For the +general practitioner who cares only to get a general idea of the extent +of the pathology, one fork of medium pitch such as a 128 or 512 will be +sufficient. + +To measure the function of hearing, the fork is set into maximum +vibration, its base held against the mastoid and the patient is asked +to state when he no longer hears it. This length of time in seconds is +recorded as “bone conduction.” The fork is then held near the concha +and the patient again states when he does not hear it. This length of +time in seconds is recorded as air conduction. + + +Normal Hearing + +=Tuning Fork Test.=—The normal time rate in seconds set of forks is as +follows: + + Fork 32 64 128 512 2048 4096 + B. C. 25 30 30 20 10 + A. C. tone 70 90 90 40 20 + +The tuning fork test, carefully made, is the only known method of +measuring the functions of the various structures concerned in audition. + +=The Whisper Test= is made by producing a clear whisper from residual +air only, which should be heard about twenty feet by a normal ear. + +=The Watch Test= is made by using some loud ticking watch (I prefer +an Ingersoll), holding it first near the ear until the patient +recognizes the tone, and then taking it beyond the hearing distance and +approaching the ear until it is heard. I prefer also to move away from +the ear until the limit is reached and strike an average of this with +the above results. The average eighteen size Ingersoll watch can be +heard for from 100 to 150 inches by the normal ear. + +The practical test for the patient is his hearing from the spoken +voice, and is the most reliable so far as permanent results are +concerned. + +=Low Tone Limit.=—The lowest limit of hearing is about sixteen double +vibrations per second, but the lowest practical limit is about +thirty-two. There are few people with normal hearing and with musically +trained ears who can recognize a definite tone lower than this, so I +consider the thirty-two fork sufficiently low for all practical tests. + +=Conduction Deafness.=—Low tones are lost in tympanic involvement or +conduction deafness, and are diagnostic in such cases, but are of no +particular value in nerve deafness except when that is complicated by +catarrhal deafness. + +=Practical Hearing Limits.=—The human voice varies from about 60 to 150 +double vibrations per second, and most sounds that we really need to +hear are less than 700 vibrations per second. This is the reason for +using the low forks, 64, 128 and 512. + +=Measurement of Nerve Force.=—To measure auditory nerve force, the fork +(say the 128, whose normal B. C. is 30 seconds) is set into vibration +and held gently and with even pressure against the mastoid and the +patient is asked to tell or signal the doctor when he ceases to hear +the tone. Two or more tests may be made to determine the patient’s +personal equation, but the use of control forks (the 64 and 512) will +show any such error. Granting that there is no complicating pathology, +tympanic or labyrinthine, the number of seconds of hearing over 30 will +be the patient’s auditory nerve force. For example, if he hears the +fork 30 seconds his hearing will be thirty-thirtieths or normal. If his +hearing is 25, 20, 15 or 10 seconds, his auditory nerve force will be +respectively 25-30, 20-30, 15-30 or 10-30. + +By means of this method an accurate measurement of the functions of +hearing can be made and a definite prognosis can be given. I never use +any of the various named qualitative fork tests for hearing, because +they have no value to one who employs this system. + + FOOT NOTE—In the chart T is used, meaning that tone is heard, while S + indicates sound but no tone. + + FOOT NOTE—It is not the purpose to give any detailed or differential + methods of diagnosis because if one cares to treat these diseases he + will of course, study a special text on this subject. The methods here + given are only for the general practician who wishes a general idea of + the condition present. + + +Summary of Diagnosis of Different Stages of Catarrhal Deafness + + =First Stage.= + 1. Fork 32 128 2048 + B. C. 35 20 + A. C. T 70 40 + +2. The drum is only slightly retracted but freely movable. + +3. Whisper heard from five to twenty feet. + +4. Ingersoll watch heard from 30 to 150 inches. + + =Second Stage.= + 1. Fork 32 128 2048 + B. C. 40 20 + A. C. T 60 40 + +Note that the tone of the 32 fork is heard, the 128 fork has increased +in bone conduction and reduced in air conduction but that the bone-air +ratio is direct, that is the patient hears longer by air than by bone +conduction. Note also that the high fork is still normal. + +2. The drum will be found retracted but that part to which the malleus +is attached is still movable when tested with the auroscope. + +3. The whisper is heard from two to ten feet. + +4. The Ingersoll watch is heard from six to sixty inches. + +5. Presbyacusia but not paracousia is present. + + =Third Stage.= + 1. Fork 32 128 2048 + B. C. 45 15 + A. C. S 20 30 + +The typical diagnostic points in third stage catarrhal deafness are: 1. +Tone for the 32 fork is lost. 2. There is an inverted bone-air ratio +for the medium fork. The drum is retracted and the malleus fixed. 4. +The whisper may be heard at less than one foot or not at all. 5. The +Ingersoll watch is heard less than six inches from the mastoid. 6. +Paracousis Willisiani is present. + +For the general practician this is important because he can make a +rather definite prognosis. + +=Treatment.=—The treatment will be given briefly because space would +not permit of lengthy discussions of details of methods and technic. + + FOOT NOTE—Note that the patient hears the tone of the low fork, that + the 128 fork has its bone conduction slightly increased (30 to 35) + that the air conduction is slightly decreased (90 to 70) and that the + high fork remains normal. + +A careful examination should be made for some source of focal infection +about the nasopharyngeal tract. Chronic or subacute tonsillitis, + +pharyngitis or sinuitis or root abscess are often a cause, and not much +will be accomplished in improving the otitis media until these focal +infections are found and properly treated. The original cause of these +focal infections may have been some bony lesion, but to successfully +correct such lesion now does not mean that the source of infection will +be removed. + +Auto-intoxication from gastro-intestinal disease is common. In my +cases, 80% of the third stage have chronic constipation or other +chronic gastro-intestinal affection. + +In many severe acute affections of the nasopharynx the inflammatory +process has left the Eustachian tube occluded or stenosed and the +pharyngeal fossa filled with adhesive bands. It is not uncommon to find +the epipharynx and pharyngeal fossa filled with partially atrophied +adenoid tissue or if the curet method has been used for removing +adenoids, there is often connective tissue adhesions and any or all of +these may prevent the normal ventilation of the tympanic cavity by way +of the Eustachian tube. + +In such cases surgical removal of these obstructions and dilation +of the tube is necessary. My practice has been to give a general +anesthetic (nitrous oxide or somnoform will be sufficient in many +cases) and by means of an adenotome (La Force or Cradle, I never +use a curet) remove all adenoid tissue. Then by means of the finger +I carefully remove any adenoid tissue in the posterior nares and +pharyngeal fossæ that the adenotome may have failed to get and also +dilate the pharyngeal portion of the tube by inserting the finger. + +This operation if carefully and thoroughly done and if preceded and +followed by the proper surgical cleanliness and supportive treatment, +will when indicated, accomplish excellent results. The after treatment +is even more important because if this is not well done, no results +or even unfavorable results may occur. The after treatment consists +of daily irrigations of the nasopharynx, thorough attention to upper +thoracic, cervical and mandibular lesions, aspiration of the Eustachian +tubes and other local treatment to the nasopharyngeal membranes. After +the operation has been done it is best to do no digital manipulation +of the pharynx for from three to six days. After this time digital +treatment, gentle dilation of the Eustachian orifice to maintain its +patency, stretching of the soft palate to reestablish proper nerve +function and the application of deep pressure in the pharyngeal fossæ +to stimulate the otic ganglion is important. This treatment is not +massage in any sense but definite, purposeful, manipulation and if +carefully done will be followed by excellent results. + +Since the origin of this method of treatment, there has been much +comment on its value and many have tried or at least they thought +they tried it with unfavorable results. The causes of failure are, +attempting treatment in cases impossible of cure, or poor diagnosis, +improper technic of operator or incomplete operative procedure and +inefficient supportive treatment. + +It must be understood that not all cases of otitis media even in the +beginning stages require the above method of treatment or will be +benefited by it. Those cases which have resulted from other causes than +acute pharyngitis seldom require such radical methods of treatment. + +In every case, the cause must be found and consistent treatment +given. In my experience, the radical method of treatment has not been +found necessary in more than twenty per cent of cases of chronic +otitis media. In the other cases the treatment consists of removing +sources of focal infection (about forty per cent) and normalizing +nasopharyngeal reflexes by osteopathic and local treatment (about forty +per cent). In all cases, the treatment must be complete. To remove +thoroughly all obstruction from the epipharynx and leave a source of +focal infection in the tonsils will accomplish little, or to remove +carefully all pharyngeal obstruction and all sources of focal infection +will not restore normal functions of the middle ear structures if the +osteopathic lesions and gastro-intestinal perversions are neglected. +Surgery in itself, even though carefully and thoroughly done, is not +efficient treatment and this is why the medical specialists fail in +this disease. After the necessary surgery has been done, then normal +tone must be restored to the various tissues involved. Normal reflex +mechanisms must be reestablished and this can be done by thorough and +efficient osteopathic corrective work and the proper local treatment +directly to the structures affected. + + +Meniere’s Symptom Complex + +This is a form of catarrhal deafness with all the characteristic +pathology of the first or second stage, but in which, due probably +to sudden tubal occlusion, there results a marked variation in the +intralabyrinthine pressure and there are, therefore, the symptoms of +conduction deafness combined with labyrinthine involvement somewhat +resembling Meniere’s disease. There is dizziness or even vertigo, +with head noises, but not the marked prostration and nausea which +characterizes Meniere’s disease. + +=Treatment.=—The treatment is the same as in the first stages of +catarrhal deafness and the prognosis is always good. The labyrinthine +symptoms are usually completely relieved as soon as the middle ear is +ventilated. + + +Diseases of the Inner Ear + +=Acute Suppurations.=—Acute suppurative diseases of the labyrinth +occasionally result from the extension of infection from the tympanum +but they are certainly very rare. Such conditions may result from +acute suppurative otitis media in which there has been an excessive +collection of pus without rupture of the drum or drainage through +the tube but this very rarely occurs and after drainage has been +established, labyrinthine infection is hardly possible. + +=Diagnosis.=—Labyrinthitis is of several forms but in general, there +are the symptoms of labyrinthine involvement such as: nystagmus, +vertigo, nausea, vomiting, headache, earache, deafness and febrile +symptoms. When labyrinthitis is suspected, an aurist of much experience +should be called into consultation at once. + +=Treatment.=—Suppurative labyrinthitis is not in itself a fatal disease +but dangerous complications may result because of the close proximity +to so many delicate structures. Threatened meningeal infection requires +surgical drainage, but unless meningeal infection is imminent, surgery +is contraindicated. Since the mortality, considering dangers of +complications, is not high (about 10%) and since such operations are +very complicated and require great surgical skill, we may conclude that +surgery is generally contraindicated. + +Non-surgical treatment consists of keeping the patient quiet in bed, +liquid diet, and good elimination. Drainage through the middle ear or +Eustachian tube must be maintained. + +Deep manipulation of the cervical structures will help to maintain +lymphatic drainage but any treatment which necessitates much movement +of the head should be avoided until the symptoms of vestibular +irritation have ceased. + + +Non-Suppurative Labyrinthine Diseases + +=Meniere’s Disease.=—This disease is caused by hemorrhage into the +labyrinth with the following symptoms: There is sudden and intense +vestibular irritation such as vertigo, marked tinnitus, nausea, +vomiting and complete deafness on the affected side. There may also be +cerebral disturbances and loss of consciousness. + +=The Prognosis= depends upon the extent and severity of the pathology. +It is probable that those cases in which recovery occurs quickly are +not true cases of Meniere’s disease but have some causes other than +labyrinthine hemorrhage. Such cases are perhaps Meniere’s Symptom +Complex. + +=The Treatment= consists of complete rest in bed, light diet, and +good elimination until the marked irritation has passed. It has been +my practice to carry out further treatment similar to that of the +treatment of nerve deafness to be given later. Many of these cases will +make complete recovery. + + +Nerve Deafness + +The term “nerve deafness” is generally used very carelessly to apply to +any chronic or non-suppurative process of the labyrinthine structures +other than those mentioned above, which cause impaired hearing. + +Nerve deafness is not an uncommon disease. In my cases of deafness +there has been some involvement of the labyrinthine structures or +auditory nerve in 27% of the cases examined. I think the reason for +most authors putting the percentage of nerve deafness much lower than +this is because of inexact methods of diagnosis. The above percentage +is based upon the actual measurement of nerve force. See measurement of +nerve force under non-suppurative otitis media above. + +A careful study of cases by the method of actual measurement of nerve +force, shows that there are two distinct forms of nerve deafness. +In one there is only a deficient function of the structures of the +labyrinth, due perhaps to some perverted physiologic function, and this +form we may call auditory nerve deficiency. The other form of nerve +deafness, due probably to an actual degeneration of the nerve or its +end organs in the labyrinth, may be properly known as auditory nerve +degeneration. + +=Auditory Nerve Deficiency.=—A study of our case reports shows that in +64% of the cases in which the nerve force was 16-30 or higher (more +than half) favorable results were obtained, provided that there was +no complicating labyrinthine affection. These cases have been classed +as “nerve deficiency” and the pathology as functional. A favorable +prognosis (64%) may be offered. + + Example of tuning fork findings: + Fork 32 64 128 512 2048 4096 + B. C. 18 20 20 20 10 + A. C. T 50 60 60 40 20 + +In addition to the tuning fork findings the voice and watch test will +be reduced to from one-tenth to two-thirds normal. The patient often +complains of itching meati and dry nares. There are usually no signs or +symptoms of labyrinthine affection. + +=Treatment.=—The treatment consists of local treatment to the +nasopharynx, tubes and meati as described under the treatment of +chronic otitis media. Everything should be done to build up the +patient’s general health and improve the local nutrition. It is highly +essential to search the entire system for sources of focal and general +infection. Auto-intoxication from chronic gastro-intestinal disease +was found in 90% of our cases. Any treatment therefore that will +restore normal gastro-intestinal function is indicated. Recently we +have had some excellent results from colonic irrigation and the proper +adjustment of diet in such cases. Any source of focal infection must of +course receive proper attention. + +The osteopathic corrective treatment consists largely of careful +attention to lesions of the splanchnic area because of the importance +of normal digestion, metabolism and elimination. This is certainly a +most important part of the treatment and should never be neglected. +Upper cervical and mandibular lesions have much to do with the local +nutrition to the ear structures and these must not be neglected. The +fact that we almost constantly find evidence of deficient nutrition +to the meati and drums in this disease together with lesions of the +mandible, suggests a local osteopathic cause. + +=Auditory Nerve Degeneration.=—In those cases in which there is a +measurable deficiency of nerve function of less than half the normal we +have found that very few respond to treatment. (See table above.) The +cause has therefore been attributed to a structural pathology and the +condition called auditory degeneration. + + Example Table: + + Fork 32 64 128 512 2048 4096 + B. C. 10 12 8 5 2 + A. C. S 20 25 15 7 5 + +There is usually very marked impairment of hearing for voice and all +other sounds. The Ingersoll watch may be heard five or ten inches, but +usually not at all, and the whispered voice heard only a few inches or +not at all. There are nearly always signs and symptoms of labyrinthine +deafness and evidence of tone islands. The deafness in these cases is +usually progressive regardless of any treatment. + +In this disease there is nearly always an associated affection of the +labyrinth as shown by the high forks. The fractions represented by the +high forks will agree in proportion provided there is no labyrinthine +involvement. + +Our results in auditory nerve degeneration have been measurable +improvement in only 2% of the cases treated. The prognosis is therefore +very poor and I believe we should always tell our patients frankly +that there is almost no chance for improving their hearing in such +cases. The treatment is the same as that given for nerve deficiency and +because of the general good that may be had from treatment, that is, +the improvement of the general resistance, it is often well for the +patient to have such treatment to stop the progress of further special +sensory degeneration. + +It should always be our purpose to treat the patient rather than to +treat some particular organ only and if this method is followed, our +general results will surely be much higher. + + +Diseases of the Nose + +=Method of Examination.=—For use in nasal examinations and treatment, +a suitable chair with adjustable headrest is of much value because if +the patient is not comfortable and in a convenient position, the work +is very difficult. A few instruments, such as the following, are very +essential: A sterilizer for instruments, head mirror and reflecting +lamp, nasal speculum, tongue depressor, tonsil pillar-retractor, a +nasal packing forceps and a few aluminum cotton applicators. These +instruments are few and comparatively inexpensive, but are of more +practical value than a lifetime collection of electrical apparatus. +Any physician can readily learn the use of these instruments and the +methods of examination by attending the clinical sessions of our +conventions. Methods and technic of treatment, however, require much +practice and experience to develop efficiency. + + +Acute Rhinitis + +This disease, commonly known as a “cold in the head” is one of the most +common, and because of the complications which so commonly result, a +disease which really requires careful consideration. + +=Etiology.=—The predisposing cause is reduced resistance and individual +susceptibility to air-borne irritants and infective organisms. + +Direct exposure of some insufficiently protected part of the body such +as the feet in cold, damp weather, exposure of some unprotected part +of the body to draughts or exposure of the whole body to slightly +reduced temperature for a considerable time, are the common causes. In +cold weather, it is very important that the proper indoor humidity be +maintained, because the drying of the mucous membranes renders them +susceptible to infection. This disease is not only contagious at times +but may even become endemic from some specific and virulent organism. + +The complications which may and often do follow such infections +are laryngitis, bronchitis, pneumonia, etc. and any one or more of +the focal infections, such as sinuitis, tonsillitis, or middle ear +infection. A focal infection thus caused may become chronic and render +the patient constantly susceptible to head colds. In fact in those +persons who suffer from chronic head colds, there may nearly always +be found some focal infection, such as the above named, and it is +often impossible to get permanent relief until such sources of focal +infection have been properly treated. + +The influence of gross structural lesions, osteopathic lesions of +the cervical and upper thoracic region, vertebræ and ribs must not +be overlooked because they exert a powerful influence upon the blood +supply, particularly the venous and lymphatic drainage and upon the +autonomic nervous mechanism, which regulates the physiologic control of +such functions. + +Gross structural abnormalities of the intranasal chambers, such as +deflected septum, enlarged turbinates or cellular turbinates, which +cause deficient or abnormal breathing space, may cause and maintain +head colds. + +=Diagnosis.=—The diagnosis is usually easy. Nasal congestion with the +usual “stuffy” feeling of the head, sneezing, headache, etc. are well +known symptoms. On direct examination the nares are congested, there is +a watery discharge and all of the membranes of the nasopharyngeal tract +are congested. + +=Treatment.=—If there is ever a demand for good, thorough and specific +osteopathic work, certainly it is demanded in such cases. I am an +advocate of thorough, deep relaxing treatment followed by specific +adjustment in such cases. + +Complete rest in bed with light diet and careful attention to the +elimination are very essential. Perhaps the most difficult problem is +to convince the patient that a head cold is really a serious disease +and demands thorough and prompt treatment. Every ear, nose and throat +specialist has had ample opportunity to know that most of the really +serious complications of the head and neck result from the lack of +prompt and proper attention to head colds. + +The local treatment consists of irrigation of the nasopharynx followed +by oil spray to protect from further irritation and the maintenance of +proper drainage from the sinuses and middle ears. I am not an advocate +of the so-called “antiseptic sprays” because they neither destroy +bacteria sufficiently to be effective nor do they maintain drainage. + +In all cases, the physician should be ever watchful for the +complications and should not hesitate to call consultation of a +specialist when such symptoms develop. + + +Purulent Rhinitis + +Persistent inflammations of the nasal membranes are usually of a +purulent nature or at least have had such a cause in the beginning. + +=Etiology.=—Purulent rhinitis may be a result of an unsuccessfully +treated infection of the nose or throat following some disease of +childhood or early life. It may be due to infection at birth. Commonly +there is a subacute or chronic sinus infection that maintains the +infection of the nasal mucosa. Polyps, enlarged or cellular turbinates, +adenoids or adhesions in the epipharynx, often retain the secretions +and cause chronic rhinitis. In many cases I have found that osteopathic +lesions of the cervical or upper thoracic region are effective causes +of chronic rhinitis. + +=The Pathology= consists of hyperemia, hypertrophy and exfoliation of +the cellular membrane. The turbinates and all membranes become enlarged +and thickened and the breathing space is usually greatly decreased. + +=The Symptoms= are nasal obstruction, and mucous or mucopurulent +discharge with usually hypersensitiveness, which causes sneezing and +other symptoms common to “head colds.” + +=Treatment.=—The same treatment as given above for acute rhinitis +applies here. A thorough examination should be made for all of the +various causes given above and the proper corrective treatment given +for any or all such causes. + + +Chronic Hypertrophic Rhinitis + +=Etiology.=—Chronic rhinitis is usually a result of an infective +rhinitis and has for its cause any one or more of the various causes +given above under purulent rhinitis. + +=Pathology.=—The pathology in chronic rhinitis varies with the cause, +but is usually characterized by a series of changes beginning with +infection and hyperemia and followed by an actual and usually marked +hypertrophy of the interstitial tissue. The posterior ends of the +inferior or, less often, the middle turbinates are usually enlarged and +extend backward into the pharynx. + +=The Symptoms= are much the same as in purulent rhinitis, except that +the purulent discharge is often not present. These cases usually suffer +from chronic head colds, headaches and persistent nasal obstruction. +The senses of smell and taste are usually impaired and there is a nasal +twang to the voice. + +=Treatment.=—In these cases, it is common to find osteopathic causes +which prevent proper drainage from the head and neck and this is +important because, if all the local causes are properly corrected, this +is not sufficient to effect a cure. + +Surgical treatment for the removal of polyps, synechia, adenoids, +adhesions, correction of septum, or hypertrophied or cellular middle +turbinates is often essential and certainly infected sinuses must be +properly drained. We have had cases in which root abscesses seemed to +be active causes, but it must not be thought that surgery and surgery +alone is likely to cure chronic rhinitis, and I want to caution against +the wholesale removal of turbinates for such conditions. The mere fact +that the turbinates are enlarged is not sufficient reason for their +removal. There has been a cause for this enlargement and turbinotomy or +turbinectomy does not remove this cause. Cautery is worse, because it +seldom accomplishes more than very temporary results and often leaves +the membranes worse than before. Cautery destroys mucous membrane, +leaving a dry and easily irritated surface which is often impossible to +normalize. + +The proper surgery, carefully done, followed by efficient osteopathic +corrective work and thorough irrigation of the nasopharyngeal tract +with the necessary oil spray protection after irrigation, will +constitute efficient treatment. Treatment, thorough and long continued, +will in due time restore nutrition, drainage and normal reflex nerve +control to the tissues. Treatment after surgery is essential. + +=Intranasal Treatment.=—Many cases are caused by the retention of +secretions under the turbinates and in the superior vault. In all +cases, therefore, it is essential to thoroughly free all possible +retention cavities by means of a small cotton-wound probe before +irrigation. The intranasal membranes are adrenalized and anesthetized +and a thorough examination is made using a good reflecting lamp, nasal +speculum and cotton tipped probe. Every part of the intranasal region +is inspected for sources of purulent discharge, mucus collections, +synechia and for hypersensitive areas. The probe is curved at the +end and passed under each turbinate and drawn forward and backward +with considerable pressure to insure that any collection of foreign +matter is thoroughly removed. Every part of the intranasal region +should be thoroughly treated in this way. The hiatus semilunaris must +be kept well open to permit free antrum drainage and all other sinus +openings should be kept free from any obstruction that may block the +drainage. This particular technic requires great care and practice, +but it is very effective and so commonly we have found that this work +thoroughly done will reduce much and in some cases all of the turbinate +hypertrophy rendering surgery unnecessary. + + +Atrophic Rhinitis + +As the term suggests, this disease is just the opposite from +hypertrophic rhinitis in that the membranes are shrunken, the nares +are wide open and usually the membranes are coated with a mucopurulent +discharge, accompanied by a bad odor. It is a chronic disease and +progressive in nature. + +=Etiology.=—Deficient nutrition, systemic or local, or some +degenerative infective process constitutes the cause. Some cases may be +traced to syphilis, but this is certainly not always the cause. Chronic +sinuitis, the cause of which is some virulent infection, is often the +cause. Too much or incorrect surgery and cautery is certainly a cause +in many cases. + +=Pathology.=—The marked atrophic appearance, the retracted +turbinates, the excessive purulent or mucopurulent foul discharge are +characteristic and diagnostic. + +The tissues underlying the mucous membranes are shrunken, and atrophic +and this tissue has usually been replaced, sometimes almost completely, +by connective tissue, and thus the blood supply is markedly deficient. + +=Treatment.=—In chronic cases, those in which the atrophy is well +progressed, there is no hope of restoration to normal conditions, but +I believe that the progress of practically every case can be stopped +and that, in most cases, a permanent cure can be effected under proper +treatment. + +Every possible source of focal infection, such as sinuitis, +pharyngitis, tonsillitis, etc. should receive proper attention +promptly. After this has been done and sufficient time allowed for +normalization, a blood count may reveal some other source of focal or +general infection, which may be reducing the general resistance. + +Auto-intoxication from some gastro-intestinal affection is commonly +a cause and must receive proper attention. The general health of the +patient must be restored and maintained. + +Thorough osteopathic treatment must be given for any cause of lowered +nutrition, local or general. The failure, I believe, in medical +practice (They admit failure in this disease) is due to the lack of +attention to the restoration of normal nutrition. Why drain a sinus +and leave an atlas or upper thoracic lesion which decreases the local +nutrition and leaves these membranes susceptible to further infection? + +Before and after surgical drainage, irrigation of the nasopharyngeal +tract. Thorough irrigation to cleanse every part. Hot irrigation (one +gallon of salt mixture solution, salt 3 parts, borax 2 parts, and soda +1 part, a tablespoonful to the gallon at 118°F. to 123°F.) to cleanse, +to free all parts from infection and to restore blood supply to the +affected parts. Frequent irrigation, daily for a sufficient time to +thoroughly sterilize and restore circulation. After each irrigation, +an oil spray (any non-irritating petroleum oil) is applied freely to +protect the membranes from irritation and further infection. + +Before each irrigation a thorough probe treatment, as described under +hypertrophic rhinitis, should be given that the membranes may be +thoroughly freed from all retained secretions. + +After the membranes are once clean, the sinuses free from infection +and the blood supply reestablished, the treatment may be reduced in +frequency to three times weekly, but the treatment must be continued +for months or even years to effect a permanent cure. The patient can +be taught to do his own irrigation after the disease is well under +control. All irritating sprays, chemical cauteries, etc. must be +avoided. The so-called “antiseptic sprays” do harm by irritating the +membranes and certainly do no good, because they do not cleanse the +parts. They only serve to deodorize, but actually accomplish nothing in +the way of cure. It has been my experience that iodine and the silver +salts in any of their various preparations are not efficient but that +they actually do harm. My experience indicates that practically every +case can be cured if the proper treatment is given for sufficient time. + + +Pharmacodynamics + +If I may be pardoned for discussing things pharmacological in a text on +practice, I want to urge that chemicals as such, are usually a failure +in treatment. My results from various series of experimental work both +laboratory and clinical, show quite conclusively that there are very +few, if any, chemical substances that have actual value by virtue of +their chemical properties alone. There are, however, cases in which +chemical agents may be used to advantage to obtain desirable physical +results and physiologic reactions. + +The salt mixture mentioned above increases the solvent power of +the water for mucus, pus, and other collected material and it also +renders the water less irritating to the mucous membranes. Other than +this, it has no value so far as I know. This solution is certainly +not antiseptic or germicidal, further than that cleanliness may be +considered an antiseptic procedure. + +The phenol-glycerine (10% phenol and 90% glycerine) which we have +recommended, is somewhat germicidal, non-irritating, except to the +nasal mucosa, is a protectant to inflamed membranes in some instances +and is also somewhat hygroscopic. These virtues to the limited extent +that they may be of advantage, depend chiefly upon physical qualities. + +Adrenalin in high dilutions (1 to 5000 to 1 to 10,000) is of value +in retracting the erectile tissues of the nares for purposes of +examination and for obtaining better drainage, etc. It also constricts +the small blood vessels and thus reduces the chances for hemorrhage or +absorption of narcotic drugs which may necessarily be used as local +anesthetics. The effects of adrenalin are very temporary and it is, +therefore, of little value in treatment. + +Following irrigation I have used the petroleum oils (liquid petrolatum) +to advantage as a protection to the mucous membrane. One-half gram +each of menthol and camphor and two or three drops of cinnamon oil to +the pint of this oil, is readily dissolved and produces a pleasant, +soothing effect to inflamed membranes, but further than this, the added +substances have no particular value. The above named chemical agents +constitute, except in rare instances, my stock of “drugs” for treatment +purposes. + + +Hyperesthetic Rhinitis—Hay Fever + +There is perhaps no disease in which there has been more speculation +concerning the etiology than in hay fever, and while osteopathy has +accomplished a wonderful advance in the treatment of this disease, I am +not sure that the cause or causes are yet thoroughly understood. + +=Etiology.=—The theoretic causes of this disease may be expressed in +the various names which have been given to it as follows: The term Hay +Fever suggests that it is a febrile condition caused by hay pollen +irritation. Peach cold, Rose cold, Rose fever, Rose catarrh, Rye fever +and Ragweed fever suggest similar specific causes. Idiosyncratic coryza +means nothing and this probably expresses what the theorists know about +its cause better than any other name. Hysteric rhinitis suggests a +probable psychic cause, which certainly does exist in some cases. If I +may be pardoned, and I know I never will be, let me suggest just one +more name—“Respiratory Reflex Inefficiency.” + +=Intoxications.=—Auto-intoxication from focal infections or from +gastro-intestinal perversions certainly have an important influence +either directly or as predisposing factors and should always be +carefully considered in treatment. + +=Osteopathic Lesions.=—Osteopathic lesions, such as interosseous, +muscular and ligamentous, seem to function as predisposing causes by +their general effects upon the system. It seems probable that their +effects upon the organs of metabolism and elimination are of greater +importance than any direct or specific effect in causing the immediate +symptoms. In practically all cases lesions of the upper thoracic +vertebræ and ribs and of the cervical region are present. It is my +opinion that such lesions are more often secondary than primary. + +=Respiratory Reflex Inefficiency.=—Measurement of nerve force in these +cases shows that none are really possessed with “an excess of nerve +force,” but that practically all vary from two-thirds to four-fifths +normal, showing that probably all cases are deficient in nerve force. + +This instability of the nervous system can be explained, I believe, in +the theory of peripheral reflex insufficiency. As evidence of this the +following facts may be cited: + +1. It is known that peripheral irritation of almost any nature, to the +mucous membranes of the nasopharyngeal tract, will excite an attack in +susceptible individuals. + +2. That any treatment which tends to increase the resistance of these +membranes will prevent or relieve an attack. + +3. That peripheral inhibition to these surfaces will temporarily +relieve an attack. + +4. That complete normalization of these membranes will make the patient +resistive to the so-called specific irritants, such as pollen, dust, +etc. + +5. That the mucous membranes of the entire respiratory and +gastro-intestinal tract react to irritants to bring about “the hay +fever state” and that any treatment which tends to normalize these +membranes, renders the patient more resistive to hay fever attacks. + +=Exciting Causes.=—There is no doubt that various air-borne irritants, +such as pollen, dust, chemical fumes, emanations from animals, etc., +act as exciting causes of acute attacks, and yet there are cases that +develop acute attacks out of season or at a time when it seems that +there could be no air-borne irritation. From evidence which will be +offered later (see prognosis) I am led to believe that probably all +susceptible cases can be made entirely resistive to the air-borne +irritants. + + +Pathology + +=Functional Pathology.=—Certainly in this disease there is ample +evidence of marked perversions of function or functional pathology. +Kyle believes that in many cases the cause of local irritation lies +in “some chemical change in the constituents of the mucus-secreting +glands,” and “it is a well known fact that in many cases of hay fever +the irritation is not limited to the nasal mucous membrane. The eyes +and mucous membrane of the stomach and bladder, and even the intestines +may be markedly irritated.” + +These chemical changes in the secretion of the mucous membranes, +together with the excess of uric acid would seem to point either to +a general perversion of the secretory mechanism or to a deficient +elimination, or to both. The periodic occurrence may be accounted for +by assuming that the systemic strain is sufficient to initiate the +symptoms. The fact that the attack is actually delayed or hastened in +susceptible individuals by the late or early beginning of hot weather, +and that these cases get relief by going to a more moderate climate is +further evidence of this. + +Again we are reminded of Dr. Still’s teaching, that the body maintains +its own chemical laboratory which adjusts or tends to adjust its work +to the needs of that body, but under abnormal strain this adjustive +mechanism may fail to meet all of the demands of function. It seems +here that the osteopathic concept may easily include all environmental +causes as well as internal causes in the predisposition to deficient +function or disease. + +=Structural Pathology.=—During the attack there is a general catarrhal +inflammation of all nasopharyngeal membranes, accompanied by a watery +discharge and marked swelling of the turbinates. Sensitive areas may be +found on the middle turbinate and opposite wall of the septum. Probably +it is this hypersusceptibility to irritation that causes the attack +from the air-borne irritants. + +The pseudo-membrane which may be found covering a part or all of the +mucous membranes of the nares probably results from this irritation and +is formed for the purpose of protection. + +=Clinical Types.=—Clinically, three rather indefinite types of hay +fever may be recognized, viz.: Vernal, those cases which have their +attack sometime during May, June or July; Autumnal, in which the attack +occurs in August or September and usually lasts until the beginning of +cold weather, and an indefinite or pseudo form occurring at any time +of the year, with no characteristic attack, as in the other forms, but +with indefinite symptoms resembling hay fever. + +=Symptoms and Diagnosis.=—Patients usually go to the physician self +diagnosed. The characteristic sneezing, the watery discharge from +the nose, and the irritation of all membranes of the nasopharynx and +conjunctiva will serve to make a diagnosis in most cases. Direct +examination will reveal the nasal congestion and other characteristic +pathology as described above. + +=Termination.=—Most cases of the autumnal form, unless successfully +treated, continue with equal or increased severity until after +the first or second frost, when they usually terminate in asthma, +bronchitis or sinuitis, which lasts for several weeks or months. Each +year the attack lasts longer and is more severe and the asthma occurs +earlier and is more severe. + + +Treatment + +=Intranasal Surgery.=—Intranasal abnormalities, such as deflected +septum, spurs on the septum, hypertrophied turbinates, polypi, etc., +which materially reduce the breathing space, usually demand surgery. +Nasal surgery, carefully and properly done, is always a great aid and +often absolutely essential to the successful treatment of hay fever and +asthma, but nasal surgery carelessly done frequently does more harm +than good. + +The correction of a deflected septum or the removal of a spur on the +septum by submucous operation often aids materially in the prevention +of pressure irritation, increases the breathing space and normalizes +drainage from the sinuses. + +Surgery is therefore very essential in many cases of hay fever, but +surgery is never the all essential part of the treatment, because if +the proper after treatment is not given, the surgery alone will seldom +result in either temporary relief or cure. + +=Focal Infection.=—The importance of focal infection of the sinuses, +tonsils, teeth and occasionally other parts, such as the nasal +cavities, epipharynx, middle ear and mastoid cavities cannot be +overestimated. Such conditions may be effective in causing hay fever, +by causing direct infection of the membranes of the nasopharyngeal +tract or by auto-intoxication. + +=Digital Surgery,= for the removal of adhesions in the posterior nares +and pharynx, is in my opinion, very essential, and this work should be +done thoroughly. Massage of the soft palate or pharyngeal walls is of +no particular value. All adhesions and adenoid tissue must be removed +because this removes an effective source of constant irritation and +focal infection and tends to normalize the direct and reflex nerve +mechanism. + +The practice of the radical intranasal technique as originated by J. +D. Edwards, D. O., is indicated, I believe, in some cases in which the +crushing of cellular middle turbinates, or the breaking of adhesions is +indicated, but I am not yet ready to accept this theory of “curetting” +the mucous membrane by radical digital technique. The fracture of +the turbinates is not necessarily a bad technique provided they are +properly readjusted as Dr. Edwards does it, but to fracture and not +readjust is a dangerous practice. The efficiency and safety of any +method depends upon the operator’s definite knowledge of what needs to +be accomplished and how it is to be done. + +There are contraindications to digital, as well as any other kind of +nasopharyngeal surgery, such as: (1) Acute infection of any part of the +nasopharyngeal tract; (2) evidence of sinus involvement; (3) septal +deflections, spurs and hypertrophied turbinates, which would not permit +such work without undue trauma. + +There are certain other precautions such as thorough cleanliness of the +parts to be treated; aspiration of the sinuses before and afterward, +and the use of a finger of sufficient size which will not produce undue +trauma. In my opinion very few doctors have such fingers. + +Failure in accomplishing results is due to three things, viz., (1) +Insufficient knowledge of diagnosis and prognosis; (2) insufficient +knowledge of what should be accomplished and the technique of doing it, +and (3) the necessary additional or supportive treatment. + +It is a great mistake to think that the removal of adhesions in the +pharynx or nares is sufficient, because if this is not followed by +the proper supportive treatment, no results or even bad results will +frequently occur. This treatment is not a massage in any sense, but a +definite operative procedure and requires as much care and skill as the +removal of adenoids or tonsils. + +Space will not permit an explanation of the digital technique and +the radical treatment should not be attempted without some definite +knowledge of the methods and technique. + +=Intranasal Treatment.=—The intranasal method of treatment as explained +above under hypertrophic rhinitis is very effective and if carefully +and thoroughly done is in most cases just as efficient as intranasal +digital surgery. This treatment followed by irrigation and oil spray +and nasal packing will be found effective in most cases if the +treatment is properly done. + +=Nasal Packing.=—Thorough packing of the nasal cavities after all +sources of focal infection have been removed and after thorough +cleansing has been done, by means of long strips of absorbent cotton +is effective in reducing the swelling and irritation. + +=The Radical Packing Method.=—This method can be done best in a +hospital. The nares are prepared as for surgical operation, by complete +retraction of all erectile tissue, thorough cleansing by irrigation +and the application of a local anesthetic. Anesthesia need not be +complete. A careful examination is then made for any synechia, or focal +infections. Packing should never be done until the doctor is sure there +is no sinus involvement. The entire nasal cavity is then packed very +firmly with sterile gauze. This is best done by means of a special +packing instrument or long nasal packing forceps, using narrow gauze +contained in tubes. In some cases the nasal cavity is lubricated before +packing. + +The packing should be done early in the morning and removed just before +bed-time, so that the patient may sleep. This treatment is repeated +daily until all signs and symptoms of nasal irritation are gone and +then replaced by irrigation and oil spray. + +If this treatment is properly done, there will be a complete sloughing +of the pseudo-membrane followed by a restoration of normal and +resistive tissue. The results of our two years’ experience (we have +tried this on only a few patients each year) are very encouraging. +Relief from the symptoms are very prompt and seemingly more permanent +than from other methods. + +=Treatment of Auto-intoxication.=—All sources of focal infection are +thoroughly treated. Sinus infection is very common and must receive +proper attention before any other treatment can be effective. + +Our experience shows that many cases have auto-intoxication of +gastro-intestinal origin. The hospital care of such cases makes +possible the thorough cleansing of the colon by irrigation and the +reestablishment of an acid producing flora which seems to prevent +fermentation. + +=Osteopathic Corrective Work.=—Thoroughness of treatment for the +removal of all causes is the secret of success. To successfully +remove the immediate sources of auto-intoxication by treating a +sinus infection or by thoroughly freeing the colon from fermentation +products means only temporary results if the underlying causes are not +corrected. A thorough osteopathic examination is necessary to determine +such causes and certainly such treatment should not be neglected. + +Correction of all cervical and upper thoracic lesions and particularly +the clavicles and ribs is important. These lesions seem to be the +result rather than the cause, but normal respiratory functions +seemingly cannot be maintained unless such treatment is done. + + +Sinuitis + +Acute or chronic inflammatory disease of the nasal accessory sinuses +with or without suppuration is more common, I believe, and is +responsible for more complications and chronic affections of the nose +and throat than is generally known. + +=Etiology.=—The cause in most cases lies in unsuccessfully treated +acute infections involving the nose and throat. Abnormalities of the +nasal respiratory passages such as deflected septum, enlarged or +cellular turbinates, adhesions resulting from cautery or careless +surgery, causing deficient drainage, constitute the local causes. +Underlying some of these direct causes, lesions of the cervical region +which impair the nutrition to and drainage from the head are to be +considered. + +=Symptoms and Diagnosis.=—Acute or chronic headaches and neuralgic +pains of the head are common symptoms. Acute sinuitis of the frontal +sinuses is accompanied by marked and persistent frontal headache and +pain in the eyes. In infections of the maxillary sinus there is usually +pain over the affected part, but there is often referred pain to other +parts of the head. Sphenoidal sinuitis usually causes general headache +with no definite location. + +By direct examination of the nasal cavities a purulent or mucopurulent +discharge may be seen and the source determined. In many cases, +however, the pus may be retained or insufficient in amount to detect by +direct examination. + +Transillumination in a dark room by means of a good transilluminator +will usually show a darkened area over the affected part. The average +battery equipments commonly sold for this purpose are of little value. +The X-ray plate when properly done, is more dependable than the +transilluminator. + +In some cases, all of these methods fail to locate the affected sinus +and the cause can be found only by opening into the sinuses, aspirating +with a catheter and making microscopic examination of the aspirated +material. The microscope is indispensable for this work. Every +suspicious discharge should be stained until pus is found and except +in well defined cases, this is the only practical method of positive +diagnosis. + +=Treatment.=—Local treatment of the nasal cavities by retracting the +turbinates and irrigation will be successful in many cases, but unless +there is a large normal opening the pus will not drain sufficiently +and probe treatment is required. In acute cases in which the pain is +marked, osteopathic treatment of the cervical region, deep relaxation +of the submaxillary structures and the application of heat over the +affected part, together with the local nasal treatment should be given, +but if this does not relieve the pain within twenty-four hours, the +sinus should be opened and thoroughly drained. If efficient drainage is +not established early the symptoms will usually increase until the pain +is almost unbearable and serious complications may result. + +In practically every case of acute sinuitis, I believe it is best to +make a good, free opening into the affected sinus first and secure +complete drainage by catheter aspiration. If this is properly done +every case will recover much more quickly and without complications or +danger of chronic infection. + + +Non-Suppurative Sinuitis + +Cases of non-suppurative sinus involvement are not at all uncommon. +The so-called “Vacuum sinuitis” which results from a closure of the +normal opening, resulting in inflammation without pus formation, is +responsible for many of the complicated cases of referred pain, which +are so often improperly diagnosed. Chronic headaches and the various +symptoms of fifth nerve affections, the neuralgias of the head, are +frequently caused by non-suppurative sinus involvement. + +=Treatment.=—The treatment consists of establishing good drainage +and proper ventilation of the affected sinus or sinuses followed by +thorough intranasal treatment as explained above. The osteopathic +corrective work must not be neglected. + + +Syphilis of the Nose + +In osteopathic practice syphilis is not a common disease. The +occurrence of syphilis of the nose is still more rare but certainly +should be recognized. + +=Diagnosis.=—The local lesions of the nose are of two types, those of +acquired syphilis and of congenital syphilis. + +There are three characteristic manifestations of acquired syphilis +as follows. The primary lesion or hard chancre is a firm, indurated +ulcerated mass with only slight discharge. Chancre of the nose is +exceedingly rare. In secondary syphilis there is the mucous patch, the +result of mucous membrane necrosis. In tertiary syphilis the local +lesion is the gumma or more commonly, the ulceration left from necrosis +of the gumma. These lesions may appear from a few to many years after +the initial infection, but they never follow immediately. The lesions +may appear on almost any part of the intranasal structures. They +resemble the lesions of atrophic rhinitis but in atrophic rhinitis +there is never the extent of destruction that so frequently results +from tertiary syphilis. + +=Treatment.=—It has been my practice to refer all suspected cases to +Dr. F. J. Stewart for differential diagnosis and treatment and his +method of the use of salvarsan has proven efficient. + + +Epistaxis—Nose Bleed + +The causes of nose bleed may be divided into two general groups, +local and constitutional. The first group consists of trauma directly +to the nose either external or internal, from nasal operations and +other causes. The presence of a cluster of thin-walled veins on the +anterior part of the septum which readily rupture from slight cause, +constitutes perhaps the most common cause of nose bleed. The ulcers of +atrophic rhinitis or syphilis occasionally cause bleeding. Malignant +growths of the nose may cause frequent and profuse hemorrhage. The +constitutional causes of epistaxis are, the acute fevers, cardiac +and arterial diseases, which cause excessive tension; and cases of +altered composition of the blood such as the anemias, malaria, purpura, +chlorosis, hemophilia, etc. + +=Diagnosis.=—Direct examination of the nose will usually reveal the +cause. If there are no signs of trauma or rupture of the anterior +group of vessels and the bleeding does not respond quickly to packing +of the affected side, there is either a rupture of a large vessel, +which requires long continued packing, or it belongs to the class of +constitutional disease. + +If there is evidence of some necrotic disease of the nose or if there +are areas of exposed bone or cartilage from careless surgery, these may +usually be seen and the point of bleeding located. + +=Treatment.=—Cold applications, irrigation of the nares with cold +normal salt solution and the application of an absorbent cotton or +gauze pack is usually sufficient to stop the average case of epistaxis +from any cause. The direct application of cold to the lower cervical +region will cause capillary restriction. + +There are many cases in which the membranes of the nose have lost their +tone due to various irritants or from deficient nutrition to the parts. +These are cases of a wholly different type from that of the well known +necrotic diseases such as atrophic rhinitis and syphilis. Hay fever +is a result of such a cause. The treatment in such cases consists of +removing any local causes or osteopathic lesions and then normalizing +the resistance of the membranes by the methods described under the +treatment for hay fever. + +The treatment for those cases of epistaxis due to constitutional +disease depends wholly upon the causative factors and the proper +treatment of these. Any local treatment in such cases will be expected +to produce only temporary results. + + +Diseases of the Nasopharynx + +The nasopharynx may be the location of acute or chronic inflammations, +neoplasms, malignant or nonmalignant, processes of atrophy or +hypertrophy, adhesions, etc. It is important to remember that the +nasopharynx admits the Eustachian tubes and supports four superficially +located ganglia of the fifth nerve. + +=Acute Nasopharyngitis.=—Acute inflammatory processes of this region +may result from rhinitis, infections of the lower pharynx, focal +infections of these parts or from direct involvement of its own +structures. + +The symptoms are post nasal tenderness and mucus dropping. Some +patients experience the sensation of a foreign body in that location. +The thick, adherent collections of mucus are difficult to dislodge and +sometimes are so persistent that they cause nausea. There is usually +occlusion of the Eustachian tubes, resulting in partial deafness, +tinnitus and often dizziness. + +=The Treatment= consists of thorough cleanliness by irrigation and +osteopathic corrective work to the cervical region. It is also +essential to keep the anterior neck structures particularly those of +the submaxillary region, thoroughly relaxed to maintain efficient +drainage. + + +Chronic Nasopharyngitis + +This is one of most common diseases of the nasopharyngeal tract, +causative of many complications and yet perhaps the least recognized in +proportion to its significance. The frequent occurrence of adhesions +of the pharyngeal fossæ, hypertrophied membranes, enlarged spongy +extensions of the inferior and middle turbinates (the posterior +turbinate bodies) occlusion of the orifice of the Eustachian tubes and +chronic, excessive secretion of thick mucus all show that this disease +has either gone unrecognized or at least has not received proper +treatment. + +=Treatment.=—Complete surgical removal of all abnormal growths, +adhesions, etc. as described under the treatment of chronic +non-suppurative otitis media and this followed by thorough irrigation +and other methods of local treatment described above are efficient. +The successful treatment of this disease requires time. There has been +a partial or, in some cases, almost a complete loss of the normal +functions of the nerve reflex mechanism of these parts, peripheral +reflex inefficiency and this must be restored. Efficient and long +continued treatment of the lesions commonly found in the cervical and +upper thoracic regions will do much to restore these normal functions, +but this alone without the surgical treatment will never effect a +permanent cure. Neither will the surgery and local treatment alone +effect a cure. The whole treatment is required. + + +Adenoids + +Adenoids are the hypertrophied lymphoid tissue of the nasopharynx. +They occur commonly in children, as a result of acute inflammations. +Possibly the suckling process of the child produces a partial vacuum of +the epipharynx and thus causes excessive blood supply to the part and +therefore excessive growth of these soft tissues. + +Adenoids, however, are not confined to children but frequently occur in +adults. In all cases they are a source of much annoyance and often the +cause of acute and chronic disease. + +=Symptoms and Diagnosis.=—Mouth breathing, head colds, partial +deafness, etc. are the common symptoms. The flattened nose, the high +arch of the hard palate and the stupid appearance of the face are +diagnostic. By direct palpation to the nasopharynx the nature and +extent of the adenoid mass can be determined and this is the best +method of diagnosis. + +=Treatment.=—Many methods of non-surgical treatment have been employed, +but there is nothing as satisfactory as complete surgical removal. +Adenoid tissue has no known function different from that of other +lymphoid tissue and there is always sufficient to perform any necessary +function without excess of adenoid growth. The excessive adenoid +growth is in every case a detriment to normal development, because it +impairs nasal respiration and usually causes chronic nasopharyngitis +and thus reduces resistance against all diseases of childhood. There +is therefore, no excuse, much less a reason, why excessive adenoid +growths should not be removed surgically, provided it is properly and +thoroughly done. + +The operation for removing adenoids requires in children, a general +anesthetic. In adults, a local anesthetic is used by some operators. +I have found it best to first break the adenoid mass away from the +side walls of the pharynx digitally. A LaForce or Gradle adenotome is +then used to remove the adenoid mass. If either of these instruments +is properly used it will always remove the greater part of the +adenoid mass without undue trauma or injury to any of the pharyngeal +structures. Curets should never be used because they almost never +remove the adenoid mass properly, but they usually do injure the +pharynx. Many cases of pharyngeal adhesions, Eustachian tube occlusion +and nasopharyngitis result from direct injury caused by curets. + +After the adenoid mass has been removed the finger is inserted into the +pharynx and any adenoid growths in the posterior nares are removed. +The pharyngeal fossæ are also thoroughly freed from adenoid tissue and +adhesions and the orifices of the pharyngeal portions of the tubes are +gently dilated. This method insures complete removal of all excessive +adenoid tissue, and normal functions of the nasopharynx. Adenoids thus +removed do not return. + +After the surgical work has been completed the nasopharyngeal tract +should be thoroughly irrigated with hot salt mixture solution. +This thoroughly cleanses the membranes, hastens healing, prevents +hemorrhage and avoids post-operative infection. Irrigation of the +nasopharynx should be continued for some days or until all evidences +of inflammation have ceased. The pharynx should then be examined to be +sure that no adhesions have developed from inflammation, but if the +operation is carefully done, complications will never result. + + +Diseases of the Oropharynx + +Acute Pharyngitis + +Acute inflammations of the pharynx alone or in common with +inflammations of other parts of the nasopharyngeal tract are common. +This disease is most common as a result of the acute infections +affecting the nose and throat. + +=Etiology.=—The predisposing causes are focal infections of the +nasopharynx, such as tonsillitis, sinuitis, etc. Deficient nutrition or +anemia of the pharynx or systemic anemia are common causes. Lesions of +the cervical, upper thoracic and hyoid are common predisposing causes. +Undue exposure of the neck in susceptible persons or too much or too +tight clothing about the neck may also predispose to inflammations of +the pharynx. + +The exciting causes are the acute infections, colds and focal +infections. Perhaps the most common exciting cause is tonsillitis, +acute or chronic. + +=Symptoms and Diagnosis.=—The characteristic dryness of the pharynx, +pain and persistent coughing are diagnostic. Upon direct examination, +the reddened, swollen appearance of the pharynx and posterior pillars +can be seen. + +=Treatment.=—The treatment should be general and local and should +be determined by the causes and conditions present. This disease is +usually an acute infection and like other acute infections, the usual +systemic treatment should be applied. + +The local treatment consists of thorough cleansing of the nasopharynx +(by irrigation if the patient can permit) and the frequent (or +occasional as required) use of some gargle until the inflammation +has subsided. Any cleansing nonirritative solution may be used for a +gargle. Equal parts of peroxide, alcohol and glycerine, a tablespoonful +to a half glass of very warm water or ten to fifteen drops of +phenol-glycerine to a half glass of warm water will make a good +cleansing gargle. + +The osteopathic treatment consists of corrective work to the cervical, +upper thoracic and hyoid and thorough relaxation of the submaxillary +musculature to obtain good venous and lymphatic drainage. If sufficient +care be taken to avoid trauma, digital stretching of the soft palate +and pharyngeal muscles by the use of the finger internally, is very +efficacious. + + +Chronic Pharyngitis + +Chronic pharyngitis may be hypertrophic, atrophic or granular. In +hypertrophic pharyngitis the pathologic changes have passed beyond the +stage of hyperemia and there is always hypertrophy or hyperplasia, +usually the latter, of the pharyngeal membranes. These changes in +most cases, have extended to and involved all of the nasopharyngeal +membranes. + +Chronic granular pharyngitis, or so-called clergyman’s sore throat, +has a similar pathology to that described above, but with swollen +and inflamed lymph follicles. This condition seems to be a result of +excessive use of the voice. + +Chronic atrophic pharyngitis has a similar etiology and the diagnostic +signs are also similar to atrophic nasopharyngitis with which it is +usually associated. + +=Etiology.=—The causative factors are similar or the same as those of +nasopharyngitis. Lesions of the cervical and upper thoracic and chronic +focal infections such as tonsillitis, sinuitis, etc. are the common +causes. + +=Treatment.=—The nature of the treatment should be determined by the +causes found. The nature of the pathology requires long continued +treatment and careful attention to all causes. Thorough osteopathic +corrective work, the removal of all sources of focal infection, proper +attention to any gastro-intestinal perversions which may be causing +auto-intoxication and thorough cleanliness of the parts by gargling +with some cleansing, non-irritating solution and by irrigation. + +In most cases there is a considerable collection of adhesions in +the nasopharynx or posterior nares or in both. Enlarged “posterior +turbinate bodies” and the extension of the inferior turbinates into the +pharynx are also common results of the hypertrophic process. Complete +surgical removal of this excess tissue and the after treatment as +described above under chronic nasopharyngitis are frequently required +to obtain complete and permanent results. + +These cases can be successfully treated if the proper attention is +given to all possible causes in each individual case. It is the +individualization, the specific and detailed attention to the cause or +causes, and such treatment continued for sufficient time, that will +obtain results. + +In atrophic pharyngitis, normal nutrition to the parts and usually to +the entire system must be restored. Many such cases are secondary to +systemic anemia or to rheumatic intoxication. A careful examination +should be made for evidence of systemic causes. In many cases, I +believe that thorough osteopathic corrective work applied to the mid +and lower spine is the most essential part of the treatment. Other than +this the local treatment as described under atrophic rhinitis applies +here. + + +Tonsillitis + +There is perhaps no other organ of the body, diseases of which have +caused a greater variance of opinion relative to treatment than +the tonsils. There are those who believe that every hypertrophied, +atrophied, or infected tonsil together with its fellow of the opposite +side should be removed. There are also those who believe that no +tonsils, regardless of their pathology, should ever be removed. These +are the radicals and their views are not at all in keeping with present +day facts. + +Those physicians and surgeons who have tried to arrive at some safe +conclusion on this subject, believe that there are certain methods of +non-surgical treatment which are effective in many cases and they also +believe that in other cases, tonsillectomy is imperative. + +=Functions of the Tonsils.=—Many and varied functions for the tonsils +have been held by various theorists such as: the absorption of the +products of salivary digestion; the secretion of an amylolytic ferment; +that they are atavistic structures and therefore have no function; +that they eliminate systemic toxins; that they serve as culture tubes +for the production of vaccines; that they protect the deeper cervical +tissues from bacterial invasion; the theory of internal secretion and +a score of other theories which so far, have never been substantiated +by either clinical or experimental evidence. + +The hematopoietic theory or the theory of blood formation has a rather +definite basis because such a function would be possible from the +histologic structure. The formation of small lymphocytes has been +attributed to tonsil tissue (Flemming) and this view has been generally +accepted. Some of the lymphocytes however, find their way through +the epithelial walls into the crypts and are discharged as “mucous +plugs”, while others are carried by the efferent lymphatics into the +circulatory system. In this respect, the tonsils, like other lymphoid +tissue, produce lymphocytes which are essential constituents of the +blood. This function is particularly marked during the growing period, +but this function is also highly developed in all lymph nodules during +this period, and in the growing child there is an abundance of such +tissue and thus it seems that the tonsils, while important to the +growing child, would not be at all indispensable structures. + +Some physicians claim to have observed deficiencies in growth and +development of children whose tonsils had been removed during the first +ten or fifteen years of life, but this is not commonly accepted. The +tonsils have their greatest cellular activity during the growing period +and unless chronically hypertrophied they atrophy during adult life. + + +Tonsillectomy + +We may safely conclude from this evidence, that in the growing child, +it may be well to retain the tonsils providing they are not directly +affected in such a way as to endanger the general health of the child, +but that there is little, if any, danger in their early removal. In +adults, there seems to be no reason why they should not be removed in +cases in which there is evidence of involvement beyond restoration by +treatment or those cases in which there is evidence of toxic absorption. + +When surgical removal of the tonsils is indicated, the complete +removal or tonsillectomy should always be done. A careful and complete +enucleation of the tonsils when properly done will never be followed +by any untoward results other than the temporary surgical sore throat. +There is never any excuse, much less a reason, for partial removal of +the tonsils or tonsillotomy, because such operations never accomplish +the desired result and they nearly always require tonsillectomy later. + +In association with a reputable vocal teacher I have studied the +results of tonsillectomy on the voice. In none of the twenty cases +studied was there any impairment following the operation, but on the +other hand sixty per cent were improved either in range of pitch, +quality or endurance, in addition to their being more free from +laryngitis, pharyngitis, etc. for which the operation was done. Doctors +Ruddy, Edwards and Reid of our profession have told me of similar +experiences, so I am certain that tonsillectomy properly done will in +selected cases, improve the voice. + + +Acute Tonsillitis + +Acute tonsillitis is an acute infectious and often a contagious disease +characterized pathologically by inflammation of the tonsils. Some +authors differentiate between follicular tonsillitis in which the +crypts or lacunæ are involved, and parenchymatous tonsillitis in which +the parenchyma is involved. + +=Etiology.=—The predisposing and exciting causes are the same as in +other acute infections of the upper air passages except that there is +usually a chronic tonsillitis as a result of some previous attack. + +=Symptoms and Diagnosis.=—The symptoms also are similar to other acute +infections of the nasopharyngeal tract, with sore throat, variable +temperature, headache, etc. By direct examination of the pharynx, the +protruding masses with white or yellow patches are readily seen. + +=Treatment.=—Infection, drainage and elimination are three words +inseparable in the therapeutics. The local treatment (I doubt if many +will agree) in either acute or chronic tonsillitis is essentially the +same—radical aspiration drainage. In all cases, except young children +who will not permit it, I place a vacuum cup directly over the tonsil +and apply as much vacuum as can be obtained. This treatment will, when +properly done, empty the crypts of all pus. This accomplished, each +crypt is probed with a cotton applicator dipped into phenol-glycerine. + +Cervical and upper thoracic treatment and deep relaxation of the +sub-tonsil tissues to increase the normal blood supply and to decrease +congestion by drainage elimination are essential. The lower thoracic +and lumbar should receive due attention for the purpose of increasing +general elimination. The diet and other treatment are no different from +that in other infectious fevers. + + +Peritonsillar Abscess + +(Quinsy Sore Throat.) + +Peritonsillar abscess results from the collection of pyogenic bacteria +and pus formation between the tonsil and the pillars of the fauces. It +is perhaps a result of the closing of an infected crypt causing deep +penetration of the pus. + +=Diagnosis.=—The symptoms are those of acute tonsillitis but usually +more marked and with one tonsil decidedly more protruding than the +other. In some cases the location of the abscess can be seen and it is +comparatively easy to open with a knife or probe, but in many cases the +abscess is so situated that it cannot be located except by exploratory +probing. + +=Treatment.=—Drainage by direct incision of the abscess pocket is +indicated as early as a definite diagnosis can be made. There is no +definite technic to be followed except to observe certain general +principles. If the “pointing” of the abscess can be located, it is +comparatively easy to make a good, free, direct incision and accomplish +complete drainage. In many cases the only way to locate the pocket +is to employ a probe or small, long, scalpel and explore between the +pillar and tonsil until the pus pocket is found. As soon as this is +located the pus pours out around the probe and this gives the location. +Free drainage by means of a liberal incision should then be made. +Aspiration of the pus pocket and filling with phenol-glycerine is +effective after drainage has been obtained, but a liberal drainage must +be maintained. + +The non-surgical treatment as described under acute tonsillitis is to +be applied here. + + +Chronic Tonsillitis + +Chronic tonsillitis usually is the result of one or many attacks of +acute infections of the tonsils. Occasionally cases of marked chronic +tonsillitis occur in which the patient denies ever having had an acute +attack. + +The pathology consists of hypertrophy of the lymphoid tissue and +connective tissue. + +=Diagnosis.=—The purpose in diagnosis is not to determine whether the +tonsil is hypertrophied but to determine whether the tonsil is causing +any local or general physiological perversions and if so, whether local +treatment or surgery should be applied. + +The direct examination should be made very carefully, because otherwise +a bad tonsil may be readily overlooked. The mere fact that a tonsil is +large or has open crypts from which a whitish mass may be expressed +does not mean that such a tonsil is directly responsible for local or +systemic physiologic perversions. + +The examination should be made by means of a tongue depressor, tonsil +retractor and a good head mirror and reflecting lamp. Every part of +the tonsil and surrounding pillars should be carefully examined. Firm +pressure applied against the tonsil from in front and behind will +often force material from the crypts or out around the capsular margin. +Any such material thus expressed should be examined microscopically. By +probing the crypts with a small pointed cotton-wound probe and staining +the material obtained, the condition of the deep parts of the tonsil +can be determined. + +The symptoms in every case, are to be considered with the microscopic +findings, but there are cases in which either of these, together with +appearance on direct examination, is sufficient to determine the +advisability of tonsillectomy. + +In general, we may say that the following factors would indicate +tonsillectomy. + +1. Chronic, recurrent tonsillitis with or without complications, which +does not respond to non-surgical treatment. + +2. Positive evidence of arthritis of any form with microscopic evidence +of some virulent organism, such as staphylococcus, streptococcus or +long-chain pneumococcus, present deep in the tonsillar tissue. + +3. Any persistent discharge of pus from the tonsil in which the +microscope shows the presence of virulent bacteria and which will not +be relieved by treatment. + +4. Markedly hypertrophied tonsils which directly interfere with the +voice, deglutition or respiration and which do not respond to treatment. + +5. Persistent focal infections of the middle ears, or sinuses or root +abscesses which do not respond to treatment and in which case there +is a virulent infection of the deep parts of the tonsil, shown by +microscopic examination. + +The above are only general conditions and there are probably many other +indications or groups of symptoms that would indicate tonsillectomy. +In most cases, unless the findings show positively that tonsillectomy +should not be delayed, we advise treatment. If treatment does not +restore to normal, it will probably reduce the time of the surgical +sore throat following the operation. + +=Non-surgical treatment.=—The local direct treatment, as we practice +it, consists of: 1. Direct aspiration by means of the tonsil cup, +applying from fifteen to twenty inches of vacuum. 2. Application of +phenol-glycerine by means of cotton applicator to the full depth of +each crypt. 3. Irrigation of the crypts by means of a catheter and +hot salt mixture solution. 4. Syringing of the crypts by means of the +catheter and phenol 10%, alcohol 20% and glycerine 70%. + +The digital treatment of the tonsil consists of: 1. Applying pressure +against the anterior pillar thus forcing the contents out of the +tonsil, the Ruddy method. 2. By the bidigital technic, the front +finger of one hand inside, posterior and inferior to the tonsil and the +fingers of the other hand outside exerting deep pressure and opposing +the finger inside. In this way the tonsil can be lifted forward and +upward and its contents expressed. The digital treatment is not as +effective as that described above. + +The osteopathic corrective treatment consists of adjustment of the +atlas and axis and the mandibular articulation and the obtaining of +free movement of the hyoid and the relaxation of the submaxillary +musculature and other deep structures. + +This treatment, if followed persistently, will relieve the local +symptoms of a very high percentage of cases of chronic tonsillitis, and +in many cases even the systemic complications will be relieved. Whether +in cases of systemic absorption this is the preferable treatment I am +not sure, because, once the local condition is improved the patient +will usually refuse operation and even if the physician finds definite +evidence of toxic absorption he cannot convince the patient that his +tonsils require surgery. + + + + +MENTAL DISEASES + +BY + +L. VAN H. GERDINE AND A. G. HILDRETH. + + +INTRODUCTION + +The subjects herewith presented, while including certain of the most +important sections of mental disease, make no claim to completeness +either in the subject matter presented or in the attempt to cover the +entire field of the psychoses. They cover those portions, however, with +which we have come in closest touch at the Still-Hildreth Sanatorium, +and in which we have the most complete records. I have been aided in +the compilation of the essential facts and statistics by the able staff +of the institution and wish to acknowledge especially the valuable +cooperation of Dr. C. M. VanDuzer in the Dementia Praecox group, Dr. H. +P. Hoyle in the Manic Depressive group, Dr. B. L. Jemmette in the group +entitled Delirium, Confusion and Stupor, Dr. J. C. Snyder in the Senile +Dementia group and Dr. G. S. Elkins in the Involutional group. The +opinions concerning each type held by Dr. A. G. Hildreth are appended +under its appropriate heading. I wish to state emphatically that +the sole treatment carried out in the Macon Institution is specific +corrective work upon spinal lesions, and it is upon this treatment that +the statistics are based which are to be found throughout the text. +These records cover more than 700 cases, including complete histories +of the patients with the physical and mental findings on examination; +these represent, therefore, by far the largest body of statistics ever +accumulated in the study of osteopathic results in mental disorders. +While the results naturally vary in different types of mental disease +the grand total shows that more than one-half of all patients admitted +recovered. Details for each group will be mentioned under its +appropriate heading. While adjuncts such as diet and hydrotherapy have +been utilized; we certainly cannot attribute any curative value to +their influence. + +It should be further emphasized that in no case whatsoever has medicine +been used as a curative agent. And the same may be said of surgery. +It has indeed been conclusively proved even in the medical world that +medicines and surgical procedures are absolutely ineffective; from +the osteopathic viewpoint this of course is perfectly reasonable +since the theory calls for definite lesions as causative factors and +these lesions can hardly be reached other than by the osteopathic +method of correction. The results obtained, therefore, could only +be attributed to the genuine osteopathic principle enunciated by Dr. +A. T. Still who kept in close touch with the work and gave it his +approval up to the time of his death. He had always maintained that +the osteopathic principle could accomplish remarkable results in this +field and considering the previous inefficiency of any other method his +confidence has been fully justified. + + +Dementia Praecox + +This condition refers to mental disorders arising usually during the +period of puberty or adolescence, therefore, between the ages of +fourteen and twenty-five for the most part, although apparently similar +cases may arise in later years. The term dementia refers to mental +deterioration and enfeeblement, while “praecox” signifies adolescence, +though some writers infer that the term praecox may be used to indicate +the early or precocious development of the mental enfeeblement. Certain +it is that in most cases deterioration, with its resulting symptoms of +mental enfeeblement giving rise to the term dementia, usually occurs +in time, though by no means always early. It is a chronic progressive +disease which may terminate in a complete loss of mentality; in other +cases it may become arrested in any stage and remain so permanently; +in still others it may recover, though this is rare. By reason of the +variability of the symptoms, three groups are generally recognized, +first suggested by Kraepelin. Each is differentiated by more or +less characteristic symptoms and referred to under the head of the +Hebephrenic, Catatonic and Paranoid types, although all have certain +symptoms in common and there are mixed types. + +=Etiology.=—According to the authorities some form of hereditary +factor can be found in some fifty per cent or more of all cases; this +is supposed to create a predisposition, a natural weakness of the +nervous system, which renders it unable to bear the ordinary storm and +stress of life, so that the mechanism becomes according to the French +expression, “wrecked upon the rock of puberty or adolescence;” in other +words, a premature giving way of the nervous system, being inherently +unable to stand the strain of life. Another suggestion is that it +represents the outcome of abnormal types or reactions of the individual +to the environment, with a failure of proper adjustment to surroundings +and the formation consequently of mental problems which to the patient +are incapable of solution. This may be called the psychological theory. +The most commonly accepted idea, however, is the physical causation. +According to this the disease results from auto-intoxication, the +intoxicant arising from the disturbances of the glands with internal +secretions, more particularly the sexual glands. This endocrine theory +is supposed to be supported by the fact of the appearance of this +disease most commonly at the time of puberty and shortly thereafter. + +The osteopathic conception fits in very well with this latter view, +inasmuch as the spinal lesions are quite capable of explaining not +only a disturbance of innervation to the glands with the resultant +interference in their normal secretion, but also could produce disorder +of the circulation and nutrition to the brain. + +=Symptomatology.=—Although each variety of Dementia Praecox has special +symptoms characteristic of the type there are certain symptoms common +to all forms, and these will be first considered. All the functions +of the mind in the course of time tend to become disturbed and to +be weakened, but in the earlier stages we find marked differences +as regards the disturbance of different functions, thus memory and +orientation in most cases seem good; on the contrary, attention and +association of ideas somewhat poor. Emotional life is almost always +markedly affected, even in the beginning. Very commonly at first there +is depression to be followed later by expansive feelings and then by +apathy in general. The will power is altered early and the conduct +is apt to be peculiar. The judgment becomes impaired. All of these +symptoms mentioned are deviations from the normal in the patient +and therefore presuppose that the patient was formerly normal. This +should sharply differentiate the praecox group from cases of defective +development (imbecility or idiocy). In this latter group there is an +arrest of development of the mind, whereas in praecox there is a loss +in a developed intellect. We see a young patient, for example, who +has lost interest in things about him, neglects his work at school or +at home, remains alone for long periods of time and seems unwilling +to mingle with other people. He gives the impression of one depressed +and worried about something he is trying to solve, perhaps he mutters +to himself or gives way to unprovoked laughter, he may refuse to eat, +or to talk unless questioned and may even then not answer. When he +does talk it will be discovered that he knows perfectly well where he +is, and knows people around him and understands everything that is +going on; his memory will be found good, he can usually recall past +incidents and tell what he has been doing recently. As the condition +progresses, however, while the patient may still for a long time retain +fair orientation and memory for past events, his accumulation of recent +ideas will be found poor, so that he will recall them with difficulty. +We notice that it is difficult to get the patient’s attention and +concentration seems to be impossible, he may answer a direct question, +but immediately seems to be occupied with other thoughts and it takes +some little effort to gain his attention again. If he continues to +talk it is plain that the association of ideas is poor, giving rise to +disconnected phrases which usually come forth sluggishly and without +show of emotion. Dissociation of ideas occurs; that is, different +ideas expressed may practically contradict themselves. For example, +the patient may say he is a king and yet when asked to sweep the floor +will do it perhaps without hesitation, not considering that is hardly +the kind of work a king would do. The dissociation is also marked in +the contradiction found between the content of the thought and its +associated emotional idea, for example, the patient may speak of a +near relative as dying recently, yet with no show of emotion, even +with a meaningless laugh. This dissociation may ultimately result in +complete incoherence, in which no sense can be found whatsoever in his +speech. Emotional indifference is noticeable early and sluggishness +of reactions to stimuli, even failure of such reactions; the patient +will neglect himself, stay away from meals, express no desires and make +no complaints. In the earlier stages, however, the patient who may +have been for some little time apathetic, suddenly without apparent +cause becomes angry, noisy, and possibly violent and destructive, +again gradually relapsing into his quiet, apathetic state. The thought +content is commonly associated with delusions, that is obviously false +ideas, but which the patient is unable to perceive are false. Delusions +of persecution are most common, the patient feeling in a dim way that +everything is not right; and in attempting to explain to himself the +reason, often attributes causes to people or forces outside of himself, +and on account of the feeling of bodily discomfort, also by reason +of the depression, he explains the external forces as unfriendly to +himself. Hallucinations may be present and furnish the material around +which the delusions form; on the other hand hallucinations may result +from the delusions. By hallucination is meant a false sense perception, +as the patient may state he sees someone before him who is not there, +or that he hears voices from individuals who are not around him; he may +also complain of receiving electrical shocks, or wireless messages, +which he usually states come from his persecutors. Symptoms of this +nature form a good example of the so-called split personality, or +“schizophrenia,” wherein certain idea complexes are split off from +the main personality and address themselves to the main portion, the +patient attributing these noises (voices), sensations (visceral and +tactile), tastes and smells to an objective rather than a subjective +source and subsequently forming delusions. However, unless we are +dealing with the paranoid form the delusions are fragmentary, transient +and absurd. + +=Hebephrenia.=—This is a progressing mental enfeeblement, terminating +usually in deterioration, and without showing marked peculiarities +in thought or action aside from the progressing deficiency. The +patient appears in general inactive, lacking in energy and ambition, +indifferent, depressed, incapable of much concentration and hence +the efficiency becomes progressively impaired until he is unable +to accomplish anything. From time to time there may be periods of +confusion, depression, passivity, at other times periods of excitement. + +=Catatonia.=—In this form the general symptoms are similar to those +of the simple type above described with the addition of the special +symptoms referred to as catatonic excitement and catatonic stupor. The +excitement period is manifested by an unrest and monotonous activity, +stereotyped actions and speech, the patient constantly repeating +some act, such as moving the hand, foot or head over and over again +in the same way, or repeating the same word or phrase indefinitely. +This occurs apparently involuntarily, the actions being automatic in +character. The patient who has been in a semistuporous state may pick +up a glass or chair and without show of emotion break it against the +wall. In catatonic stupor the patient may show in the lighter degrees +a simple loss of interest and feeling with sluggish reaction to +stimuli, or a profound inactivity and stupor in which state he cannot +apparently be reached by any stimuli; nevertheless, he apparently +retains consciousness. In this type we observe the interesting symptom +of negativism in which the patient always does the opposite of what +he is requested, or refuses outright to obey any command. There may +be a refusal of food so that the patient has to be fed by a tube, +mutism may be present, the patient may go for weeks or months without +saying a word; stereotype of attitude results in cataleptic poses and +rigidity, in which the patient may maintain any particular pose for +a prolonged period of time, and if placed in some other attitude may +similarly retain the new attitude for a long time. This constitutes +the so-called wax like rigidity, the patient reminding one of a wax +figure. Pathologic suggestibility occurs in which the patient imitates +movements, or repeats words and phrases that are spoken or performed +before him. + +=Paranoiac Form.=—In this type delusions predominate and are +characterized by variability, inconsistency, illogicality and +transitoriness on the one hand, with many gradations to the opposite +extreme where they become more or less fixed, and often dovetail into +each other forming apparently a systematic whole. They tend to be +usually of a persecutory and hypochondriacal character and in later +stages when the mind is distinctly weakened are often of a grandiose +type. Sometimes the patients have some kind of explanations for them +and at other times none whatsoever, and they are often curiously +dissociated from the emotional accompaniment. The patient may state +there is poison in his food, in an indifferent tone of voice or even +with a laugh; he may claim that his teeth are all set in wrong and +offer no explanations to these obviously false ideas. The patient +commonly thinks that somebody “has it in for him,” someone will do +him mischief, will kill him, that people are talking about him and +criticizing him, everything that he hears or reads he thinks has some +bearing on himself, so-called “delusions of reference.” Hallucinations +may be present, the patient hearing voices, or receiving impressions +or ideas which he claims come from without. These external impressions +he misinterprets as voices or forces which are accusing, threatening +and slandering him. Later on, the patient tends to change from the +depressed persecutory stage to an expansive one, when he claims he is +some celebrated person, king or president, or pope. The impairment of +the judgment is clearly demonstrated in these cases since the patient +who may claim to be the king of England may beg the attendant to change +his place at the table or for a postage stamp. + +=Pathologic Anatomy.=—This is obscure. Since a certain proportion +of cases recover, there can evidently be no degenerative changes at +the outset, though some cases deteriorate fairly early, others only +after several years. In some chronic cases there have been observed +degenerative changes in the cortical cells. + +=Diagnosis.=—First, the common age of onset during puberty and +adolescence, fourteen to twenty-four in the vast majority of cases, +this being the only common mental disease occurring during this age +period. Second, the progressive character terminating in mental +enfeeblement or deterioration, that is “dementia” proper. Third, the +evidence of defect or deficiency symptoms indicating that the patient’s +mind has altered in the sense of deterioration from its former normal +condition, whereas, in imbeciles or idiots the mind has failed to +develop in the first place. Fourth, in the earlier stages particularly +the marked dissociation of the brain powers, some being well maintained +as memory and orientation (that is knowledge of time and space), others +being weakened, such as judgment, power of attention and the like. +Fifth, the early appearance of the emotional defect, a remarkable +indifference and apathy of the patient to people and surroundings, +the patient being unsocial and taking no interest in anything. Sixth, +all the peculiar motor reactions, which are mentioned above under +the catatonic head, and which very rarely occur in any other mental +disorder. Seventh, the delusional content nearly always refers to the +patient’s exterior, forces outside of him, people or things which are +exerting an unfavorable influence upon him, delusions of persecution +and reference. The patient practically never accuses himself, as is the +rule in cases of true melancholia, never blames himself, but always the +other party or the other force outside of him. Eighth, the delusions of +grandeur are usually indicative of a stage of deterioration. + +=Prognosis.=—Some authorities are inclined to doubt if any case ever +completely recovers, claiming that in apparent recovery it may have +been a question of mistaken diagnosis, or that the recovery is more +apparent than real, that the patient is not truly well, or will have a +relapse, so that a permanent cure will be impossible. Other authorities +admit the possibility of recovery though in a very small minority +of cases. The statistics of the Still-Hildreth Sanatorium, covering +more than two-hundred fifty cases show total recoveries of at least +one-third. This includes all types and all stages of progress, many +being advanced on entrance. Of the less advanced cases and those of +not more than two or three years’ standing there have been some fifty +per cent recovery. Many cases make improvement or become stationary +in greatly improved condition, but are not included in the thirty per +cent. Of the three types, the catatonic offers the best prognosis, the +hebeprhenic the poorest, while the paranoiac occupies an intermediate +position. + +=Treatment.=—Of the etiologic factors above mentioned, that of +auto-intoxication, resulting possibly from endocrine disturbances +or other sources, is most generally accepted in the medical world +and agrees excellently with the osteopathic point of view. Spinal +lesions are regularly found more particularly in the dorsal region, +which are quite capable of disturbing the innervation to the glands; +therefore, their nutrition and activity. A correction of these before +the disturbance has continued too long, and hence before deterioration +has set in, should theoretically normalize the glandular condition and +therefore prevent deterioration and enable the patient to recover. +Such is the probable explanation of the results, and in many cases the +recoveries were obtained in patients previously considered hopeless. + + +Remarks by Dr. Hildreth + +In a great majority of the cases the cause lies in the interference +between the fourth dorsal vertebra and the eighth, which analyzed +means a disturbance of the great splanchnic nerves, through whose +interference would be caused the toxic condition and even the sexual +disturbance described in so many cases from standard authorities. The +same lesion, if deep seated enough, could produce an interference with +the vasomotors and reflexly interfere with the circulation to the +brain. In many we also find a first, second or third cervical lesion. +The effects of these lesions on the equilibrium of the circulation to +the brain are easily traced through the superior cervical sympathetic +ganglia. These lesions, namely, the mid-dorsal and upper cervical, +especially when corrected in the earlier stages, have thus far proven +to produce successful results. In a lesser number of cases we find the +cause to be from the first to the fourth dorsal vertebræ; our reasoning +here being that the interference or the physical disturbance must be +so deep that it reaches and interferes with the deeper nerve currents, +both downward and upward, thus disturbing the equilibrium of the +circulation to the brain. We have found this class to be the hardest +to respond to treatment; however, that may be due to the fact that +the physical defects at that point are harder to correct. Osteopathic +treatment applied to the lesions above described without question +offers therapeutics of intrinsic value to this class of patients. + + +Delirium, Confusion and Stupor + +This clinical group has become well established, not only in its +recognition from the dominant symptoms as indicated above, but also +from rather definite causes. The immediate cause seems to be an +abnormal blood state, or so-called toxemia, which may result from +infectious diseases, or states of exhaustion, or autointoxications, +or foreign poisons; the poison acts as an irritant to the brain. In +states of exhaustion so-called “fatigue bodies” are formed and are +apparently toxic in character. The autointoxicants may have various +sources, such as chronic kidney disease, or diabetes, and the like. +The most important of the foreign poisons are alcohol and morphine. +This morbid group is further characterized not only by a toxic cause +and dominant symptom complex of delirium, or confusion, or stupor, +but by a similar onset and course. The onset is usually acute and +the course somewhat wave like, gradually reaching a climax and +subsiding, or resulting in death or becoming chronic. To emphasize the +clinical symptoms of confusion which is so important the term “acute +confusional insanity” has often been used, or “amentia,” according to +the common German terminology. Hallucinations also play a prominent +part, particularly those of vision; hence, another common appellation, +“acute hallucinatory confusion.” Heredity is mentioned at most as +creating a predisposition, though often the personal and family +histories show no such evidence whatsoever. Intellectually there is a +definite lack of orientation, the patient is unable to identify himself +or his surroundings in time and space. He cannot clearly understand +what goes on around him, that is, consciousness is “clouded;” the +clouding may be of such extreme degree the patient’s mind becomes +blank, due to complete psychic inhibition. This is referred to as +stupor. The emotional life plays a secondary role subordinate to the +intellectual content. The patient may be greatly excited for example, +resulting from a frightful hallucination. The hallucinations are mainly +of the visual type and are almost always present. The patient lives in +a perpetual state of sense deception as if he were constantly dreaming; +the hallucinations for the most part are of distressing, disagreeable +or even frightful character. These may give rise to delusions, which +are manifold, often fantastic and usually transitory. + +Physical changes are always found associated with the disturbed mental +status. If it arises during the active stage of an infectious process +there is of course the high temperature and all other physical signs of +fever. In a certain number of cases with temperature no definite signs +can be found indicative of any of the well known fevers, hence has +been called by various names, such as “Bell’s Delirium,” “Acute Mania +Gravis,” or “Acute Febrile Delirium.” This ordinarily runs an acute +rapid course with very high temperature, very marked delirium, followed +by stupor and usually death from exhaustion. Even though no temperature +be present the physical condition reminds one very much of that found +in fever diseases. There is the lost appetite, resulting emaciation and +malnutrition, insomnia, exhaustion, etc. + +=Osteopathic Theory.=—While it may be admitted that the various factors +mentioned above may take part as exciting or predisposing causes, it +is obvious that in numerous instances mental disorders do not arise +whatsoever, even when the patient is subjected to these factors. There +must necessarily be other elements essential to produce the psychosis. +The osteopathic theory comes in at this point to fill in and complete +the chain of causes and to initiate the onset by the introduction of +the idea of nutritional and circulatory disturbances resulting from the +spinal lesions. + +The records of the Still-Hildreth Institution show 18 of the toxic +type, in which the poison is derived from without, who were treated, +with 17 recoveries. There were 25 cases connected with the infection +and exhaustion group, with 20 recoveries. + + +Remarks by Dr. Hildreth + +In this group we have to do with blood disorders, resulting from the +infections, conditions producing exhaustion, and the various toxins, or +poisons, whether originating within the body or derived from without. +These disorders are largely functional in character, resulting from +brain irritation due to the toxemia or disturbance to the centers of +nutrition. The main object of the osteopathic treatment, therefore, is +to aid elimination and regulate and build up the nutrition. In most of +the patients the physical lesions are found in the mid-dorsal area, +chiefly from the 4th to the 7th, and in the cervical region, the 1st to +the 3d. In aiding the kidneys in elimination the 10th and 11th dorsal +vertebræ must be looked after. These conditions commonly respond very +rapidly to the treatment and represent one of our most successful +groups so far as results are concerned. + + +Manic Depressive Psychoses + +The psychoses which are brought together under this classification +include mental disorders which at first glance would appear to be of +very wide variation, namely, conditions of maniacal excitement and +those of depression. Further consideration, however, reveals the very +evident reasons why they should be united as sub groups under the one +head. The fact that these two mental states of seemingly opposite +characteristics often appear alternately in the same individual, that +in certain cases of each type there is a wave like feature in the +nature of the attack and the frequency with which they tend to recur, +together with other points of similarity in respect to duration, +prognosis, etc., tend to point to their very close relationship. +Kraepelin was the first to draw attention to these facts and advocate +the present convenient and widely accepted classification of these +disorders. + +The outstanding feature is the disturbed emotional state which +dominates and overshadows all other symptoms and is fundamentally +the same whether expressed through the excitement of mania or the +depression of melancholia. + +=Etiology.=—Heredity is considered an important factor. Various +authorities claim to have demonstrated direct hereditary influences in +as many as eighty per cent and more of cases. Individual predisposition +resolves itself into a matter of constitution and temperament in which +there seems to be a greater tendency among those who are subject to the +emotional extremes. + +Early adult life is by far its most frequent period of onset, though +it may arise also somewhat later. In certain cases the beginning +of the disorder dates from some psychic or emotional shock. Just +what importance these factors have as causes is little known since +other cases develop in which the constitutional element alone seems +responsible and no immediate exciting cause can be demonstrated. + +The osteopathic viewpoint emphasizes the all important influence of +spinal lesions as exciting factors. In individuals who have a tendency +to this reaction their presence disturbing the cerebral circulation and +nutrition may act as the direct causative factor. + +=Manic Phase.=—The manifestation of this condition is brought about +by the release of the inhibiting influences which normally govern all +psychic function. Various terms as hypomania, acute mania, delirious +mania, etc., have been used to differentiate the different degrees in +which the symptoms appear. + +In the milder types we find the following symptoms present. There is +a marked feeling of well being. The patient, having lost sight of his +personal limitations, feels a consequent exalted opinion of himself. +His conduct is often rather boisterous, he talks a great deal, often +swearing and using obscene language. He is inconsiderate of others and +tries to impose his will upon those about him. There goes with this a +certain unstability of the emotional tone as manifested by the quickly +changing feeling of good humor, irritability and anger. There is a +rapid flow of ideas with a marked loss in the ability to concentrate +and direct thought. The ideas which pass through the mind do not +coordinate themselves toward a definite goal, but deviate from the +course of consecutive thinking by any passing association. Again there +is a restlessness and activity beyond all normal bounds. The individual +feels strong physically and mentally. The appetite is unusually good +and if activity is not too extreme there may be a gain in weight. The +period of sleep is diminished and the feeling of fatigue is reduced. + +In the more exaggerated cases the flight of ideas becomes more marked, +the associations are more rapid and superficial and the attention is +focused but momentarily. Illusions and delusions may be present due +to the imperfect preceptions from inability to concentrate attention +and from abnormal associations. Rhyming speech, disconnection of +phrases and even apparent incoherence are often present. The state +of mind may be such that the patient tears his clothing, breaks up +furniture, jumps, dances and shouts and often will not take time to +eat. The most extreme cases which refuse food over some period of time +progress rapidly to exhaustion and measures to conserve strength become +imperative. + +=Depressive Phase.=—In this phase of the disorder are encountered +manifestations which are in direct contrast to those presented in +the manic phase. In place of the exalted emotional state there is a +depression. There is a tendency to worry over trivial matters of the +daily routine and of instances in past life. Introspection is the +predominant mental attitude and the whole outer world is colored by +the inner feeling of worry and uncertainty. Replacing the rapidity +of thought in the manic phase there is a distinct slowing of mental +processes in the depressive phase. Thinking is more difficult and +labored, questions are answered slowly and with an apparent effort and +there is usually a tendency to avoid social life. + +Again replacing the excessive activity in mania the depressions show +a retarded action. There is disinclination or disability toward any +effort either motor or mental. The patient feels weak and incapable of +effort, the body assumes a bent attitude and the facial expression is +one of despondency. The appetite is usually impaired with resultant +loss of weight, the bowels are sluggish, the period of sleep reduced. + +In the more exaggerated cases the retardation may be complete. +Introspection is carried to the degree where the patient tries to +take unto himself the responsibility for all the sin in the world. +He himself is the arch sinner and he feels himself the subject of +punishment by divine wrath in a manner in which no other individual +was ever punished. Also the introspection tends to produce various +hypochondriacal ideas. The patient may feel that he has contracted +some incurable disease and that certain bodily functions have ceased +operating. + +Mental processes become not only retarded and difficult, but actually +painful, a symptom which has been termed psychalgia. Suicidal +tendencies are also quite frequently present. + +In extreme conditions the patient may become so retarded in thought and +activity that he apparently receives no stimulus from the outer world. +He lives in a more or less stuporous state, even requiring that food be +administered by tube. + +=Circular Insanity and Mixed Forms.