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 katabolism, 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 vaso-motor 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, vaso-motor or sweat center, a lesion to the innervation to the heart (vagi and cervical sympathetic) causing a rapid heart, or a lesion to the sympathetic 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 vaso-motor system in the medulla may be effected, 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 vaso-motor nerves to the blood-vessels being effected 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 effecting 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 effect the thermogenic centers and nerves of the brain reflexly in the same manner as the vaso-motor and sweat centers and nerves are effected, thus tending to equalize the mechanism of the thermogenic system. Besides this action on the vaso-motor, sweat, and the thermogenic nerves, there is produced an increased exhalation of moisture nerves, there is produced an increased exhalation of moisture from the lungs, on account of an increase of vascular area in the lungs through vaso-motor 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 vaso-motor 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 most 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.

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 other well informed practitioners in medicine. The most important function of the skin is as a heat regulator. Knowing this fact, the osteopath treats the vaso-motor nerves that control the cutaneous circulation and the nerves that control the excretion of the skin; the nerve supply being from the cerebro-spinal 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 vaso-motor 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

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 due to a special poison; characterized anatomically by hyperplasia and by definite lesions in Peyer’s patches, mesenteric glands and spleen and parenchymatous changes in other organs; and clinically by its slow onset, early 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 over-work, improper food, unhygienic environment, and unsanitary 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, sewerage, 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 sub-mucosa, 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, epitheloid 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 degeneration of the cells, which are destroyed and absorbed. 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 are directly proportionate to 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 clean and smooth and formed of submucosa or of the muscularis. Perforation of the bowels 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 especially involved.

The spleen is invariably enlarged and softened, even diffluent. Occasionally rupture occurs spontaneously, or as the result of injury. Infarction is not a rare occurrence.

The liver shows parenchymatous and granular degeneration and the cells are found to be loaded with fat upon microscopic examination. 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 degeneration 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 found early in the disease.

Pleurisy is not often met with. Fibrinous pleurisy and empyema are rare events.

In the larynx ulceration is sometimes met with; bacilli, however, have not yet been found in these ulcers. Diphtheritis of the pharynx and larynx is not uncommon. 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. It is noticeable that the cell fibres present little or no change, even in cases of death from heart failure. 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 exceedingly rare. The peripheral nerves are frequently the seat of parenchymatous changes, even when there have been no symptoms of neuritis. 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. The bowels may be constipated or there may be three or four loose movements a day. 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 and loses its dicrotic character. 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 may be dry; the lips are also dry. The abdomen is tympanitic and tender. Diarrhea replaces constipation. The case may prove fatal during this week from the result of pronounced 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. Loss of flesh is now more marked and weakness is pronounced. Unfavorable complications may arise during this stage, as pulmonary symptoms, increased feebleness of the 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. The diarrhea stops, the tongue clears and the patient wants food. In protracted cases the fourth and fifth weeks may present the symptoms of the third week. Frequently the following aggravated symptoms being added: stupor, low muttering delirium, subsultus, increased weakness, rapid, feeble pulse, dry tongue, distended abdomen, and urine and feces are passed involuntarily. Heart failure and inflammatory complications increase the danger.

During the fifth and sixth weeks a few cases will show irregular fever. About this time relapses or slight recrudescences of the fever may occur.

Special Features and Symptoms.—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. The first stage of the gradual step-like ascent is rarely seen by the osteopath, as the cases do not come under his care at this early stage. 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 from the bowels 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 intense 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 and it usually comes on without warning; or the patient may experience a sensation of sinking or collapse and the temperature falls.

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. It pushes up the diaphragm and interferes with the action of the heart and lungs. It also favors perforation. 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 show general collapse of the circulatory system. Recovery is rare but is possible. Peritonitis may occur without perforation by extension of inflammation from the ulcers.

The spleen is invariably enlarged and generally goes on increasing in size up to commencement of the third week. The edge is felt just below the costal cartilages. Rupture of the organ may occur spontaneously or as the result of a slight blow, but this is of rare occurrence. Infarcts and abscesses are sometimes found.

The liver can sometimes be felt to be enlarged. Jaundice and abscess of the liver are rare complications.

Gastric symptoms, as nausea and vomiting, may occur at any stage of the disease but is most common at the onset. Persistent vomiting is a serious symptom and death may occur from exhaustion.

The pharynx is frequently the seat of catarrhal irritation. There may be merely a dry, burning sensation. The tongue at first is moist, swollen, and coated with a thin white fur; later the edges clear off, while the center becomes very dry and covered with a brown or brownish-black fur. It is sometimes fissured. The lips become dry and the lips and teeth may be covered with dry, black sores. Ulcerative stomatitis often occurs if the mouth is not kept clean. Parotitis is not infrequent and the sub-maxillary gland may also be involved.

Epistaxis occurs early in most cases and is the most common febrile affection. When it occurs during the fastigium it is a grave symptom.

Laryngitis is an occasional complication. Laryngeal ulcers and parichondritis may occur.

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 physical signs are defective resonance or dullness at the bases, broncho-vasicular breathing, and moist rales.

Lobar pneumonia in a few cases develops early. There may be a marked rigor at the onset, sudden rise in temperature, pain in the side, and all the symptoms of lobar pneumonia; characteristic typhoid symptoms, however, soon follow and the pulmonary symptoms soon leave. Lobar pneumonia frequently develops during the second or third week, when it forms a serious complication. The symptoms are not marked; there may be no rusty expectoration, chill, or pain in the side and hence the condition is easily overlooked. Pulmonary infarction, abscess or gangrene of lungs are occasional complications.

The heart sounds are at first natural, but in severe cases the first sound may grow quite feeble or be gradually annihilated. Sometimes a soft systolic murmur is heard at the apex. Pericarditis and endocarditis are rare complications, while myocarditis is more common.

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.

Venous thrombosis occurs most frequently in the left femoral vein. This complications is not a very unfavorable one, but occasionally the thrombosis may extend into the pelvic veins or even into the vena cava, which makes it more serious. Sudden death has been caused by detachment of a thrombus. Thrombosis of the femoral vein causes swelling and edema of the affected limb. Gangrene, however, never results from obstruction of the vein above.

Obliterations of the large or small arteries is a rare complication and may be due either to embolism or to thrombosis. As a general rule it is the femoral artery that is involved, and gangrene of the foot and leg is the result. It is not known whether the thrombosis is caused by a peculiar condition of the blood which favors clotting or to a local arteritis; possibly it is a combination of these two factors.

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 a 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 for which it is invariably 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.

Of the nervous complications and sequelae, paralysis is the most common and is due to neuritis. Extreme sensitiveness of the skin and muscles is common during convalescence. Mental weakness and even insanity may follow and is more common after typhoid than after any other disease. This is probably due to impaired nutrition and weakening of the nervous centers. Neuralgia affecting the occipital and cranial nerves is frequent both during and after the disease.

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 chlorides are increased. Febrile albuminuria is very common but of no special significance. Acute nephritis may develop as a complication. Diabetes mellitus, in rare cases, may develop after typhoid. Pyuria is not an uncommon complication and post-typhoid pyelitis may also develop. Simple catarrh of the bladder is rare. Orchitis is sometimes met with during convalescence.

A multiple arthritis occasionally occurs. Mono-articular arthritis is more common and often precedes suppuration. Necrosis of the bones may occur during the fever, but usually it is during convalescence, the favorite seat being the ribs and tibia.

The muscles may be the seat of hyaline degeneration, and abscesses may form in the muscles.

Associated Diseases.—Erysipelas is a rare complication, coming on most frequently during convalescence, although it may appear during the height of the affection.

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.

Pseudo-membranous inflammation may affect the larynx, pharynx, and genitals. Measles, chicken-pox, and scarlatina may also arise.

Varieties of Typhoid.—These 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 ambulatory 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 cerebro-spinal 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 exceedingly 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 cerebro-spinal meningitis is invariably made, until the appearance of the colored spots on the abdomen, which must decide the diagnosis; cerebro-spinal 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 over one hundred 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 both the A. T. Still Infirmary (Kirksville) and Sanitarium, (St. Louis), 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 vaso-motor 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." (Hinckle—The Scientific Basis of Osteopathy)

Prophylactic treatment is very essential, for typhoid fever as a rule is a preventable affection. Modern hygienic 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 course 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 short 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.

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 reader unfavorable the conditions that are necessary 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 effect 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 effects 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 effects the lesser splanchnics nerves. In all cases I always carefully treat the lower two or three lumbar vertebrae, which directly effects 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 flatly 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 hydro-therapeutic 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 and a careful use of the bed-pan. 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.

When peritonitis occurs from perforation, the case is usually hopeless, although recovery has taken place. The indications are to lessen the inflammation. Hot applications, rest and thorough treatment of the innervation to the peritoneum is necessary.

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 vaso-motor 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. The question of food is a troublesome one, for the patient has a ravenous appetite and is extremely anxious for a fuller diet. 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, there is obtained: (1) 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.

See reports of typhoid fever in A. O. A. Case Reports as follows: C. M. T. Hulett, Series 1, 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.
 

MOUNTAIN FEVER

Definition.—A form of fever which develops in high altitudes; characterized by moderate fever and a group of symptoms due to the effects of a rarefied air upon the respiration and circulation.

There is no definite etiology or morbid anatomy.

Symptoms.—The pulse is quickened, severe headache, gasping for breath, vertigo, sometimes nausea and vomiting, debility, and as a rule constipation, or diarrhea may occur. Epistaxis sometimes occurs.

The duration is from two to four weeks. Some authorities consider this a form of typhoid fever accompanied by the varied symptoms, due to the effect of high altitudes upon the organic functions. It must be borne in mind that high altitudes alter the characteristic symptoms of the acute infectious diseases.

Treatment.—The treatment of mountain fever is largely symptomatic. For special indications see treatment of 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. Filth, over-crowding, famine, intemperance and bad food are the predisposing causes. Although it is an infectious disease, no special micro-organism has yet been found. Typhus fever is highly contagious, but it is not yet known in what manner the contagion is transmitted. It is more probable that the poison is inhaled and enters the system through the respiratory tract.

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 lasts about twelve days, sometimes less. The invasion is usually sudden, ushered in by either a series of chills or a single rigor. 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, 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.

The eruption appears about the third or fifth 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 become more aggravated 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. In favorable cases the crisis occurs at the end of the second week.

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. 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 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.

The osteopath would here, as in all cases of diseases, examine the patient for anatomical disorders and wherever they are found would proceed to readjust them. There are no lesions that are characteristic of typhus and consequently the treatment of the disease would of necessity be largely a symptomatic one. Isolation is necessary and the patient’s excreta should be removed and disinfected at once.

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.
 

MALARIAL FEVER

(Ague)

Definition.—An infectious disease caused by the hematozoa 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 believed to be caused by a parasite known as the hemotozoa 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 amoeba 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 parasite 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, anapheles, 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 anapheles. 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 anapheles 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 anapheles 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 phagocytes to combat with the invading parasite.

The osteopathic predisposing causes for malaria are usually interference with the vaso-motor 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 due 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 modbid lesions of the disease.

In pernicious malaria the blood is more or less hydremic and the serum may be tinged with hemoglobin. The blood discs are seen in all stages of destruction. The spleen is enlarged, 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, vaso-motor 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 intensely 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 bounding 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 and the patient falls asleep. The sweating varies greatly; it may be a very light moisture or it may be drenching.

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. Herpes labialis appears. 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 fever; 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 and chiefly 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 104 or 106 degrees F. 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 degree 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 often 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 comatose and algid.

The comatose 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 fever is usually high and the skin is hot and dry. The comatose condition lasts from twelve to twenty-four hours when consciousness usually returns, the primary paroxysm rarely proving fatal; but 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 and small; 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 affection the parasites invade the gastro-intestinal mucosa especially; sometimes forming distinct thrombosis 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, 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 form 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. Malarial hematuria is an important form. A chill may not be present, but there is usually a chilly feeling, the nose and fingers being cold and the lips blue. Prostration is marked and nervous symptoms are severe. Hemaglobinuria has been noted in malarial regions. Malarial parasites in the blood and the presence of hemoglobin in the urine will clear the diagnosis.

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 stimulate 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 vertebrae and ribs corresponding to the vaso-motor nerve supply of the spleen and liver. The most common lesion found is a marked lateral deviation between the ninth and tenth dorsal vertebrae 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 vaso-motor nerves to the spleen and liver; thus permitting a weakness of the system, especially of the blood, in resisting malarial infection. 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 vaso-motor 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.

Tete (Journal of Osteopathy—Prize Article July, 1906), of Louisiana, makes the following interesting statement, after observing about one hundred cases, that "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 (A. O. A. Case Reports—Series I) 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." Price finds cases of hematuria exceedingly difficult to cure. 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.

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. J 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 hematozoa of Laveran 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 potentiate and antitoxic and antimicrobic substances are secreted.
 

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 or staphlycocci seem to be 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 difficult as so much depends upon the general health of the patient. There is a progressive tendency in all the symptoms and fatal termination or recovery may be the gradual sequence.

Treatment.—Remove the cause of the infection, which may be surgical. Normal salt solution is of value in the depressions following toxemia. Diet should be nourishing and consist of broths, soups, eggs, milk, etc. Osteopathic treatment, according to indications, will aid very materially in stimulating and strengthening the patient. Keep the bowels, kidneys and skin active.
 

PYEMIA

A febrile disease arising from an invasion of the blood by pathogenic bacteria, wherein sepsis and multiple abscesses occur from the 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, thorombosis of the veins may take place in any region. Abscesses may form in the lungs, liver, kidneys, spleen or other internal organs. The small abscesses may unite and form a larger one. The skin presents eruptions and hemorrhagic extravasations, while there may be ulcers of the mucous membrane, as may also the serous surfaces 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 first be a slight fever, but commonly a chill is the first symptom, which may reoccur for some time. The fever is characterized by its being intermittent or remittent. 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, 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. There is delirium, and coma is present in grave cases. Abscesses are likely to occur in various regions and organs.

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

Prognosis.—Much depends upon asepsis and surgery. On the whole prognosis is unfavorable.

Treatment.—Surgical interference is the first treatment. Then the treatment as given under septicemia.
 

SMALLPOX

(Variola)

Definition.—An acute, contagious disease, characterized by a fever and eruption which passes through the stages of papule, vesicle, pustile and crust.

Osteopathic Etiology and Pathology.—The nature of the specific poison is not definitely known. It is probably the most virulent of all the contagia in its effect upon exposed persons not protected by vaccination. Physical debility, unhygienic surroundings, and poor nourishment predispose. A number of cases have been treated by various osteopaths and each case presented varying lesions that had lowered physical vitality. The disease is contagious throughout the entire attack, but especially during the suppurative and desquamative stages. The poison is conveyed in the secretions, excretions and in the exhalations from the lungs and skin, but mainly in the pustules and dry crusts. The poison probably enters the system by way of the respiratory tract. No age, sex or race are exempt from this disease. Among the uncivilized people smallpox spreads with frightful rapidity and is terribly fatal.

The essential pathology is that of the eruption, which consists of an inflammatory, cellular infiltration starting in the rete mucosum close to the true skin. The eruption has four stages—papular, vesicular, pustular and the crust. The center of the papluar represents a focus of coagulation necrosis, due to the presence of micrococci (Weigert). The vesicle appears at the apex of the papule. During this stage the rete mucosum presents reticuli which contain serum leucocytes and fibrin filaments. If the process does not extend deeper, usually, healing takes place without a scar; if, however, suppuration extends into the true skin, scarring results. The reticuli become filled with leucocytes, producing the pustules. The pustules usually rupture, sometimes they dry up; in either case a crust results. The pustules are found in the larynx, trachea, bronchial tubes and sometimes, though rarely, in the esophagus and rectum. The liver is sometimes fatty, and cloudy swelling of the secreting cells of the kidney may occur. The spleen may be hard and firm.

In the hemorrhagic form extravasations occur in the serous and mucous membranes, the connective tissues, the parenchyma of the viscera and sometimes about the nerve sheaths, bone marrow, walls of the blood-vessels and into the muscles.

Symptoms.—The incubation period varies from seven to twelve or more days. The onset is sudden, with a severe chill or chills, high fever, intense headache, violent muscular pains, particularly in the back, rapid, hard pulse and delirium, which is sometimes violent. The temperature rises rapidly to 103 or 104 degrees F., the first day. During the third, the characteristic eruption appears in red spots, first upon the forehead and lips. Each pock passes through the four stages already described. The papules feel like shot under the skin and there is much itching and burning. On the third or fourth day from the onset, when the eruption makes its appearance, the fever falls and the patient feels comfortable. The serum appears about the fifth or sixth day, when a depression is seen in the middle of each vesicle; this umbilication is very characteristic of the disease. When the suppurative stage arrives the fever again returns; this is about the eighth day. On the ninth or tenth day, the pustule becomes dry and crusts are formed, being thrown off in two or three days. During this time the fever and the constitutional symptoms subside and convalescence sets in.