=—In addition to the conditions in +which simply mania or melancholia are manifest there are certain cases +which show variations and combinations of these forms. A common type +is that in which there is an alternation of the manic and depressed +conditions. The patient may pass directly from one state into the +other, or there may be an intervening period of lucidity. The term +circular insanity has been applied to this type. Other variations +are those in which there are recurrences of the manic or depressive +attacks often at more or less regular intervals, each recurrence being +a practical repetition of the preceding. + +There is also possible a considerable intermingling of the +characteristics of the two types. In the manias may occur difficulty +of thinking, passing feelings of depression and even almost stuporous +conditions. In depressions there can exist a marked degree of +restlessness and activity and a rapidity in the flow of ideas. + +=Prognosis.=—The outlook for recovery from the individual attack is +good. The attack may last from a period of days to one of a number +of months and recovery comes with rarely any evidence of mental +deterioration. There is a tendency to recurrence of the trouble. +In fact recurrence is the rule rather than the exception. In the +osteopathic handling of these cases it has been the endeavor to +demonstrate that the correction of lesions had a tendency to lessen +the duration of the individual attack and reduce the tendency to +recurrence. Judging from the experience thus far gained in the +observation of cases under treatment during the attack and the +comparative few recurrences reported both of these aims have been +attained. + +=Treatment.=—The osteopathic measures are aimed at the correction of +the spinal lesions, especially those located in the upper dorsal and +the cervical regions. Some reflex effects from lesions in more remote +areas may have their influence so that it is wise to look to the +correction of any other structural variations when present. + + +Remarks by Dr. Hildreth + +The mental disorders of this type are purely functional and may cover +a broad scope as to causes; however, from the osteopathic viewpoint a +great majority of them seem to have as their specific exciting cause, +lesions in the upper dorsal and upper cervical regions. The treatment +should be applied specifically to the cause which may range anywhere +from the 1st to the 8th dorsal, or from the 1st to the 3d cervical, +covering the nutritional and circulatory centers and thus controlling +the nutrition and circulation to the brain. There can be no question +but what the osteopathic theory of adjustment of physical defects +forms the basis of permanent cure, since many of our recoveries had +been previously under other methods of treatment without results. Our +records cover over 200 cases with recovery in more than two-thirds, and +very few recurrences up to the present. + + +Involutional Psychosis + +In the mid years of life, between forty and sixty, a decline begins, +which in the older years results in decay; it is especially true at +this period of the sexual life and the organs underlying it. While +these organs undergo a very definite change constituting the so-called +climacteric period in women, it is not at first sight so evident in +men; however, the evidence is that a somewhat similar process, though +much slower, tends to occur in the male. Associated with the decay +of the sexual organs is a disturbance presumably of the internal +secretions; if this latter disturbance takes place slowly and evenly +the body may not notice any marked changes; on the other hand, if it +takes place more quickly, or unevenly, it may give rise to distinct +symptoms which indicate a disturbance of the nervous system in general +and often even of the mentality. Hence, the significance of the term, +Involutional Psychosis. In a large majority of cases the mental +disorder is marked by the dominance of depression and is frequently +referred to as melancholia. For a long time it was considered that +this represented a special mental disorder having little or nothing +in common with other psychoses. In recent times Dumas has studied +this group very carefully and shown that it in reality has very much +in common with the depressed phases of the Manic Depressive Group of +psychoses. Kraepelin himself, who was the first to demonstrate the +unity of the Manic Depressive Group, has accepted the conclusions of +Dumas and incorporated the Involutional Depressions as a sub type of +his Manic Depressive Psychosis. Among etiologic factors have been +mentioned hereditary elements, which have been claimed to have been +found in at least fifty per cent of all cases, forming presumably a +predisposition; it is also stated that a predisposition may be acquired +through various debilitating causes. Exciting factors are claimed +to be present, such as mental shock, grief, worry and the like. The +disease would then seem to occur when we have a combination of exciting +factors and predisposition. Careful consideration will show, however, +that no such mental disturbance occurs at this age in many people +who show evidences of such predisposition and of exciting factors, +therefore it would seem that still other causes were necessary; if +we consider the suggestion above mentioned that there are atrophic +processes taking place in the sexual glands leading to a loss of the +internal secretions and if we further consider that this may take +place unevenly and in an unbalanced way, thus aiding in giving rise +to the symptoms, we will find a definite point of contact for the +osteopathic conception. Osteopathically considered, we may say that +the spinal lesions lead to a disturbance of innervation and nutrition +to the ductless glands, and therefore produce disordered secretions in +those patients developing the disease, whereas such a condition may +not be present in others who at the same age period do not develop the +psychosis. + + +Symptomatology + +The emotional tone of depression dominates the picture. Associated +symptoms are anxiety, fears, particularly of impending danger, the loss +of interest in the external world, with a concentration of attention +upon self; psychic distress is usually present, often to an extreme +degree, leading apparently to real mental pain, so-called psychalgia. +Delusions are usually present and manifold in variety; they mainly +refer to the patient himself and are of a self-accusatory nature; +they frequently refer to notions of sins having been committed, also +unworthiness of the patient, of poverty, nihilistic ideas, either about +his own body or external things. He may claim for example that he has +no stomach or kidney, or heart, that the external world is unreal and +the like. His motor reactions become retarded, or even in the more +extreme cases inhibited, producing a form of stupor. The inefficiency +which results along with the psychic pain and distress may determine +suicidal tendencies which are very frequent. Orientation is usually +good, the patient remaining aware of his own identity and that of his +surroundings; the judgment of course is impaired so that the patient +is unable to appreciate the unreality of his delusions; as a result +he sees no hope in the future and on account of present sufferings +prefers death to life. The patient may remain in a perfectly passive +mood, giving the appearance of extreme depression, paying no attention +to the surroundings, possibly mute, giving no regard to the necessity +of the toilet, paying no attention to his clothing and the like. +This may continue for hours or days. Food often has to be forced on +him, possibly even by the tube; the result is usually more or less +emaciation and may result in marked malnutrition; similarly the sleep +may be seriously interfered with, even though the patient is quiet. +The resulting loss of sleep and malnutrition sometimes lead to the +death of the patient. On the other hand, the patient may moan and wring +his hands in anguish, walking up and down, crying out that he is a +sinner and that he wants to die and the like. This is the so-called +melancholia agitata. + +The physical symptoms of importance are sleep disturbances, poor +appetite, with emaciation, cyanosis, often a subnormal temperature, low +blood pressure, slowed heart action and weakened circulation. The hair +may become gray, the skin dry and harsh and indeed any of the signs of +senile decay may appear. + +=Diagnosis and Prognosis.=—These depend partly upon the mental +symptoms, partly upon the physical. On the mental side is to be +emphasized marked depression, with the relatively clear orientation, +resembling the depressed phase of Manic Depressive insanity; also the +dominance of the self-accusatory delusions. On the physical side the +age period, and the evidence of previous attacks, even though very +slight. The prognosis from the study of the mental symptoms depends +on the presence or absence of signs of defect, or deterioration, as +for example foolish and silly delusions. On the physical side the +presence or absence of conditions like kidney or arterial disease; in +general, it may be said if the physical findings are negative and the +mental symptoms show no deterioration there should be a good outlook, +particularly if the condition has not become too chronic. + +A favorable outlook is always possible if the disease is treated +early and the lesions disturbing the activities of the glands and of +nutrition and the circulation are corrected and if the other physical +findings are negative and signs of deterioration absent. + +Since this is probably only a sub-group of the Manic Depressive +Psychoses, as has been mentioned above, the results obtained under +osteopathic treatment are noted under the Manic Depressive group. + + +Remarks by Dr. Hildreth + +Our experience with this class of cases invariably lead us to the +nerve centers which regulate and control the process of nutrition and +circulation; it is a matter of keeping up normal equilibrium of all +organic life and especially the circulation to the brain. The basis of +the treatment therefore is to be found in the nutritive centers, as +well as those centers which control the circulation to the brain, the +ductless glands, etc. + + +Senile Dementia + +Senile Dementia may be defined as an abnormal weakening of the mind +arising in old age. As the word dementia implies, the intellectual +change is quantitative rather than qualitative, the prime +characteristic of the disease being mental loss rather than mental +perversion. + +It is commonly stated that a most important cause of the disease is the +general malnutrition incident to age. Since only a small proportion of +the aged develop dementia, this is probably only a cooperating factor. +Other causes mentioned are overwork, emotional strain, traumatisms, +intoxications (especially alcoholism), cerebral arteriosclerosis and +perhaps heredity. + +=Pathologic Anatomy.=—The disease is organic, the brain exhibiting +definite pathological tissue changes. There is an atrophy of many nerve +cells and a proliferation of neuroglia fibers, so that the cerebrum +becomes shrunken and hard, with thickened meninges and thinned cortex, +and shows a loss of weight. The cerebral arteries may or may not +exhibit sclerosis, thrombosis, or miliary aneurisms, with resultant +areas of softening. The cells show pigmentary degeneration and many of +the association fibers have disappeared. + +=Onset.=—The onset of this dementia is usually very gradual, the +condition not being recognized until rather marked. It occurs mainly +in the seventies and later and in the late sixties, being rare before +sixty. It often follows financial reverses, emotional shock, or +various diseases. The earliest symptoms are a change in the person’s +disposition, slight disorders of memory, and trivial lapses of various +sorts. + +As the disease progresses the symptoms become more marked and +fundamental, involving not only the intellectual but also the emotional +and volitional phases of consciousness. Interest in the outside world +begins to flag, attention to wander, perception to be incomplete and +inaccurate, association of ideas to be slow, memory to weaken and +judgment to be impaired. Memory of the most recent incidents is the +first to be lost, of recent years next, and then of middle age so that +the patient may not recognize his own children or know, for example, +that his wife is dead; finally the memory even of youth is lost and the +patient is to all intents and purposes a child, his condition being +an exaggeration and aggravation of that commonly known as “second +childhood.” + +Several forms of Senile Dementia exist, of which the most common +is probably the simple or non-delusional type. Other forms are +fundamentally the same as the simple, but with certain superimposed +symptoms. Fairly early in this type it becomes unsafe for the patient +to continue in business. Due to impairment of memory and judgment he +is apt to lose his property. Soon his work is poorly done or neglected +entirely. He becomes garrulous and annoys his associates with tiresome +repetitions of childish reminiscences, continually wandering from one +subject to another. His speech becomes incoherent and his sentences +fragmentary. He grows untidy and indifferent to the ordinary niceties +and conventions of life. His appetite is either poor or voracious; in +the latter case the weight may keep up fairly well. He may be either +apathetic or turbulent. If the former, he seems stupid, indifferent, +and sleepy. He is credulous, docile, and very suggestible. Patients +of the turbulent type are restless and always moving about, either +depressed or elated, giving unreasonable orders and then contradicting +them. Sleeping poorly, they are apt to get up and wander about the +house at night. In men, prostatic disease may cause a recrudescence +of sexual feeling. Patients of either type eventually become filthy, +soiling their clothing, etc. Even in well advanced cases, however, +senile dements are often able to perform well certain habitual +activities, such as signing their names, or playing certain games, such +as checkers or dominoes. + +=Confusional Type.=—Another form of Senile Dementia, which may in +severe cases usher in the attack, but which usually, when present, is +sequent to the simple form, of which it is a more severe grade, is +the confusional. The additional symptoms of this type are probably +due to defective elimination and the consequent toxicity. Usually +unsystematized delusions, and sometimes hallucinations are present. +Except for a possible occasional period of remission the confusion is +continuous. It varies greatly in degree, now being mild and passive +and again active, perhaps developing into delirium. Orientation as to +both time and place may be lacking. Such patients may ask for dinner a +few minutes after a meal, go to bed at noon, be unable to find their +own room, or to recognize their own children. They are apt to be +obstinate and peevish. Delusions vary in type but both these and the +hallucinations are usually painful and, being referred to the patient’s +associates, give rise to the thought that they are trying to kill or +otherwise harm him. + +=Delusional Type.=—A third type of Senile Dementia is the paranoid +form. Dements of this type, owing to delusions of persecution and +auditory hallucinations are sensitive and suspicious. Such cases may +sometimes show good orientation, apparently unclouded minds, and +little evidence of senility, requiring careful study to differentiate +the condition from true paranoia. A patient may, on account of +hallucinations of taste and smell, refuse food in the belief that it +is poisoned. Members of his family who are devotedly caring for him +are suspected of designs on his money, and this suspicious attitude +frequently leads to unjust wills. The delusions and suspicions may +be entirely concealed from the family. Wealthy paranoid elements +are peculiarly apt to become the prey of scheming adventuresses, +particularly in case of the above mentioned sexual recrudescence, +and marry them. Opposition of the family is regarded as part of their +general persecution or as due merely to their desire to get the estate. +Some patients merely appear odd, suspicious, untidy, peevish, and +childish. Some have expansive delusions and exhibit the euphoria so +frequently found in syphilitic dements. + +=Senile Delirium.=—A fourth type has been described by some +psychiatrists under the title of senile delirium. This may appear as +the initial form of the disease or as an acute attack in one of the +above forms. It is characterized by great incoherence and restlessness, +entire absence of orientation, and numerous rapidly changing delusions +and hallucinations, the condition resembling delirium tremens. It is +probably due to some somatic cause, such as nephritis, pneumonia, or +cystitis, which is often fatal. + +Complications may arise in Senile Dementia, such as apoplectic strokes, +hemiplegia, epileptiform seizures and aphasias. + +=Prognosis.=—It is evident from the pathology of the conditions that +the prognosis is not at all good when the disease is well advanced. It +is a chronic disease and usually progressive until death, which is due +to one of the complications, malnutrition, or especially pneumonia. +However, many cases have shown improvement, and in incipient stages +recovery. A cure of advanced cases being impossible, the important +consideration is prevention or arrest in its incipiency. + +It is evident that this can be done only by preventing, or removing +as far as possible, the predisposing causes. A glance at the list of +these shows that much depends upon the cooperation of the patient by +regulating his habits of life. Physical and mental overstrain must +be avoided, deleterious habits, such as the use of intoxicants or +narcotics given up. Much can be done by osteopathy to eliminate the +effects of these upon the organism. Cardio-vascular and renal symptoms +are very important and should be watched for in order that early +treatment may check the process initiated. To this end the patient’s +habits and diet must be regulated and treatment instituted to relieve +toxicity and promote elimination. Lesions must be corrected, special +attention being given to the lower dorsal that affect the kidneys, the +upper dorsal that affect blood pressure, and both the upper cervical +and upper dorsal that affect the blood supply and nutrition of the +brain. + +=Arteriosclerotic Dementia.=—This is a mental enfeeblement arising +sometimes in the fourth, but chiefly in the fifth, decade of life, and +associated with symptoms of arterial hardening. + +The cause is arteriosclerosis, which may be secondary to some form of +nephritis. The arterial hardening may be general or may be confined +to the arteries of the cerebrum. It is likely that the arterioles +supplying the cortical cells are especially involved in an atheromatous +condition. The disease is organic, chronic and progressive. Hemorrhage, +embolism, or thrombosis may occur, producing focal lesions and areas of +softening, with hemiplegia, aphasia, etc. + +The earliest symptoms may be headaches and dizziness. The blood +pressure is usually found to be high but not invariably. An +atheromatosis may be present in some one of the palpable peripheral +arteries, such as the radials. Further symptoms on the physical side +are quick fatigue, loss of energy, numbness and paresthesias of the +extremities, and somnolence in the daytime or perhaps insomnia at +night. Strokes may occur, usually slight and temporary, probably due +to spasm in a degenerating artery or perhaps to serous effusion. +Toxic symptoms appear, due to disorder in kidneys, liver, and other +organs. Epileptiform seizures are possible. Mentally the patient shows +impairment of memory, and perhaps some confusion and hallucinations. +Rarely stupor occurs. He may be agitated and irritable or melancholy +and depressed. Suspicious and persecutory ideas of the paranoid type +may appear; also hypochondriacal ideas. + +=Osteopathic Theory.=—In these psychoses of the older years of life the +termination is usually dementia, which means mental enfeeblement, and +which results from degenerative changes in the brain substance. As has +been shown it is largely a nutritional question and the nutritional +condition varies tremendously in different elderly people; it is well +known that many old people preserve their brain powers fairly well to +the end; on the other hand others fail relatively early, some even in +the fifties; these cases of earlier failure are referred to as the +“presenile type.” The osteopathic conception would be to find out the +source productive of the nutritional disorder and correct it at the +very outset, therefore making it quite possible to prevent the disease +process from taking place. The prognosis then in the earlier stages is +very good. + + +Remarks by Dr. Hildreth + +While many cooperating factors may be found in the causation of the +mental disorder of elderly people, our experience shows there is +always very definite disturbance of nutrition and the nutritional +centers. We find chief physical interference between the 3d and 8th +dorsal vertebræ, most definite as a rule at the 4th, 5th and 6th, with +the corresponding ribs on the right side. Contributing causes may be +found in other areas, associated with the disturbances of the heart +and circulation and of the kidney. In the cardio circulatory disorders +we find abnormal spinal conditions in the upper dorsal region and +especially the 5th rib on the left side. In the kidney disorders we +find the lesions usually at the 10th, 11th and 12th dorsal. The above +mentioned areas in general represent the centers of control of the +splanchnic nerves and therefore the important processes of digestion, +metabolism and assimilation. Specific treatment applied to these +points is very helpful and results in marked improvement and indeed in +relieving the patient’s symptoms completely when in the earlier stages +of the disease. + + + + +DEFECTIVE CHILDREN + +By RAYMOND W. BAILEY + + +It is our purpose here to impress on osteopaths the almost unlimited +possibilities in the study and treatment of mental conditions of +children, which heretofore have been considered hopeless. Osteopathy +has demonstrated that it has much to offer to this class of +defectives but the profession has not thoroughly appreciated its +great possibilities. It has been the custom to send these children +to institutions where they have received care with some attempt +toward education but with absolutely no effort being made through +physical treatment to overcome their debility. We shall show that the +osteopathic lesion is of prime importance in these cases, and that we +have been slow to realize the efficacy of osteopathic treatment for +such seemingly hopeless children. We cannot emphasize too strongly the +importance of accepting and treating these cases wherever possible. + +The mental diseases are considered under two general heads: (1) +Inherited, and (2) Acquired Tendencies. + +=1. Inherited Tendencies.=—In this class are those cases arising from +poor endowment of the protoplasmic structure through lowered vitality +of the parents or other progenitors. These taints may come from either +parent, or both, and may exist in the offspring from some preceding +generation. Such diseases are constitutional and are amenable to +supporting treatment in direct proportion to the amount of endowed +energy inherent in any given organism. + +Of the inherited tendencies, we have two kinds: + +=1. Congenital Diseases.= (a) From any influence of an inherited nature +not directly acting on the environment of the parent while the fetus is +in utero, and + +(b) From any influence which directly affects the development of the +ovum through imperfect fertilization coming through either parent or +both. + +=2. General Impairment.=—This condition exists (a) Where a similar +defect has existed in foregoing generations and is strictly hereditary; + +(b) Where general vitality is diminished from such causes as +neuropathic parents, or where there have existed constitutional +defects, such as tuberculosis, syphilis, epilepsy, alcoholism, abuse, +overwork, strain, acute inflammatory diseases, and poor health of the +mother during gestation; also consanguinity. + +(c) Premature birth tends to impairment physically and mentally +of growth of organism and frequently leaves its manifestations of +marasmus, rachitis and other nutritional disturbances. + +(d) Prolonged labor may leave its mark on the child where more or less +asphyxia has occurred resulting in obstruction to cerebral circulation. + +Causes acting after birth to the already impaired germ cell and +resulting in many of the afflictions of early life, both mentally and +physically, are + + 1. Traumatism. + 2. Convulsions. + 3. Rachitis. + 4. Infectious fevers. + 5. Meningitis. + +All of these seriously affect the metabolism within the newly-born, a +process which is begun, doubtless with difficulty, and susceptible to +easy derangement, and the same effect magnified with growth into its +subsequent mental and physical deformity. + +=2. The Acquired Tendency.=—In this the second great class are those +conditions arising subsequent to conception where germ plasm is healthy +but growth is arrested by some external factor either intra- or +extra-uterine. Thus the acquired tendency may be given to the fetus in +utero and not be considered congenital as in case of injury affecting +health and growth of otherwise healthy conception. In short, the +acquired has its beginning at conception or subsequent to it while the +congenital is previous to conception or already inherent in the germ +plasm leading to conception. + +Any influence which retards the + +1. Inherent capacity of cell for growth or, + +2. Adequate blood supply either in quantity or quality results in +enfeebled offspring and these causes are enhanced by + + (a) Traumatism or Injury + (b) Drink or Abuse + (c) Dirt or Unhygienic surroundings + (d) Depravity or Ignorance + +Factors entering into acquired tendencies affecting offspring direct +are divided into three classes, those: + + I. Before Birth such as + + (a) Abnormal condition of mother’s health during pregnancy as in + disease of any nature, mental or physical or + + (b) Injury to fetus direct by blow, fall of parent, or instrument. + + II. During Birth from: + + (a) Abnormal labor from any cause. + + (b) Primogeniture. + + (c) Premature birth. + + III. After Birth. + + (a) Traumatism. + + (b) Toxic causes such as scarlet fever, whooping cough, meningitis, + measles, mumps and exanthemata. + + (c) Convulsions. + + (d) Nutritional disturbances. + +Consanguinity or intermarrying of blood relations, or in-breeding +results in: + +1. Instability of the nervous system. + +2. Intensifying of constitutional defects. + +3. Decrease in size of offspring. + +4. Predisposition to disease through lowered vitality. + +5. Impairment of reproductive function. + +Immediate consanguinous offspring may manifest a high degree of +intellectual or physical attainment but successive processes tend to +neurotic types and are prone to physical weaknesses and insanity. This +practice is found among Quakers and Jewish peoples, inhabitants of the +Islands north of Scotland, in isolated rural localities, and among +African tribes. + + +Mental Deficiency in Children + +=Synonyms.=—Amentia; feeble-mindedness. + +There are three grades of amentia: + +=1. Morons:= those whose mental age corresponds closely to their +chronological age or is nearly normal. + +=2. Imbeciles:= those in whom there is a wide disparity between the +mental age and the chronological age. + +=3. Idiots:= the lowest form of arrested mentality or those whom it is +impossible to teach. + +=Definition.=—Mental deficiency is a pathological stage in which the +mind has failed to attain normal development. + +=Various degrees of intelligence= or mental capacity in man lie between: + +(=1=) =Genius= such as Bacon, Newton, Plato, Galileo, Shakespeare. + +(=2=) =Lesser Ability= but still conspicuous in development such as our +great leaders in science, literature, reform and the arts and medicine, +furthering, each their respective causes. These merge easily into + +(=3=) =Average= mass of mankind. + +(=4=) =Dullards= or those of inferior intelligence. + +(=5=) =Feeble minded=, merging imperceptibly into + +(=6=) =Imbeciles= and by insensible gradation into + +(=7=) =Idiots= and gross idiots. + +The mentally defective is wholly incapable at maturity of adapting +himself to his environment or local conditions in order to maintain +existence independent of any external support. + +=Dementia= is a disease of the mind or that which was once possessed, +and by some neuronic disturbance is lost totally or partially. + +=Insanity= is a disturbance of neuronic function which may or may not +end in degeneration of brain tissue. + +=Physiology.=—The normal brain begins its development shortly after +fertilization of the germ cell, by the expansion of the anterior end of +the rudimentary spinal cord into four primary cerebral vesicles. These +develop into a series of elaborate infoldings, each with multiple cells +around them. At or about the sixth month of fetal life this embryonic +brain assumes the shape of the adult brain, minus the secondary +fissures and convolutions which are characteristic of full development. + +At birth there are sometimes many convolutions and the brain weighs +from 280 to 330 grams. Growth is then rapid and at six months it weighs +from 560 to 680 grams; + +At one year, 750 grams. It continues to increase until + +At 12 to 14 years it weighs 1150 grams in the female, and 1300 in the +male; + +At 20 to 21 years the weight is 1244 grams in the female and 1374 in +the male. + +Growth is slow from this time until at 25 to 35 years the average +weight of the brain is 1269 grams (45 oz.) in the female, 1421 grams +(50 oz.) in the male. + +This growth of the brain is due, first to the rapid multiplication of +nerve cells and, secondly, to the individual enlargement of each nerve +cell. These cells arise from the floor of the four primary vesicles +and are each similar to its fellow. They finally show differences in +feature and become characteristic in size and shape which process +continues throughout life. This process of differentiation of nerve +cells results in the peculiar laminated appearance of the brain cortex. +At the period of lamination, the nerve cells throw out delicate +processes which pursue definite directions throughout the brain mass +constituting a system of association fibers which link together in a +most complicated manner all parts of the brain, and are called the +association fibers of Flechsig. Projections from these cells form the +various pathways by which the brain is connected to the various parts +of the body. + +Nerve cells in the different parts of the brain mature at different +periods, those areas which have to do with the highest intellectual +functions, viz., the frontal and parietal regions, maturing last. + +At the seventh month of intrauterine life the brain cell is a small +round type of neuroblast, undifferentiated, lying in a matrix. The +cells increase in size until about the second week (extra-uterine) +of life, tiny processes begin to develop. At the third to fifth year +these cells are mature and possess axons, dendrons and geminules. These +communicate, forming the above named association system conveying +impulses to and from all parts of the cerebrospinal system. They +multiply and elaborate after puberty into a complicated system up into +middle life after which growth ceases and they slowly diminish. + +=Greatest Growth= is between the first appearance of the primitive +brain and the end of the sixth month of life (extra-uterine), hence +it is during this period that any adverse conditions relative to +development of nerve cells may cause the greatest damage. + +=Mind and Brain.=—Whatever may be the connection between these two, +we know that the former develops with the growth of brain cells and +fails with their decay. =Amentia= is associated with the incomplete +development of brain cells and =Dementia= is coincident with their +degeneration and death. + +=Pathology=—=Brain.=—Structural abnormality of the brain tissue may +exist without variation of mentality or defect. Early observers gave +these gross defects as a cause for amentia. However, it has been +demonstrated beyond doubt by microscopic examination of cerebral +neurosis that cellular changes occur and that imperfect and arrested +development exists and is an essential basis of amentia. + +=Histology=—=Blood Cells.=—Cortical blood cells in the ament are + +1. Numerically fewer. + +2. Irregular in arrangement. + +3. Imperfectly developed. + +4. Microscope reveals changes proportionate to the deficiency during +life. + +=Blood-vessels in Amentia= show no marked changes from those of the +normal brain. Hyaline degeneration may be present; also pigmentation. +These conditions are not constant in amentia hence cannot be considered +causal. + +=Neuroglia in Amentia.=—Sclerosis and hypertrophy occur in a large +proportion of cases. This is diffuse throughout the brain, with here +and there certain circumscribed areas forming nodules. + +=Nerve Fibres of Cortex in Amentia.=—Association system fibres are +always diminished in number and not so complicated. + +=Clinical Varieties of Amentia.=—There are two varieties of amentia and +conventionally for sake of study we must arrange them into those from + +(1) Congenital causes and (2) acquired causes. + +Among those which arise from congenital causes we have the +microcephalous and Mongolian types. In both cases there exist +constitutional taints through successive or immediately forgoing +generations of such diseases as syphilis, tuberculosis, epilepsy, and +acute alcoholism affecting proper collaboration of germ cells previous +to fertilization and hence impaired germinal endowment through a +weakened nervous system. + +Those arising from acquired causes are from injury to mother or fetus. + +=Macrocephalus.=—A person whose skull measures less than seventeen +inches in its greatest circumference. This class comprises less than +10% of all aments. + +=Cause.=—The type is neither a freak reversion of the species to a +lower grade of development nor accidental, but due to an inherited +blight on the nervous system arising from constitutional disease, +alcoholic and sexual excesses, consanguinous unions and too numerous +latter-life pregnancies in undermined health states. They come entirely +from neuropathic stock and their brothers and sisters are degenerates. +Many dwarfs exhibit this type. + +=Characteristics of Microcephaly.=—(1) Circumference of skull +diminished; (2) Brain smaller; (3) Stature small (5 feet); (4) Rarely +live to advanced age; (5) Die of tuberculosis; (6) Mostly imbeciles and +idiots (few morons). + +They have their sensory impressions intact and are generally vivacious +and muscularly active, even restless. They have good sight and hearing +and are highly initiative but have not the ability to any sustained +effort. They are actively observant and the majority are affectionate +and well behaved. Some are unsteady in walking, others are helpless, +and about one-half are subject to epileptic fits. + +=Mongolian Amentia= (Mongolism).—This type (Kalunk or Tartar variety) +received its name from Dr. J. Langdon Down from their facial +resemblance to members of the Mongolian race. They number about 5% +of all aments including the semi-mongols who have only a few of the +characteristics of this type. + +=Cause.=—Eleven out of twenty-five are from syphilitic origin. +Glandular or nutritional defects are suggested as a cause. They will +show negative Wassermann test and positive tuberculin tests. Uterine +exhaustion and ill health of mother during gestation are factors +suspected of entering into this condition. The latter-born of large +families are frequently affected. + +=Pathology of Mongolian Idiocy.=—The brain of the Mongolian ament is +considerably under-sized and has less convolutions and is more shallow. +The pons, medulla, and cerebellum are about half the size of ordinary +feeble minded types. The cells by microscopic examination show an +immature condition. This lack of brain development results in deficient +expansion of base of skull, hence the characteristic physiognomy. There +is no glandular abnormality. + +=Description of the Mongol Type.=—This type is distinguished by +characteristics of skull, eyes and tongue and is usually observed at +birth. + +1. The skull (Brachycephalous) is rounded and diminished in size +particularly through the antero-posterior diameter. The face is +flattened, there being no recession of frontal and supra-occipital +regions. + +=Eyes.=—The palpebral fissures are narrow and slope obliquely downward +and inward. Lids inflamed. + +=Tongue= protrudes, is large and marked by large papillæ and scored by +transverse fissures due probably to tongue sucking, predisposing to +inflammation of the mucous membranes. + +=Ears= are small and round and have poorly developed and irregular +lobules. + +=Nose= is short and flat and has triangular nostrils. + +=Teeth= are soft and ill formed and tend to decay. + +=Hair= is usually scanty and wiry and very dry. + +=Cheeks= are flushed. Palate is high and narrow and mouth is open, and +lips are cracked. Adenoids exist in all cases. + +=Hands and Feet= are broad and clumsy. Flat foot and knock-knees are +common. Skin is rough, coarse and dry. + +=Abdomen= is large and mushy. Umbilical hernia often present. + +=Circulation= is rarely good, causing blueness and coldness of +extremities, with sores and chilblains. Heart lesions are frequent. +Lesions of a chronic inflammatory nature in respiratory and digestive +tracts exist. Nasal and bronchial catarrh and diarrhea are common. +Mongols die early (about 14 years) usually of phthisis. + +Available statistics show the various types and variations of these +conditions in great detail; however, the above will enable the reader +to classify and properly diagnose in given cases. It is not the +writer’s intention to portray here what is easily a treatise by itself. + +=Osteopathic Consideration of Amentia.=—During a period of five years, +observation of the various types has led me to believe that much can +be done to correct circulation to cerebral structure with consequent +development of brain tissue and function, where discoverable trauma +exists. From all available sources there is traumatic interference +in from 15 to 45% of these cases, according to different authors. +Where history involves constitutional findings (syphilis, tubercular, +glandular and chronic alcoholism) I have treated them with the intent +of relieving only until the next phase of the condition would appear. +Where trauma alone exists and the family history is good, I know the +case is in the field of osteopathy alone, and can be developed to a +degree limited only by the intelligent care of those having the case +in charge. Especial attention should be given to discipline, housing, +sanitation, personal hygiene and general environment. + +=Lesions.=—Atlas, generally rotated. Rarely posterior but frequently +resting beneath a posterior occiput. Lateral mass on the posteriorly +resting portion of misplaced atlas will become interlocked with +transverse process of axis in a few instances, combining the amentia +with a progressive inflammatory tendency to the middle ear which by +successive abscesses ultimately destroys structure and function; +possibly traumatic epilepsy, and surely catarrhal inflammations in all +mucous membranes of the head. + +Many bony and ligamentous irregularities exist in the various types of +mental defective where the cause is inherited weakness, nutritional +diseases or kindred sources. Spinal luxations exist singly and in +series, causing various palsies, spastic muscles, and deformity. +Postural defects, particularly of ribs and costal cartilages cause +functional disturbance throughout the thorax and abdomen. + +=Treatment.=—Invariably the care of aments entails wisdom of procedure. +Reconstruction is the prime object in every instance, hence time +and number of treatments must not be considered. Treat to =correct +structure; teach= as far as possible; =train= always. + +Deft and intelligently applied technique are certainly required in the +correction of these cervical lesions. Treatment should be given thrice +weekly (never less than twice for progress) with definitely established +mental tests before, to discern the mental level, and at succeeding +periods of three months each, noting progress, if any. The Binet-Simon +scale or some other available mental test should always be made and +record carefully kept of each case for your own benefit as well as +the patient’s. After six months, if no appreciable gain is shown +treatment is discontinued and the case must be cared for in another +manner as beyond your special field of effort. Usually it is apparent +by the end of the third month if anything can be done to improve the +mentality. The physical advantages, in some cases warrant continued +treatment where there is no appreciable mental gain. Institutional care +of these types is the only practical means of handling them properly +from an osteopathic standpoint, as it requires some one properly +equipped to make your tests and keep your record;—it is sufficient +for the doctor to do the work demanded. They can thus be classified +and progress systematically shown. The higher grades must be taught +and though self dependence may never be attained they can in many +cases by training be capable of useful pursuits and quite frequently +remunerative work. It makes for happiness at least to keep them busy +and forestalls the mischief that would otherwise result. Even imbeciles +can help in routine work of an institution or home, and idiots may, +by training, gain some power of self help and cleanliness. Training +depends on the individual capacity for such in each case—his habits, +and general character of his propensities. Prevention of their marriage +should be positive and for prevention of their propagation this and +their sterilization by operation are the only two measures at hand. +Sterilization, however, is repugnant to some elements of society and +could be abused, hence the segregation of aments would appear to be +our only solution at present. The ultimate intention of treating any +case is to use any measure tending to stabilize the nervous system. +Corrective effort alone is not sufficient but these osteopathic +endeavors in conjunction with proper discipline, good food, regular +rest and personal hygiene both mental and physical and a scrutinizing +restriction tending to any kind of excess is rendering the osteopathic +procedure in such cases rapidly indispensable for the treatment of +amentia. + + + + +POST-OPERATIVE TREATMENT + +By GEORGE A. STILL + + +At the convention of the American Osteopathic Association held in +Boston in 1918, I gave a short talk on the above subject, and during +the day after I had given the lecture, two women and one man, graduate +osteopaths, asked me if I really meant to convey the impression that we +actually gave osteopathic treatments to recent surgical cases. I do not +know whether I convinced them or not, but I do know that they convinced +me that there are people practicing osteopathy who have absolutely no +concept of its merits and underlying principles. + +To my surprise I have found that a great many osteopaths who consider +themselves absolutely “pure” are just a bit startled at the thought +of handling post-operative complications by treatment. These are +invariably fellows who have had most of their experience in office +work, and who do not come in contact with acute cases. Still it is +difficult to conceive how a man can believe that osteopathy is specific +for certain diseased conditions and not for others. As a matter of fact +osteopathic treatment has not proved itself more satisfactory in any +field of therapeutics than it has in post-operative conditions. + +The common post-operative conditions are pneumonia, pleurisy, backache +and headache, nephritis, vomiting, neuritis, phlebitis. + +Taking up these subjects and discussing the least serious first we +would of necessity discuss pneumonia last, as it is the most serious, +and is less influenced by other conditions. It will also serve to +illustrate many of the details in treatment. + +We will therefore briefly take up the other conditions and then discuss +pneumonia more fully. + + +Vomiting + +We believe there is no question that a good part of the prevention of +anesthetic vomiting is in the preparation of the patient, including +a good cleaning out of the bowels without debilitating cathartics. +In other words, the vomiting is increased if the alimentary tract is +loaded, or if on the other hand it has been irritated to the extent of +losing its tone. Combining a careful preparation with a straight ether +anesthesia and osteopathic treatment to the neck and splanchnics we +have been able to eliminate any serious post-operative nausea. I do +not recall a case in the last few years that vomited on the following +day unless the condition for which they were operated was one that +essentially in itself would cause vomiting; for instance if the patient +had peritonitis and had been vomiting due to the toxic ileus. They +might even vomit after the abdomen had been opened. This could hardly +be called “post-operative” vomiting. + +The improvement in our records in post-operative vomiting is in +proportion to our increased faith and use of the osteopathic treatment. +Time and again patients have told us that they had taken anesthetics +before and were sick from three to five days and even a week. +Invariably we have been able to surprise these patients by the fact +that they were sick less than a day. + +The usual treatment with bismuth sub-nitrate, cerium oxylate, sour +wine and the other usual remedies were not used in any case or in any +amount. No drugs whatever were employed. + + +Backache and Headache + +There is practically no difference in the post-operative headache +and the office headache. There is of course the usual multiplicity +of causes, and as a matter of fact in this condition treatment +can more nearly approach the ordinary office treatment, and the +results are about the same. As for backache, we find that speed of +operating and not keeping the patient under the ether too long has +a marked influence. Also we have a four inch Seely mattress on the +operating table which helps some. Treatment does the rest and does it +effectively. For this complication even the ordinary nurse knows enough +to give a treatment of some sort. + + +Neuritis + +Nine times out of ten the post-operative neuritis is really a local +osseous lesion, a slipped innominate, rib, vertebra, clavicle, biceps +tendon or something of the sort, and responds quickly to a specific +treatment. + + +Phlebitis + +This complication usually comes on quite late after an operation and +at first it is sometimes hard to differentiate it from a neuritis. +Absolute rest of the involved part with lower spinal treatment gives +relief, but under no circumstances should the affected part be freely +moved while there is active inflammation. The reason for treatment of +the lower spinal area is that practically always one of the saphenous +veins is involved. + + +Nephritis + +This complication is to a very big extent eliminated by a careful +urinalysis prior to the operation, and careful preliminary treatment in +indicated cases, and in other cases the postponement or if necessary +complete elimination of the operation where it is not a case of life +and death. Where the condition does appear we have found it the hardest +of the post-operative complications to control. Indeed it is the only +one that we have not found very easy to manage. + +We do not vary the treatment for a post-operative nephritis from what +we would use in any ordinary case of nephritis. We have observed +treatment of this condition in many cases under medical management, and +while we are satisfied with the osteopathic treatment comparatively +we are not yet satisfied that we have it developed to its greatest +efficiency. + + +Pleurisy + +This condition in nearly every instance can be corrected with one +or two treatments of a twisted rib unless it is the pleurisy of a +beginning pneumonia. As far as the pain is concerned the simpler type +hurts as much as the one that is going to develop a real complication. +For this reason relief obtained by a single treatment often seems +little short of miraculous to the patient. + + +Pneumonia + +When I took charge of the surgical work at Kirksville, osteopathy +was not used in post-surgical treatment. Post-operative vomiting was +treated medically, as were other post-operative conditions, including +pneumonia. Cases of a real major surgical nature rarely got an +osteopathic treatment. + +The idea seemed to be that osteopathic post-operative treatment had to +be along the same lines as it would be for such an illness as lumbago, +brachial neuritis, or ordinary pneumonia, and other non-surgical +conditions where the patient could be placed for giving a treatment in +a position that was not permissible following an operation, as it would +work great harm to the wound. + +It seemed to me that if osteopathy was effective in a case of ordinary +non-surgical pneumonia, it should certainly be good for a case of +pneumonia that was post-operative and that all we had to do to handle +the condition was to apply a new technique of treatment that could be +used on a patient who had a surgical wound. All we had to do was to so +manipulate the spine that we would get the results locally, and yet +handle it in such a manner as not to affect the wound. + +Many laymen, and even some physicians of our own school, express +surprise at the suggestion that we do much osteopathic work in the +after care of surgical patients. But the fact is we have worked it out +so that now, except for pain, during the immediate after effects of +the operation drugs are absolutely not used in our hospital for any of +the post-operative complications. The opiate immediately following the +operation, is really a follow up of the anesthetic, and we use that as +rarely as possible. Needless to say, there are cases such as un-united +fractures, extensive adhesions, etc., where the emergency conditions +positively call for some relief of the pain for a short while, but that +is the only condition that we cannot control with mechanical treatment. + +I am very glad that I had the confidence to give this an early trial +and a thorough trial, without being afraid to leave off the drugs. +The big field, however, where osteopathic treatment has won the most +impressive success and proved itself a most absolute specific, is in +the field of post-operative pneumonia with which I am proud to announce +a one hundred per cent. success for combined osteopathic treatment in +my fourteen years continuous surgical work. Not to have lost a single +case is partly due to luck. In other words, with any series of serious +cases, it is impossible but that there be some fatality finally. + +Post-operative cases have one advantage along with their disadvantage. +While they have the shock of the operation to contend with, and the +weakened condition from the disease for which they were operated, still +except in extreme emergency they would not have been operated on unless +they had a good heart and good kidneys and a good blood pressure, so +that in cases in which we are most concerned in combatting pneumonia, +we usually start with a patient who has those organs in a healthy +condition. + +=First Post-operative Pneumonia Cases Treated Osteopathically.=—At +the Chicago Convention in 1911, I reported the first post-operative +pneumonia cases that had been treated osteopathically. I believe at +that time that there had been only three cases. At that meeting I +mentioned the fact that some of the doctors and some of the internes +who treated those cases felt sure that they were not treating them +properly because they could not get away from the idea that pneumonia +needed strychnin and other drugs. One of these cases got well in three +days from the developed lobar pneumonia symptoms. The results were so +miraculous that the young man treating it began to doubt whether it +could have been pneumonia. He could not understand how he, a senior +student, could overcome this dreaded disease by merely working on the +spine. He could not believe that osteopathy, a science that he had been +able to learn himself, so easily could cure a condition that he had +thought must be almost necessarily fatal. + +One of the weaknesses of osteopathy is the fact that there is no +mysticism about it. It is so simple that any person with ordinary +intelligence can learn to use it, and yet it is so simple that it takes +an unusual intelligence to be able to grasp the fact that it is the +therapeutic discovery of the age. Many, many times I have had young +internes and students cure genuine lobar pneumonia and do it with such +obvious ease that it caused them to wonder, in a way, if it really +could be pneumonia. It is bred in our very tissues to look for some +mysticism, something impossible to understand, something supernatural, +something connected with the Unknown associated with the treatment of +disease and accordingly it is just human nature to find it difficult +to believe, even when we see it, that a simple method of treatment can +actually effect a cure. + +Real pneumonia, as we understand it, is a consolidation of the lung +tissues characterized by fibrosanguinous exudate into the pulmonary +tissues and spaces, associated with one or more particular germs as +exciting factors and proved by the physical tests and the character +of the expectoration. How many cases have been cured that had not +entered consolidation I do not know because up until the time of actual +consolidation there may be a question as to whether or not they would +have had pneumonia. I know that many cases with marked symptoms of +pneumonia have failed to develop under treatment or the case has been +aborted. + +Pneumonia lacks a great deal of being a self limited disease. The +number of cases with beginning symptoms that fail to develop is too +great to be ascribed to coincidence. Of course I know that some of +these might have been only pleuritis, some only neuritis, etc. However, +in giving the statistics of pneumonia cures we will give only those in +which pneumonia developed and showed a hardening or consolidation of +the lung tissue. In these cases there can be no argument as to whether +there was pneumonia. + +When we have an acute condition associated with the symptoms of +consolidation, we can hardly be confused as to the diagnosis. We may +make a mistake in our physical findings, but hardly after a little +experience, and certainly when we are sure of the physical findings +there will be no trouble in naming the disease. + +=The Clinical Findings.=—Post-operative pneumonia is a little +different from the common pneumonia. It always comes on a little more +insidiously. One has to watch for post-operative pneumonia more closely +than he would for the attack that we may meet in ordinary practice. +A patient may have considerable pain from his wound, may have some +pain in the back from the position he is in; there may be headache, +and an upset feeling from ether; and the pain comes in the chest. All +these symptoms are forerunners of pneumonia, but the pain in the chest +is not noticed until it gets quite severe. In other words, there are +other things to annoy the patient as well as the attendant, and at +first, this condition does not cause complaint. A strong and healthy +individual who feels a pain in his pleura, which is the forerunner of +pneumonia, knows it at once, because that is the only distress he has. +His entire attention is attracted and he asks for a physician’s help. +But in the post-operative case, the physician has to keep a look out +in order to prevent a case from getting well under way before it is +recognized. + +As an example of this I had a case of a man who was with a party +driving an automobile and they tried to cross the railroad track in +front of a train. This patient I speak of was one of the survivors. He +had a fracture of the femur, fracture of the skull, fracture of three +ribs, and otherwise more or less bruised up. Naturally the preliminary +work consisted in getting the ribs and legs attended to as well as +possible and looking out for cerebral hemorrhage or meningitis. + +This patient developed consolidation in both lungs in spite of regular +treatment, and it precipitated on him very rapidly, partly masked by +the disturbed breathing from other sources of irritation. We put him on +hourly treatment, but after a few hours his condition from the injuries +and the pneumonia was such that his wife asked us not to treat him any +more. She put it this way, that she knew he would die in spite of all +that could be done and as long as he was going to die he might as well +die easy. Every time he was treated it had the effect of bringing him +out of his stupor, and he would complain, and she thought it would be a +kind act to let him slide off into the next world uncomplaining. + +Pneumonia in a case of this sort cannot be handled with kid gloves if +we wish to save the patient. We must give firm, strong treatment. Light +treatment in this condition will do no good. Indeed light treatments in +any sort of pneumonia are of little avail. Many times I have changed +internes in a pneumonic case that was not responding and the results +were immediate. That is, the turn for the better was obvious from the +beginning of the good strong treatment. + +The case above mentioned was treated a good part of each hour for +twelve hours. He had no strychnin, no oxygen, nothing but treatments, +but he got well and is now living, and aside from a limp has no +evidence of either his injury or his illness. + +Some cases, in private practice, may get well on a treatment a day, but +I would hate to handle the kind of cases we get in that manner. I have +had severe cases, especially hemorrhagic cases, where the treatment was +almost continuous for hours preceding the crisis. Of course, after the +crisis we can ease up. On the other hand, it is not infrequent that +a few good strong early treatments, given at the beginning of a case +absolutely stop it. I have seen cases where a consolidation area of the +apex of the lower right lobe as large as the palm was easily outlined, +and this together with the clinical symptoms would be cleared up in two +or three days. + +There is no possible medical method by which this can be done. Medical +authorities agree that under their treatment pneumonia runs an +unshortened course; in other words, a course in the individual case +that has not been affected by the medication. Medically, even where +the crisis occurs early, the consolidation persists for some time, but +I have seen it cleared up time and again under osteopathic treatment +in the length of time that could have been brought about only by +osteopathic treatment. + +I have previously called attention to the fact that many of the medical +text books on physical diagnosis mention a point that is a very +practical and very plain demonstration of the efficiency of osteopathy +in pulmonary conditions. These books only mention this fact without +pointing any moral or drawing any conclusions. The point is this: +that frequently when a professor is having a class or a section of a +class examining a case of pneumonia, they will outline the size of the +consolidation at the beginning, the instructor marking it off when he +makes the first examination; then after the students have examined it, +by percussion, palpation, etc., possibly a dozen or twenty of them, +the later students will find that the area has shrunken perhaps an +inch. This fact has been frequently noted. It is said, indeed, that if +careful examination is made it will always be noted. + + +How Manipulative Treatment Benefits + +Doubtless this proved that accidental manipulations of the ribs helps +clear up the congestion about the real consolidation and reduces some +of the dull area. Very likely this explains some of the cases of +partial or real results from spondylotherapy. Naturally, scientific +osteopathic treatment would necessarily magnify such results very much. + +It is a great wonder with the obvious failure of medical treatment in +pneumonia, that at least some crude from of manipulative treatment has +not been devised by those practitioners. We have already mentioned that +the treatment of post-operative cases varies mainly in the manner of +applying it. In other words, when we raise the ribs we keep the patient +on his back, in treating the spinal centers we treat with patient on +his back, and the physician who has no grip in his hands will not be +able to treat a post-operative pneumonia to any advantage. + +In these cases one has to get at the patient’s back by reaching under +and the weight of the patient helps to give the treatment, but a strong +grip is necessary. It is much safer for the wound to handle the patient +in this way but not infrequently beginners wear their knuckles pretty +nearly off before they get the finer technique; after which it is easy. +In raising the ribs there is no more difficulty in treating in this +position than there is with a patient who can sit up or turn from side +to side and in some cases a patient can, of course, be partially turned. + +Theory is all right but in these cases practice has been added to it +in something over three hundred cases treated in this manner, and in +this manner only. I have had no case die. None of my cases had oxygen +and none of them had strychnin or alcohol unless it was a person who +had used alcohol constantly or daily and in these cases I consider that +the system has become sufficiently used to it that it is practically +a food and that sudden withdrawal is apt to bring on delirium. It is +not necessary in those cases that indulge deeply now and then, but it +is advisable in those that take a small amount regularly, just as they +take food. These patients are used to a constant heart stimulant and +its withdrawal is also apt to be reflected in the heart action. These +are the only cases in which I have ever authorized anything in the way +of a chemical stimulant of the heart during pneumonia. + +You will undoubtedly recall that in reading the newspaper accounts of +men who are big enough and prominent enough to have bulletins in the +newspapers when they are dying, that almost universally the next to the +last bulletin was that oxygen is being administered. The last bulletin +announces the time of death. You will also note that in case the +patient lives that oxygen then is not mentioned, and a few days later +the patient is all right. My observation is that the use of oxygen +may attract the attention of the family, it may attract the attention +of the patient, but as for any actual benefit on the patient I do not +believe it is in the least helpful, and that the only treatment for +pneumonia is osteopathic. I am so convinced of it that I am using only +that method. + +As to strychnin, some say strychnin must be given. Some say it must be +given at the crisis, and others say it must be given from the inception +of the disease. I do not believe the majority of cases will do as well +under strychnin. I know they will not do as well under strychnin as +under osteopathic treatment. I will not say they will not do as well as +if under no treatment. It is possible that there would be an occasion +for its use at the crisis, and I have seen such cases, and I have used +it while studying medicine. I used it at the crisis, and I used it in +cases where I am convinced that it helped them over the crisis, but I +am also convinced now that by osteopathic treatment they would have +done still better and the crisis would not have been so acute. In other +words what strychnin does in favorable cases, osteopathic treatment +does better in all cases. + +In our post-operative cases study the charts and you will see that +they do not have the acutely violent crisis that usually occurs under +other treatment. They are under better control and if we can get them +near the beginning, as we usually do, we can keep up the resistance so +that where they would otherwise have a hard crisis they have an easy +one. Instead of having a temperature of 105, pulse 165, respiration +70, or such a condition, they are more apt to run a temperature of +102, pulse 120, respiration 35 or 40 and they go through it without +that suddenness and acuteness that is common under other methods of +treatment. + +In several instances, as an example of showing how this resistance is +kept up, I had letters from boys in the camps. One letter told of a +wide epidemic of severe tonsillitis. In one group of soldiers there +were three osteopaths who treated all the men and this was the only +group that was not sent to quarantine. This group developed sore throat +and was treated osteopathically and the sore throats checked so that +quarantine was unnecessary. + +Among the detailed reports in the A. M. A. Journal there will be +nothing about this, nor about many other instances where osteopathic +treatment, given by men forced to remain in the ranks, has done +things that medicine cannot do. These examples are too frequent to be +coincidents. If I had had three cases of post-operative pneumonia and +they had all got well, it would not be surprising. If I had ten cases +and they all got well, there are medical hospitals that have been this +lucky. But there are no medical hospitals in the world that can report +one hundred cases or two hundred cases or three hundred with developed +pneumonia and all lived. The percentage of pneumonia cases that die +now in medical hospitals, is much less than formerly. But the cause of +this is not vaccine, antitoxin or drugs. It is due to the fact that +pneumonia cases now, like typhoid, are given very little medicine and +are turned over to general nursing treatment; that is, in the best +medical hospitals. + +The mortality is in inverse ratio to the drugs given. The advance +medical teaching is against so much drugs in pneumonia, though of +course the hick doctors use it because they are practicing medicine of +the by-gone age, before Andrew Taylor Still forced on the world the +idea partly started by homeopathy, that the less drugs the better. +Homeopathy failed in not quite discarding drugs and in not having a +substitute that reproved drugs. + +As a matter of interest I wish to mention that while in medical college +I had the advantage of being taught surgery by the greatest surgeon +that ever lived, John B. Murphy. I only wish that circumstances could +have permitted me to have shown him what osteopathy could do in +post-operative conditions, because Murphy was a broad minded man and +no man living ever thought less of orthodox medicine and old fashioned +drug treatment than Murphy. + +He and the Old Doctor would have been great friends had they ever met. +Murphy, whom I considered a most wonderful surgeon, and whose skill I +never hope to approach, stated to me many times while a student that he +lost more cases from post-operative pneumonia than any other condition +and that in upper abdominal conditions like gall bladder, stomach, and +similar operations, post-operative pneumonia constituted the most of +his mortality. + +This great man was afraid of post-operative pneumonia, while I, a much +less skilled surgeon, am no more afraid of post-operative pneumonia +than I am of something occurring in a distant state because with +osteopathic treatment, we have eliminated post-operative pneumonia as a +fatal condition. + + + + +PART SECOND + + + + +INFECTIOUS DISEASES + + +Fever + +=Fever= is due to various causes, so that a definite statement cannot +always be given as to the cause of fever in every disease. Each fever +case, like all other disorders, is a law unto itself; different causes +are found in different cases. Moreover, often only theories, and not +absolute facts, can be given. + +Fever may be present when a local disease assumes a constitutional +character or when the constitutional character is manifested from +the beginning of the disease. Fever may be a systemic disorder or +a symptom of disease, and is characterized by an increase of body +temperature. Other symptoms are usually present, as an accelerated +pulse, disturbances of distribution of the blood, increased catabolism, +and disordered secretions. + +=Etiology.=—In infectious diseases fever is due chiefly to the action +of various toxic or harmful agents, produced by the disease, upon the +fluids of the body and upon the nervous system. Disturbances of the +thermogenic centers and nerves of the brain or cord by harmful agents, +or by lesions of the anatomical structures affecting these nerves, are +sources of fever. Also disturbances of the vasomotor centers (in the +medulla and auxiliary centers along the cord) and nerves are causes +of fever in many instances. A disturbed or lessened function of the +nerves controlling sweating is an important factor. The multiplication +of micro-organisms in the body, acting directly on the tissues or +by producing toxic substances which affect the nervous system, is a +fruitful source of fever. A few cases may be caused by direct affection +of the nervous system, as is shown by appearance of fever in epileptic +attacks, or by the passage of a catheter into the bladder. In a large +number of all cases a demonstrable cause can be found upon careful +examination, whether the fever be due to a necrosed mass of tissue, the +introduction into the system of decomposed food, infectious diseases, a +lesion of some anatomical structure affecting a thermogenic, vasomotor +or sweat center, a lesion to the innervation to the heart (vagi and +cervical sympathetic) causing a rapid heart, or a lesion to the +lymphatic system. + +=Treatment.=—The treatment of fevers in a general way consists +principally of thorough inhibition to the posterior spinal nerves of +the upper cervical region in order that the center of the vasomotor +system in the medulla may be affected, probably by the way of the +superior cervical ganglion of the sympathetic. Thus the entire +vascular system is equalized, for there is always a disturbance in the +distribution of the blood in fever and if the center controlling the +nerves that govern the lumen of the blood-vessels can be brought under +control, there will result an equalization of the vascular system; if +such occurs, health must ensue. Besides the vasomotor nerves to the +blood-vessels being affected by this treatment, the nerves governing +the lymphatics and the sweat glands will also be controlled. The +sweat glands as a rule are rendered active by affecting directly the +innervation of the glands, also the glands are controlled indirectly by +the blood supply; this aids materially in lessening the temperature of +the body. Treatment for a few minutes to the upper posterior cervical +region would also affect the thermogenic centers and nerves of the +brain reflexly in the same manner as the vasomotor and sweat centers +and nerves are affected, thus tending to equalize the mechanism of the +thermogenic system. Besides this action on the vasomotor, sweat, and +the thermogenic nerves, there is produced an increased exhalation of +moisture from the lungs, on account of an increase of vascular area in +the lungs through vasomotor action. Also the large vascular area in the +abdomen, under control of the splanchnic nerves, becomes constricted. +Thus there is brought about a lessening temperature by evaporation, +heat radiation, and perspiration; and an increased action of the +general nervous system, a stronger cardiac force, an equalization of +the vascular system, and a more perfect elimination of toxic properties +by the skin, kidneys and lungs; consequently a reduction of the fever. + +The foregoing treatment is successful to a limited extent, only in +such cases where causative factors of the fever are involving the +predominating centers controlling the heat production or dispersion +and the vasomotor system directly; for if the lesion that is causing +the disorder should be affecting an auxiliary center along the spinal +cord instead of the predominating center, as is oftentimes the case, +treatment of the predominating center would be useless as far as any +permanent benefit is considered; although a temporary effect will be +gained by lessening the fever at that point. Consequently, in many +cases, the lesion lies within the jurisdiction of auxiliary centers +which are situated at various points along the spinal cord. When +such is the case, it will be of little benefit to give the cervical +treatment. In such instances the lesion to the auxiliary center would +have to be removed in order to cure. One cannot depend upon a set rule +to reduce a fever; determine the cause, as in any other disease or +symptom, and remove it. + +In addition to the treatment to the cervical region and along the +spinal column, as are indicated upon an examination, attention should +be given to the heart’s action. The equilibrium between the accelerator +and inhibitory nerves (cervical sympathetic and vagi) should be +maintained. The interchange of gases in the lungs should be rendered +as nearly normal as possible; this is best accomplished by raising +and spreading of the ribs from the second to the seventh dorsals, +particularly in the region of the fifth and sixth. Also stimulation +of the vagi will aid by increasing the motor power of the lungs. +The kidneys and bowels should be kept active so as to favor a rapid +elimination of various toxic properties; besides they have control +over large vascular areas. Treatment over the ureters will prevent any +clogging that might occur in them from a condensation of the urine. +Attention, also, should be given the tissues at the fifth lumbar and +over the iliac vessels to influence the circulation in the pelvis. + +The =food= of the patient should be liquid—milk, soup, broths, etc., +and almost any quantity of water allowed if called for, given little +at a time and at frequent intervals. The room should be well lighted, +ventilated, clean and kept at an even temperature. + +=Two points= should always be remembered relative to fever: + +First—That there are many causes of fever; and in order to reduce the +fever the cause must be determined and removed, the same as in any +disorder. A definite fever treatment cannot be given any more than a +definite constipation treatment; the case must be seen in order to +determine the cause. + +Second—The reduction of fever is not necessary; the fever should be +treated only as a symptom of disease when it exists as such. In fact, +fever is beneficial, for it is one of nature’s methods to relieve an +over-burdened system from harmful agents, unless the temperature is +excessive and continuous and is likely to cause more harm than the +primary trouble. + +Absolute =rest= in bed always is of decided benefit in lessening the +temperature. + +=Hydrotherapy= is of immense value in reducing a fever. It is an agent +that has been greatly used, and if applied intelligently cannot but +be of aid. There is much ignorance in regard to the principles and +practice of hydrotherapy, not only among all classes of people, but +among well informed practitioners in medicine. The most important +function of the skin is as a heat regulator. Knowing this fact, the +osteopath treats the vasomotor nerves that control the cutaneous +circulation and the nerves that control the excretion of the skin; +the nerve supply being from the cerebrospinal and sympathetic nerves. +In many difficult and obstinate cases hydrotherapeutic measures +should be used to aid the skin in regulating the temperature, as well +as to enhance system functions for the same reason that osteopathic +manipulations are given. Maintaining an equilibrium in heat production +and heat dispersion is necessary in order that the standard of the +body temperature may be kept; and the amount of the arterial blood +circulating within a tissue determines its temperature. + +The principal effect of water as a thermic agent when applied +externally is due to the influence of the action of the water upon the +cutaneous circulation. Lesser effects would be the mere extraction of +heat from the body by evaporation and the equalization of temperatures +of two bodies coming into contact. As the body is endowed with +compensatory powers, this latter means would apply only to a limited +extent. The temperature of the water used is important, as the colder +the bath the less effective would its power be in reducing internal +temperature. When a cold bath is used there is a driving of the blood +away from the surface on account of the contraction of the peripheral +vessels; consequently increasing the cutaneous circulation and cooling +by radiation is prevented and less heat is lost. A collateral hyperemia +occurs in the underlying parts which acts as a protection to the deeper +tissues. The cold also inhibits the vasomotor nerves controlling the +abdominal splanchnics, and thus a larger amount of blood passes to +this immense vascular area. On the other hand, when a warmer bath is +used the effect is opposite, and a lowering of the temperature is the +result. The cutaneous vessels being dilated, the superficial blood is +rapidly replaced by blood from the deeper vessels, thus allowing a +cooling of the body to a large degree. + +In the various fevers where hydrotherapeutic measures are employed, the +object to be gained by such methods is not primarily an anti-thermic +one but an anti-febrile reaction; consequently the use of cold +water is employed. In mere heat reduction the warmer water would be +more effective; but by the aid of the colder water the cause of the +increased temperature, as in infectious fevers, is lessened; besides +a refreshing and stimulating effect upon the entire system is gained. +Thus the aim of the cold bath and friction, is not primarily to subdue +the temperature by heat radiation or evaporation, but to correct +disturbances governing the formation and the dissipation of heat +caused by infectious fevers, and, moreover, to stimulate the nervous +system, prevent heart failure, increase the eliminating power of the +skin, kidneys and lungs, and to influence the corpuscular and chemical +constituents of the blood to a more normal condition. + +The full cold bath and friction (Brand Method) is commonly employed +in infectious fevers. The half bath, wet pack, or sponging may be +used. The modus operandi of each is given under the hydrotherapeutic +treatment of typhoid fever. + + +Typhoid Fever + +(ENTERIC FEVER) + +In writing of these acute diseases which are self-limiting, it is +understood that osteopathy aborts, overcomes symptoms and otherwise +changes conditions frequently. When this occurs the case is not typical +and it is a typical case which is here described. + +=Definition.=—An acute, infectious disease caused by the bacillus +typhosus. It is characterized anatomically by hyperplasia and definite +lesions of Peyer’s patches and mesenteric glands, and enlargement of +the spleen, and clinically by its slow onset, often diarrhea, abdominal +tenderness, tympanites, fever, headache, and rose colored spots on the +abdomen. + +=Osteopathic Etiology and Pathology.=—Lesions to the lower dorsal and +lumbar regions are always found, which impair the innervation and +vascular supply of the intestines and cause defective nutrition. This +is the most important predisposing cause, although general lowered +vitality from overwork, improper food, unhygienic environment, and +insanitary surroundings, are also of great importance. It is possible +that one’s vitality may be so lowered that the bacillus of Eberth, +if of sufficient numbers or virulency, will find a suitable medium +wherein to multiply and grow, and thus the spinal lesions found in +these cases are the result of reflex irritation. But the most probable +underlying cause is the spinal lesion, and given two individuals with +equal likelihood to infection, one with the spinal lesions and the +other not, the former within all probability will be the more likely +to suffer an attack. The severity and extent of the osteopathic lesion +undoubtedly bears a direct ratio to the probability of attack from +an infectious disease. Typhoid fever usually occurs between the ages +of fifteen and thirty years. Some families are more susceptible than +others. The autumn months, especially after a dry, hot summer, favor +the disease. One may be reasonably certain that whenever there is a +case of typhoid the individual has not been careful as to diet, or +drinking water, or some rule of health, and wherever there is an +epidemic it can always be traced to insanitary surroundings, the water +supply, contaminated garden truck or other food, sewage, etc.; although +this does not preclude the probability that the osteopathic lesion or +lowered vitality of Peyer’s patches and mesenteric glands from other +causes are important and many times primal etiological factors. The +specific poison may be so virulent that practically no one escapes and +again those of lowered vitality only will succumb to an attack. + +The =exciting cause= is a special micro-organism, the bacillus of +Eberth. The contagion may be carried through the air from one person +to another, but this is rarely the case. Though the water is the most +common mode of conveyance, the bacillus has been found during epidemics +in both water and milk. The water may be contaminated by the intestinal +discharges which have not been properly disinfected. Extreme cold does +not destroy the typhoid germs. Milk may be infected from the milk-can +being washed with the contaminated water or the unclean hands of the +milker. In fresh milk the germs multiply rapidly. Salads, celery, ice +and fruits may be contaminated. Oysters have become infected while +being fattened or freshened. It is thought by some that the poison is +not eliminated from the sick in a condition capable of transferring +disease to a healthy person, but must undergo changes in the soil +before it is able to cause the disease in another. Typhoid fever may be +caused, however, by direct contact with the stools. Filth, sewers, or +cesspools do not directly cause the disease, but they form a suitable +medium for the preservation of the typhoid germs. + +=Pathologically=, the characteristic lesions in typhoid fever consist +of changes in the lymphoid elements of the bowels. These changes +are most striking in the solitary glands and Peyer’s patches. The +alterations which occur may be divided into four well defined stages: +(1) =Infiltration=—the glands are enlarged from infiltration and there +is marked cell proliferation, particularly Peyer’s glands in the +jejunum and ileum and to a lesser extent those in the large intestine. +The glands become pale and prominent. Occasionally the solitary glands, +which are usually deeply imbedded in the submucosa, become prominent +also. + +=Microscopically=, the capillary blood-vessels are at first +considerably dilated, but later become more or less contracted, +giving an anemic appearance to the follicles. The adjacent mucosa and +muscularis may become infiltrated. The cells have the character of +lymph corpuscles, some of which are larger, epithelioid in character, +containing several nuclei. From the eighth to the tenth day this +medullary infiltration reaches its height and then undergoes either +resolution or necrosis. + +(1) =Resolution= takes place by a granular or fatty infiltration of the +cells. This produces pitting of the swollen follicles, which may cause +small hemorrhages. + +(2) =Necrosis.=—With all the severe cases of cell infiltration, +hyperplasia of lymph follicles reaches a stage where resolution is +impossible and necrosis occurs. The necrosis is partly due to the +choking of the blood-vessels and partly to the direct action of the +bacilli. The necrosis may involve only the superficial layers of the +mucosa or it may extend deep into the muscular coat and even perforate +the outer or serous coat. Usually, however, this does not extend +below the submucosa, mucosa, or muscularis. Not all of the patches +necessarily slough, but as a rule it is always more intense toward the +ilio-cecal valve. + +(3) =Ulceration.=—The extent and depth of the ulcers depend upon the +amount of the necrosis. Large ulcers are sometimes formed, especially +in the lower end of the bowel, by the union of several. The edges +are swollen and undermined. The base is usually smooth and formed of +submucosa. Perforation of the bowel occurs in a small percentage of +cases; more commonly the ulcers heal. The perforations may be multiple, +but rarely exceed two in number. + +(4) =Healing.=—Cicatrization begins about the fourth week. This +granulation tissue covers the floor. It is sometimes formed with +connective tissue and a new growth of epithelium results. The gland +is ultimately replaced by a depressed scar with a smooth, pigmented +surface. The majority of deaths occur before this stage is reached. The +gland structure is never regenerated. + +The =mesenteric glands= show intense hyperemia and later become +enlarged and softened, but rarely ruptured. The glands at the lower end +of the ileum are markedly involved. + +The =spleen= is enlarged, softened, and diffluent. Occasionally rupture +occurs. Infarction is not a rare occurrence. + +The =liver= shows parenchymatous and granular degeneration, and the +cells are found to contain much fat. Infarction abscesses and acute +yellow atrophy occur in rare instances. Diphtheritic inflammation of +the gall-bladder sometimes occurs and the bile is thinner and paler +than normal. + +The =kidneys= also show parenchymatous degeneration. They are pale in +appearance, with slight cloudy swelling. Microscopically, there are +seen granular and fatty infiltration of the cells of the convoluted +tubules. Rarely, there is acute nephritis which may be hemorrhagic. +There may be miliary abscesses in which typhoid bacilli have been +found by some observers. Diphtheritic, but more frequently catarrhal, +inflammation of the pelvis of the kidney may occur. Catarrh of +the =bladder= is not infrequent and even sometimes diphtheritic +inflammation is present. Rarely orchitis is encountered. + +=Hypostatic= congestion of the =lungs= is not uncommon. Gangrene and +hemorrhagic infarction are sometimes present. Lobar pneumonia may be a +complication. + +In the =larynx= ulceration is sometimes met with bacilli, however, have +not yet been found in these ulcers. Diphtheritis of the pharynx and +larynx may occur. Catarrhal or croupous pharyngitis may occur; while +swelling of the follicles of the pharynx and base of the tongue is +frequently noticed. + +=Peritonitis= is always present in fatal cases in which perforation +of the bowel has taken place. The perforation may occur in ulcers +from which the sloughs have already separated, or it may be caused by +a necrosis of all the coats. Extensive peritonitis may occur without +perforation, and is probably due to extension of the inflammation to +the peritoneum. + +The =heart= may be affected. Endocarditis is rare, while pericarditis +is much more frequent. Myocarditis is frequently met with, the cardiac +muscles presenting parenchymatous and rarely hyaline degeneration. +The =arteries= are frequently found to be involved. These conditions +(obliterating arteritis and partial arteritis) may affect the smaller +vessels, especially those of the heart, but more commonly affect the +arteries of the lower extremities. Thrombosis of the veins, especially +of the femoral, and more rarely of the cerebral veins and sinuses, +occurs. + +Granular and hyaline changes in the voluntary =muscles= may occur. This +degeneration does not affect the whole muscle but involves only certain +fibres. Regeneration takes place during convalescence. + +With the nervous system meningitis is rare. The peripheral =nerves= +are frequently the seat of parenchymatous changes. The ganglia of the +trunks of the vagi present an inflammatory change. + +The =blood= presents little change. During the first two weeks the +red corpuscles gradually decrease in number until the first week of +convalescence, after which they gradually increase in number. There is +often a marked decrease in the number of leucocytes. Leucocytosis is +absent. The hemoglobin is always reduced. + +=Symptoms and Course.=—The incubation period varies from a few days to +two weeks or longer. During this time the patient may feel in his usual +health, but more often there is a feeling of languor and indisposition +to exertion, loss of appetite, slight coating of the tongue, nausea, +headache, chilliness, but seldom a decided rigor, pains in the back or +legs and nose-bleeding. Any of these symptoms may be present and last +usually from a few days to a week or more. These symptoms increase in +severity and the patient takes to his bed. The invasion as a rule is +gradual. + +The =first week= dates from the onset of the fever which generally (but +by no means in all cases) rises steadily during the first week a degree +or a degree and one-half each day, reaching 103 or 104 degrees F. The +pulse is quickened to 90 to 110 per minute and is full, of low tension +and sometimes dicrotic. There is great thirst, also a coated tongue. +The skin is hot and dry and there is rather intense headache. Unless +the fever is high there is no delirium. The sleep is disturbed and +there may be mental confusion and wandering. Cough with some thoracic +oppression is not uncommon at the onset. The abdomen is slightly +distended and tender. There may be either constipation or diarrhea. The +spleen is somewhat swollen and a rose colored rash appears on the skin +of the abdomen and chest. + +During the =second week= the fever remains high and exhibits the +continued type, the morning remission being slight. The pulse is +accelerated. The headache disappears, but there is marked mental +dullness and slowness and there may be a mild delirium at night. The +tongue is coated and the lips are dry. The abdomen is tympanitic and +tender. Diarrhea replaces constipation. The case may prove fatal during +this week from the result of nervous or pulmonary symptoms, hemorrhage, +or perforation. + +The fever changes in the =third week= from a continuous to a remittent +type. The pulse ranges from 110 to 130. The patient is very weak. +Complications may arise, as pulmonary symptoms, feebleness of heart, +intestinal hemorrhage, perforation, and peritonitis. + +In favorable cases during the =fourth week= the fever begins to decline +and the general and local symptoms gradually disappear. In protracted +cases the =fourth= and =fifth= weeks may present the symptoms of +the third week. Frequently the following aggravated symptoms are +added: stupor, delirium, increased weakness, rapid, feeble pulse, +and distended abdomen. Heart failure and inflammatory complications +increase the danger. + +During the =fifth= and =sixth weeks= a few cases will show irregular +fever. Great care should be taken that complications do not occur. + +The =fever= is the most important and characteristic symptom and from +the temperature alone a diagnosis may be made. During these stages of +development, which is the first four or five days, the temperature +rises steadily; the evening temperature being about a degree or a +degree and one-half higher than the morning remissions, reaching 104 +or 105 degrees F. at the end of the first week. When the =fastigium= +is reached the fever persists with slight morning remissions. At the +end of the second and throughout the third week the temperature becomes +more remittent and there may be a difference of three or four degrees +between the morning and evening temperature. During the last stage the +fever falls by =lysis=, forming a more or less regular step-like line +of descent. The stage lasts from one week to ten days. + +When the disease sets in with a severe rigor the fever frequently rises +at once to 103 or 104 degrees F. In the lightest forms the fastigium +may be almost absent; defervescence setting in upon the first day of +the fastigium and in many cases defervescence occurs at the end of +the second week and the temperature may fall rapidly, becoming normal +in ten or twenty hours. This fall in the temperature may take place +without any apparent cause or it may follow an intestinal hemorrhage. +The temperature often falls many hours before the blood appears in the +evacuations. The occurrence of peritonitis is also marked by a sudden +fall in the temperature. =Hyperpyrexia= in typhoid fever is not very +common except just before death. + +After the temperature has been normal for several days there may be +a sudden rise of the temperature to 102 or 103 degrees F. This may +persist for a couple of days and then return rapidly to the normal. +These =recrudescences=, as they are called, are quite common and are +caused most frequently by errors in the diet, constipation, excitement +or mental emotion. These elevations in the temperature are found most +frequently in children and persons of a nervous temperament. + +=Afebrile Typhoid= is of very rare occurrence. The patient has all the +characteristic symptoms of typhoid fever with the exception of a fever. + +The =rash= is highly characteristic. It appears about the eighth or +tenth day, usually upon the skin of the abdomen or chest, rarely +found elsewhere on the body. It consists of a variable number of rose +colored spots distinctly elevated, and disappear on pressure. These +spots last three or four days and appear in successive crops. Vivid red +erythematous eruptions upon the chest and abdomen are commonly seen +during the first week of typhoid fever. Urticaria is rarely seen. + +Sweating characterizes some cases of typhoid fever, but generally the +skin is dry. This may occur with or without chilly sensations or actual +rigors. In some cases there may be recurring paroxysms of chills, +fever, and sweats and they may be mistaken for intermittent fever. +Edema of the skin may occur and is usually due to anemia or cachexia +and sometimes to nephritis. Local edema may occur as the result of +vascular obstruction, particularly thrombosis of the femoral vein. +There is a peculiar musty odor exhaled from the skin in typhoid fever, +particularly if the skin has been neglected. In all protracted cases +=bed-sores= are likely to develop. The =hair= is apt to fall out but +is generally renewed. The nails also suffer and ridges can usually be +observed upon them. + +=Intestinal symptoms= are very inconstant. Usually there is +constipation at the onset and this may persist throughout the disease +although a moderate diarrhea may occur throughout the disease. The +severity of the diarrhea is due most probably to the degree of the +catarrh rather than to the extent of the ulcers. It is probable that +the discharges are more frequent when the catarrh involves the large +intestine. The number of discharges average, as a rule, from two to +four or more daily. The stools are either fluid or of the consistency +of jelly, of a grayish-yellow color, alkaline in reaction and are very +offensive. + +=Hemorrhage= is a serious symptom, but by no means always fatal. This +usually occurs in cases of considerable severity and it generally +occurs at the time of the separation of the sloughs during the third +week. When it occurs quite early in the disease it is generally the +result of hyperemia. It may be so slight as not to be noticed by the +eye or it may be from one to three pints. Intestinal hemorrhage, +however slight, is always a grave symptom. There may be symptoms of +collapse and fall of temperature, or it may occur without any symptoms. + +=Meteorism= is an almost constant symptom, and when excessive adds to +the seriousness of the case and corresponds generally with the extent +of local lesions. Abdominal tenderness and gurgling upon pressure in +the right iliac fossa may be present; pain is generally absent, and +when present is usually slight. + +=Perforation= almost invariably causes fatal diffuse peritonitis and +is the most serious complication. It may occur at any time but is most +common between the second and fourth weeks. It is usually indicated +by sudden acute pains in the abdomen and symptoms of collapse. As +a rule symptoms of =peritonitis= appear at once; distension of the +abdomen, great tenderness, and rigid abdominal walls. Vomiting, pinched +features, and rapid, small pulse shows general collapse of the +circulatory system. + +=Bronchitis= is almost invariably present as an initial symptom. It is +indicated by the existence of sibilant rales. The cough is generally +slight. + +Hypostatic congestion of the =lungs= and edema, due to enfeeblement of +the cardio-pulmonary circulation, in the latter part of the disease are +not infrequent. + +The =pulse= as a rule is not very frequent and is generally not in +proportion to the fever until late in the disease; 90 to 120 is +the usual range. During the first week it is about 100, full, and +frequently dicrotic; later it becomes more rapid, feeble and small. +In severe cases during the extreme debility of the third week the +pulse may reach 150 or more (the so-called running pulse). During +convalescence the pulse occasionally becomes subnormal and bradycardia +is met with more frequently than after any other acute fever. + +The =blood= presents definite changes, some of which are important. +In cases where there is profuse sweating or copious diarrhea, the +red corpuscles may be relatively increased; this is due to the loss +of water. In most cases there is little change until the end of the +second week. During the third week there is generally a decrease in the +number of corpuscles and of the hemoglobin, which is always reduced. +=Leucocytosis= is always absent. The white corpuscles are slightly +diminished especially toward the end of convalescence. + +During the first week there is generally persistent headache, sometimes +neuralgia. There are a few cases in which the effects of the typhoid +bacilli or their poison is manifested in the =nervous system= from +the very onset. There are violent headaches, retraction of the head, +rigidity, photophobia, twitching of the muscles, rarely convulsions, +all indicating meningitis as which it is occasionally diagnosed. +It must be remembered however, that all nervous symptoms may occur +independently of a lesion of the nervous system. + +=Delirium= may exist from the onset, but it usually is not present +until the second or third week and only in the severer cases. As a rule +it is most marked at night. It is generally of the low, muttering type, +very seldom maniacal. When the patient picks at the bed clothes or +grasps at imaginary objects there is indication of danger, as it is a +serious symptom. Convulsions are rare. + +The =urine= is diminished in quantity, high specific gravity, and of +dark hue. Both urea and uric acid are increased and the chlorids are +diminished during the first stages. About the stage of decline the +urine becomes light in color and greater in quantity than normal. The +specific gravity is lowered, urea and uric acid are diminished, and the +chlorids are increased. Febrile albuminuria is very common but of no +special significance. Acute nephritis may develop as a complication. +Pyuria is not an uncommon complication and post-typhoid pyelitis may +also develop. + +=Malarial fever= may be associated with typhoid, especially in malarial +districts. Persons with tuberculosis, epilepsy, chorea, and other forms +of chronic nervous diseases are liable to typhoid fever. In epilepsy +and chorea the movements and fits usually cease during the attack of +typhoid fever. + +=Varieties of Typhoid= are numerous and are named with reference to +the degree of severity which varies from extreme mildness to extreme +severity. + +The =mild= or =abortive= form is of frequent occurrence. The onset is +usually sudden. The symptoms are similar to those of a typical case but +much milder and appear earlier than in the usual type. This form runs +its course in about two weeks. The fever usually reaches 104 degrees F. + +In the =severe= or =grave= form there is high fever and the nervous +symptoms show a profound intoxication of the system. The grave types +are those associated with serious complications or those cases which +set in with pneumonia, Bright’s disease, or cerebrospinal symptoms. + +In the =latent= or =ambulatory= form (walking typhoid) the symptoms +are very slight, the patient being hardly sick enough to go to bed. +The symptoms may be of this character throughout the attack, and the +patient may be able to be up and about. In other cases the first +symptoms are very mild, but later they may develop symptoms of the +severest type. + +The =Afebrile= form is rare. =Hemorrhagic= typhoid is a very fatal but +rare form. In this type there are cutaneous and mucous hemorrhages. + +=Diagnosis.=—As a general rule typhoid fever is easily recognized. +The Widal test should be made. At times the diagnosis may have to +be delayed until the distinctive signs appear, especially in those +cases which come on with severe headache, delirium, twitching of the +muscles, and retraction of the head. In these cases the diagnosis of +cerebrospinal meningitis is invariably made, until the appearance of +the colored spots on the abdomen, which must decide the diagnosis; +cerebrospinal meningitis being a rare disease and typhoid fever with +severe nervous symptoms quite frequent, it is more probable that it is +typhoid. At least one-half of the cases termed brain fever belong to +this class of nervous typhoid. + +=Prognosis.=—A positive prognosis can not be made, as even the mildest +cases are liable to have severe complications develop at any stage of +the disease. Under osteopathic treatment the prognosis is undoubtedly +more favorable than with the treatment of the older schools. If the +osteopath can see the case early, the first week, there is always a +chance to abort the attack. In all cases there is the probability that +the attack will be shortened; this is a common experience. Price of +Mississippi, has treated many cases, and invariably when the patient +is seen early the attack has been shortened to thirteen or fourteen +days, whereas under other treatment the disease runs the usual course. +Adsit of Kentucky, White of New York, and the staff of the American +School of Osteopathy (Kirksville), as well as many others, have had +the same experience. And if the attack cannot be aborted or shortened +there is the further probability that the severity will be lessened +and complications prevented. The prognosis is always more favorable in +winter than in summer, and especially favorable in children. More women +die than men, and fat persons stand the disease badly. + +=Treatment.=—Typhoid fever is one of the diseases that practitioners +of all the schools are agreed that drug therapeutics avail but little +in its treatment. The treatment of the older schools consists of +prophylaxis, good nursing, attention to hygienic principles, dieting, +and hydrotherapy. All of these have their places and are recognized +by the osteopathic school. But the above methods are of the defensive +only—allowing the disease to run its usual course and reducing the +likelihood of complications. On the other hand the above treatment +coupled with osteopathy, not only attacks the ravages of the disease +defensively, but of more importance, the disorder is attacked +offensively. Herein is where attacks are aborted, or shortened, +or severity lessened, or complications prevented. The efficacy of +osteopathy is due to the ability of the osteopath to treat disease, +not only prophylactically and palliatively, but of more consequence, +aggressively. + +The correction of the spinal lesions in typhoid fever is of first +importance. This treatment effects a tendency toward equalized +circulation of the intestines. The vasomotor nerves are disturbed by +the above lesions which in turn produces stasis in Peyer’s patches and +the mesenteric glands. Reversely some of the spinal lesions may be due +to reflex stimuli, for “Kirk ... states that muscular contractions +produced by reflex activity are often more sustained than those +produced by direct stimulation of the motor nerves themselves.”[51] + +=Prophylactic= treatment is very essential, for typhoid fever as a rule +is a preventable affection. Modern hygienic and sanitary resources +enable a community to reduce the number of cases to a minimum. The +number of cases in a locality depends almost directly upon the +condition of the water supply and drainage. Care should always be +taken in regard to the source of drinking water and milk. During an +epidemic the water should be boiled for half an hour before being used. +The patient should be isolated. In hospitals they should have special +wards; in families a special apartment should be given them. Hygienic +principles should be followed as in other infectious diseases. + +The methods of disinfection must be rigid to prevent the spread of an +infection. The excreta (stools, urine, vomitus, and sputum) are to +be received into a bed-pan or any appropriate receptacle containing +half a pint of carbolic acid (one to twenty). Three or four pints of +the carbolic acid (one to twenty) should then be added to the bed-pan +and the contents mixed carefully before emptying. All utensils used +in handling the excreta are to be carefully disinfected by the same +material, and dried. After every stool the nates of the patient should +be cleansed by a cloth compress, wet with a solution of carbolic acid +(one to forty) and the cloth burned. The sick room should be thoroughly +ventilated each day. All utensils used about the patient in feeding +should be boiled in water immediately after using. The bed and body +linen is to be changed as soon as soiled and these, with all changed +bath towels, blankets and rubber sheets, should be received in a sheet +rinsed in carbolic acid (one to forty) and placed where they may be +soaked in the solution for four or five hours. The clothes are to be +boiled for half an hour. The rubber blanket is to be washed in the +solution, dried and aired. + +The =General Management=, careful nursing and a regulated diet, is of +paramount importance in the treatment of typhoid fever. The patient +should be placed in bed as soon as the disease is determined and there +remain until the end of the attack. The room should be well ventilated +and have a sunny exposure if possible. The single woven wire bed with +soft hair mattress and two folds of blankets is best. A rubber cloth +should be placed smoothly under the sheet. When a good nurse cannot +be had, the attending osteopath should write out directions regarding +diet, bed linen, and utensils, and the disinfection of the excreta. + +A liquid =diet= should be administered. Milk is most commonly used; +care being taken that it is thoroughly digested. If milk is not borne +well by the patient, other foods, as whey, sour milk, buttermilk, and +broths may be substituted. Give food that is easily digested and which +leaves but little residue. When milk is used alone, three pints at +least may be given to an adult in the course of twenty-four hours; and +it should always be diluted, preferably with plain water. Beef juice, +mutton or chicken broth may also be used when milk is not agreeable. +Albumin water, prepared by straining the white of eggs through a +cloth and adding an equal amount of water, is an excellent food. Well +strained, thin barley gruel is considered by many an excellent food +for typhoid fever patients. Cases not able to take nourishment into +the stomach, on account of vomiting and other causes, should be fed +rectally to support life. Do not force feeding to an unwarranted degree. + +Recently a number of new diets have received commendation. These +include the “high calory” diet, which includes three pints of milk +with one of cream, two to eight ounces of milk sugar, eggs, butter; +sometimes cereals, toast, potato, and other soft foods are given. +A full sugar diet, as of candy alone, is based upon the immediate +absorption of sugar, its value as a source of energy, and the fact that +a plentiful carbohydrate supply lessens the danger of acidosis.