In the discrete form the pustules are separate and distinct, while in the confluent form the eruption appears about the second day, and the pustules are so close to each other that they coalesce into large patches. The symptoms are of greater severity and there is marked prostration.

The hemorrhagic form is still more severe and occurs in two varieties, the purpura variolosa or black small pox, and variola hemorrhagica pustulosa. In the former the hemorrhagic symptoms appear early. Hemorrhagic rash and hemorrhages from the mucous surfaces occur and death follows in from two to six days, sometimes before the appearance of the eruption. In the latter variety the case progresses like that of ordinary small pox, the blood making its appearance in the pox during the vesicular and pustular stage.

Varioloid is a modified form of smallpox, in which the patient has been previously vaccinated or has had one attack of smallpox. Each symptom is milder and its course shorter. There is no secondary fever and the rash appears a day later than in the discrete variety.

The complications that may be associated with smallpox are laryngitis, which may produce a fatal edema of the glottis; bronchial pneumonia, lobar pneumonia (rarely), pleurisy, parotitis, vomiting, diarrhea, albuminuria and true nephritis (rarely). Endocarditis, pericarditis, and myocarditis are rarely met with. Boils and abscesses on the skin are frequent during convalescence. Prolonged delirium and sometimes insanity may occur. Neuritis, arthritis, hemiplegia, aphasia, conjunctivitis, iritis, and otitis media may also become complications.

Diagnosis.—A knowledge of a prevailing epidemic will be a helpful measure. As soon as a perfect papule makes its appearance, a positive diagnosis can be very readily made. The rashes of measles and scarlatina have sometimes been mistaken for the initial rash of smallpox. In scarlatina the rash resembles that of smallpox in the early stages only. In measles care has to be taken, for many errors have arisen in making the differentiation. There are early cough and coryza, while the pain in the back and legs is not nearly so severe as in smallpox, and there is absence of the shot-like feeling of the eruption. Chicken-pox is very apt to be confused with mild epidemics of smallpox. The rash is more abundant upon the trunk than upon the face. The constitutional disturbances are slight and all of the symptoms are milder. Secondary syphilis will be distinguished by the history, the pustule base is indurate, and there is absence of fever and itching. Cerebro-spinal fever and the hemorrhagic form of smallpox may be confounded. If the patient has been exposed to smallpox or if he has not been vaccinated, even if the initial symptoms are those of cerebro-spinal fever, the patient more than likely has smallpox. The diagnosis can be made more positive by the ankles and other joints not being involved, the irregular temperature curve, the herpes, the marked hyperthesia, and muscular rigidity of cerebro-spinal fever.

Prognosis.—This depends upon the severity of the epidemic, hygienic measures, the protection by recent vaccination and the appearance of the eruption. The hemorrhagic form invariably is very dangerous. The discrete form is the most favorable. Severe pneumonia and laryngitis are fatal complications. A number of cases have been successfully treated by osteopathy.

Treatment.—Prophylaxis has done much to lessen the frequency and severity of this disease. Cleanliness, sanitary measures, isolation, and according to medical authorities, vaccination, have reduced the seriousness markedly. Notify the proper authorities and have the patient isolated. The usual fever treatment, hygienic measures, liquid diet, avoidance of extreme light, plenty of fresh air, and good general care are the immediate indications. Osteopaths have been able to promptly meet and successfully treat this disease. The room should be stripped of all unnecessary furnishings, an upstairs room being best. All communication of the nurses with members of the family should be prohibited. All utensils and clothing of the patient must be carefully disinfected and the room thoroughly ventilated. The nurse should be provided with suitable clothing, which is to be removed upon leaving the room. The doorways may be protected by hanging a sheet dampened in a solution of carbolic acid, 1:60.

The treatment consists of meeting the symptoms as they arise. Remove all lesions found and pay strict attention to the excretory organs. The pains in the back and limbs are to be controlled by careful treatment of these regions, especially relaxing the muscles thoroughly. For the fever, besides the ordinary treatment, cold sponging or the cold bath will be helpful. When the temperature reaches 103 degrees F., with presence of considerable twitchings and delirium, the patient should be placed in a bath of 70 degrees F.; this may be repeated every three hours if necessary. Let the patient have plenty of cool drinks.

Treatment of the eruptions should receive careful consideration, especially in the prevention of disfigurement. Constant applications of cold water, with carbolic acid as an antiseptic, is considered good. When the crusts are forming a thorough application of Vaseline will allay the burning and itching and prevent the diffusion of the particles of epidermis, which aids in keeping the contagion from spreading through the air. Frequent bathing helps to keep the crusts softened. The adding of the carbolic acid, ten grains to the ounce, to the Vaseline also aids in subduing the odor.

The eyes, nose, mouth and throat should be carefully watched and the parts kept clean of all crusts. Tracheotomy may be necessary if the obstruction of the larynx becomes extensive. The diarrhea is best controlled by thorough treatment of the splanchnics. During convalescence the patient should be bathed daily. When a patient’s skin is perfectly smooth, the danger from spreading the disease is over.
 

VACCINATION

Vaccina is an eruptive disease of the cow and when the contents of the vesicle of cow-pox is introduced into the blood of man, it produces a local manifestation, the vaccine vesicle, with constitutional disturbance, and the majority of persons, thus successfully vaccinated, are protected from smallpox.

The vaccine is usually taken directly from the cow (animal lymph), although it is obtained from persons vaccinated (humanized lymph) as well, but this is not as successfully used as there is danger of communicating other affections, particularly syphilis.

The vaccination should be made about the third month, but if smallpox is not prevalent it is best to wait until the end of the second year. The second vaccination should be made about the seventh year and a third at puberty. After puberty vaccinate every few years and always when smallpox is prevalent.

The favorite situation for inoculation is on the arm over the insertion of the deltoid muscle. In girls it is sometimes preferred on the leg, the point usually chosen is over the junction of the two heads of the gastroenemius muscle. The part chosen should be rendered aseptic and the skin scratched with a lancet or with the ivory point, until serum begins to exude. If blood is drawn it should be carefully dried before the lymph is applied, as it interferes with absorption. The moistened virus should then be carefully rubbed over the abraded surface. The spot must be carefully protected until thoroughly dry.

About the third day a small red papule appears. On the fifth or sixth day a definite vesicle, and by the eighth day it has attained its full size. It is filled with a limpid fluid, is umbilicated and the surrounding tissues are red, tender, swollen, and infiltrated. About the twelfth day the pustule dries up and forms a crust which separates during the third or fourth week, leaving a permanent cicatrix. If the vaccination is made on the arm, the axillary glands are often swollen and tender; if on the leg, the inguinal glands are affected.

Sometimes additional vesicles are formed near the point of inoculation. Occasionally vesicular eruptions occur. Erysipelas, various cutaneous eruptions and in a few instances tetanus are complications which may arise. Syphilis has occasionally been transmitted as, before stated, through humanized lymph. As the result of uncleanliness or owing to injury, the vesicles inflame and ulcers form. Complications should not arise if the vaccine is pure and aseptic precautions taken. If infection occurs treat with wet boracic dressing.
 

SACRLET FEVER

Definition.—An acute, contagious fever, characterized by sore throat, angina, rapid pulse and a diffuse scarlet eruption, followed by a membranous desquamation. There is a tendency to nephritis.

Osteopathic Etiology and Pathology.—The specific poison that causes scarlet fever has not yet been discovered In no disease is the contagion so tenacious; it may be conveyed by infected bedding, clothes, etc., for a year or more after the case has occurred. It is most frequent in children before the age of ten; adults are not exempt. One attack does not always give immunity; a second and third have occurred. Both sexes are alike susceptible. Epidemics occur at all seasons of the year; they are, however, of greater intensity during the autumn than in winter. The disease is not supposed to be communicable until a desquamation takes place, although it has been conveyed by naso-pharyngeal secretions after the desquamation period; hence persons kept away from the disease at this period generally escapes. It is very hard to disinfect an apartment after a case of scarlet fever. The disease has been communicated to new occupants even after the room has been thoroughly cleansed. The contagion has been carried in milk. The streptococcus pyogenes has been found in the blood, the skin, and various organs after death. The infection generally gains entrance through the respiratory tract, thence to the throat and the general system. No doubt osteopathic lesions causing catarrhal affections of the respiratory tract predispose to the disease. In some instances the infection gains entrance by way of the alimentary tract, for instance, milk contamination. In all of the eruptive fevers there can be no question that osteopathic lesions lowering physical vitality, unhygienic environment, unsanitary surrounds and insufficient food are paramount predisposing factors.

There are no morbid changes, and except in the hemorrhagic form, the eruption fades after death. The throat is inflamed and sometimes ulcerated. The morbid changes found in the other organs are those of the complications which arise.

Symptoms.—The period of incubation varies from twenty-four hours to eight days; it is usually two or three days. The onset is generally sudden, with vomiting and sometimes convulsions, and the tongue is furred. The pulse is rapid and hard (120 to 150) and out of proportion to the fever. The temperature rises rapidly to 103 or 105 degrees F. The skin is dry, the face is flushed and there is sore throat. The eruption usually appears on the second day, first upon the neck, then the chest and rapidly spreads over the entire body. When examined closely, it is seen to consist of a multitude of red points corresponding to the hair follicles; at a distance this gives the entire body a bright scarlet color. It disappears upon pressure, but returns as soon as the pressure is removed. The rash may be uniform or it may occur in discrete patches The eruption does not always appear on the face In some cases the eruption is pale and hardly visible, or it may be papular or vesicular (scarlatina miliaris) and occasionally petechial. There is itching which may be moderate or intense. The rash persists for two or three days and then gradually fades and is soon followed by a scaly desquamation. The duration of the fever is from seven to nine days, after which it falls by lysis. The respirations are hurried There is loss of appetite and the bowels are constipated. The gastro-intestinal symptoms are not marked after the initial vomiting. The urine is scanty, thick and high colored, and it contains urates and a small amount of albumin. Sleeplessness, mild delirium, headache, insomnia, and rarely convulsions, may occur during the attack. The tongue is red at the edges and tip and furred at the center, with enlarged fungiform papillae and known as the "strawberry tongue." In a few days the dead epithelium is cast off, leaving the tongue red and raw looking.

In an uncomplicated attack the duration is from three to fourteen days, according to the severity of the disease.

Malignant Scarlet Fever.—In the anginose form the throat symptoms are severe. The fauces and tonsils are swollen and are often covered with a false membrane which may extend forward into the mouth, upward into the nostrils, and may also involve the posterior pharynx, the trachea and bronchi. The throat may present all the symptoms of a severe diphtheria. The fever is high and there is great prostration. The glands of the neck are greatly enlarged. Abscesses and ulceration of the throat occur frequently. Death may result form ulceration into the carotid artery or it may occur rapidly from toxemia or exhaustion. In the malignant form there may be almost immediate prostration and death may occur within twenty to forty-eight hours, before the appearance of the rash. The onset is abrupt and the symptoms are of great severity. The temperature may rise to 106 or 107 degrees F., or higher, with the pulse rapid and feeble. There is delirium, which rapidly passes into coma. Convulsions may occur. In the hemorrhagic form hemorrhages occur into the skin, and there is epistaxis and hematuria. This form is found most frequently in enfeebled, poorly nourished children. Death may take place in two or three days. Like the preceding form this nearly always proves fatal.

Complications.—Acute nephritis, usually of a parenchymatous character, is a fairly common complication. It is found in both severe and mild cases, commonly during desquamation, which indicates that when the skin function is decreased and impaired the kidneys are required to eliminate an extra amount of poison. Osteopathic measures can do much to stimulate the kidneys and other emunctories and thus prevent this complication. Arthritis, meningitis, otitis, pneumonia, cardiac involvement, paralyses, and nervous affections are other possible complications.

Diagnosis.—This is not difficult, though for a time it may be confounded with the following diseases: Acute exfoliating dermatitis, the throat symptoms are usually absent. The tongue is not characteristic of scarlet fever The onset is sudden with fever only. The desquamation begins before the rash is entirely gone. Nephritis is not a common complication and relapses are common. In measles the sore throat is less marked, the eruption occurs later, and is of a very different character from that of scarlet fever. The pulse is in proportion to the fever; and leucocytosis is absent. In diphtheria the cutaneous rash is usually absent. The false membrane is always present, containing the Klebs-Loeffler bacillus; the tongue has not the strawberry appearance. Drug rashes follow the use of quinine, belladonna, potassium, bromide and chloral. There is no fever, no characteristic symptoms of invasion and the rash is of short duration.

Prognosis.—This varies greatly. The prognosis should always be guarded, although osteopathic treatment has been distinctively successful.

Treatment.—The treatment of scarlet fever consists of careful nursing and disinfection, watching for complications and treatment of the symptoms as they arise. The patient should be isolated and there remain until desquamation is complete. The room given the patient should be an upper one if possible. It should be stripped of all unnecessary furnishings and a competent nurse put in charge. All unnecessary communication with members of the family must be entirely prohibited the temperature of the room requires to be kept as uniform as possible, with proper ventilation. The diet should consist of milk, light broths, egg albumin and fruit juices and plenty of water.

Thorough osteopathic treatment is to be given along the spinal region to keep the muscles well relaxed and give special attention to the renal splanchnics and to the cervical vertebrae. The neck should be watched most carefully for any abnormalities that may occur to the cervical vertebrae, and the cervical muscles kept as well relaxed as possible. Particular attention must be given the deep cervical muscles, especially those beneath the angles of the inferior maxillary and those between the atlas and occiput; keeping these deep cervical muscles in normal condition will help greatly in preventing complications that may arise in the ears, besides greatly relieving the severe symptoms of the naso-pharyngeal region. By attending carefully to the intestinal and renal splanchnics, any disturbance of the intestinal tract can generally be kept under control and the liability of renal complications is greatly lessened. Direct treatment to the abdomen should be practiced during each visit, to keep the bowels, kidneys and liver active. Examine the urine frequently.

In cases of heart enfeeblement, attention to the cervical sympathetic and vigorous treatment through the upper left dorsal region are indicated. The most effective fever treatment will be in keeping the emunctories active, through spinal treatment, and an inhibitory treatment of the sub-occipitals will be of great aid. The tension of the ear drum must be watched constantly; and if severe inflammation of the ear should arise that cannot be relieved by the upper cervical treatment, which consists of correcting any deviation of the atlas and relaxing the deep muscles at the angle of the inferior maxillary and relieving the impingements at the upper dorsal of vaso-motor nerves to the ear, then perforation should be performed.

In the treatment of the eruption, which is due to a hyperemic condition of the cutaneous vessels followed by edema, using carbolized water 1-40 to sponge the surface, followed by the application of cocoa butter, will tend to reduce the fever by soothing the cutaneous burning and irritation; and later when desquamation occurs it limits the source of infection by preventing the diffusion of what would be dry scales in the air; and finally it protects the surface from the influences of sudden changes of temperature, thus to a great extent avoiding the danger of nephritis.

Bathing the patient three or four times a day with tepid water is of great aid in relieving the fever, besides preventing complications. The gradually cooled bath will be of benefit when there is high temperataure and marked nervous symptoms, besides it increases cardiac action. Cold water applications to the exterior of the throat will be gratefully received by the patient; pellets of ice in the mouth will also be of some comfort. Continued bathing, several times a day, aids the kidneys greatly by vicariously eliminating the poison generated in the system. The osteopath should take pains to disinfect himself. A linen duster after being dipped in a solution of bichlorid and dried, worn during his visit to the room of the patient, will be sufficient.
 

MEASLES

Definition.—An acute, contagious disease, characterized by an initial coryza, nasal and bronchial catarrhal symptoms, a rapidly spreading eruption and moderate fever Osteopathic lesions involving the vaso-motors to the mucous membrane of the respiratory tract and to the lymphatics draining the same area predispose.

Dr. Still considers this as largely a cutaneous disturbance and says the rash is a result of lymphatic congestion of the skin, resulting from muscular contractions along the spine, which interfere with vaso-motor centers. It is essentially an epidemic disease, yet, now and then, sporadic cases occur. The disease is in all probability due to a micro-organism, but as yet none has been isolated. One attack does not always protect from another. It occurs at all seasons, but epidemics occur most frequently during the fall and winter. Children are more susceptible, but unprotected adults are very liable to be attacked The contagion is conveyed by the nasal and bronchial discharge and by fomites.

There is no essential morbid anatomy in uncomplicated cases, except the nasal and bronchial catarrh. Fatal cases show, as a rule, capillary bronchitis, catarrhal pneumonia, pulmonary collapse and acute nephritis. The lesions of intestinal catarrh are rarely found. Measles itself very rarely kills.

Symptoms.—The period of incubation is ten days, followed by a prodromal stage of three days.

The disease generally sets in with symptoms of a cold, with some fever. There is marked coryza, watery eyes, sneezing, photophobia, fretfulness and a dry, croupy cough. The temperature rises to 102 or 104 degrees F. The tongue is usually furred The early catarrhal symptoms are more marked than in any of the other infectious diseases. The tongue is heavily coated; a marked contrast to the strawberry tongue of scarlet fever.

The eruption appears about the fourth day, when the fever and general symptoms have reached their height. It first appears upon the face, rapidly spreading over the whole body. It is composed of small, dark red papules, at times arranged in small crescents. This lasts for two or three days, when it begins to fade and "branny" desquamation soon follows. Small bluish-white spots have been noted on the mucous membrane of the lips, cheeks and hard palate as early as the first day; they are considered diagnostic. The catarrhal symptoms gradually disappear and convalescence is rapid. If the fever continues high after the rash is out, there is apt to be some complication, as severe bronchitis, pneumonia or acute nephritis.

Malignant or hemorrhagic measles, "black measles," occur, particularly when the hygienic surroundings are bad. The disease sets in with much greater intensity and is characterized by a petechial rash, by hemorrhages from the mucous membrane and great constitutional depression. This is a very serious form and death generally occurs early.

Complications.—Bronchitis, broncho-pneumonia, lobar-pneumonia (rarely), catarrhal or membranous meningitis, ophthalmia, cancrum oris, otitis, intestinal catarrh and nephritis (rarely).

Diagnosis.—Incubation period of ten days, eruptions on the fourth day. Koplik’s spots, catarrhal symptoms, cough, and mottled eruption are valuable diagnostic points. In scarlet fever there is longer initial stage with characteristic symptoms, sore throat, fever is high and the pulse is out of proportion to the fever, and there is a diffuse punctiform rash. Upon reappearance of measley redness, after the removal of a finger over the rash, the redness appears form the middle towards the periphery, while scarlet fever redness reappears from the periphery to the center. Rothel is characterized by a short prodromal stage, slight fever and catarrh, marked sore throat; there is more uniform distribution of the rash which does not assume a crescentric arrangement.

Prognosis.—Uncomplicated measles rarely prove fatal, but the pulmonary complications that may arise make this one of the most serious diseases of children. Hygienic surroundings have a distinct bearing on prognosis.

Treatment.—Cases of measles should not be attended to carelessly, as is oftentimes done, but care should be taken that the patient is properly protected from atmospherical changes and is carefully nursed and dieted. Physicians many times are careless with cases of measles and severe complications or sequelae arise.

It is best to have the patient isolated and placed in a darkened, thoroughly ventilated room of equal temperature, about 65 degrees F. The case can be controlled easily and safely by competent osteopathic treatment. The treatment is largely symptomatic, although thorough specific work, according to the indications presented, will do much to lessen severity and prevent complications. Carefully protect the organs most likely to be affected. The eyes, ears, nose and throat should be carefully watched. In mild cases simply regulating the diet and bowels and cool sponging, in addition to the fever treatment, is all that is necessary.

In severe cases thorough treatment along the spinal column in keeping the muscles relaxed is a very great aid. Especially should the cervical and upper dorsal muscles be carefully relaxed so as to reduce the catarrhal involvements of the respiratory tract, besides preventing complications of the chest and regions of the head. In all cases special attention should be paid to the bowels and kidneys, and the skin should be bathed daily with warm water until desquamation occurs. For the bronchial cough thorough treatment of the anterior and posterior thoracic region is quite sufficient. The muscles should be relaxed well and subluxations of the upper ribs should be looked for, as they are oftentimes the cause of the cough. The clavicle may impinge on the pneumogastric and cause a cough and add to the catarrhal condition; also upper ribs contribute to this. For the irritated skin, warm baths are indicated, besides careful treatment at the atlas and axis for the upper part of the body, and at the fifth lumbar for the lower part of the body; and carbolized Vaseline is a useful adjunct. In cases where the eruption is suppressed, giving the patient a thorough sweat will generally bring out the eruption.

It has frequently been noted that measles, treated osteopathically, recover much more rapidly than when treated with drugs. After convalescence has been established, the patient is practically well and able to go out doors, whereas those cases which are treated with drugs require a longer time to regain their strength after convalescence.
 

RUBELLA

(German Measles)

Definition.—An acute, contagious disease, resembling both scarlet fever and measles, characterized by no prodromal stage, slight fever, coryza, slight sore throat, mild catarrhal symptoms (rarely), a punctiform rash, and is free from sequelae.

Etiology.—It generally occurs in epidemic form, but sporadic cases are not uncommon. It is much less contagious than either measles or scarlet fever. It especially affects children, rarely adults, and spreads with great rapidity.

Symptoms.—These are usually mild and it is a much less serious disease than measles. The incubation stage is from two to three weeks. The disease begins with drowsiness, slight fever, sore throat, chilliness and pains in different parts of the body. The rash appears the first or second day on the face, first, and rapidly extends over the entire body. It consists of red, oval, slightly raised spots. This lasts for a couple of days and terminates in a slight branny desquamation. The lymphatic glands of the neck are often swollen, especially the superficial cervical and posterior auricular glands. The disease rarely lasts more than from three to five days.

Prognosis.—The prognosis is good. Complications are rare. If the surroundings are unhygienic, or if the child is delicate, it is more serious. Pneumonia, severe bronchitis and gastro-intestinal catarrh may occur and prove fatal. Relapses are quite common.

Treatment.—Rest in bed is the principal treatment, although the case should be watched on account of possible complications. Attention to the lesions found, careful treatment of the cervical lymphatics, and general relaxation of the muscles and stimulation will be effective and usually sufficient. See that the bowels are kept open and the diet is restricted for a few days. It would be well to have the attendant sponge the surface of the skin once a day with water, and apply Vaseline locally for the itching. If the fever is high give the ordinary fever treatment.
 

CHICKEN-POX

(Varicella)

Definition.—An acute contagious disease, characterized by slight fever, mild constitutional symptoms and by an eruption which is papular, vesicular and pustular.

It occurs most frequently in epidemic form, although sporadic cases are met with. The disease is highly contagious; the specific organism, however, has not yet been discovered. It is a disease of childhood and is seldom seen in adults. The greater number of cases occur between the ages of two and six. Chicken-pox and smallpox are distinct and separate diseases; an attack of one does not protect from the other.

Symptoms.—The incubation is from ten to fifteen days. In many cases the eruption is the first symptom, in others there may be restlessness, slight fever and general indisposition. Still in other cases there is a slight chill, with feverishness or there may be vomiting, with muscular pains in the back and legs. The eruption appears within twenty-four hours in the form of small reddish puncta, appearing first upon the trunk. In a few hours they become pearly pustules, rarely umbilicated, and contain a clear or turbid fluid. By the end of the third day they begin to dry up, crusts then form which drop off and, as a rule, leave no scar. The eruption usually appears in crops, so that about the fourth day one can usually see pocks in all stages. There may be excessive irritation of the rash and if the pocks are scratched by the child, scars may be left after healing. As a general rule complications seldom arise.

Diagnosis.—This is, as a rule, easy. The eruption comes out slowly and in crops. There are slight constitutional disturbances and the abundance of the rash upon the trunk will distinguish varicella from smallpox.

Prognosis.—This is favorable.

Treatment.—The child should be isolated until the crusts fall off, for as long s the crusts are present the disease may be transmitted. Usually there is no special treatment, as the constitutional symptoms are so mild. Have the child go to bed for a few days; sponge daily with tepid water; use carbolized Vaseline locally to prevent itching, and observe hygienic measures. A light general treatment should be given, as it makes the child feel more comfortable, besides it prevents complications.
 

MUMPS

Definition.—An acute, contagious disease, characterized by inflammation of the parotid gland, sometimes of the submaxillary and sublingual glands. The testicles in males and the mammae and ovaries in females, are occasionally involved. Upper cervical lesions predispose to the disease.

The disease, no doubt, is of microbic origin, but the nature of the contagion is not definitely known. It occurs sporadically and epidemically. The disease is most frequently seen in children and adolescents and during the spring and fall. More boys are attacked than girls. Very young infants and adults are seldom afflicted. One attack usually gives immunity from a second.

There is an inflammatory infiltration of the parotid glands, but there is no suppuration. The salivary gland is swollen and hardened.

Symptoms.—The incubation period is from one to two weeks. The disease is ushered in by a moderate fever, 101 to 104 degrees F., chilliness, headache, anorexia and lassitude. There is pain just below and in front of the ear, but sometimes the first pain is experienced in swallowing. A hard and sensitive tumor is then noticed, which increases rapidly until within forty-eight hours the neck and side of the cheek are swollen. This swelling persists for nine or ten days, then gradually subsides and convalescence is rapid. Relapses rarely, if ever, occur. Ringing in the ears, earache and affected hearing commonly occur. In severe cases the nervous system may be affected, causing headache, fever, delirium, great prostration, or even a low typhoid state may be present.

The most frequent complication is orchitis, which usually occurs after the inflammation of the salivary glands has subsided. One or both testicles may be involved. The organs become heavy and painful, inflammation lasting for three or four hours and subsiding gradually. Atrophy has occurred, but this is extremely rare. Mastitis, ovaritis and vulvo-vaginitis sometimes occurs in the female.

Diagnosis.—This is usually easy, as the nature and position of the swelling are quite characteristic. The prognosis is favorable; uncomplicated cases never prove fatal.

Treatment.—Consists in keeping the patient warm and well protected. The patient should be confined to the bed if the case is severe. Hot or cold applications, (usually hot is preferable to the swollen glands), will be very comforting to the patient. The cervical region should be carefully treated. Relax all the contracted muscles found, particularly the deep muscles, and give attention to the correcting of any vertebrae that may be deranged. The atlas and axis are very apt to be found sub-dislocated. In a few cases the upper ribs will be found disordered, probably interfering with either the vaso-motor nerves, or the lymphatics to the region involved. A relaxing treatment around the swollen glands will usually give considerable relief, especially of the deep muscles at the angle of the inferior maxillary. Treat the fever by the usual method and keep the excretory organs active. Probably lesions to the atlas and axis are the predisposing causes of mumps. Secretory fibres of the submaxillary gland are from the second and third dorsals. Attacks have been shortened by osteopathic treatment.
 

WHOOPING COUGH

(Pertussis)

Definition.—An infectious disease, characterized by convulsive cough, accompanied by long drawn inspiration, during which the "whoop" is produced.

Osteopathic Etiology and Pathology.—The disease occurs in epidemic form, occasionally, however, sporadic cases are met with. It attacks children of all ages and is directly contagious from person to person. It sometimes attacks older persons, in which case it becomes a serious affection. Usually one attack protects from another. Epidemics last for a couple of months, usually during the spring and winter, and often precede or follow those of scarlet fever and measles. Delicate children and those suffering with nasal or bronchial catarrh, are more subject to the disease than others. Thus general health and unhygienic surroundings are predisposing causes. The contagion enters the system through the respiratory tract. No special micro-organism has yet been found as the exciting cause of whooping cough. An attack of whooping cough frequently follows, in the same individual, an epidemic of measles.

Lesions are found in the pneumogastric, phrenic, sympathetic or recurrent laryngeal nerves. From examination of patients suffering from whooping cough, one is lead to believe that the disease is of neurotic origin. Just how a nervous lesion produces the disease, it is impossible to state. Possibly a disturbance of the vaso-motor nerves to the respiratory tract causes enlargement of the tracheal and bronchial glands, which produce pressure upon terminal filaments of the pneumogastric nerve; this has been suggested by Eustace Smith. Dr. Still considers the diaphragm a factor in the spasm and treats it, as well as the phrenic nerve, to give relief. Von Leube says, "that under the influence of the infection, an increased irritability of the recurrent laryngeal nerves is brought about and that irritation of certain areas of the respiratory mucous membrane, especially of the interarytenoid region in its lower parts, causes, by mechanical and chemical irritants, the attacks of coughing to appear." Disturbances are found in the middle and lower cervical vertebrae and first, second and third ribs. The vagi, phrenic, sympathetic or recurrent laryngeal nerves may be involved in this region.

Symptoms.—The incubation period is from seven to ten days. At first the symptoms are slight, being those of an ordinary cold, slight cough, some fever and no expectoration. This catarrhal stage lasts about a week or ten days, and is followed by the paroxysmal stage, which begins when the cough becomes more frequent and severe, and the characteristic "whoop" is recognized. The features are swollen and dusky, the skin livid and the eyes are injected. The paroxysm begins with a succession of short expiratory coughs which increase in intensity; there is then a deep inspiration, the air is drawn into the lungs, producing the "whoop." Several coughing fits may succeed each other, until a quantity of stringy mucus is expectorated and vomiting is produced. Food is ejected and in most cases a little blood. An ulcer under the tongue often forms. Rupture of a conjunctival or nasal blood-vessel sometimes happens. The urine is of high specific gravity, pale yellow, and contains much uric acid. The duration of the paroxysmal stage, in cases of ordinary severity, is usually from four to six weeks, although this has frequently been greatly shortened by osteopathic treatment. The convalescence period usually lasts four weeks, so the entire duration of an ordinary attack is from ten to twelve weeks, unless treated in the early stage and aborted or shortened.

Complications.—These are frequently numerous in severe cases. Hemorrhages are apt to occur in the form of petechia, especially about the forehead; epistaxis, hemoptysis, ecchymosis of the conjunctiva, bronchial pneumonia, pleurisy, pericarditis, laryngitis, bronchitis, collapse of the lungs and interstitial emphysema may occur as complications. Sudden death has been caused by subdural hemorrhage.

Sequelae.—Acute nephritis frequently occurs. All the viscera may undergo fatty degeneration which may eventually become a secondary tuberculosis. Permanent changes in the shape of the chest frequently occur, and there may be various nervous disturbances.

Diagnosis.—This is easily made as soon s the distinctive "whoop" is heard, and a positive diagnosis cannot be made without it. Measles may be a cause of confusion.

Prognosis.—When the many complications that may arise are taken into consideration, whooping cough must be regarded as a very fatal affection; nevertheless, many cases recover. The younger the child the greater the danger. The deaths occur chiefly among the children of the poor and in delicate infants.

Treatment.—In the beginning of the disease one may be able to cut the disease short; but after it has fully established itself the disease is apt to run its course, although the severity of the attack and liability of complications can be greatly lessened. The cervical and upper dorsal regions should be carefully examined, also the upper ribs. The disease is predisposed, most probably, by deranged vaso-motor innervation to the mucosa of the respiratory tract. Special attention should be paid the vagi and phrenic nerves Lesions to the recurrent laryngeal nerves are apt to occur from subluxation of the first or second ribs. Lesions to the vagi are usually due to a disordered atlas or axis. Irritations of branches of the vagi will produce the spasm of the glottis, and also a relaxation of the diaphragm. Lesions to the phrenic are usually found at the third, fourth, and fifth cervicals.

When the cyanotic symptoms arise, owing to the impeded respiration and interference with the heart actions, stimulate the heart’s action and relieve the obstructed respiration by raising the upper ribs, especially those over the heart.

On the whole, treatment of the entire respiratory tract is demanded and thorough correction of the vertebrae and ribs and relaxation of the muscles should be given. As in a number of diseases, only an outlined region can be given wherein one will find the lesion. Attention should be paid the diet for a few days; and the child should be warmly clad. Fresh air is a necessity. Local antiseptic sprays may be found beneficial. Do not neglect a case of whooping cough, as serious complications and sequelae are liable to occur.
 

INFLUENZA

(La grippe)

Definition.—An acute, contagious disease caused by the bacillus of Pfeiffer; characterized by great prostration, catarrh of the respiratory and digestive tracts and by muscular pains, and followed by a fever. Serious complications are liable to occur, especially pneumonia. It generally occurs in an epidemic form. Mortality is not high, but danger lies in carelessness during and after an attack.

Lowered vitality from osteopathic lesions, poor food and unsanitary surroundings predispose. Old people are likely to be attacked. The disease is highly contagious. That it is of microbic origin, the bacillus of Pfeiffer, can no longer be doubted. The origin of the bacillus has not yet been settled. The disease is probably communicated by contagion, spreading rapidly along lines of travel. The contagion most probably enters the system by way of the respiratory tract. Frequently pneumococci and streptococci are found with the bacilli, and their toxins are apt to lead to secondary infections.