[52] + +The best drink for fever patients is pure, cold water and they should +be encouraged to drink freely of it. Barley water, ice tea, lemonade, +or even moderate quantities of coffee or cocoa, may be given. + +By =Osteopathic Treatment= many cases of typhoid fever may be aborted, +if treated correctly, during the first week. If the stage of necrosis +of Peyer’s patches has set in, one can either lessen the severity of +the attack or, at least, shorten the usual course. During the stage of +infiltration, treatment to the intestinal splanchnics (chiefly from the +ninth to twelfth dorsal, the innervation to the jejunum and ileum) and +careful treatment over the abdomen is indicated. This treatment will +tend to lessen the intestinal catarrh and diminish the infiltration and +cell proliferation of the lymphoid elements of the intestines, and thus +produce unfavorable the conditions for the bacillus of Eberth. In other +words, increase the tone and activity of the intestines so that the +micro-organisms of typhoid fever will not find the proper tissue-soil +in order to grow and multiply. + +All cases of typhoid fever present lesions in the dorsal or lumbar +spine and this is really the great predisposing cause of typhoid +fever. Correcting these lesions is absolutely necessary in order to +abort the disease. Some patients may have such a lowered vitality +to begin with that the recuperative powers of the body cannot be +rendered forceful enough in a short time to combat the effects of the +micro-organism. Carefully raising the cecum is very effective (A. +T. Still), but this must be done with the greatest of caution and +judgment. Dr. Still considers a posterior condition of the third, +fourth and fifth lumbars as typical in typhoid and that it inhibits the +lymphatics to the intestines. + +R. L. Price has had excellent success in shortening the usual typhoid +course. His first treatment is to thoroughly empty the bowels by +enemata. This is followed by spinal, liver and splenic treatment, and a +liquid diet. + +E. C. White has also treated a large number of typhoid cases with +marked success. He prefers to employ the Brand method (and it must be +properly used) from the start. He is, also, a thorough advocate of the +spinal treatment. In cases of constipation give a very light treatment +over the left iliac fossa. With all patients observe careful dieting. +White believes that many lesions of the spine arise from reflex +irritations during acute attacks. Careful, frequent attention to the +spine is demanded. + +Hildreth, relative to abdominal and spinal treatment, writes as +follows: “In the abdominal treatment of typhoid fever, too much care +cannot be exercised; or in the spinal treatment, too much judgment +used in giving just the right kind of manipulation. There can be no +question relative to the seat of the disease, and consequently there +should be no trouble in knowing where or how to affect the nerves to +control the same. That Peyer’s patches or the right iliac region is +always involved, we all know. The spinal treatment should be applied +from the eighth dorsal to the first lumbar inclusive; this affects all +the lesser splanchnics and thus controls the circulation of the entire +bowel. And this treatment should be given, according to the symptoms +indicated, in each and every case. If the patient is constipated, +then the treatment should be more of a stimulative character, but if +diarrhea is present, as is commonly the case, the treatment should be +an inhibitory one. In the above I always finish with a very careful +treatment of the floating ribs on the left side; this affects the +lesser splanchnic nerves. In all cases I always carefully treat +the lower two or three lumbar vertebræ, which directly affects the +hypogastric plexus of nerves, and thus controls the circulation to the +lower bowel. + +“In all cases I always treat the bowels directly, more or less, but +this treatment =must= be given with the very greatest =care= and the +best judgment, always governed by the condition of the bowel. By +no means manipulate the bowel, but just lay your hands flat on the +abdomen, and with the most gentle pressure inhibit the peripheral +nerves, thus either quieting an excited peristalsis or equalizing a +disturbed circulation. And with this treatment remember that the two +specific points in typhoid fever are the lower dorsal and lower lumbar +nerves. + +“The above treatment is used, of course, in connection with all the +other necessary treatments, such as dieting, nursing, sponging, +relieving the headaches, etc. I am unalterably opposed to ice-packs for +the bowels in typhoid, for the reason it is too much of a shock. Cold +cloths are good and much better than ice, and should always be used +instead of ice.” + +After the disease has become thoroughly established always make it a +point during each visit to examine the entire length of the spinal +column carefully and readjust any tissue, whether it be vertebra, rib, +or muscle, that may be found disordered. The bowels are to be watched +carefully and if constipated, they should be moved with a light enema. +Great care must be taken not to treat the abdomen roughly, if at all, +after the first week. The treatment might be very injurious to the +structures diseased. A light treatment over the liver and kidneys +each time is a wise precaution. The heart’s action, should be watched +carefully. In addition to the hydrotherapeutic treatment, the general +fever treatment should be employed. The patient should usually be seen +twice a day. + +=Abdominal pain= is best relieved by light treatment over the abdomen +and by thorough treatment of the lower dorsal or lumbar region. +Applications of hot water will be helpful. + +=Meteorism= can be relieved by raising the lower ribs and by direct +treatment to the abdomen. A change of diet may be beneficial. When gas +is in the large bowel an enema may be given to remove it. + +=Diarrhea= and =constipation= are best controlled by the usual +treatment given the spine in such cases, and over the abdomen and the +liver. Light enemata may be given for constipation. The stools should +be examined when diarrhea occurs, as the presence of curds may cause +the aggravation. + +=Hemorrhage= from the bowels demands absolute rest. It is probably +better to have the patient use the draw sheet for the evacuation. +Immediate and thorough treatment must be given to the spinal column +in the region of the intestinal nerves to the diseased area, so +that existing lesions may be corrected and the vascular area of the +mesentery equalized. Ice should be given freely and an ice pack placed +over the abdomen. Food should be restricted for ten or twelve hours. +If the peristalsis of the intestines is increased, an effort should be +made to control it through the vagi and splanchnic nerves. + +In =perforation= hot applications, rest and thorough treatment of the +innervation to the peritoneum are of value, but immediate operation is +usually advisable. + +=Insomnia= is best relieved by attention to the cervical region. +Relaxation of the muscles in this region and a quieting treatment to +the posterior occipital nerves, coupled with cold sponge baths, will +usually induce sleep. + +In =delirium= attention to the circulation of the brain, by careful +treatment of the vasomotor system, and the Brand method of baths will +relieve this distressing symptom. + +During =convalescence= the patient should be restricted from any mental +or physical exercise for a week or ten days and then should move about +with care. Solid food should not be given for ten days or two weeks. If +the temperature has been normal for ten days, it is then safe to allow +such food as eggs, milk puddings, and milk toast. If diarrhea should +persist, being due to ulceration, the diet should be restricted and the +patient confined to the bed. If constipation is troublesome relieve it +by enemata. + +There are several beneficial effects obtained by =hydrotherapeutic +measures= that should receive careful consideration. Probably it is +of the least significance to lower the temperature; other beneficial +effects being of greater importance. When the baths are systematically +carried out, (1) there is obtained a general improvement of the +nervous system, the mind is rendered clear, muscular twitchings are +lessened, sleep is induced and the heart’s action strengthened; (2) +the respiration is stimulated, thus diminishing the liability of lung +complications; (3) the activity of the renal function is increased, +consequently allowing more rapid elimination of toxic matter; (4) +reduction of the temperature, and overcoming ill effects of high fever. + +A cold water bath, or what is generally termed the Brand method, is +commonly employed. The following plan is usually followed. When the +temperature is above 102.5 degrees F., rectally, a bath of 70 degrees +F. is wheeled to the patient’s bedside and he is placed into it for +ten or fifteen minutes. The patient should be lowered into the bath by +means of a sheet. Enough water is used to cover the body and neck of +the patient. The head is sponged and the limbs and trunk are rubbed +=thoroughly= during the entire procedure. When the patient is taken +out he is wrapped in a dry sheet and covered with a blanket. This +procedure is gone through with every three hours if the case is severe, +otherwise once every seven or eight hours will be sufficient. + +The luke-warm bath is occasionally used in private practice when one is +unable to use the Brand method. A bath of 90 degrees F. is employed, +which is gradually cooled ten or twelve degrees, after the patient has +been placed in it, by pouring cold water on the patient. This bath is +found very helpful. Also in private practice the cold pack is found +satisfactory. The patient is wrapped in a sheet wrung out of water at +65 degrees F. and cold water is sprinkled over him. Whenever there is +objection to any of these methods the body may be sponged off with +tepid or cold water when the temperature rises above 102.5 degrees +F., rectally. One limb should be taken at a time and then the trunk, +occupying altogether some twenty or thirty minutes. + +The Great War brought the subject of typhoid vaccination before the +world with emphasis but its results are not, as yet, in shape so an +unbiased opinion can be formed. The army medical department will tell +us that it was an unqualified success but we do know that there were +serious outbreaks among inoculated troops who were living under most +hygienic surroundings in America. There were, also, outbreaks among +protected troops in France to the extent that the medical authorities +felt called upon to warn all medical officers that vaccination should +not be considered as protecting against unsanitary surroundings +and that great precaution must be observed, the same as under +non-vaccination conditions. This does not imply implicit confidence. + +It is, also, a historical fact that the Japanese army, during the +Russo-Japanese war had as low a rate of typhoid without vaccination as +can, probably, be shown with it in this war. At that time they depended +entirely upon pure water and sanitation. + +See reports of typhoid fever in A. O. A. Case Reports as follows: C. M. +T. Hulett, Series I, p. 7, J. H. Wilson, Series III, p. 3, F. E. and H. +P. Moore, and F. A. and E. S. Cave, Series IV, pp. 4 and 5. + +In =paratyphoid fever=, an acute infectious disease caused by the +paratyphoid bacillus, the treatment is the same as for typhoid fever. +It is milder and similar to typhoid fever. + + +Typhus Fever + +=Definition.=—An acute, infectious disease; characterized by sudden +invasion, high fever, marked nervous symptoms, a peculiar maculated +and petechial eruption and a termination by crisis about the fourteenth +day. + +=Etiology= and =Pathology=.—Typhus fever is becoming less frequent than +formerly and is rarely seen in this country. It was very destructive +during the Great War, particularly in the Balkan states. Filth, +over-crowding, famine, intemperance and bad food are the predisposing +causes. Typhus fever is highly contagious and is transmitted by the +pediculus corporis (cootie) as was first discovered by the American +Red Cross workers in Serbia. Probably infection may come by contact +and fomites. The specific organism is the bacillus typhi exanthematici +(Platz). + +=Pathologically=, there are no constant lesions. There is a general +hyperplasia of the lymph follicles, but no ulceration. The blood is +dark, thin and lessened in fibrin. Hypostatic congestion of the lungs +and bronchial catarrh are frequently met with. The liver, kidneys and +spleen are found to be somewhat enlarged and softened. The petechial +rash remains after death. + +=Symptoms.=—The =incubation period= is about twelve days. The onset is +usually sudden, ushered in by chills. The temperature quickly rises +to 104 or 105 degrees F. There is headache, pains in the muscles, +especially of the back, and early, profound prostration. The pulse +is at first full and strong, 100 to 140, but soon becomes weak and +frequent. There may be distressing vomiting. The face is flushed, the +eyes injected, the expression stupid, and there is generally low, +muttering delirium. The tongue is furred and white, soon becoming dry. +The bowels are constipated and the urine is usually scanty and of high +specific gravity. There is great thirst. Conjunctiva injected; pupils +contracted; early prostration. + +The =eruption= appears about the fifth or seventh day. It first makes +its appearance upon the abdomen and chest. It rapidly extends all +over the body with the exception of the face. The eruption is of two +kinds—rose spots, which disappear upon pressure, and those which become +hemorrhagic (petechial); pressure has no effect upon them. During the +second week the symptoms are increased. The tongue is dry, brown and +fissured, and sordes appear on the teeth. Retention of the urine, +due to paralysis of the bladder, is common. The breathing becomes +more rapid and the heart’s action more feeble; the patient may die +from exhaustion. This ushers in the typhoid state with low, muttering +delirium, ataxic symptoms, subsultus, tremors, and maybe bronchial +symptoms. In favorable cases the crisis occurs at the end of the second +week. Patient sinks into a sound sleep, the temperature falls rapidly, +there is profuse sweating and a critical diarrhea but the patient now +gains rapidly. + +=Convalescence= is usually rapid; relapses rarely occur. The urine is +scanty, high colored and frequently albuminous. Bed-sores are common. +The temperature continues high, reaching 106 degrees F., or more, with +slight nocturnal remissions. In fatal cases the fever often rises to +108 or 109 degrees F. just before death. + +=Diagnosis.=—The sudden onset, frequent chills, early profound +prostration, character of the rash, history of exposure to the poison +and unhygienic surroundings decide the diagnosis. During an epidemic +there is usually no doubt, but in sporadic cases the diagnosis is +sometimes extremely difficult. + +=Prognosis.=—This is usually grave, but the mortality rate is being +greatly reduced in consequence of the better sanitary arrangements. + +=Treatment.=—Typhus fever is highly contagious and great care should +be taken in controlling the disease. Isolation, disinfection and +extermination is imperative. So far as known none of the osteopaths +have had experience in the treating of typhus fever osteopathically, +but there is no reason why the disease should not be treated with the +same success as is met with by osteopathic treatment in other diseases. +It is claimed that the disease should be treated in the open air, in +tents, as the recovery of the patient and the safety of the attendants +are greatly favored. + +For high temperature, besides the treatment given to remove any +disorder that may be found, the general fever treatment is indicated, +and hydrotherapy would also be of aid—sponging the surface of the body, +or the use of the bath. Asthenia is wherein the greatest danger lies, +and a stimulating treatment along the spine and to the heart should be +given; although correction of the primary trouble may be sufficient. +Hydrotherapeutic measures, the systematic use of the cold bath, would +be of service the same as in typhoid fever. + +Headache and delirium which are apt to arise, caused by too much blood +in the head, may be relieved by treatment of the cervical spine. +Also cold applied to the head will aid. The bowels should be watched +carefully; treat the splanchnics thoroughly and the intestines and +liver directly. Nourish the patient as in typhoid fever by nutritious +liquids—milk, broths, etc. + +Although typhus is now a comparatively rare disease, an outline has +been given to emphasize what correction of unhygienic conditions and +insanitary surroundings will accomplish. It is particularly a disease +of filth. + + +Malarial Fever + +(AGUE) + +=Definition.=—An infectious disease caused by the hemocytozoon of +Laveran. “It is characterized by paroxysms of intermittent fever of +the quotidian, tertian or quartan type, a continued fever with marked +remissions, a pernicious or rapidly fatal form, and a chronic cachexia +with anemia and enlarged spleen.” (Halbert). The varieties of malarial +fever are: intermittent fever; pernicious intermittent; remittent +fever; malarial cachexia; masked intermittent; malarial hematuria. + +=Osteopathic Etiology= and =Pathology=.—Malarial fevers are caused by +a parasite known as the hematozoon of Laveran. Three varieties of the +parasite have been separated, corresponding with the three leading +forms of the affection. The parasite of tertian fever is about as +large as a normal red blood-corpuscle, beginning as a small hyaline +ameba in the red blood-corpuscles. The parasite of quartan fever is +very similar in its appearance to the tertian parasite but smaller; +its ameboid movements are slower and the red blood-corpuscle embracing +it shrinks about the parasite, assuming a deeper greenish color. The +parasite of the estivo-autumnal fevers is still smaller. “If only one +group of parasites exists the paroxysms—quartan intermittent—will occur +every fourth day. Double quartan infection will result in paroxysms +on two successive days with an intermission of one day. Infection by +three groups of parasites will create daily paroxysms—the quotidian +intermittent. Infection by more than three groups is rare.” (Anders). +Only in the earlier stages of development, small hyaline bodies are to +be found in the peripheral circulation; being, in the later stages, +in the blood of certain internal viscera, spleen, and bone marrow, +particularly. + +It is an accepted fact among medical observers that to the mosquito, +_anopheles_, is due the spread of malaria and it has been the subject +of much investigation in all parts of the world. The mosquito becomes +infected from biting an individual whose blood contains the malarial +parasite, this is then developed in the mosquito to maturity and later +is transmitted to the next subject bitten. This explanation would show +why certain localities favorable for the breeding of mosquitoes are +particularly given to malarial outbreaks. Low, marshy grounds, banks +of rivers, small ponds, etc., as well as warm weather, are needed to +produce the conditions for the development of the _anopheles_. As +the country has developed the intensity and extent of malaria has +diminished until it is now confined largely to the southern states. +It is practically unknown in the northwest and in the St. Lawrence +basin. Regions which have never had cases, however, have developed them +when the _anopheles_ has appeared. Whiting notes cases in Southern +California, the result of the insect being brought in by ships from +Mexican or Central American ports. In certain regions the _anopheles_ +is present but has not apparently come in contact with a malarial +victim, so is incapable of spreading the disease. Also in colder +climates this species is harmless. + +By draining the lands and preventing the breeding places, the number of +the pests is reduced, while the screening of houses and care against +exposure to the bites make it possible to live in malarial sections +and not become infected. Naturally the resisting power of a patient +is called into account when bitten by the mosquito. Where it is +epidemic the inhabitants will be found, generally, poorly nourished or +debilitated from climatic or other conditions. This renders infection +easy, for immunity must come from the ability of the blood to combat +the invading parasite. + +The =osteopathic predisposing causes= for malaria are usually +interference with the vasomotor nerves to the spleen and liver, as +these two organs are so concerned in maintaining the stability of the +blood tissue. Ligon, of Alabama, notes that most cases have lesions +between the ninth and twelfth dorsal on the right side. + +The chief =morbid changes= are clue to the direct effect of the +malarial parasite upon the blood. There are also changes in the +liver, kidneys, and spleen, which changes usually vary with the +duration and intensity of the disease. The disintegration of the red +blood-corpuscles, accumulation of the pigment thus formed, and the +toxin engendered by the malarial parasite are responsible for the +morbid lesions of the disease. + +In =pernicious malaria= the blood is more or less hydremic, and the +discs are seen in all stages of destruction. The spleen is enlarged +and soft and the pulp dark from the accumulation of the pigment, and +spontaneous rupture has occurred in a number of cases. The liver is +swollen and turbid; pigmentation occurs, but is generally only visible +by means of the microscope. By the aid of the microscope all the +tissues of the body, even the brain, may be found to be pigmented. + +The =spleen= in =chronic malaria= is greatly enlarged, firm, pigmented +and the capsule thickened. The =liver= is enlarged, the color varying +from a slight gray to a deep slate gray, according to the amount of +pigment. The =kidneys= may be enlarged and deeply pigmented, as is also +the mucous membrane of the =stomach= and =intestines=. + +R. W. Connor observes that the kidneys and liver are most noticeably +involved, vasomotor obstructions the rule, the spleen in the majority +of cases shows engorgement and that special attention to these centers +will give the best results. He invariably finds spinal lesions from +the seventh dorsal to the first and second lumbar, most frequently the +eighth, ninth and tenth dorsals. A lowered vitality predisposes to +infection from the bite of the mosquito. + +=Symptoms.=—=Intermittent Fever.=—This form is what is known as fever +and ague, in which chills, fever and sweat follow each other. The +period of incubation varies from six to fifteen days, but it may be +months after exposure before the first paroxysms set in. The paroxysm +is usually preceded by a feeling of uneasiness and discomfort, +sometimes by nausea or headache. The paroxysm consists of three stages, +cold, heat and sweating. + +In the =cold stage= the chill usually begins gradually; it is generally +intense, the teeth chatter and the body shakes violently. The skin is +cool and pale, the lips are blue, the face is pinched and the patient +looks very cold. During the chill the temperature rises rapidly. +Nausea, vomiting and headache are common. The pulse is frequent, small +and hard. The urine is increased in quantity and of low specific +gravity. The chill lasts from a few minutes to a couple of hours. + +The =hot stage= succeeds the chill. The skin gradually loses its +coldness and becomes hot. The face is flushed, there is great thirst, +the mouth is dry, and the tongue is coated. Usually at the termination +of the chill the temperature has reached its maximum level, from 104 +to 106 degrees F. The pulse is full, and there may be a throbbing +headache. The duration of this stage is from half an hour to three or +four hours. During the =sweating stage= drops of perspiration appear +upon the face; the perspiration soon becomes profuse, extending all +over the body. The temperature soon falls, the headache disappears and +in a couple of hours the paroxysm is over. + +The entire duration of the paroxysm is from eight to twelve hours; +the patient usually feeling perfectly well between the paroxysms. +The spleen is enlarged. If the paroxysms of fever occur daily at the +same hour they are called =quotidian= intermittent fever; if every +other day they are known as =tertian= intermittent; and if every +third day they are called =quartan= intermittent. If there are two +paroxysms in the same day the term =double quotidian= is used; if the +paroxysms occur a couple of hours later each successive day they are +called “=retarding=;” if a couple of hours earlier they are named +“=anticipating=.” + +=Remittent Fever.=—(Estivo-Autumnal Fever).—This is characterized by a +continued fever with paroxysmal exacerbations and remissions. It occurs +especially in warm and tropical climates. In temperate climates it +usually occurs in the late summer and fall. It is also termed bilious +remittent fever on account of the intensity of the gastro-intestinal +manifestation. The estivo-autumnal parasite is the exciting cause. + +It is very often preceded by malaise, headache, nausea and vomiting. +The onset is usually gradual and the chill may be wholly absent. As a +rule, however, a chill generally occurs at the onset, but it is less +severe than that of intermittent fever. After the chill the temperature +rises rapidly to 102 or 104 degrees F. or even higher. The pulse is +full, rising to 100 or 120. There is violent headache, flushed face, +pains in the limbs and loins, nausea and vomiting, and delirium when +the temperature is very high. The urine is scanty or even suppressed, +slightly albuminous, sometimes bloody, high colored, and deposits a +sediment of urates. Jaundice is not infrequent; the spleen is enlarged +and herpes labialis is quite common. After six to twenty-four hours +the symptoms abate and slight sweating occurs. The temperature usually +drops to 100 degrees F., the headache disappears and vomiting ceases; +this is followed by a new exacerbation of fever at the end of about +twelve hours, generally without the chill; and this hot stage is in +turn again followed by the remission. These attacks may last three or +four weeks. + +=Pernicious Malarial Fever.=—This is rare in temperate climates and +is always associated with the estivo-autumnal parasite. The principal +types are the cerebral and algid. + +The =cerebral type= usually begins with a severe chill; sometimes, +however, the chill is absent. The patient is violently seized with +grave cerebral symptoms, as acute delirium or sudden coma. The comatose +condition lasts from twelve to twenty-four hours when consciousness +usually returns, the primary paroxysm rarely proving fatal; it is, +however, often followed in a short time by fatal relapse. + +The =Algid= variety is characterized by intense prostration and extreme +coolness of the surface with the internal temperature high. The gastric +symptoms are extreme nausea and vomiting. The pulse is feeble; the +breathing frequent and shallow. There is intense thirst. The voice is +feeble and indistinct. The mind is clear. The urine is suppressed. In +this type the parasites gain entrance to the gastro-intestinal mucosa, +sometimes forming distinct thromboses of the smaller vessels. This form +may be confused with yellow fever. + +=Malarial Cachexia.=—This is a chronic condition which often occurs in +cases that have not been properly treated or in persons that live in +malarial districts and are constantly exposed to the infection. The two +most striking symptoms of this condition are anemia and an enlarged +spleen or “ague cake.” There is fever at intervals, but chills rarely +occur. The skin is of a dirty yellow color. The spleen is greatly +enlarged and the blood is profoundly anemic. There is debility, and +frequent sweating, and the hands and feet are cold. The digestion may +be deranged and there may be slight jaundice. Sometimes there is edema +of the feet and even dropsy occurs. Hemorrhages of the various mucous +surfaces are common. Paraplegia and orchitis are rare symptoms. These +cases usually do well under proper treatment, and if the patient can be +moved from the malarial district. + +=Masked Intermittent.=—Malarial neuralgia most frequently involves +the supraorbital branch of the trigeminus; also the occipital, the +intercostals, sciatic and brachial nerves may be affected. Such forms +of malaria are called “masked malaria.” In this form there is no fever +and as a rule it is very hard to diagnose. A blood analysis should be +made to confirm the diagnosis. In some cases one or more stages in the +paroxysm of intermittent fever is omitted; this is especially true with +the chill, in which case it is termed “dumb ague.” Malarial cachexia is +also sometimes called “dumb ague” and both are found among the older +inhabitants of malarial districts. Persons living in malarial districts +are sometimes affected with constipation, headache, loss of appetite, +nausea, vomiting and a languid feeling; this is called “latent +intermittent fever.” Frequently “bilious attacks” are of a malarial +origin. + +=Malarial Hematuria.=—Hemorrhages may occur from the mucous membrane in +all severe and persistent types of malarial infection. It is a frequent +symptom of the pernicious variety. The parasites destroy the red +blood-corpuscles; this is the cause of the hemoglobinuria. Prostration +and anemia are marked. In =blackwater fever=, a tropical disorder, +acute hemolysis, is the cause of the hemoglobinuria. + +=Diagnosis.=—This is usually easy. The characteristic stages of the +paroxysms, the periodicity, residence in malarial districts and the +alterations in the blood will usually remove every doubt as to the +diagnosis. + +=Typhoid Fever= may simulate malarial fever, but a careful analysis of +symptoms and blood examination will differentiate. + +=Prognosis.=—This is almost always favorable under early and persistent +treatment. The unfavorable symptoms are uremia, hemorrhage and marked +jaundice. + +=Treatment.=—Attention should first be given to =prophylactic +measures=. Environment, isolation of the patient, and destruction of +the mosquito are important considerations. Cases of malarial fever +present distinct lesions in the vertebræ and ribs corresponding to +the vasomotor nerve supply of the spleen and liver. The most common +lesion found is a marked lateral deviation between the ninth and tenth +dorsal vertebræ and a consequent downward displacement of the tenth +ribs. A disturbance will always be found in the region of the eighth +to the eleventh dorsal vertebra, inclusive, or in the corresponding +ribs on either side. These lesions undoubtedly derange the vasomotor +nerves to the spleen and liver; thus permitting a weakness or lowered +resistance of the system, especially of the blood. The blood resisting +powers are lessened, probably on account of the spleen being affected, +as it is an elaborating gland of the blood; and the liver’s action is +somewhat dependent upon the action of the spleen; besides, the liver is +a secretory and excretory organ. + +The principal =osteopathic treatment= given in cases of malarial fever +is correction of these subdislocations, and thorough treatment to the +liver and spleen directly. Ligon observes that when the case does not +respond quickly to treatment it is very liable to be of considerable +duration, although in the majority of cases the disease is controlled +from the third to seventh day; the most constant lesions found are from +the eighth to tenth dorsal and also the fourth lumbar. + +During the =chilly stage= thorough treatment of the vasomotor nerves in +the upper cervical, the upper dorsal, the lower dorsal and the lumbar +regions is indicated; this treatment is given to equalize the vascular +system. + +During the =hot stage= the same treatment as in the chilly stage should +be given to control the vascular system; besides a thorough treatment +of the spleen and liver is necessary. Sponging the body with water will +be of some aid in reducing the temperature. + +During the =sweat stage= thorough inhibition at the superior cervical +ganglion to control the sweat center of the medulla, and treatment at +the upper dorsal and first lumbar to control auxiliary sweat centers +are indicated. + +The bowels should be kept active. When in a comatose form and when +internal temperature is high, place the patient in a bath. In chronic +cases, change of climate with thorough systematic treatment will +usually result in recovery. + +Tete[53], of Louisiana, makes the following interesting statement: “A +specific osteopathic treatment given within an hour before the expected +chill is a specific cure for malaria.” He follows this up by treating +on the third, fifth, seventh, fourteenth, and twenty-first days, on +account of the tendency of the return of an attack on those days. His +observation of the value of treatment just before the attack is borne +out by a report by Teall[54] where the case was cured in one treatment, +but the lesion was as high as the fourth dorsal. N. Chapman confirms +this as being her experience in many cases. The spleen has been +observed by Bandel to become engorged and upon emptying there would +follow a rise of temperature of one fourth to half a degree. This has +also been spoken of by Tucker as the “splenic wave.” Ligon makes the +statement that where the osteopathic lesion (the predisposing cause) +has been of long standing prior to the attack, and as a consequence +hard to correct, it is difficult to shorten the malarial attack. + +This would emphasize the point that the essential treatment must be a +thoroughly readjustive one, and that stimulatory and inhibitory work +can only palliate. This is borne out by several practitioners who +have had considerable experience. Very satisfactory results follow +adjustment of the seventh to tenth dorsals. + +Quinine has been accepted by medical authorities as a specific for +malaria. It is supposed to act directly upon the intracorpuscular +hematozoa. That it is not infallible is shown by the numerous cases +which come to the osteopath, suffering from both the disease and the +quinine. And even drug authorities state that other treatment is also +required. It has remained for Dr. Still to demonstrate that excellent +results follow osteopathic treatment in malaria. Frequently a single +treatment has been sufficient to free and regulate the body fluids and +forces so that the parasite was rendered inert, and this treatment +was directed chiefly to the fourth and twelfth dorsals. Whereas the +osteopath recognizes and appreciates the importance of micro-organisms +as exciting and determining factors in many diseases, still he values +them as secondary factors only and relies primarily upon removing +the predisposing and true etiologic factors, so that nature’s forces +may not be obstructed and thus predominate. Osteopathic etiology and +pathology has shown so conclusively, in a large number of cases, that +the existence of micro-organisms is dependent upon devitalized tissue, +whether the tissue is a local one or a circulating one, as the blood; +and just so soon as the anatomical is adjusted the physiological will +function and antitoxic and antimicrobic substances are secreted. + +“When the patient has the quartan parasite, as soon as the temperature +begins to fall I give him from two to six ounces of red meat juice, +extracted from rare beefsteak, sometimes as much as five pounds in the +first twenty-four hours following the chill. In almost all cases of +quartan malaria the blood is built up sufficiently by the time they +reach the second cycle to pass without the paroxysm, or chill. By the +time for the third cycle, which is the seventh day, I always have +built up the patient’s resistance so as to enable him to pass by this +cycle without any symptoms of malaria whatever. In cases of double or +triple I find the same treatment causes about the same results. I do +not give any other diet, except dry toast if they eat the beef instead +of taking the juice. If they can take the steak I prefer their taking +it, but almost all cases prefer the juice. * * * The treatment for the +tertian type of malaria is practically the same as the treatment for +the quartan. + +“The estivo-autumnal type of malaria differs from the quartan and +tertian types; first, in that the paroxysms are, as a rule, much more +irregular; second, they are much longer in duration; third, the chills +are more frequently absent; fourth, the fever is often irregular, +intermittent, remittent, or continuous in character. This type very +often takes the form of blackwater or hemoglobinuric type with +hemorrhagic symptoms, with hemorrhage from nose, gums, and bowels. The +first thing to do in a case of hemorrhagic malaria is to put an ice +bag on the abdomen, which will tend to control the hemorrhage from the +kidneys. Give the patient all the red beef juice you can get him to +take, provided he has not developed a very sick stomach; if so, give +him high saline enemas and in one-half hour give him four ounces red +beef juice per rectum. Repeat the feeding per rectum in four hours. As +soon as he can retain anything on stomach give him all the juice he can +take comfortably. Treat the liver thoroughly—at least three times in +the first twenty-four hours. At the end of thirty-six hours the yellow +cast will be very much lighter, which is a sure sign that the patient +is getting better. Watch the urine closely. The third day there may +occur a suppression. If so, give strong stimulation to the renal plexus +through the abdomen, and be sure there is a thorough relaxation of the +dorsal and lumbar muscles. + +“It is an established fact that people in the malarial districts eat +very little beef. I find that ninety-nine per cent of the cases of +malaria never eat it, or when they on rare occasion do, it has been so +overcooked that all the blood-building substances have been destroyed. +The beef raw would be better in my opinion; although, the possible +chance of getting a tape-worm or animal parasite is so considerable +that I would advise that the beef should be heated to 250 degrees.”—E. +C. ARMSTRONG, Clinical Osteopathy. + + +Septicemia + +This term is applied to any toxic condition caused by the invasion of +the blood by pathogenic micro-organisms, with or without any visible +site of infection. + +=Etiologically=, the micrococci, streptococci, pneumococci, or +staphylococci, as to frequency, in order named, are the cause. The +infection is usually introduced by a wound, of any degree of severity. +The uterus is a frequent seat following miscarriage, parturition or +operation. The virus may be absorbed by the mucous membrane. It may +also arise from infection of the deeper tissues. =Pathologically=, +the changes are not marked, but consist in brownish color of the +muscles, ecchymotic spots in the pia mater and dark appearance of the +blood, which is also less coagulable. Spleen, liver and lymphatics are +enlarged with some changes in the other organs. + +=Symptoms.=—The incubation period is from four to six days and the +onset is gradual, though often announced by a distinctive chill, +followed by a profuse sweat. The most common type is the continuous +form of fever, which may, in morning remissions, become subnormal. +Pulse is rapid at the beginning, but as cardiac failure comes on, +it becomes weaker. In the earlier stages there may be vomiting with +diarrhea later. There are punctiform hemorrhages of the skin and +possibly other eruptions. Blood examination will settle any doubt as to +diagnosis. + +=Prognosis= is good in large percent of cases and depends upon the +general health of the patient. + +=Treatment.=—“Incise and drain the infected part; if possible, apply +hot boracic acid compresses or keep part suspended in hot boracic acid +solution. Osteopathic treatment will aid materially in stimulating +and strengthening the patient. Bowels, kidneys and skin must be kept +active. Normal salt solution, hypodermically or per rectum is of value. +Diet should be liquid, fruit juices, broths, soups until temperature +has remained normal twenty-four hours then milk, eggs etc., in +gradually increasing amounts until general diet is restored. Amputation +of the part may be necessary.”—L. E. BROWNE. + + +Pyemia + +A febrile disease arising from an invasion of the blood by pathogenic +bacteria, wherein sepsis and multiple abscesses occur from absorption +and metastasis. + +=Etiologically=, the cause may be traced to various specific organisms +which enter the blood stream and produce thrombophlebitis. From these +points and from other bacteria, new foci are established. Occasionally +the lymphatics carry the germs. The disease may also start from +ulcerative endocarditis or when the appendix is infected. + +=Pathologically=, thrombosis of the vein may take place in any region. +Abscesses may form in the lungs, liver, spleen or other internal +organs. The small abscesses may unite and form a large one. The skin +presents eruptions and hemorrhagic extravasations, while there may +be ulcers of the mucous membrane, also the serous surfaces may be +purulently inflamed. The muscles, subcutaneous and osseous tissue +occasionally have abscesses. Ulcerative and suppurative heart lesions +occur. + +=Symptoms.=—The incubation period is short. There may be slight fever, +but commonly a chill is the first symptom, which may reoccur for some +time. The fever is either remittent or intermittent and when the +temperature is low, sweating is a feature. The pulse becomes rapid and +weak, when the disease is severe; breathing becomes difficult. Skin +symptoms, such as eruptions and pustules, generally occur. In a word, +there is a general intoxication. There is a lessened number of red +blood corpuscles and leucocytosis is a characteristic. In grave cases, +delirium and coma are present. + +=Diagnosis.=—The history of the case and symptoms will usually +render diagnosis easy, although care is necessary to determine from +septicemia. Malaria, typhoid and acute tuberculosis must be excluded. + +=Prognosis.=—Much depends on asepsis and surgery but on the whole it is +unfavorable. + +=Treatment.=—Surgical interference and treatment as outlined under +septicemia is the only hope. + + +Dengue + +(BREAKBONE FEVER) + +=Definition.=—An acute infectious disease; characterized by a double +febrile paroxysm, severe pains in the muscles and joints and sometimes +a skin eruption. + +=Etiology.=—It is a disease of tropical and subtropical regions. +Unhygienic conditions predispose to an attack. During an epidemic a +single attack is the rule. The disease spreads from place to place +along the lines of travel, attacking both sexes, and all ages. It +occurs in epidemics, practically affecting every one. The specific germ +has never been isolated as it is probably ultra-microscopic but there +is no doubt but that it is carried by the mosquito _Culex fatigans_. + +=Symptoms.=—The incubation period lasts about four days. The onset is +abrupt with a slight chill, headache, and extreme pain in the joints +and muscles, of a boring or breaking character. The joints become red, +swollen and painful. The fever rises gradually to 103 or 106 degrees +F., or over. The pulse is rapid and full and the respirations are +much quickened. The face is flushed, the tongue coated, the appetite +is lost, and slight nausea occurs. “Black vomit,” similar to that of +yellow fever, has been observed in this disease. Hemorrhages from +various organs may occur and the lymphatic glands are swollen. The +urine is scanty and the bowels constipated. Febrile albuminuria and +delirium are rare. + +At the end of three or four days the temperature falls and there is +a period of remission; the patient is free from pain, but profoundly +prostrated. During this time the eruption generally appears, but is +never constant in character. After a remission of two or three days, +the symptoms reappear and a second febrile paroxysm sets in. This is +usually milder and shorter than the first, lasting two or three days, +when convalescence begins. The duration is, according to medical +writers, from seven to ten days, and convalescence slow. Death seldom +occurs, so practically no pathological changes have been recorded. By +osteopathic treatment, E. B. Ligon has been able to confine the attack +to four or five days duration; this is confirmed by the experience of +N. Chapman. + +=Diagnosis.=—During an epidemic the disease attacks all classes alike, +and the distinct remission renders the diagnosis comparatively easy. An +occasional case might be mistaken for acute rheumatism, but the absence +of any glandular swelling or eruption, while the pain is more closely +limited to the joints, will aid in the diagnosis. Care has to be taken +that yellow fever is not mistaken for dengue. + +=Treatment.=—The indications of the treatment are to maintain the +patient’s strength and to treat the leading symptoms as they arise. +The severity of an attack can probably be lessened at the start by +strong and thorough treatment of the suboccipital, upper dorsal, lower +dorsal and lower lumbar regions, respectively, so as to control the +large vascular areas by means of the vasomotor nerves of the cranial +region, of the lungs, of the splanchnic region, and of the lower limbs, +thus equalizing the entire vascular system. Elimination should be +pushed and the excretory organs stimulated. Ligon has observed that the +cervical and lumbar regions are especially tender on the second day +and the lower dorsal region on the third day. The most severe symptoms +disappeared within a few hours after treatment and the attack was +markedly shortened. + +The high fever may be treated by the usual methods and by the external +application of cold water. The pain is to be controlled, according to +the region affected, by a correction of parts impinging upon the nerve +tissues and by strong inhibition. The entire spinal region should be +kept constantly in a relaxed condition, as far as muscular contractions +are concerned. Particularly should the treatment be extensive along the +spine during prostration. N. Chapman, in addition to the osteopathic +treatment, has the patient drink considerable hot water; also employs +the hot bath. The treatment frequently shortened the attack. During the +entire attack of the disease, the patient should be kept in bed and a +carefully regulated diet administered. Relapses are not infrequent. A +suitable change of air may hasten convalescence. + + +Cerebrospinal Meningitis + +=Definition.=—A specific, infectious disease caused by the diplococcus +intracellularis meningitidis, occurring sporadically and in epidemics. +It is characterized by inflammation of the membranes of the brain and +spinal cord and an irregular course. + +=Osteopathic Etiology= and =Pathology=.—The specific exciting cause of +the cerebrospinal meningitis is due to the diplococcus intracellularis +meningitidis of Weichselbaum. Lesions are found in the vertebræ +corresponding to the cervical and dorsal enlargement of the cord, as +well as in corresponding deep muscles; also, as is well known, the +muscles of the entire back are severely contracted, especially of the +cervical, upper and lower dorsal regions. More commonly it attacks +the young, although it may occur at any age. Overexertion, exposure, +overcrowded and illy-ventilated buildings, barracks and tenements, and +depressing mental influences are predisposing causes. Many times the +disease occurs among the poorer classes. Sometimes the disease prevails +in the country rather than in the city. + +In cases that prove speedily fatal there may be no characteristic +changes; simply marked congestion. Other cases in which death occurs +after the disease has been fully developed, there is found every degree +of inflammation from slight hyperemia to suppurative changes. There can +be no doubt that the osteopathic lesion, as vertebral and rib lesions +and deep muscular contractions, affects the circulation of the meninges +of the brain and cord and thus favors the invasion of the specific +micro-organism. The arteries, veins and sinuses are greatly engorged. +The walls of the ventricles soften and the ventricles contain serous +exudate. The brain matter may be congested and softened in spots. In +the spinal membranes similar changes take place and at times there is +extravasation of blood. The changes are more marked on the posterior +than the anterior surface of the cord. Abscesses sometimes form. The +exudate may follow the lymph sheaths of the cranial nerves, especially +the auditory and optic. In long standing cases the membranes become +thick and adherent and areas of softening or atrophy of the cortex +develop. The thickening and adhesions of the membranes may cause +various symptoms for months or even years after recovery from the acute +disorder. + +The spleen may be normal in size, but when the fever has been intense, +it is apt to be slightly enlarged. Bronchitis, pneumonia, endocarditis +and pleurisy may occur. The liver may become hyperemic and the kidneys +congested. + +=Symptoms.=—The prodromes vary, although the onset is apt to be +sudden with a decided chill; headache; vomiting, and pain in the +neck and back, which is usually severe, but may be so slight as not +to be noticed by the patient. The temperature rises to 101 to 102 +degrees F., in most cases. However, it may rise to 105 degrees or +106 degrees and even to 108 degrees in fatal cases, and the pulse is +full. Hyperesthesia, photophobia, and dread of noise are apt to be +prominent symptoms. The muscles of the neck and back become rigid, +and there are pains in the limbs. Orthotonos occurs more frequently +than opisthotonos. Convulsions are common in children. There may be +paralysis, especially of the muscles of the face and eyes. Delirium +usually appears early; it may be mild, but it is often maniacal. The +bowels are usually confined, though there may be diarrhea. There is +moderate and constant leucocytosis and jaundice has been met with. + +The urine is sometimes albuminous, and sugar has been noted in rare +cases. The urine may be increased, but more often it is lessened as in +other infectious diseases. + +Herpes facialis occurs shortly after the onset in more than half the +cases. The contents of the vesicles may be purulent and one or two may +coalesce. The petechial eruptions are occasionally numerous and cover +the entire skin; they do not disappear upon pressure and the number of +spots varies greatly. Other eruptions as sudamina, ecthyma, pemphigus, +urticaria, erysipelas, rose colored spots, and gangrene of the skin +(rarely) have been met with. + +In cases that are =rapidly fatal=, the onset is sudden, usually +with violent chills, headache, depression, and in a few hours coma +and collapse, which are soon followed by a fatal termination. The +temperature may rise slightly, but it is often subnormal. The pulse is +feeble; breathing is labored. These cases occur more frequently at the +beginning of an epidemic. They occasionally occur sporadically. + +The =abortive= form terminates abruptly after the development of one or +more pronounced, characteristic symptoms. + +The =mild= form can only be recognized during the prevalence of an +epidemic. The symptoms are very mild; slight vomiting, little or no +fever, headache and slight pain in the back and limbs. + +The =intermittent= form is characterized by increase in the fever +every day or second day. The strict periodicity seen in malaria is not +observed; the fever resembles that of pyemia. + +In the =chronic= form the condition may persist for weeks or months. + +=Complications.=—Pneumonia (lobar and lobular) is a frequent +complication. Pleurisy, pericarditis, parotitis, arthritis, enteritis, +optic neuritis and otitis media may be other complications. + +=Sequelæ.=—Blindness, deafness, keratitis (rarely), persistent +headache, chronic hydrocephalus, abscess of the brain, mental +feebleness, defective articulation, aphasia, and paralysis of certain +cranial nerves or of the lower extremities have occurred. + +=Diagnosis.=—=Typhoid fever= begins slowly and is unaccompanied by +vomiting, muscular spasms or rigidity, or hyperesthesia. In typhoid +the fever is higher and there is a characteristic temperature curve. +Widal’s test will confirm. + +=Tubercular meningitis= is not epidemic and has no characteristic +eruption. It is usually less sudden in its development and is +invariably fatal. Retraction of the neck, muscular spasms of the legs +and arms are not so marked as in spinal meningitis. + +=Pneumonia= may be complicated with meningitis, especially when the +meningitis is confined to the cerebrum. If the case is not seen early, +it is almost impossible to say which is the primary affection, as +pneumonia may have meningeal complications or cerebrospinal meningitis +may be associated with pneumonia. There will be motor spasms and +tremors, but the head is rarely retracted, and there is less myalgiac +pain than in cerebrospinal meningitis. + +=Prognosis.=—This varies according to the severity of the type. It +is a grave disease. Cases have been treated successfully by several +osteopaths. The duration is very variable—from two or three days to +weeks or even months, but probably in all cases this time can be +materially shortened by judicious osteopathic treatment. Convalescence +is very slow and relapses are prone to occur. + +=Treatment.=—The osteopathic treatment of cerebrospinal meningitis +requires most thorough, but very careful, work along the spinal column, +especially the cervical region and the region of the dorsal enlargement +of the spinal cord, in relaxing and keeping relaxed the deep muscles +on either side of the spine and correcting the derangements of the +vertebræ, particularly in the upper cervical spine. Such treatment +has a marked effect on the circulation of the spinal cord and brain. +Probably, a large amount of the work along the spine, in all cases +where muscles are relaxed, has a direct effect upon the circulation of +the spinal cord. This treatment constitutes the primary osteopathic +work in cerebrospinal fever and should be frequently applied until a +cure is obtained. Even in chronic cases where limbs have been greatly +affected by pressure upon the nerve centers, due to a thickened +membrane, continued osteopathic treatment along the spine has had a +marked effect in absorbing the pathological condition and restoring +strength. + +The preceding spinal treatment is also a very great safeguard in +keeping the various viscera healthy and thus preventing complications. +In all constitutional diseases of an acute nature, it is a wise +precaution to thoroughly examine the entire length of the spinal +column at each visit; and if such precaution is taken many serious +complications will never occur that might otherwise have taken place. + +The patient should be isolated in a somewhat darkened room, and care +taken that the disease is not allowed to spread. Keep the patient upon +his sides as much as possible. The diet should be a nutritious one of +milk and broths. They should drink freely of water. Cold to the head +and spine will be of service in controlling the inflammation; it should +be applied with an ice-cap and a spinal ice-bag. Sponging the body +should be employed if the temperature is above 102° F. The general +bath, as in typhoid fever, may be employed if practicable. Direct +treatment to the bowels, kidneys, liver and spleen should be given at +each treatment. + +Lumbar puncture and the Flexner-Jobling serum are considered of value +by those who have had an extensive experience. + + +Diphtheria + +=Definition.=—An acute, infectious disease, caused by the +Klebs-Loeffler bacillus, and characterized by a membranous exudation +on the mucous membrane of the fauces, larynx or nose, and by +constitutional symptoms. The presence of the Klebs-Loeffler bacillus +distinguishes true diphtheria from any other form of membranous +inflammation. The term diphtheroid is applied to all such forms as are +not due to the Klebs-Loeffler bacillus. + +=Osteopathic Etiology= and =Pathology=.—The exciting cause is the +Klebs-Loeffler bacillus. The predisposing cause is obstruction to the +circulation of the pharynx and tonsils by subdislocations of upper +cervical vertebræ, and even the lower cervical and upper dorsal, and +severely contracted deep muscles of the neck. The stasis of blood +favors the growth of the bacillus. + +Link[55] says: “The cause of nasal, pharyngeal or laryngeal diphtheria +is obstruction of the blood and lymph through the neck and the +obstruction occurs as a result of lesions in the cervical region, +affecting the cervical sympathetics, or lesions in the upper thoracic +region whence the vasomotor fibers arise. A derangement of the +vertebral articulation of the first rib is usually found. (This affects +the stellate ganglion and fibers of the sympathetic chain). These +lesions cause a condition of lowered vitality of the mucosa of the nose +and throat; the abnormal secretion favoring the rapid multiplication of +the Klebs-Loeffler bacillus—the exciting cause of the disease.” + +Dr. Still believed that, among other lesions, contracting of tissues +involving the scaleni and disturbing the relations of the first +rib with the clavicle and vertebra are causative factors. The +constitutional symptoms are produced by the toxins generated by the +bacillus and absorbed from the diseased spots by the lymphatics +and blood-vessels. The bacillus is non-motile and does not usually +penetrate the mucosa, but remains very near the site of the local +changes although there are instances where it may enter the blood and +other tissues. The bacillus is very resistant and can maintain an +existence for months outside of the body. There is great variation in +the virulence of the Klebs-Loeffler bacillus; it has been found in +healthy throats, and sometimes the bacillus may exist in the throat +after an attack of diphtheria for months after all the membrane has +disappeared. It has also been found in cases of simple catarrhal angina +without membrane, and in simple tonsillitis Of the bacteria associated +with the bacillus of diphtheria, the streptococcus pyogenes is the most +common and probably the most active. The staphylococcus, micrococcus +lanceolatus and bacillus coli communis are also found. + +The contagion is communicated, as a rule, through the air, by means of +fomites from the membranous exudate or discharges from the diphtheritic +patients, or during convalescence, from secretions of the nose and +throat. Infected milk may cause the disease. Most cases occur in +childhood, between the second and seventh year. The disease is most +prevalent in the cold autumn and spring months. It is most frequently +met with in temperate and cold climates. Defective drainage, catarrhal +conditions of the throat, enlarged tonsils, general weakness, and +feeble resisting power are predisposing factors. One attack does not +confer immunity from another, but rather predisposes to a second. + +The =false membrane= is usually found on the tonsils, the pillars of +the fauces and the pharynx, and in fatal cases it may be extensive +and involve the uvula, the soft palate and the posterior nares, and +even the trachea and bronchi. At first this membrane is yellowish +white, but later may become gray; it is more or less adherent and +when torn off leaves a raw surface. The diphtheritic poison coming in +contact with the throat leads to, first, a necrosis or death of the +epithelial cells, especially the more superficial, and the leucocytes. +The second change is the hyaline transformation, and simultaneously +coagulation; hence the term coagulation-necrosis. The irritation +produced by the bacilli causes a migration of leucocytes and these are +destroyed and undergo hyaline transformation. This process proceeds +from without inward and is usually superficial, and the necrosis may +be extensive, involving the deeper tissues, causing ulceration and a +gangrenous condition of the parts. The erosion of the tonsils may be +so severe as to attack the carotid artery. The lymphatic glands are +considerably swollen. The spleen is commonly enlarged. The kidneys show +parenchymatous changes. The blood is dark and fluid. Fatty degeneration +of the heart is not infrequent. Sometimes fibrinous coagula are found +in the heart. Capillary bronchitis, catarrhal pneumonia and areas of +collapse are almost constantly found on examination of the lungs in +fatal cases. The =urine= is typically febrile with early albumin and +often tube casts and renal epithelium. The =blood= shows an excess +of red blood cells which may reach 7,500,000. Hemoglobin is slightly +reduced. There is considerable anemia during convalescence depending +upon severity of toxemia. + +=Symptoms.=—The incubation period varies from one to ten days, usually +two or three days. According to the location, diphtheria may be divided +into pharyngeal, laryngeal and nasal forms. + +In =Pharyngeal Diphtheria=, which is most common, there is first a +slight chill or chilliness, followed by fever and sore throat, both of +which increase rapidly. The throat is swollen and red and the patient +complains of difficult swallowing. The membrane begins on the tonsils +in the form of grayish-white patches; it then spreads from the tonsils +to the soft palate, sometimes covering the uvula. The cervical glands +are swollen and tender. The neck muscles are contracted and somewhat +difficult to relax. The temperature rises to 102 or 104 degrees F. The +pulse is rapid and feeble, ranging from 120 to 140. There is loss of +appetite. There is more or less prostration depending upon the gravity +of the constitutional symptoms. The average duration is from one to two +weeks. + +=Laryngeal Diphtheria= (Membranous Croup) may be secondary to extension +from the fauces or it may be primary. At first there is slight +hoarseness and a harsh, metallic, ringing cough. These symptoms may +persist for a day or two, when the child suddenly becomes worse; there +is marked dyspnea and the lips and finger tips become livid. The child +soon becomes very restless. The temperature may be slightly above +normal and the pulse increased in frequency. In favorable cases the +dyspnea is not very marked and the child probably will have only one +or two paroxysms, when it will fall asleep and wake in the morning +feeling very comfortable. The next night, however, the attack may be +more pronounced. In extreme cases death may result from suffocation. +In some cases the suffocation is slower and results from extension of +the membrane downward into the bronchi. Dr. Still found same conditions +as in diphtheria, but also the hyoid is involved with the superior +laryngeal nerve. The sacral and lumbar nerves are also involved. He +always emphasized chilling of gluteal region as a cause for croup and +that heat should be applied at the inception of the disease. + +=Nasal Diphtheria= is generally secondary, but it may be a primary +affection. In many cases no membrane is found; in others there may +be a pseudo-membrane formed in the nose, but there is absence of any +systemic disturbance. The Klebs-Loeffler bacillus is sometimes present +in these membranes. Nasal diphtheria may be a very grave disease—the +constitutional symptoms being great prostration, high fever, marked +glandular swelling, irritating and offensive discharges from the nose, +and epistaxis. Inflammation occasionally extends through the tear duct +to the conjunctiva. + +A diphtheritic membrane may grow where the skin has been cut or +bruised, but the bacillus cannot live on normal skin. It nourishes on a +raw, moist surface and membranes have grown on the lips, tongue, vulva, +glans penis, and on ulcerative surfaces and wounds. Diphtheria occurs +occasionally in the conjunctiva and the external auditory meatus. + +It should be remembered that there are many atypical forms of +diphtheria. Bacteriological examination should always be made in +suspicious and puzzling cases. + +The complications of diphtheria are nephritis, hemorrhages, rashes, +capillary bronchitis, pulmonary collapse, catarrhal pneumonia, +myocarditis, arthritis, otitis media, and paralysis. + +=Diagnosis.=—The presence of the Klebs-Loeffler bacillus will at once +decide the diagnosis of diphtheria. + +=Prognosis.=—The prognosis should always be guarded. The nasal and +laryngeal forms are always grave. The causes of death are involvement +of the larynx, septic infection, heart failure, bronchopneumonia during +convalescence, and rarely, uremia. + +=Treatment.=—Hygienic and prophylactic measures are important. A room +should be selected that is ventilated and exposed to the sunlight. All +unnecessary articles of furniture should be removed. Great care must be +taken against the spread of the disease. Always isolate the patient and +disinfect everything that has come in contact with him. The greatest +danger lies in the spread of the disease during convalescence and in +the ambulatory form, when patients are about and coming in contact with +individuals, especially children with catarrhal conditions of the nose +and throat. The physician should be careful about disinfecting himself. + +In view of the fact that many osteopaths have treated successfully +numerous cases of diphtheria and that the osteopathic treatment is +peculiarly indicated and effective, the probable requirement of +antitoxin (the use of which we do not feel called upon to discuss) +would be lessened. Relative to the antitoxin Osier says: “The principle +of action depends on the circumstance that the blood serum of an animal +rendered immune, when introduced into another animal, protects it +from infection with the diphtheria bacilli, and has also an important +curative influence upon diphtheria, whether artificially given to +animals, or spontaneously acquired by man.” + +“The treatment of diphtheria by osteopathic methods is often a pleasure +rather than a trial because of the success which rewards us for our +efforts. There has been considerable discussion by the members of +our profession regarding the methods to be employed in successfully +overcoming this disease, and many have expressed the view that since +antitoxic serum is a physiological remedy, which naturally belongs +to all schools of healing, it should be employed by the osteopathic +physician in cases of diphtheria. I have no objections to the use of +the serum therapy by members of the profession who conscientiously feel +that they need it in their practice to secure the highest success. +However, I feel, on the other hand, that if they were well acquainted +with the technique of the methods * * * they would not feel it to their +advantage, from the standpoint of success, to use injections in a +single case.”—R. D. EMERY, Clinical Osteopathy. + +The local treatment should be carefully, but vigorously, given. By +proper treatment of the throat the extension of the disease may be +prevented. The muscles about the throat, especially the deep ones, +should be thoroughly relaxed and the cervical vertebra; corrected if +displaced. The vasomotor nerves to the blood vessels of the affected +region require careful treatment at the superior cervical ganglion, +and the cervical lymphatics from the atlas to the first rib should be +closely watched. The nerves to control are the vagi, glosso-pharyngeal, +spinal accessory, and sympathetic nerves to the pharyngeal plexus, +and in cases of nasal diphtheria the fifth nerve has to be carefully +treated. An external treatment to the pharynx will have the greatest +effect on these nerves. An internal treatment to the nerves of the soft +palate will be of considerable service. The parts diseased should be +disinfected and kept as clean as possible. Bichloride of mercury (1 : +4000) used as a spray will be found satisfactory, although there are +several other disinfectants and germicides that may be used. Pellets +of ice in the mouth will be a comfort to the patient. Cold applied +externally will be found best for the adult; heat externally is better +for the child. + +Every possible means should be used to prevent the disease from +spreading. One of the chief dangers of diphtheria is the spread of +the disease to the larynx, trachea and bronchi. When the disease has +extended to these parts it presents all the symptoms of =true croup=. +The deep cervical muscles should be thoroughly relaxed to aid in +relieving the passive hyperemia and with a view of disorganizing the +exudate. Attention should be given to the upper ribs, as interferences +with the vasomotor nerves of the mucous membrane of the trachea and +bronchial tubes usually occur. Direct treatment over the larynx and +local treatment through the mouth upon the soft palate will be of +aid. A thorough relaxation of all the dorsal muscles, even as low as +the tenth dorsal, should be given. Inhalations of slaked, freshly +burnt lime may be useful in loosening the exudation. In desperate +cases tracheotomy or intubation of the larynx should be performed. +Willard[56] says, relative to membranous croup: “It matters not whether +or not the laryngeal inflammation was immediately caused by a germ; it +would not, nor could not, have been produced by such had there not been +an unnatural condition of the circulation of and about the larynx.” + +A constitutional treatment should always be given with a view of +preventing the spread of the disease from one organ to another and to +prevent complications. The heart’s action should be carefully watched +throughout the entire course of the disease. Treatment of the spinal +cord will guard against paralysis that sometimes follows the venous +hyperemia of the vascular linings and substance of the brain and spinal +cord. Pay particular attention to the upper dorsal region to prevent +possible heart involvement. Post-diphtheritic paralysis seldom if ever +occurs in cases that are treated osteopathically. This is a common +sequela and is present in from 10 percent to 30 per cent of cases, +appearing within three weeks of apparent recovery. Sometimes it is the +only result to show diphtheria was present. It seems to follow use of +antitoxin rather frequently. Attention to the splanchnics and to the +abdomen directly will tend to keep the stomach, liver, kidneys, and +intestines in a healthy state. The diet of the patient should consist +of liquid food—milk, broths, meat juice, raw eggs and barley water. +Let the patient drink freely of water. Treatment of the rectum may be +employed with benefit when the pharynx is greatly disturbed. + +Various =sequelæ= and =complications= are best relieved or prevented, +according to Link, as follows: “First, limiting the production of +toxins by a most thorough relaxation of the muscles of the neck, +thereby favoring the unobstructed circulation of the blood and lymph; +second, by the correction of lesions which affect the vasomotor of +the head and neck; third, by spinal treatment affecting the vasomotor +to the areas involved; fourth, by increasing the activity of the +excretory organs, by treatment in the splanchnic and lumbar areas, that +the toxins may be more rapidly eliminated. In cases where laryngeal +stenosis is marked and suffocation is imminent, intubation should not +be delayed.” Post-diphtheritic paralysis usually yields to osteopathic +treatment. Apply treatment according to location. + + +Dysentery + +(BLOODY FLUX). + +=Dysentery= is an infectious disease wherein the large intestine is +inflamed, with ulceration of the mucous membrane; is characterized, +clinically, by frequent stools containing blood and mucus; fever and +exhaustion. =Osteopathic lesions= of an osseous character and deep +muscular contractions of the lumbar region are always present. These +involve the vasomotor nerves to blood vessels and lymph channels. +Catarrh of the intestinal tract is an important predisposing cause. The +disease usually occurs in the summer and autumn, and is more common +in hot, malarial regions, although it is found in various climates. +Unhygienic conditions are also important predisposing factors. In no +disease more than dysentery does specific correction of the osseous +lesion effect quick and satisfactory results. + + +Acute Ileocolitis + +(BACILLARY DYSENTERY) + +This is the variety most frequently found in temperate climates. It +occurs either sporadically or endemically. The Flexner bacillus is +frequently found, as well as pus micro-organisms. There are various +strains of the bacillus. There is a catarrhal inflammation of part or +the whole of the large bowel. Other forms may occur, as ulcerative and +membranous. + +=Osteopathic Etiology= and =Pathology=.—Sudden atmospheric changes and +simple irritants, such as unripe and indigestible food, are usually the +immediate causes. The predisposing cause of acute catarrhal dysentery +is always found by the osteopath to be due to spinal derangements in +the lumbar region. The lesion is generally a slight lateral deviation +of a vertebra. It is generally found at the second or third lumbar; +still, the trouble may be found at any point in the lumbar section. The +lesion involves vasomotor nerves to the intestinal mucous membrane, +thus causing the inflammation. The drinking of impure water in itself +may not be the cause of the disease, but is a favorable medium for the +development of the organisms which may excite it. Dyspeptic conditions +and constipation seem to predispose to the disease. + +The mucous membrane is injected and swollen and often covered with +bloody mucus. The follicles of Lieberkuhn are enlarged from retention +of their contents, the result of the swelling; the follicles are often +ruptured and the mucous membrane sloughs off in patches, forming +ulcers. These may extend along the whole colon and frequently into the +ileum. + +=Symptoms.=—Diarrhea is the most common initial symptom; the stools +being copious and painless. The stools soon become small and frequent, +covered with mucus and streaked with blood. These are passed with +straining and tenesmus, accompanied by colicky abdominal pains of a +griping character. Chills are rare. The tongue is furred and moist: +later it becomes dry. Nausea and vomiting may be present, but not as +a rule. There is fever and often excessive thirst. Later the stools +become green in color, due to the bile which causes a burning sensation +in the rectum. + +On examination there are found red blood-corpuscles and leucocytes, +and large, round and oval epithelioid cells containing fat drops +and vacuoles. In mild cases, the course is about eight days; severe +cases subside within four weeks, but if the =osteopathic treatment= +is careful and specific, the usual duration can generally be reduced +one-half. + +=Prognosis.=—The prognosis is generally favorable in the catarrhal form +when the disease is treated properly. The previous general health, +hygienic conditions, and sanitary surroundings are of great importance. +When there is ulceration or membranes the prognosis should be guarded. +The condition may become =chronic=. + +=Treatment.=—The bowel should be thoroughly washed out by warm water +enema, several times, if necessary, to remove irritating material. +Invariably a lesion of the spinal column is found at the third and +fourth lumbars or near by. It is generally a subluxation, of a lateral +nature, between these vertebræ: rarely is the lesion above or below +this point. The treatment should be applied immediately and directly +to this region. Time is valuable in these cases and one should go to +work at once to correct the irritation. An attempt should be made at +each treatment to correct the disorder. This should not be delayed +by wasting time in relaxing muscles and inhibiting, for unusually +this gives only temporary relief. When a slight movement has been +accomplished between disordered vertebræ, treatment should be stopped +and results watched, because the adjustment may have released all +obstructions or irritations causing the disease. In many cases, to +get an anatomically correct spine is an impossibility, from the fact +that the displacements may be of long standing and naturally the +subluxated vertebræ have conformed themselves to some extent to their +unnatural position. In other words, what has been lost in the position +and relation of a vertebra may have been compensated by reducing the +effect of the lesion to a minimum. A lesion of this nature at the +third lumbar impairs the innervation to the colon and consequently +produces a stasis of blood in the mesenteric circulation, followed by +inflammation, bloody discharges, cramps, etc. A single treatment is +usually quite sufficient in milder cases. Other cases require treatment +every few hours or thereabouts, until recovery. + +Treatment directly over the abdomen through the mesenteric circulation +and glands is an effective treatment in most cases and especially when +the attack is severe. It relaxes the tissues about the mesentery, +thereby relieving the stasis and freeing the circulation. The greatest +care, however should be exercised in giving this treatment. + +The constant desire to defecate, that is common to many cases, is a +very annoying symptom. Strong, thorough treatment over the sacral +region, by inhibition over the sacral foramina and by relaxing the +tense muscles of the sacrum, will relieve this condition. In relaxing +these muscles, place the whole hand against the muscles and push upward +toward the occiput. This treatment inhibits the nerves to the rectum +and lessens the =tenesmus=. + +Attention should be paid to the liver to keep it active. Washing out +the large bowel with tepid water produces a soothing effect, besides +having a tendency to allay inflammation. The blandest of liquid foods, +as peptonized or boiled milk, broths, beef juice, barley and rice, +should be given. The patient should remain in bed until completely +cured. + + +Amebic or Tropical Dysentery + +This form prevails in the tropical and subtropical countries for +the most part, and is caused by an animal parasite, the _ameba +dysenteriae_. This is constantly found in the stools, the tissue of +the intestine and also in the pus of the liver abscesses, which are +secondary to dysentery. Amebae are sometimes found in the stools of +healthy men, having probably entered the system through the drinking +water or uncooked food. + +=Pathologically=, the mucous membrane of part or whole of the large +intestine is swollen. Round or irregular ulcers which undermine the +mucous membrane, especially of cecum, ascending and pelvic colon, are +found. In later stages there is infiltration of the connective tissue +followed by necrosis. In some cases false membranes and sloughs are +formed. + +=Symptoms.=—The onset may be either sudden or gradual, with a very +irregular diarrhea, moderate fever, and copious, liquid stools, +abounding with the amebae coli. The straining may be less severe and +persistent than in catarrhal dysentery and may be absent. Sometimes +there is nausea and vomiting. + +Abscess of the liver is the most common complication, which may +be single or multiple. When single it usually involves the right +lobe. Multiple abscesses are small. The more recent abscess walls +are necrotic; the older have whitish, smooth, fibrous walls. These +abscesses do not contain pure pus, but a fatty and granular debris +containing the amebae and a few cellular elements. Sometimes they +extend into the lung. + +=Diagnosis.=—This depends upon severity of attack and general condition +of the patient. Relapses often occur and the case may become chronic. +Cases have been treated osteopathically with success. + +=Treatment.=—In this form of dysentery the treatment is largely +the same as in acute ileo-colitis. The spinal lesions affect the +innervation to the intestine, thus producing a stasis in the +circulation; this condition favoring, and in fact, inviting the +retention of the ameba coli in the system at this point. + +The diet is the same as in other forms of dysentery. Rectal injections +and hot applications to the abdomen are useful. In all cases where +strong treatment has been given to the spinal column, a quieting +treatment to the nervous system and an inhibitory treatment to the +heart will be gratefully received by the sufferer. Both of these +effects can be accomplished at the same time by simple inhibition to +the occipital nerves. The stools should be taken care of immediately +and disinfected. Ice water enemas given frequently are reported as +giving good results. For the tenesmus, inhibit strongly at 3d, and 4th, +sacrals. + + +Chronic Dysentery + +This is generally resultant from an acute attack, though the amebic +form may be subacute from the onset. + +=Pathologically=, the coats are generally thickened, especially the +submucosa and the muscular coats being hypertrophied. Ulcers are +usually present, although there are cases in which there are no ulcers. +Cicatricial contractions sometimes follow and the calibre of the bowels +is reduced, strictures being rare. + +=Symptoms.=—There is a progressive loss of flesh and strength, little +or no tenesmus, slight, colicky pain and extreme anemia. The stools +contain mucus, at times blood, and the bowels move from two to twelve +times a day. + +=Diagnosis.=—The history of the initial symptoms will establish the +diagnosis. It is not always possible to distinguish between chronic +dysentery and chronic diarrhea. The duration is from a few months to +several years, although osteopathic treatment has proven very efficient +in many instances. + +=Treatment.=—Rest and a liquid diet are most essential. Foods that are +easily assimilable and nourishing, with a minimum amount of residue, +are required. Beef juice, beef peptonoids and peptonized milk are the +types of food. Change of air, hygienic measures and environment are +important. + +In cases that become chronic, the spinal column oftentimes exhibits +lesions above and below the lumbar region. Undoubtedly they are +lesions of secondary importance in comparison to the lumbar lesions, +but it is important that they be corrected. The treatment requires +thorough, careful work of the disordered spinal column and lower ribs. +Occasionally a slight kyphosis is present in the dorso-lumbar region +that demands persistent work in order to correct it. An occasional +rectal injection is beneficial, especially in cases that have slight +ulceration of the sigmoid flexure or rectum causing colicky pains and a +few loose stools in the morning, the patient being fairly comfortable +during the rest of the day. + + +Erysipelas + +=Definition.=—An acute, infectious, specific disease, characterized +by a peculiar inflammation of the skin, due to the streptococcus +erysipelatis, with a tendency to spread. + +=Osteopathic Etiology= and =Pathology=.—Osteopathically, lesions are +found to the vasomotor nerves and lymphatics of the affected area. Dr. +Still gives lesions of the “inferior maxilla, the cervical vertebræ, +the clavicles or the upper ribs” as specially important factors. +These lead to congestion and predispose to infection. It occurs in +epidemic form, especially in the late winter and spring. One attack +predisposes to a second. Family predisposition exercises a slight +influence. Abrasions, lacerated wounds, especially of the scalp, may +be the starting point of an attack. Persons having skin diseases and +wounds, and women who have been recently delivered are liable to be +affected. Chronic Bright’s disease, chronic alcoholism, syphilis, +debility, phthisis, organic heart disease and unhygienic surroundings +are predisposing causes. + +The specific virus is the streptococcus erysipelatis, which acts as a +local irritant producing the dermatitis. These are found in the lymph +vessels and cutaneous connective tissue. The fever and constitutional +symptoms are due to toxic agents. + +It is an inflammation of the skin, and if uncomplicated, no other +structures are involved. Subcutaneous and mucous tissues may be +involved, but rarely; if so, there is apt to be suppuration. Visceral +complications are of a septic character. Endocarditis, pericarditis, +pleuritis-pneumonia, and nephritis are possible complications. + +=Symptoms.=—The incubation period varies from two to seven days. The +onset is generally sudden with chill, followed by fever, 104 or 105 +degrees F. There may be nausea, headache, and pain in the back and +limbs. The local inflammation of the skin follows, usually on cheeks +and bridge of nose, or at site of an abraded surface. The area is red, +smooth, and edematous. It spreads rapidly, the patch being elevated +above the surrounding tissue and tense. The swelling may be so great +as to close the eyes and distort the features. The cervical glands are +swollen. The temperature continues high for four or five days and falls +by crisis. The eruption begins to subside and a moderate desquamation +occurs. If the disease takes a fresh start the fever again rises and +continues as long as the disease spreads. There is usually headache +and sometimes delirium. The tongue is furred, and bowels constipated +and the urine scanty. As a result of intense infiltration the part may +become gangrenous. Suppuration frequently occurs in facial erysipelas. +The inflammation may extend to the mucous membrane of the throat and +mouth. + +=Diagnosis.=—This is not difficult. The fever, the acuteness of the +disease, the rapidily spreading eruption, and the constitutional +disturbances will serve to distinguish it from all others. + +=Prognosis.=—This is usually favorable; healthy persons rarely die. +Convalescence may be slow. + +=Treatment.=—Isolate the patient for the disease is contagious, and a +third person may convey the virus. The poison may cling to clothing, +furniture, etc. The physician should not take care of confinement cases. + +A number of cases of erysipelas have been cured by correcting disorders +in the region of the second, third, fourth and fifth dorsals. The +lesions are principally subluxations of the ribs and severely +contracted muscles. The disorder at the points named interferes with +the vasomotor nerves to the face, thus predisposing to an attack of +erysipelas by allowing the micro-organism congenial tissue for its +devastations. In many other cases derangements have been found higher +than the upper dorsal, principally through the middle and upper +cervical vertebræ. Lesions in these regions would also interfere with +vasomotor fibres, especially through the fifth nerve directly. + +The treatments on the whole are to examine for lesions to the +innervation of the affected region and remove them, besides giving +special attention to the bowels, a nutritious diet, and absolute rest. +In cases where there is much restlessness and insomnia, treat the upper +cervical region, especially the deep posterior muscles[57]. Locally, +use cold water applications; adhesive strips applied near the inflamed +area or tincture of iodine, may prevent the disease spreading. + + +Yellow Fever + +=Definition.=—An acute, infectious disease, characterized by a febrile +paroxysm followed by short remission and then relapse, jaundice, +toxemia, suppression of the urine, and gastric hemorrhage. + +=Osteopathic Etiology= and =Pathology=.—While a specific germ is the +cause of yellow fever, it has not as yet been isolated. Extended +tests by United States Army surgeons in Cuba show conclusively that +the infection is alone carried by the _stegomyia fasciata_, but “It +remains somewhat uncertain whether the mosquito is the sole means +of transmission.” (Anders). Season is the chief predisposing cause +as the outbreak is usually in summer and a frost ends its spread. +Immunity is generally conferred by one attack. Tucker[58] noted that +all cases examined had liver lesions and that most of the patients +were of the malarial or bilious type. Spinal lesions were not marked +in some cases, but when present were in the liver and renal areas. +Tete[59] believes it to be a virus secreted in the human organism under +certain atmospheric and other conditions in certain types, i. e. people +subject to hepatic and renal disturbances. He also says the vagus is an +important factor. + +=Pathologically=, there is more or less jaundice and hemorrhagic +extravasations under the skin. The blood serum is red-tinted, owing +to the destruction of the red cells. The liver is pale and presents +extensive fatty degeneration, with necrotic masses in and between the +cells. The gastro-intestinal mucous membrane is swollen, congested and +presents numerous minute hemorrhages. The kidneys show parenchymatous +inflammation. The spleen is not enlarged. The heart sometimes shows +fatty degeneration. The stomach contains more or less of the “black +vomit,” which is a mixture of transuded serum and transformed blood +pigment. + +=Symptoms.=—The incubation period varies from one to five days. The +attack generally begins with a chill, fever, 102 to 105 degrees, +headache and pains in the loins and legs. The pulse is accelerated, +the face is flushed, the tongue is coated, the throat sore, the bowels +constipated and the urine scanty and albuminous. Recent observers state +that bile is present in most cases before the albumin is noted. Nausea +and vomiting may be present at the onset, but become more severe about +the second or third day when the black vomit appears. The =febrile +stage= or stage of invasion, lasts from a few hours to several days +and is followed by a decline in the fever when the severity of the +other symptoms abates. This is called the =stage of remission= and in +favorable cases convalescence sets in or the patient may pass into the +second febrile paroxysm. The temperature rises again, jaundice appears +rapidly, nausea and vomiting return. The tongue becomes dry and coated. +The stools are black and offensive, the urine is albuminous, scanty and +may be suppressed; there may also be hematuria. Death may occur from +exhaustion or from uremia. Recovery may follow the gravest symptoms, +even when there has been black vomit. The duration of the entire attack +covers about one week. Relapses sometimes occur. + +Price says there is a point in differential diagnosis in yellow fever +and it is a symptom not met with in any other febrile affection. It +is the progressive fall of the pulse-rate during the congestive stage +of the first sixty or seventy hours, i. e., a variation of from five +to ten beats less each morning and evening. He adds, “As long as the +kidneys are active there is but little to fear.” + +=Diagnosis.=—=Remittent fever= has not the deep jaundice, the clear +mind, the black vomit, or the albuminuria of yellow fever. The enlarged +spleen and the presence of the organism of Laveran in the blood in +remittent fever will decide the diagnosis. =Dengue= is sometimes +confused with yellow fever. + +=Prognosis.=—This is always a grave disease, and in its severe forms +very fatal. Recovery, however, may occur after the severest symptoms +have been manifested. Black vomit is not always a fatal sign. Enough +cases have been treated osteopathically to state that osteopathy is +particularly effective. Improved sanitation is doing much to reduce +mortality. + +=Treatment.=—Prophylactic treatment should be carefully carried out. +All patients should be quarantined and carefully screened so they +cannot be bitten by the mosquito and the disease spread further. People +that are not acclimated should keep away from infected districts. All +pools, cisterns and other places which can breed mosquitoes should be +drained or screened. A systematic warfare should be waged against them. +The patient must be put to bed at once and plentifully supplied with +fresh air. Everything must be scrupulously clean—body and bed linen. +Use a tube for nourishment and a bed-pan for excretions as the patient +must not make the slightest exertion. + +Spinal lesions may or may not be found. They have been observed in the +cervical, eighth dorsal and second lumbar. + +The treatment on the whole is symptomatic. The chills and fever of +the first stage should be controlled by thorough work at the upper +cervical, upper dorsal, lower dorsal and lower lumbar regions. +Treatment at these points controls the superficial and deep vascular +areas of the body through the vasomotor nerves. The irritable stomach, +delirium and severe neuralgic pains of the head, back, epigastrium +and limbs are to be treated according to the conditions and severity +of the symptoms. The kidneys and bowels should be watched carefully, +and at the onset should be freely opened and control of the kidneys +never lost. Let the patient drink freely of water, which will aid. +Hydrotherapeutic measures, as a cold bath or sponging, may be employed +to aid in controlling the fever, the nervous symptoms, and the +eliminative power of the excretory organs. Discontinue the use of +hydrotherapy when a spontaneous fall of temperature occurs. + +At the beginning of the first stage and during the stage of remission +are the periods that the osteopath should do very effectual work +by paying particular attention to the four large vascular areas of +the body, viz.: head, lungs, abdomen and legs. Treat the vasomotor +nerves to these regions, thoroughly, as given in the treatment of the +first stage. During the third stage everything should be done that is +possible to support the system. Ice slowly dissolved in the mouth will +be of aid to an irritable stomach. Hemorrhages and the various symptoms +are to be treated as they arise. + +Good nursing, dieting, ventilation and keeping the skin, kidneys and +bowels active are the primary points to consider. During the period of +depression, the heart must be closely watched. The diet should be a +light, liquid one, of the nature of peptonized milk or light broths. +No food is recommended by some at the onset nor until the crisis is +passed. Others feed during the stage of remission and give stimulants. +During the last stage rectal feeding is suggested if gastric +irritability is pronounced. + + +Tetanus + +(LOCK-JAW) + +=Definition.=—An infectious disease, caused by Nicolaier’s tetanus +bacillus, characterized by persistent, tonic spasms of the muscles with +violent exacerbations. + +=Etiology= and =Pathology=.—The exciting cause of tetanus is a specific +bacillus which usually gains access to the system through some wound. +The site of infection is the only place the germs are found. + +The disease is much more prevalent in some localities than in others. +It is found in hot countries, as in India and the West Indies, far more +commonly than in temperate regions. Exposure to damp cold is one of the +recognized causes, also those localities where there are rapid changes +from cold. Such regions seem to produce conditions favorable to the +existence and growth of the bacilli. + +Earth mould, particularly where putrefaction is taking place, as in +soil that has been manured, is especially favorable to the existence +of the bacillus. It is frequently found in the intestinal tract of the +horse, so that the soil about stables is apt to contain the germs. The +highly fertilized soil of France and Belgium rendered it a special +menace to the wounded of the Great War. Antitetanic serum, according to +all reports, was particularly efficacious. + +Wounds and abrasions of various kinds, particularly contused and +punctured wounds of the hands and feet, favor the excitation of +tetanus. When an open wound is present, the term =traumatic tetanus= +is given to the disease; =idiopathic tetanus= when no wound is +discoverable; =tetanus neonatorum= when it attacks infants—this form +is usually due to insanitary conditions, especially the improper care +of the umbilical cord; =lock-jaw= or trismus when the jaw alone is +affected; =cephalic tetanus= when the throat and face is involved. + +Characteristic lesions have not been found in the cord or the brain. +The bacilli develop at the site of the wound where the toxin is +manufactured. The bacilli do not invade the blood and organs. The +toxalbumin is one of the most virulent poisons known. + +Congestion occurs in various organs, due to obstruction of the movement +of the blood during a spasm. The brain, cord, lungs and muscles are +congested. The nerves are often found swollen. + +=Symptoms.=—The period of incubation is from one to twenty days. This +is time required for the poison “to be absorbed by the end plates in +the muscles and to pass up the motor nerves to the spinal cord.” In +most cases the incubation is from five to ten days. A chill precedes +other symptoms in a few cases. The onset is quite sudden, with +stiffness in the neck, jaw and tongue. There are headache, stomach +disturbance and languor. Opening the mouth is difficult, but is not +painful. Deglutition is difficult. The stiffness increases and extends +to the spinal muscles, abdomen and legs which are held in a firm spasm. +Thus, the trunk and legs are inflexible. + +These symptoms vary in degree of severity, dependent upon the extent +of involvement. The jaws may be firmly locked or they may yield to +forced extension—“lock-jaw.” The muscles of the face may be involved, +the angle of the mouth drawn out, and the eyebrows raised—“risus +sardonicus.” The neck and trunk muscles affected produce opisthotonos. +Spasms of the pharynx and esophagus may occur, especially when there +are injuries to the fifth nerve. + +Associated with these tonic convulsions is intense pain. The distress +of the patient is extreme when the chest muscles are affected. All +symptoms are increased during the paroxysm. A foot fall, the slamming +of a door, a draught of air or any slight sensory impression may excite +a paroxysm. The paroxysm may relax and during the interval the patient +may walk about. The spasms vary in frequency from a few minutes to +one in several hours. During spontaneous or induced sleep the spasm +usually ceases. The febrile reaction is generally slight and apparently +of nervous origin; in many cases 102 degrees F. In severe cases the +temperature may be considerably higher. Perspiration is excessive. The +urine is scanty and high colored. The bowels are usually constipated. +The mind remains clear throughout. Death is generally caused by +exhaustion. =Chronic tetanus= presents similar symptoms, but less +marked, and it develops slowly. + +=Diagnosis.=—The history of a wound followed by the characteristic +symptoms would rarely occasion an error. =Strychnine poisoning= +differs from tetanus in the history, in the more rapid development of +the symptoms, no trismus at the beginning, marked involvement of the +extremities, and absence of rigidity between the paroxysms. In =tetany= +the extremities are chiefly affected by the spasms, the muscles are +relaxed during intervals, and trismus is a late or very rare condition. +In =hydrophobia= trismus does not occur and the respiratory spasm is +caused by attempts at swallowing. The mental symptoms increase. + +=Prognosis.=—The prognosis is unfavorable. Eighty per cent of traumatic +and fifty per cent of the idiopathic cases prove fatal. Cases that +are fatal usually die within six days. Cases where there is slight +elevation of temperature, and where the spasm is localized to the +muscles of the face, neck and jaw, or where muscle stiffness is late in +appearing, are more likely to recover. + +=Treatment.=—Free incision and thorough disinfection with hydrogen +peroxide and cauterization with pure carbolic acid, of the wound are +necessary. The patient should be put in a dark room and there remain as +quietly as possible. Avoid all sources of peripheral irritation. Liquid +food is to be given, and if the jaws are firmly set, rectal feeding may +be employed or food may be passed through the nose with a catheter. + +For the spasms, strong inhibition of the nerve centers controlling the +affected muscles may be of use. Probably the most effectual treatment +for the paroxysms would be strong, thorough treatment of the upper +cervical region. Hot baths give relief to the spasms. All the excretory +organs should be greatly stimulated, particularly the kidneys, lungs +and bowels. Other symptoms are to be treated as they arise. Tetanus +antitoxin is highly commended by surgeons who used it during the Great +War. As death is at a two to one ratio any method of treatment is +justified. A few cases have been treated osteopathically with fair +success, following antiseptic measures. + + +Simple Continued Fever + +=Definition.=—An acute, febrile disease, mild in character, of short +duration, not excited by any special organism and depending on a +variety of irritating causes. + +=Osteopathic Etiology.=—The most frequent cause of this form of fever +is probably gastro-intestinal disturbance. In children it may be due to +gastro-intestinal derangement, or to the eating of decomposing food or +to exposure to wet and cold. It may be caused by exposure to the sun +or great heat, or mental or physical fatigue. It may be the result of +exposure to cold sufficient to produce a slight bronchitis, tonsillitis +or other affection producing an unnoticed localized inflammation. It +may follow a prolonged exposure to noxious odors or gas. Lesions, +osseous or muscular, are always present, corresponding to the tissues +and organs disturbed. Muscular lesions, especially, are prominent. + +=Symptoms.=—The onset is usually sudden with a feeling of lassitude, +weariness, chilliness, and headache. The temperature rises quickly to +102 or 103 degrees F. or over, and is usually apt to terminate suddenly +by crisis on the third or fourth day. The pulse is frequent and the +face is flushed. The child is often irritable. Mild delirium may occur. +Anorexia is present, and the bowels are constipated. Convalescence is +rapid. + +=Diagnosis.=—This depends upon excluding other probable diseases. If +the fever cannot be attributed to some of the causes already referred +to, there may be a doubt as to its character for the first twenty-four +hours, but, if after a careful examination, one finds no other cause +and no symptoms develop of any of the recognized diseases, acute +continued fever can hardly be mistaken for any other disease. + +=Prognosis.=—Always favorable, recovery without sequelæ being the rule. + +=Treatment.=—It is necessary to find out the irritative cause in order +for one to be able to treat intelligently. Rest in bed with treatment +of the disturbing factor of the disease, whatever that may be, is the +principal treatment to be given. Careful examination of all the organs, +with due consideration of the symptoms, will generally leave no doubt +as to the cause, and treatment applied accordingly will be sufficient. +If there is any gastro-intestinal disorder, thorough treatment of the +splanchnics, anterior treatment to the abdomen and thorough evacuation +of the bowels are indicated. Use an enema if necessary. Besides the +usual fever treatment, sponging the body with tepid water at the time +of day when the fever is highest will aid in lessening the temperature +and render the patient more comfortable. In cases where nervous +symptoms are prominent, care should be taken against any excitement +and, if insomnia results, a quieting treatment in the cervical region +is usually sufficient. Use plenty of water internally, which is not +only necessary for the tissues on account of the fever, but is of great +aid in keeping the skin and kidneys active, and thus a great help in +the elimination of waste material. A liquid, nutritious diet is best. +Milk, broths and soups will be enough. The demands on the digestive +tract are not great when a light diet is administered, besides not +exciting the nervous and vascular systems unduly. + + +Tuberculosis + +=Definition.=—A general or local infectious disease caused by the +bacillus tuberculosis of Koch. The bacillus produces specific lesions +of the form of nodular bodies called tubercles that undergo caseous +necrosis with a tendency to involve neighboring tissue. There may be +a diffusion of the infection by way of the lymph and blood vessels to +various tissues and organs. + +=Osteopathic Etiology and Pathology.=—Tuberculosis exists in all +countries. It generally prevails more extensively in warm than in cold +climates, and is of more frequent occurrence in the city than in the +country. Altitude, however, exerts more influence than latitude. The +disease rarely occurs in mountainous countries, owing to the purity of +the atmosphere. The disease is very prevalent in the West Indies and +the South Sea Islands. Tuberculosis is frequently met with in Canada +among the French Canadians and the English. All races are subject +to tuberculosis, but the Indians of this continent, the South Sea +Islanders and the colored race are very susceptible to the disease. It +is estimated that from seven to ten percent of the present death rate +in the United States is due to tuberculosis. + +The tubercle bacillus was discovered by Koch in 1881. It is a short, +straight or slightly bent, rod. This bacillus has an exceedingly +tenacious hold on life and is found in greater or less numbers in all +tuberculous lesions. + +It can live almost indefinitely outside the body. The bacilli are found +in great numbers in the sputum, which dries and flies in the atmosphere +in the form of dust. The organism is thus widely spread in regions +frequented by phthisical patients. The bacillus gains entrance into the +body by way of the respiratory tract in the vast majority of cases. +Milk from tuberculous cows will produce the disease, especially in +children, causing intestinal and mesenteric tuberculosis. The meat of +tuberculous animals is not necessarily infectious, although there is a +possibility of infection by this means. Tuberculosis may be transmitted +by direct inoculation; this does not often occur in man, but when it +does, the disease usually remains local, although general infection may +occur. Persons who follow certain occupations, as butchers, dissectors +of dead bodies, and handlers of hides, are more or less subject to +local tubercles of the skin. The virus may enter the body through any +fissure or excoriation on the skin; thus by washing the clothes or bed +linen of phthisical patients, by the bite of a consumptive, or by a cut +from a broken sputum glass of a consumptive, one may become infected. +It is stated that there may be hereditary transmission. In some cases +the virus may be transmitted and the disease may not appear for many +years. + +=Predisposing Causes.=—Hereditary predisposition, which renders the +person more liable to accidental infection; delicate constitution; +scrofulous tendency; previous infectious diseases, as influenza, +whooping cough, measles, typhoid fever; diabetes mellitus, etc. +In young children meningeal, mesenteric and lymphatic forms of +tuberculosis are the most frequent. Pulmonary tuberculosis is usually +met with in adults, especially between twenty and thirty years or +age. The development of tuberculosis is favored by damp localities; +by improper and insufficient food; constant inhalation of impure +air; injuries to the chest, with or without laceration of the lungs, +and various osteopathic lesions that weaken the tissue through faulty +nutrition. Corresponding to the innervation of the organ or tissue +diseased will always be found anatomical derangements. “Every case has +a defective spine and thorax.” (Hayden[60]). + +Bronchial catarrh, tonsillitis, diseases of the stomach and intestines, +especially enterocolitis, tubercular pneumonia, pleurisy (rarely), +intrathoracic tumors and congenital or acquired contraction of the +orifice of the pulmonary artery increase the susceptibility to +infection. Lessened vitality of the tissues, whether inherited or +acquired, is necessary before the germ can become implanted and +proliferate, producing tuberculosis of the tissues and organs. In +nearly every instance, when the lungs are involved, lesions are found +at the second, third, or fourth ribs. These lesions undoubtedly +predispose to the tubercular infection, by lessening the vitality +of the lung tissues through interference with the innervation or +vascular supply. Possibly a lesion at the second rib or second dorsal +vertebra would interfere directly with the vasomotor nerves of the +upper thoracic ganglia. The condition of the middle and lower cervical +vertebræ should be carefully examined, for lesions at that point would +involve the lymphatics of the lungs. The lowered vitality caused by the +lesion is the predisposing cause and the tubercular bacillus is the +=exciting cause= which determine the character of the affection. + +C. A. Whiting in Clinical Osteopathy says: + +“=The spinal outline= characteristic of tuberculosis and of the +pretubercular stages presents the following peculiarities: The cervical +spine presents various abnormalities, usually lesions involving single +vertebræ and associated with irregular muscular tensions. The upper +thoracic spine is anterior, the ribs drooping and rather more freely +movable than normal; the vertebral articulations are less movable than +normal; the tissues in the neighborhood of the upper two or three +dorsal spines are abnormally sensitive and the muscles innervated from +these segments are contracted irregularly when the disease involves the +apices. The lower interscapular region is found sensitive and these +muscles are contracted when the lower lobes of the lung are involved, +and the location of these sensitive areas may be employed in the +localization of the lung area infected. + +“In every case recorded in this clinic, lesions involving the area of +the origin of the upper and middle splanchnic nerves have been found. +The typical tuberculosis spine must include lesions of the lower dorsal +area. Probably these lesions are predisposing factors in tuberculosis, +partly because of the effects produced upon nutrition thereby, but +doubtless the lack of the normal mobility of this part of the spine +prevents the normal stimulation of the liver, the spleen, perhaps the +pancreas, thus the normal opsonic index is lost, and immunity broken. +The treatment of tubercular cases should include careful attention +to the splanchnic area, the maintenance of the normal mobility +and structural relationship of the entire spinal column, and such +stimulating movements to the ninth and tenth thoracic neighborhood as +is indicated in each individual case.” + +=Pathology.