No special anatomical lesions have been found, as uncomplicated cases recover. The lesions, therefore, are those of the complications. The complications are greatly varied. Pneumonia (lobar and lobular), pleurisy, endocarditis, severe bronchitis and nephritis may exist. They may either be the result of the action of the toxin or the bacillus may be carried in the blood, located in a weakened portion of the body and thus cause the secondary infection.

Symptoms.—The incubation period is from two to four days, sometimes longer. The onset is usually sudden with a chill or continued chilliness. Sometimes there is a severe rigor; the temperature rises suddenly to 102 or 104 degrees F. Headache; pain in the back and ribs; great prostration, and cardiac weakness, out of all proportion to the intensity of the fever, occur. Mental depression, restlessness, insomnia, and frequently delirium are among the nervous symptoms. In many cases there are coryza, sneezing and watering of the eyes as the first symptoms. Cough and copious expectoration soon follow these symptoms. Gastrointestinal symptoms may be marked. Nausea and severe vomiting may usher in the attack, adding greatly to the general weakness. The pulse is feeble, small and frequently intermittent. Dyspnea may be a marked symptom. Widely different symptoms are presented by different cases; the same is true of the different epidemics.

Sequelae.—The sequelae are chronic gastrointestinal catarrh, phthisis, chronic bronchitis and rarely abscess or gangrene of the lungs. Persistent headache, neuralgia, neuritis, insomnia, melancholia, mania, meningitis and locomotor ataxia are some of the nervous sequelae.

Diagnosis.—In epidemic form the disease is easily diagnosed. Isolated cases are often mistaken for a "bad cold." Fever of short duration, marked prostration and the muscular pain are the diagnostic symptoms. The duration is usually from four to seven days. Convalescence is protracted. One attack predisposes to a second and relapses are frequent.

Prognosis.—This is favorable if the patient goes to bed or at least keeps to the house. Fatal cases are due to complications as a general rule; especially pneumonia.

Treatment.—The osteopathic treatment in all cases is simple, but effective. Rest in bed; attention to the regions involved by appropriate treatment; careful hygienic management, including drinking hot water and a light diet, will meet the requirements. Pay special attention to the bowels and kidneys. The osteopathic treatment required varies with the nature of the attack and consequently a definite method of treatment cannot be given. The case is to be treated by the same method as when the various affected organs are involved in like manner under other circumstances. And whether the attack assumes the respiratory, gastrointestinal, or nervous type, definite predisposing osteopathic lesions will be found. The fever is treated in the usual way. The pain, aching and tired feeling of the patient are best relieved by careful treatment of the entire spine and by relaxation of contracted muscles. Dr. Still considers that the condition of extreme contraction of the spinal musculature which characterizes influenza results in interruption of the nervous and vascular systems. Great relief is experienced by the patient when the muscles of the legs are stretched and the internal and external rotary movements are executed. The patient should be kept in bed until the fever subsides. The general nervous system, the heart and the functional activity of respiration should be carefully watched. During the entire course of the disease the bowels should be kept open. This is best performed by treatment to the splanchnic nerves, and to the liver, bile ducts and intestines directly. If constipated at the onset, give a hot water enema.

The patient is to be protected from changes in the weather, particularly those who are at either extreme of life and who are weakened by chronic organic disease. The various complications are to be treated as when they are simple diseases. Cooling drinks should be used. Such food as milk, vegetables, gruels, eggs, etc., are to be given, but do not force the appetite.

Insist upon disinfection of the catarrhal discharges, chiefly the bronchial, which usually contain the bacilli of Pfeiffer. Isolate the patient when convenient and obtain pleasant surroundings, if possible.
 

DENGUE

(Break-Bone 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. No morbid anatomical observations have been made, as the disease rarely proves fatal.

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. 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 isolated 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 sub-occipital, upper dorsal, lower dorsal and lower lumbar regions, respectively, so as to control the large vascular areas by means of the vaso-motor nerves of the cranial region, of the lungs, of the splanchnic region, and of the lower limbs, thus equalizing the entire vascular system. 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. Chapmen, 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. A suitable change of air may hasten convalescence.
 

CEREBRO-SPINAL MENINGITIS

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

Osteopathic Etiology and Pathology.—The specific cause of the cerebro-spinal meningitis is believed to be a micro-organism, the diplococcus meningitis. Lesions are found in the vertebrae 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. The disease is not directly contagious. More commonly it attacks the young, although it may occur at any age. Overexertion, prolonged marching in the heat, overcrowded and illy-ventilated buildings, barracks, 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 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., and the pulse is full and strong. Hyperesthesia is a prominent symptom. The muscles of the neck and back become rigid, and there are pains in the limbs. Orthotonos occurs more frequently than ophisthotonos. 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 leucocytosis; 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.

The cutaneous symptoms are important. 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 exacerbations in the fever every day or second day. The strict periodicity seen in malaria is not observed; the fever resembles that of pyemia.

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

Sequelae.—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.

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 cerebro-spinal meningitis may be associated with pneumonia. There will be motor spasms and tremors, but the head is rarely retracted, and there is less myalgic pain than in cerebro-spinal meningitis.

Prognosis.—This varies according to the severity of the type. It is a grave disease; the old and young almost invariably perish. 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 cerebro-spinal meningitis requires most thorough 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 vertebrae, 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 cerebro-spinal fever and should be vigorously and continuously 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. The diet should be a nutritious one of milk and broths. 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 degrees 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.
 

DIPHTHERIA

(Membranous Croup)

Definition.—An acute, contagious 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.

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 sub-dislocations of upper cervical vertebrae, 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 (E. C. Link, Diphtheria—The Bulletin, 1905) 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 vaso-motor 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 believes that, among other lesions, contracting of tissues involving the scalene 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 penetrate the mucosa, but remains very near the site of the local changes. 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 perfectly 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 lacuna tonsillitis. Of the bacteria associated with the bacillus of diphtheria, the streptococcus pyogenes is the most common and probably the most active, as cases of general infection with this organism have been found in diphtheria. The staphylococcus albus aurens, 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. 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 very 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 procedes 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.

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

In Pharyngeal Diphtheria 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 child 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 glands in the neck are swollen and tender. 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 and usually grave constitutional symptoms for a few days. 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 return with greater severity. 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 finds same conditions as in diphtheria, but also that the hyoid is involved with the superior laryngeal nerve. The sacral and lumbar nerves are also involved.

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 an entire absence of any constitutional disturbance. The Klebs-Loeffler bacillus is sometimes present in these membranes. Nasal diphtheria is apt to be a very grave type of the disease. The constitutional symptoms are grave—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 flourishes 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.

Complications and Sequelae.—The complications and sequelae are hemorrhages from the nose and throat, skin rashes—especially diffused erythema urticaria and sometimes purpura; also capillary bronchitis, pulmonary collapse, catarrhal pneumonia, and gangrene of the lungs. Albuminaria, myocarditis, endocarditis, arthritis, otitis media, and paralysis have occurred.

Diagnosis.—The presence of the Klebs-Loeffler bacillus will at once decide the diagnosis of true 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, sudden heart failure, broncho-pneumonia 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 facts that C. E. Still and several other 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 Osler 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 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 vertebrae corrected if displaced. The vaso-motor 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 vaso-motor 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. Inhalation 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 (A. M. Willard, Membranous Croup—Journal of Osteopathy, March, 1904) 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 has been successfully treated osteopathically.) 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 sequelae 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 vaso-motor of the head and neck; third, by spinal treatment affecting the vaso-motor 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."
 
 
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 vaso-motor 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 affect quicker and more satisfactory results.

Medical writers class dysentery, etiologically, under the bacillary and amoebic varieties. Bacillary dysentery is subdivided into catarrhal and diphtheritic. Probably the bacillus dysenteria is the exciting cause of both.
 

ACUTE CATARRHAL DYSENTERY

This is the variety most frequently found in temperate climates. It occurs either sporadically or endemically. There is a catarrhal inflammation of part or the whole of the large bowel.

Osteopathic etiology and Pathology.—Sudden atmospheric changes and simple irritants, such as unripe and indigestible food, are usually the immediate causes. The primary 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, although the displaced vertebra may be posterior or anterior. 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 vaso-motor 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 occasionally 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 slight 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 epitheloid cells containing fat drops and vacuoles. No specific organisms are found and bacteria are scarce. 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 when the disease is treated properly. The condition may become chronic.

Treatment.—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 vertebrae; 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 usually this gives only temporary relief. When a slight movement has been accomplished between disordered vertebrae, treatment should be stopped and results watched, because the movement 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 luxated and subluxated vertebrae have conformed themselves to some extent to their unnatural position. In other words, what has been lost in the form and size of a vertebra may have been gained 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 cured.

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 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.
 

DIPHTHERITIC DYSENTERY

This is by far the most serious of all forms of dysentery.

Etiology.—As a primary disease, coming on acutely, it is due to the bacillus dysenteriae. In diphtheritic dysentery there is a true diphtheritic exudation. It usually occurs in armies, ships, etc This is frequently fatal.

As a secondary disease, it occurs as a terminal event in many acute and chronic diseases. It is sometimes found in chronic Bright’s disease and it is not infrequent in chronic heart disease, cachetic states and in acute diseases with pneumonia. This variety prevails in epidemic form, often attacking camps, hospitals and crowded cities.

Pathology.—In milder forms the tops of the folds of the colon are capped with a thin yellowish membrane. In severer forms the mucous membrane is intensely swollen. The colon is greatly enlarged and covered with a false membrane resulting from coagulation-necrosis. This membrane is thick and adherent and whenever it becomes separated there is ulceration and soughing.

Symptoms.—Chill and high fever with prostration. Severe pains in the abdomen and tenesmus. Frequent bloody stools containing the false membrane. In a secondary form these are less severe than in the primary. They are the ordinary symptoms of the catarrhal form, intensified with the following typhoid symptoms: muttering delirium, stupor, brown furred tongue, bloody stools containing false membrane and sloughs.

Complications and Sequelae.—Abscess of the liver is by far the most serious complication and is most frequently caused by foci of suppuration forming in and extending along the vessels of the portal system and passing as an embolus into the liver. A local peritonitis may arise by extension of the inflammation and perforation. This is not a very rare complication and may be followed by peritonitis which is usually fatal. Paralysis in the form of paraplegia is not an uncommon sequela. In severe, long continued cases pleurisy, pericarditis, endocarditis and occasionally pyemic manifestations and chronic Bright’s disease may be sequelae.

Diagnosis.—The diagnostic symptoms are the same as in the other forms of dysentery, but manifested to a greater degree. The finding of the false membrane and the occurrence of the disease in epidemic form are important.

Prognosis.—This is the most unfavorable of all forms of dysentery, most cases proving fatal.

Treatment.—Isolate the patient and disinfect evacuations. Pay attention to the drinking water and all hygienic measures. Correction of the lumbar lesions is indicated, and strong stimulation of the splanchnic nerves with inhibition of the vagi to lessen peristalsis, especially when the necrotic membrane is being removed, so that the ulcerated surface will heal more quickly.

Peptonized milk, beef peptonoids and beef juice are the best foods. Foods that are non-irritating, but nourishing and leave as little residue as possible, are the ones required.
 

AMOEBIC OR TROPICAL DYSENTERY

This form prevails in the tropical and subtropical countries for the most part, and is caused by an animal parasite, the amoeba coli or 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. Amoebae are sometimes found in the stools of healthy men, having probably entered the system through the drinking water.

Pathologically, the mucous membrane is swollen. This is due to the edema and cellular infiltration of the submucous coat. Round, oval or irregular, undermined ulcers are found. The lower part of the ileum may be invaded with these ulcers, but rarely. The ulcers may be so deep that their floor is formed of the muscular or even the serous coat. The disease progresses through infiltration of the connective tissue layer of the bowels. This causes superficial necrosis and the formation of the irregular, undermined ulcers. 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 amoebae coli. The straining is less severe and persistent than in catarrhal dysentery and may be absent. Sometimes there is nausea and vomiting.

Complications.—Abscess of the liver is the most common, which may be single or multiple. When single it generally involves the right lobe. Multiple abscesses are small and generally superficial. The abscess walls are ragged and necrotic, the older abscesses have whitish, smooth, fibrous walls. These abscesses do not contain pure pus, but matter consisting of a fatty and granular debris containing the amoebae and a few cellular elements. Sometimes they extend into the lung. In addition to the abscesses there are found in the liver local necroses of the parenchyma scattered throughout the organ and due to the action of the amoebae.

Diagnosis.—Microscopic examination of the stools. Cases last from six to twelve weeks. The termination is most variable in the uncomplicated cases.

Prognosis.—Is generally unfavorable on account of the exhausted 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 the acute catarrhal form. 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 amoeba 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 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 of the occipital nerves. The stools should be taken care of immediately and disinfected.
 

CHRONIC DYSENTERY

This is generally resultant from an acute attack, though the amoebic form may be sub-acute 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 caliber 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 vaso-motor nerves and lymphatics of the affected area These lead to congestion and predispose to infection. It occurs in epidemic form, especially in the spring of the year. 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 a simple 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 numerous and are of a septic character. Septic endocarditis, pericarditis, and pleuritis may occur Infarcts have occurred in the spleen, kidneys and lungs.

Symptoms.—The incubation period varies from seven to fourteen days. The stage of invasion is often marked by a chill, followed by fever, which rapidly rises to 104 or 105 degrees F. If there is a local abrasion the spot becomes reddened; but if it is idiopathic, it begins as a small, red, burning spot, usually on the face or over the bridge of the nose. It spreads rapidly, the patch being elevated above the surrounding tissue. The swelling may be so great as to close the eyes and distort the features. The cervical lymph 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, bowels constipated, and there are headache and restlessness. 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.

Complications.—The complications are meningitis, edema of the glottis, pneumonia, nephritis, ulcerative endocarditis and septicemia. Albuminuria is almost always constant.

Diagnosis—This is not difficult. The fever, the acuteness of the disease, the rapidly 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.—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 vaso-motor nerves to the face, thus predisposing to an attack of erysipelas by allowing the microorganism congenial tissue for its devastations. In other cases derangements have been found higher than the upper dorsal, principally through the middle and upper cervical vertebrae. Lesions in these regions would also interfere with vaso-motor fibres, especially through the fifth nerve directly.

The treatment on the whole is 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. The patient should be isolated s there is danger of the disease spreading. In cases where there is much restlessness and insomnia, treat the upper cervical region, especially the deep posterior muscles. (See Dr. Still—Philosophy and Mechanical Principles of Osteopathy)
 
 
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; is probably due to the action of a specific parasite as yet unknown.

Osteopathic Etiology and Pathology.—While a specific germ must be the cause of yellow fever, if the theory of its spread by the mosquito is valid, it has not as yet been isolated. Extended tests by United States Army surgeons in Cuba seem to show conclusively that the infection is alone carried by the stegomyia fasciatus, 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 (Journal of Osteopathy, October 1905) 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 (Journal of Osteopathy, October 1905) 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 gastrointestinal 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 onset is sudden, usually without preliminary symptoms. The attack generally begins with a chill, followed at once by headache and pains in the loins and legs. The fever rises rapidly to 102 or 105 degrees F. 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 it 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 vaso-motor 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 vaso-motor 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 the 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 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. Dark skinned races are more subject to the disease than the Caucasian race. Exposure to damp cold is one of the recognized causes, also those localities where there are rapid changes from cold. Such regions 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. Spores are probably carried by the air. This would be a reason why tetanus occasionally prevails in epidemics.

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 condition of the wound is not constant. The bacilli develop at the site of the wound where the toxin is manufactured. The bacilli do not invade the blood and organs. The tox-albumin is one of the most virulent poisons known.

Congestion occurs in various organs, due to obstruction of movement of the blood during a spasm. The brain, cord, lungs and muscles are congested. The nerves are often found injured and swollen. Peri-vascular exudations and granular changes occasionally occur in the nerve cells.

Symptoms.—The period of incubation is from ten to fifteen days. In some cases the incubation may be shorter or longer than ten to fifteen 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 entire trunk and legs are inflexible; orthotonus has occurred.

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 eye-brows raised—"risus sardonicus." The nect and trunk muscles affected produce opisthonotonos. 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. 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. Strichnine 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. The prognosis in children is more favorable than in the adult. Cases that are fatal usually die within six days. In cases where there is slight elevation of temperature, and in cases 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 and cauterization of the wound are necessary. The patient should be put in a dark room and there remain as quietly as possible. All sources of peripheral irritation should be avoided. 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. A few cases have been treated osteopathically with fair success, following antiseptic measures.
 