=—In adults the most common site of tubercles is the lungs; +in children it is the lymphatic glands, joints and bones. No organ +is exempt; the salivary glands and pancreas are the least frequently +involved. The military tubercle is the beginning of tubercular +deposits. This may develop in any tissue where the tubercle bacillus +is found and it is only distinguished by the presence of a tubercle +bacillus, as similar conditions are produced by the aspergillus glaucus +and actinomyces. + +In the development of a tubercle there is proliferation of the fixed +tissue cells, particularly those of the connective tissue and the +endothelium of the capillaries, due to the irritation of the bacillus, +producing the epithelioid cells and in some instances the giant cells, +in both of which bacilli may be found. The epithelioid cells vary in +shape. The giant cells are formed by enlargements of the epithelioid +cells and a repeated division of their nuclei or possibly by fusion +of several cells. On account of the inflammation produced by the +bacillus, there is migration of leucocytes from the adjacent vessels +and lymphoid cells. The leucocytes are largely polynuclear and are +rapidly destroyed, but later mononuclear leucocytes appear, which +are able to resist the action of the bacilli so that they are not so +readily destroyed. A reticulum of connective tissue is formed around +the various cells. The tubercles are non-vascular and when once formed +undergo caseation and sclerosis. + +=Caseation= is a process of coagulation-necrosis or destructive change, +beginning at the central part of the growth, due to the action of the +bacilli. The primarily transparent tubercular tissue may become a +gray gelatinous body containing bacilli. Frequently the caseation is +followed by softening; less frequently, calcification, or it may be +surrounded by fibrous tissue. + +During the time the cell destruction is going on at the center of +the tubercle, hyaline and fibrous changes may render the tissues +=sclerotic=. These changes, =caseation=, the destruction of forces, +which are dangerous to the patient, or =sclerosis=, which is a healing +process, depend upon the power of the body to produce an antitoxin to +overcome the effects of the special toxin produced by the bacilli. + +There may be a widespread =tuberculous involvement=. This is the result +of fusion of the new foci of infection or of miliary tubercles. The +lungs are the usual site of infection, varying from a small area, to a +lobe or a still greater area. + +The irritation of the bacilli is capable of producing =associated +inflammatory processes= in its own neighborhood. There may be an +overgrowth of interstitial tissue. In other instances, changes to +catarrhal or croupous pneumonia may occur. Suppuration is associated +with tuberculosis, especially of the lungs, and is due to a mixed +infection or the presence of pus organisms. Some authorities claim that +the tubercle bacilli alone are able to produce suppuration; it is, +however, more probable that suppuration is due to a mixed infection. +The constitutional features in tuberculosis are more dependent upon +this secondary infection, especially by the streptococci, than upon the +primary infection. + + +Tuberculosis of the Lymph Glands + +(SCROFULA) + +=Scrofula= is a true tuberculosis of the lymphatic glands. The virus is +less virulent than that from other sources, which accounts for the slow +development and milder course of tuberculosis of the glandular system. + +=Tuberculous Adenitis= may occur at all ages, but is most common +in children and young adults. It is rarely congenital. Catarrhal +inflammation of the mucous tissues weakens the resisting power of the +lymph tissue, thus allowing the bacilli to develop, and is an important +predisposing cause. The glands most frequently affected are those of +the neck; more rarely there is involvement of all the lymphatic glands +of the body. Invariably lesions of the upper and middle cervical +vertebræ and upper dorsals and corresponding ribs are found, as well as +lesions to the lymphatics at various points along the spinal column and +ribs. These lesions affect the innervation to the lymph glands, as well +as mucous membranes, and thus predispose to the disease. In all cases +anatomical derangements are found in the region of the innervation to +the involved gland. + +In =general tuberculous adenitis= all the lymph glands of the body are +more or less involved, while the other organs and tissues are rarely +affected. All the visible glands are found to be swollen, tender and +painful. There is more or less protracted fever, with wasting and +debility. This is a rare affection. + +In =local adenitis= the glands of the neck are most frequently affected +and this is especially the case with children. Negroes are more +frequently affected than whites. It is seen especially among those +living in an unsanitary environment. Measles, whooping cough and an +hereditary tendency are predisposing factors. The submaxillary glands +are usually the first affected. At first they are swollen to various +degrees and are tender; later they suppurate and rupture if one is not +able to cure them. There may be fever. The skin over the glands is +usually freely movable; it may, however, be adherent. + +The glands above the clavicle, those in the posterior cervical +triangle, and the axillary glands may all be affected. In such cases it +is likely that the bronchial glands are also involved and may infect +the living tissue. + +Lesions of the upper and middle cervicals and deep muscles are always +found and undoubtedly are the underlying causes. Lesions of the lower +cervical, upper dorsal, ribs and clavicle, are of frequent occurrence. +Infection may gain entrance by way of the pharynx and tonsils. + +The affection often runs a slow course. + +The =bronchial= glands may be affected primarily, but usually +secondarily to infection of the lungs. The primary form is seen most +commonly in children and is apt to be associated with suppuration. +Lesions of the upper and middle dorsals and of the cervicals will be +found. Catarrh of the bronchial tubes is a predisposing cause. The +X-ray is of great value in the diagnosis. + +The most noticeable symptoms are those due to pressure or irritation. + +Systemic infection may follow rupture into a vessel. Local infection of +the lung may occur and the pericardium become infected. + +=Mesenteric= cases occur among children and may be primary or +secondary. The primary form is rare. Swallowed sputum is a frequent +cause. The trunk and limbs are puny. The child is anemic, and often +the abdomen is tympanitic. Diarrhea is marked and there is pain and +indigestion. Fever is almost constantly present and of an intermittent +type. The disease is most frequently met with among poor children +in unhygienic, poorly ventilated houses. There may be an associated +tuberculosis of the peritoneum. + + +Acute Tuberculosis + +This shows best the truly infectious nature of tuberculosis. In it +miliary tubercles develop in many and various parts of the body. In +some cases these growths seem to be uniformly distributed throughout +all the viscera. In other instances they are localized in the lungs +or in the meninges of the brain. In nearly every instance it is an +auto-infection, arising from an old tuberculous focus, which may be +latent and quite unsuspected. General infection, in most instances, +arises from the rupture of a nodule into a vein, from tuberculous lymph +glands, tuberculosis of the bones, joints, or even the skin. + +=General Miliary Tuberculosis or Typhoid Form.=—This is similar to a +general infection of the body and resembles, to a marked degree, the +symptoms of typhoid fever. The onset is rarely rapid. + +In most cases there is a period of incubation, during which the health +fails, the appetite is lost, headache occurs, and the patient soon +becomes feverish, with increased debility. The temperature rises and +the pulse is rapid and feeble. The tongue is dry. The respirations are +increased. Delirium may be present. In rare cases, there may be little +or no fever. The temperature ranges from 101 to 103 or even 105 degrees +F. It is irregular and marked by evening exacerbations and morning +remissions. Occasionally there is an inverse type of temperature in +which it rises in the morning and falls in the evening. In some cases +the pulmonary symptoms are marked, while in others the meningeal +symptoms are more prominent. Tubercle bacilli are rarely found in the +sputum. + +The spleen is usually enlarged. Constipation is present, as a rule, but +there may be diarrhea, and hemorrhage from the bowels may occur. The +urine may contain traces of albumin. There may be excessive sweating, +and herpes is often present. Choroid tuberculosis is frequently met +with. In doubtful cases the blood should be examined for tubercle +bacilli, although they are not always present. The duration is from two +to four weeks, the disease usually terminating unfavorably. + +=Diagnosis.=—It is often very hard to differentiate between this form +of tuberculosis and typhoid fever. In =typhoid fever= epistaxis is a +common, early symptom. The temperature curve of the continued type +is quite diagnostic. The Widal test should be made. The respirations +are moderately hurried and the pulse is often dicrotic. Diarrhea is +frequent. Typhoid rash is diagnostic. No tubercles are found on the +choroid. No tubercle bacilli are found in the blood. Hemorrhages from +the bowels are common. + +=Pulmonary Form.=—When the lungs are chiefly affected the pulmonary +symptoms are marked from the onset. It may develop suddenly or there +may be a long period during which the general health fails markedly. +In children the disease may follow measles or whooping cough. There +is dyspnea, cough and the expectoration is mucopurulent. There is +broncho-vesicular breathing with sibilant and subcrepitant rales. The +temperature is high, ranging from 103 to 105 degrees F., or higher. +Respiration and pulse are rapid. + +The disease may last from several weeks to months, or, on the other +hand, it may prove fatal within a few days. As the end draws near the +signs of suffocation become intensified. + +=Diagnosis.=—The history and general symptoms, together with the +dyspnea and cyanosis, will generally decide the diagnosis. The blood +should be examined for malarial parasites. The Widal test will +differentiate typhoid. + +=Cerebral or Meningeal= (Tuberculous Meningitis).—This form which is +sometimes called acute hydrocephalus, occurs quite frequently and is an +infection of the pia mater of the brain or cord. + +It occurs most frequently in the first two years of life, although +it may occur later. It is usually tuberculous in some other region, +especially in the bronchial glands. Rarely does the disease involve the +meninges primarily. + +The meninges at the base of the cerebrum is the principal involvement. +There is more or less inflammation, with fibrous purulent exudation. +There are tubercles along the blood vessels. The ventricles may be +distended. + +=Symptoms.=—The onset is slow, lasting one or more weeks. Headache, +constipation, vomiting and chills, followed by a fever, are the initial +symptoms. When the onset is sudden, the disease is generally ushered in +with a convulsion. The fever rarely rises above 102 or 103 degrees F. +The pain is often severe, causing the child to give a sudden cry—the +hydrocephalic cry. During sleep the child is restless and there are +slight muscular twitchings. + +The =irritative symptoms= now abate. The child becomes quiet and +is dull and apathetic. Constipation still persists. The abdomen is +boat-shaped, and the neck may be retracted. The pupils are dilated. +Convulsions and other cerebral symptoms may occur. The temperature +ranges from 100 to 103 degrees F. The respiration is irregular and +sighing. + +Following this, the mental faculties are lost and coma occurs. +Convulsions or spasmodic contractions of the muscles of the neck, +back and limbs may occur. The pupils are dilated and do not respond +to light. The pulse is frequent, irregular and small. The temperature +rises to 103 to 105 degrees F., or it may be subnormal. The duration is +from two to five weeks; chronic cases may last for a number of months. + +=Prognosis.=—Generally very unfavorable. + + +Acute Pneumonic Phthisis + +The infection of the lungs is rapid and may be primary or secondary. +This form is met with most frequently in children and young adults, but +may occur at any age. + +The =Pneumonic form= is more rare than the bronchopneumonic form and +may be very rapid in its course. The attack sets in abruptly with a +chill and the temperature rises rapidly. There is pain in the side; +cough; dyspnea and mucous and rusty sputum, which may contain tubercle +bacilli. There is impairment of resonance, increased fremitus, and +bronchial breathing. The whole or part of the lung may show signs +of consolidation and dullness, all the symptoms of pneumonia being +present. The patient rapidly loses flesh. This attack may come on a +person in good health after exposure to cold; but there may have been a +debilitated condition, or a predisposition to phthisis. Death may occur +in the second or third week or the case may continue from three to four +months. + +One or both lungs may be involved. The lung is heavy and airless, +sinking quickly in water. There is destruction of lung tissue and upon +section, cavities are found. The cavities are generally small and are +surrounded by tubercles. Older caseous areas of a yellowish white color +may be visible. Miliary tubercles are found upon careful examination. + +The =bronchopneumonic form= is the most common and occurs most +frequently in children. It often follows the infectious diseases, +especially measles and whooping cough. The child may be taken ill +suddenly with what seems to be an ordinary bronchitis, the temperature +rises, the cough is severe, and there may be consolidation with +submucous and subcrepitant rales. Rapid respiration and sweating are +often marked. The course of the disease varies. There is rapid loss of +flesh, and in many cases the disease develops into chronic phthisis. In +other instances death occurs in from three to eight weeks. + +The disease may attack the adult whose resistance is impaired. Chills, +fever, pain in the chest, hemorrhages, wasting are most noticeable +symptoms; these are the various signs of bronchopneumonia. Tubercle +bacilli are often found in the sputum. The course is usually from three +to eight weeks, while a number pass into a chronic stage. + +Areas of caseous tubercles are found, which later suppurate, break down +and form cavities. The bronchial lymph nodes are found enlarged, and +usually there is acute tuberculous pleurisy. + +=Diagnosis.=—In the =pneumonic form= it may be impossible to make a +diagnosis early in the disease. Tuberculosis may be suspected if the +patient has been in bad health, has a predisposition to phthisis, or +has had any pulmonary disorder. Pneumonia will present the typical +symptoms, but if fever continues, tuberculosis will be suspected. +Examination of the sputum will probably decide. + +In the =bronchopneumonic= form it is very difficult, in the early +stages, to distinguish it from simple bronchitis and bronchopneumonia. +The irregular fever and rapid loss of flesh are important signs. The +sputum will show elastic tissue and tubercle bacilli early in the +disease and should be carefully examined. + + +Chronic Pulmonary Tuberculosis + +The chronic form of the disease is more common than the acute. It +seems probable that many cases of pulmonary tuberculosis are due to +inhalation of the tubercle bacillus, though no doubt, particularly in +children the bacillus frequently gains entrance to the system through +the intestinal tract from infected milk and food. =Deformities= of the +chest, especially where there is constriction and rigidness of the +upper part, with more or less immobility of the first, second and third +ribs and the junction of the manubrium and gladiolus, associated with +weak muscles and a stooped posture are definite predisposing factors. +This condition may be congenital or acquired. The local innervation, +blood supply and lymphatic drainage is involved, so that the individual +is less resistant and consequently susceptible to infection. The +bronchi are thus weakened, favoring the infectious process so that +the disease may advance and involve the neighboring tissues, or if +infection has gained entrance to the lymph or blood stream elsewhere, +the susceptible pulmonary organs may become diseased. + +Owing to the above predisposing factors the =primary lesion= of the +lungs is often in the bronchus a little below the apex near to the +posterior and external borders. A lower lobe may be involved, or +several lesions may occur at the same time, involving one or both +lungs. Frequently the other lung is infected from the lesion or lesions +of the first. + +In the acute cases the exudative process involves the lung tissue, +becomes caseous and softened, and later necrotic with cavity formation. +In the =chronic type= the exudative process is slower, with thickening +of the walls of the air vesicles and increase of fibrous tissue. +=Cavities=, the result of caseation, are of various size, ragged, +often coalesce and open into the bronchus. Fibrous tissue forms about +them and frequently arrest the process. In the necrotic involvement +blood vessels are often injured causing hemorrhages. Pleurisy, +empyema, catarrhal bronchitis, and bronchiectasis are often associated +involvements. + +In addition to the tubercle bacillus, other micro-organisms, +streptococcus and staphylococcus pyogenes, influenza bacillus, and +diplococcus pneumoniæ, are often found, and no doubt are important +exciting factors. + +The =bronchial glands= are swollen, and contain tubercles. They may +undergo purulent disintegration. Tuberculosis of the =larynx= is +common. In severe cases there may be amyloid changes of =liver=, +=kidneys=, spleen, and mucous membrane of the intestines. Tuberculous +lesions are found in the intestines, spleen, kidneys, and brain in +nearly equal proportions; then come the liver and pericardium. + +=Symptoms.=—The onset of the disease is either abrupt or gradual. +Frequently it succeeds influenza, measles, or bronchitis. There is +a cough, expectoration, loss of weight, afternoon temperature and +probably night sweats. The disease is likely to develop slowly. In +other cases gastro-intestinal disorders are the first symptoms, +especially with weakness and debility. Again, the disease may follow +pleurisy. When the attack is abrupt, pneumonia is simulated. However, +the apex of the lung, instead of the middle or lower lobe, is involved; +expectoration is considerable and the fever is not so high and +pronounced. Hemoptysis frequently occurs. + +The =local symptoms= are important. =Pain= is an early either moderate +or severe, symptom, although there are cases where it is absent. When +associated with pleurisy, it is severe. The pain is usually situated at +the base, anteriorly or laterally, of the scapulæ, but may be between +them. =Cough= is present, in the majority of cases, throughout the +entire course. It usually grows worse, and is dry and hacking at the +beginning but looser and paroxysmal and accompanied by a mucopurulent +expectoration later on. The =expectoration=, at first, is slight and +there may be more or less blood mixed with it, or even hemorrhage may +occur. With the formation of cavities, the expectoration increases +and is of a greenish-gray or greenish yellow color. In some instance +the sputum is more or less fetid. The expectoration is composed of +pus cells, blood, elastic tissue, fat globules and tubercle bacilli. +=Hemoptysis= is present in a majority of cases. Early hemorrhages +are usually slight, due to rupture of weakened vessels. When there is +softening or cavity formation, erosion of vessels may be pronounced +and hemorrhage considerable. Dyspnea is a variable symptom, but is +characteristic of lung changes. + +=Fever= is a characteristic symptom. It is probably always present at +the beginning and the afternoon increase of temperature is common. +Where there is softening and formation of cavities, a remittent or +intermittent type is present. The pulse is frequent, regular and +compressible. =Sweats= may occur at any time, but especially during +sleep. They indicate fever activity, and are increased during cavity +formation. =Emaciation= is a prominent symptom. This is due to +gastro-intestinal disorders and prolonged fever. Loss of weight is +gradual, especially if the disease is advancing. Where the lung is +considerably diseased, heart disturbances are common. + +Other disorders, as of the gastro-intestinal tract, genito-urinary, +cutaneous, and nervous systems, are frequent, especially in long +standing cases. The =gastro-intestinal disturbances= are gastric +catarrh, vomiting, loss of appetite, coated tongue, constipation, and +later on, diarrhea. Among =genito-urinary symptoms=, albuminuria is +frequent. The kidney involvement may be either of an acute or chronic +character. Pyelitis and cystitis are present in some cases, and amyloid +degenerations are not uncommon. With the =cutaneous symptoms=, the +skin is frequently dry and scaly, and the hair of the head dry. The +hectic flush is common. Upon the chest and back there may be pigmentary +stains. The =nervous symptoms= vary according to the involvement. +Tuberculous meningitis is rare. The mind usually is clear and even in +advanced stages the patient is always hopeful. + +=Physical Signs.=—=Inspection= reveals that the shape of the chest +is often characteristic. A phthisical thorax is flat, especially +the thoracic opening with wide intercostal spaces, prominent costal +cartilages, and depressed sternum. Sometimes the lower sternum forms +a deep concavity (funnel breast). Another type of thorax is long +and narrow, with very oblique ribs, and little expansion. In other +instances the chest is of apparently normal build. Defective expansion +is observed early, especially at the apex of the affected side. The +clavicle of the affected side often stands out more prominently. + +=Palpation= shows there is decreased expansion and increased fremitus. +Normally, the fremitus is stronger at the right than at the left apex. +If the pleura is thickened, the fremitus is decreased, but increased in +lung involvement. + +On =percussion=, if the diseased areas are minute, the percussion +note may not be changed. Always compare the two sides of the chest. +Dullness is first noted, as a rule, above, on or below the clavicle. +As the disease progresses, the dull sound increases. The size of the +cavity, its walls and the amount of secretion modify the note. Large, +thin-walled cavities elicit the “cracked-pot” sound. Consolidation, +thickened pleura, large amount of material in a cavity and a connecting +bronchus impair resonance. + +On =auscultation= the breathing is harsh and the expiration is +prolonged and high-pitched (bronchial). Early in the disease crackling +rales may be heard. After consolidation takes place there is bronchial +breathing and crepitant rales. When softening occurs they become moist, +louder and sometimes bubbling. These may be heard upon inspiration and +expiration. Pleuritic friction sounds, as in case of pleurisy, may be +heard at any stage. Vocal resonance is increased. + +The =signs= of =cavity= are: =Percussion.=—There is more or less +defective resonance or tympany. Over large cavities a “cracked-pot” +resonance is obtained. This is best obtained when the patient has his +mouth open. There may be normal resonance if the cavities are covered +with a considerable thickness of unaffected air cells. + +=Auscultation= may detect cavernous or amphoric breathing, pectoriloquy +and coarse, bubbling rales. Metallic tinkling may be heard over large +cavities. Vocal resonance is increased. + +=Complications.=—The larynx and trachea frequently undergo tubercular +inflammation, due to invasion from the lung tissue. Pneumonia is of +common occurrence. Gangrene, pleurisy and endocarditis are other +complications. + +=Diagnosis.=—Bacilli may be found in the sputum before the physical +signs are well developed. It may be necessary to examine the sputum +several times before the tubercle bacilli are detected. The presence of +bacilli will set the diagnosis at rest, provided clinical symptoms are +present. Fever, hemoptysis, cough, emaciation and a continuous, local +induration are diagnostic. The X-ray should be employed as an aid in +diagnosis. + +=Prognosis.=—The prognosis of pulmonary tuberculosis varies greatly in +different cases. Undoubtedly a number of cases have been cured; many +arrested; even spontaneous cures have occurred. A great deal can be +done to prolong life and to make the patient comfortable. The average +duration is about three years, although by careful treatment this time +is probably being increased. + + +Fibroid Phthisis + +This term is applied to a form in which there is induration, followed +by contraction of the affected lung tissue, due to an overgrowth of +fibroid tissue. The greater number of cases are primarily tubercular, +but have run a fibroid course. Other cases are primarily fibroid, +followed by tuberculous infections. It may begin as an ordinary +ulcerative phthisis, or it may begin as an inhalation bronchitis. In +other instances it may follow a chronic tuberculous bronchial pneumonia +or pleurisy. + +The =onset= is extremely insidious. There is persistent cough, often +paroxysmal in character. Dyspnea is marked, especially on exertion, +but little or no fever is present. The expectoration is profuse and +mucopurulent. There is slight loss of weight. In the later stages edema +is marked. It is a disease of long duration, lasting from ten to twenty +years. The patient is often able to pursue some occupation and may have +fair health. + +There is marked dullness over the affected side, which is commonly much +depressed. There is distinct bronchial breathing at the base, while +at the apex there may be cavernous sounds. The heart is frequently +displaced and the right ventricle hypertrophied. The bronchi are +dilated. The clinical history is identical with that of simple +cirrhosis of the lung from which it is often separated with difficulty. +Both lungs may become the seat of tuberculous disease. Prolonged +suppuration results in amyloid changes in the liver, spleen, kidneys +and intestines. X-ray plates are of value in diagnosis. + + +Tuberculosis of Other Tissues + +The =alimentary tract= is frequently the seat of tubercular +inflammation. The intestines may be involved primarily or else +secondarily from the lungs or peritoneum. The =primary form= is +most common in children. There is slight fever, pains of a colicky +nature, irregular and persistent diarrhea. The disorder is commonly +unrecognized, being mistaken for appendicitis or other intestinal +disorders, until emaciation, sweats, the continued fever or lung +involvement are manifested. + +The stomach, esophagus, pharynx, tonsils, palate, tongue and lips may +be the seat of a tubercular lesion. + +The =serous membranes= are usually secondarily involved. The peritoneum +is generally invaded from contiguous organs, especially the intestines, +although the pleurae may be the starting point (and in the female the +generative tract is a source). The disease may be either acute or +chronic. In the former it starts abruptly with vomiting, pain in the +abdomen, fever, and possibly diarrhea. In the chronic form there are +fever, pains, emaciation, weakness and the abdomen is distended. The +enlarged glands may be felt through the walls. There may be ascites, or +the walls of the peritoneum are adherent, or the tubercles may ulcerate. + +The endocardium is occasionally the seat of acute or chronic +tuberculosis. It is usually secondary. Likewise the pleurae are +sometimes involved. The chronic form is more common. + +The =genito-urinary system= is subject to tuberculosis. The bladder, +ureters and pelvis of the kidney are attacked, and from these the +kidney; or possibly the kidney involvement is part of a general +tuberculosis. (See pyelitis). The ovaries, Fallopian tubes and uterus +are also subject to tubercular invasion. The =diagnosis= depends +upon finding the bacilli, the symptoms indicating, oftentimes, an +inflammation only. Also the prostate, testicles and seminal vesicles +are attacked. + +Tuberculosis of the mammary glands is rare. In miliary tuberculosis +the liver is commonly affected, often secondary to other tissues, +especially the peritoneum, lymphatics and lungs. + +The blood-vessels and heart are sometimes involved from nearby organs +or from miliary tuberculosis. The brain and cord are also at times +invaded. This has been described under meningeal tuberculosis. + +=Diagnosis and Prognosis of Tuberculosis.=—The osteopath should be +familiar with the various forms of the disease. An understanding of +the pathology and clinical symptoms is essential. The finding of the +bacillus, provided there are symptoms of inflammation, is diagnostic. +Much depends upon the patient’s constitution, hygiene, sanitation, +food, fresh air and general management. The osteopathic lesion is +decidedly an important factor, but the treatment must be balanced from +both the distinctive osteopathic view and that of general management. +Then the patient’s part is as necessary as the osteopath’s. Under +proper care and treatment, unless the disease has progressed to a +marked degree, there is always a tendency toward recovery, but, to +emphasize again, the osteopathic treatment, the environment and +general hygiene should be thoroughly understood and appreciated, for +at best, the disease is treacherous. Even after an apparent recovery +is made, the patient should be under observation; there is always +danger of recurrence. Tuberculosis can often be treated successfully, +or arrested, provided the disease has not progressed to a late stage; +although many times, in the later stages, life can be considerably +prolonged by careful treatment. + +=Treatment of Tuberculosis.=—The =prophylactic treatment= of +tuberculosis should receive first consideration. The sputum should +be thoroughly disinfected and care taken that the patient does not +spit about carelessly. A spit-cup should be provided and the sputum +collected and destroyed by burning and the cup sterilized. The patient +should be well taken care of and given a separate apartment, so that +the danger of conveying the disease to others is reduced to a minimum. +He should occupy a single bed. All unnecessary furnishings of the room +should be removed and the objects that remain in the room should be +frequently aired and disinfected. The general and sanitary environment +of the patient should be as favorable as possible to hygienic living. +Many times a change of residence is of great benefit. When possible +the patient should be out of doors and light exercise taken. The body +should be well protected by flannels, the year around. + +Keene[61] would carry prophylaxis to careful examination of the +pregnant woman to avert a sudden development of tuberculosis after +parturition; also of the child, after birth, to remove any predisposing +lesions. The mother with a tubercular tendency should, under no +circumstance, nurse the child and should be instructed to observe +any disposition on the part of the child to acquire malpositions in +sitting, standing or walking. + +Another important consideration in the prophylactic treatment is +the inspection of dairies and slaughter houses. The disease may be +transmitted by infected milk. There is less danger of infection through +meat; although all animals that present distinct lesions should be +confiscated. Sanatoria and other special arrangements for the care of +patients should be encouraged. + +The =Treatment of the disease= consists primarily in locating the +cause of the devitalized condition of the cellular tissue. This is +the vital point to be considered and requires a thorough examination +of anatomical structures in the region involved. There is a reason +why the tissues are in a depraved state and it is our work to examine +thoroughly the structures that might become deranged anatomically and +cause an obstructed innervation or vascular supply. The disease is +not primarily due to the bacilli; the bacilli would not have infected +the system had it been in a healthy state. Hence, the object of +the treatment in tuberculosis is to favor a building up of normal, +well-nourished tissues so that it is impossible for the bacilli to +infect the region. Of course, destruction of the bacilli is important, +but we cannot expect to do much by the use of a parasiticide, for we +are not then influencing or affecting the real cause of the disease. +If we can improve the arterial circulation to the diseased tissues, +we will be striking at the root of the disease and the healthy blood +will be the only parasiticide necessary. This is where the osteopathic +theory of the cause of disease differs from that of other schools +of medicine. At the local points of infection there is a decided +malnutrition of the tissues, due to a lack of proper blood to the +parts, thus favoring the lodging of micro-organisms; by reestablishing +normal nutrition nature will repair the tissues if the condition is +curable. Hence, it can be seen at once that if the case is curable +osteopathic treatment will meet the demands scientifically. + +The preceding is the keynote of osteopathic therapeutics; not +only in the treatment of tuberculosis, but in all diseases where +micro-organisms play an important part. In =tuberculosis of any part +of the body=, it is the duty of the osteopath to carefully examine +the structures that may become anatomically deranged, from any cause, +affecting the nerve, blood and lymphatic supply to the tissues or +organs diseased. Correction of anatomically deranged tissues and +attention to the hygiene, diet and general health of the patient +constitute the treatment. + +On the subject of Pulmonary Tuberculosis, W. Banks Meacham says: + +“In cases of =pulmonary tuberculosis= it should be remembered that +the pathological lesion in the lung is a result of a general systemic +interference—an interference so great that the body as a whole loses +its stored-up heat in excessive temperature, loses its reserve +nutrition, as manifested by early and continuous loss of weight. + +“Therefore the causative osteopathic lesion should not be sought alone +over the site of the pathological lung lesion but rather in that area +where general nutrition is osteopathically affected. + +“A few general considerations of =osteopathic mechanics= involved in +nutrition should be ever present with the searcher for the cause of +pulmonary tuberculosis. For instance we know that ingested fat is acted +upon by the pancreatic enzymes; that the invertin of the intestine is +an endocrine secretion. In diet we seek to administer an excess of fats +to take the place of fat-loss in this disease, often losing sight of +the fact that some mechanical maladjustment prevents fat-splitting into +a form suitable for tissue assimilation. + +“It is common osteopathic knowledge that lesions of the upper dorsal +area have a profound influence on general nutrition. Consequently it +is to this area that we must look for the causative osteopathic lesion +in this disease. The influence of this area is due to the fact that +the nervous mechanism of the secretory glands gets its most direct +disturbance in this area where the nerves leave the spinal cord to +become distinct innervation to these organs. + +“Apart from the nutritive and general circulatory influence of +upper dorsal lesions we must consider the germicidal action of the +endocrinous secretions in devitalizing the specific bacterial agent in +tuberculosis. Undoubtedly these internal secretions have marked effect +in agglutinating the bacilli, thus enabling the phagocytes to perform a +larger duty. + +“The correction of upper dorsal lesions, with due regard for the +pathological condition within the thoracic cavity gives a scientific +physiological and bacteriological therapeutic action in tuberculosis. + +“=Other lesions= may and do demand attention and correction when +possible. But we must not lose sight of the fact that our specific +action comes from a corrected relation of the upper dorsals. In the +cloud of unproved theories and guesses in the literature of pulmonary +tuberculosis nothing seems nearer an established truth than that +it is a disease contracted in infancy, that it develops, later, in +those persons who retain the infantile type of chest—thorax of large +antero-posterior diameter in contrast with the lateral diameter. + +“In the progress of the disease we do get a costal malformation giving +the ‘horse-collar’ thorax, with an apparent lesion of the osseous walls +of the thoracic cavity. But these lesions are the result of nutritive +changes brought on by the active infection already present; and are +not in any true sense, causative factors in the establishment of +pathological areas within the lung. + +“The =osteopathic treatment=, then, of this disease is, manifestly, a +correction of a plastic posterior upper dorsal lesion. And where the +pathological lesion of the lung contraindicates forceful correction, +mobility of the area should be sought. + +“The =general care= of the case should look to the normal functioning +of all organs, with emphasis on ease to the patient. The =diet= should +be what the patient can assimilate properly even though it be much less +than the amount a normally active person should ingest. =Altitude= +has a favorable effect in selected cases only. It is remarkable that +many cases recover in the extremes of the Rockies and the coasts of +California and Florida. + +“No violent =exercise= should be undertaken on account of the possible +embarrassment of an already overworked heart and in consideration of +the possibly engorged pulmonary vessels. For these reasons, too, rest +in bed is advisable with temperature above 99° F. and pulse above 85.” + +In =scrofula=, lesions will be found to the lymphatic glands, impairing +their innervation and function. The treatment is not to be applied +over the glands directly. First, it is necessary to locate the lesions +of the bones, ligaments and muscles or such tissues that would cause +disturbances to the glands, then readjust the parts. The object of +the treatment is to modify the soil conditions on which the bacilli +multiply, by correcting the local derangement of the tissues. The +entire body is not in such a depraved state that the bacilli will grow +and multiply wherever they happen to come in contact with the body; +tissues of any organ favor a receptivity for the bacillus only when +these local tissues are in a morbid condition. It is then our work to +aid nature in relieving obstructed forces that are causing such an +effect. + +There are =general measures= which influence the tubercular process. +The diet of the patient should be nutritious. A diet of milk, +buttermilk, egg albumen and meat juice will probably be found best, +although many will be able to take ordinary food. The patient should be +out of doors as much as possible. Meacham[62] says “Fresh, pure air, +wherever found, is essential; elevation is an individual requirement, +an even temperature is not necessary and sunshine is important only +as it allows the patient to be out of doors. Exercise should not be +taken when the patient has a temperature above 99 degrees.” The dry, +even climate of the Southwest certainly tempts the patient to be out +of doors more than one with opposite conditions. Even when the patient +is greatly debilitated and weakened, insist upon his taking outdoor +exercises or rides. Gymnastic and methodical breathing exercises +are essential in widening and strengthening the chest. Bolles[63] +believes that the appetite should control the diet and forced feeding +be not insisted upon. Fasting, to test the sense of food desires, has +points well worth looking into, as gastric disturbances with a loss +of strength follow overfeeding. He also recommends deep breathing and +physical culture to elevate the ribs and increase thoracic expansion. +Outdoor sanatoria are being established over the country, in many +cases by state appropriation as, “the treatment of tuberculosis itself +has not been a satisfactory procedure except by climatic changes or +the outdoor treatment persistently applied.” (Halbert). The fresh +air treatment may be taken at home by sleeping in the open air or by +appliances fitted to the window of the room so only the head is exposed +to the air. The only factor is to get the air. The skin, as well as the +excretory organs, should be kept active. Always make it as comfortable +for the patient as possible. + +The =fever= is indicative of the activity of the disease, so that +treatment to influence the process and to promote elimination is best. +Sponging with either cold or tepid water will be helpful. The =cough= +is a troublesome symptom. Attention to the underlying irritation is +demanded, although one cannot hope to influence, to any great extent, +the cough dependent on cavity formation. Catarrhal processes in the +respiratory tract can be lessened. Lesions that are acting as a cause +of irritation, will frequently be found in subluxated ribs or vertebræ. +The seventh and eighth dorsals are frequent sources of cough. The +tissues about the pharynx and larynx, and the hyoid bone, disturbing +the vagus and other nerves, should be carefully watched, also possible +reflex irritation from the abdomen and pelvis. =Night sweats= are due +to tubercular processes weakening the system and particularly lessening +nervous control. These will subside as the body is strengthened. +Sponging will be of service. Disorders of the =stomach= and +=intestines=, such as nausea, vomiting and diarrhea, require treatment +of the splanchnic area and regulation of diet. Considerable can be done +to relieve =tubercular laryngitis= by careful treatment of the larynx +and contiguous tissues. =Hemorrhage= is likely to be self-limiting. +Attention to the upper dorsal vertebræ and ribs and muscles will tend +to equalize the circulation. Rest and use of ice upon the chest, as +well as internally, will be beneficial. + +McIntyre, in an article on “Fat Food in Consumption,” sums up the +treatment for tuberculosis in the following words: “The treatment, +then, for consumption should include rich, stimulating diet, +proportioned to the digestive power of the patient, containing an +excess of fats in most digestible form, of which sweet cream, fresh +butter and well-cured bacon are the best examples, and the free use +of pure drinking water, coupled with the promotion of blood flow, +respiration and elimination of waste by osteopathic means.” + +Surgical measures may be necessary where glandular or other tissue has +broken down and is a menace to recovery. + + +Spanish or Epidemic Influenza[64] + +By GEORGE M. MCCOLE + +The epidemic of influenza which swept over the world and reached the +United States in August 1918, starting in at the Atlantic sea-board +cities, developed rapidly there and passed westward over the country. +It reappeared the following winter. + +=Epidemiology.=—In the United States it was called Spanish influenza, +as it was at its worst in Spain at the time it broke out here and was +thought to have been brought from that country. + +In Europe it was called the Ukrainian influenza and in southern Russia +it was said to have emanated from the Orient. No country in the world +was exempt. It was at one time thought to be a type of the pneumonic +plague and while plague is the severest toxemia known many cases of +Spanish influenza were equally as prostrating and fatal as the ordinary +type of pneumonic plague. The bacillus pestis was never proved to be +the cause of this pandemic of influenza but the clinical analogy was +very evident. + +A study of European conditions of health and hygiene shows how +reasonable it is to believe that some disease would develop and sweep +a world lowered in vitality and immunity by the abnormal conditions +of war. Every known communicable disease was raging in Europe and +Asia where millions of people existed under exceedingly poor hygienic +conditions. + +The period of incubation of influenza was extremely short, averaging +about two days. All ages were attacked, although persons over 60 +rarely. Those between 25 and 35 seemed to be the most susceptible but +it was, perhaps, because they were in active life and more exposed. +There is considerable evidence that the disease was not air-borne but +conveyed by contact with active cases. The secretions of the mouth, +nose and eyes were considered the active carriers. Masks, made of +several layers of gauze fastened over the face, have been worn by many +people but experience taught that their use did not avail against +infection. + +=Mortality.=—The mortality under drug medication as shown in a +statement by Henry S. Bunting was as follows: “New York City 9.8%; +Chicago 14.5%; Boston 27%. Osteopathy’s influenza salvage represents +the difference between these figures and the low score of one fourth of +1%.” He gives the following statistics on pneumonia following influenza +under drug medication. “Reports from 148 health commissioners show +an estimate (called conservative) of 33% of fatalities in epidemic +pneumonia under medical care. In some large centers it ran as high as +68% to 73%. As officially compiled to date, the fatalities in epidemic +=pneumonia= in our army and navy cantonment hospitals amounted to +34½. Osteopathy’s fatalities were only 10% which included all those +eleventh-hour appeals to Osteopathy. + +“The Chicago and New York departments of health figures, each show +total death losses of 18% in all of their epidemic cases. Osteopathy’s +remarkable salvage of life is best measured from this point of +comparison. Its total death rate from both influenza and pneumonia has +been actually less than one percent.” And this is based on 110,000 +cases reported to the American Osteopathic Association. + +=Pathology.=—The pathology of Spanish influenza is practically a study +of lung involvement. There we find an exudative pneumonia of a rapidly +confluent type, a transudate of blood serum and red cells appearing in +the lower lobes of both lungs and rapidly flooding the entire space. +Air bubbles were scattered through the serum soaked lungs, giving a +frothy appearance to some parts. At times some parts of the lungs +showed drops of liquid pus. + +Where pneumonia did not develop there was no typical pathology. The +toxins left an irritated bronchial tube, intestine or kidney just as in +any other severe toxemia. + +Bronchial and the old type of lobar pneumonia also appeared as a +complication of Spanish influenza, making three types of pneumonia +which were to be guarded against. + +=Symptoms.=—The attack is usually ushered in by a chill or prolonged +chilly sensations, sometimes lasting for two or three hours; fever 103° +to 105° F.; if it does not fall in three days or if it comes up after +once falling, pneumonia is to be suspected; pulse, full and bounding +with a varying rate; headache usually general in type and in severity +from slight discomfort to a most violent type; intense pain in the +back and legs; tenderness the whole length of the spine but especially +distressing in the upper dorsal, lower lumbar and sometimes the upper +cervical; a dyspnea which is best described as being a constricted +feeling of the chest with air hunger; often the bronchial tubes are raw +and dry, the patient feeling as if the breathed-in air were hot to the +bronchial tubes, an active exudative bronchitis developing; sometimes +there is an active bronchitis with distressing cough; nose bleed is a +frequent symptom (and is often a sign of threatening pneumonia); most +cases sweat more or less, some have drenching sweats; sleeplessness; +albuminuria frequent. + +When the temperature breaks it practically always falls below normal +during the course of that day. A typical case of severe character often +presents all of the above symptoms; the lighter cases perhaps only two +or three of them, of which the chilly sensations, fever and bounding +pulse are the most common encountered. + +A severe case is impossible to differentiate from the first symptoms +of smallpox. Where a case of this type is encountered, it is always +advisable to get history of vaccination or smallpox. + +=Examination.=—The successful treatment of disease calls for attention +to little things. Some little thing properly cared for very often gives +us our margin over adverse conditions and spells success in the care of +our patient. + +During the epidemic I found a few cases which ran a temperature much +below normal, sometimes as much as three or four degrees, and still +with enough symptoms to be easily diagnosed as influenza. + +=Pulse= was taken at the time the thermometer was in the mouth. Pulse +was practically always bounding and hard. Its rate varied widely, being +influenced by many other conditions. I often, early in the attack and +where other symptoms were indefinite, made a diagnosis principally from +the pulse. + +=Respiration= was taken while holding the watch and with the finger +on the pulse so that patient would not know that breathing was being +watched. + +Many patients complained of a sensation of weight on the chest and +difficult breathing—hardly what one would term true =dyspnea= yet a +real air hunger and sensation of constriction in the chest. The breath +was often tainted with the odor of acetone, indicating a high degree of +acidosis and giving an important diagnostic point. + +The =heart= was then examined, both by auscultation and percussion. + +The examination was then extended over the lungs and pleural rub +listened for. + +Patient was questioned as to having had a chill, general health, +occupation, undue exposure, fatigue, what physic if any, had been taken +or other drugs used, bowel movements and bloody stools, food taken, +sleep the night before, and dreams, headache and backache. + +The full examination could not be given at each call and not all of +it to each patient, as time would not permit during the height of the +epidemic. + +Throat was always examined. This is an important point. + +The urine was examined in a great many cases and often albumin and +sometimes casts were found. + +=Treatment.=—I consider it advisable to give a strong deep treatment if +the patient is seen before the attack has gained full headway; after +that I give short light treatments. + +If the disease has not developed much at the time of the first visit +vigorous treatment with adjustment of the deep-lying and tightened-up +ligaments over the spinal cord is indicated. Subsequent treatments are +given to overcome the invariable and recurring contractions along the +spinal cord. The spine is gently sprung and the muscles pulled away +from the intervertebral foramina so that arteries, veins and nerves of +the spinal cord are free to function. + +I might note here that I consider Spanish Influenza does its damage +through the attack of its peculiar and virulent toxin and the +accompanying acidosis, on the body’s reservoir of energy—the spinal +cord and related structures, the vegetative glands and nerves. + +If the patient is in a serious condition he is often treated in the +position in which found, so as not to disturb him. Care is particularly +taken to keep a patient who is moist with sweat from taking cold +or being exposed. An extra covering is thrown across the neck and +shoulders, and pulled down as the bed covers are moved to get to the +area to be treated. + +The musculature of the upper dorsal and cervical region is given +special attention, the region of the first and second cervical and +the first to sixth dorsal being special seats of trouble. The region +between the spine and scapula on the left side, first to sixth ribs +left, and the region of the suprascapular notch on the left side are +given specific treatment to free them of contractions. The tissues of +the suprascapular notch are in direct connection with the nerve supply +of the heart muscle and treatment here is astonishingly effective. + +This treatment for the heart is best given with the patient lying on +the right side, leaning a little forward, with his left forearm against +the chest, hand at neck or chin. Stand then at the patient’s head and +with the thumbs give all the region on the left side at the base of the +neck and around the suprascapular notch thorough muscular adjustment +for circulation and removal of contractions which disturb the heart’s +vitality. Treat first to sixth dorsal region. + +I consider this treatment specific for the heart debility of influenza +and many other heart conditions, as well. I have found it especially +effective in the weakened and nervous states following influenza and in +so-called “run down conditions” generally. + +Vibration with the tips of the fingers on the anterior chest wall is +often used. Tender and contracted tissues are often found along the +anterior ends of the ribs which are involved at their spinal ends. +These are gently treated. Children are often given vibration, holding +their chests with my hands under their arms. + +If the patient is stout and not easy to treat I have him sit up in bed +and give the upper dorsal thorough percussion with the side of the +hand[65]. About 100 strokes at each treatment are usually given. I +remember one very fat patient in the eighth month of pregnancy to whom +I could give hardly any other treatment. It was especially valuable +here and we saved the mother after a hard fight, though the child was +still-born. + +When nature is meeting the emergency and holding her own in the battle +against infection we have a moderate fever—a benign fever. When the +body is overworked with other duties and irritations the fever may rise +dangerously high. Here it is that the physician must give further aid. +Here it is that osteopathic treatment further aids by giving rest to +the patient, easing pain and promoting general circulation (this in +itself often quickly reduces fever). Here it is that the attention we +give to clothing, diet, ventilation, quietness, good nursing, etc., +comes in. The body is relieved of all duties but the one. Its functions +are all turned to one end—the destruction of the invading infection. +The osteopathic physician adjusts. Nature cures. It is all a matter of +adjustment. + +For labored breathing, an effective treatment is to have the patient +with hands clasped and arms raised above the head, patient being in +bed, face up. Stand directly at head of patient. Reach over patient’s +arms and under the upper dorsal and lift up against the heads of the +ribs with your fingers, thus raising the chest, beginning as far down +the spine as you can and working up as you treat. Relax the muscles at +the same time. + +=Frequency and Amount of Treatment.=—Frequency and extent of treatment +depend upon the condition of the patient. In influenza the patient is +approached with the idea of a daily visit. If then there is any doubt +about his being entirely safe for 24 hours he is seen in 12 hours or as +often as the condition indicates. Patients are usually seen more than +once a day. + +The average time which the patients are confined to the bed is about +five days. Some are free from fever in three days; some not for six or +seven days. According to conditions they are then kept in bed from one +to three days longer. + +As to the amount and length of treatment, I agree with James M. Fraser, +who says adjustment of the soft tissues should be made and made with +as little disturbance to the patient as possible. He says[66]: “The +ill effects of too long-drawn-out general treatments, or in short, +over-treatment, I consider one of the most important questions +for osteopaths because I incline to the belief that in many acute +infections more harm may be done by such fatiguing over-treating than +if the patient were really not treated at all. A “flu” or pneumonia +patient should never be treated over fifteen minutes at the longest in +one treatment. It is much better to treat often and not treat so long, +as over-treatment may result from a desire to be thorough. If we always +would stop and think what we are doing and just what we are trying to +prevent we would be more careful when we treat these infectious cases. +A patient’s resistance may really be lowered, his bowels inhibited, his +heart overstimulated, his muscles fatigued and his nerve force depleted +by treating overtime. When the reaction begins, stop.” + +Congestions and contractions should be removed wherever they are found, +be it in the region of the throat, spine, ribs, liver or spleen. I +order a daily enema and give positive instructions—after having had one +or two almost fatal cases from this cause—to use no physics. Purging +killed more people here than any one other thing. If a heavy physic be +given two or three times and the patient comes to a crisis, so much +vitality has been taken out of the blood that he does not have enough +strength to carry him over and he dies. + +If the patient comes to pneumonia I find it good and effective to use +the “constipation treatment.” It is best to let the bowel take care of +itself. Nature can do many things, and caring for the bowel in a crisis +is one of them, providing the correct diet has been given the patient. +If the patient is getting nothing but fruit juices there may be a +natural bowel movement and even if he has been getting other food it is +better to leave the bowel alone until after the crisis and then give +the enema. + +A patient with a frank pneumonia following influenza has but little +chance of living if his strength is being drained from the blood stream +through the bowel every few hours. + +I see to it that no draft blows on the patient’s bed. In a windy +location a cold draft can appear suddenly and do great damage in a +short time. The patient should not breathe cold air. Fresh air is all +right but it must not be cold air. I order extra covering for the neck, +arms, shoulders, back and chest. I like a wool workshirt best but use +pneumonia jackets, extra undershirts, sweaters, etc., when the wool +shirt is not to be had. In fact continued warmth seems to be an almost +necessary condition to the proper handling of influenza. It is because +heat, even the heat of the fever itself seems to aid the nervous system +in building up antitoxins. + +The patient is instructed that if a sweat comes on, either from a hot +bath, hot drink or as a result of the disease, to lie and take it, +for throwing off the covers is a sure way of taking cold and inviting +pneumonia. + +If the house is cold or the patient weak or very sick the urinal and +bed pan are used. In fact I prefer their use even when those conditions +are not present, as the less the exposure the less chance of pneumonia +and the quicker recovery. =Rest= lying in bed is absolutely necessary +to a satisfactory course and quick recovery. + +For lung congestions and bronchial irritation, in addition to +osteopathic treatment along the spinal cord, raising the ribs and +chest, and vibration of the chest wall, I sometimes use the old +fashioned mustard plaster (made with one teaspoon each of flour and +mustard, mixed with olive oil or with water and white of egg), keeping +it on about ten to thirty minutes or until a good, red reaction is +brought about. The feet must be kept warm with hot water jugs. A hot +mustard foot bath is excellent when the feet persist in staying cold. + +At first I did not use the hot tub-bath. I am now ordering it if I see +the patient early in the attack and where there is no contraindication, +such as a dangerous heart condition. I do not use it unless it can be +given properly and without undue exposure to the patient. I never give +it late in the disease. + +A good method is to get the patient into the tub, lay two canes or +sticks across the tub, and cover all with a blanket or rug. Place a +bath towel for the head to rest on and pull the blanket around the +neck. The patient can then take a good hot sweat in comfort. His arms +and shoulders, his knees and legs will not be exposed to chill. When +he gets up the blanket can be drawn about him if desired. He then goes +back to bed for a good rest and sweat. A cold towel is placed on the +head and water given to drink. + +Every patient should have a good sweat early in the attack. Another +good method is to cover with a blanket and place outside fruit jars or +jugs filled with hot water, cold towel to the head and several glasses +of water or lemonade to drink. + +The use of cold compresses on the chest I do not favor. They are used +by some osteopathic physicians, but I believe the result is better with +other methods. Applied in a hospital where the technique is well in +hand they might be successful, but personally I fear them. I am even +careful about putting an ice bag on the heart. Cold packs are sometimes +used in my practice but only on the head for pain or delirium. Chill +must be avoided. Warmth must be conserved, even the fever is benign. + +Neither do I favor “rub-on” of camphor, turpentine or onions when they +irritate the patient. If the patient has been used to them or has +faith in them and wants them I order them. I also order something of +the kind where “something must be done”. When a family calls a doctor +they “want something done,” and it is best to do something; ever +keeping in mind, however, that our patient’s strength must be conserved. + +I do favor “rub-ons” in that I think it is well to keep the skin soft +with some oil. It helps to keep an even temperature and the skin +active. The skin should be wiped dry often, however, to remove the skin +secretions which if left on become stale. + +I remember being called to see one little girl who could not get her +breath, and found she was holding her nose with the bed clothes. She +told me that the smell and stickiness of the lard and turpentine and +the onions made her so sick and uncomfortable that she felt she could +stand it no longer. When she was cleaned up, and clothed in nice clean +white cotton she showed a wonderful improvement, and it was real as +well as apparent. + +As to =baths= in influenza, I instruct the nurse to bathe the patient +only as necessary for cleanliness and his comfort. Dabbling around in +water is not a safe procedure in a disease where pneumonia is so easily +contracted. + +I do not use alcohol rubs where the patient is in anything like a +serious condition, as alcohol closes the pores and dries out the skin. +A rubbing or massage by the nurse is good for a restless, nervous +patient, but it had better be done with olive oil or some other good +oil. In influenza we do not want the pores closed. We need elimination, +and all we can get. A small saving of vitality or a little elimination +of toxins may be the margin that saves a patient for us. I do not favor +the use of turpentine, for if it is absorbed it irritates an already +sick kidney; if it is not absorbed it is useless. Why disturb the +patient? + +For the bronchial irritation, in addition to osteopathic treatment, +and the accessory mustard plasters, inhalation of steam is often used. +A pan of boiling water is set by the bed and the patient leans over +the edge of the bed with a bed-sheet or paper over the head and steam +vessel, breathing the steam as long as it lasts. + +For the =throat= most any cleansing gargle can be used but I prefer the +use of the common baking soda gargle. I have about one-half teaspoonful +of soda placed in a glass and boiling hot water poured over it. As soon +as this is cool enough to use I have the patient gargle thoroughly. The +idea is to get the mouth, pharynx and tonsillar area clean and free +from accumulations. Lemon-water gargle is often gratefully accepted. + +If a very sick patient breathes through a dirty and dried-out mouth, +all the stage is set for him to draw into the devitalized lung large +quantities of infectious material. For this reason if not for the +comfort of the patient it is necessary that the mouth be kept clean and +also moist. + +It is not possible to kill this germ life with any antiseptic. The +field must be made and kept clean. + +The =nasal passage= also should be looked after, to keep it clean as +possible and also to allow the patient to breathe through the nose. + +For the nasal passage any good non-irritating oil is effective but +I like best 2½ iodine in oil. It is a good lubricant and as far as +possible we do get the germicical action of the iodine. + +Patients asking me what to do to avoid influenza are advised to keep +the mouth clean and closed and to use the oily solution of iodine in +the nasal passages. + +And when treating the respiratory tract we must keep in mind the fact +that all healing comes from the blood side of a membrane. No healing +ever comes to a membrane from its exposed surface. Local treatment to +a membrane must be a treatment which removes irritation, not one which +adds more. Healing must come from within. “The rule of the artery is +supreme.” + +=Diet.=—The diet used is liquid, so that the digestive functions will +be taxed as little as possible, for they are weak at this time. Fruit +and vegetable juices only are used. + +The influenza germ propagates largely in the intestine and if the +intestine has in it the products of a full diet the bacterial growth +soon overpowers the patient. Germ life cannot develop on fruit and +vegetable juices. + +Another reason for using the liquid and fruit diet is that influenza is +a disease running a short course and feeding is not necessary. If it +were a disease such as typhoid, running a fever for several weeks, we +would then give a more liberal diet, but the patient’s strength will +not be lost on a liquid and fruit-juice diet in three or even eight +days. + +The frequency with which the urine contains albumin in this disease +shows us what a heavy load the kidneys are carrying. This makes a +salt-free diet advisable and again brings fruit juice to our favorable +attention. + +To activate the kidneys and thus relieve the headache we give always +plenty of water and often hot lemonade. Orange juice and lemonade are +used frequently as are blackberry, raspberry, pineapple, loganberry and +grape juices. When the acid juices are not well borne we use non-acid +juices, such as pear and raspberry juice. A ripe, cooked pear mashed +with a fork and mixed with one or two different fruit juices makes a +satisfying dish. + +Bottled sweet cider is also a most valuable food and a good beverage. +We use it in almost every case and find it the most acceptable to the +patient of any food offered. I am of the opinion that apple cider has +been neglected as an article of diet, both in disease and health, but +especially in fevers. It contains considerable iron for the blood, as +well as having considerable food value. It has the added virtue of +being pleasing to the patient. + +In addition to these juices we often use spinach juice. I have the +nurse get a can of the best grade spinach and serve the juice hot, as +a broth, with a little salt and pepper and perhaps celery salt and a +piece of bacon in it to flavor it and to appeal to the patient. Spinach +juice contains much iron and iodine in a form readily absorbable by the +blood. It also is useful in maintaining the alkalinity of the blood and +body fluids, thus counteracting the acidosis of the disease. It renders +the urine alkaline and thus relieves the kidneys of the irritation of +acidosis and of an acid urine. Where the kidneys are or are likely to +be involved the spinach juice must be served without salt. + +All the mentioned fruit juices tend to counteract acidosis and produce +alkalinity, but are not so effective as the spinach juice. They have +the advantage, however, of being used in larger quantities. The spinach +juice has considerable food value and has the added value of appealing +to the patient’s reason, when the iron and iodine content is explained +to him. It is especially useful when treating those patients who are +wondering if they should not be getting some sort of “tonic.” + +The juice taken from ground fresh lettuce is also valuable. It contains +more iron, iodine and phosphates than the spinach but it is not so easy +to prepare. I have used it in the cases of several anemic and quite +sick babies and consider it well worth all the expense and effort it +took to secure it. + +The breaking down of the alkaline reserve of the body and the +consequent acidosis, comes early in the disease and is disastrous, and +all the attention given to the diet is amply repaid in results. Careful +attention to the diet is the only way the acidosis can be overcome. + +Raw fruit and vegetable juices also supply that most valuable element, +vitamines. For this one thing alone is the raw fruit juice most +valuable. I do not believe too much attention can be given to securing +a liberal supply of vitamines for the body, especially during an attack +of fever. + +Some especially interesting points are brought out by contributors +to the Journal of the American Osteopathic Association in the March, +1919 number. I wish here to add a discussion of these points. The +contributors are physicians and good representatives of our profession +and they report uniform and excellent success in handling the recent +epidemic. + +It seems to be the consensus of opinion that the treatment should be +specific and light to avoid fatigue, with the possible exception of the +first treatment, which often should be general and vigorous. + +All are agreed that the patient should be kept in bed, not even leaving +it to go to the bath room. The patient must be protected in every +way from fatigue and exposure. The enema was used by all. A number +of writers state plainly their opposition to the use of physics and +laxatives. A hot tub-bath is recommended by several, but there is +opposition to much bathing. + +Practically all the writers used the fruit-juice diet. However, a few +gave a heavier diet and were successful with their patients, which is +one more proof that the osteopathic treatment is the deciding factor in +bringing about a cure. + +J. R. Thornton wrote after having had about 100 cases. He speaks +especially of his cases of pneumonia. They resolved by crisis. +There were no deaths. He says: “All cases were, preceding the first +treatment, given a generous plain water enema. Orders were left for two +enemas per day until told to discontinue, and in most cases the patient +got the enema. A few cases, with the highest fever, the stationary +fever, were given tap-water enemas, one each hour until the temperature +dropped two or three degrees. + +“Sponge baths were given to reduce fever in every case. Diet was liquid +until the temperature was normal. + +“The osteopathic treatment of the usual spinal work, paying special +attention to cervical and dorsal areas, and strong inhibition. + +“Pneumonia cases were treated three to five times a day and had as much +time as they required at each visit. They required action. Heating +compresses were used on each case, except the ice bag to the heart +when rapid. One case of delirium was treated with ice caps to the head +and neck. Normal salt solution per rectum. Murphy drip was given in +each case. Diet, liquid consisting of egg-nog, milk, strained soup and +broth.” + +Mary Alexander Patton: “Treatment should be quick, every motion +significant so as not to tire the patient, for exhaustion is always +present. Each patient was treated two or three times a day until +temperature became normal. The nasal douche was given twice a day +followed by K-Y jelly. Hot soap bath followed by soap enema and +enteroclysis when fever persisted.” + +W. Curtis Brigham ordered “Hot packs the full length of the spine +twenty to thirty minutes, three times a day. This will produce profuse +sweating and often put the patient to sleep.” + +I have used this same treatment, especially in nervous cases, and hold +it in high esteem. I have the patient put a bath robe on backwards +so that the arms and legs are well protected but the spine easily +accessible. The hot packs can then be used and covered over and the +patient not exposed. + +R. H. Nuckles maintains that lung and ear trouble will not follow +influenza where osteopathic treatment has been given to adjust the +cervical and upper dorsal circulation. + +H. A. Price: “We have kept particularly in mind, first, the nerve, +blood and lymphatic supply to the lungs; second, the circulation to the +spine (meaning spinal cord); third, the internal secretory functions +and to the general excretion.” + +Ralph M. Crane says: “A great deal of my work is among the Italians. It +was necessary to give quick specific treatment that I might do as much +good as possible to the greatest number. I did not treat them as often +as I would like to, and because of this fact I learned that osteopathy +got control of the ‘flu’ immediately, the first treatment sufficing to +start them on the road to recovery; in fact, many of them got no more +than one treatment.” + + +FOOTNOTES: + +[51] Hinckle—The Scientific Basis of Osteopathy. + +[52] Clinical Osteopathy. + +[53] Journal of Osteopathy—Prize Article July, 1906. + +[54] A. O. A. Case Reports—Series I. + +[55] E. Link, Diphtheria—The Bulletin, 1905. + +[56] A. M. Willard, Membranous Croup—Journal of Osteopathy, March, 1904 + +[57] See Dr. Still—Philosophy and Mechanical Principles of Osteopathy. + +[58] Journal of Osteopathy, October 1905. + +[59] Journal of Osteopathy, October 1905. + +[60] Journal of the American Osteopathic Association, March 1906. + +[61] Journal American Osteopathic Association, December 1904. + +[62] Journal American Osteopathic Association, May, 1905. + +[63] Journal American Osteopathic Association, May, 1905. + +[64] Rewritten from article in Osteopathic Physician, June 1919. + +[65] This treatment was described by Henry M. Stovel, in The +Osteopathic Physician of January 1917. + +[66] O. P. June 1919. + + + + +ACUTE ERUPTIVE FEVERS, MUMPS AND WHOOPING COUGH + +By EDGAR S. COMSTOCK + + +GENERAL CONSIDERATION + +In the consideration of these diseases, it is well to bear in mind +that lowered resistance is the primary condition that has made the +infections possible, and that lowered resistance implies an imbalance +of or obstruction to the vital fluids and forces of the body, thereby +interfering with the functional activity of the body’s normal +protective mechanism. + +The imbalance of or the obstruction to these vital fluids and forces, +which is structural in nature, is produced by many conditions, as +fatigue, exposure, sudden changes of heat and cold, emotions, dietetic +errors, physical force or violence, etc. These conditions, because +of the response of the tissues of the body to environmental changes, +produce contractures of the elastic tissues, such as muscle, fascia, +etc., which disturbs the structural integrity of the body and thus +produces obstructions, irritations or interference with the media of +exchange of these vital fluids (blood and lymph) and forces (nervous +energy) of the body. + +It is evident, then, that the most potent curative factor in the +treatment of these diseases, as in all others, is the removal, whenever +possible, of the obstructions and interferences that pervert the +activity of these protective forces. It is necessary, therefore, to +remove the exciting causes (fatigue, dietetic error, etc.) and by such +physiological means as may seem necessary to readjust the structures +of the body so as to remove the above mentioned obstructions and +interferences. + +The structural lesions most frequently found in the infectious +diseases are of the muscular and fascial type and are very evident +to the careful observer. The interosseous lesions are probably often +the predisposing factors to the susceptibility of the softer tissues +to reaction to environmental changes, but it has been the experience +of the writer that the adjustment of the softer tissues was of +greater primary importance in the acute stages of these diseases. +The interosseous lesions may be easily adjusted in the very early +stages of these diseases, that is before the severe symptoms have +appeared, but after the more severe conditions have appeared it has +been our experience that the soft tissue work was sufficient unless the +interosseous lesions were very easily adjusted. + +It is the writer’s desire to impress upon the reader the necessity of +careful attention to the structural lesions that are always constant +in these diseases, using whatever physiological means seem necessary +to adjust these lesions and keep them adjusted, and to insist upon +carefully restricted diet; continuous, thorough elimination of the +waste products of the body; hygienic surroundings and well-regulated +environments both mental and physical. Then Nature, which has given +the body its own protective mechanism, may have full control of the +situation and all of the normal protective chemicals and forces in the +body organism are utilized in the battle with the invading infective +forces: the glands secrete the chemicals of protection; the antibodies +are rapidly developed and thrown into the battle area; metabolism +begins to return to normal; elimination becomes increased because of +the stimulating action of foreign substances in the body structures; +and the work of repair and recuperation begins. + +If reliance is placed upon the inherent protective forces of the body, +the knowledge of the special type or character of the invading organism +is of little importance from the standpoint of the treatment of the +disease after it has become established. The value of the knowledge +of the specific organisms is in preventive medicine, in seeking out +the habitat and breeding ground of the organism and its mode of +transmigration. Knowing these, effective measures may be adopted to +prevent their propagation and spread. Examples of this are Yellow Fever +and Malaria. + + +Variola + +(SMALLPOX) + +=Definition.=—=Variola= is an acute, specific, highly infectious and +contagious, epidemic disease. Its beginning is sudden with a chill, +vomiting, severe headache and lumbo-sacral pains. It has a typical +fever curve and a typical eruption on the skin and mucosæ of macules, +papules, pustules and crusts successively. + +=History.=—Prevailed in China and India at least 1000 years before the +Christian era. Epidemics occurred in the sixth century and during the +crusades. Its first clinical description was given in Arabia during the +ninth century. It was brought into Mexico about 1520 by the Spaniards +and between three and four million people contracted the disease. In +1718 preventive inoculation was introduced into England and in 1796 +Jenner discovered vaccination. + +=Etiology.=—The specific agent which is the cause of this disease is +unknown, but the virulence of the agents is retained for a long period +and is the most virulent found in all diseases. There is no period +from the initial fever to the final desquamation that the disease is +not contagious, although the stage of suppuration is the most violent. +Although the disease is so highly contagious and the entrance of this +particular poison into the system produces this disease, still no +one has yet been able to discover a germ nor what the nature of the +infective agent is. To contract the disease it is not necessary to +touch an individual already afflicted, not to even approach the sick +room. It may be only necessary to touch a garment that has once been +in contact with a smallpox patient, or which has simply hung in his +vicinity. + +The blood is infectious at a very early stage. As smallpox is +contagious without eruption it seems that the secretions and +excretions convey the virus. The dried pustules seem to have the +greatest infectiousness. Cadavers of smallpox (Variola) victims are +very dangerous and relatives of them should be carefully warned. The +disease often persists in infected communities for years. The disease +is evidently spread by fomites, contact with the pustular contents, and +crusts or scales of the desquamating skin. It attacks all classes, ages +and conditions of people, which is unlike other erythematous diseases. + +A previous attack usually confers immunity. Vaccination is claimed to +confer immunity but apparently in not all instances, for there are +records of “successfully vaccinated” individuals having severe attacks +of the disease. + +The susceptibility to smallpox, as to all other infectious diseases, +varies in different individuals, in different races, and under +the influence of conditions as yet unknown. Some persons are not +susceptible to the disease, nor are they to vaccination, and yet others +have been known to have had the disease as much as three times. The +Negro and Indian races seem to be more susceptible than the Caucasian. +Then again at intervals of a few years, the general susceptibility of +the people seems to be increased so that cases of smallpox become far +more numerous than usual. + +A point of considerable interest is the fact that the child, while in +the mother’s womb, may experience the disease along with the mother +and thereby acquire, before birth, the usual immunity conferred by one +attack of the disease. In most cases of smallpox in pregnant women, +abortion or miscarriage occurs, yet a sufficient number of instances +are on record in which healthy children have been born, exhibiting the +characteristic pitting of smallpox, and possessing no susceptibility to +vaccination. Again there are other cases in which pregnant women have +smallpox and the babes in the wombs have escaped entirely; while the +most singular fact is that while the fetus may experience the disease, +the mother through whom the exposure was effected, escapes, either +because of a previous attack or possibly because of vaccination. + +While there seems to be no reason for believing that an attack of +smallpox can be, or ever has been, aborted by artificial means, yet +there is a prevalent belief that this process occurred during certain +epidemics of smallpox, cases having been known in which individuals +presented all the symptoms indicating the invasion of smallpox, and +yet no eruption occurred, and yet such individuals were thereafter +insusceptible to smallpox or vaccination. + +The mortality of smallpox varies like the susceptibility of it—with the +age of the patient and with some unknown conditions of the atmosphere +or soil which favor the occurrence of the epidemics. The average in +scattered cases—sporadic—is probably not greater than one in nine or +ten. A fatal result occurs more frequently in the second week of the +disease than at any other time. + +=Pathology.=—Granular and fatty degeneration occurs in the liver, +spleen, kidneys and heart. Infiltration is found in the adrenal glands +and testicles. During the papular stage, there is local hyperemia of +the papillæ, with interstitial exudation and colliquative necrosis +of rete cells, so that a vesicle is formed, peculiar in that it is +traversed by delicate bands of epithelial cells. This, with the fact +that coagulation-necrosis occurs mainly in the center, gives it the +umbilicated, or depressed appearance. The contents of the vesicle are +plasma, fibrin and cell detritus. Leucocytic invasion converts vesicles +into pustules. This has a more globular, elevated appearance than the +umbilicated vesicle. Pyogenic organisms are found in the pus. When the +inflammation injures the corium, scars are apt to result; this occurs +when the skin is scratched. The actinic light rays increase the danger. + +=Diagnosis.=—Mistakes in the diagnosis of the first cases of smallpox +in an epidemic are almost inevitable. Hemorrhagic scarlatina or measles +sometimes cause confusion; in the hemorrhagic scarlatina the mucous +membrane hemorrhages are less frequent than in smallpox. The prodromal +eruptions plus purpura are very suggestive. The invasion stage lasts +about three days. + +Smallpox is characterized by sudden onset with violent chill and +shivering; agonizing pain in the back and legs; intense headache, +mostly frontal; temperature rapidly reaching 102 to 104 degrees +F.; full, strong, rapid pulse, going to 100 to 140; uncontrollable +vomiting; pharyngitis; red face, bright eyes, coated tongue; anorexia; +constipation; sleeplessness; delirium; often copious perspiration and +extreme prostration. + +An “initial exanthem,” clearing within 24 to 48 hours, appears. It +is either hemorrhagic or erythematous. About the third day the true +eruption appears, first upon the forehead and in the scalp, then the +rest of the face, the backs of the wrists, trunk, arms, and lastly the +legs, most abundant upon the parts exposed to the atmosphere. With the +appearance of the eruption, all symptoms abate, the temperature falls, +and the patient may feel quite comfortable. The eruption consists of +coarse, red spots upon the body, like flea-bites, rapidly becoming, +within 24 hours, slightly raised red papules, feeling hard and shotty +to the touch, and each surrounded by a broad red inflammatory band, +the areola. Usually by the sixth day the papules become converted into +umbilicated vesicles, at first clear, then turbid. They are hard and +indurated to the touch, and on the eighth or ninth day they become +pustular. The areola becomes much darker, the temperature rises to 103 +to 105 degrees F., and the pulse to 110 to 120. The other symptoms +all reappear, with salivation and delirium. Marked edema of the skin +renders the skin unrecognizable. The pustules are painful, especially +in places where the skin is thickened. The maturation lasts about three +days, when the fever falls by lysis. If fatal, death usually takes +place about the tenth day, preceded by feeble and more rapid pulse, +marked delirium, subsultus and sometimes diarrhea. About the eleventh +day, desiccation begins, the pustules begin to dry, forming tight scabs +which are closely adherent. The fever and other symptoms subside but +itching becomes annoying. The odor from the pustular stage on is a +peculiar greasy one. + +After the rupture of large pustules the centers frequently dry and sink +in, often in the shape of the Maltese cross. This is most typically +seen on the backs of the hands and is pathognomonic. Toward the end +of the third week the scabs fall, leaving red glistening pits which +disappear or change into deep white striated scars. The hair falls but +may grow again. The diagnosis is not certain until the eruption is +seen. In the smallpox without eruption the diagnosis must be made from +the history of exposure, the presence of an epidemic, fever, lumbar and +head pains, delirium, and possibly the initial rash. + +Mistakes in diagnosis may be made even by smallpox experts, but +attention to the history, somatic findings and the course of the +disease, rather than to the eruption, will prevent disastrous results. +Always isolate any and all suspected patients. + + +Varicella Compared with Variola + + Vaccination and smallpox never Smallpox may closely resemble + prevent. chicken pox; especially mild + cases. + + AGE—usually before puberty, may Usually after puberty (many + occur in adults. exceptions.) + + Initial stage practically absent. Initial stage severe, even in mild + cases. + + TEMPERATURE,—no remission on Typical remission and secondary + onset of rash. fever. + + White cells normal or decreased. Leukocytosis. + + Prodromal rash very exceptional. Prodromal rash quite frequent. + + Vesicles in crops. Vesicles never in crops. + + Vesicles rarely shotty. Vesicles, following macules, are + hard and shotty. + + RASH EVOLUTION,— RASH EVOLUTION,— + Very rapid, vesicles on first or Much slower, vesicles on seventh + second day. day. + + Eruption is universal, successive Development progresses downward, + crops, most abundant on back, face first, then wrists, + begins on body, less on face, trunk, arms and lastly legs. Less + scalp, hands and feet. on trunk. + + Vesicle is superficial and fluid Fluid pearl-colored and NOT + transparent. transparent. Thicker covering. + + Halo (areola) usually absent. Areola is marked. + + Involution is quite rapid. Involution is slow. + +The =Secondary Toxic or Septic Rash= appears during the stage +of decrustation, sometimes with a mild fever. It may be either +scarlatiniform, morbilliform, or hemorrhagic. The skin immediately +surrounding the drying pocks is often exempt leaving an anemic halo. +The rash lasts about three days and fades or desquamates. With the +development of the skin eruption, an exanthem appears upon the mucous +membranes of the body cavities, developing into ulcers. This may +develop before the dermal rash and be of diagnostic importance. + + +Forms or Varieties + + I. Variola Vera. { a. Discrete. + { b. Confluent. + + { c. Purpura variolosa + II. Variola Hemorrhagica. { (black smallpox) + { d. Variola hemorrhagica pustulosa. + + III. Varioloid. e. Smallpox modified by vaccination + or partial immunity. + +=Discrete Variola Vera.=—Incubation symptomless and averages 12 days. + +Prodromal stage, from first symptom to eruption. Averages three days. +The longer the stage the more severe the infection. Intensity bears +little if any relation to prognosis; however, if onset is mild, disease +will not be confluent or hemorrhagic. + +Invasion begins with severe chill, often repeated. Initial fever +rises suddenly to 103° or 104°, and reaches maximum on second or +third day. Pulse is rapid and full. Skin is red, hot and dry. There +may be sweating in the discrete form and in the favorable cases. The +headache appears with the chill and is usually frontal. When severe +and accompanied with neckache and vomiting it may suggest meningitis. +The backache appears with the chill and lasts about two days. It is a +lumbar pain, very like lumbago; it occurs slightly less frequently than +the headache and vomiting. This pain is rare in other fevers likely to +be confused with smallpox. Vomiting is constant in children and usual +in adults. The initial eruptions, which are present in about 10 to 12 +per cent, are of considerable diagnostic importance. They are usually +limited to the lower abdomen, inner side of the thighs, axillæ, and +sometimes on the extensor surfaces of the knees and elbows. + +=The Eruptive stage= consists of the following sub-stages: =macules and +papules; vesicles, and pustules=. + +The macules and papules occur on the fourth day and progress for about +three days. They begin on the forehead, near the hair, with itching and +burning and resemble flea-bites. These soon become papules, which are +reddish, elevated, circular, hard or shotty and discrete. On second +day of this stage they appear on the body, and on the next day on the +extensor surfaces of the extremities. If the eruption appears on the +second day the confluent type may be anticipated; if on the third day +of the disease, the discrete type. + +The vesicles which occur on about the seventh day of the disease, +contain lymph. Umbilication occurs in the centers of many of the +vesicles, and it is suggestive of smallpox. + +The suppurative stage begins about the ninth day with clouding of the +vesicles and inflammation around them. This continues for three days. +The pustules become opaque, then yellow, and a thick pus obliterates +the umbilication. The inflammatory “halo” becomes more vivid and edema +may follow around these haloes. This edema causes increased tension +and deformity, particularly of the face, and produces great tenderness +and pain. The pustulation follows in the order of eruption, from the +face downward, and are the thickest on the extremities and head. The +pustules evacuate spontaneously, or may dry up without rupture. The +skin gives off a peculiar, offensive odor. Bed-sores are now most +likely to develop. + +The eruptions also may occur in the mucous membranes, particularly in +the mouth and nasopharynx. These pass through the successive stages as +do those of the skin, but less typically. With the pustulation there +is usually a gradually rising =secondary fever=. In the discrete type +the secondary fever does not remain high more than twenty-four to +thirty-six hours, with morning remissions. A marked leucocytosis occurs +with the secondary fever and its extent depends upon the severity +of the infection. Delirium, albuminuria, acute exhaustion and heart +paralysis are to be guarded against during this stage. + +The state of involution, or decrustation, begins about the twelfth day. +It follows the order of eruption, and is accompanied with a decrease +in edema, redness and pain, but is attended with intolerable itching. +Crusts form, the hair falls out and by the end of the second week the +temperature returns to normal. If fever persists during this stage +it indicates some complications. Scars occur when the true skin is +involved and lasts three or four weeks. Complete convalescence follows +the disappearance of the last crust. + +=Confluent Variola Vera.=—This is a malignant type and used to be more +prevalent than now. The initial stage is violent, and the headache and +backache very agonizing. The fever remission is very slight or absent, +and attended with hardly any improvement in symptoms. The earlier the +exanthem occurs in variola the more likely it will be of the confluent +type. The confluent eruptions occur especially upon the face and head, +sometimes on the hands and feet. It is largely discrete on the body +and extremities. Great edema appears with the fusion of the eruption, +with the swelling and erosion of the mucous membrane, the eyes close +and the nostrils become obstructed. The fever is high, pulse high and +rapid (often irregular), dilirium, albuminuria, persistent nausea +and vomiting, great thirst, husky voice, enlarged cervical glands, +salivation in adults and diarrhea in children are symptoms present. +Death occurs from acute toxemia, usually within a week, but may last a +little longer. Recovery from confluent variola is very infrequent. + +=Purpura Variolosa.=—This is “Black Smallpox.” That is, smallpox with +primary hemorrhage in the initial stages. It is the worst type and +results almost invariably in death. It is very important because it is +so difficult to diagnose. Its incubation period is short (6 to 8 days), +invasion very severe, lumbar pains almost unbearable, prostration +great, pulse soft, small and rapid and respiration unusually high. The +initial pains and vomiting may last until death. + +On the first or second day a plum colored eruption appears, with +brick-red, purple or inky ecchymoses particularly about the eyes. +The condition is desperate. Hemorrhages may occur from any cavity +of the body, sometimes accompanied by gangrene of the pharynx. The +disease does not usually reach the period of real eruption, because +death usually occurs within four or five days. The diagnosis of this +condition is by history of exposure to smallpox and the characteristic +prodromes. + +=Variola Hemorrhagica Pustulosa.=—This is the type with the =secondary +hemorrhage=, or the hemorrhage after the eruption appears, and is more +common than primary hemorrhage. It occurs in weakly and alcoholic +subjects. The initial stage is severe, and the hemorrhages occur +into the vesicles or pustules. There may be epistaxis, hematuria and +metrorrhagia. The outcome is almost always fatal, though the hemorrhage +at the vesicular stage may be followed by rapid abortion of the rash +and recovery. + +=Varioloid.=—This is modified or mitigated smallpox; also known as +variola benigna. Persons exposed to smallpox sometimes suffer from +varioloid, and persons who have had smallpox may suffer from varioloid +at subsequent exposure to smallpox. Vaccination appears to initiate an +attack in persons peculiarly susceptible, or as a result of improperly +performed vaccination. The lesions remain in the epidermis, the course +of the eruption is shorter, the papules vesicate by the fifth day, the +process of suppuration is abridged, decrustation occurs rapidly with +little or no scarring, and all symptoms are milder. There are many +modifications. + +=Other varieties= are (1) Variola sine exanthemate, which has the usual +symptoms without the eruption; (2) Variola verrucosa, which has large, +solid, conical papules with small vesicles at their apices, which +rapidly desicate and form crusts, and finally disappear without scars; +(3) Variola cornea (horn pox) which is known by the large mahogany +crusts. + +=Complications and Sequelæ.=—Variola is often accompanied by many +complications and sequalæ which are an early severe toxemia and a +later secondary infection. During the secondary fever, there may be +bronchopneumonia, pleurisy, dysentery, hemorrhages of all kinds, +ulcerative eye, ear or laryngeal conditions, purulent arthritis, +orchitis, gangrene when the swelling is great and subcutaneous +abscesses form, often attacking the penis and scrotum, erysipelas +attacking the face, and rarely nephritis. + +During convalescence, carbuncles, boils and other subcutaneous +abscesses are very common. Disturbances of the peripheral nervous +system as neuritis, paralyses especially of the palatal muscles, +neuroretinitis, and otitis media are less common. The sequalæ most +common are boils, abscesses, deep pitting, otitis media, blindness and +permanent baldness. + +The =urine= has the usual febrile changes. =White blood= cells reach +10,000 to 20,000 or more. Lymphocytosis occurs during pustulation; +polymorphonuclear cells are decreased to 40%, sometimes to 12%; +myelocytes and irritation forms are found. During the febrile stage +there is a polycythemia followed by an anemia to 3,000,000 or less +during the pustular stage. Regeneration is slow, lasting about +fourteen days. Normoblasts are rare except in hemorrhagic forms. +Exudate taken from the pustules show streptococci, staphylococci, and +pseudodiphtheria bacilli. + +=Treatment.=—The imperative demands of treatment are isolation, +ventilation, cleanliness and disinfection. + +If symptoms are suspicious of smallpox, =notify the proper authorities +at once and isolate patient=. When diagnosis is made, cut hair and +beard very short. + +1. Isolate patient in room free from draperies, rugs, carpets, +curtains, pictures, etc. + +2. Disinfect all vessels used in room of the patient in carbolic acid +solution or in bichloride of mercury solution. + +3. Family of patient should be isolated for from sixteen to twenty days. + +4. Room should be well ventilated, with windows screened and slightly +darkened with red curtains to exclude the ultra-violet rays of light. +Temperature should be maintained at 65 degrees. Door-way may be +protected by a sheet dampened with a 1:60 carbolic solution. + +5. Nurse must be robust, perfectly immune and not afraid. If male +nurse, hair must be very short and must have no beard; if female, hair +must be short and must wear close fitting cap. + +6. Absolute cleanliness is secured by plenty of baths, clean bed and +personal linen, and careful nursing. Physician must put on special +suit with cap and gloves which are kept in the house, but not in the +sickroom. + +The first symptoms being the headache, nausea and vomiting and the +lumbar pains, the first points of attack in the treatment would be the +relief of these pains in the head and back by thorough relaxation of +the spinal muscles, paying particular attention to the suboccipital, +mid-dorsal and lumbar areas. The headache may be partially relieved +by steady pressure between the frontal and occipital regions. No +interosseous adjustments requiring painful or difficult technique +should be given after the more severe symptoms have appeared. Patient +should be visited from one to three times per day, and the reflex +contractures of the muscles must be relieved as often as they occur. + +Dysentery and diarrhea are controlled by strong inhibitory pressure in +the sacral and lumbar regions. Give vasomotor treatment to the superior +cervical ganglion. Stimulate the anterior aspect of the solar plexus to +stir up its acid function, the blood being alkaline in smallpox. + +During all the stages up to the stage of pustulation, the patient +responds very readily and successfully to osteopathic treatment. The +headache, the backache and the aching joints respond to treatment as +readily as, if not more readily than, the headache and backache of +influenza do to osteopathic care. The constipation is usually quite +readily relieved. It has been the experience of those who have handled +smallpox cases, that the tendency to the confluent type is greatly +reduced by this treatment and that the response of the patient to +osteopathic treatment is very gratifying. Indeed, those of experience +have less fear of the outcome of their smallpox cases than do they have +of scarlet fever or pneumonia. + +After the pustules have formed, each pustule is treated with iodine +painted on the pustule with a camel’s hair brush. During the pustular +stage it is not necessary to give manipulative treatment, and indeed +it is sometimes impractical because of the tenderness of the skin. +However, about all that is needed during this period is good hygienic +treatment and good nursing. During convalescence constitutional +treatment should be given. + +=Diet.=—During period of vomiting, pellets of ice in the mouth are +comforting. During periods of fever give plenty of water with, +preferably, lemon juice. As the fever declines begin with barley and +oatmeal water with lemon juice; then follow with easily digested and +nutritious diet of milk, eggs, broths, beef juice and gruels. Feed +every three hours during that period but not large quantities. During +convalescence a full, well-regulated, nutritious diet should be ordered. + +=Hygienic Care.=—Keep nose cleansed with glycerine, cold cream or +olive oil, which keeps the crusts soft. The mouth and nasopharynx may +be cleansed with any mild antiseptic. The eyes are washed with warm +boric acid solution. Cold compresses applied over the eyelids assist in +reducing the edema. A daily tepid sponge bath is necessary. Bath may be +given with bichloride of mercury solution (1:20,000) or creolin (1:500). + +=Headache.=—Deep, steady digital pressure in the suboccipital fossa and +at eighth thoracic spine; ice bag to the head; or a mustard plaster at +the back of the neck may relieve. + +=Vomiting.=—Thorough relaxation and adjustment of the great splanchnic +and cervical areas, with deep, steady digital pressure in the occipital +triangles, and at the fourth and fifth dorsal vertebræ on the right +side will usually control the condition. + +=Fever.=—Relaxation of the upper dorsal area, relaxation of the +cervical area, and deep, steady pressure in the suboccipital region +often reduce temperature. Warm sponging in lower grades of fever, bath +at 70° F., and cold pack may be needed. If temperature goes very high +give a continuous cool colonic irrigation. + +=Pitting.=—Cold wet dressings of lint soaked in any comfortable mildly +antiseptic solution, or of ice water and glycerine, are to be used on +the hands and face to prevent pitting. Hot water dressings are more +comfortable to some patients. It is well to protect the skin from the +light, especially from the ultra-violet rays. This, however, must not +lead to any lack of ventilation. When crusts are forming keep them +moist with vaseline, oil, glycerine, or carbolic acid in lanolin or +vaseline. + +=Odor.=—Baths, the daily toilet and the use of dusting powder or 5% +iodoform powder, an open bottle of smelling salts or of weak ammonia +are good. Plenty of fresh air is best of all. + +=Cardiac Weakness.=—If pulse is feeble and frequent, a general quieting +treatment should be given, including relaxation of the cervical area +and of the fourth and fifth dorsal segments. An ice bag in flannel +directly over the heart is often very useful. Gentle, careful spinal +extension is very restful and eases the spinal circulation. + +=Delirium= is usually relieved, or prevented, by spinal extension, +the prolonged warm bath or the cold pack, if given when signs of +nervousness appear. Morphia or chloroform may be necessary in violent +and suicidal cases. + +=Laryngeal Obstruction.=—Usually caused by edema and may require +tracheotomy. + +=Bed-sores.=—These and abscesses may occur even under the best of care. +Place patient upon a water-bed or in a continued warm bath. + +Convalescence is not complete until the skin is entirely free from +crusts and is perfectly smooth. + +=Prognosis.=—Prognosis depends upon age of patient; complications; and +environment from which patient comes, as well as upon the nursing. In +varioloid the prognosis is recovery; in the discrete variety, good; +in the confluent type over 50% are fatal; in the malignant types +practically all die. In patients under five years old and over forty +years old the prognosis is very grave. A filthy environment predisposes +to complications. Recurrences seldom occur; second attacks are usually +varioloid. + +=Prophylaxis.=—Usual rules of health authorities are: rigid quarantine +or isolation, vaccination, disinfection of the skin and all fomites, +and final fumigation. Quarantine of a suspected individual is sixteen +days after exposure. Isolation continued until every trace of eruption +has disappeared. The dead body is very dangerous and a public funeral +is not permitted. The clothes used by the patient must be steamed and +other articles must be washed with bichloride of mercury and fumigated +with formaldehyde vapor. Disinfection of the hands, face, beard and +hair of attendants with bichloride solution is imperative. + + +Vaccination + +(VACCINIA; COW-POX) + +=Definition.=—=Vaccinia= is an eruptive disease of the cow, +communicable only by inoculation and causing, when transmitted to the +human being, local reaction in the form of a pock and constitutional +disturbances which are followed by a more or less lasting immunity +against smallpox. =Vaccination= is the artificial inoculation of +vaccine virus for the purpose of producing an immunity against smallpox. + +Arm to arm vaccination was formerly very generally practiced but has +been practically discontinued because of the possibility of infection +from syphilis and other infections. When it is necessary to use the +human lymph it should be taken upon the eighth day from a typical +unbroken vesicle in a perfectly healthy child at least three months +old. The vesicle must be pricked at several points, care being taken +not to draw blood. The bovine vaccine lymph is now in general use +because it practically eliminates the possibility of syphilis and other +infections. Also because it is more easily transported. + +It is thought best by many authorities to vaccinate in infancy +after the sixth month, at the seventh and eighth year, at puberty, +and thereafter at intervals of about seven years, but depending +considerably on the prevalence of small pox. The virus is prepared +under sterile conditions from carefully selected and tested calves. It +is put up under aseptic conditions in hermetically sealed capillary +tubes or, in the old style, on ivory points. + +There is a great variety of opinions as to the efficacy of vaccination +in producing immunity against small pox, this variety of opinion being +very prevalent among representatives of the medical schools. Dr. F. +P. Millard of Toronto says the lymphatic system is the keynote, and +that vaccine virus poisoning spreads through the lymphatics, causing +diphtheria and allied throat affections. Dr. A. T. Still said, “We are +opposed to vaccination.” He repeatedly emphasized the fact that “Nature +furnishes within the body all the remedies necessary to cure disease.” +In the recent Canadian epidemic (1919-1920) the medical authorities +have met with a most strenuous opposition. The Homeopathic profession, +almost to a man, went on record as opposed to compulsory vaccination. +The Illinois Supreme Court has ruled that compulsory vaccination is +unconstitutional. + +=Technic.=—The area usually selected is the left arm at a point above +the insertion of the deltoid muscle. Some prefer the leg over the +junction of the two heads of the gastrocnemius muscle, because it is +more easily cared for, and, because of the style of wearing short +sleeves among women, it does not expose the scar which results from the +vaccination. + +The surface must be washed, dried, with a soft towel, and then +sterilized with alcohol. With a sterilized needle or lance scratch +an area about a quarter of an inch in diameter, being careful not to +produce bleeding but merely an oozing of pinkish lymph. A drop of the +virus should be deposited upon the abraded surface, rubbed in with +the side of the needle and let dry. A thin layer of sterilized gauze +should be lightly applied and held by means of adhesive plaster, not +encircling the limb. This should be occasionally removed and redressed. +The pock should be kept dry and clean, and may be lightly dusted +with starch or toilet powder. “Persons exposed to the contagion of +small pox should be immediately revaccinated. The immunity conferred +diminishes with time.” It is the writer’s personal opinion that, with +the amount of complications that so frequently follow vaccination and +with the fact that “it is necessary to revaccinate during an epidemic +or after exposure,” it were better to defer vaccination, if parties are +favorably inclined to the practice, until such time as the presence of +small pox in the community make it apparently necessary. + +=Typical Vaccination.=—The period of incubation varies from three to +five days. At the end of this time local reaction shows itself in the +form of reddish papules at the point of inoculation. In about five days +these develop into compound vesicles, which at first have clear and +then later opaque contents. About the eighth day the vesicle is fully +developed and is round or oval with prominent and well defined edges +and a depressed center. An erythematous areola usually appears about +the tenth day and the contents are purulent. The surrounding skin is +swollen and tender, and a scab now begins to form in the center of the +pock and rapidly extends toward its edges. About the end of the second +week the areola fades, and the pock is changed into a thick brownish +crust which becomes dry and hard, and comes off between the twentieth +and twenty-fifth days after vaccination. A dusky red scar is left and +this gradually becomes white and pitted. During the evolution of the +pock the glands through which lymphatic drainage takes place become +slightly enlarged and tender. + +The constitutional reactions are usually moderate fever, restlessness +at night, irritability and loss of appetite. These symptoms usually +appear about the fourth day and continue about three to five days. At +any time during the vaccinia erythema, roseola or urticaria may appear. +The constitutional reaction in revaccination is sometimes very severe. + +There are many atypical symptoms following vaccination as variation +in the number of the pocks, in the size, in the severity of the +constitutional symptoms, in the contents of the pock, in the healing +and formation of the scar and in the transmission of specific diseases +as syphilis, tuberculosis, leprosy, cancer and tetanus. + +=Complications.