SIMPLE CONTINUED FEVER

(Febricula)

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. A true ephemeral fever lasts about twenty-four hours. If it persists from three to six or more days without local affection, it is termed simple continued fever or febricula.

Osteopathic Etiology.—The most frequent cause of this form of fever is probably gastro-intestinal disturbance. In children it may consist of a gastro-intestinal catarrh or it may take the form of indigestion, due to exposure to cold or to the eating of decomposing substances; or, in cases of longer duration it may be due to the absorption of toxic substances. It may be caused by exposure to the sun or great heat or cold, or mental or physical fatigue. It may be the result of exposure to cold sufficient to produce a slight bronchitis, tonsillitis or other affections producing an unnoticed localized inflammation. It may follow a prolonged exposure to noxious odors or sewer gas. Lesions, osseous or muscular, are always present, corresponding to the tissues and organs disturbed Muscular lesions, especially, are prominent.

Symptoms.—The disease usually sets in abruptly with a feeling of lassitude, weariness, chilliness, headache, loss of appetite and furred tongue. 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. Herpes on the lips are common. Mild delirium may occur. Anorexia is present, and the bowels are constipated. The disease lasts from a few days to two weeks and may end by crisis or lysis. 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 sequelae 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 rendering the patient much more comfortable. In cases where nervous symptoms are prominent, care should be taken against any excitation that may occur, 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 it 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, soups and broths 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. The bacillus produces specific lesions either of the form of nodular bodies called tubercles or diffused infiltration of tuberculous tissue. The tubercles undergo caseation and sclerosis and may be followed by ulceration or in some instances calcification.

Ostopathic 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 liable to have 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 per cent 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 tubercle 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 influents, 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 of 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 tissues nutritively. 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 - Journal of the American Osteopathic Association, March, 1906)
 
Bronchial catarrh, diseases of the stomach and intestines, especially entero-colitis, tubercular pneumonia, pleurisy (rarely), intra-thoracic 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 tuberculois 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 vaso-motor nerves of the upper thoracic ganglia. The condition of the middle and lower cervical vertebrae 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.

Pathology.—In adults the favorite seat of tubercle 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 identical structures are produced by other parasites, such as aspergillus glaucus and actinomyeces.

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 epitheliod cells and in some instances the giant cells, in both of which bacilli may be found. The epitheliod cells vary in shape and may be rounded, polygonal or cuboidal. The giant cells are formed by enlargements of the epitheliod cells and a repeated division of their nuclei or possibly by fusion of several cells. In lupus, joint tuberculosis, and scrofulous glands, in which the bacilli are relatively few, the giant cells are numerous; while in the military tubercles, in which the bacilli are numerous, the giant cells are scanty. On account of the inflammation produced by the bacillus, there is migration of leucocytes from the adjacent vessels and lymphoid cells. The leucocytes are chiefly polynuclear and are rapidly destroyed, but later mononuclear leucocytes appear, which are able to resist the action of the bacilli and they do not undergo the rapid destruction of the other variety. A reticulum of connective tissue is formed around the various cells by the infiltration of the protoplasm of the cells and the rarefaction of the connective tissue matrix. The tubercles are nonvascular 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 bascilli. The primarily transparent tubercular tissue is gradually converted into a yellowish gray body. Bacilli are still present. Most frequently the caseation is followed by softening; less frequently calcification or it may become encapsulated.

During the time the cell destruction is going on at the center of the tubercle, hyaline transformation is going on with conversion of the cellular elements into fibrous tissue, thus converting the tubercle into a hard, firm structure. In all tubercles one of these two processes occurs: caseation and the destruction of forces, which are dangerous to the patient, or sclerosis, which is a healing process. The ultimate result, in any case, depends 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 wide spread tuberculous involvement. This is the result of fusion of the new foci of infection or of military tubercles. An entire lobe, or even the greater part of the lung, may be involved and undergo caseation; usually, however, caseation takes place in the small groups of lobules. The bacilli may cause a diffused infiltration and caseation without any special foci, producing tuberculous pneumonia.

The irritation of the bacilli is capable of producing associated inflammatory processes in its own neighborhood. There may be an overgrowth of interstitial tissue produced. 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 membranes 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 vertebrae 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.

Local Tuberculous Adenitis—Cervical.—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 badly ventilated lodgings and among the very poor classes. The submaxillary glands are usually the first involved and are affected on one side more than on the other, as a rule, although both sides are commonly involved. At first they are swollen to various degrees and are tender; later they suppurate and rupture if one is not able to cure them. 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 become the exciting cause of tuberculous pleurisy or of pulmonary tuberculosis.

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 runs a very slow course, lasting often for a number of years.

Bronchial.—These glands may be affected primarily or 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.

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

Mesenteric (Tabes Mesenterico).—These cases occur among children and may be primary or secondary. The primary form is rare. The trunk and limbs are puny, wasted, and anemic, while the abdomen is enlarged and tympanitic. Diarrhea is marked and constant, with thin, offensive stools. Fever is almost constantly present and is of an intermittent type. The disease is most frequently met with among poor children in unhygienic, illy-ventilated houses. There may be tuberculosis of the peritoneum; in such instances the abdomen is hard, large and tender, and uneven nodules may be felt.
 

ACUTE TUBERCULOSIS

This shows best the truly infectious nature of tuberculosis. In it military 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.

Three chief clinical forms are recognized; acute general infection, without special localization; marked pulmonary symptoms; marked cerebral or cerebro-spingal symptoms.

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 degrees F. It is irregular and marked by evening exacerbations and morning remissions. Occasionally there is an inverse type of temperature in which the temperature rises in the morning and falls in the evening, and is held by some to be characteristic. The countenance is dusky. In some cases the pulmonary symptoms are marked, while in others the meningeal symptoms are more prominent. Tuberacle 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 are 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 choroids. 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 muco-purulent and occasionally rusty. There is broncho-vascular breathing with sibilant and subcrepitant rales. The temperature is high, ranging from 103 to 105 degrees F., or higher. The pulse is rapid and feeble.

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

Diagnosis.—There may be history of tuberculosis in the family or of a previous cough. Occasionally tubercle bacilli are found in the sputum. The general symptoms, together with the dyspnea and cyanosis, will generally decide the diagnosis. The blood should be examined.

Cerebral or Meningeal Form (Tuberculous Meningitis).—This form, which is sometimes called acute hydrocephalus, occurs quite frequently and is an acute tuberculosis of the membranes of the brain, sometimes of the cord.

It occurs most frequently between the ages of two and seven years, although it may occur at any age. A focus of an old tuberculous disease, especially in the bronchial glands, or a history of a fall, will often be found as the cause. Rarely does the disease involve the meninges primarily.

The meningnes at the base of the cerebrum (basilar meninigitis) are most involved. There is more or less inflammation, with fibrous purulent exudation, especially in the Sylvian fissures. The tubercles vary in size and number; in some cases they are very apparent, while in others they are very difficult to find. The lateral ventricles are dilated and filled with a turbid fluid. The convolutions are frequently flattened and the sulci obliterated on account of the undue intraventricular pressure. The meninges are not alone involved, but the cortex is more or less edematous; while tuberculous infiltration of the cranial nerves occurs.

Symptoms.—Prodromal symptoms are usually present, lasting one or more weeks. Headache, vomiting and chills, followed by a fever, are the initial symptoms. The child gets thin, pale, restless and peevish; the appetite is lost; the bowels are constipated and the urine diminished in quantity. The onset is usually gradual, but when the onset is sudden, the disease is generally ushered in with a convulsion. The fever rarely rises above 102 or 103 degrees F. At first, the pulse is slightly accelerated, but soon becomes slow and irregular. The pain is often agonizing and intense, causing the child to give a short, sudden cry—the hydrocephalic cry. During sleep the child is restless and there are slight muscular twitchings. The pupils are contracted and the skin is dry and harsh.

The irritative symptoms now abate. There are no vomiting and headache and the child becomes quiet and is dull and apathetic. Constipation still persists. The abdomen is boat-shaped and the head is often retracted; the child cries out only occasionally. The pupils are dilated. Convulsions may occur. The temperature ranges from 100 to 103 degrees F. The respiration is irregular and sighing. A patchy erythema may appear on the skin.

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; the eyelids partly closed and the eyeballs are rolled up. The child may drop into a typhoid state with diarrhea, great prostration, dry tongue and low delirium. The pulse is frequent, irregular and small. The temperature rises to 103 to105 degrees F. The duration is from two to five weeks; chronic cases may last for a number of months. A more rapid form, occurring most frequently in adults, sets in with great violence and runs its course in a few days. It is a very rare, but exceedingly fatal form.

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.

Two forms may be recognized, the pneumonic and broncho-pneumonic.

The Pneumonic form is more rare than the broncho-pneumonic form and may be very rapid in its course. The attack sets in abruptly with a chill and the temperature rises rapidly. There are pain in the side; cough; dyspnea, and mucous and rusty sputum, which may contain tubercle bacilli. There are 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. This attack may come on a person in good health after exposure to cold; but there may have been debilitating circumstances or a predisposition to phthisis. Death may occur in the second or third week or the case may drag on from three to four months.

Only one lobe is usually involved, though occasionally the entire lung is affected. 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 in the consolidated tissue. Older caseous areas of a yellowish white color may be visible. Miliary tubercles are found upon careful examination.

The broncho-pneumonic 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 rapidly, the cough is severe, and there may be consolidation with submucous and subcrepitant rales. The child has sweats. The fever may become hectic. 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.

In adults the attack may occur in persons in good health or those run down with over work. In a few cases the attack is ushered in with hemorrhage. There is high fever, rapid pulse, increased respiration and rapid wasting. Elastic tissue and tubercle bacilli are found in the sputum. Death may occur in three weeks. Other cases begin to improve in six or eight weeks, but again decline, the case dragging on and becoming chronic.

The air vesicles and bronchioles are filled with a cheesy substance. The solidified areas have a grayish red appearance at first, but later they are of an opaque white. These areas are usually separated by areas of crepitant air tissue, but by fusion of contiguous smaller areas large sections are involved—sometimes the whole lobe. In other instances the masses are small and widely separated. These tissues tend to break down with the formation of irregular cavities.

Diagnosis.—In the pneumonic form it is 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 trouble. Pneumonia will present the typical symptoms, but if fever continues, tuberculosis will be suspected. Examination of the sputum will probably decide.

In the broncho-pneumonic form it is very difficult, in the early stages, to distinguish it from simple bronchitis and broncho-pneumonia. In this form the sputum will show elastic tissue and tubercle bacilli early in the disease and should be examined carefully if the disease lasts more than three weeks.
 

CHRONIC PULMONARY TUBERCULOSIS

(Chronic Ulcerative Phthisis)

This form is much more common than the acute form. The lesions ulcerate and soften. To the primary tuberculous infection is sometimes added septic infection, producing a mixed disease.

The primary lesion is not actually in the very apex, but a little below it and near to the posterior and external borders. From here the disease spreads downward and farther backward and for this reason examination in the supraspinous fossa will give the first manifestation of disease. In a large proportion the starting point of the process is in the smaller bronchi and the bronchioles and their alveolar territories become obstructed with inflammation products. These areas soon undergo caseation; ulceration occurs in the bronchial walls; the caseous matter softens and breaks down, resulting in the formation of a cavity. The more rapidly the caseous masses are formed, the more apt are they to soften. In other instances, fibroid transformation or calcification, with encapsulation of the cheesy matter takes place, and recovery may occur. In many instances these processes are not complete; the apparently healed lesions undergo ulceration.

Large cavities have a well defined limiting membrane. The content is usually purulent; rarely it is gangrenous. The surface of the smooth walled cavities constantly produce pus. New cavities have walls made up of softened, necrotic, caseous masses; they develop near a healed focus or near a large old cavity with limiting walls, and if situated just beneath the pleura they may rupture and cause pneumothorax. Quiescent cavities are generally small, though they vary in size. The lining membranes of these old cavities may be smooth, resembling mucous membrane. Medium sized and large cavities do not heal completely. The cavities are most frequently single, but they may be multiple and series of these small cavities may be surrounded by fibrous tissue.

In the neighborhood of tuberculous degeneration there is frequently interstitial pneumonia. There is either a simple pneumonia or that due to the tubercle bacilli. K This takes place in the alveoli.

The area is hyperemic, hard and consolidated. In some instances the contents of the alveoli undergoes fatty degeneration. Pleurisy is constantly associated with a chronic form of phthisis. Sero-fibrinous, purulent or hemorrhagic pleural effusions are met with. The pleurisy may be simple, but in a great many cases it is tuberculous. Miliary tubercles and cheesy masses may be found in the thickened membrane.

The bronchial glands are swollen, edematous and contain tubercles. They may become caseous and sometimes calcareous. Not infrequently they undergo purulent disintegration. Tuberculosis of the larynx is common. Ulceration, especially of the vocal cords, and destruction of the epiglottis may occur. Amyloid changes of certain organs, especially the liver, kidneys, spleen, and mucous membrane of the intestines, are frequent. Enlargement of the liver, caused by fatty infiltration, may occur. Tuberculous lesions are found in the intestines, spleen, kidneys, and brain in nearly equal proportions; then come the liver and pericardium. Other groups of lymphatic glands, besides the bronchial, may be affected.

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 scapulae, 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 muco-purulent 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 instances the sputum is more or less fetid. The expectoration is composed of pus cells, blood, elastic tissues, 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 of the general symptoms. It is probably always present at the beginning and the afternoon increase of temperature is common. Where there are 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 gastrointestinal tract, genito-urinary, cutaneous, and nervous systems, are frequent, especially in long standing cases. The gastrointestinal 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, the intercostals spaces are wide, the costal cartilages are prominent, and the sternum is depressed. Sometimes the lower sternum forms a deep concavity (funnel breast). The scapulae may be distinctly winged. Another type of thorax is long and narrow, the ribs are more vertical in direction, the intercostal spaces are wide, and the costal angles are very narrow. 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, while the spaces above or below it are often more marked.

Palpation shows there is difficult expansion and increased vocal fremitus. Normally, the fremitus is stronger at the right than at the left apex. If the pleura is thickened, the vocal fremitus is diminished, and if there is pleural effusion, it is absent.

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. In the early stages the percussion note is of a slightly higher pitch. 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 (bromchial). 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 cases 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, trachea and bronchi 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.

Prognosis.—The prognosis of pulmonary tuberculosis varies greatly in different cases. Undoubtedly a number of cases have been cured; 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 modern 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 and chronic tuberculous pleurisy.

The chest is sunken and the shoulder on the affected side is lowered. The heart is frequently dislocated, and if the left lung is involved, distinct cardiac pulsation is sometimes seen in the second, third and fourth interspaces. There is marked dullness over the affected side. There is distinct bronchial breathing at the base, while at the apex there may be cavernous sounds. There may be hypertrophy of the right ventricle; sometimes of the entire heart. 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. As a result of prolonged suppuration, amyloid changes in the liver, spleen, kidneys and intestines may take place. Dropsy often occurs from failure of the right heart.
 

TUBERCULOSIS OF OTHER TISSUES

The alimentary tract is frequently the seat of tuberculous 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 pericardium 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, pelvis of the kidney are attacked, and from these the kidney, or possibly the kidney involvement is part of a general tuberculosis. 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 military tuberculosis the liver is commonly affected, and it may be 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 is also at times invaded by tuberculosis. This has been described under meningeal tuberculosis. The spinal cord is rarely affected.

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 be treated successfully, 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 environment of the patient should be as favorable as possible to hygienic living. Many times a change of residence is of great benefit to the patient. When possible the patient should be out of doors and light exercises taken. The body should be well protected by flannels, the year around.

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. Keene (Journal of the American Osteopathic Association, Dec., 1904) would carry this point of 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.

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 obstructive 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 effecting 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 re-establishing 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 key-note 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.

In cases of pulmonary tuberculosis there is usually a dislocation of the second, third, or fourth ribs over the diseased lung. In the majority of cases these dislocated ribs are the real cause of pulmonary tuberculosis. Such a lesion would produce a weakened circulation in the lung, (chiefly underneath the deranged ribs) and thus favor a deterioration of the tissue. No matter what part of the lungs is involved, a rib lesion or a corresponding vertebral lesion will be found. Another place that is oftentimes involved in pulmonary tuberculosis is in the locality of the second and third dorsals. Lesions of the ribs and vertebrae would interfere, not only with the intercostal nerves, but with the dorsal sympathetic ganglia and thus have a direct influence upon the vaso-motor nerves to the lung. Again, lesions are apt to occur in the middle and inferior cervical vertebrae, which would involve the lymphatics to the lungs and produce more or less clogging of the tissues with the debris. These vertebral lesions are usually lateral.