=—All cases are not benign, as due to impurity of +vaccine, carelessness in technic, improper care in dressing, handling +of the wound by the patient himself, scratching it with the finger +nails, and other accidents of like nature, infections may set in +and very serious complications arise. These result in abscesses, +erysipelas, tetanus and various eruptions. Otitis media may leave +deafness. + +The writer knows personally of a young man in the Army during the World +War who was vaccinated while in the Army and two abscesses developed +which ate entirely through the arm, one abscess passing through the arm +just anterior to the humerus and the other just posterior to it. It was +many, many months in healing, and nearly caused loss of the arm. + +There are many cases of record where vaccination was followed, directly +or indirectly, by paralysis, deformities, and chronic constitutional +diseases. It is usually claimed these conditions were due to accidents +following the vaccination and not due to the vaccination itself. +However, it can not be denied that the vaccination was at least the +indirect cause of these deplorable conditions. + +=General Vaccinia.=—(Vaccinal eruptive fever; Vaccinola). This consists +of a vaccine rash, developing usually from the fourth to the tenth day +following vaccination, and appearing in various parts of the body, +particularly about the wrists and on the back. The secondary pocks +usually develop about the eighth or tenth day after vaccination and are +usually more abundant on the vaccinated limb than on any other part of +the body. As the pocks appear in successive groups, all stages of the +disease may be seen at one time, and the condition may last for many +weeks. Fever may be absent or present, but is usually proportionate to +the extent of the eruption and the associated complications. + +=Treatment.=—After vaccination, the patient should be told to return +in seven days, when the dressings should be removed, and if the +vaccination has been successful, a pearl-like vesicle will be present. +If the vesicle has been broken by accident or by rubbing of the gauze, +the free portions of the dressing should be cut away and the adherent +part left undisturbed. A new gauze should be applied in any case, and +in five or six days more, the dressing should be again changed, and +this changing continued at intervals until the crust falls, which is +usually during the third or fourth week. + +If no vesicle forms by the tenth or twelfth day, the vaccination has +not been successful. It is suggested by the vaccination advocates that +another attempt should be immediately made. + +=Prognosis.=—Uneventful recovery is to be usually expected. Pitting +from generalized vaccinia; various constitutional diseases; paralyses +and other maiming disabilities sometimes occur. While it is not +usually considered dangerous to life, there are nevertheless many +cases of record where death has resulted. It is not wholly unattended +with danger. + +The best of care should always be taken following vaccination to +prevent the possibility of complications, though even then they do +occur. + + +Scarlet Fever + +(SCARLATINA) + +=Definition.=—Scarlet fever is an acute, specific, contagious, +infective disease of unknown origin, characterized by very sudden +onset, fever, vomiting, sore throat and diffuse exanthem. + +=History.=—It was first recognized in the sixteenth century, but first +fully described and differentiated from measles by Sydenham in 1660. It +was introduced into America about 1735. + +=Etiology.=—The causative organism or agent is unknown. The virus +of scarlet fever produces severe necrosis, but no suppuration. The +streptococcus is the most important factor in the production of +complications and in their mortality. It is claimed to be the cause +of the malignancy of the disease but not of the disease itself. +Susceptibility to the disease is by no means universal as only 38% of +children and but 5% of adults exposed to the infection acquire the +disease. Over 90% of the cases occur under ten years of age, and rarely +during the first year of life. + +“Scarlet fever is a toxic superficial expression of internal +malnutritive conditions of the blood as a tissue. The cause of the +toxicity is usually overfeeding, or the feeding beyond the demands +of the proximate principles of the body, or the overfeeding under +unhygienic conditions.—J. MARTIN LITTLEJOHN. + +“It was once held that the virus was disseminated during desquamation, +but oral, nasal and otitic discharges probably perpetuate the +infection, perhaps months after scaling is complete. In no other +disease is the virus so tenacious. It may persist ten years on clothes, +furniture, etc.”—A. R. EDWARDS. + +The light forms are as contagious as the severe ones, and inoculations +have occurred from the living subjects as well as from autopsy cuts. +In degree of infectiousness smallpox ranks first, measles second and +scarlet fever third. The infection may be spread by any third person +or by articles coming in contact with the patient, and often the mode +is obscure. Sporadic cases apparently frequently appear. The reason +for the sporadic cases may easily be explained by the theory of J. +Martin Littlejohn, given above. One attack usually confers immunity, +but not always. This disease occurs more often in the autumn and +winter, and is more prevalent in cities than in the country. (Measles +is more prevalent in the country.) Scarlatina sometimes occurs with +other infections, such as diphtheria or measles, and more rarely with +varicella, pertussis, etc. + +=Predisposing Factors.=—Age, one to ten years; lowered resistance from +overfeeding, unhygienic environments, exposure to sudden temperature +changes; lesions, both muscular and interosseous which interfere with +the distribution of the fluids and vital forces of the body; season of +the year (autumn and winter); puerperal women, and wounds. + +=Pathology.=—No specific lesions are found. No trace of the rash shows +after death except in the hemorrhagic form. The anatomical changes in +cases coming to autopsy are those of simple inflammation, follicular +tonsillitis, or diphtheroid angina. Streptococci are abundantly found +in the glands and foci of suppuration. + +=Symptomatology.=—Scarlet fever is divided into four stages: (1) +Incubation, (2) Invasion, (3) Exanthem, (4) Desquamation. + +=Incubation Stage.=—Has no noticeable symptoms and lasts from two to +four days. Some authors claim as high as ten to fourteen days. + +=Invasion.=—The invasion lasts one day. The onset is very sudden +beginning with a chill which is followed by a characteristic vomiting, +occurring in 75% of the cases, which is more frequent than in any other +disease of childhood except pneumonia. + +The vomiting is followed by headache and the beginning evidence of sore +throat, which usually soon develops into a tonsillitis. The severity +of the sore throat is indicative of the severity of the scarlet fever +that follows. The temperature suddenly rises to 103° or more, the +pulse becomes unduly rapid for the temperature, 120 to 160 per minute, +and the respiration is increased. The skin begins to burn, there is +dysphagia and intumescence of the cervical glands. The muscles of +the back become hypersensitive to touch and to extremes of heat and +cold; and particularly sensitive spots are found over the transverse +processes of the first to 4th cervical vertebras, the 4th and 5th +dorsal and the 11th and 12th dorsal vertebras. At these points will be +found intensely contractured tissues which must be kept relaxed. + +=Exanthem.=—The eruption appears at the end of the first day or early +the second day, showing first over the clavicles and on the neck, then +over the upper trunk, next the lower trunk and limbs. The eruption +on the extremities appears particularly over the flexor surfaces of +the joints. By the end of the second day the eruption has covered +practically the entire body, leaving a white circle about the eyes and +mouth. The eruption pales, or disappears on pressure, quickly returning +to the scarlet color on the removal of the pressure. Frequently, the +skin itches and is very uncomfortable. + +A punctiform eruption in the arm-pits, over the groins, or on the roof +of the mouth is considered positive proof of scarlet fever. + +The eruption at first consists of small red spots which fuse as the +skin swells and results in an intense lobster-colored erythema. This +lasts four to six days. The tongue, at first, is red at the tip and +margins with a greyish-yellow or whitish fur in the center through +which is often seen the swollen red papillæ, the “strawberry tongue.” +The “fur” desquamates on the third or fourth day, leaving a surface +intensely red with marked raised, swollen papillæ, the “raspberry +or cat tongue,” which lasts nearly a week. The breath has a heavy, +sweet odor. The pharynx, uvula and tonsils become swollen, and often +creamy-white patches cover the mouths of the tonsillar follicles. + +Between the second and third day the eruption reaches its height, when +it has a vivid scarlet hue unlike any other eruption, and becomes +darker each day until it may be a bluish-red, when it gradually fades +and desquamation begins. By the seventh or eighth day the rash has +disappeared, together with the fever. + +=Desquamation.=—Scaling begins on the face first, from the sixth to the +ninth day and lasts several weeks. The skin looks somewhat stained, +is a little rough like “goose-flesh” and gradually the upper layer +begins to separate, and the scaling begins in large lamellæ or flakes. +Casts of the fingers or toes may be shed. The swelling of the glands +disappears, and the fever falls by lysis, and convalescence begins, +unless complications intervene. + +=Diagnosis.=—In typical cases diagnosis is easy, especially during +epidemics or when the eruption is accompanied by other criteria. + +1. Sudden onset, with nausea and vomiting, sore throat, quick +appearance of fever and rapid development. + +2. Punctate spots in the throat, swelling and dysphagia are usually +present. The severe sore throat symptoms with the above are always very +suspicious. + +3. Strawberry tongue is constant. + +4. Eruption, typical in character, appearing on second day, first +showing on the neck above the clavicles, intense on the body and +practically absent around the mouth. Eruption confluent, with no +intervening free areas of the skin, followed by desquamation. + +5. Lymphadenitis much more pronounced in the inguinal and other glands +than in the cervical. + +6. Desquamation, tender joints and albuminuria will force the +conclusion of scarlet fever, if former symptoms have been indefinite. + +In the atypical cases we may have very light attacks with all the +symptoms present but very poorly developed; or some symptoms absent +as in cases with no temperature, or others with no rash. Some cases +are so atypical as to be impossible of diagnosis. The writer has very +recently had the experience of one case when there were absolutely +no typical symptoms present after being called on the case, but four +days after the invasion of the disease in the patient a sister of +the child developed typical scarlet fever, and not until the sixth +day did any eruption or sore throat appear, and then the eruption +was more characteristically measles than scarlet fever. Consultants +with the writer agreed with him that the case was one of an atypical, +non-eruptive scarlet fever. + +=Differentiation.=—Scarlet fever is not always easily differentiated +from other diseases, such as a septic rash, drug rashes, diphtheria, +measles and German measles. + +A. R. Edwards gives this differentiation between scarlet fever and +septic rash. + + =Scarlet Fever= =Sepsis=. + Bright red erythema, with small A very deep purple-red rash, + red papules. sometimes spreading over the + entire body. + The eruption is much the same in + both diseases, the same places + being exempt. + Miliaria are rare. Miliaria are frequent. + Rather typical desquamation. Desquamation observed less + frequently. + CRITERIA: angina, tongue, onset, Etiology, chills, sweats, fever + glands, etc. irregularity, polymorphous + exanthems, etc. + +=Diphtheria.=—Often difficult to differentiate. The simple erythema is +sometimes observed in diphtheria, but is darker, more on the trunk, and +more transitory than in scarlet fever. + +=Drug Rashes.=—These rashes are caused by belladonna, iodoform, +quinine, iodide, chloral, copaiba or aspirin. They may be easily +differentiated if the cardinal symptoms of scarlet fever are considered +instead of the rash alone. At the present time, perhaps the most +frequent drug rash that we meet is that produced by aspirin. It is +sometimes hard to diagnose because the aspirin has been taken for a +sore throat or tonsillitis, which so resemble the early symptoms of +scarlet fever. + +=Measles and German Measles.=—The symptoms of the invasion stage of +these diseases is sometimes quite similar, and even the rash may be +quite similar; the differentiation will be discussed under measles +(q.v.). + +=Types and Forms.=—(a) Mild and abortive form (scarlatina sine +eruptione). In this the rash may be scarcely perceptible, while the +fever, sore throat and strawberry tongue are present. Desquamation may +be present and it may be followed with a severe nephritis. + +(b) Malignant forms, (1) Atactic variety, violent intoxication, onset +of great severity, fever very high (107° to 108°), extreme headache, +delirium, and often convulsions. Initial delirium gives place to coma; +dyspnea may be urgent; pulse very rapid and feeble; and death occurs +before eruption appears. (2) Hemorrhagic variety: there are hemorrhages +into the skin, beginning with scattered petechiæ, becoming more +extensive and ultimately involving the whole skin. It is characterized +by severe fever and brain symptoms at the onset; incomplete exanthem, +necrosing angina, marked glandular and splenic swelling; subcutaneous, +serous and mucous membrane hemorrhages with ulceration. Death may take +place on the second or third day. This is more common in enfeebled +children, although it may attack adults in apparently full health. + +(c) Anginose form (Scarlatina anginosa.) This form resembles septic +diphtheria, with marked toxemia, necrosis and adenitis. The throat +symptoms appear early and progress rapidly. Temperature high, cyanosis, +diarrhea, rapid weak irregular pulse, and stupor occur. The fauces and +tonsils are covered with a thick membranous exudate which may extend to +the posterior wall of the pharynx, forward into the mouth, upward into +the nasal chambers, and may occasionally reach the trachea and bronchi. +The Eustachian tubes and middle ear are usually involved. The glands of +the neck rapidly enlarge and become the seat of brawny induration, and +the inflammation extends beyond their limits. Necrosis occurs in the +tissues of the throat, fetor is extreme, the constitutional symptoms +are great and the child dies of toxemia. If he does not die, extensive +abscess formation in the tissues of the neck takes place with sloughing +and danger of hemorrhage from the opening of a large artery. + +=Blood Pressure.=—Rises at first, thereafter it follows the pulse +and temperature. After the seventh or eighth day it may be below +normal. Cases of albuminuria show hyperextension and slowing of heart +action. With the subsidence of the kidney irritation the pulse-rate is +increased and the blood pressure returns to normal. + +=Urine.=—Shows ordinary febrile character, being scanty and high +colored. Slight albuminuria is rather common after the stage of +eruption, even a few tube casts may be present without any serious +irritation of the kidneys. Urinalysis should be made daily. + +=Blood.=—The red cells are moderately reduced to 3,000,000 or 4,000,000 +per c. mm. during convalescence. There may be some poikilocytosis, and +normoblasts are occasionally seen. Leucocytosis is early, 15,000 to +30,000 per c. mm., falling with the decline of the fever usually by +the fourteenth day, but may persist for weeks after the temperature is +normal. The count runs roughly parallel to the temperature. Over 40,000 +leucocytes per c. mm. are of bad prognostic omen. Polymorphonuclear +cells are increased to 80% or 90%; early returning to normal in +favorable cases. + +Eosinophilia is present in all but malignant cases. It reaches its +maximum two or three days after the rash appears and returns to +normal after the leucocytosis has disappeared. The early presence of +eosinophilia excludes septic conditions. When these cells are absent in +scarlet fever, myelocytes are to be found. + +=Treatment.=—Clinically scarlet fever represents, from the osteopathic +viewpoint, (a) a toxic condition due to internal malnutrition and +a decrease of the detoxinating function of the thyroid gland; (b) +secondarily associated with the sore throat is a type of toxic +tonsillitis, but it is due to the toxic elements in the blood; (c) in +the lesion field it is associated with extreme stiffness and muscular +tension in the upper cervical area and also in the entire dorsal +area, overlapping the upper lumbar. The eruption is a superficial +expression of the attempt of the body to eliminate the toxins, and +this elimination should be aided by enhancing the activity of all the +other eliminative functions. Cases are on record where patients have +been exposed to scarlet fever, have gone the usual incubation period +and developed the invasion symptoms, and by thorough, oft-repeated +osteopathic treatments, with the aid of enemata and copious hot water +drinking, have not gone beyond the invasion period and the disease +apparently aborted within two or three days. It is therefore well to +give thorough, oft-repeated attention to these cases during the very +early stages. + +(1) In all cases where the first symptoms indicate the possibility of a +contagious disease, the patient should be immediately isolated and kept +isolated until all danger of contagion is past. In scarlet fever cases +get a competent nurse. Keep room light, quiet and thoroughly ventilated +with a constant temperature of as nearly 70° as is possible. (It were +better to have two rooms if possible, one for day and one for night: +have room or rooms on upper floor if in a house). Arrange suitable +means for thorough disinfection of all articles used in the sickroom. +These are very essential. + +(2) Patient should be clothed in usual night wearing apparel. The bed +clothing should be warm, but not heavy. The physician should wear an +operating gown or a sheet which thoroughly covers his clothing, also +a cap. He should carefully wash his face and hands immediately after +leaving the sickroom. The quarantine should be maintained for the +legally required period, and even after if there continue discharges +from the nose, nasopharynx or the ear. Bichloride wrappings should be +placed about the body of the dead, and funeral must be private. + +(3) Have enema given immediately to cleanse the lower bowel. Follow +this with frequent draughts of hot water, or better hot lemonade for +the first day. Place hot water bottles at feet. If eruption is slow in +coming out, it may be aided by a hot bath, followed by wrapping the +patient in warm blankets to prevent chilling. + +(4) Thorough osteopathic treatment should be given along the entire +spinal area from the atlas to the sacrum, inclusive, to keep the +muscles well relaxed, giving special attention to the relationship of +the vertebræ and the tension of the muscles from the occiput to the +fourth cervical; the third to the sixth dorsal; and the tenth to the +twelfth dorsal areas. Also give special attention to the deep cervical +muscles, particularly those at the angle of the inferior maxilla, and +at the articulation of the inferior and superior maxillæ. Remember the +tendency of the kidneys to complication in scarlet fever, therefore +do not neglect the renal splanchnics, for here you not only control +the renal functions but also regulate the adrenal functions and +their internal secretions. Keep the clavicles properly adjusted and +articulate them by bringing them well forward to relieve any irritation +that may have started in that area. Careful direct treatment to the +abdomen should usually be given at each visit besides the work in the +splanchnic area to keep the bowels, kidneys and liver active. + +=Diet.=—Water must be given freely. If fever is very high, pellets +of ice held in the mouth will give comfort. During the height of +the fever it is preferable to withhold all nourishment, but if in a +particular case it seems to be indicated, confine the nourishment to +fruit juices, especially oranges. Never force feeding during the fever. +For infants cut down their feeding to at least half, making the milk +very thin with water or gruel. After defervescence, carefully increase +to a light diet using sparingly of nitrogenous foods except milk. After +four weeks in the usual case, gradually return to the ordinary diet. +This is a good time to make corrections in the ordinary diet if any are +needed. + +The =bowels= must be kept regulated. An enema is usually indicated +after the onset of the disease. During the time that food is permitted +it should be of a laxative character. During the fever stage the enema +should be given daily to help keep the bowel cleansed and to help +reduce the temperature. If bowels are persistently sluggish and the +fever is constantly high the abdominal heating compress (so-called +“cold compress”) will give much relief. + +The =nose and throat= should be constantly looked after. The nose may +be cleansed by instillation by means of a medicine dropper, using +normal salt solution. If the throat symptoms are mild, a gargle of warm +normal salt solution is enough for cleanliness of the membrane. If the +throat symptoms are too severe to permit the use of the gargle, or if +the patient is too small to be taught the use of the gargle or to wash +the throat, irrigation may be employed. The use of raw lemon juice, or +of raw pineapple juice, on a cotton swab is of great value in cleansing +the tonsils and throat. The swabbing should be repeated several times +per day. + +The =teeth= should be carefully and thoroughly cleansed twice per day. + +The =skin= must be constantly cared for. During the fever it is well +to cover the skin with linen or soft cotton. Daily sponge baths of +carbolized water (1:40) of tepid temperature followed by applications +of cocoa-butter will give much comfort. Use only good toilet soap and +do not use the so-called antiseptic soaps because, authorities claim, +there is a chance of renal injury. During the period of desquamation +the use of the cocoa-butter will assist in limiting the source of +infection by preventing the diffusion of the dry scales which are +considered infectious by many physicians. A. R. Edwards says: “During +desquamation, oil-rubs were once employed to decrease the dissemination +of dry scales, but they decrease the function of the skin, which is +of great importance when the kidneys are involved; also, infection is +carried by means of throat secretions. Soap and water serve equally +well.” Some authorities suggest that during the desquamation, after +bathing the patient, the skin should be thoroughly rubbed and then the +oily application used, using cocoa-butter, unmedicated cold cream, +liquid albolene or the like. Olive oil and vaseline are usually +irritating. The writer inclines to the opinion that the soap and water +bathing is sufficient, except perhaps the use of cocoa-butter over the +areas that are desquamating severely. + +The =temperature= can usually be controlled by the usual osteopathic +methods; steady deep pressure applied in the suboccipital region for +a few minutes, followed by relaxing the muscles of the back from the +first to the eighth dorsal, by raising and spreading the ribs in the +mid-dorsal area, and by light inhibition over the solar plexus. The +tepid enema will assist in lowering the temperature. If temperature +is high and patient is delirious and has other nervous symptoms the +cold pack is useful. The ice cap may be used almost constantly in high +fever. If glands are swollen treat by crowding the tissues toward the +gland =but never work upon the gland itself=. + +If pain is felt in the =ear= immediate attention must be given it. +Correct any deviations of the atlas or other upper cervical vertebræ, +relax the deep muscles at the angle of the jaw, and relieve any +impingements in the lower cervical and upper dorsal regions. The +ear should also be treated with copious boric solution irrigations, +as hot as can be borne and at low pressure. The condition of the +ear drum membrane must be watched daily and if there is bulging and +congestion it is safer to puncture the drum under cocaine than to await +spontaneous rupture. Use small amount of boric powder after rupturing. + +The =heart= must be examined daily. Vigorous treatment through the +thoracic region is indicated, if cardiac symptoms appear, and the +patient must be kept quiet and in bed. If heart seems feeble it may be +well supported by the cold packs directly over the heart. + +=Nephritis= is most common in the second and third weeks of the +illness, but may develop later. In all cases where any symptoms of +nephritis appear, light or severe, the patient must be =confined to +bed= for at least four weeks, and kept on a milk diet. All irritants +must be absolutely avoided. Hot baths should be given twice daily to +increase the sweat and the urinary functions, the bath lasting half an +hour and the patient kept afterward between blankets. Treat thoroughly, +daily, the splanchnic and renal areas, paying particular attention to +the tissue conditions in the lower dorsal region. + +In the milder cases, the urine contains albumin and a few tube casts, +very rarely blood, and edema is slight or transient. Though the +patient improves, he remains pale and there is a slight trace of +albumin in the urine for months. If recovery does not take place, then +chronic nephritis becomes established. + +In the more severe cases there may be a puffy appearance of the +eyelids, slight edema of the feet, urine diminished in quantity, smoky, +containing albumin and tube casts. The kidney symptoms dominate, dropsy +persists and there may be effusion into the serous sacs. The condition +may become chronic, the patient may succumb to uremia, but in the +majority of cases recovery takes place. + +The nephritis may be hemorrhagic, in which the urine is suppressed or +there may be a very small amount of bloody fluid laden with albumin and +casts; constant vomiting and convulsions follow and the patient dies +with symptoms of acute uremia. + +Other =complications= are arthritis, malignant endocarditis, +severe toxic myocarditis and acute phlegmonous inflammation, the +last three of which are usually fatal. Chorea is a fairly frequent +nervous complication. The mental symptoms are mania and melancholia. +Progressive paralysis of the limbs with wasting, may simulate infantile +paralysis. The fever may persist after the eruption disappears and the +child remain in a septic state (scarlatinal typhoid). + +=Relapses= are rare. Scarlatina may coexist with almost any other acute +infection. It lowers the resistance of the body to disease and is often +followed by other acute infections or by tuberculosis. Therefore the +necessity of care during the entire convalescent stage. + + +Measles + +(RUBEOLA; MORBILLI) + +=Definition.=—Measles is an acute infectious, contagious, erythematous +disease, occurring in epidemics, characterized by an initial coryza, +bronchial catarrh and an eruption of a general maculopapular type; also +by the presence of Koplik’s buccal spots. + +=Etiology.=—=Predisposing Influences=: The chief predisposing factor in +measles, as in all other contagious diseases, is a lowered resistance +in which some structural or functional change has taken place that +reduces the functional activity of the body’s inherent protective +agencies. These predisposing factors may be classed under three heads, +namely; (a) structural, (b) environmental, (c) dietetic. Under the +first we find structural disturbances in the upper cervical area +affecting the functional control of the nose, throat and head, as +well affecting the thyroid and its internal secretions: structural +disturbances in the upper and mid-dorsal areas affecting the vasomotor +control to the head, neck, and chest, thereby perverting nutrition +to all these structures and rendering them more susceptible to the +infective organisms; also the dorsal lesions disturb the functional +integrity of the lungs and heart, with the result of disturbed +respiration and circulation, both of which are vital factors in body +resistance: we also find structural lesions in the lower dorsal region, +affecting the function of the kidneys and their elimination and the +function of the adrenals and their internal secretions. Under the +second or environmental, we have unsanitary and unhygienic conditions, +exposure to sudden changes of temperature, wet clothing, fatigue, etc., +all of which produce secondary structural lesions and the effects above +mentioned. Under the third or dietetic classification, we have the +errors of diet so common in children and adults as well; such as too +much candies and other sugars, also too much starches, as well as over +eating and unbalanced diet. + +Measles prevails in all climates and attacks all races, the Negroes +appearing to suffer more severely than the whites and to be more +subject to complications. Outbreaks are more common in winter and +spring, but occur at all seasons. The disease is particularly a +children’s disease but adults may contract it if not protected by an +attack in early life, and with adults the disease frequently manifests +the more aggravated forms. It is more common after puberty than scarlet +fever. + +=Exciting Cause.=—While the disease is probably produced by a +micro-organism, it has not yet been demonstrated. Inoculation +experiments upon human beings have shown the presence of the infecting +principle in the blood, in the tears, in the secretions of the nasal, +pharyngeal and bronchial mucous membranes, and in the contents of +vesicles occasionally present. Inoculation with the epithelial scales +thrown off at the end of the disease has been unsuccessful. Ordinarily +the transmission of the disease takes place through the breath or +the nasal and bronchial secretions. The disease may be carried by +a third person or by fomites. The infecting principle is intensely +active, but not so tenacious nor persistent as scarlet fever. Measles +is communicable throughout its entire course from the earliest +appearance of the coryza. The individual predisposition toward measles +is apparently so general that few, upon exposure, escape it, though +we have observed cases where children have been directly exposed and +who were immediately thereafter put under osteopathic care and did +not develop the disease. Second, or even third, attacks may occur +at intervals of some years, but these are unusual. Sporadic cases +do occur and are often the starting points for epidemics. Extensive +outbreaks occur at intervals of five or six years. + +The incubation period is from seven to eighteen days, usually about ten +days. + +=Symptoms.=—Prodromes are common, usually consisting of loss of +appetite, restless sleep, fretfulness, and often feverishness. There +are three stages, (a) Invasion, (b) Eruption, (c) Desquamation. + +(a) Stage of Invasion. The prodromal symptoms are intensified. There +is often chilliness but seldom distinct chills. The temperature rises, +often reaching 102 to 104 degrees, upon the first and second day. It +then falls one degree or more to rise again upon the appearance of the +eruption. Nausea, vomiting and headache are often present. The tongue +is furred. With these symptoms coryza has developed and is sometimes +intense, often simulating severe influenza. Irritation and smarting of +the eyelids, lachrymation, photophobia, persistent sneezing, running +of the nose, sore throat, discomfort in swallowing, hoarseness, and +cough, at first of a croupy character, appear in rapid succession +and with varying intensity. These initial catarrhal symptoms are +characteristic and occur in the mildest cases in which chilliness, +fever and the associated signs of the reaction of the organism to +general infection are not observed. The vessels of the conjunctivæ are +injected, the eyelids swollen, the nasal mucosa tumid and reddened. The +mucous membrane of the mouth and throat is erythematous, while upon +the soft palate and the roof of the mouth, and particularly upon the +buccal mucous membrane, are to be seen pin head or split pea sized, +circumscribed, round or irregularly shaped reddish blotches slightly +or scarcely at all raised above the surrounding tissues, usually +discrete, but sometimes confluent. This eruption also shows itself in +the larynx and is undoubtedly the cause of the croupy cough and other +throat symptoms. In a strong light there may be seen upon some of the +spots on the mucous membrane of the cheeks and lips minute bright +whitish, or bluish-white flecks which are called Koplik’s Spots. These +spots appear early and soon disappear, and as they are not found in +any other disease they are of value in the early diagnosis of measles. +The duration of this stage is usually three or four days; rarely it is +shorter or it may be as long as a week. + +(b) Stage of Eruption. On about the fourth day the temperature again +rises, increasing as the rash develops, often to 104 or 105 degrees +and reaching its maximum about the sixth day when it usually falls by +crisis; followed on the seventh or eighth day by normal temperature. +The pulse-rate increases with the fever, often reaching 140 or higher. +The eruption usually appears on the fourth day, and shows first about +the hair line on the forehead, spreading to the face, chest, trunk and +the arms and legs. The eruption is attended by itching and burning, and +completely develops in from twelve to thirty-six hours, the catarrhal +symptoms persisting during this time. During this time, in the more +severe cases, delirium or stupor may be present, and the patient +complains of sore throat and general discomfort, and is restless and +wakeful. Usually upon the second or third day of the eruption, great +and rapid amelioration of all these symptoms takes place and the fever +falls to normal or subnormal. When the eruption is fully developed +the individual spots are irregularly circular or oval, and differ +greatly in size, averaging about the size of a split pea. The eruption +is unevenly set, but usually close together and sometimes confluent, +especially on the face, buttocks, hands and feet. Frequently they +take on a crescentic arrangement and the spots are circumscribed, the +intervening skin being normal or slightly hyperemic. + +About the ninth day the rash begins to disappear, on the face first, +then the neck and the rest of the body in about the same order as the +eruption appeared. The skin takes on a yellowish discoloration and +the rash disappears in a bran-like desquamation which lasts several +days to a week. In the beginning of the stage of eruption, and in many +cases throughout its course, the skin is moist and often bathed in free +perspiration. At the height of the eruption the superficial lymphnodes +of the neck, and elsewhere, are often slightly swollen and tender. + +(c) Stage of Desquamation. The fine branny scales of desquamation +are often so fine as to be easily overlooked. This process occupies +about a week. The catarrhal symptoms in uncomplicated cases gradually +disappear, so that, by the end of the second week from the initial +coryza, convalescence is fully established. The cough frequently +persists and is of a bronchial nature. Epistaxis is common at the +height of the attack. Relapses of measles are extremely rare. Diarrhea +is apt to occur at some time during the attack, without any particular +significance. + +=Varieties.=—Atypical cases may occur but are not common. They are as +follows: (1) Morbilli Papulosi, development of distinct papules, hard +to the touch but not extending deeply into the skin. (2) M. Vesicular; +a vesicular form. (3) M. Sine Exanthema, cases in which the eruption +does not appear, but general symptoms and coryza are present. (4) M. +Sine Exanthema, in which the mucous membranes are not involved. + +=Variations in constitutional symptoms.=—(1) M. Afebriles, rare cases +in which there is no rise of temperature. (2) M. Hemorrhagica. This +is the malignant form and in it the organism is unable to withstand +the intensity of the infection and death takes place in the course of +two or three days after sustained hyperpyrexia, profound adynamia, or +hemorrhages into the skin and mucous membranes. These malignant forms +are very rare in private practice, but they occasionally occur in +asylums and in the fierce epidemics of camps, and were common in the +first outbreaks among the natives of the Fiji Islands, where measles +prevailed as a scourge. Death may occur before the rash appears or a +few papules may show themselves upon the forehead and wrists. This is +also known as =black measles=, and it is characterized by convulsions, +delirium and coma, petechiæ, bleeding from the mucous surfaces and +profound constitutional depression. The patient is rapidly exhausted, +the pulse frequent and thready, the skin pale and cold, and death +occurs. (3) Adynamic measles is a serious type in which the symptoms +are grave from the onset but without hemorrhages and a typhoid status +is early present. + +=Complications.=—In the absence of complications, measles is +comparatively a benign disease, but these complications are frequently +enough present to place measles among the more serious diseases of +childhood. The ordinary complications are due to the extension or +intensification of the catarrhal processes peculiar to the disease. + +(1) Otitis media is quite common, and may result in perforation +of the tympanic membrane and permanent impairment of the hearing; +or lead to sinus thrombosis, meningitis, or abscess of the brain. +(2) Bronchopneumonia is the most common complication. (3) Purulent +conjunctivitis may occur and in neglected cases infiltration and +ulceration of the cornea. (4) Catarrhal laryngitis is a frequent +complication. (5) Pseudo-membranous type is very uncommon but very +dangerous. (6) Edema of the glottis is not common but does occur. (7) +Diphtheria is much less common in measles than in scarlet fever. The +high death rate of measles is due to the bronchopneumonia complication +in which the lesions become extensive, the symptoms become urgent and +a large proportion of these cases die. (8) Acute enterocolitis is a +frequent and serious complication. (9) Gangrenous stomatitis occurs in +young and debilitated children, and in girls gangrene of the pudenda +occur during convalescence with greater frequency than in other +infectious diseases. + +=Sequelæ.=—The more common sequelæ are chronic local inflammations, +conjunctivitis, otitis, nasal catarrh, laryngitis, and bronchitis. +Tuberculosis is a common sequel. + +=Diagnosis.=—During an epidemic, coryza, persistent sneezing and fever +are suspicious. The appearance of the eruption on the third or fourth +day upon the mucous membrane of the mouth and throat, and Koplik’s +spots are positive. + +Measles is often confused with 1. Rubella or German measles, 2. +Variola, 3. Typhus Fever and 4. Scarlet Fever, which see. Occasionally +=drug exanthems= are confused with measles. These may be caused by +salicylates, antipyrin, quinine, turpentine or copaiba. These rashes +are not accompanied by fever or throat symptoms unless they have been +given to allay these very conditions. + +=Treatment.=—Measles is so often a serious disease that it should +not be attended with carelessness as it so often is, but the best of +care and attention given. Parents should be informed of the danger +of complications and of the absolute necessity of proper care and +attention. + +As soon as a susceptible individual is exposed to the measles, he +should be immediately isolated, watched and corrections made of any +dietetic errors, unsanitary conditions or structural lesions that may +exist. He should be protected from sudden atmospheric changes and +carefully watched for the first symptoms of the prodromal coryza. + +On the appearance of the prodromal, or invasion symptoms the patient +should be put to bed in an isolated, well ventilated room of as nearly +constant temperature as is possible, from which all hangings, rugs and +unnecessary furniture have been removed. The windows must be shaded to +protect the eyes from direct or strong light, and any artificial lights +in the room must also be well shaded. + +The cases can usually be easily handled by careful, well-directed +osteopathic treatments. In the manipulative treatment we must pay +especial attention to the muscular and other soft tissue conditions in +the suboccipital region, over the transverse processes of the upper +four or five cervical vertebræ, under the angle of the lower maxilla +and the lateral cervical tissues to remove any obstructions to the +circulation and nerve control of the head and throat; see that the +muscles in the lower cervical and upper dorsal areas are kept well +relaxed, and articulation of these vertebræ, the upper three ribs and +the clavicles are kept free; remove all lesions in the mid-dorsal area, +whether muscular or otherwise, to prevent involvement of the lungs +or heart, and to keep up function of the respiratory and circulatory +systems; treat and keep normal the tissues and the articulations at +the kidney and adrenal center, 11th and 12th dorsal; raise the ribs +and keep them freely movable, this especially for the bronchial cough. +Painful manipulations should be avoided and are not necessary. Dr. +Still said, “The arms must be raised and the axillary region freed and +kept so.” During the acute stage two or three treatments per day are +advisable. Do not treat severely or to cause discomfort to the patient. +Best results are obtained in the gentle, but thorough, treatments. + +In the beginning of the case have the bowels cleansed with an enema, +and then careful attention must be constantly given to the bowels and +kidneys. The bowels can be kept open by manipulations and diet. The +diet should be light and easily digested; during the fever it is best +to withhold all food but give plenty of water. Follow fast with fruit +juices and then the light diet. + +The temperature is usually controlled by treatment, but if it remains +high for some time and if the physician cannot reach the patient, the +nurse should be directed to give a tepid sponge bath of ten to twenty +minutes duration, and repeated at intervals of two or three hours. Also +the tepid enema will often reduce the temperature. + +For the itching of the skin, a tepid bath with water at 100 degrees +given twice daily should be used, the patient dried carefully, and an +application of olive oil, cold cream, liquid albolene, or a two per +cent menthol salve, rubbed over the entire body will give relief. + +The cough is best relieved by thorough treatment of the anterior +thoracic regions and the correction of any upper rib or clavicular +lesions. Keeping the air of the room moist with vapor is agreeable to +the mucous membranes. The dropping of a few drops of eucalyptus oil in +the boiling water produces a very soothing vapor. + +If the eyes are much involved, they should be bathed every hour or two +with a three per cent solution of boric acid, using cotton which is +immediately destroyed after use. Dark glasses in a well ventilated room +is better than an unaired darkened room. + +The nose and mouth should be carefully cleansed at regular intervals +and the cloths burned. The throat should be carefully examined daily +at first, and at least every other day later, until the case is +discharged. The conditions of the lungs must be observed by daily +examinations, and the lung and bronchial areas should be daily treated +to prevent the possibility of respiratory involvement. + +If rash is slow in appearing and the temperature is high, a hot bath +(105 to 110 degrees) for three to five minutes will often bring out +the rash and relieve the more serious symptoms. During convalescence +the patient must be protected against cold. Recovery is hastened by +the continuation of treatment during convalescence and treatment given +should be indicated by the symptoms present. + +=Prognosis.=—Practically all uncomplicated cases recover. In the +hemorrhagic and adynamic types, the majority succumb. One attack +usually confers immunity. Sequelæ are frequent under the “old school” +treatment, but are infrequent under careful, conscientious osteopathic +treatment and careful nursing. + +“In and of itself measles is usually not particularly serious, but +the after effects are so far-reaching and so serious that students of +the history of medicine rank measles third among infectious diseases +for causing death. During recovery from measles the patient stands in +special danger from pneumonia, and pneumonia following measles is more +dangerous than uncomplicated pneumonia. There is a considerable length +of time during which he is particularly susceptible to tubercular +infection. This is so often insidious, and its evidences are so +obscure, that by the time the disease has fully developed, one may have +forgotten the mild attack of measles which really paved the way for the +serious malady.”—C. A. WHITING. + + +Rubella + +(GERMAN MEASLES; RUBEOLA NOTHA; ROTHELN; EPIDEMIC ROSEOLA) + +=Definition.=—A specific acute, contagious, infectious, eruptive +disease, characterized by a diffuse maculopapular eruption and swelling +of the superficial lymphatic glands. It is attended by a mild fever, +suffused eyes, mild cough, slight sore throat but no catarrh, a macular +rose-red eruption of the throat accompanied by the swelling of the +cervical lymph glands and by a rose-red eruption of irregular size and +shape appearing on the first day of the disease. + +Rubella, in some ways, resembles scarlet fever and also measles and was +at one time considered a hybrid of the two. It is now known to be an +independent disease. + +=Etiology.=—The exciting cause, or the infective principle, has not +yet been discovered. The disease is probably carried by fomites, is +readily transmissible, attacks children especially, and usually occurs +in epidemics, though sporadic cases are frequently found. The epidemics +usually occur at intervals with several years intervening, during +which time there are comparatively few cases. Persons of all ages are +susceptible unless having acquired an immunity through an attack of the +disease at some former time. Rubella does not confer immunity against +any other disease, as scarlet fever or measles, nor do these diseases +confer immunity against rubella. One attack of rubella confers immunity +against any succeeding attacks. + +The incubation period is from five to twenty-one days and is without +symptoms. + +The predisposing factors are the same as in measles or other infectious +or contagious diseases. + +=Symptoms.=—=Invasion Period.= This stage is usually of very short +duration, lasting from a few hours to perhaps two days. The initial +symptoms are usually mild, being a sudden chilliness, but not chills; +mild fever of about 100 degrees; a slight headache; mild sore throat; +swollen cervical and post auricular lymphatic glands; little or no +coryza; sometimes slight pains in the back and legs; and the macular +rose-red eruption in the throat which is constantly present. Often the +initial symptoms are so mild that the presence of a disease is not +recognized until the eruption appears, which usually occurs on the +first day and rarely not until the fourth day. + +=Eruption Period.=—The rash, which consists of round or oval reddish +spots about the size of a split pea, mostly discrete, but sometimes +confluent, and surrounded by areas of hyperemic skin, usually shows +first upon the face and follows a wavelike progression over the body +and limbs. The rash usually begins to fade upon the face before it +has appeared upon the last affected areas, and usually remains in one +region from a few hours to a half day. It extends over the entire +body in from twenty-four to thirty hours. Occasionally the skin is so +hyperemic in extensive tracts that the rash more resembles scarlet +fever rather than measles. The crescentic arrangement of the papules +usually seen in measles can not be made out in rubella. In the course +of two or three days the rash disappears with very fine desquamation, +leaving a faint pigmentation, which remains for a short time. Slight +etching usually accompanies the rash. + +Relapses are rare and complications infrequent. There are no special +sequelæ, but albuminuria, bronchitis and pneumonia have been noted. +Although one attack usually confers immunity, second attacks have been +reported, which may have been real second attacks or the first attack +may have been an error in diagnosis. + +=Diagnosis.=—Early or sporadic cases may present great difficulty in +diagnosis, but when an epidemic is present diagnosis becomes much +easier. The =direct= diagnosis of the disease rests upon the very mild +nature of the disease, its short initial onset, the character of the +eruptions and the early enlargement of the glands with the absence of +severe throat symptoms and coryza. + +Rubella is frequently mistaken for mild cases of measles or scarlet +fever. Unlike measles, it does not have the prominent catarrhal +symptoms, the higher fever, the crescentic grouping of the eruption and +Koplik’s sign. In measles the adenitis is not so severe as in rubella, +and especially are the suboccipital and post-auricular glands involved +in rubella. Scarlet fever has a very sudden onset with severe symptoms, +a very sore throat, the characteristic tongue and the peculiar rash, +all of which are decidedly different from rubella. In the latter stages +the character of the desquamation is also a distinguishing feature. + +=Treatment.=—Patient should be kept in a properly heated and well +ventilated room, being careful that no draughts chill the patient, and +should remain in bed for at least two days. Patient should be isolated. +Treatment should be directed to the upper cervical, mid-dorsal and +lower dorsal areas to keep normal the function of the internal +secreting mechanism, and to normalize and keep normal the respiratory +and circulatory systems. Treat carefully to upper lymphatics, working +around the enlarged glands and not directly over them. Watch the +excretory functions and keep them active by judicious measures. If +annoying itching occurs, the hot bath followed by being wrapped in a +soft warm blanket will usually relieve. Daily tepid sponging should +be given and if hot bath does not relieve itching an application of +olive oil or cold cream will often relieve. Diet should be reduced and +regulated according to age of patient and severity of the case. Usually +the above is all that is indicated, but if more severe symptoms present +themselves vary your treatment according to the symptoms present. + +=Prognosis.=—Recovery is the general rule. Relapses sometimes occur, +and are usually much more severe than the initial attack. The symptoms +are often more severe in adults than in children. Like measles, this +disease seems to lower resistance to other infections, and therefore +especial care should be taken to protect the patient from exposure to +other diseases for some time after recovery from rubella. See that the +patient is built up constitutionally after recovery by plenty of fresh +air, suitable exercises and good food. + + +Varicella + +(CHICKEN POX) + +=Definition.=—Chicken pox is an acute, specific, contagious, slightly +febrile, eruptive disease, usually of childhood, affecting the whole +organism through the blood. It is an epidemic disease that spreads +rapidly, is highly contagious but not inoculable, and confers immunity. + +=History.=—Varicella was first recognized about 1553 and was +distinguished from smallpox by Trousseau. + +=Etiology.=—The agent that causes the disease is not known; the +disease usually affects children under ten years of age, but does +occasionally attack adults. It bears no relation to variola, except the +very slightly similar eruption. It is transferred by direct personal +contact, by the air or by a third person. It is infective from the +first symptoms until all the crusts have disappeared. Although the +disease usually occurs in epidemics, frequently we see sporadic cases. + +As in all other contagious or infectious diseases the predisposing +causative factors are those conditions which lower the resistive +powers of the body, such as fatigue, improper diet, exposure to sudden +temperature changes and imperfect elimination of the body wastes. The +structural lesions found as predisposing factors are contractured +muscles of the neck and behind the jaw, and muscular and interosseous +lesions of the upper cervical, mid-dorsal and dorso-lumbar areas, also +of the clavicle and upper ribs. + +=Symptoms and Diagnosis.=—There are three stages to the disease: (1) +Incubation, (2) Prodromal, (3) Eruptive. + +1. Incubation Period.—This period lasts about fourteen days though it +may vary from seven to seventeen days. During this period there is +practically no symptomatology except perhaps the last two or three +days, when the child shows evidence of a little excitability and +irritability. Often on the day before the first noticeable symptoms the +child appears even more active than usual. + +2. Prodromal Stage.—Prodromal symptoms are not common and usually +last but about twenty-four hours. The first noticeable symptom is +the irritability of the patient, which is followed by a temperature, +usually 99° to 101°, which temperature persists during the course of +the disease. There are sometimes thirst, anorexia, constipation, seldom +vomiting, and a furred tongue. Some cases have been observed to have +the following as prodromal symptoms, but these we believe are usually +due to concurrent conditions that exist at the time of the infection: +delirium, convulsions, angina, conjunctivitis, dysphagia, bloody +vomiting and stools, and an initial erythema, usually scarlatiniform. + +3. Eruptive Stage.—The eruption comes within twenty-four hours and is +often the first symptom that is noticed. It appears first as hyperemic +macules and then rose colored papular spots, somewhat comparable to +the typhoid roseola and not hard. These papules rapidly become raised, +flattened, ovoid, pin-head to pea-sized vesicles containing a fluid at +first watery and then pearly. They disappear on pressure. The vesicles +mature within twenty-four hours, are very superficial, and leave a +slight areola about them, which is not inflammatory as in smallpox. +The eruption appears first on the chest and then on the neck, face, +scalp, and then trunk and limbs in the order named. The eruption is +most abundant upon the back, and over the entire body they may number +anywhere from eight to many hundred and are usually scattered. + +The vesicles are not umbilicated, but some may have slightly depressed +centers, are discrete, and appear in successive crops which require +from three to six days to complete. Pustulation and hemorrhage into +the vesicle rarely occur. On the third or fourth day yellowish-brown +crusts form and gradually disappear. Scars may result from scratching +or infection. By the fifth day we may find all stages of the eruption +because of the appearance of the successive crops. There may be an +efflorescence upon the mucous membrane of the oral cavity and of the +pharynx causing slight difficulty in deglutition. + +The itching may be more or less intense. As scratching may cause +pitting it should be guarded against. The fever which is usually +slight may persist during the entire eruptive stage, but if it is high +and persists as high temperature it suggests complications. Muscular +tension of the cervical muscles, especially those in front, and around +the angle of the inferior maxilla are usually found, and often the +clavicles are bound down, and relation of ribs is disturbed. Ulceration +sometimes follows scratching, and even gangrene may appear around the +vesicles in debilitated children, especially those who are tubercular +or congenitally syphilitic. It is apt to be fatal in these cases. +Complications of tubular nephritis, which occurs within two weeks; +cardiac hypertrophy; uremia; otitis media; and bronchial affections, +are sometimes met with. + +=Treatment.=—Isolate patient so as not to come in contact with other +children. The younger children should be put to bed until the crusts +have formed; older children may be allowed to be up around the room if +their cases are light. Pay particular attention to the muscular lesions +of the neck, lower maxilla, mid-dorsal and dorso-lumbar regions, +keeping them relaxed by gentle relaxing treatments. A general systemic +treatment is soothing and helps to prevent complications. + +“Be very careful and very thorough in your neck adjustments. Loosen the +atlas and axis and draw forward the inferior maxilla from its pressure +upon the vessels and nerves back of its angle. Draw the hyoid bone +forward and secure good circulation of blood throughout the entire +cervical area.”—A. T. STILL. + +Give treatment at the 4th and 5th dorsals to stimulate the superficial +circulation and thus increase elimination through the eruption as well +as the sweat glands. Remember the eruption is the expression of the +body’s attempt to eliminate the toxins within. + +Keep the bowels active by splanchnic and abdominal manipulations and +by laxative diet. If bowels are persistently inactive use enemata. +Diet should be bland and easily digested. During fever, diet should be +liquid or better restricted, giving only water in abundance. + +During the eruptive stage do not use tub baths. Daily tepid sponges +with either plain water or boric acid solution answers both as an +antiseptic wash and bathing. After the daily sponging, and as often as +necessary to control itching, anoint with a 10% boric acid ointment +or with carbolized vaseline. If scratching can not be controlled, the +hands should be tied in muslin bags. As in smallpox the ultra-violet +rays seem to irritate the eruptions and to increase the tendency to +scarring, therefore the windows and lights should be screened with a +dull red material. + +=Prognosis.=—Invariably favorable unless complications set in, which is +seldom. Recurrences are very rare. + +=Prophylaxis.=—The child should be kept in quarantine for three weeks +or until the skin is entirely clean. + + +Epidemic Parotitis + +(MUMPS; EPIDEMIC PAROTIDITIS) + +=Definition.=—Mumps is an acute, infectious, contagious disease, +occurring in limited epidemics, and characterized by inflammation of +the salivary glands, particularly the parotid, swelling slight fever +and pain over the involved glands. There is special liability to +orchitis or to mastitis. + +=Etiology.=—Predisposing Factors: Mumps is peculiarly a disease of +childhood and adolescence, not being common in infancy or after the +twentieth year. It affects boys nearly twice as often as girls. +Mandibular and upper cervical lesions, both of the interosseous and +soft tissue types, are undoubtedly potent predisposing factors, as +they obstruct and interfere with nerve and circulatory function to the +glands affected. Also any condition which lowers the child’s resistance +to infections makes them more susceptible to this disease than to any +other, these conditions being fatigue, exposure to dampness and sudden +weather changes, dietetic errors, etc. The cases are more numerous in +the spring and autumn seasons. Extensive epidemics are infrequent, but +do occur in reformatory institutions and children’s homes. It is much +more widespread in large cities than in the country or villages. + +=Exciting Cause;= The specific cause has not been demonstrated. The +disease is usually transmitted by direct contact, but there are +instances where it has been transmitted by a third party or by fomites. +There are two views as to the mode of infection; the first being that +the active principle travels along the course of the salivary ducts +from the mouth to the glands, probably most often through the duct +of Stenson to the parotid gland. This is the most generally accepted +theory. The second is that the infection is a general one to which +certain structures are more susceptible, principally the salivary +glands, and the parotid in particular. + +=Symptoms.=—The period of incubation is from fourteen to twenty-one +days. Prodromes are usually absent, though in the more severe cases +constitutional disturbances, with chilliness, vomiting and mild fever +may precede the local inflammation. In the milder cases the local +swelling may be the first manifestation of the disease. The temperature +is usually moderate but may rise to 103 or 104 degrees in the more +severe cases. The left side is more often affected than the right. +The disease is characterized by a feeling of tension with soreness +just below the ear. Soon a slight swelling may be observed directly +under the ear and in the course of forty-eight hours it reaches its +maximum size. The parotid gland becomes greatly enlarged and the +adjacent tissues of the neck and face become tense and edematous. The +skin becomes hard and glossy and usually white in color because of the +obstruction to the circulation from pressure. The swelling is between +the angle of the jaw and the mastoid process, pushing the ear upward +and its lobule is pushed sharply outward. In the majority of cases the +other side becomes affected in two or three days, but sometimes the +spread of the disease to the other side is delayed for several days, +and occasionally the other side escapes the infection. Frequently the +swelling of the other side is so slight that it is only recognized +by the closest scrutiny. Infrequently the submaxillary glands become +affected without involving the parotid glands, but these cases are +rather rare. + +The patient is usually unable to open the mouth without considerable +pain; acids, and rarely sweets, produce spasms of the jaw muscles; +speech and even deglutition are difficult; the salivary secretions are +usually increased but quite frequently they are decreased. The breath +is foul and the tongue is furred. The mucous membrane of the cheek and +pharynx are reddened and there may be a slight angina. + +The spine shows subluxations of the upper cervical area, particularly +of the atlas and axis, also upper rib lesions and upper dorsal lesions +are frequently found. The lesions of the second and third dorsal, and +their ribs, are most frequently found when the submaxillary gland is +involved. + +The symptoms persist from six to fourteen days, when the swelling +disappears and the patient regains normal health. Orchitis occurs in +about one-third of the cases after puberty. In infancy and childhood +it is extremely rare. Usually one testicle is involved, and is +characterized by weight, swelling and pain in the scrotum. The testicle +may become greatly enlarged when the pain becomes intense. Atrophy may +result and if both testicles are affected the loss of reproductive +ability may result. In females, usually after puberty, the breasts may +become enlarged and tender, pain and tenderness of one or both ovaries, +hematoma of the labia, or a vulvovaginal discharge may occur. However +these complications are very rare. As a rule the patient is not very +sick and relapses are very uncommon. The attack confers immunity which +is practically permanent. + +=Diagnosis.=—Under ordinary conditions, especially during an epidemic, +the diagnosis of mumps is very easy. The swelling in front of and +below the ear, with the displacement of the lobule outward is quite +indicative of mumps. The relative rapidity with which the swelling +appears, develops and subsides is characteristic of mumps. In acute +cervical adenitis the swelling is below the angle of the jaw and does +not at any time correspond with the outline of the parotid gland. +In Hodgkin’s disease, which is a chronic affection of the lymphatic +glands, the salivary glands are not involved. + +=Treatment.=—The patient should be kept away from other children, +and should remain in a well lighted, well ventilated room of even +temperature, and if the temperature is high or moderately high he +should be kept in bed. + +The correction of all interosseous lesions is indicated, especially of +the upper cervical area, though the second and third dorsal should be +given attention because of the influence of these dorsal nerves upon +the submaxillary glands. Also correct upper rib lesions that may exist. +As mumps is an infective disease the channels of elimination should be +watched and stimulated. Build up the body resistance by treatment at +the mid-dorsal area to affect circulation and respiration; and lower +dorsal area to affect kidney and adrenal function. Watch the bowels and +keep this avenue of elimination functioning freely, using enemata if +necessary. + +The diet should be liquid, of fruit juices, thin gruels, milk and +plenty of water. Tepid sponging allays the fever and restlessness. +Relaxation of the deep muscles of the neck and shoulders will do much +to make the patient comfortable, also the muscles under the angle of +the jaw. A very gentle relaxing of the tissues around the gland itself, +by crowding them toward the gland, assists in relieving the tension by +securing a better venous and lymphatic drainage. + +Hot applications to the swollen glands will give a considerable relief; +these may consist of hot fomentations, hot salt bag, electric heating +pad, hot water bottle, etc. The mouth is kept in good condition by the +use of a mild antiseptic mouth wash. + +Orchitis should not occur if the boy is kept warm and in bed. If it +does occur the best treatment is relaxation of the lower dorsal and +upper lumbar spinal muscles, rest in bed, support and protection of the +scrotum with cotton wool, cold applications, correction of any bony +lesions affecting the pelvic viscera. + +If mastitis occurs, rib lesions will be found and should be corrected, +as they are probably the predisposing factor to this complication. +Treatment would consist of correction of these lesions, if it can be +done without irritating the inflamed glands. The manipulation of the +surrounding tissues, with gentle crowding of the normal tissues toward +the inflamed glands, without exerting any pressure on the gland itself, +is helpful and comforting. Free tissues back to the axillary lymphatics. + +=Prognosis.=—The outcome is usually favorable. In the rare fatal cases, +meningitis is the usual cause of death. Under osteopathic care the +duration of the swelling, fever and pain is usually greatly lessened. + +Quarantine of twenty-four days is necessary. + + +Whooping Cough + +(PERTUSSIS; TUSSIS CONVULSIVA) + +=Definition.=—It is a specific, epidemic, infectious, contagious +disease affecting the respiratory organs, characterized by a cyclic +course, a severe convulsive cough, paroxysmal, with the characteristic +“whoop.” + +=Etiology.=—It usually occurs in children, most frequently during +the fourth year, and extremely seldom after the twentieth year. It +appears to be slightly more frequent among girls, and most cases occur +in March and April. Pertussis is highly contagious, being carried by +direct contact and by fomites. The Bordet and Gengou bacillus is the +specific cause. This is found in the sputum most abundantly during the +first week, the most infectious period, and becomes gradually less. One +attack usually confers immunity. + +The incubation period is from seven to ten days. The patient may be +considered non-infectious five weeks after the first whoop. + +Lesions of the cervical and upper dorsal vertebræ and of the +first, second and third ribs, affecting the vagi, the phrenic, the +sympathetic, the recurrent laryngeal or the vasomotor nerves predispose +to the disease. + +The bacteria were found by Mallory and Horner to be characteristically +between the cilia of the trachea and the bronchi. They interfere, +mechanically, with the movements of the cilia, preventing the normal +removal of secretions. + +=Symptoms.=—The disease is divided into three stages: 1. The catarrhal +stage, which lasts one to two weeks; 2, the spasmodic stage, three to +six weeks; 3, the declining stage, three weeks. + +=The Catarrhal Stage:= Characterized by headache, photophobia, +conjunctivitis, coryza and a cough which becomes drier and harder +toward the end of this stage. Often the invasion is insidious and +sometimes well marked with a temperature of 100° to 102°. Frequently +this stage cannot be differentiated from a “hard cold,” except toward +the end of the stage when the cough becomes worse instead of better, +and the child will seek some support to steady itself during the +coughing paroxysm. Also the eyes will water freely during the coughing +spell and the child will not be able to “get his breath” between +coughs, but will have a number of coughs without inhaling. + +One to two weeks. + +=The Spasmodic Stage:= This stage dates from the “first whoop.” The +fever now usually ceases, unless there are complications. The cough +becomes paroxysmal, consisting of a succession of fifteen or more +short, rapid expiratory puffs with no intervening inspirations, +immediately followed by a deep, loud inspiration, which is the +characteristic “whoop,” and is due to the partial closure of the +glottis. Each paroxysm is composed of three or more such spells, the +last one often followed by the expectoration of a small plug of mucus +or by vomiting. During the paroxysm the facies presents a swollen, +dusky appearance, eyeballs protruding, eyes reddened, and puffy, +pinkish lids. The child is well except for the paroxysm, which has +an aura, tickling in the larynx, thoracic constriction, a creeping +sensation, when the child attempts to brace himself, or runs in terror +for support. The “whoop” is a deep, singing or whistling inspiration +which is absolutely characteristic. During the cough the child’s body +is bent forward and he is perfectly helpless, often passing urine and +feces involuntarily. Cyanosis often occurs from the strain. + +After the attack patient regains control of himself, the respiration +is fast, and there is fatigue, sweating and often pain in the abdomen +from the strain of coughing. During the severe cough petechiæ of the +forehead, ecchymosis of the conjunctivæ, epistaxis, bleeding of the +external auditory meatus or from the frenum of the tongue may occur. +Ulcer of the frenum of the tongue is quite common. The parosyxms vary +from four to a great many per day, averaging about twenty. + +Three to six weeks, usually four weeks. + +=The Terminal or Declining Stage:= This stage is longer in proportion +in the mild cases. The paroxysms occur at longer intervals, are of +shorter duration and of less intensity, the catarrhal symptoms are +more marked, the expectoration becomes thinner, fluid, mucopurulent, +and looser. The “habit cough” may follow. It is during this stage +that complications are most likely to occur, therefore it is the most +dangerous. + +=Complications.=—Catarrhal inflammations are common in the initial +stage. =Bronchopneumonia= is the most frequent and severe complication. +Lobar pneumonia, exudative pleurisy, endocarditis, pericarditis, +meningitis and nephritis are infrequent complications. Spasms of the +glottis in nervous or scrofulous children is largely nocturnal, and +may cause death from asphyxia even in the lightest cases. Hemorrhages +may occur in the skin, conjunctivæ, nose, throat, ears or cerebrum. +The writer knows of one case where death was sudden from a cerebral +hemorrhage in an apparently mild case. Other complications are cardiac +dilatation, emphysema, bronchiectasis, pneumothorax, aneurysm hernias, +muscular ruptures, and visceral prolapses. + +Spasmodic cough from diseased bronchial glands very closely resembles +whooping cough. Barthez and Sannee give the following differentiation: + + =Whooping Cough vs Enlarged Glands= + + 1. Contagious, epidemic. Isolated, not contagious. + 2. Three periods, 2nd parosyxmal. No distinct periods. + 3. Paroxysmal cough with whoop, Paroxysms without whoop, + vomiting, viscid expectoration. expectoration or vomiting. + 4. Respiratory sounds normal. Signs of enlarged glands sometimes + present. + 5. Respiration normal in interval; Asthma in some cases, febrile + apyrexia if simple. movements, sweats, wasting, etc. + 6. Voice natural. Voice sometimes changed. + 7. Acute. Chronic. + +=Treatment.=—Isolation of patient in well ventilated, sunny room where +there is plenty of fresh air day and night is essential. Children +exposed to infection should be disinfected and isolated for three +weeks, as the disease can not be diagnosed during the catarrhal stage. +If case is at all severe, patient should be put to bed. + +Cases receiving early treatment are sometimes aborted. Treatment of the +whole respiratory tract with correction of vertebral and rib lesions, +and relaxation of the contracted muscles should be given. Treatments +for the first few days should be at least twice per day. Pay especial +attention to the vagi and phrenic nerves. Lesions of the first and +second ribs will affect the recurrent laryngeal nerves which will +aggravate the cough. The muscles of the shoulder girdle are always +very tense and should be kept well relaxed, as should the subscapular +muscles. Frequently after treatment the child will have a coughing +spasm and raise large quantities of mucus, after which there will be no +more spasms for several hours. + +Children who play and live out of doors get along best. To support +the diaphragm and abdominal muscles from the strain of coughing a +muslin bandage tightly pinned about the trunk is very valuable, a pad +being placed over the stomach under the bandage. In a very young child +instruct the nurse to strongly flex thighs on abdomen during the severe +coughing. Inhalations of steam from water with a very few drops of +eucalyptus oil in it often relieves the first tickling sensations. + +If cyanotic symptoms appear they may be relieved by raising the ribs, +especially those over the heart; by relaxing the subscapular muscles; +and by supporting the heart by application of cold cloth over the +heart. Elevating the abdominal viscera and diaphragm is, also, of +distinct benefit. + +The diet should be nutritious and easily digested, restricted to +liquids during the fever. The child should be warmly clad and protected +from drafts. The excretory systems should be kept active by plenty +of water drinking and by diet. Treatment should be continued during +the terminal stage to prevent the possible complications. Irritants, +as beef-tea, stimulants, dry bread, cookies and overfeeding, provoke +coughing and vomiting. Food should be given at frequent intervals in +concentrated form—gruels, milk with lime water, zwieback in milk, eggs, +meat juice, etc. Older patients tolerate more solid food. + +=Prognosis.=—With the complications, this is the most fatal of +the acute infections under five years of age. Infants and little +children should receive special care. Ordinary uncomplicated cases +are favorable for recovery. The prognosis depends upon the age and +strength of the patient, the severity and number of the paroxysms, +and the presence or absence of complications. No recurrence is to be +expected. + +Death is due to spasm of the glottis or to extensive subdural +hemorrhage, occurring chiefly in the children of the poor and in +delicate infants. + +Prophylaxis consists of isolation, disinfection of sputum and final +fumigation of the premises. Children should be protected from exposure +to infection from whooping cough. It must be realized that it is a very +serious disease. + + + + +CONSTITUTIONAL DISEASES + + +Rheumatic Fever + +(INFLAMMATORY RHEUMATISM) + +=Definition.=—An acute, febrile, non-contagious disease; it is +infectious, although there is some controversy as to its exact nature; +characterized by a multiple arthritis and a tendency to involve the +heart. + +=Osteopathic Etiology= and =Pathology=.—The prevailing thought is that +the disease is an infection due to a diplococcus. This micro-organism +is called by others micrococcus rheumaticus and streptococcus +rheumaticus. + +“Rheumatic fever occurs most frequently in the temperate zone, among +people who live under conditions which are unhealthful and which +especially induce focal infection. It is most prevalent in the young +and in the more exposed male of all ages. The excess of lymphoid tissue +in the pharynx and nose of the young explains the frequency of the +incidence of the focal infection and the subsequent rheumatism. The +frequent association of the onset of rheumatic fever with lowering of +the body temperature by exposure to cold and a wetting is explained by +the increased specific virulency of the bacterial cause acquired by a +low temperature and the coincident lessened resistance of the patient +due to the exposure. The frequent absence of evidence of acute focal +infection at the onset of the systemic disease is not an evidence +that no focus exists. The latent chronic streptococcus infection of +tonsillitis, pyorrhea alveolaris, sinusitis, etc., may suddenly acquire +increased virulence and specific pathogenic affinity with varying +degrees of focal tissue reaction. This transmutation of type and +pathogenicity certainly occurs in the focus of infection. The removal +of the tonsils and other sites of focal infection has been followed by +complete recovery of prolonged, subacute and chronic types of arthritis +and has unquestionably prevented recurrent attacks of rheumatic fever +to which the susceptibility is increased by one or more attacks. The +occurrence of rheumatic fever after the removal of an apparent focus +may be due to secondary systemic latent foci in lymph nodes proximal to +joints, in the neck or elsewhere. The streptococci of these secondary +foci may take on new virulence and specific pathogenicity, from the +same causes which induced like changes in the pathogenic bacteria of +the primary focus.[67]” + +Osteopathic lesions play an important role, both in their relationship +or bearing upon the tissues of a possible site for a focal infection +and upon systemic conditions that derange general bodily tone. This has +been definitely confirmed in those cases of rheumatism where correction +of the osteopathic lesions, with attention to hygienic measures, have +resulted in recovery. This is a feature of osteopathic etiology and +therapy that can hardly be over-emphasized, for an intact innervation, +circulation and chemism of the organism is basic to both preventive and +curative therapy. Rheumatism, like most diseases, is of local origin +and if tissues and structures can be kept up to the normal, infectious +or the other pathologic processes can rarely become active. + +=Pathologically=, the synovial membrane is hyperemic. The muscles and +ligaments are inflamed. The fluid is serous with more or less fibrin +and leucocytes. In severe cases slight erosion of the cartilages is +found. Acute rheumatism is rarely fatal; when death does occur it is +generally due to the complications which arise. + +=Symptoms.=—The onset is usually sudden; although it may be preceded +by slight fever, aching in joints, chilliness, and sore throat. It +generally involves the larger joints and is almost always multiple; +it has a tendency to move from one joint to another. The pain in the +joints usually develops rapidly with slight chilliness and a rapid +rise in the temperature from 102 to 104 degrees F. The pulse is +frequent, often disproportionately to the fever. There are profuse +acid sweats, often causing sudamina. There is loss of appetite and +thirst is present. The urine is scanty, high colored, very acid, and +deposits urates upon standing. The tongue is coated and the bowels +are constipated. The joints are reddened, swollen, extremely painful +and tender to the touch. Every movement, jarring of the bed, or the +pressure of the bed clothes is agony to the patient. The blood is +greatly deranged, anemia develops rapidly and there is well marked +leucocytosis. The duration varies from a few days to several weeks. + +=Complications.=—The temperature may rise to 106 or 109 degrees F.; +this is often associated with delirium, great prostration and a feeble, +frequent pulse. Endocarditis, pericarditis, myocarditis, pneumonia, +pleurisy, iritis, chorea, convulsions and meningitis may occur. Coma +may develop without preceding delirium or convulsions; this is very +serious and may prove fatal. Subcutaneous fibrous nodules attached to +tendons and fascia sometimes develop. They vary in size and are most +common in children and in young adults, occurring most frequently in +the fingers, hands and wrists. They are also sometimes seen about +the elbows, knees, scapulæ and spines of the vertebræ. They usually +last a few days, sometimes for months, and generally develop during +the decline of the fever. Cutaneous affections, such as urticaria, +erythema, nodosis, purpura and sweat vesicles sometimes appear. + +=Diagnosis.=—This is seldom very difficult; there are, however, +several affections which resemble acute articular rheumatism. In +=septic arthritis= its association with some other septic process +and the tendency of the inflammation to end in suppuration with more +or less destruction of the joints, will determine the diagnosis. +Septic arthritis may develop during the course of pyemia, puerperal +fever, or acute osteomyelitis. =Gout= is rarely mistaken for acute +rheumatism. Gout occurs later in life and usually affects the greater +toe; history and mode of onset will usually render the diagnosis +easy. In =gonorrheal rheumatism= the history of recent infection, its +obstinate character and being generally connected with a single joint +from the start are diagnostic. It especially affects the knee. Heart +complications are rare. =Rheumatoid arthritis= begins in the small +joints; then attacks them all, leaving permanent deformity. There is +no fever or sweats and the heart is not affected. Acute arthritis of +infants usually attacks the hip or knee. The effusion becomes purulent. + +=Prognosis.=—Recovery is the rule, but the prognosis nevertheless, must +be guarded. Relapses and recurrences are common. + +=Subacute Rheumatism.=—In this form both the local and general symptoms +are of a milder type and are more prolonged than in the acute form. The +temperature seldom rises above 101 degrees F. The inflammation of the +joints is not so severe and fewer joints are involved. It may last for +weeks or months, and then it may pass into the chronic form. Usually +though, when the course is prolonged, the joints return to their normal +state. + +=Treatment.=—Place the patient in a room that is well ventilated and +maintain a temperature of about 70 degrees F. Avoid draughts of air. +The bed should be soft and smooth and blankets should be used. The diet +should consist largely of milk, and let the patient drink freely of +water. Oatmeal, barley water, egg albumen and meat juices may also be +used. + +Treatment should be given along the entire spine, especially if the +rheumatism changes from one joint to another; otherwise treat the +innervation directly to the affected joint. Correct any derangements +that may be found along the spinal column and carefully relax the deep +back muscles. Particular attention should be given to the bowels and +kidneys. Also, treat the liver most thoroughly during each treatment. +The liver is many times considerably enlarged and tender in rheumatism +and a thorough treatment of it seems to favor a more rapid cure. + +Carefully treat the affected tissues. If you cannot treat over the +joint, then manipulate the tissues above and below the joint; and +usually after a few minutes’ manipulation the swelling is somewhat +relieved so that direct treatment of the joint can be given. It is best +to wrap the inflamed joints in flannel if the pain is severe. Besides +treatment of the innervation of the joint, hot applications will be +helpful. Some claim that cold compresses are of aid to the inflamed +joints. + +=Complications= are to be treated separately. Besides the ordinary +fever treatment for the fever, the cold bath is very effectual. After +=convalescence= has been established, the patient should be carefully +protected for several days from cold and damp. For any stiffness that +may persist, manipulation and hot baths will be quite sufficient. + +H. M. Still[68] writes “If the fever is not over 103 degrees I do not +try to reduce it.... After treatment in a majority of cases, the fever +is reduced within twenty-four hours unless complications have set in. +These are usually of the heart, so no matter how mild the attack, keep +this in mind. If the action is irregular and weak, stimulate it two or +three times a day. If it is rapid and high fever, go to the vasomotor +centers and reduce fever, then inhibit the heart action and keep the +excretions active. If the joints are affected I always move them gently +no matter how great the inflammation. As yet I have never had a case of +rheumatism in which cardiac lesions or ankylosed joints were a sequela.” + +If the tonsils are evidently badly diseased and osteopathic treatment +does not clear them up do not hesitate to have them removed. + + +Chronic Articular Rheumatism + +=Osteopathic Etiology= and =Pathology=.—This disorder should be studied +in connection with arthritis deformans owing to similar sources of +infection and various common factors. It usually develops slowly and +follows an acute or subacute attack and is common among the poor, +especially those exposed to damp and cold. Heredity, advanced years, +although the disease may appear at any age, and constant exposure to +cold and wet are predisposing causes. Chronic lesions to the spinal +column corresponding to the affected area are found. Too much stress +from an osteopathic point of view cannot be placed upon the importance +of lesions to both the digestive organs and to the joints especially +involved. Then, in addition, particular attention should be given +osteopathically or surgically, or both, to sites of focal infection. + +=Pathologically=, the capsules and ligaments of the joints are +thickened also, the sheaths of the tendons around the joint, so that +in long standing cases the movements are impaired. In severe cases the +cartilages may be eroded. Atrophy of the muscles covering the joints +sometimes occurs, especially when there is neuritis; thus producing +marked deformity. This muscular atrophy is particularly marked when +the shoulders or hips are involved. The atrophy is caused partly from +disease; in cases where the joint is distended with effusion, the +wasting may be due to pressure upon the muscles or blood-vessels. + +=Symptoms.=—Several joints are usually affected; but it may be limited +to one joint, particularly the knee, hip or shoulder. Pain and +stiffness are the most common symptoms. The pain is increased upon +motion, while the stiffness is often lessened by using the limbs. The +joints are slightly swollen, but seldom reddened and are usually tender +upon pressure. All the symptoms are aggravated on the approach of +stormy weather. There is fever but the general health is not greatly +impaired. There may be distortion of the joints and ankylosis may +occur. Arterial degeneration and chronic endocarditis may develop as +complications. + +=Prognosis.=—This should be guarded so far as a complete cure is +concerned; although most cases are greatly benefited. + +=Treatment.=—The treatment of chronic articular rheumatism is largely +correcting lesions of the spinal column, which affect the diseased +tissues as well as the digestive organs, local treatment of the joints, +and removal of focal infections. A certain percentage will respond to +osteopathic measures alone, though surgery has a definite place in +others. The joints and limbs should be thoroughly treated so as to +restore a better circulation and relieve the inflamed tissues. Wrapping +the affected joint with cold cloths and then covering the cloths with +flannel and oiled silk is often helpful. Due attention should be given +the general health, such as nourishing food, free elimination and +outdoor exercise. + +Probably in some cases where the primary infection has been eliminated +secondary foci are present and a general treatment will arouse +sufficient reaction to cope with the condition. + + +Arthritis Deformans + +(RHEUMATOID ARTHRITIS) + +=Definition.=—A chronic affection of the joints, characterized by +progressive changes in the cartilages and synovial membranes, and by +new osseous formations restricting the motion of the joint and causing +deformity. + +=Osteopathic Etiology= and =Pathology=.—It is due to lesions of the +spinal column affecting the spinal and sympathetic nerves as well as +disturbing the circulation to the cord. Lesions of the spinal column +and ribs are found corresponding to the innervation of the diseased +joints. The osteopath has been able in every case to demonstrate +clinically important osteopathic lesions. In addition the symmetry of +joint involvement, muscular atrophy, sweating, etc., point to nervous +lesions. Falli found upon autopsy that the anterior horns had undergone +atrophic changes. Nervous lesions are probably of a predisposing +character while some infection is the exciting cause. A thorough search +of the entire body should be made for foci of infection. Malnutrition, +traumatism, exposure to cold, and pelvic diseases are important +causative factors. In all cases lesions will be found disturbing the +organs of digestion. Females are more frequently affected than males. +The disease is frequently seen in women suffering from ovarian and +uterine troubles, especially at the menopause. Hereditary influence may +be a factor, also auto-intoxication. The disease is most common between +the ages of twenty and thirty. Mental worry, anxiety, grief and injury +are also predisposing factors. + +=Pathologically=, in one class of cases, the cells of the cartilages +and of the synovial membrane proliferate. The cartilages undergo +atrophy, or may become soft, degenerate, and are absorbed, leaving the +ends of the bone bare. The bones naturally atrophy and become smooth. +In another class the edges of the cartilages where the pressure is +slight, thicken and form outgrowths which ossify and enlarge the heads +of the bones, forming osteophytes which greatly impair the motion; +true ankylosis is rare. The synovial membrane becomes thickened, also +the capsule and ligaments, thus greatly restricting the movements of +the joints. The muscles around the joints atrophy. In the spinal cord +atrophic and degenerative lesions are found. In Still’s disease there +is an enlarged spleen and marked changes in the joint. + +=Symptoms.=—Pain and swelling of the joints and fever and enlargement +of the lymphatics near the joint are characteristic. The spleen +is congested and later on there is gastro-intestinal disturbance. +=Multiple arthritis deformans=, also known as Heberden’s nodosites, +is characterized by nodules developing at the sides of the distal +phalanges. It occurs most frequently in women between the ages of +thirty and forty, and gradually increases with age. At first the joints +are swollen, tender and painful and then apparently become better. +These attacks may appear at different intervals while the nodules at +the sides of the joints gradually increase in size. The larger joints +are rarely affected. The progressive form may be either acute or +chronic. The acute form at the onset may resemble articular rheumatism. +It is more common in women between the ages of twenty and thirty, but +may occur in children. Pregnancy, recent delivery, lactation, the +menopause, and rapid child bearing are common antecedents. There is +swelling and tenderness of the joints and slight fever. Several joints +are usually involved. The =chronic form= is most common. Symmetrical +joints are usually involved. The affected joints slowly enlarge and are +painful and red. Usually the hand is first affected; then the wrists, +knees, toes, jaws and spine; in extreme cases every joint is affected. +The vertebræ, =spondylitis deformans=, may be attacked. The cervical +spine may be alone involved, in which case the head cannot be moved +up or down, although rotation usually remains. In some instances the +entire spinal column is affected and may become perfectly rigid. In +some cases there is hardly if any pain, while in others the pain is +agonizing and is almost constant. The joints gradually become deformed, +stiff and creak when moved; later they become completely ankylosed. +This deformity is due partly to the thickening of the capsule, to +the presence of osteophytes, and to the contraction of the muscles. +These contractures flex the leg upon the thigh and the thigh upon the +abdomen. Muscular atrophy increases the deformity. Numbness, tingling, +pigmentation and glossiness of the skin, and local sweating may be +present and are of trophic origin. + +The =monoarthritic form= affects old persons chiefly, and women more +frequently than men. It affects particularly the hips, the knees, the +shoulders, and the vertebral articulations. This is often caused by an +injury. The muscles waste away and the knee-jerk is usually increased +upon the affected side. + +=Diagnosis.=—Care has to be taken in not confusing it with rheumatic +fever or gout. Radiographs should be made. + +=Prognosis.=—If treated early there is a fair chance for curing +the disease. Advanced cases usually improve under treatment. The +osteopathic treatment should be persistent for at least several months. + +=Treatment.=—Osteopathic treatment, if long continued in rheumatoid +arthritis, has given satisfactory results, although owing to the +extent of the deformity, a cure in advanced cases cannot be expected. +An important cause of the disease is probably a trophic or vasomotor +disturbance to the tissues of the joint. Osteopathically, there +is never any difficulty to locate disorders in the spinal column +corresponding to the innervation of the involved joints. The fact that +many of the joints are affected symmetrically indicates that the lesion +is a spinal one involving the nerve center. During the incipiency +marked improvement is the rule. + +A thorough attempt should be made in every case to discover the source +of infection and remove it, though this does not preclude the essential +osteopathic adjustment. + +The treatment consists of attempts to correct the spinal derangement +and careful manipulation of the diseased joints to restore vitality and +motion in them. The preceding simple, but effective treatment, must be +continued two or three times per week for months or even years in order +to be of particular value. Coupled with the specific treatment should +be a careful consideration of the general health. The emunctories +should be kept active and the food of the patient be nutritious. The +osteopath should require the patient to take considerable physical +exercise at regular intervals, warm baths and plenty of fresh air. +Massage and friction of the diseased joints will be of aid in absorbing +effusions and in restoring the tone of atrophied muscles. Hot +compresses are a help. The baths at various hot springs are sometimes +of benefit, and change of climate is invigorating. + +O. J. Snyder[69] has this to say: “I must be very emphatic, however, +to here advise exceptional caution in your manipulative procedure. +* * * You cannot attempt to move the joint, for, if you do you will +cause excruciating pain and do irreparable harm in that you will cause +breaking down of the cartilage and cancellous bone tissue. Your first +endeavor should be to reduce inflammation and to mitigate pain. * * * +Osteopathically much comfort and reduction of pain can be accomplished +by inhibition in the proper spinal areas. A little friction and very +gentle extension or traction of the joint can be attempted as soon +as the condition of the joint, by the foregoing treatment, has been +made possible. At no time should rotation or sidebending, or any other +manipulation that produces irritation of tissue be attempted.” + +In stout adult women a villous arthritis of the knees may develop owing +to faulty posture and poor elimination. These conditions are often +amenable to treatment. + + +Muscular Rheumatism + +=Definition.=—A painful disease of the voluntary muscles and of their +fascia and the periosteum. It is regarded by many as a neuralgia of +these muscles. The pain is greatly increased by motion and pressure. + +=Osteopathic Etiology= and =Pathology=.—Osteopathic experience with +cases of muscular rheumatism shows that the nerves, as they pass to +and from the spinal muscles, are affected. The lesion is caused, +principally, by subdislocations of the vertebræ, ribs or pelvis, +according to the region involved. A gouty or rheumatic diathesis, +heredity, exposure to cold and wet and previous attacks are +predisposing causes. Men are more often affected, owing to their more +frequent exposure. The disease affects persons of all ages. It occurs +in acute, subacute and chronic forms. + +In cases of frequent recurrence focal infections and intestinal toxins +are often important factors. Vertebral and muscular lesions, septic +foci, intestinal stasis, exposure to cold and drafts are principal +causes. + +=Pathologically=, there is swelling of the muscles of the nature of +myositis. In chronic cases there is often atrophy of the muscles, due +to interference of the trophic nerves. + +=Symptoms.=—These are generally local and are never accompanied by +marked constitutional disturbances. There is seldom fever, and the +pulse is only slightly increased in frequency. Pain is the chief +symptom; it is increased by motion or pressure. Tenderness is generally +present and there may be swelling of the tissues. Rheumatic nodules +have been found. The duration is usually three or four days, though it +may last longer with frequent recurrences. + +=Lumbago= is a painful affection of the muscles of the lumbar area and +their tendinous attachments. The onset is generally sudden. In severe +cases it sometimes renders the patient helpless. In =torticollis,= or +stiff neck, the muscles of the side and back of the neck are affected. +It is usually confined to one side of the head. Any attempt to turn the +head causes a sharp pain. In =pleurodynia= the intercostal muscles, and +sometimes the pectorals and serratus magnus, are affected. It usually +affects but one side, more frequently the left; it is the most painful +form of the disease, since the pain is aggravated by breathing. The +respiratory movements are consequently restricted on the affected +side. The absence of fever and physical signs will distinguish it from +pleurisy. In =intercostal neuralgia= the pain follows the distribution +of the nerves and there are tender spots along their courses. +=Cephalodynia= affects the muscles of the scalp. =Scapulodynia=, +=omodynia= and =dorsodynia= affect the muscles of the shoulder and +upper dorsal. =Abdominal rheumatism= affects the muscles of the abdomen. + +=Prognosis.=—The prognosis is good. Favorable results are the general +rule under careful treatment. + +=Treatment.=—Muscular rheumatism is usually an easy affection to cure. +The cause of the disturbance is generally found in the region involved, +and is due, in the majority of cases, to some dislocated tissue, +usually osseous, that irritates the nerves to the muscles. In addition +to correcting the lesions, removal of septic foci, free elimination, +lessened diet, stretching of the muscles, application of heat, ironing +and rest are beneficial. + +In =lumbago= there is invariably found a slight lateral deviation of +some vertebræ along the lower dorsal or lumbar region. Occasionally +deformity of the vertebræ, asymmetry, or arthritis are factors. The +radiograph may be a diagnostic aid. Occasionally, a floating rib or +an innominate becomes displaced. Stretching the loins by placing the +patient upon his side or back and flexing the thighs on the abdomen is +very beneficial. Maintain the tension for three or four minutes. Hot +fomentations and rest are helpful. + +=Torticollis=, or stiff neck, is generally due to a lesion of the +middle cervical vertebræ. The lesion is usually between the third, +fourth and fifth vertebræ, occasionally as low as the second dorsal. +A reduction of the subdislocation will often relieve the attack. +Stretching of the muscle and application of heat will also be of +aid. In some cases of torticollis (chronic) there is a curvature of +the cervical spine, and occasionally the muscles are more or less +fibrinous. Surgical measures may be instituted. In such instances a +cure cannot always be accomplished. The tonsils, nose and teeth should +be examined for sources of infection. + +A few cases of acute torticollis are caused by some of the deep +muscular fibres becoming caught around a process of a vertebra. Severe +contraction of the muscles by cold or extensive rotary flexions of the +neck, may result in torticollis. Occasionally a case is found due to +injury at birth. The cervical vertebræ should be carefully examined. +The spinal accessory is the nerve generally involved. Lesions to +the spinal accessory occur commonly at the third, fourth and fifth +cervicals, or the atlas and axis. The muscles involved in torticollis +are the sternocleidomastoid, trapezius, splenius and scaleni. +Operations should not be performed until a thorough course of treatment +has failed to relieve. + +=Pleurodynia= is often a neuralgia of the pleural nerves. It is +usually caused by subdislocations of the ribs exactly over the regions +involved. Occasionally, a lesion may exist to the corresponding +vertebra, but rarely. The rib is at times completely dislocated. +Applications of heat and rest of the part are of aid. Strapping of the +region will give considerable relief. + +In =cephalodynia= the muscles of the scalp are generally involved +by lesions in the upper five cervical vertebræ. In =scapulodynia=, +=omodynia= and =dorsodynia= the muscles of the shoulder are usually +affected by displacements of the second and third ribs, although the +lesion may be found slightly lower in the ribs, or in the corresponding +vertebræ. The lower cervical vertebræ may also be at fault. In +recurring and chronic cases carefully examine for infectious sources. +Dislocations of the shoulder occur frequently; and muscular fibres may +slip out of the bicipital groove (rarely). In a few cases muscles may +become contracted about the coracoid process, or the acromial end of +the clavicle may become dislocated. + +=Abdominal rheumatism= is generally caused by lesions in the lower six +dorsal vertebræ, which involve the innervation to the muscles. In some +cases lesions of the lower ribs are found, and in a few instances a +lesion may be discerned in the upper lumbar vertebræ. + +=Myalgia= of the =upper extremity= is caused by lesions of the cervical +or upper dorsal vertebræ or upper ribs. Occasionally some trouble may +be found in the shoulder or elbow joints. In the =lower extremity= +lesions may be found in the lower dorsal or lumbar vertebræ, or there +may be derangements of the pelvic bones. Occasionally disorder is found +at the hip and knee joints. + + +Gout + +=Definition.=—A nutritional disorder in which there is an abnormal +accumulation of uric acid and other purin bodies in the blood and +tissues; and arthritis, deformity of joints and visceral derangements +being the characteristic features. + +=Osteopathic Etiology= and =Pathology=.—Hereditary influences are the +predisposing factors of about one-half of the cases of gout. Men are +more frequently affected than women. It rarely develops before the age +of thirty. Overeating, sedentary habits, drinking alcohol, especially +fermented drinks, and lead poisoning are predisposing factors. +Emotional disturbances may excite an attack. Gout is not confined to +the rich by any means; but there is also a “poor-man’s gout,” due to +poor food, unhygienic surroundings, and to an excessive use of malt +liquors. Uric acid seems to be a causative factor, but whether there is +an increased formation or a diminished excretion of the uric acid has +not yet been fully decided. The ultimate result is the same in either +case; there is an accumulation of uric acid and other purin bodies in +the blood, which is responsible for some of the effects of the disease. + +Osteopathic experience with cases of gout shows that lesions affecting +the nervous system are important factors that control uric acid +accumulation or excretion. The nerve centers controlling the affected +portions of the body are almost invariably involved, as well as the +nerve control to the digestive and excretory organs. A neurosis of +these nerve centers probably occurs and is thus a predisposing cause +of gout. Considerable can be accomplished in the treatment of gout by +careful examination of the spinal column, in the region corresponding +to the innervation of the affected area, for vertebral lesions, and +correcting them. Usually, slight dislocations of the bones of the foot +are found, when that region of the body is involved. The most common +subdislocations of the foot are involvements of the astragalus with its +articulations and the metatarsals. + +=Pathological= changes are those of the joints principally. There is +deposit of uric acid in cartilages, synovial membranes and ligaments. +The joint of the great toe is most frequently affected, then the +fingers, ankles, knees, hands and wrists. The exudates become hard and +are then called tophi. In severe cases the cartilages of the ears, +nose, eyelids and larynx are involved. Finally the joints become stiff, +deformed and ankylosed, and sometimes there is ulceration. + +The kidneys are usually the seat of chronic interstitial inflammation +with a deposit of urates. The heart and blood-vessels almost always +present changes. Arterial sclerosis is quite a constant lesion; the +left ventricle of the heart is hypertrophied. Urate of sodium has been +found deposited upon the valves. There is an excess of uric acid in the +blood. Chronic bronchitis, emphysema and asthma are among the changes +in the respiratory system. + +=Symptoms.=—In =acute gout=, before the attack, the patient may +complain of dyspeptic disorder, restlessness and twinges of pain in the +small joints. He is apt to have irritability of temper and depression +of spirits. The first symptom of the attack is great pain in the +metatarso-phalangeal joint of the great toe, which usually comes on +suddenly at night with swelling, heat and discoloration of the joint. +The temperature rises to 102 and 103 degrees F. Towards morning the +symptoms generally abate to recur again the next night. This lasts for +several days, the symptoms gradually abating. The urine is scanty, +high colored, of high specific gravity and acid in reaction. It +deposits urates and often contains a small quantity of albumin. There +may be gastro-intestinal symptoms—pain, vomiting, diarrhea, faintness +and a rapid, feeble pulse. Pharyngitis is an occasional symptom. The +cardiac symptoms are pain, shortness of breath and irregular action +of the heart. These attacks may appear with varying severity. In some +cases there may be severe cerebral symptoms. + +=Chronic gout= follows repeated attacks of the acute form. The +articular symptoms continue for a longer time and the condition extends +to other joints. The chalk deposits slowly increase until the joint +becomes swollen and deformed. The morbid changes already described +are characteristic. The urine is increased in quantity, is of low +specific gravity and may contain albumin and hyalin and granular casts. +Involvement of the heart and blood-vessels gradually occurs. + +=Irregular gout= or =lithemia= is seen in persons who have been gouty +or have a hereditary predisposition. It includes a set of symptoms that +are not alone distinctive, but when taken with this gouty tendency, +all forms of irregular gout can be recognized. There are various +gastro-intestinal disturbances; cutaneous eruptions; heart and blood +vessel changes; pains in the various muscles and joints; nervous +symptoms, as headache, neuralgia and neuritis; urinary symptoms, and +pulmonary and ocular disorders. + +=Diagnosis.=—Only the irregular form of gout should be difficult to +diagnose. Differentiation is to be made from arthritis deformans and +acute and chronic rheumatism. + +=Treatment.=—The hygienic treatment of gout is very essential. The +patient should live a quiet life, avoiding mental and physical strains. +Plenty of fresh air, exercise and regular hours should be insisted +upon. Alcoholic drinking should be avoided and the food taken in +moderate quantities. Keeping the skin active by the use of cold baths, +if the patient is strong, and warm baths should he be weak, is a +helpful measure. The dress of the patient should be warm and suitable +for the climate. + +A regulated diet of nutritious food, taken at regular hours, is +necessary. Each patient should receive separate instructions as to +diet. The food given may be small amounts of beef, mutton and chicken, +with fresh vegetables; with the exception of strawberries, tomatoes +and bananas, fruits may be used; fats, milk and stale bread are also +suitable. The patient should avoid tea, coffee, pastry, hot breads, +highly seasoned dishes, and such articles. The free use of water is +beneficial. + +The =osteopathic treatment= consists of careful correction of the +lesions of the spinal column in order to free the nerve force to +the affected region. The spinal treatment in gout is the most +essential treatment and is effective. A most thorough examination +should be made of the tissues about the diseased area; in the foot +the astragalus oftentimes is subdislocated from its articulations, +causing obstructions to the local vessels and nerves. The metatarsal +bones should receive due attention, as occasionally one of the +bones corresponding to the affected tissues is dislocated, usually +downward. All the joints between the diseased tissues and the spinal +nerve centers should be carefully manipulated so as to favor a better +circulation. During a severe attack of gout, besides careful treatment +of the blood supply to the diseased region, wrapping the joint in +cotton wool and applying warmth and moisture to the joint may be +helpful. + +The kidneys, liver and bowels are to be kept active. A light treatment +to the kidneys and liver each time is very helpful in aiding the organs +to eliminate the waste material, and especially in controlling any +inflammation that may exist in the kidney. The essential treatment +in gout is to relieve the disorder of the nerve centers, to increase +the activities of the emunctories and to regulate the hygiene of the +patient. + + +Diabetes Mellitus + +=Definition.=—A nutritional disorder in which there is an abnormal +amount of sugar in the blood, characterized by an excessive urinary +discharge, in which grape sugar is constantly present, and by a +progressive loss of flesh and strength. + +=Osteopathic Etiology= and =Pathology=.—Almost invariably there will +be found a posterior dorso-lumbar curvature wherein the spinal column +tissues are much contractured. This condition probably involves the +sympathetics (vasomotor and trophic) to the pancreas, liver and +intestines. Important lesions may also be found as high as the occiput. +Tenderness and congestion over the abdomen, especially the liver, are +frequent. It affects men more frequently than women and is a disease +of adult life, ranging between the ages of thirty and sixty, though +cases have occurred in the very young. It is more serious in the young, +the very young seldom recovering. Hereditary influences are believed +to be a predisposing cause. It affects the better classes principally +and especially those of a neurotic temperament. The Hebrew race is +specially predisposed. The colored race is seldom affected. + +Obesity, certain chronic diseases (malaria, gout, syphilis), +occupations taxing the mind, and pregnancy are predisposing influences. +Injury or disease of the spinal cord or brain frequently cause +diabetes, especially any irritation of Bernard’s diabetic center in +the medulla. Derangements of the endocrine system are important. +Injuries to the spine, chiefly in the dorso-lumbar and sacral regions, +and to the abdomen, and diseases of the pancreas or liver are, as +has been stated, oftentimes causes. Lesions to the spine may disturb +the glycogenic function of the liver, the glycolytic ferment of the +pancreas, or produce an alimentary glycosuria. Extirpation of the +pancreas is immediately followed by diabetes, but if a fragment of +the pancreas is left it is not always followed by diabetes. The +normal amount of sugar in the blood is 1-1000 while in diabetes the +amount of sugar is 3 to 4-1000 up to 7 or 8-1000. The healthy kidney +will not excrete sugar when it is at the normal ratio. Concerning +the presence of acetone-bodies von Noorden[70] says: “The excretion +of acetone-bodies may serve, like glycosuria, as a measure of the +intensity of the diabetic disease ... it will be at once understood +that in no other disease do the acetone-bodies occupy so important a +position as in diabetes.” Irritation of the centers of the vasomotor +nerves to the liver or direct stimulus to the liver cells is followed +by glycosuria. Interference with the pneumogastric nerve also +influences diabetes. + +=Pathologically=, the liver is enlarged, firmer and darker in color +than normal. Often there is fatty degeneration of the organ. The +pancreas is diseased in about one-half of the cases of diabetes, +especially the islands of Langerhans. The lesions found are granular +atrophy, occlusion of the pancreatic duct, atrophy from pressure, +fat necrosis, and sometimes it is small, soft and anemic. The kidney +changes are those of catarrhal nephritis. In the fatty degeneration +hyalin changes take place. The heart is hypertrophied in a few cases. +Arterial sclerosis is frequently met with. In the lungs bronchitis, +pneumonia and tuberculosis occasionally develop. In the stomach and +intestines catarrh is common. The blood presents an increase of sugar. +In the nervous system are found many lesions, especially congestion, +extravasation and sclerosis of the brain; disturbances of the posterior +part of the cord, and congestion and sclerosis of the sympathetic +ganglia. The bony lesions, however, (almost invariably a posterior +lower dorsal and lumbar) must involve the sympathetics, via the +splanchnics, to the extent of profound metabolic disturbance, for in no +other way can the results of osteopathy be explained. The importance +of specific treatment at this point cannot be over estimated. + +=Symptoms.=—The =onset= is gradual; thirst and frequent micturition +being the first symptoms noticed. After an injury or a sudden, severe +nervous shock, diabetes may set in abruptly. As the disease progresses +there will be marked thirst, polyuria, an abnormal appetite, wasting +and debility. The tongue is dry, red and coated. There is constipation +and the skin is dry and harsh. Temperature is often subnormal; pulse +frequent with increased tension. + +In some cases the =urine= is not increased in quantity; usually +however, the amount varies from four to five pints to several quarts in +twenty-four hours. It is pale in color, of high specific gravity and +acid reaction. Sugar is present in variable quantities from one or two +per cent to five or ten per cent. Sugar in the urine must be constant +in order that the affection is a true diabetic one. Albumin is often +present; urea is increased and uric acid may be slightly increased. +Acetone-bodies are often found and usually indicate a more serious +condition. + +=Diabetic Coma= is the most important and gravest complication. +There is either a sudden or gradual loss of consciousness. This may +occur after some form of exhausting exercise. There may be previous +headache or a feeling of intoxication. It may be preceded by nausea, +vomiting, colicky pains or some local affections, such as pharyngitis +or pulmonary complications. Peripheral neuritis, neuralgia, numbness, +are possible symptoms. Impairment of hearing, cataracts, strabismus, +diabetic retinitis and atrophy of the optic nerve may occur. The sexual +function is lost early in the disease. Eczema, with burning and itching +of the labia and vicinity, (and in men a balanitis), furuncles, boils +and carbuncles are common. Gangrene and edema are not uncommon. Acute +pneumonia, bronchitis and tuberculosis are possible complications. +=Progressive loss of flesh= is a serious indication. + +=Diagnosis.=—The diagnosis is easy, as there is no other disease with +which it can be confounded. Careful urinalysis should always be made. +Examination for acetone, diacetic acid and oxybutyric acid is valuable. + +=Prognosis.=—Many cases have been cured by osteopathic measures while +nearly all treated have been benefited. If the patient is put upon a +diet free from carbohydrates, in mild cases the sugar will disappear, +while in severe cases it will still be present. Mild cases usually +yield readily to treatment. In cases over forty years of age the +outlook is quite favorable, but in cases under forty, and especially +the young, the prognosis is not so favorable. In cases under puberty +the results are apt to be fatal. Stout persons bear diabetes better +than lean. All cases are liable to complications, which render the +prognosis more serious. It is a disease of long =duration=, although +death has occurred in a few weeks. + +=Treatment.=—In nearly all cases of diabetes mellitus examined there +have been found posterior conditions of the lower dorsal and lumbar +regions. The posterior curve has always been fairly well marked and +generally is a symmetrical curve. By that is meant a spinal curve that +is not irregular and the relation of the various vertebræ, one to the +other, is not seriously deranged. Correction of this condition of the +spinal column has almost invariably given satisfactory results and +in the majority of cases the condition of the patient has improved +remarkably, and many entirely cured. To get the best results the +patient should be laid on his side on the operating table and the knees +drawn up so that the thighs are flexed upon the abdomen. The osteopath +standing in front of the patient throws his weight against the flexed +thighs and reaching over upon the spinal column springs the entire +weakened portion of the spine toward its normal position, stretching +the spinal column to separate each vertebra from its neighbor so that +the deranged nerves, as they pass through the intervertebral foramina, +may be released. Meeker[71] reports a case with a marked kyphosis which +was treated two years before enough motion could be had between the +vertebræ to produce any results, but after that they were favorable. +Direct treatment to the abdominal organs to correct liver congestion +and stimulate the pancreas and increase activity of the intestines is +essential. + +The nerves affected by the posterior pathological curve of the spine, +mentioned above, and by separate lesions that may exist within the +pathological curvature, are probably the vasomotor nerves to the portal +system, pancreas and the intestines. The vasomotor nerves to the portal +system branches are given off principally from the fifth to the ninth +dorsal vertebræ, although fibres may escape from the cord as low as +the first lumbar vertebra. The nerves to the intestines are given off +principally from about the ninth dorsal to the lower lumbar vertebræ. +Possibly there are nerve fibres direct to the hepatic cell protoplasm. + +How lesions in the dorso-lumbar region cause diabetes mellitus is an +important question and is hard to answer. An unnatural acceleration +of the portal circulation may cause an increased quantity of sugar to +pass to the liver, resulting in part of the sugar not being changed +into glycogen and thus passing into the circulation; or a paralysis +of the vasomotor nerves to the liver causes congestion and slowness of +the blood stream. Thus a disturbed circulation of the liver may cause +accumulation of sugar in the liver, so that the blood ferment has time +to act upon the glycogen and transform it into sugar; or there may be +a saccharinity of chyle or blood in the portal vein, due to an impeded +conversion of sugar in the intestines into lactic acid; or there may +be an accelerated absorption of sugar due to an abnormal state of the +intestines; or the nervous control to the pancreatic functions may +be disturbed. Hence, one or many pathological changes may occur and +influence a case of diabetes, due to a disordered dorso-lumbar region. + +The center for the hepatic vasomotor nerves, “diabetic center,” is in +the floor of the fourth ventricle at the level of the origin of the +vagi nerves. A lesion of the “diabetic center” or an obstruction to the +pneumogastric anywhere along its course may cause diabetic symptoms; +hence, there may be lesions of the cervical region that would affect +reflexly the diabetic center, or lesions of the pneumogastric may +occur, particularly at the atlas or axis, and cause diabetic symptoms, +or, at least, these may influence the course of a case of diabetes +mellitus. Or the upper cervical lesions may disturb the pituitary gland +which is of importance in carbohydrate metabolism. + +There are nerves from the superior and inferior cervical ganglia of +the sympathetic that have considerable influence upon the liver. These +nerves do not pass down the cord to the splanchnics, but pass in the +sympathetic to the celiac and hepatic plexuses and then to the liver. +Stimulation of these nerves causes the hepatic vessels at the periphery +of the liver lobules to become contracted. Possibly in a very few +cases, a stagnation of blood in other vascular regions of the body may +cause the blood ferment to accumulate in the blood to such an extent +that diabetic symptoms occur. + +=Dietetic treatment= is essential, but is not so necessary as some +medical authors would have us believe. A regulated diet should be +insisted upon in all cases, but one should not go to extremes in +dieting. A complete elimination of the carbohydrates is no longer +considered the best treatment, as it withdraws too important an element +from the diet, producing weakness without any corresponding return for +good. A patient’s appetite is often inordinate and it will be necessary +to regulate the quantity and character of foods. Proctor[72] mentions a +case which recovered when carbohydrates were restored, as the patient +was too starved to build up. Under osteopathic treatment much more +liberty can be allowed in selection of foods. Von Noorden[73] reported +a number of cases in which excretions of sugar continued upon the +strict anti-diabetic diet, but which were sugar free when they received +a large amount of oatmeal along with some vegetable proteid or white of +egg and butter, other carbohydrates being excluded. It is suggested by +the editor of the Series that the oatmeal may be used alternately with +diabetic diet, and relieve the monotony greatly. It can also be used +as a test of the patient’s digestive and sugar destroying powers. The +following food may be included in the dietary: + +Animal Foods.—Meats of every variety, except livers; game, poultry, +fish and eggs. + +Vegetables.—Cabbage, cauliflower, celery, lettuce, green string beans, +the green ends of asparagus, tomatoes, spinach, mushrooms, cucumbers, +watercress, young onions, or any other green vegetable. + +Bread and Cakes.—Made of gluten flour, bran flour or almond flour; +griddle cakes, biscuits, porridges, etc., may be made of these flours. + +Beverages.—Skimmed milk, buttermilk, coffee and tea without sugar, and +carbonated water. + +Relishes.—Pickles, cream cheese and nuts of all kinds except chestnuts. + +Fruits.—Oranges, lemons, cranberries, cherries, strawberries, all in +moderate quantities. + +Other foods may be used, but each case requires a thorough study in +order to determine what is best to do. + +Various foods should be tested out and controlled by urinalysis. +The point is to increase metabolism so that the body can store up +considerable carbohydrates without the appearance of sugar in the urine. + +In severe cases Allen’s fasting treatment to be followed by a low +diet should be instituted. However, it should be remembered that the +correction of dorsal and upper cervical lesions is invaluable. + +Mental excitement and worry should be avoided as much as possible. +Frequent bathing and regulated exercise will be of considerable value. +The diabetic patient should have a well ventilated room and plenty +of rest and sleep; flannels are to be worn next to the skin the year +around. + +Various symptoms and =complications= are liable to arise, which the +competent osteopath is prepared to meet by following general rules. + +Keep the bowels open. And frequently examine for acetone and diacetic +acid. If there are any symptoms of =coma= fast the patient, and +neutralize the acid intoxication with bicarbonate of soda until the +urine is alkaline. + + +Diabetes Insipidus + +(POLYURIA). + +=Definition.=—A constitutional disorder in which there is a continued +excessive secretion of urine, free from albumin and sugar. There is +constant thirst. + +=Osteopathic Etiology= and =Pathology=.—This disease is more frequent +in males than in females. It occurs most commonly between the ages of +twenty and thirty. It is due to chronic disturbances of the nerves. +The lesions usually found upon osteopathic examination are lateral +derangements of the vertebræ in the renal splanchnic region, (ninth to +twelfth dorsal inclusive) or a slight kyphosis in the same locality. +Such lesions probably affect the central nervous system in the region +of the sympathetic nerves to the kidneys, by a paralysis of the +muscular coat of the renal vessels. The disease may be associated +with other conditions, as injuries and diseases of the nervous system +elsewhere; exposure to cold; prolonged debility and fatigue; cerebral +diseases, as meningitis, paralysis of the sixth nerve, tumor of +the brain, and blows on the head; injuries of the cervical region; +sunstroke; cerebrospinal fever; malaria; syphilis; pregnancy; hysteria; +hereditary influences, and drinking too freely of cold water. There +are many diseases and conditions which may be associated with diabetes +insipidus; and which act as irritants, directly or reflexly, upon the +center in the medulla oblongata (which is just above the diabetic +center), or upon the sympathetic ganglia in the abdominal region. Thus, +there is a vasomotor neurosis, due either to central or reflex lesions. + +Second in importance to lesions of the renal splanchnics are lesions +of the upper cervical region. Irritations in the cervical region may +act upon the center in the medulla or the lesions may affect some +of the sympathetic fibres as they pass from the brain to the renal +sympathetics. The pituitary gland may be disturbed. Probably axis and +atlas lesions are factors. + +Lesions of the nerve centers and of the sympathetic ganglia have been +found upon post-mortem examination, but they are not constant. Nervous +lesions have been found in the region of the base of the brain. The +kidneys are sometimes congested and enlarged. The tubules may be +dilated. + +=Symptoms.=—Great thirst and an enormous secretion of urine of a pale, +watery and slightly acid nature are the characteristic symptoms. The +skin is usually dry and harsh, the bowels are constipated, and the +appetite may be voracious. The health on the whole is quite perfect, +although if the affection is not arrested, considerable loss of flesh +and strength may result. There is a tendency for the disease to become +chronic. + +The nervous lesion causing polyuria may be the outcome of a debilitated +condition of long standing or the symptoms may occur suddenly. +Preceding the large flow of urine such symptoms as nervousness, +irritability, headache, sleeplessness, failure of memory, and inability +to concentrate the mind commonly occur. Other symptoms may be present +in addition, as debility, diarrhea, epigastric and lumbar pains, and +impaired sexual function. + +=Diagnosis=.—The diagnosis is not difficult. Thirst, polyuria and the +absence of albumin and sugar characterize the disease. In =diabetes +mellitus=, finding of grape sugar in the urine would at once exclude +polyuria. In =paroxysmal diuresis=, the increased amount of urine is +not permanent. In =interstitial nephritis=, there is albumin, casts, +etc. + +=Prognosis.=—Depends upon the cause. The disease yields to treatment +much quicker than diabetes mellitus and is without doubt much less +serious. The disease, in a large majority of cases, can be cured. Under +osteopathic treatment most cases will yield good results or be cured in +from a few weeks to six months. + +=Treatment.=—The treatment of the disease causing diabetes insipidus is +of first consequence, but frequently such a disease is undiscoverable. +There is often a tendency toward neurasthenia; consequently, habits, +environment, etc., should be carefully attended to. Examine for sexual, +rectal and other reflex irritations. + +Correcting lesions of the renal splanchnics is important; in fact, in +a fair number of cases treatment of this locality will entirely cure +the disease. A very effective treatment, in addition to the ordinary +methods of treatment, is to have the patient lie flat upon the back +while the osteopath reaches around the patient on either side, placing +the fingers firmly upon the transverse processes of the lower dorsal +vertebræ and springing the spine forward by lifting upward on the +patient, enough even to raise the patient from the surface he is lying +on. This treatment is especially effective in lessening the increased +amount of urine. Attention should be given to the false ribs on either +side and to the condition of the spine below and above the renal +splanchnics. The cervical vertebræ should be examined carefully for +disorders, and if any are found they should be removed at once, if +possible. + +=Hygienic treatment= is of as much importance as in diabetes mellitus. +The clothing should be warm, warm baths taken, and general friction +and care of the skin utilized so that the circulation may be somewhat +diverted from the kidneys. Restriction of water is not always +necessary, except in cases where excessive drinking has become a habit, +as the thirst is caused by the diuresis and not the diuresis by the +large ingestion of water. Regulate the diet and see that the bowels are +acting normally. + + +Rickets + +RACHITIS + +=Definition.=—A constitutional disease of children, characterized +by impaired nutrition and changes in the growing bones, causing +deformities. The physical growth is disturbed and the bone deformity is +due to an over growth of cartilages and delayed calcification. + +=Etiology= and =Pathology=.—Rickets may occur in the new-born, but it +rarely begins before the child is six months old. It is a disease of +the first and second years of life. Heredity is probably not a factor +but certain races, especially the Negro and Italian, have a tendency to +be rickety. The disease is much more common in the large cities than +in rural districts; also it is more common in Europe than America. The +disease is most frequently met with among the ill-fed and badly housed +poor of the large cities, though it is not rare to find it among the +well-to-do. Lesions to the digestive organs predispose. Breast-fed +children seldom have the disorder. Improper or insufficient food (a +diet too low in fats and proteins) bad air, want of sunlight, prolonged +lactation, exposure to cold and dampness are predisposing factors. + +=Pathologically=, the most marked changes are seen in the long +bones and the ribs. The cartilage between the epiphysis and shaft +is thickened and is soft and irregular in outline. Underneath the +periosteum the tissue is spongy. Microscopic examination shows +an increase of proliferation of the cartilage cells with scanty +calcification. The bones are soft and there is a diminution in the +calcareous salts. In a word ossification is delayed and the bones +are not perfectly developed. In the cranium the frontal and parietal +eminences are prominent, while the top of the head and the occiput are +flattened, giving the head a square appearance. The fontanelles remain +open until the second or third year of life. The ribs become affected +very early. At the point where the ribs join the costal cartilages, +bulging occurs, forming the so-called “rachitic rosary.” The normal +shape of the chest walls is markedly changed. Just outside the junction +of the ribs with the cartilages, the ribs fall in, producing a shallow +depression, while the sternum and cartilages are pushed forward. The +bones of the leg may be distorted. The normal curves of the spine are +occasionally disturbed. The liver and spleen are often increased in +size. + +=Symptoms.=—The =onset= is slow. In many cases digestive disturbances, +with their usual effect upon the nutrition, precede the appearance of +the characteristic lesions. The child is irritable and restless, and +there is usually slight fever and profuse sweats. The child is often +languid, pale and feeble. The lymph gland are enlarged. The tissues are +soft and flabby and skeletal changes begin to make their appearance. +Among the first are changes in the ribs and head, already described +under pathology. Changes sometimes occur in the bones of the face, +particularly the maxillæ. Dentition is delayed. The spinal column is +frequently curved antero-posteriorly or laterally. The long bones are +curved and their extremities become thickened. The pelvis is distorted +and twisted and in women this may seriously complicate labor. “Chicken +breast” and “bow legs” are common, as well as muscular weakness, and +the child walks late. The abdomen is large and prominent, due to +flatulency and to the enlargement of the liver and spleen. + +=Diagnosis= and =Prognosis=.—By observing the symptoms, diagnosis is +not difficult. Prognosis should be guarded, owing to danger from other +diseases; still, on the whole, prognosis is fairly favorable. + +=Treatment.=—Rickets being a disease of malnutrition due to weakness +of the digestive organs, improper food, or to influences of disease, +the treatment must be principally following hygienic rules and good +dieting. The child under six months, if not nursed satisfactorily by +the mother, should be given diluted cow’s milk. Salts may be obtained +from barley gruel and whole wheat. Diluting the milk with barley water +is highly recommended. Fresh meat juice and cream are invaluable. If +curds are found in the stools, the digestion is not perfect and is +usually due to overfeeding the child. The child should be out doors as +much as possible. Fresh air is a necessity. The worst air outside is +better than the best air of the house as far as purity is concerned. +Protect the child carefully with warm clothes, and when sitting or +walking the child should be supported. Baths will be found beneficial. + +In the older child, beef juice, light meats, yolks of eggs, green +vegetables and fruits may be given. Lessen the amount of carbohydrates. +Careful osteopathic treatment of the various affected tissues of the +child will aid a great deal in correcting deformities. Attention +to the lesions found will also aid in increasing the nutrition to +the involved tissues as well as correcting digestive disturbances. +This, also, is of distinct benefit in improving the assimilation +of lime salts. Possibly treatment of the “nutritional” centers, +(fourth dorsal and fourth lumbar) would be effectual. Carefully guard +against complications of the nervous and respiratory systems. After +ossification the deformities may be corrected by the orthopedic +surgeon, though in the young child considerable can be accomplished +by repeated attempts at straightening by bending and molding the long +bones. All those conditions which predispose to rickets should receive +attention; chief among these is the care of the nutrition of the mother +during pregnancy. Nursing should be regulated, and possibly future +pregnancies discouraged. + + +Obesity + +=Definition.=—Obesity is essentially a nutritional disease and is an +inconvenient accumulation of adipose tissue in the body, sometimes +impairing the bodily function. With some individuals obesity is a +normal condition. In others it means impaired health, especially poor +elimination. + +=Etiology= and =Pathology=.—Heredity, overeating, sedentary habits, +hot, moist climates are predisposing causes. Exciting causes are +especially the eating of fat-making food, excessive use of alcohol +and insufficient exercise. Obesity may follow the menopause or an +infectious disease. Osteopathic lesions are frequently found in +the upper and middle dorsal region. These probably are causes of a +disturbed metabolism. An excessive diet of starches and sugars will +indirectly act as a fat producer. In young people the possibility of +hypopituitarism should be considered. Lesions of the upper cervical, in +these cases, are frequent. + +=Pathologically=, adipose tissue is deposited throughout most of +the tissues. Usually the abdomen is encumbered with a large amount. +Passive congestion probably favors the deposition of fat, for in cases +of pendulous abdomen, simply drawing the abdomen in and up and the +patient, through voluntary effort, keeping it up, will frequently cause +absorption of the fat in a few days or weeks. The fat is distributed +underneath the skin, throughout the viscera and about the heart. The +tissues may suffer from fatty infiltration, especially the heart, +arteries and veins; also the liver, kidneys and stomach. There is an +increase of specific gravity of the blood. Edema occurs from passive +congestion, due to weak heart. + +=Symptoms.=—The round, fat face, double chin, hanging cheeks, large +waist, the thick, prominent, sometimes pendulous abdomen, and the +bulky extremities form characteristic features. At first obesity +presents no harmful symptoms. Usually the first troublesome symptom +is increased frequency in the breathing, due to a weak and overworked +heart, and to the fact that the motion of the lungs is hampered by +the heavy chest walls, and also by the interference with the descent +of the diaphragm on account of the enlarged liver. Dyspnea, passive +congestion, anemia, poor digestion, uterine disorders, and mental +inactivity are common. There is cardiac hypertrophy; later the heart is +overlaid with fat. The pulse is usually frequent, but may be irregular +and slow. + +=Treatment.=—Obesity being a nutritional disease it seems but +reasonable that alterations of the anatomical structures will produce +a change in the proper balance of nutrition. Along osteopathic lines, +derangement of tissues affecting the nerves to the digestive and +lymphatic systems will produce obesity. In the majority of cases +examined have been found disturbances at the sixth and seventh +cervical, fourth and fifth dorsal and from the tenth dorsal to the +second lumbar. Lesions at these points could readily interfere with +the thoracic duct and the receptaculum chyli, as well as with the +processes of digestion, assimilation and elimination. It is claimed +that stimulation of the splanchnic nerves causes dilatation of the +receptaculum chyli. Direct treatment to the abdomen and to areas of +fatty deposit will aid very materially in absorption. + +The =dietetic treatment= is essential, the principle being to furnish +less food to oxidize. Restrict fats, sugar and starches and limit the +amount of water. Alcohol should be prohibited. Another important point +in the treatment is exercise, which must be carried out in a systematic +way. Rules can be laid down only in individual cases and should be +governed by the osteopath in charge. The principal effect of general +mechanical treatment is to promote oxidation. Massage and baths are +beneficial. The patient can do much for the abdomen by keeping it in +and up, and walking erect. + + +Scurvy + +=Definition.=—A constitutional disease, characterized by extreme +general weakness, anemia, spongy condition of the gums, disintegration +of tissue and a tendency to hemorrhages. + +=Etiology= and =Pathology=.—In comparison with former times scurvy is +now a rare disease. Lack of fresh vegetables or their substitutes, +over-crowding, dampness, bad hygienic surroundings, and prolonged +fatigue under depressing influences are the predisposing causes. Arctic +explorers have shown that fresh bear’s meat and bear’s blood are a +preventative. + +There are extravasations of blood into the skin, muscles and mucous +membranes. Hemorrhages may occur in the internal organs, especially +the kidneys and liver, and in the serous membranes. The gums are +swollen and spongy. The teeth decay. The spleen is soft and enlarged. +Parenchymatous degeneration of the heart, liver and kidney is frequent. +Ulcers occasionally occur in the skin and bowels. The blood is thin but +there is no leucocytosis. + +=Symptoms.=—The disease is usually slow in development. The general +manifestations of anemia with debility are among the first symptoms. +The gums are swollen, soft and spongy, they bleed easily and in severe +cases there is ulceration. Petechial spots appear upon the body. +Subcutaneous ecchymosis occurs, first on the legs, then on the arms +and trunk. The eyes and face are swollen; the patient appears as if +he had been bruised. Hemorrhages from the mucous membrane frequently +occur. The temperature is usually normal. The pulse is small, feeble +and frequent; sometimes irregular and slow. The appetite is impaired +and constipation is present at first, as a rule, although this may be +followed by scorbutic dysentery. + +=Diagnosis.=—The disease is readily recognized when several cases occur +together. It is somewhat hard to recognize in isolated cases, and to be +able to distinguish it from certain forms of =purpura=. The etiology, +the gingival changes and the hemorrhages usually decide the diagnosis. + +=Prognosis.=—Scurvy being a disease due to malnutrition, it is +necessary to remedy such condition by attention and correction of the +faults producing it. Hygienic surroundings and a wholesome diet will do +more in curing the disease than anything else. An outdoor life and good +ventilation with anti-scorbutics, as fruit juices, especially lemons +and oranges, fresh vegetables, (onions, potatoes, etc.) and fresh milk, +are necessary. + +It is held by Garrod that scurvy is caused by an absence of potash, +for a deficiency of potassium salts is found in the blood. The +anti-scorbutics named above contain potash. A careful treatment along +the splanchnics would help to improve the appetite and digestion. Treat +the gums and ulcers according to surgical indications. + + +Infantile Scurvy + +SCORBUTUS + +This form usually follows the prolonged use of condensed milk, +sterilized milk or proprietary foods for children. The disease occurs +during the first two years of life, but it is most common from the +seventh to the fourteenth month. + +It develops rapidly. Joint pains, anemia and irritability are early +symptoms. The child is pale, has a muddy complexion and may show signs +of rickets. The gums may be soft and spongy. There is tenderness and +pain on motion. There may be hemorrhages under the skin. The lower +limbs are drawn up and motionless. The bones become thickened from +sub-periosteal hemorrhage, and there is apt to be softening between the +shaft and epiphysis. The back and legs become very weak. The lesions +are usually symmetrical. The temperature is variable. + +=Treatment.=—The treatment of scurvy in children consists in, first, +omitting all proprietary foods and substituting fresh cow’s milk, meat +juice, strained gruel and a moderate quantity of fresh orange or lemon +juice. Under this treatment, cases that have not progressed too far +will promptly recover. + +Northrop says: “It is a significant fact that the country which +furnishes most of the literature on scorbutus in children is the same +which is posted from end to end with advertisements of proprietary +foods.” + + +Purpura + +=Purpura= is a symptom rather than a disease. It is characterized by +extravasation of blood into the skin and bleeding from the mucous +membranes, irrespective of direct injury. These extravasations do not +disappear upon pressure and vary greatly in size. They may be small, +(petechiæ) or large (ecchymoses). They are bright red and gradually +become darker. Clotting of normal blood requires three to five minutes, +purpuric blood, ten to fifteen minutes. + +It is a symptom of =infectious diseases=, as in pyemia, septicemia, +mycotic endocarditis, typhus fever, smallpox, etc. =Toxic=, as produced +by venomous snake bites and by =certain medicines=, as copaiba, +mercury, quinine, iodides and others in overdoses. =Cachectic purpura= +may be observed in cancer, tuberculosis, Bright’s disease, scurvy, +etc. In =senile purpura= the spots are generally confined to the +extremities. In certain =nervous diseases=, bleeding spots appear on +the skin, as in tabes, myelitis and severe neuralgia. =Mechanical +purpura= is seen in venous stasis; this is rare. + +=Purpura simplex= affects only the skin. It occasionally follows +attacks of infectious diseases. The spots are found upon the legs, more +rarely upon the trunk and arms. Articular pains may or may not occur. +Fever is seldom present. Loss of appetite, diarrhea and slight anemia +may be manifested. The duration is one to four weeks. + +=Purpura rheumatica= is a much more serious affection, characterized +by multiple arthritis of rheumatism. Seldom seen under five years, +and lasts about two weeks. The joints are swollen and painful and the +temperature rises to 101 and 103 degrees F. The amount of edema varies +greatly and occasionally it is quite excessive. In addition to the +purpura there is usually urticaria. =Henoch’s purpura= is seen most +frequently in children and is characterized by severe gastro-intestinal +disturbances as pain, vomiting and diarrhea, hemorrhages from the +mucous membranes and acute enlargement of the spleen, in addition to +the symptoms already named under the foregoing form. There is some +danger of hemorrhage into the kidneys. + +The disorder of =purpura hemorrhagica= is usually associated with +rheumatism, malaria and other infectious diseases. This is the most +serious form of purpura. It is most commonly met with in delicate girls +during early life; but it may occur at any age and in the most robust +of either sex. Fever, weakness, vomiting and diarrhea are the early +symptoms. After a couple of days of languor and weakness, purpuric +spots appear upon the skin; and bleeding occurs from the mucous +membranes and may cause profound anemia. Hemorrhages into the internal +organs occur. Favorable cases recover in ten days or two weeks. Others +may end fatally. Care should be taken not to confuse the disease with +scurvy. + +=Treatment.=—In the treatment of purpura the disease from which it +develops should receive due attention. Occasionally there is danger +of overlooking the primary disease and treating some symptoms of the +disease, although it is true that sometimes an important symptom is +nearly all that is manifested. Outside of treating the conditions under +which purpura arises, general measures should be considered, as a +nutritious diet, rest, fresh air, and general treatment of the patient +so that normal circulation and strength may be restored. The treatment +of the purpura locally should be such as to restore normal circulation +of the part by removing any obstruction or irritation of the blood +supply that may be found, by careful manipulation of the tissues. As +stated the management of the disease under which it arises should be +embraced in the treatment. In cases of hemorrhage from various organs +see article under hemorrhage. Some cutaneous hemorrhages are best +relieved by local manipulation. + + +Hemophilia + +(BLEEDER’S DISEASE). + +Hemophilia is a hereditary condition manifested by a tendency to +uncontrollable hemorrhage with or without injury. The usual mode of +transmission is through the female line, rather than by the male. The +mother does not necessarily have to be a bleeder, but the daughter +of one, in order to transmit the disease to her offspring. Atavism +through the female alone is almost the rule. Not all the children of a +bleeding family are afflicted; the male children are more subject to +the condition than the female children. The tendency usually appears +within the first two years of life. The families of bleeders are often +large and are commonly healthy looking and have fine soft skins. It is +claimed blondes are most likely to be afflicted. + +=Pathologically=, an unusual thinness of the blood-vessels with a +fatty degeneration of the intima has been noted. In many cases there +is deficient coagulability of the blood and a lessened number of +leucocytes. Hemorrhages have been found in and about the capsules +of the joints, and in a few instances inflammation of the synovial +surfaces. The arteries are situated superficially, but that does +not explain anything. The real nature of the disease has not been +determined. Emotional excitement is a factor, consequently vasomotor +disturbances may be important. The frailty of the blood-vessels and the +peculiar constitution of the blood preventing thrombotic formation are +the two facts of importance that have been recognized. + +=Symptoms.=—Hemorrhages occur from the most trifling injuries. Blowing +the nose may cause severe epistaxis; the extraction of a tooth is a +frequent cause of hemorrhage; the prick of a pin, a slight cut, a +scratch, or a blow may result in profuse bleeding. The bleeding may +occur spontaneously from the mucous membrane of the mouth, nose, +lungs, intestines, etc.; or it may occur directly from the fingers, +toes, back of the hands, and lobes of the ears. The hemorrhages may +last several hours. As soon as checked the patients rapidly resume +natural appearance providing the bleeding is not often repeated, +thereby causing a permanent anemia. There may be attacks of arthritis +with fever, as with acquired hemorrhagic tendency, closely resembling +rheumatism. + +=Diagnosis.=—Hereditary tendency and persistent hemorrhage from slight +injury. + +=Prognosis.=—In a few cases the tendency to bleed gradually diminishes +until at last it entirely ceases. The younger the subject the more is +it liable to prove fatal. In the majority of cases death occurs between +the first and eighth years. After maturity the chances of an attack are +much lessened. + +=Treatment.=—Members of the bleeder’s family, particularly the boys, +should be guarded against traumatic influences, and operations of +all kinds should be avoided. Outdoor exercise, fresh air, bathing and +plain nourishing food, in fact, the hygienic surroundings, and all food +should be carefully watched so that the threatened subject may become +strengthened and hardened. Marriage should be discouraged, especially +with the daughters, as it is through them the tendency is propagated. +Possibly, coupled with the foregoing prophylactic treatment, a +stimulation of the glands of elaboration of the blood will be of +service to build up the physical constitution of the patient. During +attacks absolute rest and the required symptomatic treatment should be +given. For resultant anemia the usual treatment is to be employed. + +In severe cases direct transfusion should be considered. + + +FOOTNOTES: + +[67] Billings, Focal Infection. + +[68] Massachusetts Journal of Osteopathy, Jan. 1906. + +[69] Journal of the American Osteopathic Association, November 1919. + +[70] Diabetes, p. 90. + +[71] Journal of the American Osteopathic Association, Oct., 1904. + +[72] Journal of the American Osteopathic Association, Oct., 1904. + +[73] Practical Medical Series, 1905. + + + + +DISEASES OF THE DIGESTIVE SYSTEM + + +Diseases of the Mouth + + +Stomatitis + +=Definition.=—Inflammation of the mouth. + +=Etiology.=—Chemical, mechanical, thermal or parasitic irritations; +secondary to disorders of the gastro-intestinal tract, scarlet fever, +measles and variola; cachexia, due to such diseases as cancer and +phthisis; dentition; artificial feeding; hot weather and poor hygienic +surroundings are the most common causes. Lesions to the innervation +and vascular supply of the mouth are found, principally, in the upper +cervical vertebræ, occasionally in the upper dorsal vertebræ and +corresponding ribs. + +=Varieties.=—Catarrhal, aphthous, ulcerative, parasitic, gangrenous. + + +Catarrhal Stomatitis + +=Etiology.=—Most common in infants and children. Hot and irritating +substances; secondary to diseases of the stomach, to measles, scarlet +fever and variola; difficult dentition; alcoholic or tobacco excesses. + +Hazzard says in all cases of stomatitis “there is generally lesion to +the bony or other tissues in the cervical region (sometimes also in the +upper dorsal), which deranges vasomotor control of the tissues of the +mouth and tongue, obstructs venous return, weakens the tissues and lays +them liable to the effects of some particular irritant, local or in the +system, but there is, generally, lesion affecting the gastro-intestinal +tract which is the real underlying cause of the trouble.” + +=Symptoms.=—Diffuse, red swelling of the mucous membrane, heat and pain +in the mouth, increased flow of saliva, fetor of breath, restlessness +and languor. In children there is a disinclination to nurse and a +slight fever may be present. The sense of taste is blunted and there is +commonly a bitter taste in the mouth. The neck glands are enlarged. + +=Treatment.=—Removal of the exciting cause is the most important point +in the treatment. Good hygienic conditions must be enforced. The +mouth should be kept clean. Wipe it out at frequent intervals with a +soft piece of absorbent cotton and cold water. A borax solution is +frequently used. Attention should be paid to the diet and secretions. +Light but thorough treatment of the upper cervical region is to be +given, with careful attention to the tissues about and below the +angles of the jaw, so that the innervation, blood and lymphatic supply +may be equalized. + + +Aphthous Stomatitis + +(CANKER) + +This disease is characterized by little, painful, grayish-white spots +upon the superficial layer of the mucous membrane. They consist, +primarily, of an exudate of fibrin and wandered-out leucocytes. It +is principally a disease of childhood. Among the common causes are +difficult dentition, disorders of digestion and uncleanliness of the +mouth, such as neglect to cleanse the child’s mouth after nursing. It +may be a symptom of measles or of local diseases. + +Probably the innervation to the region of the little grayish-white +spots or canker is obstructed at some points by a disordered tissue. +The lesion may be mechanical or it may arise from a disordered +digestion. If one is able to locate such a lesion and remove it, a cure +will be hastened. The seat of the infection is the internal surface of +the cheeks, gums, roof of the mouth, tongue and lips. + +=Symptoms.=—There is redness of the mucous membrane of the mouth, +followed by the appearance of the vesicles with a red areola. Pain +in the mouth and an increased flow of saliva occur. Mastication, +deglutition, and even speaking, may be painful. This condition is +followed by sleeplessness, feverishness, diarrhea and fetor of the +breath. + +=Treatment.=—Removal of the cause, as in other varieties of stomatitis, +is paramount. Give attention to the food. The milk should be +sterilized. The disordered digestion should be corrected at once. All +secretions must receive prompt attention. The child should be nursed at +regular intervals. Locally, keep the parts clean and carefully treat +the innervation. + + +Ulcerative Stomatitis + +This is a disease of children, although it may not be limited to them, +as it occasionally occurs in epidemics and affects all ages. It occurs +chiefly in the families of the poor and in places where the hygienic +surroundings are bad, the food poor and personal cleanliness lacking. +It may begin as an aphthous stomatitis. Often sufferers from severe, +acute diseases are subjects of attack. + +=Symptoms.=—The gums of the lower jaw are chiefly affected. They are +at first congested, swollen and bleed readily. Pain is increased by +mastication and deglutition, the mouth is hot, the breath fetid, the +saliva dribbles and the digestion and bowels are disordered. The ulcers +may appear at various points upon the cheeks, lips and tongue; the +deposit is yellowish-gray. + +In the more severe cases the gums are spongy and the teeth are +loosened. In proportion to the constitutional disturbances, fever and +enlargement and tenderness of the submaxillary glands occur. Even +necrosis of the bone may follow. + + +Parasitic Stomatitis + +(THRUSH) + +The exciting cause is a fungus known as Laccharomyces albicans. It +is claimed that a catarrhal stomatitis is the soil upon which the +fungus develops. Parasitic stomatitis is chiefly a disease of nursing +children and is promoted by unhygienic conditions. It is seldom seen +after ten years of age, occurring in adults only in the last stages of +consumption, cancer, and severe chronic diseases. + +=Symptoms.=—Upon inspection there are seen numerous milk-white +elevations. These appear first about the angles of the mouth, soon +extending to all parts of the mouth, and in a few cases, even to the +pharynx and to the esophagus. When removed bleeding points are left. +The general symptoms of stomatitis are present—pain upon mastication +and swallowing; fetid, hot breath; increased saliva; increased +temperature; restlessness; swollen lips and disordered digestion occur. + +=Diagnosis.=—The microscope will remove all doubt as to the nature of +the affection. In aphthous stomatitis the ulcers are preceded by the +formation of vesicles. + +=Prognosis.=—Is favorable in the majority of cases. + +=Treatment.=—Hygienic measures, absolute cleanliness, correction of +the disorders of the gastro-intestinal tract and local treatment as +in other forms of stomatitis, is the required treatment. A boric acid +solution will be found beneficial. + + + + +SPINAL LESIONS AND THEIR RELATION TO DISEASES OF THE GASTRO-INTESTINAL +TRACT + +Acute Gastritis, Chronic Gastritis, Gastric Neurosis, Gastric and +Duodenal Ulcer. + +By CHARLES J. MUTTART + + +The instant relief that Osteopathy can give in acute indigestion is +one of its outstanding achievements. It impresses the patient and +his friends with a deep conviction of the superiority of osteopathic +therapy. The results in these cases are not, in any sense, a matter of +chance. They follow logically from the osteopathic viewpoint, teaching, +reasoning, and practice. In dealing with the manifestations of disease, +such as heredity, onset, course, duration, subjective and objective +symptoms, etc., and in the effort to differentiate cause from effect, +and to reconstruct a mental picture of the sequence of cause, effect +and sequelæ, the osteopath has the advantage of binocular vision in +that he recognizes two distinct pathologies cooperating to produce the +symptom complex, syndrome or disease which he is called upon to treat. +One pathology is to be found in one or more of the vertebral and rib +articulations and the immediately adjacent or corresponding segments +of the spinal cord. The other is in some one or more of the organs or +tissues connected with the pathological segment or segments of the cord. + +=The function of the joint is MOTION.=—Unrestricted normal range +of motion is essential for the normal function of all parts of the +articulation as well as for the nutrition of the nerve mechanisms +immediately adjacent. When a spinal articulation ceases to perform +its function all of its parts are more or less impaired, muscles +atrophy, ligaments lose their tone, and circulation to and from the +spinal segment is interfered with because action is a large factor in +promoting the flow of blood and lymph and maintaining normal stimulus. + +As a result of this spinal pathology, internal organs and tissues, +supplied by nerves arising in the segment that is in lesion, will be +variously disturbed in their function. + +Dr. Carl P. McConnell says: “My observation of lesioned animals so +far as the digestive organs are concerned is that the lesion affects +the reflexes of and through spinal and sympathetic ganglia so that +the vasomotors are involved with a consequent hyperemia of the +submucous coat. This means involvement of the endothelial layer of the +blood-vessels, diapedesis, derangement of the secretory function and +disturbance of the motor mechanism, all of which lead to functional +upset and disturbance.” + +The dominant part played by the osteopathic lesion as a causative +factor in acute and chronic diseases of the alimentary canal becomes +increasingly evident as clinical observation and laboratory research +permit a more thorough appreciation of the anatomy and physiology +of the parts involved. The abnormal stands out more clearly from +the normal. Finally, the task of restoring normality is becoming a +clear-cut problem to which the correction of the osteopathic lesions +furnishes an almost complete solution. + +The normal alimentary canal transports food, macerating it, mixing +it, and treating it with various chemicals and enzymes on the way, +breaking it down physically and chemically, and absorbing from it +such end-products as are needed to maintain metabolism. The abnormal +alimentary tract may be at fault in any of these functions. This +delinquency is generally traceable to a mechanical origin. Correction +of the mechanical deviation is followed by restoration of normal +function except in cases where extensive tissue changes have occurred. + +=Thorough mastication= is essential to good digestion. Any dental +defects or deficiencies should be corrected. =The temporo-mandibular +articulation= should be examined, and full free motion restored if +lacking. The muscles on the affected side are softer than on the sound +side. Tonic spasm rigidly closes the mouth. It may be due to tetanus, +caries of the lower teeth, cutting of the lower wisdom tooth, or other +irritations to the sensory branches of the inferior maxillary nerve. +There is enough space back of the wisdom teeth to pass a catheter to +administer food. + +=The tongue= assists in mastication and deglutition and is the seat +of most of the nerves of taste. The hypoglossal nerve, which supplies +it, leaves the skull through the anterior condyloid foramen and may +be impinged there or lower in its course. =Lesions of the occiput and +upper cervical vertebræ= and obstructions to the lymphatic drainage +at the angle of the jaw may cause pressure on this nerve and cause +disturbances in the movements of the tongue, atrophy, swelling, etc. +Swelling may be due also to endocrine disturbance, constitutional +diseases, anemia, glossitis, local irritants, injuries, etc. Pressure +may be made on the hypoglossal nerve behind the angle of the jaw. + +=The special sense of taste= plays an important role in normal +digestion. The lingual nerve supplies the anterior two-thirds of the +tongue with taste. The sense of taste may be lost, impaired, perverted +or otherwise abnormal. + +The sense of smell plays an important part in our appreciation +of flavors, and when it is impaired by colds, adenoids, or other +affections of the nose or pharynx, the sense of taste is measurably +impaired. =Normalization of nose and pharynx= restores the sense of +taste in such cases. Impairment or loss may also be due to lesions +of the chorda tympani, or glosso-pharyngeal nerves. Lesions of the +mandible, hyoid, occiput or upper cervical nerves, parotid disease or +obstructed lymphatic drainage behind the angle of the jaw may cause +pressure directly or indirectly on the glosso-pharyngeal and chorda +tympani nerves. Perversion of taste occur in pregnancy, hysteria, +epilepsy and insanity. + +=Foul taste=, fetororis in the mouth is frequent in pneumonia, typhoid +fever, peritonitis, septicemia and other severe fevers; also after +ingestion of pungent foods or strong drugs; in constitutional diseases; +as a result of inattention to oral hygiene, excessive smoking, mouth +breathing at night, furred tongue, etc. It clears up on removing the +cause. + +=Furred tongue= occurs in gastritis, fevers, and a variety of other +conditions. The fur is composed of broken down epithelium which would +normally be removed by friction with solid food. When none is taken, +the fur accumulates. When blood or hematin becomes mixed with the +broken down epithelium, the fur is brown. Ordinarily it is white. +=A clean red tongue= is frequently found in hyperacidity. It is +probably due to vasodilatation due to hyperactivity of the autonomics +or inhibition of sympathetics. The sympathetic supply is from the +=superior cervical ganglion=. It may be affected by lesions of the +occiput, atlas, axis and third cervical vertebra, of the hyoid, by +anterior cervical muscular contractures, by obstruction to venous and +lymphatic drainage and blood supply. Correction of the lesions named +and normalization of the other structures involved will usually restore +the tongue to normal condition. + +=The salivary glands= have a two-fold innervation. The thin, full, +watery, salty secretion is produced by activity of the cranial +autonomic fibers; the sparse, viscous secretion containing the organic +elements, ptyalin, etc., is produced by the sympathetics. =The +sympathetic nerve supply= is from the middle and superior cervical +ganglia and can be disturbed by lesions affecting them as mentioned +above. The secretion of ptyalin may be disturbed by any lesion from the +fifth dorsal up. + +It must not be forgotten that a =posterior occiput= draws the superior +cervical ganglion back against the axis and third cervical with +just as much pressure as is exerted by an anterior atlas or third +cervical. This pressure or stretching tends to inhibit it, preventing +vaso-constriction and permitting vasodilatation of the internal +carotid artery and its branches and congestion of the parts supplied, +mid-brain, cerebrum, etc. + +If, for any reason, the venous drainage from the lateral sinus into +the internal jugular vein, or the ebb and flow of the cerebrospinal +fluid between brain and cord, is reduced or hampered, an extra burden +is thrown on the cerebral veins and sinuses, and the intra-cranial +pressure is raised at each heart-beat, ultimately producing pressure +on the meninges and causing violent headache over the fifth and tenth +cranial nerves which supply the meninges with sensation. These nerves +are intimately connected with the digestive system. Any increase of +intra-cranial pressure causes increased irritability and hyperactivity +of the cranial nerves, many of which are concerned with various +functions of the digestive system. Moreover, the nuclei of these nerves +lie on the floor of the fourth ventricle which is supplied mainly by +the vertebral arteries and the basilar artery. Lesions of the cervical +vertebræ affecting the plexus on the vertebral artery or filaments to +it from the upper parts of the cervical gangliated sympathetic cord, +may impair the blood flow through the vertebral arteries and cause +similar increased irritability of the nerve cells in the medulla, +mid-brain and cerebellum. Such disturbance is reflected in awkward +movement, hyperesthesia, and symptoms due to increased irritability of +the autonomic nerves such as slow pulse and respiration, watering of +the mouth, hypersecretion and hypermotility of the gastro-intestinal +tract, rapid digestion and poor assimilation, vasodilatation, +impoverished blood, and so through a vicious cycle back to still +greater impairment of nutrition to the nerve cells within the cranium. +Until the lesions are corrected, the condition becomes progressively +worse till exhaustion occurs. + +Ordinary medical hygiene can do little or nothing. The palliative +remedies employed simply mask the symptoms, or actually accelerate the +destructive process. Lesions that irritate the cervical sympathetics +would cause vaso-constriction and give rise to opposite symptoms, +namely, cerebral ischemia, decreased flow of saliva, atony of stomach, +lack of digestive juices, sluggish intestinal peristalsis, rapid +pulse and respiration, etc. Correction of the lesions and restoration +of normal blood supply and drainage to the brain and removal of any +lesions tending to inhibit the sympathetics from the fifth dorsal up, +will usually in a short time restore the activity of the salivary +glands to normal. The otic and sphenopalatine ganglia can be disturbed +by abnormal conditions within the pharynx. These must be corrected when +found. + +=Deglutition=, or swallowing, is a very rapid, highly complex movement. +It takes not more than a second for the food to cross the pharynx. The +soft palate and larynx are raised to close off the air-way, making the +food-way practically continuous for the second needed to complete the +transfer of the food across the air-way. The tongue is pressed against +the roof of the mouth and the mylohyoid contracts vigorously and shoots +the bolus of food across the pharynx. Bolting the food leads to serious +digestive disturbances, not the least of which is the loss of the +normal reflex which prevents swallowing unprepared food. When lost, +this reflex can be restored by thorough mastication for three or four +months. + +The voluntary part of swallowing is performed by the motor portion of +the fifth cranial and the hypoglossus. The involuntary part involves +afferent impulses over the superior laryngeal and efferent impulses +over the inferior laryngeal. The levator palati which raises the soft +palate is probably supplied by the spinal accessory nerve through +the pharyngeal plexus. This nerve can be affected by lesions of the +occiput, atlas, mandible and hyoid, and by any obstruction to lymphatic +drainage which increases pressure behind the angle of the jaw. In +paralysis of the levator palati, as =after diphtheria= or other +peripheral neuritis, fluids regurgitate through the nose during the act +of swallowing. The raising and closing of the larynx is accomplished by +the superior and recurrent laryngeal nerves by way of the pharyngeal +plexus. Pain in swallowing is generally due to some inflammation or +infection of the tonsil or pharynx. This does not occur when everything +is normal from the fifth dorsal up. + +The second and third stages of swallowing occur in the =esophagus=. +The esophagus receives esophageal branches from the vagus, carrying +autonomic fibers which contract its longitudinal muscles and dilate +its arteries. It also receives sympathetic impulses from the plexus +on the arteries which supply it. These sympathetic impulses convey +vaso-constriction and constriction of the circular muscles of the +esophagus. Any lesion from seventh cervical to ninth dorsal might +affect the esophagus; probably fifth dorsal is the most nearly +specific, as the heartburn which results from regurgitation into the +esophagus is usually localized there. + +Lesions of the upper six dorsal vertebræ interfere with digestion and +nutrition in another vital way by reducing the activity of the lungs +and consequent =intake of oxygen= into the system. If there is not +sufficient oxygen to oxidize the proteins to amino-acids there will be +harmful products left for the tissues to neutralize. Lesions of the +third, fourth and fifth cervical affecting the =phrenic= may have a +like effect. Sub-oxidation must be noted when present and treated by +removing lesions affecting respiration, by deep breathing exercises, +and by diet rich in the needed mineral salts, and properly balanced. +An improperly balanced diet changes the structure of the tissues and +amounts in effect to an osteopathic lesion which causes disturbed +function. It must be searched for, found if present, accounted for, +corrected and kept corrected to obtain maximum therapeutic results. + +The stomach, intestines and rectum are intimately related with the +other abdominal viscera. + +It will therefore be readily seen that any disturbance of the liver, +gall-bladder, pancreas, spleen, duodenum, pleura or peritoneum will +disturb the function of the stomach, and that any disturbance of any +organ will disturb the function of the intestine. In fact, clinically, +it would seem that the majority of cases can be accounted for by +the lesions found, the stomach or intestinal disturbances which are +regarded as reflex from some other organ, being in reality caused +by the same lesion as disturbed the organ which first manifested +disturbance. + +Going more deeply into the nature of the mechanism whereby symptoms +of gastro-intestinal disturbance are produced, we find that the +alimentary tract has an ingenious conveyer mechanism with a number of +sphincters. These are operated by intrinsic sympathetic or myenteric +nerves, called plexuses of Meissner and Auerbach. In conveying food, +impulses are passed from one portion of the tract to the next over +these myenteric arcs. Normally the peristaltic movement is always +forward because the point of highest irritability is at the proximal +end. There is an exception to this rule in the ascending colon, where +antiperistalsis occurs normally. When the irritability of a distal +point of the alimentary tract becomes greater than the more proximal +points, an antiperistaltic wave is set up causing vomiting. The +myenteric activities are regulated by the autonomic impulses over the +vagus, and by the sympathetic impulses over the splanchnic nerves. The +autonomics contract the longitudinal muscles, dilating and shortening +the tube. They also stimulate secretion of digestive juices and fluids +and mucus and dilate the blood-vessels. The sympathetics contract +the circular fibers and sphincters, narrowing and lengthening the +tube, retarding the food, inhibiting the secretions and constricting +the blood-vessels. The myenteric reflexes can continue after the +vagi and splanchnics are cut. The vagi simply stimulate them and the +splanchnics inhibit them. The pathways are from the coeliac plexus +where the vagi and splanchnics meet with various other plexuses on +the arteries and following the courses of the arterial supply to +the minutest parts of each organ. Each cell is surrounded by nerve +fibers. Visceral-afferent fibers over both vagi and splanchnics convey +impulses to the cord segments and medulla which modify the systemic +blood supply, drawing blood from the head and surface by constricting +their arteries during digestion and filling the abdominal arteries. +If opposite impulses should be received drawing blood away from the +abdominal arteries, digestion would be interfered with. Any lesion or +other condition causing hyperirritability or overstimulation of the +vagus will result in overstimulation of the myenteric nerves, with +vasodilatation, hypersecretion, contraction of the longitudinal coat, +widening and shortening of the digestive tube, sluggish peristalsis but +rapid movement of food through the sphincters, incomplete digestion +and undernourishment. Inhibition of the splanchnic nerves will produce +a like result. The opposite condition would come about as a result of +inhibition of the impulses over the vagus to the myenteric nerves, or +of overstimulation of the splanchnic nerves. + +Inhibition of the splanchnic nerves may be secured by extreme flexion +of the spinal column. This raises the cord in the spinal canal, +lengthens it, stretches or draws on the nerve roots and vessels, +squeezes the fluid out of the cord, and inhibits the splanchnics in two +ways, first by a partial anemia or ischemia of the cord, and secondly +by direct traction of the visceral afferent fibers in the posterior and +anterior roots. + +Conversely, stimulation of the splanchnic nerves may be secured by +complete extension of the spinal column. This lowers the cord in +the spinal canal, shortens it, releases the strain on the nerve +roots and vessels, flushes the cord with blood, and tones up the +sympathetic impulses in two ways, first by increasing their relative +and absolute nutrition, through richer supply of richer blood, and +secondly by releasing the nerve roots from strain, permitting free +entry of afferent impulses over the posterior roots, and free exit of +visceral-efferent impulses over the anterior roots. + +Any lesion, inasmuch as it limits or alters the normal motion in a +joint, produces an exaggeration or diminution of the normal spinal +curves, and more or less lateral curvature. The altered equilibrium +thus produced affects the viscera in three ways: 1. Mechanically, by +pressure, gravity, altered position of ribs, vertebræ, diaphragm, etc.; +2. Reflexly, influence on nerves to and from affected segment; 3. +Directly, by interference with nutrition of nerve cells by hyperemia or +ischemia. + +There is always a functional kyphosis in visceroptosis or +splanchnoptosis. The nerves in the cord are inhibited. The skeletal +muscles are hypotonic, allowing the functional kyphosis to occur, +and the viscero-motor nerves are inhibited, allowing the abdominal +viscera to become hypotonic and sag out of place within the abdominal +cavity. The ribs are held up by the cervical fascia, and the abdominal +muscles are held up by the ribs. The hypotonic condition extends to +intercostals and abdominal muscles, with the result that the abdominal +muscles are unable to play their part in maintaining the viscera in +their proper places. The contraction or tonus of the abdominal muscles, +the external and internal oblique, transversalis, rectus abdominis, +diaphragm and levator ani, maintain the viscera firmly in position. It +is only when the muscles of the abdominal wall have lost their tone +that any strain or weight is thrown on the peritoneal and vascular +supports. The inhibition of the restraining sympathetic impulses via +the splanchnic nerves, allows hypersecretion and hypermotility of the +alimentary tubes and further complicates the clinical picture by a +colicky diarrhea or spastic constipation. + +There are eight sphincters of circular unstriped muscle in the +alimentary tract. Inhibition of sympathetic supply or increased +autonomic supply causes sphincter insufficiency, overstimulation by +sympathetic impulses or an insufficient supply of balancing autonomic +impulses causes sphincter spasm, stasis, vomiting, fermentation, +putrefaction, auto-intoxication. At each of these sphincters food is +held back and controlled till the proper time has elapsed and the +proper chemical environment is prepared for it in the next portion +of the tract. Normal function of these sphincters is absolutely +essential to normal metabolism and nutrition. The upper esophageal +sphincter controls the entrance to the esophagus; the cardia controls +the entrance to the stomach, the pylorus controls the entrance to +the duodenum, the X-Ray shows a duodenal sphincter that controls the +entrance of food into the jejunum. Here the food enters the long +tract of the jejunum and ileum which measures twenty-five feet when +the longitudinal muscles are relaxed and the circular muscles tonic, +and which a short time later may measure only fifteen feet when the +longitudinal muscles are contracted and the circular are relaxed. This +section ends at the ileo-cecal valve, which controls the entrance +of food into the cecum. There is the mid-colic sphincter about the +junction of the proximal third with the distal two-thirds of the +transverse colon, and the recto-colic sphincter which controls the +passage from the sigmoid to the rectum. The rectum ends in the internal +sphincter ani. There is some evidence of a ninth sphincter, the +mid-gastric at the point where the peristaltic waves of the stomach +begin. Absorption takes place mostly from the ileum and jejunum and it +is worthy of note that four of these sphincters hold the food up on its +way into this part of the tract, and four of them hold it back on its +way out. Any lesion may affect one or other of these sphincters. It +is believed that antiperistalsis from the mid-colic sphincter to the +cecum during digestion is normal permitting more complete absorption of +nourishment. Yet here, after absorption is complete, and at all times +elsewhere in the alimentary tract, peristalsis is normally forward +because the point of highest irritability is at the upper esophageal +sphincter and the irritability decreases as the tract is further from +the esophagus. + +When the splanchnics are inhibited and the vagus autonomic impulses are +normal or increased, the intestinal sphincters from the pylorus down +may all be incompetent, so that food passes along too rapidly to be +properly digested and absorbed. This results in undernourishment. + +Any lesion anywhere in the body will affect =peristalsis=. It begins +at the lower third of the stomach where it joins the pyloric portion +and goes forward to the internal sphincter ani, being modified in its +course by local conditions. Compensation may be established. Many cases +of diarrhea and constipation are thus to be accounted for. =Diarrhea= +is a symptom due to vasodilatation, hypersecretion and relaxation of +the circular muscles especially at the sphincters. When these three +factors are cleared up by correction of the lesions and hyperextension +of the spine, the diarrhea stops unless some other factor is at +work to irritate the myenteric nerves or to excite the autonomics +or inhibit the splanchnics. Lesions from the sixth dorsal down are +usually accompanied at first by some diarrhea, which afterwards +becomes constipation, through loss of tone in the longitudinal muscles +especially in the distal part of the colon. In these cases, correction +of lesions, and extreme flexion of the lower dorsal and lumbar spine +will give relief while the body is returning to normal. + +When gastric digestion begins, simultaneous action is set up in the +ileum. When disease of the cecum, appendix or ascending colon is +present, there is contraction of the ileo-cecal valve causing stasis +of the lower ileum and disturbed or retarded action of stomach and +duodenum. These reactions are brought about by impulses to and from the +myenteric plexus. The sympathetic and autonomic nerves affect the motor +system of the alimentary tract not directly but through the myenteric +or Auerbach’s plexus. + +The =external sphincter ani= muscle is supplied by the pudendal +nerve from the third and fourth sacral segments. It is in a state +of tonic contraction, and having no opposing muscles keeps the anal +orifice closed. The autonomic supply to the longitudinal muscles in +the descending colon and rectum is from the second and fourth sacral. +Inhibition here will, therefore relax the longitudinal muscles and +external sphincter and permit free peristalsis in the descending colon +and rectum. Pelvic disturbances may affect these nerves, or pressure +due to visceroptosis, etc. The circular muscles of this section are +supplied from the lumbar cord. They may be affected in any lumbar +lesion, with the end result of spastic constipation by reason of a +shortened markedly distended descending colon, sigmoid and rectum, and +little peristalsis because of inhibition of the circular fibers, and +contraction of the external sphincter ani. + +The fundus of the stomach, lying in the left dome of the diaphragm, +always contains a cushion of air which supports the left dome of the +diaphragm, as the convexity of the liver supports the right. Normally +the air is regulated and causes no symptoms. A lesion, usually of the +mid-dorsal or lower dorsal segments may inhibit the circular fibers +and permit distension, which becomes enormous when the pylorus is +obstructed. The shortness of breath, palpitation of the heart, etc., +accompanying this distension are probably due to pressure on the heart +and lungs from which the stomach is separated only by the diaphragm. + +Eighth, ninth and tenth dorsal lesions play a large part in peptic +ulcers by permitting hyperemia, hypersecretion, and lowered vitality +of the mucosa, and pyloric incompetence or spasm, because the pylorus, +pyloric end of the stomach and first part of the duodenum get their +chief sympathetic supply from the ninth and tenth dorsal segments of +the cord. The tenth vertebra is more freely movable than the higher +dorsal joints and is therefore more frequently in lesion, which helps +to account for the greater frequency of duodenal ulcer. + +The main sympathetic supply to the appendix seems to be derived from +the eleventh dorsal segment. The appendix has the same motor and +secretory mechanism as the rest of the alimentary tract but is richly +supplied with lymphoid follicles. One of the twigs from the eleventh +dorsal nerve pierces the rectus muscle to supply the skin at McBurney’s +point, thus explaining the great frequency of pain and cutaneous +hyperalgesia at this situation in appendicitis. Lower dorsal and upper +lumbar lesions are unquestionably causes of many cases of appendicitis +and other obscure diseases traceable to appendicitis. Correction of +these lesions has restored the appendix and related structures to +normality in hundreds of cases. + +Sensory reflexes are shown in hyperalgesia and pain or tenderness in +the abdominal skin and muscles and the parietal layer of the peritoneum +from the ensiform cartilage to the pubes in an area extending about two +inches on each side of the mid-line, corresponding to the distribution +of the twigs of the lower six thoracic nerves which supply sensation to +this region. =Esophageal= disturbance at the cardia causes pain in the +region supplied with sensation by the fifth and sixth dorsal, near the +ensiform. =Gastric derangement= causes pain midway between the ensiform +and umbilicus, which radiates to the left, in the area supplied by the +eighth dorsal. =Hepatic disturbance= causes pain on the right of the +median line, radiating to the right in the sensory distribution of the +ninth dorsal. =Intestinal pain= is located in the sensory distribution +of the tenth dorsal nerve in an oval area around the umbilicus. Pain +due to =duodenal ulcer= is sharply localized at a point about an inch +or two above and to the right of the umbilicus where twigs of the tenth +dorsal nerve come to the surface. This point corresponds closely to the +normal position of the underlying duodenum, though the duodenum may be +displaced, and the sensitive spot remain at the same point. The pain +from =fundal gastric ulcer= or =carcinoma= is usually localized sharply +about an inch or two to the right of the median line midway between +the ensiform and umbilicus, at the spot where the twigs from the +eighth dorsal nerve pierce the rectus and come to the surface. In the +disease of the =pylorus=, reflex pain is lower; of the =cardiac end=, +higher. The reflex pain at McBurney’s point in =appendicitis= has been +referred to, but it must be borne in mind that pain from disturbance +in the =colon= also shows in the sensory distribution of the eleventh +dorsal nerves midway between the umbilicus and pubes. Pain may also be +referred to areas supplied in the back by the corresponding segments. +These reflex pains can usually be stopped by inhibiting along the spine +corresponding to the sensory area affected. This reduces the impulses +entering the posterior roots and lowers the irritability of the segment. + +The =motor reflexes= from gastro-intestinal disturbances result in +muscular contractures of spinal, abdominal and other muscles supplied +by motor nerves arising in the anterior horn of the segment which +innervates the part of the viscus that is affected. Stomach, liver, +gall-bladder, pyloric and duodenal disturbances cause increased tone, +contraction, contracture and rigidity of the rectus muscles above +the umbilicus, for instance, and the other viscera contract it in +lower portions. More important are the extreme contractures of the +musculature of the back which is supplied by the segments which supply +the affected part of the viscus. These contractures produce some +distortion and loss of motion in spinal joints and thereby produce the +same effects as primary lesions, causing widespread disturbance which +persists until the spinal musculature is normalized. In =colic=, the +lumbar segments being involved, there is marked contraction of the +ilio-psoas which causes the characteristic drawing up of the thighs +on the abdomen, while the extreme contraction of the rectus abdominis +draws the thorax down. + +Most persistent vomiting may arise reflexly from other organs as +in so-called biliousness, jaundice, pregnancy, brain affections, +appendicitis, onset of acute infectious diseases, alcoholism, +sea-sickness, colic, hernia, intestinal obstruction, migraine, +shock, and anesthesia. Irritation of any sensory branch of the vagus +or of nerves which connect with it in the medulla, or reflexly +from consciousness via the cerebral cortex, as in the case of +nauseating sights, smells, tastes, as well as irritation from any +viscera innervated from the sixth dorsal down, may overstimulate +the corresponding efferent nerves going to parts of the alimentary +tract supplied by that segment, increase its irritability and start +antiperistalsis. Similarly disturbances in almost any viscus may +reflexly disturb the normal balance between sympathetic and vagal +autonomic stimuli resulting in hypersalivation, hyperchlorhydria, +pylorospasm, distension, gastric atony, gastrosulcorrhea, +enterocolitis, spastic constipation, achylia, or colicky diarrhea. +In these cases, the derangement of the viscus reflexly disturbs the +alimentary tract through central nerve connections. Correction of the +primary trouble is followed by removal of the reflex symptoms. In this +connection it is important to note that the visceral reflex symptoms +may arise from irritation of the alimentary tract by improper diet, +poor cooking, or wrong combinations. Carbohydrates digest quicker +than proteins, and these more rapidly than fats. Food is handled by +the fundus in the order in which it was swallowed. If the fats are +swallowed first, the starches may be held up for five or six hours, +subjected to the acid stomach secretions and allowed to ferment causing +distension, which reflexly produces a variety of symptoms. + +Mental exertion, strong emotions, heavy physical exertion, interfere +with the function of the alimentary tract and set up disturbances in +the balance of sympathetic and vagal autonomic impulses, through the +nervous reflexes via the cortex, and through the demand for blood, +which impoverishes the abdominal circulation at a time when it needs +all the blood it can get. The ischemia produced in this way has about +the same effect as ischemia produced by a spinal lesion. Conversely, +disturbances of the alimentary tract produce profound changes in +character and personality, by reflexes to the cerebral cortex causing +dullness of perception, in all the senses, poor memory, sluggish +thought, erratic judgment, irritable disposition, fear, worry, lack +of ambition, indecision, lack of energy, vacillation, and finally a +psychosis in which manic depressive symptoms are balanced by paranoiac +symptoms. + +The alimentary tract is so intimately bound up with the whole stream of +vital activity, whether vegetative, sensorimotor, or psychic, that any +disturbance of body or mind is likely to affect it in some part, and +conversely any disturbance of the alimentary tract is bound to affect +all the rest of the body and the mind. A satisfactory classification +of its diseases is therefore difficult to make, but the one here +adopted is probably the best for the purpose. The early stages of +gastro-intestinal diseases are often so similar that it is nearly +impossible to differentiate them with certainty; the classification +is therefore based on the clinical picture and pathology of advanced +stages. Fortunately, with the exception of cancer, diseases treated in +the early stages usually clear up when the lesions are corrected, and +the necessary attention given to the other causative factors present. + + +Acute Gastritis + +Acute dyspepsia is one of the frequent disorders of the stomach. It +may occur as an early symptom of an infectious disease, but very often +it is due to some non-specific irritation. The usual exciting causes +are errors of diet, over-indulgence in improperly cooked and highly +seasoned food, or food that has been spoiled, such as meat, fish and +milk, or over or under ripe fruit. Food that is either too hot or too +cold may develop an attack. Alcohol is a common cause in those not +accustomed to its use. Overuse of tobacco may bring on an attack. Many +acute “bilious” attacks are brought about by some mental shock or +excitement at the time of taking food, for it has been shown by the +researches of Pawlow that both gastric motion and secretion are altered +by mental irritation during digestion. + +Unquestionably osteopathic lesions of the splanchnics and vagi are +important predisposing factors. These lesions produce a lowered +resistance of the tissues, which will frequently explain why certain +exciting factors that will initiate an attack in one individual will +not do so in another. A healthy mucosa will not be so readily irritated +by either indigestible or partly decomposed food. + +Osteopathic experimental work reveals that the vertebral and rib +lesions readily affect both the spinal nerves and the sympathetic +ganglia, which is followed by vasomotor and trophic disorder to the +mucous and submucous coats of the stomach, as shown by eccymosis and +hemorrhage of the submucosa and beginning parenchymatous degeneration +of the free ends of the glands of the mucosa. Upon the other hand +irritation of the muscles from dietetic errors always causes more or +less contraction of the muscles in the upper and middle dorsal, which, +in turn, may produce through imbalance of tension and fibrositic +changes, constant interosseous lesions and thus be the cause of the +catarrh becoming chronic. This vicious cycle phenomenon should not be +overlooked. Viscero-motor, viscerosensory and viscerotrophic reflexes +may be factors in the pathogenesis of the osteopathic lesion. + +=Pathologically=, the mucous membrane is more or less covered with +mucus. Upon removal of the mucus the membrane is found red and swollen, +and the epithelial cells of the glands are granular. This is especially +noted in the pyloric area. There are minute extravasations of blood and +hemorrhages of the mucous coat, and infiltration of the submucous layer. + +=Symptoms.=—Acute gastritis occurs at all ages, so particularly in +children care has to be taken that the attack is not the beginning +of some infectious disease. A careful inquiry into the history, and +examination of the vomitus will usually make the diagnosis clear. +The sudden onset of nausea, vomiting, pain in the epigastric region +referred to the back and head, vertigo in some cases, if the infections +can be ruled out should leave no doubt as to the nature of the disorder. + +Other symptoms are weakness, and chilliness which later if the attack +is severe, is followed by fever. The tongue is coated, the lips dry, +and there may be herpes. Belching of gas, constipation in some and +diarrhea in others, and dark colored urine are noticeable. There is +tenderness on palpation over both the stomach and splanchnic areas. +Examination of the stomach contents show deficient hydrochloric +acid, the presence of organic acids, bile and undigested food, and +considerable mucus. + +=Diagnosis.=—In young children acute gastric indigestion is common, +though a casual gastritis is rare. In the former prostration, +vomiting, and undigested, greenish stools are noted. In some cases +there is no fever, while in others it may range from 102 to 105 +degrees. In all cases care should be taken, as has been stated, +that the attack is not the beginning of some infectious disease. +Appendicitis, acute bowel constriction, pregnancy, uremia, meningitis, +gall-stone colic, and gastric crises of tabes dorsalis should be +differentiated. Most attacks of acute dyspepsia are over in twenty-four +hours. The prognosis depends upon eliminating the cause. The X-ray may +be of value in protracted cases. + +=Treatment.=—If the case is seen early, emptying the stomach by induced +vomiting or the stomach tube is the first indication. If several hours +have elapsed and much of the stomach contents have passed into the +intestine, emptying the colon with an enema will commonly give quick +relief. Withhold all food for from twelve to twenty-four hours, or +longer if necessary. In some cases the sipping of hot water will be +beneficial, while in others pellets of ice in the mouth will give some +relief. + +Whether or not there existed previous spinal lesions there will always +be found muscular tension and spinal rigidness during an attack of +acute gastritis. These should be corrected for immediate relief, but +what is of greater importance, if these acute lesions are not corrected +the patient’s recuperative forces are interfered with and recovery is +delayed. Then, also, these lesions tend to chronicity and predispose +to future attacks. Treatment should be given daily, or oftener if +special indications arise. Though the most common area that demands +attention is from the fourth to tenth dorsals, still the vagi nerves, +especially the right, should not be neglected. Lesions of the upper +three cervicals are the most frequent disturbances of the vagi. + +=Vomiting= is a common and distressing symptom. Pathologically, it is +due to an antiperistaltic contraction of the stomach and a spasmodic +contraction of the diaphragm and the abdominal muscles. It is caused, +usually, by irritation of the vagus in the stomach, or in the pharynx +by irritation along the spine (particularly in the cervical and upper +dorsal regions), or to the sympathetic nerves or to various parts of +the body, or by direct influence of the brain. Relief can usually +be given by inhibition of the vagus in the occipital region or by +inhibition at the fourth or fifth dorsal vertebra on the right side. +In a few instances, placing the patient in the knee-chest position and +gently raising the abdominal organs gives relief. If this does not +suffice the stomach and colon should be emptied, providing the vomiting +is protracted. A frequently effective measure for nausea and vomiting +that can be carried out by the attendant, is the application of hot +fomentations to the dorsal spine. + +=Flatulency= may be very distressing. The spinal treatment may be +sufficient to control this condition, or careful direct pressure for a +few minutes over the pit of the stomach. Adjustment of the lower ribs, +especially of the left side, may be effective. Occasionally the gas +can be passed into the intestines by careful inhibitory treatment in +the region of the eighth and ninth dorsals. The inhibitory treatment +causes relaxation of the pyloric orifice; also, inhibition of the left +vagus relaxes the pylorus. Inhibition at the sixth and seventh dorsals +relaxes the cardiac orifice, thus favoring the passing of the gas from +the stomach out through the esophagus. + +In all cases subject to gastritis the dorsal spine should receive +considerable attention in order that recovery may be complete. The +habits of the patient should be thoroughly regulated and overfatigue +guarded against. And, also of special importance in recurring attacks, +is the fact that a number of cases present some derangement of the +biliary tract, or duodenum, or the appendix region. + +=Diet.=—After twenty-four or forty-eight hours, if the attack has been +severe, albumin water may be given in small quantities; also whey, +milk, bouillon, and chicken or lamb broth. If there is no return of +gastric distress, add junket, custard, cornstarch pudding, gelatine, +dropped eggs, scraped beef, and white meat of chicken; vegetables +purees made with cream or meat stock are usually well borne at this +time. Foods containing much cellulose, fats and sweets should be +withheld until all symptoms have subsided. + + +Chronic Gastritis + +It is unnecessary here to repeat the causes of acute gastritis, any +one of which continued over a long period of time will cause chronic +catarrh of the stomach, as it is sometimes called. + +Spinal and rib lesions anywhere from the occiput to the coccyx, but +more particularly from the fourth to the tenth dorsal, will predispose +to chronic gastritis, the particular type and degree of local pathology +depending upon the exciting factor. + +A commonly found _en bloc_ lesion is a flattening of the normal +convexity in this region, with more or less immobilization, shown by +attempting to reestablish the normal convexity through flexion. + +In addition there may be single spinal or rib lesion in the same area, +or cervical lesions affecting the pneumogastric, which is the secretory +nerve to the stomach. (See chapter on the “Lesion and Its Applied +Anatomy.”) + +=Pathology.=—Chronic gastritis probably never develops as such without +going through several preliminary stages beginning with alimentary +hypersecretion, or hypersecretion occurring only during the active +period of digestion. These are the cases usually classified as +hyperchlorhydria. At this time no actual pathology can be demonstrated +in the glandularis. + +If the condition is not treated intelligently at this time the next +step will be periodic attacks of what is known as “hypersecretion +periodica chronica” followed by “hypersecretion continua chronica.” +The stomach contains abnormal amounts of gastric juice even after a +night’s rest. At this stage there is a transition from the functional +to the organic condition. All stages are characterized by an abundant +secretion of mucus. + +If allowed to go on there will finally result a destruction of the +secreting cells known as Atrophic Gastritis or Achylia Gastrica in +which the stomach presents a smooth functionless appearance. + +=Secondary Chronic Gastritis.=—Portal obstruction from any cause +predisposes to chronic gastritis. The most common of these is failing +compensation in heart lesions, which through back pressure causes +portal stasis; the same thing may follow obstruction in the liver +itself. Chronic gastritis is also a late accompaniment of the nephritic +trinity, kidneys, heart and arteries. It may also be associated with +diabetes, gout, anemia and other constitutional disorders. + +Tuberculosis is commonly ushered in by symptoms of chronic gastritis. +We should be constantly on the alert to avoid the mistake so commonly +made of treating the stomach as an entity and overlooking the real +trouble in some other part of the anatomy. + +It is probably safe to say that there are only two primary diseases of +the stomach, ulcer and cancer. All others are suspiciously associated +with diseased processes elsewhere, and when the spinal lesion is given +its full significance even these will be found to be directly traceable +to anatomical perversions somewhere within the mechanism of local +nutrition. + +=Symptoms.=—These are governed by the stage of progress in which the +patient is seen. During the stage of hypersecretion of acid gastric +juice there will be vague feelings of distress, fullness and burning +in the stomach, and “heartburn” during digestion. When the stomach is +empty all symptoms will subside. Later there will be periods of a few +days or weeks when there will be more or less continuous distress with +some vomiting of highly acid gastric juice containing mucus. + +When the condition has progressed to the stage of continuous +hypersecretion there will be continuous symptoms as above, but with +nausea, vomiting becoming more frequent especially late at night or in +the morning, always accompanied by sticky mucus. + +Appetite is variable, there is often a disagreeable taste in the mouth +(the “dark brown” taste of the chronic alcoholic). Heart palpitation +and vertigo and other vagus symptoms are common. + +=Diagnosis.=—On physical examination the stomach is found distended, +and in some cases displaced (gastroptosis). There will be diffused +tenderness on pressure over the whole organ which should help to +distinguish it from gastric ulcer or cancer in which the tenderness is +quite localized. + +Chronic gastritis cannot be =positively= diagnosed without making a +gastric analysis. Many cases are wrongly diagnosed through neglect of +this very important procedure. + +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. + +=Prognosis= is rather favorable. Examination should show the cause of +the nerve interference and its correction bring relief. + +=Dubini’s disease= is probably associated with certain diseases of the +cord and brain and is characterized by sudden, sharp pains in the head, +neck and lumbar muscles, extending to the lower extremities in the form +of a short, sharp spasm, usually at regular intervals. Later there may +be symptoms of hemiplegia. The disease is apt to progress and death may +occur during a convulsion. + +=Habit spasm= usually results from overstudy and nerve exhaustion +with impairment of general health, and is incident to early life. The +child is usually a neurotic. The symptoms are twitching of the mouth +and eyelids, grimaces and jerking of the shoulders. =Treatment= for +the general condition, with correction of any spinal lesions, will +generally give relief. + +=General tic= resembles habit spasms closely. In some cases the patient +is apparently healthy, while in others there is some brain disorder. +There are coordinate spasmodic movements of the head, face and upper +trunk, swallowing and abnormal vocal sounds. The movements are rapid +and frequently repeated. =Prognosis= is uncertain and will depend +largely on general conditions. In =convulsive tic= there is usually a +repetition of certain words or sounds with a convulsive twitching or +movement of certain muscles. + + +Infantile Convulsions + +(ECLAMPSIA) + +=Infantile convulsions= may be due to various causes. A neurotic +inheritance is an important predisposing factor. They may precede the +development of many diseases of the nervous system, and also occur as +the result of peripheral irritation. Dentition in association with +rickets, and intestinal parasites are common causes. They may be the +early symptoms of acute, infectious diseases. Scarlet fever, measles, +pneumonia and smallpox are very frequently preceded by convulsions. +They may be due to debility, resulting from gastro-intestinal +disorders. Malnutrition is a predisposing cause. Disease of the bones, +especially rickets, may be associated with convulsions. Lesions of the +brain are other causes. A protracted instrumental delivery may cause a +hemorrhage of the meninges. + +=Symptoms.=—In severe cases the fit may be identical with epilepsy. +It is more often not so complete as true epilepsy. Convulsions vary +considerably, but there will be no difficulty in diagnosis. It may +come on suddenly, or be preceded by restlessness, twitching, sometimes +grinding of the teeth and fever. The spasms may be either of a tonic +or clonic type preceded by a cry and loss of consciousness. The attack +may be single, but the fits may follow each other with great rapidity +and terminate fatally. It is rare for the child to die during a +convulsion. Exhaustion and asphyxiation may cause a fatal termination. +As in epilepsy the temperature often rises during the fit. A transient +paresis sometimes follows, if the convulsions have been chiefly limited +to one side. + +=Diagnosis.=—The diagnosis is generally easy. The attack is usually +due to the ingestion of some indigestible food or to some peripheral +irritation, or an acute disease. Convulsions, appearing immediately +after birth or injury, are probably due to meningeal hemorrhages or +serious injuries to the cortex; although a few of these cases will +present grave lesions of the cervical vertebræ, probably often due to +protracted instrumental delivery. Infantile convulsions usually occur +between the fifth and twentieth months. Convulsions occurring after +the second year are more likely to be true epilepsy. The =prognosis= +depends almost wholly upon the cause, severity and duration. + +=Treatment.=—The =first step= in the treatment is to determine the +cause if possible. Treatment in the region of the sixth and seventh +dorsals will often give relief; thorough work along the lumbar region +and the sacrum will many times be sufficient, if the convulsion is due +to intestinal disorder. C. M. Proctor reports that in male infants he +has relieved convulsions quickly, in several cases, by pushing back +the foreskin and has always found, in such cases, either a phimosis +or an adherent prepuce. In female infants it might be well to examine +the clitoris. Dilatation of the rectal sphincter may be of aid. It may +be necessary to vomit the patient, when it is due to undigested food +in the stomach; and in some cases an enema should be used, when the +irritation is in the intestines. In a few cases, when the convulsions +are due to dentition, a lancet applied to the gums will be all that +is required. A thorough treatment to the cervical region, to control +the circulation, should always be given; at the same time apply ice to +the head. The patient should be put in a bath of 95 to 98 degrees F., +should the preceding treatment not have the desired effect, or, better +still, use the bath at once and treat at the same time. + +Owing to the neurotic tendency and the ofttimes trivial causes that +precipitate an attack everything possible should be done to build up +the general condition—adjustment of all lesions, regulated diet and +disciplined habits. + + +Epilepsy + +=Definition.=—A chronic affection of the nervous system, characterized +by attacks of unconsciousness, which are usually accompanied by general +convulsions. When there is merely a momentary loss of consciousness it +is called =petit mal=. Loss of consciousness with convulsions is called +=grand mal=. When the convulsion is localized, with or without loss of +consciousness, it is called =Jacksonian epilepsy=. Certain cases of +temporary loss of consciousness are termed =psychic epilepsy=. + +=Etiology.=—Epilepsy usually begins before puberty, and comparatively +seldom after the twenty-fifth year. Males suffer somewhat more +frequently than females. Heredity predisposes to the disease to some +extent, but probably not so greatly as many writers would claim. +Neuroses, as insanity and hysteria, and intermarriage of relatives, +are important elements to consider. When epilepsy is inherited, it is +almost always due to some morbid state of the nervous system. Other +predispositions to the disease may be caused from defective general +development of the brain, from impairment of the general health, and +from an exhausted nervous system. + +Many =exciting causes= may be found: mental emotion, fright, excitement +and anxiety; blows and injuries to the head; infectious diseases; +syphilis; alcoholism; masturbation; ocular and aural irritation; +disturbed and delayed menstruation. Epilepsy may be excited by reflex +convulsions from intestinal worms, gastric irritation, etc. Also +thickening of the membranes of the brain, pressure from a tumor at the +periphery, uterine diseases and many other sources of irritation may be +found, that are the exciting causes of epilepsy. + +Important exciting causes of epilepsy are, undoubtedly in many cases, +due to =lesions= of the =vertebræ= and =ribs= especially the vertebræ +of the cervical region, although in some cases the lesion is in the +lower splanchnic region or in the ribs (chiefly from the fourth to the +eighth). These lesions to the spinal tissues disturb the nutrition +to the vasomotor nerves. If the real seat of the disease is in the +cerebral cortex and the medulla, the cervical lesion, and in fact other +lesions, could readily affect the nerve force and circulation to and +from these regions. The vertebral artery circulation, where a cervical +lesion exists, may be involved and affect the brain. In cases where +lesions of the vertebræ and ribs exist in the upper and middle dorsal +region, the vasomotor innervation to the brain may be involved, for in +this region the vasomotor nerves to the cranium, etc., pass from the +cord into the sympathetics. Birth injuries may affect the brain tissue, +through cervical lesions, hemorrhages and asphyxiation. + +Conklin attaches considerable importance to stasis of the sigmoid and +ascending colon. Lesions involving this region may result in toxins +entering the blood and affecting nervous tissue. + +To illustrate a specific exciting lesion, the following is interesting. +The case was one of epilepsy that was evidently caused by a dislocated +right fifth rib. By producing an irritation in the region of this +rib, so that the lesion was increased, the patient could be made to +immediately suffer from an attack of epilepsy. By resetting the rib, at +once the sufferer would be entirely relieved. The case was cured after +three months’ treatment, the chief work being to keep the rib in place. +Rarely a subdislocated innominate bone, or some lesion remote from the +brain, is located and found to be causing epilepsy. Important lesions +in most cases will be readily located in the cervical region. Booth +reports: “I have records of seven fairly defined cases of epilepsy—such +as have been so pronounced by M. D.’s. I find in all of them =marked +lesions= in the =upper cervical= and in most of the cases the occiput +is posterior upon the atlas or twisted. In all cases there was a +thickening of the soft tissues, especially in the upper cervical. The +lower cervical was also much involved but not so noticeably. All of the +cases also presented marked disturbances in the upper dorsal; most were +decidedly anterior, and one very posterior. One was almost a confirmed +drunkard; notwithstanding the fact, he recovered to such an extent that +he went to work, and I understand has been holding his position for +more than three years. He had had to give up his work entirely. One +was a hopeless case in every particular and did not seem to receive +any benefit from the treatment. I think it was entirely beyond help +from any source. The others responded very well and the results were +definite and decided. The length of treatment in successful cases +ranges from about five weeks to a little over a year. But those that +were treated the greater length of time were not treated continuously.” + +After one convulsion has occurred, others readily occur, owing to +the proneness to changes in the nerve centers. Very little is known +as to the pathology of this disease. Convulsions may be caused from +irritation of both the cortex cerebri and the medulla oblongata. From +a study of the character of the auræ, one is led to believe that +there is a disturbance, in most cases, in the centers of the cerebral +cortex; and that the lesions so generally found along the spinal column +are the true exciting causes of the disease. Perhaps in a few cases +the irritation may be to the medulla reflexly. The lesions found on +osteopathic examination may act reflexly, as has been stated, upon the +centers in the brain and excite them; or the circulation is deranged, +and consequently the nutrition to the brain and meninges, by vasomotor +control and the vertebral vessels, is impaired. + +The splanchnic area and the cervical region should always receive +special attention. This in conjunction with all possible reflex +sources, and, not least, the general health, restoring a stable nervous +system if possible, are of greatest importance. + +As a rule, =pathological= lesions are not found. To the naked eye the +appearance of the nerve centers is largely that of healthy organs. The +changes revealed by the microscope are most probably those of secondary +origin. Recent experiments seem to show that the motor zone of the +cortex is affected. + +=Symptoms.=—These will be considered under the three varieties, known +as grand mal, petit mal and Jacksonian. =Grand mal.=—In most cases the +seizure is preceded by a pronounced sensation known as the =aura=. This +differs greatly in various individuals. It may begin in a finger or +toe and rise until it involves the head, when the patient screams and +falls to the floor unconscious. In other cases the sensation may start +from other parts of the body, as the epigastric region, where it may +simply be a slight discomfort; or other sensations may be felt, as that +of a ball rising from the stomach. The aura may start from any part of +the body as a numbness, tingling, chilliness, etc., and may, also, be +manifested through the optic, olfactory, auditory and gustatory nerves, +by flashes, smells, sounds and tastes. “Intellectual auræ” may also be +manifested. Some form of auræ is met with in nearly one-half the cases +of epilepsy. Others lose consciousness so early that the patient is not +aware of the onset. In cases not attacked suddenly and not preceded +by an aura, a prolonged prodrome may be present for several hours or +a day. The patient may feel irritable, dizzy or dispirited. Or he may +be quiet and calmly await the attack. In a few cases certain movements +may precede an attack, as running rapidly forward in a circle, or +standing on the toes and rotating rapidly. The attack proper is sudden. +The patient falls with a peculiar cry. The =convulsion= or fit may be +divided into =three stages=, that of =tonic= spasm, of =clonic= spasm +and of =coma=. + +The =tonic spasm= succeeds the epileptic cry; there are loss of +consciousness, pallor of the face and the contraction of pupils. The +body assumes a position of tetanic rigidity, the head is retracted and +rotated, and the spine curved, owing to an unequal affection of the +muscles of the two sides. The jaws are fixed, the arms are flexed at +the elbow, the hands at the wrist, and the fingers are clinched. The +legs and feet are extended. The muscles of the chest are involved and +respiration is suspended. This stage lasts a few seconds. The =clonic +spasm= follows the tonic spasm. The muscular contractions become +intermittent. From slight vibratory motions, the intermittent muscular +contraction becomes general. The arms and legs are thrown about +violently, the muscles of the face are distorted, the eyes rolled, and +the lips open and close. The muscles of the jaw contract violently +and the tongue is apt to be bitten. The pupils are dilated, the face +cyanosed (though at first the face is pale and pupils contracted) and +blood-streaked, frothy saliva pours from the mouth. The feces and urine +may be discharged involuntarily. The temperature rises about one degree +F. This stage lasts about one or two minutes. The period of =coma= may +last from a few minutes to several hours. Usually if left alone, the +patient will awaken after a few hours. In a few cases mental confusion +follows the waking. During the stage of coma, the face is congested +but not cyanotic. The muscles are relaxed and the breathing is noisy. +Epileptic attacks during sleep, =nocturnal epilepsy=, are not rare. +This may continue for some time without the patient being aware of it. + +=Petit Mal.=—In this variety of epilepsy, convulsions are absent. The +seizure consists of momentary unconsciousness with fixed, staring eyes, +dilated pupils and rarely any twitching of the muscles. After the +attack the patient resumes his work. There may be attacks of vertigo, +without unconsciousness, and the patient may fall. In a few instance +there may be auræ of various kinds. Petit mal may be a forerunner of +grand mal or the two may alternate. Between grand and petit mal there +are many grades of epilepsy varying in severity. + +=Jacksonian Epilepsy.=—The affection is always symptomatic of lesion in +the motor area of the cortex. The lesion is quite apt to be a tumor, +though various injuries, inflammation, sclerosis, softening, hemorrhage +or an abscess may be the cause. Consciousness is retained and the +convulsions are limited in extent. Tonic and clonic spasms of the same +character as in general epilepsy occur. A slight numbness, tingling, or +twitching may precede the attack. + +The =severity= of epilepsy =varies= extremely. The seizure may occur +but once a year or it may occur several times in a day. In many cases +a marked periodicity is observed. The mental functions are not, as a +rule, injured, but when the seizures are frequent, the health fails +and the mental capacity is reduced. Many sufferers from epilepsy are +subjects of chronic gastric catarrh, and have at the same time an +inordinate appetite. Quite frequently a fit may follow inordinate +eating. + +When there is a =series= of =convulsions=, which follow one another in +rapid succession and which are associated with high fever, the term +“=status epilepticus=” is applied. The most =common form= of epilepsy +is the =major= form. About two-thirds of all attacks occur between +eight a. m. and eight p. m. + +=Diagnosis.