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 in 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 albumin 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 (Journal of the American Osteopathic Association, May, 1905) 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 90 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 (Journal of the American Osteopathic Association, May, 1905) believes that the appetite should control the diet and forced feeding be not insisted upon. Fasting, to test the sense of food desire, has points well worth looking into, as gastric disturbances with a loss of strength follow over feeding. 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 vertebrae. 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 vertebrae 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.

In the April number of the Journal of Osteopathy 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.
 
 
CONSTITUTIONAL DISEASES

(RHEUMATIC FEVER)

(Inflammatory Rheumatism)

Definition.—An acute, febrile, non-contagious disease; it is probably infectious, although its exact nature is not known; characterized by a multiple arthritis and a tendency to involve the heart.

Osteopathic Etiology and Pathology.—No specific micro-organism has yet been found, although claimed by some to be due to a diplococcus; it is considered to be an infectious disease and it occurs in epidemic form. The disease is most prevalent in the temperate zone and is almost unknown in cold or tropical latitudes. It prevails most extensively during the spring months. Acute rheumatism results from an interference with the nerve centers by damp and cold. Lesions may occur anywhere along the spine, especially to the splanchnics, and sometimes are trophic in character. Particularly, are the lesions likely to disturb the process of the digestion, assimilation and excretion, as well as directly the tissues specially diseased. Catching cold, heredity, occupations which require exposure to cold, wet, or sudden changes of temperature, lowered vitality from overwork, improper food, fatigue, etc., and a previous attack are predisposing causes. Individuals in early life (twenty to forty years) are the usual subjects.

Pathologically, there are few or no changes characteristic of the disease. The synovial membrane is hyperemic and swollen. The fluid is turbid, mainly serous, containing fibrin and sometimes leucocytes. In ssevere cases slight erosion of the cartilages is found. The blood generally contains an increased amount of fibrin. Acute rheumatism rarely proves fatal; when death does occur it is generally due to the complications which arise.

Symptoms,--The disease usually begins abruptly; although it may be preceded by slight fever, aching in joints, malaise, chilliness, and sore throat. A number of authorities believe that rheumatism is secondary to tonsillitis; that infection gains entrance by way of the tonsils. 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, scapulae and spines of the vertebrae. 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 closely 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, acute necrosis, or acute osteo-myelitis. Gout is rarely mistaken for acute rheumatism. Gout occurs later in life and usually affects the greater toe; history and mode of onset will 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 effects 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 one joint, the hip or knee. The effusion becomes purulent.

Prognosis.—Recovery is the rule, but the prognosis nevertheless, must be guarded. Relapses and recurrence 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 albumin 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 (Massachusetts Journal of Osteopathy, Jan., 1906) 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 vaso-motor 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."
 

CHRONIC ARTICULAR RHEUMATISM

Osteopathic Etiology and Pathology.—This 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.

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 is very apt to be unfavorable 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, and local treatment of the joints. 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.
 

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 nervessas 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. Falli found upon autopsy that the anterior horns had undergone atrophic changes. 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. Hereditary influence is 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, the cells of the cartilages and of the synovial membrane proliferate. The cartilages undergo fibrillation, become soft, degenerate, and are absorbed, leaving the ends of the bone bare. The bones naturally atrophy and become smooth. 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.

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 gastrointestinal disturbance. Multiple arthritis deformans, also known as Heberden’s nodosities, 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 are 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 vertebrae only (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 cases 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.

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. The cause of the disease is probably a trophic or vaso-motor 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 shows that the lesion is a spinal one involving the nerve center. During the incipiency marked improvement is the rule.

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.
 

GOUT

Definition.—A nutritional disorder, possibly due to an auto-intoxication, in which there is an abnormal accumulation of uric acid in the blood and tissues, an arthritis being the characteristic feature.

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, drinking alcohol, especially fermented drinks, and lead poisoning are predisposing factors. 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 decided. The ultimate result is the same in either case; there is an accumulation of uric acid in the blood, which is responsible for some of the effects of the disease.

Osteopathic experience with cases of gout shows that the cause is primarily an affection of the nervous system, as it is undoubtedly the important factor that controls 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 the predisposing cause of gout. More can be accomplished in the cure of gout by careful examination of the spinal column, in the region corresponding to the innervation of the affected areas, for vertebral lesions, and correcting them, than by any other method. 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 wrist. 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. 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. Toward 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 on cooling and often contains a small quantity of albumin. There may also be traces of sugar. There may be severe gastrointestinal 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 a slight amount of albumin with hyaline and granular casts Involvement of the heart and blood-vessels gradually occurs.

Irregular gout 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 gastrointestinal 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 very 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.
 

MUSCULAR RHEUMATISM

Definition.—A painful disease of the voluntary muscles and of their fascia and 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 vertebrae, 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, sub-acute and chronic forms.

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 from a few hours to several weeks. The disease is very apt to recur.

Lumbago is a painful affection of the muscles of the loins 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 readily 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 dorsolynia affect the muscles of the shoulder and upper part of the back. 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, stretching of the muscles, application of heat, ironing and rest are beneficial.

In lumbago there is invariably found a slight lateral deviation of some vertebrae along the lower dorsal or lumbar region. Occasionally, a floating rib or an innominate becomes displaced. Stretching the loins by placing the patient upon his side and flexing the thighs on the abdomen is very beneficial.

Torticollis,--or stiff neck, is generally due to a lesion in the middle cervical vertebrae. The lesion is usually between the third, fourth and fifth vertebrae, occasionally as low as the second dorsal. A reduction of the subdislocation will often relieve the attack. Stretching of the muscles 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. In such instances a cure cannot always be accomplished.

A few cases of acute torticollis are caused by some of the deep muscular fibres becoming caught around a process of a vertebra. Severe contractions 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 injury may be to a nerve center, a nerve or to the muscles. The spinal accessory is the nerve generally involved. Lesions to the spinal accessory occur commonly at the third, fourth and fifth cervicals, or at the atlas and axis. The muscles involved in torticollis are the sternocleido-mastoid, trapesius, splenius and scaleni. Operations should not be performed until a thorough course of treatment has failed to relieve.

Pleurodynia is often really 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.

In cephalodynia The muscles of the scalp are generally involved by lesions in the upper five cervical vertebrae. 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 vertebrae. The lower cervical vertebrae may also be at fault. 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 vertebrae, 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 vertebrae.

Myalgia of the upper extremity is caused by lesions of the cervical or upper dorsal vertebrae 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 vertebrae, or there may be derangements of the pelvic bones. Occasionally disorder is found at the hip and knee joints.
 

LITHEMIA

Definition.—A constitutional disease closely related to gout, due to the faulty oxidation of nitrogenous matter. It is characterized by an excess of uric acid in the blood, with various digestive, circulatory and nervous symptoms. It differs from gout in there being no joint involvement.

Osteopathic Etiology.—Lesions are always found in the splanchnic region and are an important factor in preventing free elimination. Impaired digestion, inactivity of the liver, insufficient exercise, overeating, overdrinking and sometimes heredity are causes.

Symptoms.—The gastrointestinal symptoms are important. The appetite varies greatly, sometimes it is lost; at other times it is inordinate or it may be perverted. The tongue is coated, the breath is heavy and there is an unpleasant taste. The bowels are generally constipated. In some cases there is fullness, oppression and sometimes nausea and vomiting after meals. The liver is enlarged and tender. Circulatory symptoms are high arterial tension, due to the action of the uric acid upon the vaso-motor nerves; palpitation, especially after meals; sharp accentuation of the aortic second sound, and slow pulse. Nervous symptoms, such as vertigo, headache, depression of spirits, nervous irritability, and neuralgic pains, especially down the back and legs, are frequent. The urinary symptoms are scanty, high colored urine with high specific gravity. Diagnosis.—This depends upon the general symptoms, the condition of the urine and the habits of the patient. This is apt to be confused with irregular gout.

Prognosis.—This is ordinarily favorable, provided treatment is persistent and the habits of the patient can be regulated.

Treatment.—In this disease it is evident that the food should be thoroughly masticated and overeating and overdrinking reduced. Exercise in the open air should be taken so that the fats in the body may be consumed. Attention to the diet is important. Green vegetables, fish, oysters, game and fruit will be found suitable.

Correction of the splanchnic lesions is necessary in order to cure. Thorough treatment should be given the liver and kidneys. All the secretory organs should act freely. The free use of water will be a helpful measure.
 

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 (vaso-motor 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 are specially predisposed. The colored race are 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. 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 (Diabetes, p. 90) 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 vaso-motor nerves to the liver, or direct stimulus to the liver cells is followed by glycosuria. Interference with the pneumogastric nerve also influence 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, epecially 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 hyaline 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, a voracious appetite, progressive emaciation and debility. The tongue is dry, red and glazed or coated. Saliva is scanty, the teeth decay, the gums become swollen. The appetite may become enormous. As a rule, 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 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. The urine has a sweetish odor and there may, or may not be, a sediment. 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.

Complications.--Diabetic coma is the most important and gravest symptom. 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, tingling and diabetic tabes characterize the pain in the legs. 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 complications. Progressive loss of flesh is a serious indication.

Diagnosis.—The diagnosis is very 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 oxybutynic acid is valuable.

Prognosis.—A number of 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 melliltus 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 vertebrae, 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 a few were 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 impinged nerves, as they pass through the intervertebral foramina, may be released. Meeker (Journal of the American Osteopathic Association, Oct. 1904) reports a case with a marked kyphosis which was treated two years before enough motion could be had between the vertebrae to produce any results, but after that they were favorable. Direct treatment to the abdominal organs to correct liver congestion, stimulate the pancreas and to 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 vaso-motor nerves to the portal system, pancreas and the intestines. The vaso-motor nerves to the portal system branches are given off principally from the fifth to the ninth dorsal vertebra, 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 vertebrae. 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 vaso-motor 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 sasccarinity 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 vaso-motor 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 pneumogasdtric 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.

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 (Journal of the American Osteopathic Association, Oct., 1904) 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 (Practical Medical Series, 1905) 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 protein 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, sour wines, 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. On the whole it is best to eat considerable meat and abstain from garden material and fruit. Water should be drunk freely.

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.
 

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 vertebrae 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; cerebro-spinal fever; malaria; syphilis; pregnancy; hysteria; hereditary influence, and drinking too freely of cold water. There are many diseases and conditions which may be associated with diabetes insipidus; and which set 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 vaso-motor 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.

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 very often 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 vertebrae 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 vertebrae 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 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

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. There is no evidence that rickets is hereditary, 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 in America. The disease is most frequently met with among the ill-fed and badly housed poor of the large cities. Lesions to the digestive organs predispose. Improper or insufficient food, bad air, want of sunlight, a starchy diet, prolonged lactation, exposure to cold and dampness, and syphilis are predisposing factors. Male and female children are affected equally.

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, spleen and sometimes the mesenteric glands are enlarged.

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, restless, and there are usually slight fever and profuse sweats. The child is often languid, pale and feeble. 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 maxillae, which are reduced in size. 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. The abdomen is large and prominent, due partly to flatulency and partly 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 intercurrent diseases; still, on the whole, prognosis is fairly favorable.

Treatment.—Rickets being a disease of malnutrition due to hereditary 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. If curds are found in the stools, the digestion is not perfect and is usually due to overfeeding the child. The child should be outdoors 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. 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. 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. 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.

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 pedulous 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, overcrowding, dampness,, bad hygienic surroundings, and prolonged fatigue under depressing influences are the predisposing causes.

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 out-door life and good ventilation with anti-scorbutics, as fruit juices, (especially lemons) 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

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. 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. The lower limbs are kept drawn up and are 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 posed 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. When small, they are called petechiae; when large they are known as ecchymosis. At first they are bright red and gradually become darker until they fade into brownish spots. Clotting of normal blood requires three to five minutes, of purpuric blood, ten to fifteen minutes.

Symptomatic Purpura.—The purpura 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 over-doses. Cachetic 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.

Primary Purpura.—The following forms are recognized by medical authorities: Purpura simplex, arthritic purpura, and purpura hemorrhagica.

Purpura simplex is a mild form, seen most commonly in children. 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 patients get well in a week or ten days.

Arthritic purpura is a much more serious affection, characterized by multiple arthritis and an eruption which may be simply purpuric, or it may be associated with urticarial wheals or with erythema exudativum. The disorder is possibly due to rheumatism. It is more common in males between the ages of fourteen and thirty. The spots usually occur first upon the legs and around the affected joints. 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. Endocarditis, hematuria and hemorrhagic nephritis are complications which may arise. Relapses may occur; recovery is the rule. Henoch’s purpura is seen most frequently in children and is characterized by severe gastrointestinal 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 prognosis is good.

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. 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. There is usually light fever. Favorable cases recover in ten days or two weeks. Death may result from loss of blood or from hemorrhage into the brain. Except in the mild cases prognosis is unfavorable. 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, 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

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 vaso-motor 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 slight 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 year. 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.
 

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 gastrointestinal 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 vertebrae, occasionally in the upper dorsal vertebrae 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 vaso-motor 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 gastrointestinal 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.

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.
 

APTHOUS STOMATITIS

(Canker)

This disease is characterized by little 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 point 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 apthous 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.

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.

Mercurial stomatitis (ptyalism) is a form of stomatitis seen in artisans who work in mercury. A frequent attendant of mercurialization in all instances is found whether from handling the mercury or after its administration as a medicine. The first symptom usually observed is fetor of the breath which is followed by tenderness of the gums, a metallic taste and increase of saliva and redness of the gums near the insertion of the teeth. These premonitory symptoms are followed, in severe cases by profuse salivation, protrusion of the tongue if that organ is affected, ulceration of the mucous membrane, loss of teeth and necrosis of the jaw.

Syphilitic Stomatitis is also ulcerative. The syphilitic ulcers exhibit the same gray color, but are found in the throat as well as at various points on the mucous membrane of the mouth. They are much deeper than those of ulcerative stomatitis, but do not bleed as easily, nor are they as angry looking.

Diagnosis.—The disease may be confounded with gangrenous stomatitis, although the progress of the disease is slower and there are fewer constitutional symptoms. Scurvy, though a general disease, is characterized by ulceration of the mouth, but the general symptoms will usually make the diagnosis easy.

Prognosis.—Is favorable if the disease is promptly and properly treated.

Treatment.—The hygienic surroundings should at once be corrected; this being remedied, any tendency to an epidemic will be prevented. In all forms of stomatitis the cause of the affection must be removed before a cure can be accomplished. Pay strict attention to the diet and secretions. The mucous membrane of the mouth must be kept absolutely clean. An antiseptic wash is necessary. Carbolic acid (a teaspoonful to five ounces of water), listerine diluted with twice as much water, or any other antiseptic may be used. Treatment of the vascular supply and innervation of the mouth, as in other forms of stomatitis, is indicated. General treatment should not be overlooked. Pay attention to the bowels. Vaso-motor nerves to the mouth are from second to fifth dorsal.
 

PARASITIC STOMATITIS

(Thrush; Sprue)

The exciting cause is a fungus known as oidium albicans or saccharomyces 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 or cancer.

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. 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 apthous 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 gastrointestinal tract and local treatment, as I other forms of stomatitis, is the required treatment. A boric acid solution will be found beneficial.
 

GANGRENOUS STOMATITIS

A rare disease that attacks debilitated children, probably due to some parasitic micro-organism. It is generally seen between the ages of two and six years. It is usually a sequela to specific fevers, especially measles and whooping cough.

Symptoms.—Its approach is usually insidious, ulcerative stomatitis or a sloughing ulcer on the gums or on the inside of the cheek being first noted. Even a gangrenous odor may be the first symptom noticed. The process is essentially a rapid, progressive, moist gangrene. The cheek swells and becomes edematous until finally the whole side of the face is affected. The mild form is generally limited to perforation of the cheek. In severe cases the bones of both jaws, the eyelids and ears may be involved. High fever, 104 degrees F., may be present. The pulse is rapid and feeble and the adjacent lymphatics are swollen. The patient rarely recovers, death occurring in from five to seven days.

Treatment.—Local treatment of the cervical and upper dorsal regions, hygienic measures, nourishing food, local antiseptics and the actual cautery.
 

DISEASES OF THE TONGUE

GLOSSITIS

Inflammation of the parenchyma of the tongue is a rare disease. It may be either acute or chronic; the result of direct injury to the tongue, boiling liquids, corrosive substances, accidental biting, poisonous stings, the sharp edges of the teeth or the use of a tobacco pipe. In a few cases the atlas will be found anterior; in others, frequently lesions to cervical vertebrae and muscles.