=—=Uremic convulsion= closely resembles an epileptic +convulsion. When the history of the case, analysis of the urine, +increased temperature and the general health of the patient are all +closely observed, error should be avoided. In =reflex convulsions= of +=children=, a careful search, and if necessary waiting a short time, +will readily determine the source of the attack. When =nocturnal +convulsions= take place without the knowledge of the patient the attack +is epileptic. In =hysterical convulsions= the patient rarely loses +consciousness. They rarely hurt themselves, never bite the tongue, the +temperature is normal, opisthotonos does not occur, and the duration +is usually longer. In =Jacksonian epilepsy=, the attack is limited to +some portion of the body, or it may gradually extend into a general +convulsion. Care should be taken to recognize petit mal. + +=Prognosis.=[121]—Records show that many cases have been cured and a +much larger number have been benefited. + +=Treatment.=—Osteopathic treatment has been especially successful in +epilepsy, as compared with other treatment. Although the osteopaths +do not claim a cure in every case, by any means, still about four out +of every ten have been cured, while one-half of the remaining have +been greatly helped in regard to the lessening of the severity of the +attack, and in rendering the attacks less frequent. Conklin through his +special treatment of fasting, dieting, enemata, spinal adjustment, and +particular attention to the large bowel, especially cecum and colon, +has increased this percentage. This is based on several hundred cases. + +Important lesions are usually found in the cervical region, from the +third to the seventh vertebra, though they may be as high as the +atlas. These lesions may affect the brain in various ways; probably +in the manner described under the etiology. Lesions are also found in +the dorsal vertebræ and when occurring below the cervical region, the +lesions are generally found in the upper and middle dorsal regions, +though they may be located at any point along the spinal column. + +The treatment is according to the rule that applies to all osteopathic +work: an individual correction of the lesions presented in the case at +hand. If any general movement or treatment might be given, it would +be strong traction of the head to stretch the cervical vertebræ, or +rather to separate them, so that the circulation to the brain may be +equalized. Another general measure is to hyperextend the neck with +fulcrum at juncture of atlas and occiput, thus releasing the upper +anterior tissues that may impede cerebral circulation. + +If the lesions in such cases are in the cervical vertebræ, probably +they affect the cervical sympathetics. A =careful search= for a source +of excitation must be made throughout the entire body. An irritation +of the intestinal tract may be the exciting cause; or some irritation +of the genito-urinary tract may be found, as phimosis, masturbation, +etc., so that it is very necessary that great care be taken in the +examination. Subjects of masturbation usually present lesions along the +genito-urinary center in the spine. All possible reflex irritations +should be eradicated. + +Proper =hygienic measures= should be added. Pay particular attention to +the bowels. Place the patient in the knee-chest position and thoroughly +raise the cecum and ascending colon in order to improve circulation +and promote elimination. Baths are important, and plenty of fresh air +and outdoor exercise are of much significance. The patient’s mind +should be occupied. The question of food is an important one; general +diet—carefully regulated as to the amount given—should be prescribed. A +vegetable diet is usually best. Reduction of salt seems to have a good +effect. The patient must not be allowed to eat too much at a time, nor +too often. If the bromides are being used, they should be withdrawn +gradually. + +In most cases of true epilepsy a continued treatment of several months +is necessary. Unless the patient can follow out the treatment for +several months, or even years, in a number of cases it will be entirely +useless to take the treatment; although if the lesion present is very +apparent, and the patient is enjoying fair health otherwise, and has +not been affected long, a treatment for a few months, or even weeks, +might be all that is necessary. + +=Surgical interference= may be indicated in Jacksonian epilepsy. +Trephining has been practiced successfully in a number of cases and +the risk from operation with modern surgery is so reduced that one is +frequently justified in advising an operation. + +=During= an =attack=, a special treatment cannot be given to lessen the +severity of the fit in all cases; in fact, most patients prefer not to +have the seizure shortened as the after effects are more disagreeable. +In some cases, at the beginning of the seizure, exerting a firm +pressure upon the suboccipital will quiet the patient. This treatment +probably controls the circulation of the brain, by way of the superior +cervical ganglion. In cases where the exciting factor seems to be in +the intestines, and the peristaltic action of the bowels is reversed, +causing a reversion of the nerve current of the vagi, a rapid, firm +kneading over the abdomen, so as to establish normal peristalsis, will +suffice to prevent an attack, if one is notified of its approach. In +some cases a rapid, thorough stimulation of the solar plexus will +lessen an attack. Possibly it reduces the blood pressure in the brain, +by bringing blood to the splanchnic region. + +In all cases during the convulsion the patient should be carefully +protected from injuring himself. A towel should be twisted and placed +in the mouth, so that the tongue cannot be bitten. Do not place small +articles as corks, etc., between the teeth, as they are liable to enter +the pharynx and cause suffocation. The patient should be watched to +protect him from any injury; otherwise the attack should usually be +allowed to spend itself. + + +Migraine + +(SICK HEADACHE) + +=Migraine= or sick headache is a neurosis, characterized by a +paroxysmal pain in the head, usually unilateral and periodical, with +nausea, frequently vomiting, and disorders of vision. + +=Osteopathic Etiology.=—The disease usually begins in the first half +of life, rarely earlier than puberty and is slightly more frequent +in females. Some weakened or depressed condition of the nervous +system, due to lesions of the upper cervical vertebræ, lesions of the +inferior maxilla, anxiety, overfatigue, anemia, digestive derangements, +=eye strain= and menstrual disorders, is generally the cause. The +hereditary factor is very important. This is frequently associated with +derangement of the =large bowel=, especially cecum and ascending colon, +resulting in toxemia. + +It is supposed by some to be a =vasomotor= disturbance, because +there are symptoms, as pallor and flushing of the skin, which show +an involvement of the sympathetic system. It is possible a spasm of +cerebral arteries, followed by vascular dilatation, takes place. The +seat of the pain is believed to be in the meninges of the brain. +Possibly in many cases where the atlas is found involved and causing +the affection, some meningeal fiber of the fifth nerve is impinged by +the lesion. Caries of the teeth and =nasal troubles= are causes of the +disease in children. + +=Symptoms.=—A =paroxysmal= headache is the principal feature of +migraine. The attack may occur without warning, although there are +usually malaise, restlessness and a disturbed vision preceding the +headache. The =prodromal= symptoms vary to a great extent. Other +prodromal symptoms besides those given, may be vertigo, spots before +the eyes, tinnitus, chilliness, etc. The pain is of a sharp and +stabbing nature and is oftentimes limited to the temporal region of one +side. Others describe the pain as of a binding or of a boring nature. +It is continuous. It may be in the occiput instead of in the side of +the head. + +=Hyperesthesia= of the surface is noticed, but the tender points of +neuralgia of the fifth nerve are absent. The patient is sensitive to +light and noise. Flashes of light occasionally attend the pain in +the head. Hemianopia is not infrequent. The temporal artery may be +contracted, the face pale and the pupil large. In others the eye is +dilated, the face flushed and the pupil small. Nausea and vomiting +are frequent, with loss of appetite. In some cases where the stomach +is full, vomiting the contents will relieve the attack. Should the +stomach be empty, vomiting of mucus may occur, and is later followed by +vomiting of bile. Tenderness is commonly found about the region of the +occipital and upper cervical muscles. Attacks rarely occur oftener than +once in ten or fifteen days. During the intervals the patient may be +quite well. The =duration= is anywhere from a few hours to several days. + +=Diagnosis.=—The sensory symptoms, the paroxysmal character, the +severity and definite course, usually readily distinguish migraine. +=Growths= of the =brain= may be the cause of symptoms closely +simulating migraine. In such cases an ophthalmoscopic examination may +reveal a choked disc. + +=Prognosis.=—Is usually favorable when the attacks are light and of +short duration. Cases of long standing and of great severity are not so +easily cured, although in most instances great relief can be given the +patient. There are very few cases in which the severity and frequency +of attacks cannot at least be lessened. Oftentimes attacks of migraine +cease after middle life. + +=Treatment.=—The =atlas= or one of the =upper cervical= vertebræ is +almost invariably subluxated. This is not always the direct cause of +migraine, but it is an important factor in the causation. =During= the +=attack= many cases can be completely, or at least partially relieved, +by a careful treatment in the upper cervical region. But there are some +cases where treatment of the cervical region is entirely unsuccessful, +and, in fact, aggravates the attack. The details of treatment vary in +every case. If any defects in general health or any error in the mode +of living can be found, these of course must receive first attention. +Rest, diet (a vegetable diet is best) and regularity of meals are +usually to be specially considered. Anything that is known to induce +an attack must be carefully avoided. In some patients the attacks +cease so long as they remain free from mental work, but as soon as they +return to their studies the paroxysms occur. + +Every case should be thoroughly examined before a course of treatment +is laid down. Causal conditions can generally be found, and the +correction of such usually results in a cure, or at least in great +relief. Errors in diet; digestive disturbances, as a disordered biliary +tract; disorders of the pelvic organs; eye strain; nasal disorders; +mental and physical fatigue, and affections of the nose may induce +attacks. + +A beneficial treatment for many, aside from adjusting the spinal +lesions, especially the cervical and usually a rigid splanchnic area, +is to place the patient in the knee-chest position and thoroughly raise +the bowels of the right side beginning in the right iliac, loosening +possible adhesions, etc. + +The earlier the treatment, the more likelihood of a cure. Cases of long +standing are generally harder to cure. Preceding a paroxysm, relief can +usually be given, but after the paroxysm has reached its height it is +harder to give relief. The patient should rest in a quiet room which +is darkened and well ventilated. Besides the indicated osteopathic +treatment (generally a cervical one), hot applications to the nape +of the neck and keeping the extremities warm are helpful. The nerves +involved are the vasomotor, occipital, frontal and temporal. A free +evacuation of the bowels will relieve a few cases, while washing out +the stomach will help others. Hot fomentations over the splanchnics +for thirty minutes may be beneficial. During the intervals, valuable +adjuncts will be found in the use of systematic exercises and frequent +bathing. Do not fail to have the eyes examined. + + +Occupation Neurosis + +These are a group of maladies of the nervous system, due to excessive +use of certain muscles in some oft-repeated act, and characterized +by spasm of the muscles concerned. There are several varieties, as +writers’ cramp, telegraphers’ cramp, piano players’ cramp, violin +players’ cramp, typewriters’ cramp, etc. + +Professional spasms, that involve muscles of the shoulder girdle, are +not rare among osteopathic practitioners, due to prolonged faulty +methods of technique. + +=Osteopathic Etiology.=—A nervous temperament predisposes to the +development of the affection. Previous injuries and strains of the +involved parts are important factors. Faulty methods of writing, and +in the other disorders, strained or cramped positions of the affected +tissues, predispose to attacks. Slight =lesions= of the bones, joints, +ligaments and muscles are commonly found, involving the motor and +sensory nerves of the immediate locality. The majority of all cases +occur between twenty and fifty years of age. + +Distinctive =pathological= changes have not been found. Each case +has particular lesions of its own. The details of the case are +characteristic of the one case only. The affection is often primarily a +spinal one, due to deranged action of the spinal centers concerned in +the various acts; though, no doubt, excessive use of a group of muscles +may result in contractions, spasms, contractures and nutritional +changes, that in turn will establish definite osteopathic lesions. This +is an illustration of a “vicious circle.” + +=Symptoms.=—Symptoms of the various varieties of professional neuroses +develop slowly and gradually. A cramp or spasm affecting the used +member is an early symptom. Tremor, weakness, stiffness, fatigue and +heaviness of the affected part are present most of the time. In severe +cases neuritis may develop, and a glossiness of the skin be present. +Associated with the inability to perform the usual work, may be mental +worry and depression. + +=Diagnosis.=—The history of the case and the limitation of the disease +to one member, usually make the diagnosis easy: =Cerebrospinal= +diseases, as hemiplegia; early =tabes=, affecting the arms; and +progressive =muscular atrophy=, have to be carefully excluded. + +=Prognosis.=—As a rule is favorable. Osteopathic treatment, in the +majority of cases treated, has resulted in recovery. + +=Treatment.=—Rest of the part, mental quiet and attention to the +nutrition of the patient, are the first essential considerations. A +change of occupation may be necessary if excessive use of parts and +faulty methods can not be corrected. The treatment consists of a +correction of the parts irritating or disturbing the spinal centers +or nerves affected. The ulnar, radial and median nerves all innervate +muscles employed in writing. Lesions of the cord affecting these +nerves may be found from the fifth cervical to the sixth dorsal. In a +few cases lesions occur as high as the atlas. When the =radial= and +=median= nerves are involved the lesions are principally found in the +upper dorsal vertebra. When the =ulnar= nerve is involved the lesions +are usually slightly lower. The lesions may affect the fibers of these +nerves directly (mechanically), but more probably the vasomotor nerves +are involved, as in this region the vasomotor fibers to the arm pass +from the cord to the sympathetic fibers. The brachial plexus originates +higher than the upper middle dorsal region, still some of its nerves +are frequently affected in the dorsal region by osteopathic lesions, +for removal of the same relieves the disorder. + +Other lesions affecting the arms are oftentimes found in the ribs on +the side involved. Any of the first five ribs may become deranged and +affect the innervation of the arm. The clavicle in a few cases may +be abnormally low. A bursitis may be present. Occasionally slight +subdislocations of the shoulder joint (especially anterior) and elbow +joint are found. Gymnastic exercises of the arm and hand, coupled with +a general treatment of the shoulder, arm and hand, are beneficial. +Hydrotherapy, massage and friction of the involved member are useful. +In severe cases “breaking up” fibrotic tissue, and muscle training +frequently secures good results. + + +Hysteria + +Oppenheim defines hysteria as “a psychosis, which does not express +itself by disorders of the intellect, but in defects of character and +emotional disturbances, whose real nature is hidden under an almost +unlimited and varied number of physical symptoms of disease.” + +The affection is about equally divided between the two sexes. A +neurotic tendency, often inherited, is an important underlying factor. +This condition, when associated with lack of mental discipline, is very +apt to lead to the mental depression and outbreaks of hysteria. A large +number of cases are between the ages of puberty and twenty-five. After +forty-five the disorder is infrequent. + +White, Osler’s System of Medicine, says: “The significance of +Freud’s theory is the tracing of every case to sexual traumata +during childhood. Sexual experiences differ, however, from ordinary +experiences—the latter have a tendency to fade out, while the idea +of the former grows with increasing sexual maturity. There results a +disproportionate capacity for increased reaction which takes place in +the subconscious. This is the cause of the mischief.” A distinction is +made between the sexual and the sensual. + +Anders points out that lack of proper mental development, improper +hygienic surroundings and chronic toxemia are causes. + +The =direct causes= of hysteria may be many, and include physical and +mental influence, or both. Traumatism of various regions of the body, +but especially of the spinal column, may excite hysteria. Some slight +lesion of the vertebra or rib may be all that is discoverable. A +correction of the same is occasionally all that is necessary to remove +the direct cause; still there is usually considerable disturbance +of the spinal tissues, especially slight curvatures and muscular +contractions. Prolonged emotional excitement, overwork, defective +education and many moral and mental influences are potent and frequent +causes. Masturbation or an adherent prepuce occasionally is the cause +of the affection in boys, or any excitation that produces exhaustion. +Disturbances of the sexual system in both sexes are responsible for +many cases. The menstrual period and the menopause are frequent periods +for the manifestation of the disease. The disease often affects +prostitutes. Disturbances of the digestive, nervous and circulatory +systems, and general diseases of an exhaustive kind are exciting causes +of hysteria. Dr. Still said that occasionally the colon is prolapsed +and crowded down upon the pelvic organs. Hazzard[122] is of the opinion +that “a majority of the cases show a depression of all the ribs, +narrowing the thorax and often causing enteroptosis.” + +=Symptoms.=—The symptoms may be extremely varied, including any symptom +of the many nervous diseases. The =sensory symptoms= are numerous. The +most common is anesthesia, which may be found in certain parts of the +body, usually one side (the left) of the body. Geometrical areas that +bear no relation to the innervation is characteristic. The patient may +not know of the sensory derangements until discovered by the physician. +When there is =anesthesia= without other nervous symptoms, the case +is commonly hysterical. The most marked symptom is analgesia, where +the patient is insensible to painful impressions. A pin may be placed +deeply into the flesh, and not be felt by the patient. The anesthesia +may extend to the mucous surfaces, and even deeply down to the tissues +of the joints. Organic and tendon reflexes are not changed. There may +be other symptoms of disturbed sensation; as an absence of pressure, +temperature and muscular sensation. + +=Hyperesthesia= may be present nearly as often as anesthesia. +Hyperesthetic areas may be found in various regions of the body, +but especially along the spinal column and in the ovarian region. +The “hysterical spinal irritability” is of special interest to the +osteopath. The spinal column may be affected as a whole, or in +segments, or confined to a single vertebra. Especially when a spinal +irritability is in segments, or confined to a single vertebra, are +local derangements of the spinal column apt to be found. Correction or +even =pressure= upon these areas will often relieve the patient. Severe +pain over the heart may simulate angina pectoris. =Globous hystericus= +is of quite common occurrence. + +Charcot refers to the ovarian hyperesthesia as follows: “It is +indicated by pain in the lower part of the abdomen, usually felt on +one side, especially the left, but sometimes on both, and occupying +the extreme limits of the hyperesthetic region. It may be extremely +acute, the patient not tolerating the slightest touch; but in other +cases pressure is necessary to bring it out. The ovary may be felt to +be tumefied and enlarged. When the condition is unilateral, it may be +accompanied with hemianesthesia, paresis, or contracture on the same +side as the ovarialgia; if it is bilateral, these phenomena also become +bilateral. Pressure upon the ovary brings out certain sensations which +constitute the aura hysteria, but firm and systematic compression has +frequently a decisive effect upon the hysterical convulsive attack, the +intensity of which it can diminish, and even the cessation of which it +may sometimes determine, though it has no effect upon the permanent +symptoms of hysteria.” + +The =special senses= may be disturbed, although these symptoms are +usually transient. There may be blindness; narrowing of the field of +vision, due to anesthesia of the periphery of the retina; loss of +hearing; loss of smell or loss of taste. + +=Motor disorders= may be of different forms of paralysis, as +hemiplegia, paraplegia or monoplegia. In fact all forms of =paralysis= +may be found in hysterical patients. Osier says: “There is no type or +form of organic paralysis which may not be simulated in hysteria.” The +affected muscles do not atrophy. The paralysis is usually general, and +contractures are common. Local paralysis, as of the bladder, vocal +cords and other parts of the body, commonly occur. + +=Contractures= and =spasms= may also occur. True epilepsy may even +be simulated by hysterical spasms, but on careful observation the +characteristic attack of epilepsy is found wanting. Firm pressure may +increase the severity of an attack as well as bring it on. The spasms +are of various parts of the body, as the diaphragm, bronchi, abdominal +muscles, bladder, etc. + +Various =disturbances= of the =viscera= may occur. Of the digestive +tracts, the appetite may be disturbed or depraved. Diarrhea or +constipation may be present. Flatulency is a common symptom. The +respiratory tract may be another point of considerable disturbance +in many cases. Dyspnea, aphonia, hiccough, cough, and exaggerated +breathing, as when cold water is poured on one, are common +manifestations. Various =cardiac= vascular symptoms may be manifested, +especially a rapid heart. Various =vasomotor= derangements are common. + +=Physical manifestations=, as amnesia, lack of will power and an +excitable nature—easily moved to laughter or tears—are frequent. The +moral tone may be lowered. Even delirium, catalepsy, ecstasy and +trance, may be mentioned among the psychical phenomena. + +The =hysterogenous zones= are of more than passing interest to the +osteopath. Tyson writes as follows, in regard to the hysterogenous +zones: “These are hyperesthetic areas especially studied by Richet, +on which persistent pressure will sometimes excite a hysterical +attack. While the ovaries are favorite hysterogenous zones, the zones +may be in any part of the body; as for example, the sides of the +trunk. Such pressure may also cause an existing attack to subside. +Hysterical spasms may also be localized or limited to groups of +muscles.” Especially when zones along the spine and side of the trunk +are located, the attack of hysteria may be completely relieved by +correcting the localized deranged tissues. + +=Convulsive seizures= are not uncommon and may follow various prodromal +symptoms. Some authors divide the symptoms of hysteria into convulsive +and non-convulsive forms. + +These are part of the many manifestations that are presented by various +hysterical patients, and it is readily seen that an osteopath has to be +continually on his guard. + +=Diagnosis.=—The diagnosis is generally quite easy. The characteristic +emotional symptoms, associated with any of the many other symptoms +which have no organic lesion, are characteristic of the disease. Care +has to be taken, though, in some cases where symptoms are presented +which have organic lesions. The history, the attack and neurotic +temperament, will largely decide the nature of the affection. After the +“outbreak” the patient often feels decidedly better. + +=Prognosis.=—Death may occur from exhaustion, but such a termination +is rare. Recovery is the rule, although the duration may be long. +Recovery usually takes place rapidly, after the exciting cause has been +determined and removed. + +=Treatment.=—First of all, the osteopath should have due appreciation +of the mental characteristics of the disease. Whatever is dominating +the patient mentally must be either changed or abolished. It is not +always necessary to be harsh and severe with the patient; but one +should be firm and unyielding. He can do a great deal by having +complete mental control of the hysterical patient. + +A most careful examination should be made for an exciting cause, +and when found it should be removed. This naturally constitutes a +very important part of the treatment. A light general treatment is +commonly indicated. The general health, especially the bowels, +should be carefully attended to. The hygiene, exercise and amusement +of the patient should receive due consideration. One has to gain the +confidence of the patient, and then be firm but kind to him. Relative +to diet Yeo[123] says: “The diet should be simple, abundant, and +supplied regularly, and at not too long intervals as is frequently the +case in boarding schools. All strong stimulants are best avoided, and +the hysterical should not indulge in strong tea or coffee, or exciting +wines and liquors.” + +The “rest cure” as introduced by Weir Mitchell, is applicable in +some cases. This method consists of plenty of food, especially milk, +absolute rest of the body and mind, massage and electricity with +isolation of the patient from friends and sympathetic relatives. +Doubtless a general osteopathic treatment would be much better than +massage. Yeo says that to the application of hypnotism and suggestion +“we look with little sympathy and less confidence.” + +During the hysterical =convulsions=, the patient should be watched, but +extreme measures should not be practiced. There is little danger of +patients hurting themselves. Throwing cold water in the face, or a cold +bath may produce the necessary mental shock. Pressure over the ovary +as stated in hysterogenous zones, or some other zone of the body, or +pressure upon a large blood vessel, as a carotid, will oftentimes stop +an attack. + + +Neurasthenia + +“Closely allied to, and in some cases almost inseparable from, +hysterical states are those morbid conditions to which, in modern +times, has been applied the term neurasthenia.” (Yeo). Neurasthenia +is a fatigue neurosis that is characterized by mental and physical +irritability and inefficiency. Headache, backache, insomnia, and +debility of the gastro-intestinal tract are common symptoms. + +The affection is often found in that class of people who are +predisposed to hysteria. The disease is more common among men than +women, usually occurring after the twentieth year. The predisposition +may be inherited or acquired. Church states that “debilitating +conditions in the antecedents of neurasthenics,” and “defective +education that omits discipline and the cultivation of self control” +are important predisposing causes. Many of the exciting causes that +produce hysteria will cause neurasthenia. Various =lesions= along +the spinal column, chiefly in the cervical and upper dorsal regions, +include the predisposing causes of a large majority of cases. This +spinal irritation, taken in conjunction with overstrain of mind +and body, or probably in many cases the spinal irritation as the +predisposing cause of the over strain, results in nervous exhaustion. +Particularly overwork, associated with care and anxiety, is an exciting +cause of great significance. + +The neurasthenic patient is generally of a =neurotic temperament=. +The affection may, also, result from various chronic diseases, toxic +conditions, sexual excesses, alcohol and tobacco. Thompson[124] +believes that improper sexual hygiene and perversion or abuse of the +marital relation are most important factors in the development of +neurasthenia in both sexes, and a regulation of this is imperative +for a cure. The symptoms are due, to a greater or less extent, upon +=spinal=, =cerebral=, =cardiac= and =gastric disturbances=, but all +of these conditions are usually dependent upon =vertebral= and =rib +lesions= of the upper dorsal and cervical regions. Care should be taken +whether the condition is secondary to organic lesions. The lesions +in the vertebræ are generally slight lateral deviations, in the ribs +upward displacements of the vertebral ends, followed by contraction +of the deep muscles in the neighborhood of the lesions. A posterior +condition of the atlas and a lateral lesion between the third and +fourth dorsal are especially apt to be found. As to spinal areas most +affected Stearns[125] says the predisposing irritations are located +particularly in the first two cervical, the first two dorsal and the +last two lumbar vertebræ. + +These various lesions probably cause an impairment of nutrition in +the nerve centers of the cord and brain, or both. Definite =morbid +anatomical= changes have not been found resulting from nervous debility +or irritability. Still, it seems probable that certain changes in the +nerve cells may result from excessive functional activity. =Traumatism= +is a prominent causative factor in both =neurasthenia= and =hysteria=. +=Railway= and other =injuries= frequently produce osteopathic lesions +that result in nervous disorders. That there is a demonstrable +pathological basis resting in sympathetics and spinal nerves, there can +be no doubt. + +=Symptoms.=—To enumerate the many symptoms of neurasthenia in detail +is hardly necessary. The nervous debility may affect any organ of the +body, owing to the exhaustion of the nervous energy, thus lessening the +functional activity of that organ. + +The most noticeable symptoms are various =sensory disturbances= and +=muscular weakness=, dependent in part upon the spinal lesions. The +patient generally feels weak and tired. Headache, pains in the back +and sacrum, tender points along the spine, and various sensations of +numbness, tingling, etc., are felt. + +The =mental faculties= are oftentimes irritable and weak. An inability +to concentrate the thoughts with depression, fear, vertigo, insomnia, +and many other mental symptoms, may be manifested. + +=Palpitation=, irregular action of the heart and pain over the +precordia may be present. =Ocular= disturbances, particularly blurring +of letters and narrowing of the visual field, =visceral= symptoms +of many kinds, and =vasomotor= phenomena, as chilliness, flashes of +heat and sweating, are among the many symptoms of which the patient +complains. + +=Genito-urinary= disorders in the male, and ovarian and uterine +irritation and painful menstruation in the female, are occasionally +symptoms dreaded by the sufferer. Polyuria is frequent. + +The symptoms or signs of great importance to the osteopath in +neurasthenia, as in many other diseases, are the tender points along +the spinal column. They give direct clues as to where the lesion may be +found. + +=Diagnosis.=—Error in diagnosis can usually be prevented by a study of +the history of the case and symptoms. Care must be taken in determining +between symptoms of organic diseases and the symptoms of a true nervous +exhaustion. + +=Prognosis.=—Is almost invariably good. Only in cases where there is +a tendency to mental disorder should the prognosis be guarded. Much +depends upon the thorough cooperation of the patient. It usually takes +some time to perform a cure among the poorer class, as the requirements +demanded for a cure are oftentimes expensive. + +=Treatment.=—Naturally the treatment, exclusive of the manipulation to +correct the various lesions found, is extremely varied, owing to the +many exciting causes and symptoms to contend with. + +As has been stated, the lesions are usually found in the upper spinal +region; still lesions are occasionally located in the lower spinal +region, especially in female sufferers, when the pelvic organs are +disturbed. The many mental symptoms, as inability to concentrate the +mind, insomnia, vertigo, headache, etc., are best treated through the +cervical region, with attention to the heart’s action and the excretory +organs. Careful attention should be paid to the deep posterior muscles +between the atlas and occipital bones. + +=Rest= is very necessary. Changes of scene and occupation, attention to +the surroundings, careful dieting, hydrotherapeutic measures, pleasant +companions, relief from responsibility, bathing, etc., should receive +careful attention and consideration by the osteopath. Set rules cannot +be given. The details of treatment that should be adopted are dependent +upon the individual case. Every well trained osteopath will be familiar +with such measures. + +Careful attention must be given to the secretions, excretory organs +and the circulation. A study of each case will bring out the various +irregularities that may exist. + +When the nervous involvement is extensive, a “general treatment” may be +given. Such a treatment would affect the entire nervous and muscular +system, and tend to equalize disturbed nerve force. Bringing the +muscular system into play and relaxing contracted muscles calls for +more blood and nerve force, and consequently a nutritious diet. + +The “rest cure,” as introduced by Weir Mitchell, may be employed to +considerable advantage in many cases. Yeo says: “It is in certain cases +of this disease that the ‘rest cure,’ devised by Weir Mitchell, has +proved so remarkably successful. But there can be no sort of doubt +that it has been applied far too indiscriminately, and that for this, +as indeed for any special method of treatment, a careful selection of +suitable cases is needful.” The diet should consist principally of milk +at first, followed in a few days by soft boiled eggs, boiled rice, lamb +chops, graham bread, stewed fruits and butter, and a little later by +roast beef, vegetables and light puddings. Porter’s system of milk diet +has proved effective in many cases. Tea, coffee and alcohol should be +avoided. + +During the entire course of the treatment, care should be taken +to correct any lesion that may bear directly upon the cervical +sympathetic, the solar plexus and the hypogastric plexus, as they are +the great reflex centers of the body. + + +FOOTNOTES: + +[119] A. O. A. Case Reports, Series IV. + +[120] See A. O. A. Case Reports, Series II., III., IV., V. + +[121] See A. O. A. Case Reports, Series I., III., V. + +[122] Practice of Osteopathy. + +[123] Manual of Medical Treatment. + +[124] Cosmopolitan Osteopath, October, 1903. + +[125] Journal of Osteopathy, January, 1904. + + + + +DISEASES OF THE SPINAL CORD + + +Acute Myelitis + +=Acute myelitis= is an acute inflammation, with softening of the +substance of the cord, giving rise to marked disturbances of motion, +sensation and nutrition. When the whole thickness of a section of the +cord is involved, the condition is termed =transverse myelitis=. When +an extensive area is involved, it is termed =diffuse myelitis=. When +the gray matter around the central canal is especially affected, it is +termed =central myelitis=. + +=Etiology.=—There can be no doubt that osteopathic lesions are very +potent predisposing factors. Osteopathic lesions of the spine, even +of a muscular nature, readily disturb the cord circulation. It may +follow repeated exposure to wet, cold or exertion; or be a sequel to +the infectious diseases, as smallpox, typhoid fever, typhus, puerperal +fever or measles. It may be due to traumatism or disease of the +vertebræ, as caries or cancer. Syphilis is a frequent cause. + +=Pathology.=—To the untrained, naked eye, the cord may present +little or no change. The nervous tissues are in various stages of +degeneration. On section the substance of the cord is red and soft, +the line of demarcation between the gray and white matter is lost or +extremely indistinct, and minute hemorrhages are sometimes seen. In +very acute cases, affecting the white and gray matter, after injury, +when the membranes are cut, the substance of the cord may flow out as a +reddish creamy fluid. + +The nerve fibers are much swollen and the axis cylinders broken up. +Blood discs, leucocytes, and numerous granular fatty cells may also +be present. The blood-vessels are distended and dilated. There may be +thickening and hyaline degeneration of the vessel walls and hemorrhagic +extravasation. + +=Symptoms.—Acute Transverse Myelitis.=—This is the type most frequently +met with. The symptoms differ with the situation of the lesion, which +is generally in the dorsal cord. At the onset there may be pain; +numbness and tingling in the back, radiating into the limbs. There +is usually moderate fever, malaise, chills, muscular pains, a coated +tongue and constipation. Symptoms of =motor paralysis= soon develop, +which may become more or less complete. Both motor and sensory symptoms +vary to a marked degree, depending upon the pathologic involvement. The +reflexes are lost at first. They may soon return and are exaggerated +below the lesion. Following this the muscles often become rigid and +contracted. Unless the lesion is in the lumbar or cervical cord, +reaction of degeneration or much wasting of the muscles, as a rule, +does not occur. A girdle sensation frequently occurs at the level of +the disease. At first there is retention of the urine and feces, later +incontinence. Bed-sores soon develop; also drying and hardening of +the skin. The nails become thick and brittle. Death may occur from +exhaustion, or heart or respiratory failure, but it is rare; segments +of the cord may be completely and permanently destroyed, causing +persistent paraplegia. H. A. Greene[126] reports a case, due to injury, +which was greatly benefited by treatment. + +=Acute Diffuse Myelitis.=—In the acute forms the course of the disease +is rapid. The trophic disturbances are more marked than in the former +type. This form is likely to follow exposure to cold, injuries, tumors, +syphilis or one of the infectious diseases. There may be chills, fever, +malaise, pain in the back and limbs, and occasionally convulsions. The +reflexes are generally lost. The motor functions are rapidly lost. +There is incontinence of urine and feces, rapid wasting of the muscles +and bed-sores develop. The disease may prove fatal in from six to ten +days. + +=Diagnosis.—Landry’s Disease.=—In this the bladder and rectum are +not affected. Trophic disturbances are absent. There is but slight +loss of sensation, no reactions of degeneration and no girdle pains. +=Multiple Neuritis.=—Both arms and legs involved, and slow onset. The +bladder and rectum are rarely involved; the girdle pain is absent. +=Acute Poliomyelitis.=—There are no sensory symptoms and the rectum and +bladder are not affected. + +=Prognosis.=—In very acute cases death occurs in from three to ten +days. Milder cases generally recover with some loss of motor power, +although in a few cases treated by osteopathy recovery was complete, +due probably to the case being seen early and thus degeneration +prevented. + +=Treatment.=—Lesions of the vertebræ are usually readily found in +cases of myelitis. Generally, deranged vertebræ are found in the upper +dorsal region, and occasionally lesions are located in the lumbar and +cervical vertebræ. The treatment of myelitis is chiefly to correct +these lesions, so that the normal circulation of the cord may be +reestablished. One has to be very =careful= when treating the lesions +not to cause additional injury to the cord. An inhibitory treatment +to the muscles about the lesion may be all the treatment that can be +given at first; nevertheless, it aids nature just so much in overcoming +the excessive irritation of the cord tissues. Nature has the curative +means, provided they may operate unobstructedly. In a few cases the +ribs in the region of the spinal lesion will be found deranged and +interfering with trophic fibers, blood-vessels and lymph vessels of the +cord. The patient should be kept in the prone posture at first. + +Warm baths and massage will be found of additional value. The bowels +and bladder should receive special attention. An ice-bag to the spine +may be beneficial. If there is any danger of bed-sores, use alcohol to +stimulate and harden the skin. Rest, liquid diet and good nursing are +necessary. Later on careful exercising of the limbs will be beneficial. + +=Chronic Myelitis.=—This defines the conditions when the inflammation +is subacute with the paraplegia and other symptoms which then naturally +appear, present, and also with the signs of both degeneration and +repair. The symptoms develop slowly as compared with the acute form. It +should not be confused with atrophy, pachymeningitis or tumors of the +cord. =Treatment= is practically the same as in acute form. Surgical +measures may be indicated. Loudon[127] reports a case due to injury +which was greatly benefited. + + +Poliomyelitis + +(INFANTILE PARALYSIS) + +=Definition.=—An acute infectious disease occurring most commonly in +young children, characterized by paralysis, rapid wasting of certain +muscles, and fever. It is an acute myelitis that affects the anterior +horns of the cord. There are no sensory symptoms. + +=Etiology.=—It usually occurs in children under ten years of age, +and the majority of cases occur before the fourth year. It is more +common in summer than in winter. The infection seems to gain entrance +through the nasal mucous membrane. Traumatism, exposure to cold and +overexertion, are probably predisposing causes. It has occurred in +severe epidemic form. + +=Morbid Anatomy.=—The disease is most frequently seen in either the +lumbar or cervical enlargement and is usually unilateral, though there +is considerable variation in the extent of the lesions. In very early +cases, the condition of acute hemorrhagic myelitis, with degeneration +and rapid destruction of the large ganglion cells, has been found. In +older lesions the anterior cornu in the affected region is atrophied +and there is destruction of the multipolar ganglion cells. The +anterior nerve roots are atrophied, the muscles are wasted and undergo +a fatty and sclerotic change. + +=Symptoms.=—The child may have a slight fever, malaise, muscular +twitching, headache, some rigidity of the neck, and sometimes vomiting. +This may last a day or several days or only a few hours, when paralysis +sets in abruptly. The =paralysis= is rarely complete and groups of +muscles only may be affected. As a rule, the paralysis comes on +abruptly, but it may come on slowly, taking several days to develop. +In a few weeks, atrophy sets in and the limb becomes flaccid, soft and +wasted. The paralysis remains stationary for a time when improvement +takes place, but complete recovery is rare. Sometimes the growth of the +bone of the affected limb is impaired. Usually there are no sensory +disturbances and the bladder and rectum are not affected. The condition +of the reflexes is dependent upon the extent of involvement of the +cornual cells. Occasionally the bulbar muscles are affected. + +=Diagnosis.=—This is not difficult except in the early stages. Careful +study of the case is commonly all that is necessary. Landry’s paralysis +and peripheral neuritis are to be differentiated. + +=Prognosis.=—Complete recovery is rare. Improvement is the rule. +Ivie[128] tabulates sixteen cases, all showing good results. W. B. +Davis[129] reports a case cured by six months treatment and still well +after three years. T. M. King[129] one case cured and one greatly +benefited and A. S. Craig[129] one much helped. Florence Gair, F. P. +Millard, A. G. Walmsley and others report gratifying results in many +cases. + +=Treatment.=—In the treatment of chronic cases, F. P. Millard[130] +says “Five minutes’ time is sufficiently long in treating a patient, +and sometimes too long. * * * Start in and move every spinal joint. +That takes about two minutes. Spring the sacro-iliac articulations +just enough to get motion. Then give a specific cervical treatment. Do +not stop to relax muscles in a child. Adjust as rapidly as possible. +Make every spinal joint yield to motion. Spend only one minute, or +possibly two, on the cervical vertebræ. So far we have consumed four +minutes. The last minute we loosen up the wrist or ankle, according +to the extremities that are involved.” This outline has been followed +with gratifying success by Gair, Green, Bush and others in many +chronic cases. The procedure in acute cases is condensed from A. G. +Walmsley[130]: “Isolate, keep cool and absolutely quiet. Stop all food +until the temperature drops to 100° F. or lower and until the pain +subsides when fruit juices may be given followed by heavier foods. Give +patient all the water he will drink. Where the spine is sensitive, and +it will be in many, use hot fomentations until a specific treatment can +be given. If the fever is running high cool compresses will be grateful +and help reduce temperature. Irrigate the colon twice daily with saline +water. Do this first thing when called. Later once daily will do and +then discontinue. Look carefully to the nose and throat and wash with +saline or boracic solution. Keep feet warm as they may be cold even +with high fever. Treat the case over a long period. See that he does +not overdo and observe all dietetic and hygienic measures.” Both these +men lay great stress on the importance of specific adjustments and +massage of muscle tissue has little place in their treatment. This, +with drill at home can be attended to by the mother. + +Ivie[131], among other good ideas on treatment, gives the following: +“May I suggest that when such severe results (the acute stage) follow +a slight infection, that we may expect to find a lesion located at +such a point as will interfere with one or more of the anterior root +arteries which join and supply the anterior spinal plexuses. As there +are only five or ten of the anterior root arteries (Dana), the lesions +affecting them can be located throughout a wide range of the spine. In +a great many cases we find that the correction of lesions well up in +the dorsal and even in the cervical region have increased the amount +of the improvement well beyond that received in the correction of the +lumbar lesions alone. To =promote resolution=, correct the lesions, +both muscular and bony, and relax the muscles of the spine daily; move +every vertebra to the limit of all its possible motions; use flexion, +extension, rotation, and lateral flexion at least once every day for at +least a week; and help to overcome stasis by keeping the child off its +back, turning it from side to side, and letting it lie on its stomach +as much as possible. The limb, to be kept in its best condition, should +be kept warm; treated gently; held in a natural position by the use of +sand bags and clothes cradle, thus beginning early the =prevention= of +deformity; the paralyzed muscles should not be kept on a stretch, as +that will retard any possible improvement; stimulating rubs and baths +should be given frequently.” In the =chronic stage= he advocates: “Now +that the nerve cells have been given a chance to regenerate (removal of +lesions), the best thing to do is to force them to work if possible. To +do this, the so-called resistance exercises or educational movements +are to be strongly recommended; the idea being to place the limb in a +given position and then ask the child to fix all its attention on the +limb and to earnestly attempt to hold it there while you move it, or to +keep making the attempt while you move the limb through its whole range +of motion in that direction. These movements should be so calculated +that the resistance of the child will exercise the group of muscles +affected. The mother or nurse can give these exercises every night on +going to bed.” + + +Acute Ascending Paralysis + +(LANDRY’S PARALYSIS) + +=Definition.=—An acute disease, characterized by an advancing +paralysis, beginning in the legs, passing upward to the trunk and the +arms and finally it may involve the centers in the medulla. =Toxic= and +=infectious= influences that congest the nerve courses and ultimately +destroy the cells seem to be the important factor. The anterior gray +matter of the cord is involved, and it is probable that many cases are +a form of acute poliomyelitis. The spleen is congested and in some +instances the lymphatics. + +=Etiology.=—A definite cause has not been found, although osteopathic +lesions are important predisposing factors. A toxic cause seems +probable. The disease is most common in males between twenty and +forty years of age. It may follow traumatism, exposure, cold or the +infectious fevers. + +=Symptoms.=—Weakness of the lower extremities is generally the first +symptom, though the arms may be involved first. This is shortly +followed by paralysis. The paralysis then extends to the trunk and +within a few days the arms are also affected. The muscles of the neck +are next involved and finally those of respiration, deglutition and +articulation. The reflexes are abolished. The muscles are relaxed, +but generally do not waste or show electrical modification. Sensation +is usually not affected, but there may be tingling, numbness, +hyperesthesia and muscular tenderness. The sphincters are not +involved as a rule. The spleen is usually enlarged. The =course= is +variable. Death often occurs in from two days to a few weeks. When the +improvement takes place, the part last affected recovers first. + +=Diagnosis.=—This is not always easy. It is sometimes impossible +to differentiate between this disease and =multiple neuritis=. The +history, the motor paralysis, the absence of wasting and of electrical +modification, as well as the absence of involvement of the sphincters, +will definitely aid in the diagnosis. + +=Prognosis.=—The prognosis is unfavorable. A large majority of cases +prove fatal. In a few cases treated osteopathically, results were +favorable if the patient was seen early. The muscles of the spinal +column were markedly contracted. + +=Treatment.=—The treatment of Landry’s disease consists principally +of thorough treatment of the spine, especially of the lower dorsal +and lumbar regions, and attention to the underlying toxic condition. +The treatment should be most thorough; the vertebræ and ribs found +disordered should be corrected and each vertebra should be carefully +separated (if conditions permit) from its neighbor. When the paralysis +has extended to the trunk and neck, a thorough treatment all along the +spinal column should be given with a view to relaxing the contracted +muscles and to render flexible the entire spinal column, so that the +cord may be properly nourished and the progress of the disease checked. +Careful relaxation of the contracted spinal muscles unquestionably has +a potent effect upon the cord circulation, which tends to check and +retard degenerative processes. Treatment of the limbs directly will be +found a help, as well as direct treatment of all tissues paralyzed. If +swallowing is impossible, the patient should be fed through the rectum, +or by the stomach or nasal tube. See that the patient is carefully +nursed. Massage is beneficial. + + +Locomotor Ataxia + +(TABES DORSALIS) + +=Locomotor Ataxia= is frequently met with. It is a disease of the +spinal cord wherein the ultimate effect is a sclerosis of a progressive +character of the nerve courses of the posterior column. It is claimed +that the origin is in the protoplasmic processes of the posterior +spinal ganglion. The characteristic symptoms are incoordination, Argyll +Robertson pupil, lightning pains and loss of knee-jerk. + +=Osteopathic Etiology= and =Pathology=.—Most cases develop between +the ages of thirty and forty, although it is occasionally seen in +young men, and rarely in children from hereditary syphilis. Males +are much more frequently affected than females (10 to 1, Osler), and +the disease is much more frequent in cities. Predisposing causes are +given as syphilis, prolonged exposure to wet and cold, and sexual +excesses, although there is a disposition on the part of neurologists +to confine the cause of true tabes to syphilis, some records showing +as high as 90 per cent. of the cases from that cause. Tabetic symptoms +develop in from five to fifteen years after syphilitic infection. +There are no data to show the probable proportion of syphilitic cases +which later develop tabes, but it is undoubtedly small. As all cases +of tabes examined by osteopaths show spinal lesions, it is reasonable +to suppose that by interfering with the nutrition to the spinal cord, +they allow consequent degeneration. It is also quite probable that +osteopathic treatment for syphilis would, for the same reason, prevent +sclerosis and resultant tabes. That syphilis is not the only cause, is +also held by some authorities. Starr cites a true case from a severe +blow in the dorsal region. Osteopathic observation would lead to a +differentiation of tabes, according to the cause. Cases have been +recorded, which simulated true tabes in most symptoms, which did not +have a history of syphilis. J. Knowles makes the point that probably +certain cases simulating tabes have reached what might be called an +irritation stage (pathologically) of the nerves and their centers, +sclerotic changes not having taken place; and he believes these cases +would naturally yield to osteopathic treatment. Teall confirms this +view by being of the opinion that these cases are the ones largely due +to traumatism, exhaustion or exposure, and the probabilities are that +in time sclerotic changes would take place, resulting in true tabes. In +such cases there can be no question as to the osteopathic lesion, which +would be sufficient to materially interfere with the peripheral sensory +nerves and disturb the protoplasmic processes to the spinal ganglia +and sensory tract. As a rule they are in the lower dorsal and lumbar +regions. Cases are reported which had marked sacral and coccygeal +lesions. + +=Pathologically=, Dana speaks of locomotor ataxia, “as a post-infective +degeneration, which first attacks the posterior spinal ganglia or +corresponding cells of the special senses, due to a prolonged poisoning +of these parts by the toxins of the infection.” The first change is +in the posterior roots. Without doubt osteopathic lesions can readily +affect the nutrition of these roots. This is shown upon examination +in cases where the vertebral lesions impinge the tissues surrounding +the spinal nerve at its exit, (or otherwise damage nervous stimuli +and circulation) and also where the displaced head of the rib crowds +upwards against the spinal nerve and again where the rib impinges the +corresponding sympathetic ganglion which lies anterior to the head +of the rib. Very likely in many cases the syphilitic infection is an +exciting factor, but it seems plausible that osteopathic lesions, +traumatism, cold, exposure and excesses predispose by disturbing the +circulation to involved areas. The changes are at first inflammatory, +followed by degenerative changes in the nerve courses which cause +connective and neuroglia overgrowths to take the place of fibers in the +sensory tract, and finally in the motor tract. Thus from the posterior +ganglia, a section between the columns of Goll and Burdach is involved, +and the progress of the sclerotic change is upward in the cord. The pia +mater and coats of the vessels are thickened. The principal changes in +the cord are in the lower dorsal and upper lumbar segments and the cord +may be changed in shape. In long standing cases there is degeneration +of the ascending antero-lateral tract, of the direct cerebellar tract, +and of the pyramidal tract. The cerebral changes in some cases consist +of sclerosis in the restiform bodies in the inferior peduncles of the +cerebellum, and of certain cranial nerves, especially the third, optic, +vagus and auditory nerves, and also cortical changes may occur. + +=Symptoms.=—Authorities divide the symptoms into three stages—the +preataxic, ataxic and paralytic. This division is largely an arbitrary +one. =Motor symptoms= are usually the most prominent. There is +inability to coordinate the muscles. The patient first notices that +he cannot walk steadily when in the dark or when he has his eyes +closed. Later he finds that he cannot maintain his equilibrium even +in daylight; this is ascertained when the patient places his feet +together and the eyes are closed (sign of Romberg). As a rule this is +unaccompanied by muscular wasting, so there is no loss of motor power. +Soon the gait becomes characteristic; in walking the feet are lifted +high and are brought down heavily on the heel; the ball of the foot +comes down last, producing what is called the “double step;” the walk +is straddling: the limbs are thrown about, and there is staggering, due +to =incoordination=. Incoordination also develops in the hands, but +usually later in the disease. Sudden involuntary movements and palsies +are other motor symptoms. The latter occur in about twenty per cent +of cases and as a rule are of short duration. Paralysis and muscular +atrophy do not develop until after a few years. + +=Pain= is an early symptom and always present; it is of a darting, +shooting or stabbing character and appears in paroxysms. It is most +common in the legs, lasting but a second or two, and often accompanied +by a hot, burning feeling. Herpes may appear along the course of the +nerve. Anesthesia and hyperesthesia of certain areas may occur. A +girdle sensation may be a noticeable symptom. The =muscular sense= +is more or less impaired; there is a feeling as if there were cotton +between the patient’s feet and the floor. Retardation of tactile +sensation is a common symptom. The power of localizing pain is often +lost. The =knee-jerk= is lost early in the disease. Occasionally, +however, cases are met where it is retained. The skin reflexes are +also impaired; in some cases they may be increased at first, but later +are sure to be involved with the deep reflexes. The =pupil= does not +respond to the light, but still accommodates for distance, constituting +the =Argyll Robertson= pupil. Ptosis may develop with or without +strabismus. Optic atrophy, which may lead to blindness, paresis of the +ocular muscle, and contracted pupils, may occur. The ocular symptoms +may appear early in the disease. + +The =visceral pains= or =crises= are chiefly gastric and are sometimes +accompanied by obstinate vomiting. Laryngeal, rectal, urethral and +nephritic crises may occur, and at times are exceedingly severe. +Laryngeal crises may be manifested by intense dyspnea and noisy +breathing. Constipation is common. There may be retention of the urine +resulting in cystitis. Sexual power is generally lost early. + +=Trophic changes= occur later in the disease. The so-called +arthropathies, or joint lesions, may occur at any period of the +disease. It consists of an enlargement of the joints, associated with +serous exudations, which rarely become purulent; atrophy of the heads +of the bones; destruction of the bones and cartilages; or spontaneous +fracture or dislocation may occur, owing to the brittleness of the +bones. There is no pain and the large joints are most frequently +affected; these may be excited by an injury. Herpes, skin ecchymoses, +edema, local sweating, alterations in the nails, perforating ulcer of +the foot, onychia, decay of the teeth and atrophy of the muscles may +occur. The auditory nerve is rarely affected, but in some cases there +may be deafness. There may be attacks of vertigo. Olfactory symptoms +are rarely met with. Cerebral symptoms are rare. =Paralysis= may +develop and the patient becomes bed-ridden. The disease itself does not +prove fatal; the patient may live for years until some intercurrent +disease causes death. + +=Diagnosis.=—This is usually easy when the characteristic symptoms are +developed. The presence of lightning pains, absence of the knee-jerk, +early ocular palsies, a squint, ptosis and Argyll Robertson pupil make +the diagnosis conclusive. Care has to be taken in making diagnosis from +peripheral neuritis, paresis, ataxic paraplegia, cerebral disease and +some diseases in which the posterior columns are disturbed. + +=Prognosis= will depend largely on the exciting cause, as it is least +hopeful from syphilis, but the earlier the case is treated the better +the chance. The progress of the disease can sometimes be arrested and +occasionally cases presenting symptoms of the first and second stage +are entirely relieved with persistent treatment. + +=Treatment.=—Experience in the treatment of locomotor ataxia has been +that often the disease can be checked and the symptoms relieved; but +curing a case of locomotor ataxia, except in the early stages, is +seldom possible. When there is degeneration of nerve centers, there +is no hope for a cure. Those with a syphilitic history are by far the +hardest to relieve. Antisyphilitic treatment should be considered. +Cases with a syphilitic history presenting preataxic symptoms, Argyll +Robertson pupil, lightning pains and loss of patellar reflex have been +cured; unfortunately these cases are not always diagnosed. + +The treatment consists of thorough correction of the spinal +derangements found, especially through the lumbar and lower dorsal +regions. If the disease has involved the arms or brain, thorough +treatment should be given the entire length of the spine with a view +to increasing the circulation in the spinal cord and brain, and thus +checking or preventing the tissue degeneration. “In the early stage, +deep massage to the muscles of the back promotes the flow of venous +blood through the spinal vessels and their anastomotic branches, and is +the best means of relieving the congestion which is supposed to exist.” +(Starr) The lower spine will be found to be rigid and should be well +sprung to get mobility. + +Careful treatment of the limbs should be given, but be exceedingly +=cautious= in the treatment of the limbs of =advanced cases=, as there +is considerable danger of producing fractures. Stretching the thigh +muscles and internal and external rotation treatment of the legs should +be given. See that the bowels are moved daily and be positive that +there is no retention of the urine in the bladder. A catheter has to be +used in some cases. The patient should be careful about taking too much +food, and especially beware of indigestible food, as it irritates or +excites gastric crises. + +During =painful attacks= the patient should rest in bed, and +with careful treatment the attack can generally be relieved. Hot +applications are of considerable aid. + +At all times excesses should be avoided. Occupation of some character +should be given the sufferer. Do not promise to cure the patient, and +make it plain at the start that it will probably require a long time to +show much improvement. Systematic exercises to reestablish coordination +should not be neglected. + + +Hereditary Ataxia + +(FRIEDREICH’S ATAXIA) + +This is a rare hereditary disease, due to sclerosis of the columns of +Goll and Burdach and the pyramidal tracts. There are ataxia, muscular +weakness, nystagmus, speech disorders and loss of knee flex. Almost +invariably there will be found a neuropathic history. Alcoholism, +syphilis and insanity in the parents are predisposing causes. +Tuberculosis may be a factor. Acute diseases, especially infectious +fevers, dentition and injuries to the spine may be exciting causes. +It occurs most frequently in males about the seventh or eighth year +and very seldom after puberty. Several members of the same family are +apt to be affected. The disorder is transmitted by the female. “The +degeneration of the posterior and pyramidal columns seems to occur at +the time of cord development, when malnutrition or hereditary dyscrasia +would disturb it most.” + +=Pathologically=, “the spinal cord is smaller throughout than normal; +we have also a combined disease of the posterior and lateral tracts +(Schultze), a degeneration of Goll’s tract in toto, of Burdach’s almost +entirely, and of the direct cerebellar, the crossed pyramidal (?), and +of Clarke’s columns, in which we find not only atrophy of fibers, but +also a degeneration of the ganglion cells. Gower’s tract may likewise +be involved.” (Oppenheim). + +=Symptoms.=—Impaired coordination, beginning in the legs and later +extending to the arms, is the first marked symptom. The gait is +peculiar; it is swaying and irregular and it lacks the pronounced +stamping gait of locomotor ataxia. There is a loss of reflexes, while +no sensory symptoms are present as a rule. The sphincters are normal. +Nystagmus is present and is a characteristic symptom. The speech is +scanning. Talipes and lateral curvature of the spine are common. The +mind becomes sluggish in later stages. The course is always very slow. + +=Diagnosis.=—This is not difficult as a rule, owing to the usual +family history presented. The spinal curvature, nystagmus, +incoordination, scanning speech, irregular gait, and deformity of the +feet are symptomatic. In =locomotor ataxia= the gait, sharp pains, +anesthesia and Argyll Robertson pupil will differentiate between the +two. Differentiation will also have to be made from chorea, ataxic +paraplegia and multiple sclerosis. + +=Treatment.=—The same treatment as in locomotor ataxia is followed. +Lesions presented have been found at the tenth and eleventh dorsals, +and at the second and third cervicals, although, as a rule, the entire +spinal column is quite debilitated. Some improvement will be noted in +these cases, but not much can be expected from treatment; contractures +may be prevented. + + +Spastic Paraplegia + +=Spastic paraplegia= begins as a stiffness in the legs, with no sensory +symptoms, but finally the muscles become rigid and slowly paralyzed. +The reflexes are exaggerated. + +It may occur, in a few instances, as a primary disease, “being a +degeneration of the motor neurone, whose body lies in the brain cortex +and whose axone lies in the lateral pyramidal tract.” Usually it is +secondary to tumors, inflammation and softening of the brain. Multiple +sclerosis, hemorrhage, transverse myelitis, syringomyelia and other +diseases of the cord, injury, exposure and overexertion are exciting +causes. Syphilis may be a cause. It generally develops between the ages +of twenty and forty. + +=Pathologically=, the degeneration involves the lateral pyramidal +columns of the cord. It begins at the periphery and extends upward +until finally the axones atrophy and neuroglia overgrowth takes place +and sclerosis of the motor tracts results. + +=Symptoms.=—Muscular stiffness in one leg is usually the first symptom, +which gradually disturbs both sides. The muscular stiffness increases +to a rigidity, and even cramps, so that it is with considerable +difficulty that the patient moves about. The reflexes are exaggerated. +The joints, as well as the muscles are stiff, so that the toes are +dragged upon the ground and the legs are kept close together, abduction +of the limbs being difficult. On the whole, there is much tiredness, +stiffness, rigidity and hardness of the leg muscles, so that all +motions with them are performed with great effort. Sensory and trophic +symptoms are lacking; control of the bladder and rectum is usually +normal. The progress of the disease is slow. The upper extremities may +be involved in after years, but the common extensive disturbance is +with the legs, so that they may be entirely useless and the muscles +atrophy from disuse, although rigidity and contractures remain. + +=Treatment.=—The prognosis is usually unfavorable, though frequently +the patient may be considerably benefited. A few cases that have +been =caused= by =traumatism=, cold or exposure have yielded to +osteopathic treatment and all symptoms disappeared. The treatment is +largely that of locomotor ataxia. The lesions are readily located in +the spinal column. In a few cases a slight posterior curvature of the +dorso-lumbar region is found, but the majority of the lesions are in +the lower dorsal region. Special care should be given to the bladder +and bowels. Prolonged warm baths are beneficial. Treatment of the legs +is always secondary to that of the spine. The diet should be nutritious +and one easily digested. Give the patient plenty of fresh air and +sunlight with cheerful surroundings. E. C. Link[132] reports two cases, +one of over one year’s standing, completely recovered, and another much +improved. + + +Ataxic Paraplegia + +In =ataxic paraplegia= there are ataxic and spastic symptoms, due to +both posterior and lateral sclerosis. Traumatism, cold and exposure are +etiologic factors. It is found in diffuse myelitis, general paresis, +leptomeningitis and in toxic conditions as in pernicious anemia. The +posterior and lateral columns are degenerated, so that in the former +there is an ascending degeneration and in the latter a descending. + +=Symptoms.=—These comprise those of =tabes= and =spastic paraplegia=. +Incoordination, ataxia, lightning pains, anesthesia, rigidness of +muscles and exaggerated reflexes are the principal symptoms. The +muscles easily fatigue; sensory symptoms are not so troublesome as in +tabes; there may be visceral crises, sometimes Argyll Robertson pupil; +and possibly spasms of the upper extremities and jaw. The course of the +disease is slow. + +=Diagnosis.=—This is not difficult as a rule. First, there is ataxia; +then increased reflexes, fatigue of the muscles and paraplegia. =Tumor= +of the =cerebellum= may confuse the diagnosis. + +=Treatment.=—There is frequently a chance to greatly benefit these +cases, and even in some instances a cure may be performed, provided +the case is seen early. Thorough treatment of the spine to relax +the muscles and to adjust the ribs and vertebræ is the indication. +Stretching the spine, if carefully done, is beneficial. Muscular +manipulation improves the spinal cord circulation, and osseous +correction removes probable impingements to nutrient channels and +nervous influences induced by cold, exposure, traumatism and secondary +disturbances. Care of the general health, hygiene, diet, etc., are +important. + + +Syringomyelia + +=Definition.=—A chronic affection of the spinal cord in which there +is an embryonal neurogliar overgrowth about the central canal, with +cavity formation. It is characterized, clinically, by progressive +muscular atrophy, peculiar disturbances of sensation and various +trophic and vasomotor disorders. The onset generally takes place before +the thirtieth year. Males are much more commonly affected than females. +It is claimed by some that the disease is infectious. It frequently +follows trauma. + +=Pathologically=, the condition begins with an overgrowth of embryonal +neurogliar tissue. This is followed by degeneration of the gliomatous +tissue with a formation of cavities, or this cavity formation may be +the result of hemorrhage. The disease, in most cases, involves only +the cervical or dorsal regions, and is usually in the posterior or +postero-lateral tracts. The cavity may prevail throughout the entire +cord, but usually only the cervical and dorsal regions are involved. +The cavities lie in the gray matter outside of the canal. + +=Symptoms.=—The onset is slow. The symptoms depend upon the situation +and extent of the cavity. As the disease most frequently involves the +cervical region, the neck and arms are usually affected. At first +neuralgic pains may develop in the muscles. Later there is progressive +muscular atrophy and loss of painful and thermic sensations. Tactile +and muscular senses are usually intact. The reflexes are increased and +a spastic condition is present. The lower limbs usually escape, but +when they are involved the clinical picture may be that of =amyotrophic +lateral sclerosis=. A lateral curvature is present. When the disease +extends into the medulla, there will be various bulbar symptoms. +Trophic changes and vasomotor disorders are common. + +A form of syringomyelia, known as =Morvan’s disease=, is characterized +by neuralgic pains, cutaneous anesthesia and painless felons. + +=Diagnosis.=—The progressive muscular atrophy, the retention of +muscular and tactile senses, and the loss of thermic and painful +sensations are typical symptoms. The diseases with which it may be +confounded are: =Cervical Pachymeningitis.= The pain is usually +greater, the tactile sense is lost and it runs a more rapid course. +=Anesthetic Leprosy.= The trophic changes are more marked, tactile +sensation is lost and the phalanges often drop off. =Progressive +Muscular Atrophy= and =Amyotrophic Lateral Sclerosis=. Sensory symptoms +are wanting. + +=Prognosis.=—The prognosis is unfavorable. Duration is from five to +twenty years. + +=Treatment.=—Little can be done except attending to the diet and +hygiene of the patient and meeting urgent symptoms. Probably, continued +treatment along the spinal column would influence to some extent +the circulation of the cord in the region of the involvement. Hot +applications are of value in relieving pain and cramps. The X-ray has +proven of some benefit in checking the progress of the disease. + + +Amyotrophic Lateral Sclerosis + +“This is a chronic, progressive form of spinal paralysis, characterized +by the symptoms of progressive muscular atrophy in the arms and by +lateral sclerosis or spastic paraplegia in the legs.” (Starr). It +is similar to progressive muscular atrophy, except, in addition, +there is sclerosis of the pyramidal tract. (See Progressive Muscular +Atrophy.) Osler classes progressive muscular atrophy of spinal origin, +amyotrophic lateral sclerosis and progressive bulbar paralysis as +diseases of the whole efferent or motor tract, wherein these disorders +may simply be various stages in the same case. He says, “A slow, +atrophic change in the motor neurones is the anatomical basis, and the +disease is one of the whole motor path, involving, in many cases, the +cortical, bulbar, and spinal centers.” There can be no question that +for the student, a classification of spinal cord diseases according +to the whole motor tract, the upper motor segment, the lower motor +segment, etc., is a scientific classification from our present +knowledge of the histology and physiology of the neurone, but for +clinical purposes the usual classification is given. Osteopathically, +we are greatly in need of a new nosology, either according to the cause +of the disorder or to the physiological disturbance. + +=Amyotrophic lateral sclerosis= does not occur so frequently as +progressive muscular atrophy. Heredity plays a part, and it affects +older people. =Injury= to the =spinal column= is undoubtedly an +important factor. Exposure and cold may be exciting causes. Infectious +diseases and syphilis are probably important causes. + +=Pathologically=, there are atrophy in the anterior cornu and sclerosis +of the crossed and direct pyramidal tracts. There is sclerosis of +centers in the medulla. + +=Symptoms.=—Atonic atrophy, muscular weakness and fibrillary +contractions, of varying degrees, are characteristic. The reflexes are +exaggerated; the arm and leg muscles become weak and finally rigid and +atrophied. This results in deformity. Disturbances of sensation are not +pronounced. The sphincters may be slightly affected. + +=Diagnosis.=—The disease is not so prolonged as progressive muscular +atrophy. Differentiation has to be made from multiple arthritis and +transverse myelitis and syringomyelia. + +=Treatment.=—The same treatment as outlined for progressive muscular +atrophy is indicated. The disease may be retarded and life prolonged. + + +Progressive Muscular Atrophy + +A disease characterized by a slow, but progressive, loss of power +and by muscular atrophy. Anatomically, it is characterized by +degeneration of the ganglion cells of the gray matter in the cord. +This atrophic affection develops just opposite to that of chronic +anterior poliomyelitis. It is commonly a disease of males in middle +life. Syphilis, rheumatism and lead poisoning predispose. It sometimes +follows cold, wet, exposure, traumatism, mental worries, overuse +of certain muscles, or prolonged emotional excitement. Hereditary +influences are present in some cases. In all cases =lesions= are +detected in the =vertebræ= and =ribs=, corresponding to the innervation +of the diseased areas. Very likely these lesions are the starting +point of the disease, by impairing nutrition to the motor cells of the +anterior cornu, and thus resulting in atrophy. + +=Pathologically=, the muscles are wasted, the fibers undergo fatty +degeneration and there is an overgrowth of connective tissue. The +peripheral motor fibers are degenerated. The anterior nerve roots +leading to the horns are atrophied. The large ganglion cells of the +anterior horns are atrophied, or even entirely removed. The neurogliar +tissue is increased. There is sclerosis of the anterior and lateral +pyramidal tracts of the cord in the majority of cases. (See Amyotrophic +Lateral Sclerosis). The pyramidal tracts have been found degenerated +through the pons and internal capsule, even up to the motor cortex. +When bulbar symptoms are present, there is degeneration of the motor +nuclei of the medulla. The posterior columns are not involved. + +=Symptoms.=—Irregular pains, numbness or exhaustion are usually felt +in the region that is soon to become wasted. The upper extremities +are first affected. The muscles of the ball of the thumb waste first, +then the interossei. From atrophy of the interossei and lumbricales +and contraction of the long extensor and flexor muscles, the deformity +known as “claw hand” results. The wasting creeps up from the forearm, +arm and shoulder. The muscles of the trunk are gradually affected. +The muscles of the lower extremity may escape entirely. The platysma +myoides does not waste and is often hypertrophied. The face muscles +are attacked late or not at all. The affected muscles often twitch. +Deformities and contractures develop, notably lordosis. Sensation +is not impaired although the patient may complain of numbness and +coldness. The bladder and rectum are not affected, but sexual power +may be lost. The paralysis is flaccid and the reflexes absent in the +so-called =atonic cases=. In =atonic= atrophy there is more or less +spasm, the reflexes are greatly increased, there are often contractures +and the wasting is usually trifling. + +=Diagnosis.=—Differential diagnosis has to be made from syringomyelia, +chronic anterior poliomyelitis, lead palsy and muscular dystrophies. + +=Prognosis.=—The prognosis of progressive muscular atrophy is not +favorable, although a number of cases have been greatly helped by an +extended course of treatment. + +=Treatment.=—The treatment consists of a thorough, stimulating +treatment of the innervation of the affected regions, with manipulation +of the muscles and parts diseased. =Correction= of the =lesions= to +the =vertebræ= and =ribs=, which are involving the innervation to +the diseased tissues, is of primary importance. A cure cannot be +expected when degeneration of the nerve centers has occurred; still, +the progress of the disease may be checked in many cases, and the +patient occasionally gain considerable strength. When atrophy starts +in the muscles of the ball of the thumb, the lesion is to the median +nerve, and derangements of the cervical vertebræ, from the fifth to the +seventh, may be found. Attention to the general health is important. +Outdoor life is preferable and gymnastic exercises are of value, but do +not overtax the strength. + + +Bulbar Paralysis + +(LABIOGLOSSOLARYNGEAL PARALYSIS) + +A progressive atrophy and paralysis, invading the lips, tongue, pharynx +and larynx, due to involvement (sclerosis) of the motor nuclei of the +medulla oblongata that supply these tissues. It is rarely primary, +more =frequently secondary= to tabes, amyotrophic lateral sclerosis +and diseases involving the motor nuclei of the medulla. Diphtheria, +syphilis and lead poisoning are said to predispose. =Osteopathic +lesions= of the upper cervical are also important factors in many +cases. Halbert says: “The nuclei of the hypoglossal, the spinal +accessory, the facial and the motor part of the trifacial nerves suffer +most decidedly from the sclerotic degeneration. The nerve trunks and +the muscles which they supply gradually show the effects of a similar +degeneration.” + +The =acute form= results from hemorrhage, embolism or inflammatory +softening. The onset is usually sudden. The speech is difficult or +entirely lost. There are dribbling of saliva, difficult swallowing, +flabbiness and flaccidity of the lips and frequent choking spells +occur. These cases may prove rapidly fatal. + +The =chronic form= may result from progressive muscular atrophy, +insular sclerosis, amyotrophic lateral sclerosis, acute ascending +paralysis or chronic poliomyelitis. The paralysis starts in the tongue, +the first symptom being a slight defect in the speech. When the lips +become involved, the patient cannot whistle and speech is rendered +still more difficult. The lips are prominent and the lower one drops. +The saliva is increased in amount and there is drooling. Mastication +of the food becomes difficult. The tongue becomes atrophied and the +mucous membrane wrinkled. Fibrillary tremors of the lips and tongue are +present. Sensory symptoms are not present. Taste is normal. Paralysis +of the larynx is not so pronounced as of the other parts. + +=Diagnosis.=—This is generally easy as the symptoms are well marked. +The =prognosis= is unfavorable. + +=Treatment.=—Little can be done in the majority of cases. Only in those +cases where the paralysis is caused by =cervical lesions= can much hope +be given. Derangements of the cervical vertebræ, especially the atlas +and axis, occasionally influence the circulation in the medulla to such +an extent that the motor nuclei are greatly involved. The subluxated +vertebras may interfere with the blood-vessels directly or through +the vasomotor and trophic nerves. When the onset is not abrupt, the +prognosis is more favorable. When deglutition is impaired, the stomach +tube should be used in feeding the patient to prevent the food passing +into the trachea. + + +FOOTNOTES: + +[126] A. O. A. Case Reports, Series V. + +[127] A. O. A. Case Reports, Series II. + +[128] A. O. A. Case Reports, Series V. + +[129] A. O. O. Case Reports, Series I. + +[130] Millard, Poliomyelitis. + +[131] Journal of the American Osteopathic Association, February 1906. + +[132] Journal of Osteopathy, Oct. 1904. + + + + +ORTHOPEDIC SURGERY + +By H. S. HAIN + + +Orthopedic surgery deals with the mechanical or surgical prevention +and correction of all deformities, especially those of children. It +is not alone justifiable, but imperative, that orthopedic surgery be +given a prominent position in any up-to-date text on the Principles +and Practice of Osteopathy. The justification is threefold: though +orthopedics was practiced to a limited extent before the Science of +Osteopathy was developed, it has always been considered to be outside +the realms of true surgery, in that it is practically bloodless, and +those engaged in such practice have sought to establish it upon a +platform of its own. + +The basis of the practice of orthopedic surgery and osteopathy is +similar, if not identical, in that it deals almost entirely with bony +abnormalities. It is recognized by the whole osteopathic profession, +and unconsciously by some adherents of medical science, that the +maintainance and restoration of normal function are alike dependent on +a force inherent in bioplasm and that function perverted beyond the +limits of self-adjustment, is dependent upon a condition of structure +perverted beyond those limits. This, then is the platform upon which +the two sciences of osteopathy and orthopedic surgery are erected. + +The technique of osteopathic practice consists of passive manipulative +measures, designed to render to the organism such aid as will enable it +to overcome or adapt itself to the disturbed structure; and does not +seek, in itself, the aid of any instrument, mechanical appliance or +plaster of Paris cast. + +Surely it is but a short step from our osteopathic therapeutics to +a system of therapeutics where we find all sorts of mechanical and +plaster of paris appliances, etc., to help our passive manipulation in +rendering to the human organism such aid as will enable it to overcome +or adapt itself to a disturbed structure. This latter, of course, is +the modern science of orthopedic surgery, and because of the shortness +of this step, I insist that it is one of the most valuable adjuncts +of the science of osteopathy. It is frequently necessary for the +osteopathic practitioner to take this step as conditions are met with +that have progressed beyond the possibilities of passive manipulations +and again other conditions of perverted structure can be much more +quickly reduced by the aid of each. + +It is then indisputable that the therapist who approaches disease from +the osteopathic standpoint, above enunciated, is far more competent +to deal with the mechanical problems of orthopedic surgery than any +other known therapist. Secondly, in many conditions originally treated +by orthopedic methods, subsequent ordinary osteopathic manipulations +obtain a much more satisfactory and more lasting result than if it is +withheld. Thirdly, in order to avoid possible error, it is of extreme +importance that all osteopathic practitioners be particularly familiar +with the conditions hereinafter described, more especially tubercular +conditions of the spine, bones and joints, primary spinal curvatures +and others. + +It is reasonable and furthermore true that osteopathic physicians are +confronted in practice with an unusually large percentage of cases +indicated above, and the early recognition of such conditions is of +fundamental importance in order that osteopathic manipulations be +withheld and supplemented or replaced by orthopedic methods. + +Space of course will not permit of the entire discussion of this vast +subject but the most important and serious conditions met with in +general practice are fully discussed in the following pages of this +chapter. + +Perhaps the commonest condition coming under this line of therapeutics, +and one in which we, as osteopaths, are most vitally interested is +rotary lateral curvature of the spine. From my personal observation +and from experiences of some of the most prominent members of our +profession, I am led to believe that this is one of our most difficult +lesions to overcome osteopathically, hence my desire to go further +into this condition than most of us might expect. I had opportunity +to obtain personally some very valuable information from Dr. Joachim +Stahl in the King’s Charity Hospital in Berlin, and to him I am +deeply grateful for many of the ideas of treatment presented in the +following article. I believe that I have an accurate conception of the +pathological condition that exists in connection with this deformity, +and I believe that my treatment of it has been more successful than +any that I have seen under other methods, in that I have gotten most +excellent results, in selected cases, in a comparatively short time, +entirely because osteopathic manipulations and exercises were used in +connection with the modified Abbott method. + + +Scoliosis or Rotary Lateral Curvature + +Scoliosis or Lateral Curvature of the Spine is a deformity where the +spine is deviated in whole or in part to one or the other side of the +median line, which deviation is accompanied by an element of rotation. +Though usually considered as a spinal deformity its =effects= are +obvious outside the spinal area in so much as it will cause deformity +of the pelvis, legs, ribs, sternum, scapulæ, and in severe cases, of +the thoracic and abdominal viscera. + +Curvatures of the spine are the result of one of two distinct factors: +first where there is a primary disease of the bone causing more or less +destruction of the bone and spinal articulations, and resulting in +permanent spinal curvature. The most common example of this condition +is seen in the angular curvature of Pott’s disease. =Rickets= is +usually responsible for a general long posterior curvature of the whole +spine, as is osteomalacia with the superimposition of some lateral +deviation. Further, any type of inflammation or trauma is capable +of producing curvatures of various types. Second, where there is no +primary disease of the bone, joints, or ligaments, and where the +curvature is due to external forces acting constantly or at frequently +recurring intervals on the spine. + +Scoliosis or lateral curvature belongs to the second class. It is +unfortunately necessary to further subdivide scoliosis into two +classes; one where the curvature is a position permanently maintained +but capable of being reproduced by extreme physiological movement of a +normal spine, and secondly, a position which no normal spine can assume +and which necessarily implies a change in the normal shape of the bones +and intervertebral discs. The first may be described as a functional or +postural lateral curvature, and the second as an organic or structural +lateral curvature. Further, I might say that the first type may +progress until it becomes the organic type. + +=Pathology.=—In scoliosis the spine undergoes not only curvature or +lateral deviation but also rotation of the vertebral bodies which you +will note always takes place towards the convexity of the curve. + +=Changes in the Individual Vertebræ.=—The bodies may be either +wedge shaped or lozenge shaped. In wedge shaped vertebræ, the bodies +are compressed on the concave side and extended on the convex side, +the intervertebral discs being atrophied on the shortened side. In the +lozenge shaped type, the change in the bodies is most marked at the +junction of the opposite curves, and is thus more commonly observed in +compound curvatures. The pedicles are directed more antero-posteriorly +on the convex side and more transversely on the concave side. The +transverse processes on the convex side are more antero-posterior +than normal, causing the vertical furrow between them and the spine +to be narrower on this side. The spines point towards the concavity +in structural curvatures and toward the convexity in the functional +type. The vertebral foramen is rounded in the convexity and pointed in +the concavity. The edge of the anterior common ligament toward the +convexity is greatly thinned while it has a well marked edge on the +concave border. A fibrous degeneration occurs in the muscles on the +convexity owing to stretching, while atrophy from disuse takes place in +those on the concave side. + +=Associated changes in the Viscera.=—The =dorso-lumbar= curvature +decrease in the volume of the lower thorax on the dorso-convex side +tends to cause pleural adhesions with obliteration of the pleural +sac and consequent collapse. Tuberculosis of the =lung= is common in +patients who suffer from scoliosis. The =heart= is often overworked +but the above lessening of the pulmonary area in turn results in +hypertrophy and dilatation of the right ventricle and subsequent +general venous stasis. The =kidney= on the convex side is compressed, +and as a result degenerative changes are prone to occur. The =spleen= +is frequently displaced upward and is liable to pathological changes. +Organs such as the stomach, transverse colon, esophagus and trachea are +frequently displaced owing to the bony deformity and are thereby more +prone to pathological change. + +=Etiology.=—The essential factor in the production of scoliosis is +spinal insufficiency, which includes spinal muscles and ligaments as +well as the bones. In many instances, however, the following factors +have an important augmenting or predisposing effect. + +=1. Occupational Deformity.=—Primarily under this classification, I +have found faulty positions adopted by school children as being the +most comfortable, to be perhaps most important. Occupations such as +those of nurse-maids, hod carriers, or stone cutters, are apt to induce +scoliosis. + +=2. Diseases of the Central Nervous System.=—Unilateral weakness or +paralysis of the muscles of the trunk are common causes of scoliosis. +Anterior poliomyelitis plays a particularly important part as it +may induce deformity by distortion of the lower extremity or by any +inequality in the length of the limbs due to retardation of growth, as +well as inducing general weakness of the muscles of the trunk. Other +nervous disorders that should be considered are spastic paralysis, +locomotor ataxia, syringomyelia and Friedreich’s ataxia. + +=3. Incidental Deformity.=—Scoliosis may be caused by direct injury or +by fracture, Pott’s Disease, or organic affections of the spine. Marked +deformity caused by Sciatica or lumbar neuritis, if persistent may +finally induce permanent deformity. + +=4. Deformities Due to Diseases of the Chest.=—In =empyema= or +=pleurisy= one side of the chest is retracted and it will be noticed +that the curvature occurs toward the healthy side. Chronic pulmonary +tuberculosis producing fibrosis of the lung gives the same result as +empyema and pleurisy. + +=5. Deformity due to obliquity of the pelvis.=—This type may be due to +any inequality of the limbs, such as equinus of the foot. Congenital +dislocation of the hip may play a part while one naturally lays stress +on pelvic and lower lumbar lesions. + +=6. Deformity due to Distortion of Other Parts.=—Unequal visions, +unequal hearing, and torticollis by causing malposition are etiological +factors especially in school children. The loss of an arm will tend to +cause an asymmetrical position of the trunk. + +=7. Congenital Deformity.=—Congenital scoliosis occurs, but is usually +associated with other congenital deformities of the spine, such as the +reduction or increase of the vertebræ, cervical rib, elevation of the +scapula, etc. The deformity is usually not apparent until later years, +though it may occur at birth. + +=8. Spinal Lesions.=—Any osteopathic lesion predisposes to curvature +because it interferes with the nerve supply and tonicity of the spinal +muscles and could readily cause the faulty position. + + +Functional or Postural Lateral Curvature + +This is a condition where there is a gradual curve to one side +unaccompanied by any marked rotation. The maximum deviation may be no +more than one inch and a half from the middle line, which point is +generally found about the tenth dorsal vertebra. In the vast majority +of cases deviation is to the left and in such the following alterations +will be noticed: a general convex curve to the left; elevation, and +anterior displacement of the left shoulder; posterior displacement +of the right shoulder; in extension, the right side of the back will +be higher than the left and in addition some torsion to the concave +side, which is easily understood if one recalls the exact changes that +take place during side movement of the normal spine. It is important +to remember that functional scoliosis disappears when the patient is +suspended or assumes the recumbent position. + + +Organic or Structural Scoliosis + +This term is applied to cases where definite change has taken place +in the vertebræ. Organic curves may be simple when the deviation +is unaccompanied by any compensatory curve, or compound when a +compensatory curve is present. We shall consider the deformities as +they present themselves in the various regions of the spine. + +=Cervico-Dorsal Curvature.=—This condition is comparatively rare and +according to Lovett occurs in only three and six tenths per cent of +cases. The head is slightly deviated towards the concave side, the +shoulder on the concave side is lowered, while on the opposite side or +the side of the convexity it is naturally at a higher level. The angles +of the upper ribs are prominent due to the co-existing rotation. + +=The Dorsal Curvature.=—The shoulder is raised on the convex side, and +the rotation of the vertebræ is very marked, causing a very definite +projection of the angles of the ribs on the convexity. This rotation +also projects the scapula backwards on the convex side. On the concave +side the scapula is flat and sunken, and the inferior angle rotated +inwards and at a higher level than the opposite side. Viewed from the +front the thorax may not be displaced at all, or it may be displaced +toward the convex side, and if the latter is the case it is, of course +more prominent on the concave side. In severe cases the lower end +of the sternum is deviated towards the convexity and you will find +that usually the arm hangs further from the convex side than from the +opposite one. + +=The Lumbar Curvature.=—Here we find the trunk displaced toward the +side of the convexity, and the waist retracted on the opposite side. +The difference in the level of the hips is the most prominent deformity +in this region, and it will be found that the hips are raised on the +concave side. Rotation in this region is much less evident than in the +dorsal region, but can be demonstrated by a fullness on the convex side +of the curve, due to the projection of the transverse processes. + +=Dorso-Lumbar Curvatures.=—This condition is similar to a certain +extent, to a severe functional scoliosis. The findings observed in the +last two regions above described will naturally be present in this type +of curvature. It is not so frequently associated with compensatory +curves as in the other types described. + +=Compound Structural Curves.=—The appearance in this type of scoliosis +will, of course, be a combination of those described above according +to the types of curvature in combination, that is to say right dorsal +and left lumbar, etc. If one type predominates the appearance will be +chiefly that found in that particular type of curvature. The relative +frequency of the common type, as given by Schaltless, in eleven hundred +and thirty seven cases is as follows; functional scoliosis, 15.39%; +lumbar, 11.7%; dorsal, 19%; dorso-lumbar, 20%; cervico-dorsal, 3.6%; +compound, 30%. + +=Diagnosis.=—To the osteopathic physician the diagnosis of scoliosis +is not difficult. Let me caution you that true scoliosis must be +distinguished from the lateral curvatures caused by Pott’s disease. +Vertebral rotation, the absence of pain, the extreme rigidity, the +characteristic appearance of the ribs and thorax should, however, make +the diagnosis of scoliosis easy. + +=Treatment.=—In general the treatment of scoliosis is difficult to +present, because every case is considerably different, and the amount +of correcting force used in any form is almost entirely a matter of +judgment, as is also the time when corrective pressure should be +discontinued. Continual practice in the treatment of these conditions +is most essential to your success with them. I have had most gratifying +results in a comparatively short time simply because I used osteopathic +treatment and exercises along with a modified Abbott method. + + +Functional or False Scoliosis + +The functional or false scoliosis might be regarded as a habitual +inability to stand correctly, simply a postural malposition and lack +of muscle tone without marked structural change, which is maintained +for a considerable length of time or where the position is repeated +several times daily. The treatment of selected types of this deformity +is most successful and may well be divided into three procedures: +first, the substitution of a correct attitude for the faulty one, that +is careful investigation should be made to ascertain the condition +which might be the cause of the incorrect position such as poor school +desks which might cause the child to reach either up or down to write, +poorly fitting clothing which causes a pulling on the shoulder, eye +strain which would cause tilting or twisting of the neck, congenital +shortening of one limb or too rapid growth, should all be looked for +and removed; second, regular osteopathic manipulation, at least three +times per week to increase the tonicity of the already weakened spinal +muscles and aid correction, are highly essential and shortens the time +required for a complete cure; third, supervised gymnastic exercises of +various kinds are very beneficial to develop and bring the musculature +back to normal. Such simple exercises as crawling on the hands and +knees in a small circle towards the side of the convexity, and the +hanging from a horizontal bar by the arm on the side of the concavity +will prove to be helpful. Some authors recommend the regular army +setting up exercises for some cases or a frame by means of which the +hips are fixed, and rotating and side bending exercises of the head +and trunk given. These last two exercises are indeed very reasonable +procedures but I have found them unnecessary mainly because I used +osteopathic manipulations instead. + +In advising and supervising exercises it is best to have the patient’s +back bared so that the effect of each movement can be noticed and the +exercises directed accordingly. Care and judgment should be used as to +the number and severity of the exercises and would depend of course on +the vigor of the child. Treatment should continue until the condition +has been overcome, and the patient should be under observation for a +couple of months afterwards so that any recurrence of the deformity +would be noticed and attended. + + +Organic or Structural Scoliosis + +The treatment of organic or structural scoliosis is more complicated +for it must be remembered there are two elements of the deformity +demanding correction; one, the lateral curve to be corrected by a side +force, and the other, the rotation of the vertebræ to be corrected by +a twisting force. I find both osteopathic manipulation and gymnastic +exercises are of great value in the correction of this deformity as +they help to loosen the curve and develop the musculature but used +alone good results can rarely be obtained especially in obstinate +curvatures. I believe that I have improved nutrition and probably +prevented further deformity by treatments and exercises, but I am +quite positive that it is not possible to correct an organic scoliosis +without the forcible correction used in the Abbott method. + +As the details of treatment are tedious to follow, we will take for +example a case of right dorsal curvature presenting a marked hump +deformity, with a compensatory curve to the left in the lumbar region, +as this is the most common type. I might say here that whether or not +a compensatory curve is present, makes no difference, as treatment +is directed entirely to the primary curve on the assumption that +overcorrection of it will cause a secondary curve to disappear by +compensation. + +The patient is prepared by putting on a snug fitting undershirt and +sewing pads of saddler’s felt over all bony prominences, especially +the crest of the ileum and anterior superior spine. Sometimes I take a +piece of felt of four or five inches wide and long enough to go around +the entire pelvis, just high enough to cover the brim, and fasten it in +front with adhesive. Next I make a bunch of pads two or three inches in +thickness and large enough to fill up the concavity of the left side, +and first sew them together, and then with a few stitches fasten them +to the undershirt thereby filling up the space on the concave side. +The edges of the pads should, of course, be trimmed down to conform +with the general contour of the body, the main thickness being in the +middle. I then sew a single pad on the right side of the thorax in +front and a little to the right side. + +[Illustration: Patient suspended on canvas hammock in regular Abbott +frame ready to apply cast for a right dorsal curvature. Notice manner +of applying the correcting canvas straps.] + +The patient is now ready for the Abbott frame and is placed on a +canvas hammock about twelve inches wide, which is cut on the bias so +the right side is three inches shorter than the left. The hammock +can be adjusted to the desired degree of flexion by a ratchet at the +foot of the regular Abbott frame. The limbs of the patient should be +elevated to increase the flexion as this has a tendency to unlock the +articulation and thereby help in overcoming the rotation. Next a canvas +bandage four inches wide is passed around the patient under the axilla +of the concave side and fastened to the frame on the opposite side, and +another one is placed around the pelvis and fastened to the same side +of the frame, both on a level with the body plane. A third bandage is +next placed around the point of greatest convexity and fastened to the +opposite side of the frame in such a way that it can be tightened and +a direct pull be made on the curve. Before tightening the last bandage +the left arm and shoulder should be brought up high beside the face and +pulled backward toward the floor as it is this twisting force that +produces some rotation of the thorax. The correcting bandage is now +tightened being careful not to cause the patient too much discomfort. + +[Illustration: Cross section sketch of a right dorsal curvature showing +deformity in the thorax and rotation of the vertebræ, also windows +which are cut in the cast to allow expansion in these two directions +and the directing force of the pads. These are placed over the angles +of the ribs. Arrows show directions of the various forces.] + +I always use ordinary absorbent cotton for padding, which is held in +place by the regular gauze bandage. The plaster of Paris bandages +should be applied high up under the left shoulder and well down over +the sacrum and innominate bones and should be of a uniform thickness +of half an inch. Sometimes I carry the plaster over the right shoulder +to hold it down and back, though not always. I always let the cast set +pretty well before removing the patient from the frame and if it has +been applied in the morning I find it best to wait until afternoon +before trimming and cutting the windows because there is less danger of +breaking it. In trimming I always smooth up the edges, lower the right +shoulder, but keep the left well up, trim off enough at the bottom in +front to allow the thighs to be readily flexed without obstruction, +and leave it low behind so as to maintain the flexion. Next, two holes +or windows are cut in the cast, one over each area where the pads +were inserted, and remove them. The hole in the back on the left or +concave side permits expansion of the chest to the back, while the +hole on the right side in front allows the ribs, which are posterior, +to move forward under pressure or the pads to be inserted at the +posterior angle or backward prominence of the ribs of the convexity. +The canvas bandages or straps around both the axilla and pelvis are +removed, but the one about the convexity of the curve is left in place +so as to assist in the after treatment. The patient usually suffers +some discomfort such as difficulty in breathing and the inability to +move the body freely, and should remain in bed a day or two after the +cast has been applied. Usually they sleep very poorly the first few +nights, but the spine soon gives under the pressure and they become +comfortable. When the cast has become quite comfortable an assistant +pulls on the canvas bandage which was left around the convexity, while +pads are inserted so that the greatest pressure is exerted on the angle +of the ribs to further overcome the rotation and decrease the lateral +deformity. Also heavy felt pad may be inserted over the bulging ribs +in front of the left side to push them back. Care should be taken that +too much pressure is not brought to bear on the side of the convexity +because if more pressure is exerted here than on the angles of the +ribs, it will tend to increase rather than decrease. + +Casts should be worn for different periods, some being changed in a +month while others can be worn for three months. It is entirely a +matter of judgment. My best results have been secured by only slightly +correcting the curvature at the time the cast was applied, and relying +more on the proper insertion of the pads. Often at the end of a month +or six weeks, in selected cases, I have split the cast down the front +and removed it by springing it apart, and administered osteopathic +manipulations to the spine freely in all directions, thoroughly +loosening up the muscles. Then I replace the cast and hold it together +in front with moleskin adhesive and insert the pads as before. I repeat +this procedure three times per week for another month, together with +daily exercises each morning and evening of drawing the left shoulder +up and forward while in the cast to develop the muscles of the left +shoulder girdle. The treatments and exercises certainly do build up +the spinal muscles for it must be realized that they have suffered in +nutrition to a great extent as a result of wearing the cast. Next the +cast can be worn during the day and removed at night, and gradually +it can be left off several hours at a time. If no bad results occur +it can be left off for longer periods until finally its use can be +discontinued. However, the patient should still be under observation +once a week for a couple of months to determine any recurrence of the +deformity. The resumption of active corrective treatment, or increasing +relaxation in gymnastic work, will, of course, depend upon the progress +of the case. + +In the more obstinate cases, casts should be applied as long as further +correction can be obtained. The procedure is entirely the same, only +the time required for correction is longer, sometimes a year or year +and a half, and when overcorrection has been maintained, it is better +to use a removable jacket made of celluloid or light stiffened leather, +with large windows cut over the region where pressure is to be avoided, +than the removable cast described above. + +In closing let me say that this method of correcting lateral curvature +is best adapted to patients during their growing period and though it +may be employed in older cases you will usually be disappointed in the +final result. The only reason I can see for treating older cases is +purely mercenary. + + +Congenital Dislocation of the Hip + +Unilateral + +Undoubtedly as far back as 1829, the actual recognition of this +condition was due to the pathological research of a French surgeon +Dupuytren, who described this deformity with great accuracy and +insisted that there was no possible chance of correction. From then +on until 1886 nothing was done by medical science to overcome the +deformity, though it is claimed some were made. It was in this year +that the famous Bavarian surgeon, Hoffa, gave to the medical profession +the results of his successful attempts at reduction by opening the hip +joint from behind and enlarging the acetabulum to a size sufficient to +hold the head of the femur. + +Orthopedic surgery has to thank the irritating effects on the skin, +of antiseptics necessary in preparing his hands for ordinary surgery, +as it was due to this triviality that Lorenz, a promising surgeon of +Vienna, transferred his energies to the field of bloodless surgery and +gave to us the most valuable early work and present day technique in +the bloodless reduction of congenital dislocation of the hip. + +The name, of course, is applied to a congenital deformity which +involves one or both hip joints, resulting in lameness, due to a +misplacement of the head of the femur from the acetabulum. Of all +congenital dislocations the hip joint is by far the most common and +most important. The misplacement is far more often unilateral than +bilateral and far more frequent in females than in males, the cause for +the latter probably being the difference which exists in aspect and +position of the acetabulum as well as the disproportionate laxity of +the capsule in the two sexes. It must be remembered that normally at +birth, the acetabulum covers only about one-third of the head of the +femur, and our most accepted theory as to the cause of this deformity, +is a defective development of the acetabulum or its posterior margin, +which may be primary or secondary to an abnormally prolonged fixation +of the limb in a position of flexion or adduction while in utero. At +birth it is quite probable that the dislocation is a subluxation only, +which becomes complete by muscular action and the use of the limb in +standing and walking. + +The pathology of this disease is clearly established, and varies, of +course, with the age of the patient in strain and friction to which +the misplaced parts have been subjected. In children over two and +one-half years of age the acetabulum is usually shallow and small, and +filled with a deposit of fat and fibrous tissue. It is covered with +normal hyaline cartilage and nearly always the ligamentum teres is +present, but is so badly stretched and ribbon-like that ultimately the +artery accompanying it fails to function, resulting in a malformation +of the head of the femur. The capsular ligament is elongated and +thickened to accommodate the upper displacement of the femur, and the +anterior wall of it is stretched tight across the acetabulum like an +hour glass. The interior of the capsule is always partly lined with +synovial membrane. Usually a secondary acetabulum is found upon the +ileum, formed by the direct pressure of the head of the femur through +the capsule and the result of irritation of the periosteum of the +ileum, but it is as a rule, not deep enough to form a secure support +for the head of the bone. The neck of the femur is usually shorter +than normal and the upper extremity of the bone is somewhat atrophied. +The pelvis is usually slightly atrophied on the affected side, and +a lateral inclination of the spine may be present. The long muscles +of the thigh are shortened; while those attached to the pelvis and +trochanter are changed in direction and are usually lengthened. + +[Illustration: Typical congenital dislocation of the hip, showing the +“hour glass” constriction of the capsular ligament.] + +=Symptoms.