Lesions to the atlas, axis, lower cervical, or upper dorsal vertebrae; sometimes of the upper few ribs; of the clavicle; of the cervical muscles, especially those of the throat; of the hyoid bone; of the lower jaw, may be present." (Hazzard)

Symptoms.—The tongue is greatly congested, reddened, swollen and painful. It may be so swollen that speech is difficult, as well as mastication and swallowing. In fact, in a few cases it may be so large that it protrudes from the mouth. Obstruction to breathing may occur, also restlessness, fever and increased flow of saliva. In a few instances suppuration takes place.

Treatment.—Ice applied constantly, internally and externally, at the angles of the jaw, or the persistent use of hot water held in the mouth and applied externally; with a continued thoroughly relaxed condition of the cervical muscles about the angle of the jaw and also the deep cervical muscles will generally give prompt relief. The vaso-motor nerves are largely from the fifth cranial. Some of them make their exit from the cord as low as the fifth cervical and pass upward through the superior cervical and Gasserian ganglia. If pus has formed, the use of the lancet must be employed. If suffocation is imminent, perform tracheotomy. Pay due attention to the general health. Examine carefully for any possible reflex irritations.

Fetor Oris, or foul breath, is common. It is usually due to some digestive trouble, chronic tonsillitis, phyorrhea alveolaris, or decayed teeth.
 

DISEASES OF THE SALIVARY GLANDS

Hyper-secretion,--(Ptyalism).—This is an abnormal increase in the secretion of saliva. It is a common effect of certain drugs, as mercury, gold, copper and iodine, and vegetable substances producing the same results are jaborandi, muscarin and tobacco. Pryalism may be the result of oral disease—noma and ulcerative stomatitis. It is sometimes seen in smallpox, during gestation, in rabies, and occasionally in mental and nervous affections.

Xerostoma (Aptyalism; "Dry Mouth").—This is a condition in which the salivary and buccal secretions are arrested The tongue is red, dry, glazed and sometimes cracked. The mucous membrane is dry, smooth and shiny. Mastication, deglutition and articulation are difficult. This is a rare condition and the majority of cases have been observed in women in conjunction with nervous phenomena. It is probably due to an interference with the center which controls the salivary and buccal secretions.

Treatment.—The treatment of hypersecretion and xerostoma depends altogether upon the conditions producing them; although treatment over and around the salivary glands in dry mouth will tend to stimulate the glands’ activity. The center or the nerves from the center that control the secretion of saliva and buccal glands may be interfered with by a subdislocated atlas—usually an anterior dislocation. Secretory fibres to the submaxillary gland are from the second and third dorsals. Dana says the fifth nerve controls salivary secretion.

Symptomatic Parotitis (Parotid Bubo).—Inflammation of the parotid glands, apart from mumps, occurs under the following conditions:

During an attack of infectious fever, such as typhoid, typhus, scarlet fever, pneumonia and pyemia. It may also occur in secondary syphilis. Parotitis is seen especially in typhoid fever. It is doubtless either the result of septic infection or due to the extension of inflammation through the duct of Steno. The inflammation is often intense, going on rapidly to suppuration.

From diseases or injury of the abdomen or pelvis, especially of the genito-urinary tract. Also, injury or disease of the alimentary canal, of the abdominal walls, peritoneum or the pelvic cellular tissue may produce it. Derangements of the testes or ovaries, the use of a pessary, menstruation or pregnancy may also cause it.

Peripheral neuritis with facial paralysis (Gower’s).

Treatment.—When the parotid glands are involved, the deep tissues about the angle of the jaw are usually severely contracted or the atlas and axis are displaced. A reduction of such derangements is usually very effectual in obtaining relief from the involved glands. In a few instances the deep lateral cervical muscles, and even the first and second ribs on the side affected, are found deranged. There is probably, in such instances, an involvement of all the cervical lymphatics on the side affected. The glosso-pharyngeal supplies secretory and vaso-dilator fibres to this gland.

Applications of cold, especially ice, should be used at first. If the affection has progressed to a later stage, use hot applications. Use the lancet if suppuration has occurred.

Chronic Parotitis.—The glands are enlarged and may be tender and painful or painless. It may succeed mumps or acute inflammation of the throat. It is also met with in Bright’s disease, syphilis and in mercury or lead poisoning.

Treatment.—In cases of chronic parotitis the atlas and axis are commonly subdislocated anteriorly, or else there is a rotary lesion of the atlas, the gland involved being generally on the side of the transverse process which is most anterior.

In disturbances of the salivary glands there will always be found lesions to the cervical vertebrae or muscles, or the upper dorsal vertebrae, ribs, or muscles, or the clavicle may be depressed and obstructing lymphatic drainage. These lesions are primary or else they are predisposing to the production of constitutional and reflex irritations.
 

DISEASES OF THE TONSILS

ACUTE TONSILLITIS

(Quinsy)

Definition.—An acute, parenchymatous inflammation of the tonsil.

Osteopathic Etiology and Pathology.—Exposure to cold and wet are the most common exciting causes. Injuries and strains to the upper cervical vertebrae and muscles are invariably found. In a few cases infection may be the cause. Many persons have a predisposition to attacks of tonsillitis and probably all that a predisposition means, in a large percentage of cases, is that there is a weakened or strained condition of the cervical vertebrae, and whenever one is exposed to atmospherical changes the uneven contraction of the cervical muscles derange still more the already disordered tissues and the lesions to the vaso-motor and secretory nerves of the tonsils are increased. Lesions which cause disturbances to the vaso-motor nerves and the lymphatic drainage may be found as low as the upper dorsal vertebrae and corresponding ribs and at the clavicles. The disease usually occurs between the tenth and fortieth years.

Pathologically, one or both of the tonsils, more often one, swells rapidly and may extend to the median line; in fact, if both tonsils are affected the isthmus of the fauces may become occluded. The tonsils, as well as the adjacent mucosa, become red and sensitive. The surface of the tonsils presents yellowish patches. Where distended follicles of the gland are protruding, the tonsils are painful, and if undergoing suppuration, they gradually soften.

Symptoms.—The onset is commonly somewhat sudden, with rigors and a temperature of 104 to 105 degrees F., while the pulse is full, bounding and frequent, 110 to 130 per minute. The jaws are stiff and painful on account of the swelling at the angle. There is difficulty in swallowing and in opening the mouth, the voice is greatly changed, the salivation increased, and respiration may be considerably impeded. Accompanying this condition are headache, thirst, an anxious face, earache, deafness and pain in the floor of the mouth and Eustachian tubes.

When suppuration is imminent, the pain becomes increased and throbbing, the patient more depressed, the fever higher and all the symptoms are increased. The rupture of the abscess may occur spontaneously or from an effort of vomiting. The contents of the abscess is ejected from the mouth. If the contents should go into the larynx suffocation may occur. The disease lasts from three to seven days, although by thorough osteopathic treatment this time may be materially shortened. It may terminate by suppuration or by gradual resolution.

Prognosis.—In the large majority of cases the prognosis is favorable. The danger lies in suffocation, the rupture of the abscess, when the obstruction is complete by double sided quinsy, and when the giving of food is seriously interfered with.

Treatment.—At the beginning of the attack measures should be taken to subdue the inflammation as much as possible. Treatment should be given often, to free the lingual, tonsillar, pharyngeal and palatine vessels. Thorough treatment should be applied over the tonsillar, nasal and external pharyngeal plexuses. A thorough examination should be given to note any lesions of the cervical sympathetics to vaso-motor fibres of the fifth cranial and glosso-pharyngeal nerves. Pay particular attention to the condition of the upper cervical vertebrae and also to relaxing the cervical muscles, especially the antero-lateral muscles over the region of the tonsils. A downward, forward, firm treatment from the angle of the inferior maxillary over the tonsils to the anterior median line of the body is very effectual. If there is ulceration an alcohol gargle, one part to three, will be beneficial. An antiseptic spray will reach all diseased tissues.

The bowels and other excretory organs should be kept active from the beginning of the attack, and the diet should be of the nature of fluids, as thin oatmeal, gruel, peptonoids, milk, beaten eggs, meat juice, etc., so it can be most easily swallowed. Cold or hot applications about the neck and pellets of ice held in the mouth will be helpful. Examine the tonsils frequently with the finger and when suppuration occurs use the lance. If there is danger from suffocation the tonsil may be taken out and in extreme cases tracheotomy may be performed.
 

CHRONIC ENLARGEMENT OF THE TONSILS

Definition.—A chronic, inflammatory enlargement of the tonsils. A chronic, inflammatory enlargement of the adenoid tissues of the pharynx will also be considered here.

Osteopathic Etiology and Pathology.—Repeated attacks of acute tonsillitis are common causes; chronic lesions of the upper cervical vertebrae, involving the innervation and blood supply to and from the naso-pharyngeal region; diseases associated with circulatory disturbances of the region of the tonsil, as scarlet fever, diphtheria and measles; rheumatism; rachitis; tuberculosis and syphilis are occasional causes. The disease may be hereditary. Skin diseases, improper food and unsuitable surroundings may favor the disease.

Adenoids are frequently associated with chronically enlarged tonsils. The disease may be congenital. Age is an important etiological factor, the disease occurring usually between the ages of three and fifteen years.

The two diseases are so intimately associated that one rarely sees enlarged tonsils without adenoids and those conditions that would cause chronically enlarged tonsils would cause adenoids of the naso-pharyngeal region. The adenoids occur most frequently in boys at the ages stated above.

Pathologically, all the tissues of the tonsils are increased in size, especially the number of lymphoid cells; in fact, the enlargement is a true lymphoid overgrowth. The enlargement is usually symmetrical and firm. In children the tonsil is in a developmental stage and is not as firm as in the adult, so if it is thought best to remove the tonsils, the earlier it is done the better. The crypts are deepened and widened, making the surface of the tonsil quite uneven. The opening into the throat varies according to the size of the enlarged tissues and may be almost closed.

The adenoids are hyperplasia of the lymphoid tissues in the naso-pharynx. In children the mass is soft and lobulated after the manner of the enlarged tonsils.

Symptoms.—In a few simple cases there may be no symptoms until the tonsils or lymphatics further enlarge, induced by an attack. The first noticeable symptom is an obstructed breating, necessitating the patient’s breathing through his mouth. This especially disturbs his rest and is the cause of considerable dyspnea. The blood is poorly oxygenated as a result and the general health may be greatly impaired. The voice is thick and muffled, the breath fetid, and there may be difficulty in deglutition. The hearing is usually defective and smell and taste are impaired. A constant cough is a very annoying symptom. Epistaxis is frequent.

This condition gives rise to the so-called "chicken breast" and is quite common when the lymphatics of the upper air passages are enlarged. These children usually complain of headache, a dried, parched mouth and tiredness, and are, as a rule, dull and stupid. Their countenances are expressionless. They have broad noses, thick, everted lips and their mouths are open. They do not learn easily nor readily at school and the teacher should have patience with them, as their hearing is generally impaired and their night’s rest disturbed. On the whole, both mental and physical deterioration gradually occurs.

Diagnosis.—There should be very little difficulty in the diagnosis. Enlarged tonsils can be determined quite readily through the external wall; but a thorough ocular examination will be more accurate. Malignant growths of the tonsils are of rare occurrence, especially in children. They start on one side, are very painful, bright red in color, and grow rapidly.

Prognosis.—Depends largely upon early discovery of the disease, although persistent treatment in severe cases will usually induce the disease to yield to some extent at least. It requires several months’ treatment in a large percentage of cases to accomplish much. Removal of the growth in a few cases will be best. After the disease has been cured the peculiar facial expression and deformity of the chest will be out-grown. In a majority of cases the adenoids and tonsils will atrophy at puberty, but something should be done before that late day, as both the mental and physical conditions may be greatly impaired.

Treatment.—Requires most careful and painstaking work. In many cases the work will seem discouraging on account of the slowness of the case to yield to treatment. An attempt should be made during each treatment to correct any disordered cervical vertebra that may be found. Thorough and continuous treatment should be applied over the tonsils and glands externally. A downward, forward and sweeping motion over the tonsils and glands is best. Pay attention to the condition of the clavicle and upper ribs so that they may not interfere with the vascular drainage from the naso-pharynx. Occasionally an internal treatment through the mouth to the soft palate will be helpful. (See treatment of Nasal Catarrh).

Care should be taken of the spine, especially in the dorsal region, and of the ribs. If the chest is deformed an attempt should be made to correct the disordered condition. A nutritious diet and due attention to hygienic surroundings are certainly advisable.

Those cases that have been subject to snoring and retain the habit can overcome that annoyance by wearing a cloth or pad over the mouth during the night. When the voice remains altered after the case has been cured, training of the voice should be encouraged to overcome the defect. A few cases will require removal of the growth, but this should not be done until after a thorough course of treatment and then as a last resort; still, do not delay surgical interference too long.
 

DISEASES OF THE PHARYNX

ACUTE CATARRHAL PHARYNGITIS

(Sore Throat)

Definition.—An acute, catarrhal inflammation of the mucous membrane of the pharynx, tonsils, soft palate and uvula.

Osteopathic Etiology.—Exposure to atmospherical changes is the most frequent cause. A strained condition of the upper cervical or lower dorsal vertebrae predisposes to an attack. Improper use and overuse of the voice may produce the disease, also, hot drinks and local irritants. Thoracic diseases, weakness and debility, rheumatism, gout, scrofula and infectious fevers are occasional causes.

Symptoms.—Chilliness, slight fever, dryness and soreness of the throat are the first symptoms. Associated with these symptoms are a painful deglutition, a hacking cough, dryness, soreness and tickling of the throat, and tenderness and stiffness of the neck muscles. The inflammation may extend into the Eustachian tubes, causing more or less deafness, or into the larynx, causing hoarseness. Upon inspection of the throat, the mucous membrane is red and swollen. The caliber of the pharynx is lessened and the uvula enlarged. Whitish spots may occur on the mucous membrane and in a few cases ulcers will be present.

Prognosis.—The prognosis is favorable in a large majority of cases. Most cases are readily cured, rarely lasting longer than a week.

Treatment.—Many cases get well without any treatment. In severe cases, if the patient would remain in bed twenty-four hours and attend carefully to himself, the inflammation would rapidly subside. The object of treatment is first to correct any slight strain or irregularity that may exist in the cervical vertebrae (chiefly the atlas) and impinge upon the innervation to the pharynx, viz.: pneumogastric, spinal accessory, glosso-pharyngeal and sympathetic nerves. These nerves from the pharyngeal plexus send fibres to the mucous membrane of the pharynx and soft palate as well as to the muscles of the same region. Following this correction, a thorough relaxation should be given to all the cervical muscles, superficial and deep, especially over the pharynx and the deep cervical muscles. By a firm, downward and inward movement from the lobe of the ear around the angle of the inferior maxillary, considerable relief may be given by mechanically freeing the pharyngeal blood-vessels. If ulceration is present, an alcohol gargle, one part to three, or some antiseptic spray, will be beneficial.

Should the inflammation extend into the Eustachian tube, a finger introduced through the mouth to the roof of the soft palate, and thoroughly relaxing the tissues and inhibiting the local nerves, will be of considerable benefit, not only in relieving the inflammation of the Eustachian tube, but also in lessening the pharyngeal swelling and in clearing the nasal passages.

In a number of cases of acute pharyngeal inflammation, slight lesions to the lower dorsal vertebrae and severely contracted muscles of the same region will be found. This evidently causes the inflammation of the pharynx (via vaso-motor nerves), for upon correction of these parts, immediate relief will be given the sufferer. There have been well marked cases of acute catarrhal pharyngitis with a temperature of 102 degrees F., cured in a few hours by treatment of the lower splanchnics. The pharyngitis, in such cases, may be due to an interference in the circuit between the two great reflex brains, cervical sympathetic and solar plexus, which are connected by the spinal cord and splanchnic nerves on the one side and the vagi on the other. A few cases of pharyngeal inflammation are associated with chronic irritations of the pelvic organs. Thus, care should be taken that obstinate cases do not present some pelvic disorder. A light, nutritious diet and attention to the excretory organs should be given in all cases.
 

CHRONIC PHARYNGITIS

Osteopathic Etiology.—This disease is found more often in the adult than in the child. Repeated attacks of acute pharyngitis are a common cause of the disease. Chronic lesions to the upper cervical vertebrae are frequently found. Improper use of the voice, as by public speakers and singers; continuous action of irritants, like tobacco smoke; the irritating discharages trickling down the fauces from a chronic nasal catarrh; irritating gases and dust, and alcoholic drinking may be causes.