=—As a rule congenital dislocation of the hip is not +accompanied by the defective development or deformity elsewhere, and +the symptoms are so diagnostic that there is little difficulty in +recognizing this condition even without the X-ray which is, of course, +a positive diagnosis. + +Rarely does the displacement attract attention until the child begins +to walk. Often the child does not walk as early as it should. Sometimes +it may be delayed until the eighteenth month or second year and then +it walks with a limp which becomes more pronounced as the child grows +older until at the fourth or fifth year it is very decided. The limp +is peculiar and its character is explained by its cause; for the +shortened limb, owing to the elasticity of the capsule, becomes still +shorter when the weight is borne upon it, thus causing a peculiar lunge +of the body towards the short side like the normal motion of walking +downstairs. In compensation, of course, the pelvis is tilted towards +the short limb and its inclination is thereby increased, so that the +anterior superior spine lies at a lower level and in advance of the +opposite side. Usually the affected limb is about an inch shorter than +the sound one, and in adult life it is considerably more. The range +of abduction is much diminished, but flexion, extension and adduction +are quite normal, and the trochanter will be found elevated about +an inch above Nelaton’s line. If the thigh be flexed and adducted +to its extreme limit, the neck and head of the femur can be easily +distinguished moving under the gluteal muscles when the limb is +rotated, or the head can usually be readily palpated in front when the +limb is extended. Then, too, by fixing the pelvis and using traction +and upward pressure on the limb, the abnormal mobility or telescopic +motion is easily demonstrated and this, I might add, is a very +important test. + +[Illustration: Outline of a radiograph following reduction and removal +of the first cast in unilateral dislocation of the hip. Notice the head +in the socket and the thigh still flexed and abducted.] + +Rarely do we find a unilateral anterior dislocation, in which the +head of the bone lies beneath the anterior superior spine, but when +this position is present, the symptoms are much less marked than in +the ordinary form because the relation of the pelvis to the femur is +more nearly normal. The limp and the shortening of the limb are less +noticeable because the tissues attached to the anterior superior spine +form a relatively secure support. + +The X-ray, of course, makes the diagnosis complete. Even though the +clinical diagnosis is certain, a radiograph is indispensable in every +case, particularly for the purpose of ascertaining the exact position +of the head and condition of the acetabulum and femur. The acetabulum +is usually shallow and poorly developed, more particularly the iliac +portion of its rim. After the reduction of the dislocation, an X-ray +picture should always be taken within the first few weeks, and before +the plaster of paris cast has been removed, to ascertain whether the +head of the femur is still in place. + +[Illustration: Outline of the same case following removal of the second +cast. The head of the femur is firmly fixed in the acetabulum and the +position of the limb is nearly normal.] + +As to bilateral dislocation of the hip, the pathology, of course, is +the same as in the unilateral type. The shortening of the limbs is +as a rule equal or nearly so, and when both femurs are displaced +backward, the pelvis is tilted forward thus presenting a marked lumbar +lordosis and protruding abdomen. The pelvis seems to be abnormally +wide, both buttocks are flattened and the thighs are separated by a +considerable space. The characteristic limp in this condition is an +exaggerated waddle, often spoken of as “sailor gait.” Again in this +condition rarely do we find an anterior dislocation, but when such +is the case, the entire body is swayed entirely backward, though the +lumbar lordosis is not increased, in fact usually presents a peculiarly +flattened appearance. Other symptoms differ only in a slight degree +from those of the ordinary posterior displacement. The physical signs +are the same as the unilateral displacement and are even more readily +recognized by the peculiar appearance and distinctive gait of the +patient. The swaggering gait of lumbar Pott’s Disease is somewhat +similar, but this is an acquired clinical condition of the spine in +which the hip joints are normal in appearance and nearly so in function. + +Before taking up the usual procedure for the correction of congenital +dislocation of the hip, it might be interesting to touch on several +cases of this deformity in young children that I have reduced without +an anesthetic. If future experience proves as successful as these +cases it will entirely revolutionize the treatment of this condition +especially in children under twenty months of age. To begin with, +these children had just started to walk and it must be remembered that +at this stage the acetabula are nearly normal and there has been no +muscular or ligamentous contraction because very little weight has been +borne on the limb. + +First the pelvis is held fixed by the assistant, and the thighs +completely flexed on the abdomen. Next firm pressure is made on the +knee to force the head of the femur beneath the acetabulum and as the +limb is abducted in the flexed position, the head is raised into the +acetabulum with the thumb of the operator’s other hand. The whole +procedure takes but a moment’s time and the child should be placed +at once upon the floor and allowed to walk. Time will tell if the +reduction has been successful, and if failure of retention develops, +the Lorenz method followed by plaster of Paris fixation can still be +used. I should always recommend the trial of this method in children +who have walked not longer than six months, before resorting to the +following Lorenz treatment. + +=Treatment by the Lorenz Operation.=—This treatment is based on the +fact that there is normally present an acetabulum of sufficient size +and capacity to retain the head of the femur, providing the limb can be +fixed in a favorable attitude, and as soon as possible weight borne +upon it to deepen the rudimentary acetabulum. The typical operation +of today is best divided into four distinct steps; first, to overcome +the resistance of the tissues surrounding the joint; second, to reduce +the dislocation, or rather to force the head of the femur over the +posterior border of the acetabulum; third, to increase the security +of the articulation by stretching the anterior border of the capsule; +fourth, to fix the parts in a plaster of Paris bandage. + +The child is completely anesthetized, and an assistant firmly fixes the +pelvis on the table with his hand. The operator first flexes the thigh +to a right angle with the body and forcibly abducts, at the same time +kneading and stretching the tense adductor muscles and if necessary +rupturing the adductor tendons in order to bring the limb down to the +plane with the body. Next to overcome the contraction of the posterior +tissues, the limb fully extended is flexed upon the trunk and gradually +forced downward until the toes touch the patient’s face. To overcome +the resistance of the tissues on the front of the joint, it is best +to move the patient to the edge of the table and forcibly extend the +thigh downward behind the plane of the body. It is also well to apply +direct traction in the line of the body. This preliminary stretching +is absolutely necessary, because all the tissues about the joint are +so shortened, and it will now be noted that with slight traction the +trochanter can be drawn down to Nelaton’s line. + +Next reduction is attempted by grasping the limb with one hand at the +knee and strongly abducting it while the palm of the other hand is +placed on the anterior spine of the ilium with the thumb placed beneath +the great trochanter to act as fulcrum. As the limb is gradually forced +downward to and behind the body plane, the head of the femur is forced +upward until it finally slips over the posterior and inferior border of +the acetabulum. In the more resistant cases a padded wedge-shaped block +placed behind the trochanter will be an aid in pushing the head forward +and upward while the patient’s knee is forced downward. A successful +reduction is usually accompanied by a distinct jar and audible thud, +and it would be observed that the tension upon the ham string muscles +causes fixed flexion of the leg. After reduction has been made, the +limb should be brought down carefully into a straight position to test +the security of the re-position. If dislocation appears during this +manipulation, the tissues must be still further stretched and the +displacement further reduced. If displacement occurs readily due to a +shallowness of the acetabulum the prognosis is not so good as where +the stability remains when the limb is brought down into a straight +position, and one must be more particular in the fixation of it. I have +also observed that the more difficult the reduction the more stable +the end results. The easy replacements are usually just as easily +displaced. Sometimes the head slips into the socket quietly without the +distinct jar or thud but the results in these cases are just as good +provided they are properly cast. + +[Illustration: Patient in position for the first cast in a left +unilateral dislocation. The thigh should be a little past a right angle +in relation to the trunk, with about 80° abduction.] + +The application of the plaster spica is by far the most important part +of the treatment, as the reduction is usually quite easily accomplished +in children under six years of age. If the cast is improperly applied, +the hip will slip out of the socket and the case is a failure. A pair +of soft knitted cotton drawers are put on and the patient is placed +upon a pelvic rest with the limb held in the position of greatest +stability at a right angle with the trunk, or even slightly more and +about eighty degrees abduction. In a case where the socket is very +shallow, the position to be cast should be about one hundred degrees +flexion, and in abduction the limb should lie slightly behind the plane +of the body to secure the best results. + +[Illustration: Correct position and proper application of cast for +double congenital dislocation of the hips.] + +The limb and pelvis are covered with ordinary absorbent cotton which +is held in place with a roller gauze bandage. A snug fitting plaster +of Paris cast is now applied around the pelvis and well down over the +knee. I leave this over the knee for five or six days or until the +child ceases to be fretful, then I cut it away just back of the knee +joint to permit motion there. The ends of the drawers are drawn back +smoothly over the cast and are sewed to each other. For about a week +following the operation the adductor region is swollen and discolored +and more or less painful due to rupturing and stretching of those +tendons. After this discomfort has passed away, walking is encouraged +on the theory that the weight bearing and the stimulation of functional +activity will increase the stability of the joint by deepening the +acetabulum. + +[Illustration: Proper position of the limb in the second cast for +unilateral dislocation.] + +The first cast should remain from three to six months according to +the stability of the joint at the time of reduction. If in young +children the cast becomes offensive, it must be changed as often as is +necessary. When the first cast is removed, the limb is pulled down to +about thirty degrees abduction and the same amount of flexion, without +an anesthetic, and a second cast is applied, which extends only to +the knee, to be worn from three to six months longer. After removal +of second cast, the child is permitted to get about carefully. The +limb will be everted and slightly flexed, which position invariably +causes much concern among the relatives of the patient, but this +abnormal condition disappears after a few months’ time. Sometimes for +even a year following removal of the second cast there will also be a +noticeable hitch in the walk of the child; but this, too, disappears +and in the course of two years’ time one could never tell that such +an operation had been performed. Massage of the posterior and lateral +muscles of the hip always helps considerably towards the relief of any +stiffness or lameness. + + +Reduction by Open Incision + +In the more resistant older cases, where manipulative reduction has +failed, reduction by incision can be employed with success, but this +procedure requires the exercise of care in order to do as little injury +to the muscles as possible. A crucial incision of the capsule is made +and the capsular constriction and ilio-psoas tendon divided. With a +little traction, the head of the femur slips easily into its socket. +The capsule is stretched firmly around the neck and the incision into +the capsule is then closed by suture, and the limb fixed in a plaster +of Paris spica in the fully abducted position. The operation should of +course be done under the strictest asepsis. + + +Talipes or Club Foot + +The word talipes signifies some deformity of the foot and is quite +common in orthopedic practice, being found in nearly ten per cent +of the cases coming under this branch of the science. Club foot may +be classified into two types—the congenital and the acquired. The +congenital type is the most common and is due probably to abnormal +intrauterine pressure or to a perversion of normal intrauterine +development. The acquired type is due usually to injury or infantile +paralysis, but either joint disease or cerebral paralysis may be +the cause. The deformity presents six different forms with most +characteristic clinical pictures which, with the exception of talipes +planus I have taken up in the order of frequency. + +[Illustration: Illustrating the more common types of talipes. A +combination of any may be present.] + +=Talipes Equinovarus= is usually congenital and is the most common +type. It is characterized by inversion and torsion of the foot with +elevation of the heel. The weight is borne on the outer side of the +foot and in extreme cases upon the dorsum as well. Calluses are always +present which are red and painful upon the point where the greatest +weight is borne. The most common method of treating this condition +is to divide the tendo Achilles at a level with the malleoli. The +operation should be done aseptically and under complete anesthesia. +As an assistant raises the end of the foot so as to stretch the tendo +Achilles the surgeon enters the knife parallel to the border of the +tendon through the skin and tendon sheath into the tendon itself. Next +with a tenotome inserted into the incision and turned at right angles +to the tendon, the tendon is divided first on one-half then on the +other. Care should be taken to disturb the tendon sheath as little +as possible for it serves an important purpose in repair. When the +division is complete as indicated by the separation of the divided +ends, the tenotome is withdrawn and the minute opening in the skin, +from which there is only slight bleeding, is covered with aseptic +gauze. The foot is forced into dorsal flexion and if in severe cases +the deformity is not then corrected, the tendons on the outer side +of the foot may be shortened, while those on the inner side may be +lengthened in the same manner as the tendo Achilles. A plaster of Paris +cast is then applied well up to the knee with the foot in the over +corrected position, care being taken that no undue pressure is brought +upon the seat of operation, as this might interfere with the effusion +of plastic material. Personally I believe that functional use of the +limb and foot stimulate repair, and I always encourage the patient to +stand and walk after the discomfort of the operation has passed. At the +end of four weeks the space between the two cut ends will be filled +with new material and the cast can be removed, and in another month the +splice, which is somewhat larger and thicker than normal, should be +strong enough for use. In the course of a year the lengthened tendon is +perfectly normal. + +=Talipes Equinus.=—In this type the patient walks on his toes with the +heel highly elevated, in the same position as the horse, and it will +be noticed that the foot has no dorsal flexion whatsoever. Infantile +paralysis affecting the anterior muscles of the leg is usually the +cause of this condition, though sometimes shortening of the leg +following knee joint disease, or fracture may lead to an adaptive +equinus which serves to make the limb of equal length for walking. +This type is by far the easiest to remedy, and the results following +operations are perfect. A simple division of the tendo Achilles is +made under anesthesia and a cast applied as above, in a position of +exaggerated dorsal flexion. Functional use of the limb after the cast +has been removed overcomes any stiffness that might occur and perfect +results are obtained in a short time, compared with the other types. + +=Talipes Calcaneous.=—This is a condition in which the foot is held in +a position of dorsal flexion. The patient walks on the heel with an +inelastic gait because the spring of the foot is absent and the whole +weight is borne upon the os calcis. The best procedure in this type is +manipulative treatment into a position of plantar flexion to overcome +the contraction of the anterior muscles of the foot and leg, and bring +about contraction and shortening of the posterior muscles. A tenotomy +of the anterior tendons or an anesthetic is rarely indicated, though in +severe cases, a series of casts holding the foot in position of plantar +flexion may be necessary to secure good results. I have found it a help +to have a shoe with a heel prolongated backward, or a steel splint +laced to the leg to prevent the foot from upward motion. + +=Talipes Valgus.=—This is a very uncommon type of deformity, +characterized by eversion of the foot. The patient walks on the inside +of the foot and, as a rule, experiences very little trouble. I find a +manipulative treatment is best for this condition, aided by braces. + +=Talipes Cavus.=—This form is sometimes called “=hollow foot=” and is +very uncommon in this country. It is characterized by a markedly high +arch sometimes as in Chinese women to the extent that the anterior +part of the foot is approximated to the heel. The plantar fascia is +badly contracted and one can distinctly palpate the bands beneath the +skin. This condition is practically the same as the ordinary so-called +“=contracted foot=” except that it is much more exaggerated. The +ordinary high arch of today is usually the result of wearing too short +a shoe, and if painful, long last shoes, aided by manipulations, will +usually correct the trouble. In severe cases of contracted foot the +plantar fascia may be divided, under anesthesia and the arch brought +down and put in a cast, though this procedure is not very successful. +In case it is done the patient should be made to walk in two or three +weeks, as this helps materially to overcome the deformity and hasten +repair of the fascia. + +=Talipes Planus.=—This condition is commonly known as “=flat foot=” and +is taken up in another part of this text. However, it is one of the +classifications of “club foot” and is far the most common type. + +=Prognosis.=—These conditions never correct themselves and if +uncorrected usually get worse and the more severe types certainly +become obstinate malformations. In general the tendency to relapse +is strong, though if properly treated the results are excellent. In +infantile cases the time required for correction is relatively short, +but retentive appliances are needed for a longer time. The older +the cases and larger the foot the more difficult, of course, the +correction, but usually there is less danger of relapse. A perfect +correction, that is when the gait and attitude are normal, will never +relapse. I find it better to leave the fixation appliance on too long +than not long enough. Never remove a cast under four weeks except in +the cavus type, then apply a brace such as can be obtained from any +supply house for any type of case, for from one to three months longer. +The tendons involved in these conditions are so apparent that it is +almost impossible to make a mistake in the division of them. About +the only precaution necessary is to be assured that the tendon itself +is completely divided, but that the tendon sheath is only slightly +disturbed. + + +Tuberculous Disease of the Bones and Joints + +Perhaps no bony lesion has caused so much difference of opinion in +this profession as tubercular conditions of the spine, bones and +joints and I wish it understood that in the following discussion, it +is not my desire to reopen the argument. My observations have been +of cases treated both osteopathically and by fixation, in private +practice and institutional work. And I have come to the conclusion that +the fixation method of treatment is absolutely always indicated. In +general the pathology and etiology of all tubercular bone conditions +is the same. It begins as a tubercular infection of the spongy tissue +of the epiphysis, the first change being a local hyperemia of the +portion involved, followed by one of three courses: the diseased focus +being absorbed and a spontaneous cure resulting; it may extend to +the periphery of the bone and break through the periositum and empty +itself there by abscess formation; or most commonly it may extend to +the joint, which becomes involved through attendant injury. Repair is +brought about by the formation of fibrous tissue probably arising from +the layer of non-tuberculous granulation tissue which grows in and +replaces the tuberculous tissue. Also the replacing material may become +calcified and encapsulated. A fibrous or bony ankylosis may result from +this process of repair. + +The vulnerability of growing bone accounts for the frequency of +tubercular bone disease in children as compared with adult life. +Injury not only causes a local predisposition to the disease, but it +favors its progress when it is once established. About seven-eighths +of the cases of this trouble occur under fourteen years of age, more +especially when the vertebræ or hip-joint are involved. The knee and +ankle joints as well as the elbow and shoulder joints are more often +diseased in later life. While the inherited predisposition is very +direct and positive in twenty-five percent of the cases, the acquired +predisposition is of most importance since it includes lessened +vitality due to poor food and imperfect hygienic surroundings. As +to the distribution of the disease the vertebræ are most commonly +affected, followed closely by the hip and knee joints, and then in the +order of frequency the ankle, elbow, shoulder and wrist joints. + + +Tubercular Disease of the Spine + +This condition is commonly called =Pott’s Disease= or =Caries=. It is +a chronic destructive process of the bodies of the vertebræ. The spine +bends at the weakest point and the compression and collapse of the +affected parts cause the characteristic posterior angular projection +at the seat of the disease. If one vertebral body is destroyed, the +projection will be sharp; if several are involved it will be less +angular and if one side breaks down before the other, there may be a +lateral as well as posterior distortion. The size of the deformity and +its effect upon the patient depend upon its situation; that is, if +either end of the spine is involved the angular projection is slight +because the area of the spine directly involved in the deformity is +small compared with that which is free from the disease. If the middle +of the spine is affected, the deformity is great, because the entire +spinal column may enter into the angular projection. In the latter area +the internal organs are compressed and, of course, the effect upon the +vital organisms of the body is disastrous. + +=Pathology.=—The first indication of tubercular disease of the spine +is usually found in the anterior part of a vertebral body just beneath +the fibro-periosteal layer of the anterior longitudinal ligament. From +this point the foci may advance along the front of the spine following +the course of the blood vessels and invading the adjacent vertebral +bodies. The destruction may begin in the interior of the body itself, +more often in several minute foci near the upper or lower epiphysis, +which coalesce, gradually enlarge and form a cavity surrounded, for a +time, by unbroken cortical substances which finally collapse under the +pressure of the weight above. The intervertebral discs seem to offer +some resistance to the extension of the disease from one vertebra to +another but once the bone is destroyed on either side, they too quickly +disintegrate and disappear. Pedicles and articulations which come into +direct contact with the disease may become involved. Originally the +disease is confined to one or two adjacent vertebræ and may extend +in either direction, and the final area of deformity and rigidity +shows that from three to six bodies may be involved before a cure is +established. The infected granulations advance rapidly with the usual +retrograde change of shape and structure to a cheesy degeneration and +frequently liquefaction and abscess formation may follow. + +=Symptoms of Pott’s Disease.=—There are three main symptoms of Pott’s +disease, namely the peculiarity of attitude and gait, limitation +of motion or muscular stiffness and the pain and referred pains. +In the cervical region, the chin is held somewhat raised and the +patient may have somewhat the same appearance as in wry-neck. In the +mid-dorsal region one will always find an elevation of the shoulder +besides the deformity. In the lumbar region, the patient nearly always +leans backward and has a sort of sidling gait or waddle due to the +contraction of the psoas and iliacus muscles. The patient in walking, +stooping, or lying down most carefully guards the spine against any jar +or motion, and always assumes attitudes which will relieve the strain +on the involved vertebræ. There is always present an unnatural mode +of standing or walking, especially when the dorsal and lumbar regions +are involved, as the patient walks more on his toes and with the knees +slightly bent, because in this posture all possible strain of the step +may be brought into play to diminish jarring of the spine. The child +becomes tired very easily and lies down or rests on the arms of a chair +or seat. The pain rarely occurs in the back, but is usually referred +to the peripheral end of the nerves and is thus felt in the chest, +abdomen or limbs. The abdominal pain passes sometimes as a stomach +ache and often times in the limbs, as rheumatism or “growing pains”. +I have noticed also a peculiar grunting respiration and sometimes +cough especially when the mid-dorsal region is involved. Muscular +stiffness is always present, all mobility being lost. The temperature +is not at all diagnostic, though sometimes in the afternoon it will +be one or two degrees higher than normal and does occur independently +of abscesses. About the only complication that occurs is paralysis or +abscess formations. Paralysis is given as a frequent complication, +though I have never seen it. It is usually flaccid and bilateral and +may exist from a mere muscular weakness to a complete loss of power. +It is certainly uncommon under proper treatment, and the prognosis is +favorable. Abscesses, though a very distressing complication, are very +uncommon in my experience and are certainly an evidence of improper or +incomplete treatment. They may subside in any region and be absorbed +without detriment to the patient, though if they increase in size there +is no tendency towards absorption. It is best to incise them and secure +complete drainage. It is hard, of course, to do this on account of the +depth. Abscesses occur always in close proximity to the disease. + +=Treatment.=—Some authors recommend a brace for the treatment of this +condition, while others recommend a frame to which the patient is +strapped, and rest in bed. I have found nothing that gets results like +a plaster of Paris jacket applied with the patient suspended by the +neck and shoulders. I make no attempt at correction of the deformity +present other than the traction of the weight of the body at the time +the cast is applied. The spine is, of course, fully extended by this +and any undue pressure on the cord relieved. The cast should extend +over the shoulders and well down over the pelvis and sacrum. If the +disease is in the neck the cast should include the head as well. A +large window is cut in front and one must be cut over the involved area +of the spine behind. Ordinary absorbent cotton is used for padding +with, of course, extra padding over all bony prominences. From two to +five years’ time is required for a complete recovery. The X-ray is +invaluable in diagnosing this trouble, and each time a cast is removed +to see how much progress has been made. The casts should be changed as +often as they become soiled. + + +Tuberculosis of the Hip + +This is a chronic tubercular condition of the head of the femur or of +the acetabulum commonly known as =hip-joint disease=. + +=Pathology.=—Primarily the head of the femur is the seat of the +disease, the epiphysis being attacked in seventy-five per cent of +the cases and the acetabulum in twenty-five per cent. The irritated +pelvic femoral muscles which are in a state of chronic contraction +crowd the head of the femur against the upper and back border of the +acetabulum. Under this continual pressure, absorption of that portion +of the rim takes place with actual enlargement of the acetabulum from +below upwards. This is spoken of “migration of the acetabulum” and is +one cause for the shortening of the limb. Changes in the head of the +femur are the result of inflammation and pressure. Partial destruction +of the head also helps shortening of the limb and elevation of the +trochanter above its proper level the same as the wearing away of the +acetabulum. The synovial membrane is found to be reddened and thickened +and granulation tissue is present, and usually the cartilage is gone +from the head of the femur. Rarely does perforation of the floor of the +acetabulum take place, but if such is the case a dense wall of fibrous +tissue and thickened periosteum shuts off the head of the femur from +the pelvic cavity. A natural cure results in two ways,—by absorption +or calcification of the tubercular tissue, or by the evacuation and +discharge by an external opening. This latter suppuration seems to +be nature’s effort to eliminate the disease, and when a cure is +established this way it is usually characterized by malpositions and +shortening of the limb, and, of course, an ankylosed joint. + +=Early Symptoms.=—The most characteristic symptoms of the disease +are the ‘night cries’, stiffness and limping, shortening of the leg, +atrophy of the muscles of the hip, leg, and thigh, and the unconscious +protection of the joint. A referred pain is usually present to the +inside and front of the thigh near the knee or directly at the knee +joint itself, due to the intimate relations and anastamosis of sciatic, +obturator, and anterior crural nerves. + +=Diagnosis.=—The chief diagnostic sign is muscular spasms or the +presence of stiffness of the joints and limitations of its proper arc +of motion, due to the tonic contraction of the muscles controlling the +joint. If there is no limitation of motion it is almost safe to say +there is no hip-joint disease. The lameness may be intermittent. The +attitudes or abnormal positions of the diseased limb are caused by the +action of muscles holding the limb stiffly in a distorted position. +The pelvis is usually tilted and always one will find the patient +assuming attitudes which will favor the diseased limb. Atrophy is +very significant and a comparison of the two limbs should be made by +measuring at the middle of the thigh and the middle of the calf. Nearly +always one will find a deep thickening over the front of the hip joint +and behind the trochanter. + +=Physical Examination.=—1. Observe the general condition of the patient. + +2. Note the attitude in standing. + +3. Note character of the limp. + +4. Note shortening of the limb. + +5. Remove the clothing and lay patient on the back. + +6. Test the function of the groin. Always begin on the sound side +for comparison in order that the patient may become accustomed to +the manipulation before the limb suspected of disease is tested. +Tuberculosis in a joint is always accompanied by muscular spasms that +positively limit motion in every direction, while in other affections +only one or more limitations are observed, but never in all directions. +Compare closely the motions of the sound and affected limbs while the +patient is on the back. Turn patient on face and test for extension by +holding pelvis flat on table with one hand and gently elevating thigh +with the other. The normal range in a child is about twenty degrees +backward from the line of the body and limitation of this range is +perhaps the earliest indication of hip-joint disease. It is due to +psoas contraction. If this range of motion is unrestricted hip disease +can be practically excluded. + +The X-ray completes the diagnosis when used with a thorough knowledge +of the physical signs. It must be remembered that in early life a +larger part of the extremity of the femur is cartilaginous and does +not show well in a radiograph. The X-ray picture shows clearly the +destructive effect of the disease on the femur and acetabulum and gives +a clear conception of the actual condition of the joint. + +=Treatment.=—The object of treatment of this condition is threefold: +first, to relieve the pain that depresses the vitality of the patient; +second, to relieve the muscular spasms that induce distortion of the +limb and which stimulates the destructive process by increasing +pressure and friction of the diseased surfaces of the opposing bones; +third, to correct and prevent deformity by lessening pressure and by +restraining motion, thereby keeping the femur from upward displacement. + +Rest and protection are the two cardinal features of treatment of +this condition. Sunshine, fresh air and good nutritious diet are very +important. + +Complete rest of the joint offers the most favorable opportunity for +nature to repair this disease. The recumbent period of the treatment +necessitates rest in bed for the reduction of the deformity and +subsidence of acute symptoms. By the aid of traction, which is applied +to the length of the legs by means of a Buck’s extension. As much +weight should be applied as can be borne without discomfort to the +patient. + +As soon as the deformity and acute symptoms have subsided, the +ambulatory treatment should be substituted to keep up the general +health of the patient. This merely consists of the application of a +long plaster of Paris spica of the hip which should reach well up to +the thorax and extend down and include the foot. All bony prominences +should be well padded, and a moderate amount of traction with about +twenty degrees abduction should be used while applying the plaster +bandage. Though various forms of apparatus have been devised for +fixation and traction, I believe that the plaster of Paris spica is +far the most effective and should always be used, changing the cast +as often as it becomes soiled. Locomotion is possible with crutches +providing the shoe on the well side is stilted by an iron patten which +is high enough to allow the casted limb to clear the floor. + +The earlier treatment is begun, the better the outlook. Recovery with +perfect motion occurs in about twenty-five percent of hospital cases; +fifty per cent will obtain useful motion and the other twenty-five per +cent will obtain practical fixation, but it must be remembered that +results will range entirely according to the thoroughness of treatment, +the severity of the disease in the individual case, and the natural +resistance of the child. In general, the hip should be fixed as long as +it is sensitive, it should be protected and distracted as long as there +is muscular spasm, and protected until the congested and inflamed bone +of the epiphysis is replaced by firm healthy bone. + + +Tuberculosis of the Knee Joint + +Tuberculous disease of the knee is next to the hip in frequency. It is +a chronic destructive process of the epiphysis of the femur or tibia, +or it may start in the patella, head of the fibula, or primarily in +the synovial membrane of the knee joint. The condition presents two +distinct types; one, the adult type beginning as a chronic synovitis, +of which the early symptoms are subacute; and the other, the childhood +or most common class, in which the symptoms of pain, muscular spasms +and deformity seem to indicate clearly a primary disease of the bone. + +=Symptoms.=—This disease is commonly known as “white swelling” and +the symptoms as a rule are quite characteristic. The affection begins +with a limp and limitation of motion, and is usually slow in progress +with periods of severe pain. There is usually much swelling and +this together with the distortion of the limb by muscular spasm and +atrophy of the muscles both above and below the joint, gives a most +characteristic knock-kneed appearance. The affected limb is usually +longer at first, owing to the congestion of the epiphysis of the knee. +Local heat is always present in the more acute stages and the lameness +is usually a constant symptom. The differential diagnosis from other +joint troubles is easy because of the slow insidious onset. + +=Treatment.=—Like other tubercular bone conditions the fixation +treatment is best. Rest in bed with a Buck’s extension to overcome +the deformity and the local application of hot packs until the acute +symptoms have subsided, is the best preliminary treatment of this +condition. Five- to ten-second exposures to the X-ray each day for ten +days seems to relieve the pain and in most instances causes less marked +infiltration of tissues. + +When the acute stage has subsided, the ambulatory treatment by fixation +in a plaster of Paris cast extending from the groin to the ankle, with +about 10 degrees flexion, is most efficient. + +The patient is allowed to walk about with the aid of crutches, having +the shoe on the sound side stilted enough so that the diseased limb +clears the floor. The functional results after conservative treatment +are in the average case excellent, that is providing proper treatment +is begun at an early stage. Useful motion is obtained in fifty per cent +of these cases, perfect motion is restored in twenty-five per cent, and +complete rigidity results in the other twenty-five per cent of cases. + +Any chronic, painful inflammation confined to a single joint, in which +motion is limited by muscular spasm, and in which there is a tendency +towards deformity, is almost always tubercular in character. + + +The Plaster of Paris Bandage + +The plaster of Paris bandage was perhaps first applied by Kluge of +Berlin in 1829, but to the Dutch physicians Mathysen and Vander Loo +belongs the credit of the modern bandage. + +It is imperative to give, in this chapter, a detailed and complete +description of what constitutes a properly made plaster of Paris +bandage and the application of it, in order that the general +practitioner may become familiar with its use. Even though one +cares not to treat the conditions heretofore enumerated, I have +found that for fractures of almost every bone in the body requiring +immobilization, the plaster bandage properly applied is far superior +and rather to be preferred to any other form of splints. + +It has been used very little in the past in private practice because +the ordinary commercial bandage found in any supply house does not come +up to requirements, in that it is usually air slaked or the plaster has +been shaken from it by the time it is received. Then too the mesh is +too closely woven and the plaster lies on the bandage instead of in the +meshes and there is, in consequence, an excess of plaster; also as a +rule the bandages are rolled so tightly that the water does not reach +the deeper layers. + +The ordinary plaster of Paris bandage made in your own office can +always be successfully applied because the right quantity of plaster +can be incorporated in the bandage and it can readily be made into +the desired widths. The plaster of Paris to be used should be of the +superior quality used by dentists and should be of the quick setting +kind. It can be procured at almost any drug store but the surest place +for quality will be your dentist. + +Absolutely, the only kind of gauze to be successfully used is white +crinoline of the ordinary variety used by dressmakers and obtainable +at any dry goods store in twenty-four yard bolts. It is especially +desirable to get a kind not too rich in starch or dextrin and of a mesh +running about one hundred holes to the square inch. + +The bandages should be made in six yard lengths, and of widths ranging +from three to five inches according to the part that is to be cast; +for instance the three inch widths are most suitable for casts for the +extremities, while the larger ones serve best for conditions of the +spine. After the length had been measured and cut the desired widths +can be torn the full length without trouble. The edge of the crinoline +nearly always frays out and naturally will become so entangled as to +prevent rolling in the plaster or as to hinder the free unrolling of +the bandage when applying it. To prevent this, three threads should be +plucked from each side of each strip before starting to roll in the +plaster. + +A hard surface of, at least, two feet in width should be used on which +to roll in the plaster. Starting at one end, a handful of plaster of +Paris is rubbed into the crinoline with the palmar surface of the hand, +bearing down hard, so that all excessive plaster passes to either edge +of the bandage. No more plaster should be rubbed into the crinoline +than the meshes will hold, and as each successive yard is incorporated +with the necessary amount of plaster, it is loosely rolled in such +manner that in the center of the bandage there is a hollow cylinder of +the thickness of the index finger, and the concentric layers are easily +movable on one another. This manner of rolling permits of the rapid and +uniform spread of water through the bandage when it is to be applied, +and prevents parts of the bandage from being insufficiently moistened. + +The general practitioner should always keep on hand about two dozen +completed bandages that he is most accustomed to using in his daily +practice. These should be corded as it were, to prevent unrolling, in +an air tight container, either of glass or tin in the bottom of which +is placed a small quantity of plaster of Paris, and should always be +kept in a dry place. I have never found either a nurse or an office +girl who could not make these bandages successfully so that in the +future there is no excuse for a practitioner not using this superior +form of splints. + + +The Immediate Use of the Bandage + +While plaster of Paris is in no way harmful to either garments or +surroundings, both the operator and the assistants should be properly +gowned and the floor covered with newspapers to prevent unnecessary +soiling. It should be borne in mind that if a properly made bandage is +used, which is squeezed to the extent of ridding it of an excess of +water, very few drippings will be scattered and the whole procedure of +the application of the plaster differs in no way from simple roller +bandaging. + +The number of bandages intended for use should be taken from the +container and placed in a pan near the pail holding the water, in +which they are to be immersed, in a position in relation to the pail +that will guard against water being splashed upon the dry bandages, +which would render them unfit for subsequent use. Water as hot as the +hand will tolerate, as opposed to cold, facilitates setting. I do not +recommend any chemicals to hasten setting, because a properly made +bandage, prepared as above, of quick setting plaster sets in remarkably +fast time. + +The area to be cast should be encased in ordinary absorbent cotton of +the thickness in which it comes rolled, putting an extra pad over all +marked bony prominences, and a roller gauze bandage applied to hold +it in place and snug to the part. Under no consideration do I advise +the use of flannel bandage or the ordinary sheet wadding cotton that +are recommended by some authors, because padding with these materials +is always conducive to applying a cast far too tightly, especially +in fractures where the swelling increases after application thereby +causing constriction of the limb and interference with circulation. The +regular absorbent cotton as padding beneath a cast is always best for +it is almost impossible to apply a cast too tightly when it is used. + +The bandage should be completely submerged on its side, and should +remain so until the bubbles cease to come off, which time takes place +most readily in the properly rolled dressing. When the bubbling has +ceased, the bandage is lifted out of the pail and squeezed with the +hands merely to free it of the excessive water, the end is found and +handed to the operator ready to apply. No undue traction should be +made in applying the successive turns of the bandage, though it must +be remembered the cast should fit snugly to the part, and the ordinary +rules of simple roller bandaging followed, except that the reverse +spirals are unnecessary. The assistant should constantly rub the layers +as they are applied by the operator, as this not only helps the cast to +fit more snugly, but also makes the rough edges of the bandage adhere +more firmly to the layer beneath, thereby making a smoother cast. + +As a rule there need be no dread of an increased swelling beneath the +bandage because usually several hours have elapsed after the injury +before the physician has arrived and made preparations to apply the +plaster. Indeed, one of the best means of limiting swelling after a +fracture is the prompt application of a plaster of Paris bandage. If +there is any concern that the cast is too tight, while the plaster is +still soft it can be easily cut through the entire length with a knife, +and thus relieve the pressure existing. Also it is a good plan to cut a +window or opening over the sight of injury, which would in no way harm +the object of the cast and would allow a gentle massage to the part. A +neat finish may be given to the edges of a plaster cast by turning over +the ends of the cotton, in cuff-like fashion and held in the grasp of +the last few turns of the plaster at either end. + +On clothing you will find it best to allow the plaster to dry before +removing, while on furniture or the hands it is readily removed by +washing off in warm water. The water in which the bandages were +immersed contains, of course, considerable plaster, and under no +circumstances should this be emptied into a sink or waste pipe for +it will certainly demand the services of a plumber. The water may be +poured out on the ground and the paste shaken into a refuse barrel or +ash pile. The best way to remove a cast is to moisten it with water or +vinegar along the path of the knife. I might add that all patients are +in constant fear of being cut either while you are trimming, cutting +windows, or removing the cast, but because of the cotton padding +underneath you will find that it is almost an impossibility. Care, of +course, should be taken that the knife does not slip in any of these +procedures and come in contact with the unprotected parts. + +In general, for fractures of the extremities it is best to apply the +plaster with the patient in the recumbent position to secure complete +muscular relaxation, and the part to be cast should be supported by an +assistant. It is also a general rule that in fractures of the shaft +of the long bones, especially of the lower extremities, the plaster +bandage should be applied to include the adjacent articulation and +extend well beyond the joints. + + + + +INDEX + + + A + + Abbott treatment, 98, 774, 778. + + Abdomen pendulous, 127. + + Abdominal examination, 51. + rheumatism, 466, 467. + technic, 77, 536, 539. + dangers of, 87, 540. + + Abducens nerve, lesions affecting, 717. + + Abscess of rectum, 174. + perinephritic, differentiate pyelitis, 628. + peritonsillar, 278. + + Achylia gastrica, differential diagnosis, 508. + + Acne, 150. + + Accommodation in the eye, 192. + + Acetabulum, migration of, 791. + + Addison’s disease, 704. + differentiated from jaundice, 559. + + Adenitis, tubercular, 384. + + Adenoids, 273. + + Adhesions, broken up after sprains, 108. + + Adjustment, osteopathic, 90. + + Adrenal glands, diseases of, 703. + + Aged, spine of the, 101. + + Agitans, paralysis, 723. + + Agitata, melancholia, 297. + + Ague, 347. + + Alcohol in post-operative pneumonia, 319. + + Amentia, 290, 307. + + Amyloid kidney, 626. + liver, 562. + + Amyotrophic lateral sclerosis, 762. + + Angina pectoris, 666. + differential diagnosis, 667. + pathology in, 308. + + Anemias, the, 672. + + Anemia, costogenic, 673. + Burns, 673. + pernicious, 678. + + Aneurism, cardiac, 660. + + Animal experiments, 91, 490. + parasites, 151. + + Ankle, 56. + sprain, 112. + + Ankylostomiasis, 155. + + Anterior dorsal lesions technic, 76. + + Antidotes may be necessary, 62. + + Antiseptics may be necessary, 62. + + Aortic regurgitation, 649. + stenosis, 551. + + Aphonia, 571. + + Aphthous stomatitis, 488. + + Appendectomy, colitis following, 552. + + Appendicitis, 547. + differential diagnosis, 550. + + Appendicitis from ileo-cecal trouble, 141. + pseudo, 550. + + Appendix innervation, 498. + + Arch supporters, 114. + + Arhythmia, 665. + + Arm affected by rib lesions, 740. + + Arm examination, 56. + technic, 80. + vasomotor nerves to, 94. + + Arteries, diseases of, 669. + + Arteriosclerosis, 669. + + Artery complications from typhoid, 332. + + Arthritis deformans, 462. + rheumatoid, 462. + differentiated from inflammatory rheumatism, 459. + septic, differentiated from inflammatory rheumatism, 459. + + Articular rheumatism, acute, 460. + + Ascaris lumbricoides, 153. + + Aspiration pneumonia, 605. + + Asthenopia, 232. + + Asthma bronchial, 589. + caused by rib lesions, 94. + + Ataxia, Friedreich’s, 759. + hereditary, 759. + differentiate chorea, 726. + locomotor, 754. + + Ataxic paraplegia, 761. + + Atheroma, 669. + in heart, 647. + + Atlas examination, 44. + lesions, 44. + + Atrophy of optic nerve, 231. + progressive muscular, 762, 764. + + Auditory—See also ear. + + Auditory meatus, diseases of, 236. + nerve degeneration, 256. + nerve lesions affecting, 718. + + Auerbach’s plexus, 494. + + Auto-intoxication in nose diseases, 268. + + Axis lesions, 45. + + + B + + Backache, post-operative, 313. + + Bandage, abdominal, for floating kidney, 137. + liver, 139. + sprain, 106. + + Barbadoes leg, 158. + + Baths, hot, in skin diseases, 147. + + Bee sting near eye, 199. + + Bell’s paralysis, 717. + + Belt—See bandage; also brace. + + Biceps, long tendon dislocated, 114. + + Bile duct, diseases of the liver and, 553. + + Biliary colic, 565. + differentiate, 551, 565, 632. + + Binocular vision of osteopath (two pathologies), 489. + + Birth injuries, causes of heart irregularities, 666. + + Black eye, 199. + + Blackwater fever, 351. + + Bladder, diseases of, 635. + hemorrhage, 164. + sensory nerves to, 95. + + Bleeders disease, 484. + + Blennorrhea, acute, 209. + + Blepharitis, 200. + + Blood flow directed to abdomen, 582. + + Blood, diseases of, 671. + + Bones and joints, tuberculous disease, 788. + + Bothriocephalus latus, 151. + + Bowel—See intestine. + + Brace in Pott’s disease, 103, 131. + in prolapse, 133. + in spinal curvature, 99, 103, 122. + + Brachial neuralgia, 711. + neuritis, 123. + differential diagnosis, 125. + plexus, lesions affecting, 721. + + Brachycardia, 664. + + Brain, pathology of, 307. + its relation to mind, 307. + physiology of, 306. + tumors, differentiate migraine, 737. + + Brand bath, 329, 343. + + Breakbone fever, 356. + + Bright’s disease, 618. + + Bronchi, diseases of the, 579. + + Bronchial asthma, 589. + + Bronchiolectasis, 587. + + Bronchitis, 579. + + Bronchopneumonia, 605. + caused by tubercle bacillus, 606. + + Broncho-pulmonary hemorrhage, 160. + + Bulbar paralysis, 765. + + Bunions, cause of, 112. + + Bursitis, 123. + differentiate from neuritis, 125. + + + C + + Calcification in heart, 647. + + Calculus, renal, 631. + + Cancer of liver, 562. + of stomach, differential diagnosis, 508. + + Canker, 488. + + Carcinoma, location of reflex pain in, 499. + + Cardiac—See heart. + + Caries—See Pott’s disease. + + Catalonia, 286. + + Cataract, 229. + + Catarrh + dry, 583. + of conjunctiva, vernal, 216. + stomach, chronic, 505. + + Catarrhal deafness, 246. + pneumonia, 605. + stomatitis, 487. + + Center, diabetic, 474. + + Centers, osteopathic, 88. + nutritional, 480. + + Cephalodynia, 465, 467. + + Cerebrospinal fluid interfered with, affects digestion, 492. + meningitis, 358. + + Cerumen, inspissated, 236. + + Cervical—See also neck. + examination, 41. + glands, examination of, 47. + lesions affect eye, 93, 86. + region, caution in treating, 66. + treatment for vasomotor effects, 92. + + Cervico-occipital and cervico-brachial neuralgia, 711. + + Chalazion, 200. + + Character and disposition affected by alimentary disturbances, 502. + + Chest examination, 51. + + Chiasma, diseases of, 715. + + Chicken-pox, 446. + differentiate from smallpox, 417. + + Childbirth resulting in pendulous abdomen, 128. + + Children—See also infants. + defective, 303. + diarrhea of, 529. + + Chlorosis, 676. + + Cholecystitis, 557. + + Cholera infantum, 531. + morbus, 532. + + Chorea, 725. + differential diagnosis, 726. + differentiate paralysis agitans, 724. + + Choreiform affections, 727. + + Choroid, diseases of, 226. + + Choroiditis, 226. + + Chromaffin system, 702, 703. + + Chronic lesions, reduce gradually, 66. + + Chvostek’s phenomenon, 701. + + Chyluria, chylocele, chylous ascitis, 158. + + Ciliary injection in keratitis, 221. + body, diseases of the, 225. + + Ciliospinal center, 187. + + Circulatory system, disease of, 638. + + Circumflex nerve, lesions affecting, 721. + + Cirrhosis of liver, 560. + + Clavicle examination, 49. + + “Claw hand,” 764. + + Club foot, 784. + + Coccygodynia, 713. + + Coccyx examination, 55, 81. + fractured, 81. + technic, 81, 713. + + “Cold in the head,” 257. + + Cold in treating sprain, 106. + + “Colds” inadvertently cured, 90. + + Cole’s irrigator for high enema, 170, 546. + + Colic, biliary, 565. + differentiation of, 535, 566. + intestinal, 535. + renal, 631. + differential diagnosis, 632. + + Colitis following appendectomy, 552. + + Colitis, mucous, 526. + + Coma, diabetic, 472. + + Confusion and stupor, delirium, 289. + + Congestion of the lungs, 610. + thyroid, 686. + + Conjunctiva, diseases of, 202. + + Conjunctivitis, 202. + catarrhal, 204. + corneal ulcers complicating, 204. + follicular, 207. + differentiated from trachoma, 208. + gonorrheal, 209. + granular, 212. + phlyctenular, 214. + vernal, 216. + + Constipation, causes and technic, 497, 537. + from pendulous abdomen, 127. + resulting in diarrhea, 538. + + Constitutional diseases, 457. + + Contracted muscles relieved by inhibition, 89. + + Convulsions, infantile, 728. + + Cornea, anatomy of, 217. + diseases of, 217, 219. + examination of, 219. + ulcer of, 219, 221. + + Coughing, 573. + + Coughing (superior laryngeal nerve), 719. + + Cow-pox, 424. + + Cramp, constitutional, 738. + + Cranial nerves, diseases of, 715. + + Cretinism, 698. + + Croup treatment, 68. + differentiate from spasm of glottis, 573. + false, 574. + + Croupous pneumonia, 597. + + Curschmann’s spirals, 586. + + Curvatures, spinal, 96, 99, 103, 122, 768. + See Abbott treatment, + braces for, 99, 131. + cervico-dorsal, 772. + complicated by innominate lesion, 99. + differentiate organic and functional, 769. + dorsal, 772. + dorso-lumbar, 772. + + Cophosis, 97. + lateral, 98, 177. + lumbar, 772. + other organs affected, 770. + pathological, 96. + rotary lateral, 768. + postural, 128. + (scoliosis), 96, 768. + differentiated from Pott’s disease, 773. + false, 773. + structural, 774. + technic for, 98. + treatment for rotation and sidebending, 76. + + Cystitis, 635. + + Cystitis, differentiate pyelitis, 628, 636. + + + D + + Dalrymple’s sign, 694. + + Deafness, catarrhal, 246. + nerve, 255, 718. + + Defective children, 303. + + Deformans, spondylitis, 463. + + Degeneration of heart muscle, 661. + + Deglutition, 493. + + Deglutition pneumonia, 605. + + Delirium, confusion and stupor, 289. + senile, 300. + + Dementia, arteriosclerotic, 300. + defined, 306, 307. + praecox, 287. + senile, 297. + + Dengue, 356. + + Dental troubles should be corrected, 490. + + Descemetitis, 226. + + DeSchweinitz, Dr., 215. + + Diabetes, differential diagnosis, 477. + insipidus, 476. + mellitus, 470. + + Diabetic coma, 472. + + Diagnosis, osteopathic, 38. + see also under lesion. + reliable, osteopathic, 21. + sight, 38. + + Diaphragm, paralysis of, 720. + + Diarrhea, causes and technic, 497. + acute, 523. + dyspeptic, 529. + caused by constipation, 538. + of children, 529. + chronic, 529. + catarrhal, 524. + differential diagnosis of, 530, 533. + nervous, 524. + through impactions, 538, 544. + + Diet and osteopathy, 22, 62. + + Diet, diabetic, 475. + + Dietl’s crisis, 137, 635. + + Digestion, relation of lungs to, 494. + + Digestive disturbances affect character, 502. + system, diseases of, 487. + trouble due to intra-cranial conditions, 492. + + Digital surgery in hay fever, 226. + treatment in tonsillitis, 281. + + Dilatation of heart, 657. + of sigmoid, 543. + of stomach, 153, 517. + + Diopter defined, 192. + + Diphtheria, 362. + differentiated from scarlet fever, 431. + laryngeal, 364. + nasal, 364. + neuritis following, 707. + pharyngeal, 364. + + Disease should be studied by regions, 586. + constitutional, 457. + general and functional, 723. + + Dislocation, differentiated from neuritis, 125. + + Disposition and character affected by digestive disturbances, 501. + + Diuresis, Paroxysmal, differentiated from diabetes insipidus, 477. + + Dorsal spine examination, 49. + technic, 74. + + Dorsodynia, 466, 467. + + Drugs not useful in nose and throat work, 262. + Why medics give, 21. + + Dubini’s disease, 727. + + Duodenal ulcer, Gastric and, 512. + + Duodenitis, 524. + + Dupuytren’s contraction, 115. + + Dysentery, 368. + + Dysentery, a word on treatment, 170 + amebic, 370. + bacillary, 368. + chronic, 371. + treatment, a word on, 170. + tropical, 370. + + Dysmenorrhea caused by lumbar curvature, 126. + + Dyspepsia, acute, 501. + + Dystrichiasis, 201. + + + E + + Ear—See also auditory + + Ear, Diseases of, 236. + of inner, 254 + of middle, 239. + foreign bodies in, cause cough, 575. + normal hearing, 249. + nose and throat, diseases of, 236. + pain in diagnosis of diseases of, 238. + test for hearing, 249. + vasomotor nerves to, 92. + wax, hardened, 236. + + Eccymosis, 199. + + Eclampsia, 728. + + Ectropion, 201. + + Eczema, 147. + in ear, 230. + + Edema of the lungs, 611. + + Edwards finger treatment in hay fever, 267. + trachoma treatment, 213. + turbinate adjuster, 197. + + Egophony, Lænnec’s, 613. + + Elbow, 56. + sprains, 114. + + Elephantiasis, 158. + + Emboli in endocarditis, 642, 641. + + Emphysema, 592. + compensatory, 609. + differential diagnosis, 595. + + Endocarditis, 641. + complicating pneumonia, 601. + + Enema, directions for, 546. + + Enteric fever, 329. + + Enterocolitis, acute, 532. + + Enteroptosis, 521. + + Entropion, 201. + + Enuresis, 637. + + Epididymis sensory nerves to, 95. + + Epilepsy, 729. + differential diagnosis, 734. + nocturnal, 733, 734. + grand mal, 732. + Jacksonian, 733. + petit mal, 733. + + Epilepticus, status, 734. + + Epistaxis, 160, 271. + differential diagnosis of, 161. + + Erb’s phenomenon, 701. + + Erysipelas, 372. + + Esophagus, 493. + location of reflex pain from, 499. + + Estivo-autumnal fever, 350. + + Etiological factors, 25. + + Etiology, osteopathic, 25. + + Examination—See under various structures and regions. + thorough, essential, 38. + + Exercise and postural defects, 120, 129, 131. + cannot take place of osteopathy, 120. + in treatment of ptosis, 521. + of false scoliosis, 773. + to reduce abdomen, 128, 139, 480. + + External cutaneous nerve, lesions affecting, 722. + + Eye, accommodation in the, 192. + affected by osseous lesions, 93, 185, and under individual + diseases. + + Eye diseases, 183, 713. + + Eye diseases, osteopathic manipulation in, 196, 223, 716. + examination by special methods, 191. + how to examine, 183. + lesions affecting certain nerves of, 716. + osteopathic, 184. + neuralgia, 197. + restored by osteopathy, A case history, 185. + schematic, 194. + strain and its reflexes, 231. + trouble, nose and throat in, 191. + vasomotor nerves, 92. + + Eyelids, diseases of, 199. + + + F + + Face examination, 46. + technic, 68. + + Facial nerve, lesions affecting, 117. + + Fatty degeneration of heart, 661. + liver, 561. + + Fecal impactions palpated, 52, 543. + with diarrhea, 538, 544. + + Feet, neuralgia of, 714. + + Fetor oris, 491. + + Fever, 325. + acute eruptive, mumps and whooping cough, 411. + enteric, 329. + estivo-autumnal, 350. + malarial, 347. + paratyphoid, 344. + remittent, 350. + rheumatic, 457. + simple continued, 379. + treatment, 325. + Brand method, 329. + usually beneficial, 327. + typhoid, 329. + typhus, 344. + yellow, 374. + + Fibroid phthisis, 393. + induration, 609. + + Fifth nerve, neuralgia of, 710. + + Filaria, 158. + + Fingers, sprains of, 114. + surgery in hay fever, 266. + treatment in catarrhal deafness, 252. + in tonsillitis, 281. + trigger, 115. + + First rib—see rib. + + Fissures of rectum, 174. + + Fistulae, rectal, 174. + + Flat foot, 112, 787. + + Flatulency, technic for, 505, 537. + + Focus of infection—see infection. + + Foot, club, 784 + neuralgias, some causes of, 112. + sprains of, 112. + + Fractures, 115. + and sprains, 104. + summary of massage and immobilization in, 118. + of treatment of, 119. + + Frequency of treatments—see treatments. + + Friedreich’s ataxia—See ataxia. + + Functional and general diseases, 723. + + Furunculosis of ear, 238. + + + G + + Gall bladder, sensory nerves to, 95. + + Gall-stones, 563. + easily diagnosed by osteopath, 52. + + Ganglion (weeping sinew), 115. + + Gas in stomach, technic for, 505, 537. + + Gastritis, acute, 502. + chronic, 505. + due to portal disturbance, 506. + gastric analysis essential to diagnose, 507. + + Gastric—see also indigestion. + + Gastric derangement, location of reflex pain from, 499. + and duodenal ulcer, 513. + neuralgia, 510. + neuroses, 510. + trouble often reflex, 510. + + General treatment—see treatment. + + Generative organs, vasomotor nerves to, 94. + + Genitocrural nerve, lesions affecting, 722. + + Genito-urinary system, 175. + + Germ theory—its relation to osteopathy, 26. + + German measles, 444. + differentiate measles and scarlet fever, 446. + + Glands enlarged, differentiate from whooping cough, 454. + examination of thyroid and cervical, 47. + + Glaucoma, 227. + + Glenard’s disease, 521. + + Glosso-pharyngeal nerve, lesions affecting, 718. + + Glottis, spasm of, 572. + + Goiter, do not treat direct, 691, 696. + exophthalmic, 690. + findings at Mayo clinic, 692. + parathyroid glands in, 699. + simple, 687. + + Gonorrhea germs in prostate, 176. + + Gonorrheal conjunctivitis, 209. + rheumatism, 459. + + Gout, 467. + differentiated from rheumatic fever, 459. + + Grand mal, 730, 732. + + Grattage, 213. + + Great occipital nerve, point of control, 719. + + Great auricular nerve, point of control, 719. + + Green Sickness, 676. + + + H + + Habit spasm, 728. + + Hammer toe, 112. + + Hand, sprain of, 114. + + Hay fever, 263. + relation of focal infection to, 266. + treatment, 68. + + Head examination, 41. + technic, 64. + vasomotor nerves to, 92. + + Headache, from eye strain, 188. + post-operative, 313. + sick, 736. + technic, 720. + + Hearing—see also ear. + test, 249. + + Heart, affected by stomach pressure, 498. + aneurism, 660. + changes in goiter, 693. + complications in typhoid, 332. + crowded by round shoulders, 121. + contraction mechanism, 665. + dilatation, 657. + diseases, 638. + due to ribs, 47. + causing hyperemia of liver, 554. + enlargement causing cough, 575. + failure in pneumonia, 603. + hypertrophy, 655. + hypertrophy and dilatation often recover, 654. + irregularities due to birth injury, 666. + muscle degeneration, 661. + neuroses of, 662. + palpitation of, 662. + sensory nerves to, 95. + stimulated through rectum, 169, 170. + trouble and osteopathy, 647, 648, 652. + + Heat in treating ear, 238, 240, 241. + in treating sprain, 106. + prostration, 181. + stroke, 180. + + Hebephrenia, 286. + + Hematemesis, 162. + differential diagnosis of, 161. + + Hematuria, 163. + + Hemophilia, 484. + + Hemoptysis, 160. + differential diagnosis of, 161. + + Hemorrhages, 160. + in feces, 163, 174. + of intestines, 163, 174. + of lungs, 160. + of nose, 160. + of stomach, 162, 516. + of urinary tract, 163. + of uterus, 164. + + Hemorrhoids, 171. + acute, 173. + due to portal obstruction, 560. + treatment briefly discussed, 170. + + Hemorrhagia subdermalis, 199. + + Hepatic colic. See biliary colic. + flexure prolapse, 140. + + Heredity, See Inherited. + + Hernia, 141. + treatment, 546. + + Herpes, 149. + conjunctivæ, 214. + zoster, 712. + zoster ophthalmia, 199. + + Hiccoughs, 165. + + Hip, 56. + congenital dislocation, 778. + Lorenz operation, 781. + open operation, 784. + lesion affecting knee, 112. + the prominent, description and treatment, 125. + sprains of, 111. + treatment following intracapsular fracture, 111. + tuberculosis of, 791. + + Hip-joint disease, 791. + treatment following, 111. + + Hives, 149. + + Hobnailed liver, 559. + + Hodgkin’s disease, 684. + differentiate from mumps, 451. + + Holmes electric auroscope, 236. + + Homatropine, 194. + + Hook-worm disease, 155. + + Hordeolum, 200. + + Hospital—See post-operative treatment. + + Hot fomentations to relieve and relax, 95. + + Hydrophobia differentiated from tetanus, 378. + + Hydrotherapy in fever, 327. + bronchial asthma, 589. + often necessary with osteopathy, 62. + + Hygiene necessary with osteopathy, 62. + + Hyoid examination, 47. + lesion affecting sense of taste, 491. + causing cough, 46, 574. + furred tongue, 491. + in bronchial asthma, 589. + in laryngismus stridulus, 572. + in laryngitis, 571. + + Hyperemia renal, 617. + + Hypertrophy of heart, 655. + + Hypoglossal nerve, lesions affecting, 719. + + Hypopyon in keratitis, 221. + + Hysteria, 740. + + Hysterical convulsions, differentiated from epilepsy, 734. + spine, 101. + + Hysterogenous zones, 743. + + + I + + Icterus, 557. + + Idiots, 305. + + Ileocolitis, acute, 368. + + Ileus, 540. + + Iliohypogastric and ilio-inguinal nerves, lesions affecting, 722. + + Imbeciles, 305. + + Immobilization in relation to tuberculosis, 115. + See also under sprains. + + Impacted lesions, 92. + + Impactions, fecal, palpated, 52. + of intestines, 543. + of small intestine, 546. + + Impotency, 177. + + Indigestion—see also gastric. + and asthma, 590. + caused by pendulous abdomen, 127. + by round shoulders, 121. + nervous, 521. + + Infantile convulsions, 728. + paralysis—see poliomyelitis. + + Infants—see children. + constipation treatment, 539. + + Infection differentiated from neuritis, 125. + foci of, look out for, 131. + + Infectious diseases, 325. + + Inflammatory rheumatism, 457. + + Influenza, Spanish or epidemic, 399. + causes bronchitis, 79. + + Inherited tendencies in defective children, 303. + + Inhibition, Osteopathic, 89, 94. + + Insanity, See also Mental diseases. + acute confusional, 290. + Circular, 293. + defined, 306. + (Physiology of brain), 305. + + Innominate examination, 52, 54. + lesions preventing knee recovery, 112. + sprains, 111. + technic, 79. + dangerous, 87. + + Insect bites and stings, 199. + + Insipidus, diabetes, 476. + + Interrenal system, 704. + + Intestinal colic, 535. + diseases, 523. + relation of spinal lesions to gastro-, 489. + obstruction, 541. + differential diagnosis, 545. + strangulation, 541. + + Intestine, examination of, 52. + foreign substances in, 542. + impactions of, 52, 543. + treatment, 545, 546. + with diarrhea, 538, 544. + knots of, 542. + treatment, 541, 545. + location of reflex pain from, 499. + obstruction of, 52, 78, 545, 546. + differentiate from appendicitis, 551. + prolapsed, 52, 139. + sensory nerves to, 95. + strictures of, 543. + treatment of, 545. + technic, 78. + tumors of, 543. + treatment, 545, + twists, 542. + treatment, 545. + vasomotor nerves to, 94. + + Intranasal surgery, 266. + + Introduction, 17. + + Intercostal neuralgia, 712, 721. + + Intussusception, 541. + + Invagination, 541. + treatment, 545. + + Iridocyclitis in keratitis, 221. + + Iris, diseases of, 225. + + Iritis complicating conjunctivitis, 204. + in keratitis, 221. + + Iron not indicated in anemic conditions, 623. + + + J + + Jaundice, 558. + differentiate from Addison’s disease, 559. + simple catarrhal, 555. + + Jacksonian epilepsy, 730, 733. + + Jaw, full motion essential, 490. + lesions, 46, 491. + technic, 68. + + Joints and bones, tuberculosis of, 788. + function is motion, 489. + + + K + + Keratoconus, 218. + + Keratitis, 219. + cornea-phlyctenular, 214. + neuroparalytica, 223. + parenchymatous or interstitial, 224. + + Keratitis, phlyctenular, 224. + + Keratomalacia, 219, 223. + + Kidney, amyloid, 626. + complications in typhoid, 331. + diseases of, 617. + examination, 52 + hemorrhage, 164. + movable, 634. + prolapsed, 136. + belt for, 137. + sensory nerves to, 95. + stones, 631. + treatment, 78, 620, 623. + vasomotor nerves to, 94. + + Knee, tuberculosis of, 793. + + Kraepelin’s classification of dementia praecox, 283. + + Kyphosis—See curvatures. + + + L + + Labioglossopharyngeal paralysis, 765. + + Laboratory experiments on animals (Lesions), 91. + + Labyrinthitis, 254. + + Lachrymal apparatus, Diseases of, 202. + + Laennac’s egophony, 613. + pearls, 586. + + Landmarks of spine, 39. + + Landry’s disease differentiated from myelitis, 749. + paralysis, 753. + + Laryngeal nerve technic, 719. + lesions affecting superior and inferior, 719. + + Laryngismus stridulus, 572. + differentiated from croup, 573. + + Laryngitis, acute catarrhal, 569. + chronic catarrhal, 570. + edematous, 577. + spasmodic, 573. + syphilitic, 577. + tuberculous, 575. + + Larynx complications in typhoid, 332. + diseases of, 569. + examination, 47. + technic, 67. + + Lateral curvature, 98. + + Lead colic differentiated from intestinal colic, 535. + poisoning, Neuritis from, 707. + + Leg examination, 56. + neuralgia of, 714. + technic, 80. + vasomotor nerves to, 91. + + Lens, diseases of, 229. + opacity, 229. + + Lenses explained, 191. + + Leprosy, anesthetic, differentiated from syringomyelitis, 762. + + Lesions of each part or organ indexed under respective names of + parts, but not under all diseases in which they may be found + + Lesion affecting one viscus affects others also, 494. + caused by visceral disturbance, 501, 503. + chronic, reduce gradually, 66. + composite, 30. + dominant in causing gastro-intestinal disease, Osteopathic, 489, 490. + effects of, 33. + effects in heart cases, Osteopathic, 647, 648. + impacted, 92. + is absence of motion, 489. + ligamentous, 28. + muscular, 27, 41, 45. + caused by visceral disturbances, 500. + of various structures and regions, considered in connection with + osseous lesions of same. + osseous, 26. + also listed under various bones, organs and regions. + pathognomonic signs of, 39. + results stated by McConnell, 490. + to diagnose, 38, 30, 91. + visceral, 29. + + Leyden’s crystals, 586. + + Leukemia, 680. + acute myelogenous, 681. + lymphatic, 682. + splenomedullary, 681. + + Lithemia, 469. + + Liver, amyloid, 562. + and bile duct, diseases of, 553. + cancer of, 562. + (cholecystitis), 557. + cirrhosis of, 560. + complications in typhoid, 332. + examination, 51. + fatty, 562. + (gall-stones), 564. + hyperemia of, 554. + inactivity from pendulous abdomen, 127. + innervation, 474. + involved in rheumatism, 460. + (jaundice), 558. + location of reflex pain from, 499. + nutmeg, 553. + pain reflex to scapula, 721. + (simple catarrhal jaundice), 555. + prolapse, 138. + sensory nerves to, 95. + technic, 77. + vasomotor nerves to, 94. + + Lobar pneumonia, acute, 597. + + Lock-jaw, 377. + + Locomotor ataxia, 754. + differentiated from Friedreich’s ataxia, 759. + + Lordosis, 97. + + Lorenz operation, 781. + + Lumbago, 465, 466. + + Lumbar curve and prolapsed uterus, 143. + prominent hip, 125. + examination, 49, 52. + lumbar nerves, lesions affecting, 722. + technic, 74. + + Lumbo-abdominal neuralgia, 713. + + Lungs affected by stomach pressure, 498. + complications in typhoid, 332. + congestion, 610. + crowded by round shoulders, 121. + diseases, 592. + due to ribs, 47. + causing hyperemia of liver, 554. + edema of, 611. + relation to digestion, 494. + sensory nerves to, 95. + stimulated through rectum, 169, 170. + vasomotor nerves to, 93. + + Lymphatic leukemia, 682. + + Lymphadenoma, 684. + + + M + + McBurney’s point, 549. + why pain in appendicitis, 499. + + Macula lutea, 195. + + Maddox rod, 193. + + Mal, grand, 730, 732. + petit, 730, 733. + + Malaria associated with typhoid, 337. + + Malarial cachexia, 351. + fever, 347. + pernicious, 350. + hematuria, 351. + + Mammary gland innervation, 722. + + Manic depressive psychoses, 291. + + Massage following hip joint disease, 111. + intracapsular fracture of hip, 111. + of fractures, 116. + of sprains, 109. + not osteopathy, 19. + + Mastoiditis, 240. + + Mayo clinic’s goiter findings, 692. + + Measles, 437. + a cause of bronchitis, 579. + differentiate German measles, 446. + scarlet fever, 432. + German, 444. + + Meatus of ear, atrophic, 237. + infection of, 238. + + Medulla contains vasomotor center, 92. + + Meibomian cyst, 200. + + Meissner’s plexus, 494. + + Melancholia agitata, 297. + + Mellitus, Diabetes, 470. + + Meniere’s disease, 254, 718. + symptom complex, 253. + + Meningeal tuberculosis, 387. + + Meningitis, cerebrospinal, 358. + complicating pneumonia, 601. + tubercular, 360. + + Menopause, thyroid enlargement during, 686. + + Mental deficiency, 305. + diseases, 282. + osteopathic lesions in, 289. + + Microcephalous, 308. + + Migraine, 736. + + Milk leg, 167. + + Mind, relation to brain, 307. + + Miner’s anemia, 155. + + Mitral regurgitation, 648. + stenosis, 649. + + Moebius’ sign, 694. + + Morbilli, 437. + + Mongolian amentia, 309. + + Morons, 305. + + Morphine habit, physicians responsible, 715. + + Morton’s disease, 112. + + Morvan’s disease, 762. + + Mosquito carrier of filaria, 158. + + Motion is function of joint, 489. + + Motor oculi nerve, lesions affecting, 716. + + Mouth, diseases of, 487. + + Mucous colitis, 526. + + Mumps, 449. + whooping cough and acute eruptive fevers, 410. + differential diagnosis, 451. + + Murmurs, Heart, 642, 643. + + Muscle contractions caused by visceral disturbances, how, 500. + relieved by inhibition, 89. + + Muscular lesions, 27, 41, 45. Also considered in connection with + osseous lesions of various parts. + rheumatism, 465. + + Musculacutaneous nerve, lesions affecting, and results, 721. + + Myalgia, 467. + + Mydriatic, 194. + + Myelemia, 681. + + Myelitis, 707. + acute, 748. + chronic, 750. + diffuse, 749. + transverse, 748. + + Myelogenous leukemia, acute, 681. + + Myeloid leukemia, 681. + + Myocarditis, 659. + + Myoclonia, 727. + + Myxedema, 697. + + + N + + Nasal—See nose. + + Nasopharyngitis, 272. + + Nasopharynx, diseases of, 272. + + Neck—See also cervical. + + Neck examination, 47. + muscle lesions, 46. + stiff, 465, 466. + technic, 64, 66. + dangers of, 66, 86. + + Nephritis differentiated from pyelitis, 628. + hemorrhagic, chronic, 622. + interstitial, 624. + differentiated from diabetes insipidus, 477. + parenchymatous, acute, 618. + chronic, 621. + post-operative, 314. + + Nerve centers (osteopathic), 88. + deafness, 255, 718. + degeneration, auditory, 256. + diseases of, 706. + cranial, diseases of, 715. + spinal, diseases of, 719. + sensory, 94. + vasomotor, 92. + + Nervous indigestion, 511. + prostration from prolapse, 128. + system, diseases of, 706. + + Neuralgia, 710. + cervico-brachial and brachial, 711. + cervico-occipital, 711. + differential diagnosis, 714. + intercostal, 721. + of eye, 197. + of fifth nerve, 710. + of foot, some causes, 112. + of legs and feet, 714. + of sacral nerve from impacted feces, 537. + of sacral region, 713. + of spinal column, 713. + of trunk, 712. + relieved by inhibition, 89. + + Neurasthenia, 744. + + Neuritis, 706. + brachial, 123. + differentiated from neuralgia, 714. + multiple, differentiated from Landry’s paralysis, 753. + from myelitis, 749. + optic, 230. + post-operative, 313. + retrobulbar, 231. + + Neuroses of heart, 662. + gastric, 510. + + Neurosis, occupation, 738. + + “Neurotic spine,” 101. + + Nocturnal epilepsy, 733, 734. + + Nose and throat in eye troubles, 191, 196, 225, 229. + antiseptic sprays etc., 258, 262. + conditions in torticollis, 466. + diseases of, 257. + intranasal treatment, 260. + packing, 267, 268. + pharmacodynamics of, 262. + syphilis of, 270. + throat and ear, diseases, 236. + nosebleed, 161, 271. + differential diagnosis, 161. + + Nursing necessary to osteopathy, 62. + + Nutmeg liver, 554. + + + O + + Obesity, 480. + exercises to reduce abdomen, 128, 139, 480. + + Obstetric cases, innominate leosin in, 168. + + Obstruction, intestinal—see intestinal. + + Obturator nerve, lesions affecting, 722. + + Occipito-atlantal examination and lesions, 45. + technic, 67. + + Occupation neurosis, 738. + + Olfactory nerve, diseases of, 715. + + Omodynia, 466, 467. + + Ophthalmia neonatorum, 210. + purulent, 209. + sympathetic, 227. + + Ophthalmology, 183. + + Ophthalmoscope, 193. + + Optic disc, 195. + nerve atrophy, 231. + probably connection with third, 234. + neuritis, 230. + tract, diseases of, 715. + + Oropharynx, diseases of, 274. + + Orthopedic Surgery, 767. + + Osteopathic centers—see centers. + diagnosis and prognosis, 38. + etiology and pathology, 24. + examination of eye, 184. + inhibition, 89. + lesion defined, 24. + manipulation in eye diseases, 196, 213. + readjustment, 90. + stimulation, 88. + theory, proof of, 34. + scientific demonstration, 89. + treatment, general directions, 58. + + Osteopathy, definitions of, 18. + includes many measures, 62. + not massage, 19. + not passive exercise, 129. + not Swedish movements, 19, 63, 68. + + Otitis media, acute suppurative, 239. + chronic suppurative, 243. + differential diagnosis, 244. + non-suppurative, 246. + + Ovarian examination, 56. + + Ovary, prolapse of, 144. + sensory nerves to, 95. + + Oxyuris vermicularis, 154. + + + P + + Pachymeningitis, cervical, differentiated from syringomyelia, 762. + + Packing, nasal, 267, 268. + + Pains, location of reflex, 499. + + Palpation, educated, 60. + practice in, 87. + + Palpitation, 662. + + Pannus, 224. + + Panophthalmitis, 227. + + Papillae in rectum, 174. + + Paralysis, acute ascending, 753. + + Paralysis agitans, 723. + differential diagnosis, 724. + bulbar, 765. + + Paralysis, infantile, 750. + + Paranephritic abscess differentiated from pyelitis, 628. + + Paranoia, 287. + + Paraplegia, ataxic, 761. + spastic, 760. + + Parasites, animal, 151. + + Parathyroid glands, diseases of, 699. + + Paratyphoid fever, 344. + + Paris, plaster of, 795. + + Parotiditis, epidemic, 449. + differential diagnosis of, 451. + + Parotitis, epidemic, 449. + + Patheticus nerves, lesions affecting, 716. + + Pathologies, osteopathy recognizes two distinct, 489. + + Pathology, osteopathic, 31. + + Patient’s receptivity to treatment, 61. + + Pearls, Lænnec’s, 591. + + Pelvic examination, 52. + prolapse caused by abdominal prolapse, 128. + technic, 78. + + Pendulous abdomen, 127. + + Pericarditis, 638. + complicating pneumonia, 600. + + Pericardium, diseases of, 638. + + Peristalsis explained, 494. + reversed, normal in parts of colon, 497. + technic to affect, 495. + + Peritonsillar abscess, 278. + + Pernicious anemia, 678. + + Pertussis, 452. + + Petit mal, 730, 733. + + Pharyngitis, 274. + + Pharynx complications in typhoid, 332. + technic, 67. + + Phenol-glycerine formula, 263. + + Phlebitis, 167. + post-operative, 313. + + Phlegmasia alba dolens, 167. + + Phlyctenular keratitis, 224. + + Phrenic nerve, lesions affecting, 720. + + Phthisis, see tuberculosis. + + Piles, 171. + + Pin-worm, 154. + + Plaster of Paris, 795. + + Pleura, diseases of, 611. + + Pleurisy, 611. + complicating pneumonia, 600. + differentiated from pneumonia, 601. + post-operative, 314. + + Pleurodynia, 465, 466, 712. + + Pneumogastric nerve, lesions affecting, 718. + + Pneumonia, acute lobar, 597. + aspiration, 605. + alcohol not indicated in, 319. + associated with endocarditis, 644. + bronchial, 605. + caused by tubercle bacillus, 606. + catarrhal, 605. + complication of typhoid, 332. + chronic interstitial, 609. + croupous, 597. + differential diagnosis of, 609. + deglutition, 605. + differential diagnosis of, 601. + post-operative, 314. + + Pneumonia, strychnine not indicated in, 320. + + Pneumonic phthisis, 388. + + Poliomyelitis, 750. + causing scoliosis, 770. + differentiated from myelitis, 749. + + Polyuria, 476. + + Portal system, vasomotors to, 94. + + Posterior spine technic, 101. + thoracic nerve, lesions affecting, 721. + + Post-operative treatment, 312. + + Postural curves of spine, 128. + defects, 120. + + Posture, correct, 127, 128. + + Pott’s disease, 102, 788. + differentiated from kyphosis, 97. + from scoliosis, 773. + treatment, 102. + + Proctitis, 170. + + Prognosis and diagnosis, osteopathic, 38. + osteopathic, 56. + + Progressive muscular atrophy, 764. + differentiated from syringomyelitis, 762. + + Prolapse—See also ptosis. + + Prolapsed hepatic flexure, 139. + intestines, 139, 170. + kidney, 136. + liver, 138. + organs, 127, 133, 521. + ovaries, 144. + rectum, 171. + sigmoid flexure, 141, 170. + stomach, 134. + uterus, 143. + + Prominent hip, 125. + + Prostate gland, 175. + technic, 637. + sensory nerves to, 95. + + Prostatitis, 175. + + Prostatorrhea, 176. + + Pseudo-angina pectoris, 667. + appendicitis, 550. + croup, 572. + leukemia, 684. + + Psychalgia, 293, 296. + + Psychosis, involutional, 295. + + Ptosis—See also prolapse. + of abdominal organs, 127. + of eyelids, 201. + + Pulmonary regurgitation, 650. + stenosis, 650. + + Punctum proximum, 192. + remotum, 192. + + Purpura, 483. + variolosa, 420. + + Pyelitis, 627. + differential diagnosis, 628, 636. + + Pyelonephritis, 627. + + Pyemia, 356. + + + Q + + Quinsy, 278. + + + R + + Radial nerve, lesions affecting, 739. + + Rash, differentiate scarlet fever from drug or septic, 431. + + Receptaculum chyli, vasomotor nerves to, 94. + + Rectal conditions requiring surgery, 174. + disorders, brief discussion, 141. + examination, 55, 56, 169. + + Rectum, 169. + to dilate, 170. + technic, 169. + + Reflex gastric troubles, 509. + pains, location of various, 499. + + Reflexes, somatic, Burns experiments, 189. + + Regions of body should form basis of disease classification, 586. + + Regurgitation, aortic, 649. + mitral, 648. + pulmonary, 650. + tricuspid, 650. + + Remittent fever, 350. + differentiate from yellow fever, 375. + + Renal calculus, 631. + + Renal colic—see colic. + differentiate from appendicitis, 551. + + Respiratory diseases, 569. + reflex inefficiency, 264. + + Retina, diseases of, 230, 715. + + Retinitis, 230. + + Retrobulbar neuritis, 231. + + Rheumatic fever, 457. + + Rheumatism, abdominal, 466, 467. + cause of heart valve defects, 645. + chronic articular, 460. + differential diagnosis, 459. + and brachial neuritis, 125. + gonorrheal, 459. + inflammatory, 457. + muscular, 465. + subacute, 459. + + Rheumatoid arthritis, 462. + differentiated from rheumatic fever, 459. + + Rhinitis, acute, 257. + atrophic, 261. + chronic hypertrophic, 259. + hyperesthetic, 263. + purulent, 259. + + Ribs, danger in elderly patients, 87. + examination, 47. + false, technic, 74. + first, examination, 49. + technic, 72. + floating, 49. + technic, 73. + lesions cause heart trouble, 648, 653. + described, 48. + sprains, 111. + technic, 69. + + Rickets, 478. + + Rose spots, 334. + + Round shoulders, 121, 130. + worm, 151. + + Rubella, 444. + differentiated from measles and scarlet fever, 446. + + Rubeola, 437. + + Ruddy nasal third finger, 197. + third finger eye instrument, 214, 229. + treatment of tonsillitis, 281. + + + S + + St. Vitus’ dance, 725. + + Saccules in rectum, 174. + + Sacral nerves, lesions affecting, 722. + neuralgia, 713. + caused by impacted feces, 538. + + Sacro-iliac—see innominate. + + Sacrum examination, 55. + technic, 82. + + Salivary glands, 491. + + Sallow skin, 559. + + Scalp, 46. + technic, 68. + + Scapula, technic, 68. + + Scapulodynia, 466, 467. + + Scarlatina, 428. + differentiate diphtheria, 432. + drug rash, 431. + German measles, 432, 446. + measles, 432. + septic rash, 431. + types and forms, 432. + + Scarlet fever—see scarlatina. + + Schematic eye, 194. + + Sciatica, 708, 714. + + “Scissors” technic dangerous, 86. + + Sclerosis, amyotrophic lateral, 762, 763. + differentiate from syringomyelia, 762. + cerebral, differentiate from chorea, 726. + disseminated, differentiate from paralysis agitans, 724. + + Scoliosis—See curvatures. + + Scrofula, 384, 396. + + Scrofulous ophthalmia, 214. + + Scurvy, 481. + + Seminal vesicles, 176. + + Senile delirium, 300. + dementia, 297. + + Sensory nerves to various viscera, 94. See also under various viscera. + + Septic rash, differentiate scarlatina, 431. + + Septicemia, 355. + + “Setting up” exercises for pendulous abdomen, 128. + + Shaking palsy, 723. + + Shoulder, 56, 80. + painful, 122. + round, 121. + sprain of, 114. + + Sight—see eye. + diagnosis, 38. + + Sigmoid impaction causing cough, 575. + prolapse, 141. + + Sinusitis, 269. + vacuum, 270. + + Skin diseases, 147. + + Small occipital nerve, point to control, 719. + + Smallpox, 412. + black, 420. + differentiate from chicken-pox, 417. + + Smell, sense of, 491. + + Snellin’s test type, 191. + + Solar plexus inhibition, 582. + + Somatic reflexes—Burns experiments, 188. + + Spasm—see convulsions. + habit, 728. + + Spastic paraplegia, 760. + + Sphincters, alimentary, 496. + ani, external, 498. + + Spinal accessory nerve, lesions affecting, 719. + centers (osteopathic), 88. + column, neuralgia of, 713. + postural curvatures of, 128. + cord, diseases of, 748. + curvature, pathological, 96. + technic, 97. + examination, importance of, 41. + landmarks, 39. + lesions—see lesions. + nerves, diseases of, 719. + stretching, dangers of, 86. + + Spine the center of osteopathic interest, 38. + hysterical, description and technic, 101. + neurotic, description and technic, 101. + of the aged, description and technic, 101. + posterior, technic, 101. + sprains of, 110. + straight, 99. + technic, 100. + tubercular disease of, 788, 102. + typhoid, description and technic, 100. + + Splanchnic technic, 495. + + Spleen complications in typhoid, 332. + diseases of, 567. + examination, 52. + treatment, 78. + vasomotor nerves to, 94. + + Splenitis, 567. + + Splenomedullary leukemia, 681. + + Spondylitis deformans, 463. + + Sprains and fractures, 104. + bandaging not always good, 107. + heat and cold in treatment, 106. + immobilization and rest, 106, 115. + massage, 109, 116. + of ankle, 112. + of elbow, 114. + of fingers, 114. + of foot, 112. + of hip, 111. + of innominate, 111. + of knee, 112. + of ribs, 111. + of shoulder, 114. + of spinal column, 110. + of wrist and hand, 114. + passive movement, 107. + summary of treatment, 110. + + Stand erect, how to, 127. + + Status epilepticus, 734. + lymphaticus, 702. + + Stenosis, aortic, 650. + mitral, 649. + pulmonary, 650. + tricuspid, 650. + + Sternum examination, 49. + technic, 73. + + Still, early struggles of Dr. A. T., 17. + + Still-Hildreth Sanitarium 280, 291. + Several times in chapter on mental and nervous diseases. + + Stimulation, osteopathic, 88. + + Stomach,—see also digestive system. + cardiac relaxation by inhibition, 89. + conditions in bronchial asthma, 589. + dilatation, 134. + differentiate from gastroptosia, 134. + distention, 498. + examination, 52. + hemorrhage, 162, 516. + pain over pit of, due to cutaneous sensory nerves, 721. + prolapse, 134. + sensory nerves to, 95. + technic, 78. + ulcer, spinal causes of, 498. + + Stomatitis, 487. + + Stones, gall, 563. + kidney, 631. + + “Straight spine,” 99, 130. + technic for, 100. + + Strangulation of intestines, 541. + + Stretching, indiscriminate, 86. + + Strychnine not indicated in post-operative pneumonia, 320. + poisoning differentiated from tetanus, 378. + + Stupor, delirium and confusion, 289. + + Sty, 200. + + Sunstroke, 180. + + Supports, arch, 114. + in prolapse, 133, 142. + + Suprarenal capsule, Dr. Still’s theory, 633. + + Surgery, relation to osteopathy, 22. + in various conditions, taken up in connection with treatment. + orthopedic, 767. + + Swallowing, 492. + + Swedish movements not osteopathy, 19, 63, 68. + + Synechiae in keratitis, 221. + + Syphilis of nose, 270. + of thyroid, 687. + + Syphilitic laryngitis, 577. + + Syringomyelia, 761. + differential diagnosis, 762. + + + T + + Tabes dorsalis, 754. + + Tachycardia, 663. + + Taenia flavo-punctata, 151. + saginata, 151. + solium, 151. + + Talipes, 784. + + Tape-worm, 151. + + Taste, bad, in mouth, 492. + sense of, 491. + + Technic, see under osteopathic treatment; also under various regions, + and organs. + dangerous, 86. + osteopathic, 60. + + Teeth conditions in torticollis, 466. + defects should be corrected, 490. + + Temporo-mandibular—see jaw. + + Tenesmus treatment, 170. + + Testes, sensory nerves to, 95. + + Tetanus, 377. + differentiated from hydrophobia, 378. + strychnine poisoning, 378. + + Tetany, 699. + + Thorax examination, 51. + + Thread-worm, 154. + + Throat and nose in eye trouble, 191, 196, 225, 229. + + Throat, diseases of the ear, nose and, 236. + (Edwards’ turbinate adjuster), 197. + irritation due to hyoid, 47. + (Ruddy’s nasal third finger), 197. + technic, 67. + + Thrombosis from typhoid, 332. + + Thrush, 488. + + Thyroid gland, direct manipulation dangerous, 696. + diseases of, 686. + + Thymus gland enlarged in goiter, 691, 693. + diseases of, 702. + + Tic, convulsive, 728. + douloureux, 711. + general, 728. + + Tongue, 490. + furred, 491. + vasomotor nerves to, 92. + + Tonsils, 67. + function of, 276. + in rheumatism, 457, 460. + in torticollis, 466. + palpated, 47. + (peritonsillar abscess), 278. + trouble in eye disease, 196. + + Tonsillectomy, 278. + summary of indications for, 280. + + Tonsillitis, 276. + technic, 68, 279, 280. + + Torticollis, 129, 465, 466, 719. + + Touch, educated sense of, 60. + + Trachoma, 208, 212. + differentiated from follicular conjunctivitis, 208. + + Traction, reasons for, 62. + + Transillumination in diagnosing sinuitis, 269. + + Treating (over-treating), 84. + in influenza, 404. + + Treatment—see also technic. + after a meal, 83. + frequency of, 83, 84. + general, 62, 68, 90. + should be given when, 63. + inhibition to begin, 89. + length of, 84. + misapplied, 85, 87. + position of physician and patient, 63. + receptivity of patient to, 61. + resulting in some motion, leave lesion for that time, 76. + to be avoided, 86. + value of vacation from, 85. + + Tremors, differentiate from paralysis agitans, 724. + + Trichiniasis, 156. + + Trichiasis, 201. + + Tricuspid regurgitation, 650. + stenosis, 650. + + Trigeminus nerve, lesions affecting, 717. + + Trigger-finger, 115. + + Trousseau’s phenomenon, 701. + + Tubal disease, differentiated from appendicitis, 551. + + Tubercle bacillus may cause bronchopneumonia, 606. + + Tuberculosis, 380. + and joint immobilization, 115. + of alimentary tract, 393. + acute, 386. + begins as chronic gastritis, 506. + bones and joints, 788. + bronchopneumonic, 388. + cerebral, 387. + deformities predisposing factors, 389. + differentiate from brachial neuritis, 125. + pneumonia, 601. + (fibroid phthisis), 393. + differentiate from chronic interstitial pneumonia, 609. + of genito-urinary tract, 394. + of hip, 791. + of knee, 793. + of lymph glands, 384. + of miliary, 386, 394. + pneumonic, 386. + pulmonary, 387, 389. + of spine, 102, 788. + orthopedic surgery necessary in, 767. + of thyroid, 687. + + Tuberculous laryngitis, 575. + + Tumor, brain, differentiate from migraine, 737. + + Tuning fork tests, 294. + + Turbinates, to clean around in rhinitis, 200. + + Tussis convulsiva, 452. + + Typhoid fever, 329. + afebrile, 334. + fever associated with malaria, 387. + do not manipulate abdomen, 163. + differentiated from appendicitis, 551. + spine, 100. + + Typhus fever, 344. + + + U + + Ulcer of cornea, 219, 221. + gastric and duodenal, 512. + location of reflex pain in gastric or duodenal, 499. + of stomach, spinal causes of, 498. + differential diagnosis, 508, 515. + + Ulcerative stomatitis, 164. + + Ulnar nerve, lesions affecting, 726, 739. + + Uncinariasis, 155. + + Uremia, 628. + + Uremic convulsions, differentiated from epilepsy, 734. + + Ureter, sensory nerves to, 95. + hemorrhage, 164. + + Urethra hemorrhage, 164. + + Urinary system, diseases of, 617. + + Urine, blood in, 163. + massage prostate for retention of, 176. + + Urticaria, 149. + + Uterine examination, 56. + hemorrhage, 164. + + Uterus, prolapsed, 143. + sensory nerves to, 95. + + + V + + Vaccination, 424. + + Vaccinia, 424. + + Valve diseases, heart, 642, 644, 645, 649, 651. + + Varicella, 424, 446. + differentiated from variola, 417. + + Varicocele, 176. + + Varicose veins, 166. + + Variola, 412. + cornea, 421. + differentiated from varicella, 417. + hemorrhagica pustulosa, 420. + vera, 418. + verucosa, 420. + + Varioloid, 420. + + Variolosa purpura, 420. + sine exanthemate, 420. + + Vasomotor nerves, 92. + + Venereal disease and eye trouble, 184. + + Vertebræ, landmarks for distinguishing, 39. + + Vision explained, 230. + + Volvulus, 541. + + Vomiting, persistent, mostly reflex, 501. + post-operative, 312. + technic to relieve, 504. + + von Graefe’s sign, 694. + + + W + + Water, drink plenty, 540. + + White swelling, 793. + + Whooping cough, 452. + + Whooping cough, mumps, and acute eruptive fevers, 411. + differentiate enlarged glands, 454. + + Worms, intestinal, 151. + + Wrist, 56. + sprain, 114. + + Wry-neck—see torticollis. + + + Y + + Yellow Fever, 374. + differentiate from remittent fever, 375. + + + Z + + Zuckerkand’s organ, 703. + + + + + Transcriber’s Notes + + pg 48 Changed: resistance is a helpful guide in dignosis + to: resistance is a helpful guide in diagnosis + + pg 71 Changed: Still another method of adjustfng ribs + to: Still another method of adjusting ribs + + pg 79 Changed: slip one hand bteween the thighs + to: slip one hand between the thighs + + pg 91 Changed: In other words pathogological changes are just as real + to: In other words pathological changes are just as real + + pg 111 Changed: Diagnosis, Etiology, and Tecnhique, and the general + to: Diagnosis, Etiology, and Technique, and the general + + pg 112 Changed: Another joint frequent overlooked is the innominate. + to: Another joint frequently overlooked is the innominate. + + pg 112 Changed: of the innominate that is preventing revovery + to: of the innominate that is preventing recovery + + pg 130 Changed: There is often a shortning of the anterior structures + to: There is often a shortening of the anterior structures + + pg 140 Changed: Of particular local interest to the osteopth + to: Of particular local interest to the osteopath + + pg 186 Changed: goins then to the innominates + to: going then to the innominates + + pg 214 Changed: The exact cause of ocular lesions, or phlycentular + to: The exact cause of ocular lesions, or phlyctenular + + pg 215 Changed: diathesis and the exanthemata play their roll + to: diathesis and the exanthemata play their role + + pg 220 Changed: progressive ulcer (second sage.) + to: progressive ulcer (second stage.) + + pg 228 Changed: which begins by contration of the field + to: which begins by contraction of the field + + pg 238 Changed: paraffin oil and the heat applied continusously + to: paraffin oil and the heat applied continuously + + pg 254 Changed: Labyrinthitis is of several forms but in gerneral + to: Labyrinthitis is of several forms but in general + + pg 261 Changed: mucopurulent discharge, accompanied by a bad ordor + to: mucopurulent discharge, accompanied by a bad odor + + pg 271 Changed: The constitutioual causes of epistaxis + to: The constitutional causes of epistaxis + + pg 275 Changed: treatment consists of throrough cleansing + to: treatment consists of thorough cleansing + + pg 288 Changed: nearly always refers to the patinet’s exterior + to: nearly always refers to the patient’s exterior + + pg 288 Changed: and hence before detrioroation has set in + to: and hence before deterioration has set in + + pg 290 Changed: the term “acute confusional insantiy” + to: the term “acute confusional insanity” + + pg 296 Changed: fears, particulary of impending danger + to: fears, particularly of impending danger + + pg 306 Changed: mental capacity in man lie betweeen: + to: mental capacity in man lie between: + + pg 311 Changed: gain is shown treatment is discontinuted + to: gain is shown treatment is discontinued + + pg 314 Changed: if necessary completely elimination of the operation + to: if necessary complete elimination of the operation + + pg 317 Changed: tried to cross the railraod track + to: tried to cross the railroad track + + pg 340 Changed: care being taken that it is thoroghly digested + to: care being taken that it is thoroughly digested + + pg 340 Changed: lymphoid elements of the inteatines + to: lymphoid elements of the intestines + + pg 345 Changed: and maybe bronchial symptms. + to: and maybe bronchial symptoms. + + pg 349 Changed: If there are two parosyxms in the same day + to: If there are two paroxysms in the same day + + pg 350 Changed: twelve to twenty-four hours when consciouness + to: twelve to twenty-four hours when consciousness + + pg 362 Changed: A derangement of the veretbral articulation + to: A derangement of the vertebral articulation + + pg 369 Changed: for unsually this gives only temporary relief + to: for unusually this gives only temporary relief + + pg 376 Changed: Let the patient drink freely of tater + to: Let the patient drink freely of water + + pg 377 Changed: Esposure to damp cold is one of the recognized causes + to: Exposure to damp cold is one of the recognized causes + + pg 382 Changed: artery increase the susceptiblility to infection + to: artery increase the susceptibility to infection + + pg 411 Changed: blood and lympathic supply to the lungs + to: blood and lymphatic supply to the lungs + + pg 423 Changed: During convalenscence a full, well-regulated, + to: During convalescence a full, well-regulated, + + pg 433 Changed: fever usually by the fourteeneth day + to: fever usually by the fourteenth day + + pg 436 Changed: temperature is high and patient is delirius + to: temperature is high and patient is delirious + + pg 437 Changed: may simulate infantile paraylsis + to: may simulate infantile paralysis + + pg 437 Changed: Measles is an acute infectious, congatious + to: Measles is an acute infectious, contagious + + pg 438 Changed: functional integrety of the lungs and heart + to: functional integrity of the lungs and heart + + pg 441 Changed: greater frequency than in other infectiouss diseases + to: greater frequency than in other infectious diseases + + pg 442 Changed: rugs and unnecessary funiture have been removed + to: rugs and unnecessary furniture have been removed + + pg 444 Changed: is readily transmissable, attacks children especially + to: is readily transmissible, attacks children especially + + pg 448 Changed: stratching may cause pitting + to: scratching may cause pitting + + pg 449 Changed: are undoubtedly potent presisposing factors + to: are undoubtedly potent predisposing factors + + pg 457 Changed: tonsillitis, pyorrhea alveolaris, sinuitis, etc. + to: tonsillitis, pyorrhea alveolaris, sinusitis, etc. + + pg 478 Changed: cold and dampness are presisposing factors + to: cold and dampness are predisposing factors + + pg 487 Changed: Removal of the exciting cause is the most improtant + to: Removal of the exciting cause is the most important + + pg 492 Changed: result of inattention to oral hygience + to: result of inattention to oral hygiene + + pg 493 Changed: the ebb and flow of the crebrospinal fluid + to: the ebb and flow of the cerebrospinal fluid + + pg 497 Changed: further complicacates the clinical picture + to: further complicates the clinical picture + + pg 500 Changed: Stomach, liver, gall-gladder, pyloric and duodenal + to: Stomach, liver, gall-bladder, pyloric and duodenal + + pg 508 Changed: confidence by making an intellegent examination + to: confidence by making an intelligent examination + + pg 515 Changed: Referred pain from cholesystitis, chronic appendicitis + to: Referred pain from cholecystitis, chronic appendicitis + + pg 522 Changed: There is dypspesia, flatulency, constipation + to: There is dyspepsia, flatulency, constipation + + pg 527 Changed: The nurtition is generally well maintained + to: The nutrition is generally well maintained + + pg 537 Changed: (affecting reciprocal inneravtion) + to: (affecting reciprocal innervation) + + pg 539 Changed: peristaltic action and the secertory nerves + to: peristaltic action and the secretory nerves + + pg 545 Changed: Kinks of the pelivc colon, ileum + to: Kinks of the pelvic colon, ileum + + pg 546 Changed: stretched sufficiently to resore normal function + to: stretched sufficiently to restore normal function + + pg 548 Changed: appendix can be stimulated by purcussion + to: appendix can be stimulated by percussion + + pg 548 Changed: pyogenes aureus, typhoid baccilli, tubercle bacilli + to: pyogenes aureus, typhoid bacilli, tubercle bacilli + + pg 551 Changed: large proportion of cases revover + to: large proportion of cases recover + + pg 555 Changed: tenth rib on the right side, thus interferring + to: tenth rib on the right side, thus interfering + + pg 564 Changed: particularly fond of starchy and saccahrine food + to: particularly fond of starchy and saccharine food + + pg 571 Changed: mucous membrane, osccaional superficial erosions + to: mucous membrane, occasional superficial erosions + + pg 572 Changed: On the whole, careful, continued treament + to: On the whole, careful, continued treatment + + pg 582 Changed: The primary form is the result of expossure + to: The primary form is the result of exposure + + pg 583 Changed: lungs, abscesses, bronchiestasis + to: lungs, abscesses, bronchiectasis + + pg 585 Changed: Death occassionally results from suffocation + to: Death occasionally results from suffocation + + pg 597 Changed: especially by diploccocus pneumoniæ. + to: especially by diplococcus pneumoniæ. + + pg 634 Changed: symptoms as neuresthenia, melancholia + to: symptoms as neurasthenia, melancholia + + pg 645 Changed: stands foremost as a cuase of valvular defects + to: stands foremost as a cause of valvular defects + + pg 647 Changed: Through analagous reasoning from other organic + to: Through analogous reasoning from other organic + + pg 648 Changed: involve inhibitory (vagi) fibers or accellerator + to: involve inhibitory (vagi) fibers or accelerator + + pg 656 Changed: process or an act of compenation + to: process or an act of compensation + + pg 666 Changed: discovering irregulartities in the young + to: discovering irregularities in the young + + pg 675 Changed: The mononuclear neurtophiles are relatively increased. + to: The mononuclear neutrophiles are relatively increased. + + pg 681 Changed: It is a disease occuring at all ages + to: It is a disease occurring at all ages + + pg 691 Changed: supply is estensive, and the veins expecially + to: supply is extensive, and the veins especially + + pg 692 Changed: due to the incresee of epithelial cells + to: due to the increase of epithelial cells + + pg 703 Changed: Death in adults has ocurred from trifling injuries + to: Death in adults has occurred from trifling injuries + + pg 708 Changed: In a few cases there are intraplevic causes + to: In a few cases there are intrapelvic causes + + pg 720 Changed: he knows at once that the headadche is relieved + to: he knows at once that the headache is relieved + + pg 724 Changed: kness so close together that they rub in walking + to: knees so close together that they rub in walking + + pg 742 Changed: these phemomena also become bilateral + to: these phenomena also become bilateral + + pg 770 Changed: curvavature decrease in the volume of the lower + to: curvature decrease in the volume of the lower + + pg 770 Changed: that should be considered are spastic parlaysis + to: that should be considered are spastic paralysis + + pg 788 Changed: arising from the layer of non-tuberculus granulation + to: arising from the layer of non-tuberculous granulation + + pg 790 Changed: flacid and bilateral and may exist + to: flaccid and bilateral and may exist + + pg 790 Changed: must be cut over the invoved area + to: must be cut over the involved area + + + +*** END OF THE PROJECT GUTENBERG EBOOK 75696 *** |