Varities.—Chronic pharyngitis may be either diffuse or circumscribed. It is termed catarrhal pharyngitis when only the mucous membrane is involved, and follicular pharyngitis when the follicles are disturbed. In the hypertrophic the mucous membrane is thickened and inflamed. The lymphatic tissues of the pharynx become granular in appearance and the veins greatly dilated. This is the so-called granular or chronic follicular pharyngitis or clergyman’s sore throat. In the atrophic form the mucous membrane becomes pale, dry and atrophied, with a smooth glossy appearance.

The common form of chronic pharyngitis seldom produces ulceration. A lowered nutrition, as found in various infectious diseases, syphilis, tuberculosis, diphtheria and cancer, may tend to ulceration of the pharynx. The ulcers are yellowish white. The most common symptom is pain during deglutition.

The phlegmonous form is a suppurating inflammation involving the pharynx, except post-pharyngeal abscess. It is due to infectious fevers, quinsy, injuries, corrosive poisons and foreign bodies.

A retro-pharyngeal abscess is a phlegmonous inflammation behind the pharyngeal tissues proper, caused by caries of the cervical vertebrae and inflammation of the local lymphatics and favored by a depraved nurtition. This is a rare disease.

Symptoms.—There is a constant desire to clear the throat. A fullness, tickling and various sensations in the throat are present. The secretions of the throat are increased and the voice is husky.

When ulceration occurs, pain is present during swallowing. Especially is the pain intense in phlegmonous pharyngitis, and in post-pharyngeal abscess as well. Swelling and stiffness of the neck, fever and exhaustion are also prominent symptoms.

Treatment.—To remove the cause of the disease is of first importance, whether it is due to nasal catarrh, smoking, luxated cervical vertebrae, the use of alcohol or foreign bodies. Other treatment will be of little use until the irritation producing the disease is removed and the general health carefully looked after.

The nasal pharyngeal region should be kept clear; care being taken of the use of the voice, and scraping of the throat stopped. The patient should live an outdoor life. Sponging the throat, night and morning, first with warm water, then cold water, will lessen the liability of the patient to acute attacks from exposure. With thorough cooperation on the part of the patient in carefully taking care of himself, the osteopath can, in most instances, cure the case, or at least give great relief, by a persistent course of treatment. The treatment must be directed to the innervation and blood supply of the pharynx. Correcting the disordered cervical vertebrae or upper ribs or a clavicle, thoroughly relaxing the cervical muscles (chiefly the deep vertebral muscles), and a firm, direct treatment over the pharynx, as in acute catarrhal pharyngitis, will be the necessary treatment.

In phlegmonous pharyngitis everything should be done locally that would be helpful in lessening the inflammation. Thorough treatment and close attention to the affected parts are necessary. Locally, ice will be of aid. When pus has formed it should be freed at once. The case cannot be watched too closely, for gangrene may occur. It is best to have the aid of a surgeon. Post-pharyngeal abscesses require incision and evacuation at once, besides treatment directed to its cause.
 
 
DISEASES OF THE ESOPHAGOUS

Acute Esophagitis

0steopathic Etiology and Pathology.--Lesions to the middle dorsal vertebra may be predisposing factors; also, disturbances of the vagi. Traumatism is the most common etiological factor, the inflammation being such as is induced by the presence of foreign bodies, chemical irritations, from corrosive poisons, and thermal irritations, from the swallowing of hot liquids, occaisonally cause emphagitis. Other causes are the catarharral processes of the specific fevers, extension from catarrh of the pharynx and local diseases of the esophagus.

The pathological changes are those of simple catarrhal inflammation of the mucosa. Commonly the epithelium is thickened and undergoes rapid desquamation so that the surface is covered with a fine granular substance. Follicular ulcers may occur from the swelling and breaking of the mucous glands. The diphtheritic false membrane, when occurring in the esophagus, presents the same characteristics as elsewhere, and is seldom found in the lower portion.  The calibre of the esophagus may be diminished by a purulent inflammation of the submucosa, the pus generally passing into the esophagus.

Symptoms.--Pain beneath the sternum, increamed by deglutation, is always present. In mild forms of a catarrhal nature, the pain beneath the sternum is duller and may be absent; but in some severe cases the svmptoms may all be mild, so that a true condition of the disease cannot be determined in every case from the symptoms. Mucus and blood, and occasionally pus, may be discharged from the esophagus. In severe cases, spasms of the Esophagus may occur.

Treatment.-- A bland diet should be given, preferably milk, and when the dysphagia is intense it will be best to feed entirely by enemata.

The treatment of the esophagus is principally executed through the innervation of that orgam - the pneumogastric and sympathetic. Branches from the pneumogastric as given off above and below the pulmonary branches. A correction of any of the cervical vertebras that might involve the pneumogastric, and thorough treatment of the spinal column from the sixth cervical to the elevanth dorsal, besides a raising and spreading of the ribs, chiefly at their sternal ends is necessary.  Fragments of ice may be given and cold applications externally often give relief.
 
 
SPASMS OF THE ESOPHAGUS

Osteopathic Etiology.--Spasmodic contraction of the muscular layer of the esophagus is due to several causes. The irritation that produces the spasm is genereally of reflex origin and is found in those of a nervous temperament, especially hysterical and hypochondriacal patients. Occasionally the direct innervation of the esophagus is irritated at some point; generally a rib or a middle dorsal vertebra acts as the irritant. It occurs as a symptom in organic esophageal obstruction, hydrophobia, tetanus, chorea and epilepsy.

Symptoms.--Dysphagia is the chief symptom. Pain beneath the sternum, a choking feeling and inability to swallow food usually accompany dysphagia. An esophageal bougie can generally be passed without much difficulty.

Diagnosis.--Careful attention to the symptoms, the use of the sound, the age and the sex and the absence of any wasting symptoms or others that might indicate organic stricture, will usually readily determine the condition.

Prognosis.--Is always favorable, although it is impossible to prognose the duration of the condition.

Treatment.--A thorough search should be made to find the irritation or cause on which the condition depends. If found to be due to reflex irritation or to lesions of a rib or vetrtebra, the disorder should be corrected. Attention to the diet, hygienic surroundings and an occasional passage of the bougie--the psychic effect of which is particularly good--are usually followed by a speedy and permanent cure. S. A. Ellis (Journal of the American Osteopathic Association, Jan., 1905) reports a case of complete stricture of the esophagus at the level of the clavicle with permanent recovery. The lesion was at the sixth cervical together with the first rib.
 
 
ORGANIC ESOPHAGEAL OBSTRUCTION

Osteopathic Etiology.--There are several conditions that may result in organic obstruction of the esophagus: (a) Congenital narrowing. (b) A tumor external to the esophagus, such as aneurism, enlarged thyroid, enlarged lymphatics and various other tumors. (c) A tumor growing in the walls, generally a cancer. (d) Cicatricial constriction from ulceration, usually due to syphilis or corrosive poison. (e) Foreign bodies.

Symptoms.--Difficulty in swallowing, regurgitation of food, and considerable emaciation are symptomatic. A permanent obstruction is found upon the passage of a bougie.

Diagnosis.--Obstruction from a cicatrix may occur anywhere in the esophagus, but is usually found either quite high or low. Corrosive poison or history of syphilis would suggest a cicatricial obstruction. In cancer, the cachetic condition, the age, pain, enlargement of cervical lymph glands and enlargement of other organs indicate the nature of the obstruction. Examination should be carefully made for an aneurism before passing the bougie, as an aneurism may produce all the symptoms of organic esophageal obstruction.

Treatment.--The treatment in most instances requires surgical work, although lesions may be found to the innervation and vascular supply of the esophagus, which warrant persistent and continued treatment. In most cases, if the patient is willing, esophagotomy or gastrotomy should be performed to prolong life. Rectal feeding may be necessary. In aneurism, little can be done to strengthen the walls of the affected portion of the vessel. Probably careful treatment to the innervation of the muscular coat of the vessels, rest and dieting will be of aid. Surgical works should be consulted. The prognosis is unfavorable, especially in cancerous conditions. In cicatricial contraction, a systematic dilation with graduated bougies should be performed, with thorough treatment of the innervation of the esophagis. The prognosis in such cases is generally quite favorable. An enlarged thyroid can usually be reduced by the treatment indicated for such disorder.

For other disorders of the esophagus consult surgical works.
 

DISEASES OF THE STOMACH

ACUTE CATARRHAL GASTRITIS
(Acute Dyspepsia)

Definition.--An acute, catarrhal inflammation of the stomach, due to simple, non-specific irritation.

Osteopathic Etiology and Pathology.--This condition occurs at all ages and is usually traceable to errors of diet. It is due either to the irritation of indigestible food upon the mucous membrane of the stomach or to the decay and fermentation of undigested food. Simply overloading the stomach may produce more or less inflammation. The use of too hot or too cold food or drink may induce attacks. Alcoholic excess is oftentime the cause. Taking cold or getting wet, also mental excitement, worry and grief frequently induce the disease. Occasionally the use of tobacco brings on an attack. Injuries and irritations to the splanchnics and the vagi nerves will produce gastric fever. The irritation from dietetic errors always causes more or less contraction of the muscles in the upper and middle dorsal region, which, in turn, may produce constant osseous lesions and thus be the cause of the catarrh becoming chronic. McConnell showed in his experimental work that vertebral and rib lesions readily affect both the spinal nerves at their exit and the sympathetic ganglia contiguous to the head of the ribs, which is followed by vaso-motor and trophic disorder to the mucous and sub-mucous coats of the stomach, as revealed by ecchymosis and hemorrhage of the sub-mucosa and beginning parenchymatous degeneration of the free ends of the glands of the mucosa.

Pathologically, the mucous membrane is more or less covered with mucus. Upon removal of this mucus the membrane is found reddened and swollen. Slight hemorrhages and small erosions may occur and in some cases slight edema of the sub-mucous coat. Less gastric juice is secreted on account of the inflammation.

Symptoms.--In the outset there may be weakness and chilliness, with paleness and cold extremities. Later on the chilliness may alternate with flushes of heat, red face and febrile reaction. There is loss of appetite, nausea, fullness and soreness over the pit of the stomach. There is rarely any pain. To these symptoms may be added a belching of gas, headache, dizziness and mental depression; the stools become fetid and mushy, and the urine dark in color. Other symptoms may be present, as epigastric distention, a coated tongue, dryness of lips, vomiting and jaundice.

Diagnosis.--Usually there is no difficulty. When the disease is preceded by a chill it is sometims difficult to diagnose between it and infectious fevers, but a few days will furnish differential symptoms. Generally the disease is preceded by dietetic faults or some other cause. Specially, splanchnic lesions will be found sufficient to produce or keep up the inflammation.

Prognosis.--Favorable in every case of simple gastritis; duration about one week unless one is called early.

Treatment.--Give the stomach as much rest as possible. Mild cases generally recover in a day or two if food is not allowed for twenty-four or thirty-six hours. In cases where food remains in the stomach and decomposes, emesis should be produced at once. Strict attention should be paid to the bowels, so that all indigestible and putrefied matter may be eliminated, besides preventing inflammation from extending downward from the stomach.

Treatment of the spinal nerves, from the fourth to the tenth dorsal vertebra, is essential to the cure. An irritaiton of these spinal nerves may produce the catarrhal inflammation of the mucous membrane. As indicated above, obstruction or irritation of the vagi nerves, especially the right vagus, occasionally is an etiological factor; consequently, attention must be paid to these nerves, particularly at the atlas and axis.

Vomiting is a common and distressing symptom. Pathologically, it consists of an anti-peristaltic contraction of the stomach and a spasmodic contraction of the diaphragm and the abdominal muscles. It is caused, usually, by irritation of the vagus nerve in the stomach, or in the pharynx by irritation along the spine (particularly in the cervical and upper dorsal regions), or to the sympathetic nervdes or to various parts of the body, or by direct influence of the brain. Relief can usually be given by inhibition of the pneumogastric in the occipital region or by inhibition at the fourth or fifth dorsal vertebra on the right side.

In cases of flatulency, one may frequently cause physiological absorption of the gas by direct pressure on the pit on the stomach. The pressure must be somewhat firmly exerted. It seems to remove obstructions and irritations to the solar plexus. Sometimes one may be able, also, to absorb the gas by correcting lesions to the lower ribs, especially on the left side. The gas may be forced downward into the intestines or, by firm pressure over the stomach, belching will occur. 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 gas from the stomach out through the esophagus.
 

CHRONIC CATARRHAL GASTRITIS

Definition.--A chronic, catarrhal inflammation of the stomach, associated with excessive secretion of mucus and deranged formation of gastric juice, with hypertrophy of the coats of the stomach and atrophy of the gastric glands.

Osteopathic Etiology and Pathology.--Repeated attacks of acute catarrhal gastritis; constant overeating, and excessive use of alcohol are common causes; also excessive use of coffee, tea and tobacco; improper food and imperfect mastication. Chronic injuries and lesions to the vagi and splanchnic nerves are important factors, and are always found.

The disease may be secondarily produced by heart, lung, liver, pleural and kidney diseases causing a passive congestion of the stomach and ultimately the characteristic lesions of chronic catarrhal gastritis. Pathologically, on account of constant hyperemic swelling of the mucosa it bcomes slate colored, hypertrophied and covered with a yellowish white, alkaline, tenacious mucus. The peptic glands undergo granular changes, and finally atrophy of their cells. In more chronic cases parenchymatous and interstitial inflammation may occur, leading to more or less atrophy of the glandular and mucous tissues. Upper and middle dorsal vertebral and rib lesions affect the vaso-motors by way of the spinal and sympathetic nerves and thus cause congestion and degeneration of the stomach tissues.

Symptoms.--The symptoms vary with the extent of the mucous membrane and glands involved. The mucous membrane may be considerably covered with mucus, the secretion of the gastric juice is impaired and altogether digestion is imperfect. There are considerable fermentation and decomposition of the food, and peristalsis is delayed on account of absence of its natural stimulus. Loss of appetite, fullness of the stomach, epigastric tenderness and prominence, nausea and vomiting are common symptoms. The patient is irritable, peevish and gloomy, and the skin is hard, dry and pale. The tongue is coated; there is heartburn, constipation and highly-colored urine; the circulation may be feeble, and there is more or less emaciation. Reflected symptoms may be present, as palpitation of the heart and slow, irregular pulse.

Diagnosis.--There is usually very little difficulty in diagnosing chronic gastric catarrh. A correct diagnosis is important, as this disease may accompany carcinoma and ulcer of the stomach. Dilation of the stomach, diseases of the kidneys, liver and heart may give some trouble in making diagnosis.

Prognosis.--This depends largely upon the cause. If it is secondary to other diseases, the prognosis depends upon the curability of the primary disease. In many instances one can not expect complete recovery, but with careful living the patient may survive many years. Osteopathy has cured many cases that were termed incurable by the other schools.

Treatment.--In cases depending upon other diseases, the treatment of the first disorder is most essential, and very little can be done with the stomach before the primary disease is remedied.

Of first importance in performing a cure is the removal of the errors in diet or other causes that may exist. Then come rest, not only of the stomach, but of the body and mind, and the use of light wholesome food, such as milk, eggs, oysters and green vegetables. The treatment must be persistent and thorough. In some of the cases, see the patient every day. Cases of chronic disorders of the stomach usually present to the osteopath marked lesions in the dorsal region from the fourth to the sixth dorsal vertebra. Occasionally lesions will be found lower in the dorsal splanchnics. A number of cases present lesions in the upper cervical region, undoubtedly affecting the vagi nerves. A few present lesions in the lower cervical vertebrae, possibly affecting vagi nerves, but probably a few fibres of the greater splanchnics occasionally originate as high as the lower cervical.

Treatment over the stomach is of very little use in inflammatory diseases of that organ; in fact, the treatment may be actually detrimental. This, however, does not hold true in debility or atrophy of the stomach walls. The affection is usually a nervous one if there is pain upon slight pressure over the stomach that decreases upon gradual, deeper pressure, and in such instance it is perfectly safe to manipulate the stomach directly. But if the pain increases with the pressure, the affection is probably an inflammatory one.

A lesion at the sixth and seventh dorsal vertebrae may cause pain in the pit of the stomach, by irritating the posterior spinal nerves; in these cases the pain is only superficial, not within the abdomen.

Lavage is a helpful measure in a few severe cases of chronic gastric catarrh, as it washes away the mucus which is a hindrance to the secretion of the gastric juice and nauseous to the patient. It should be performed in the morning before eating.

Careful attention to the habits and mode of living is essential. Pay strict attention to the bowels and kidneys. A lesion occasionally exists at the cartilages of the eighth and ninth ribs in catarrh of the stomach. A correction of such a lesion may be necessary in order to cure certain cases.
 
 
GASTRALGIA
(Stomachic Colic; Neuralgia of the Stomach)

Definition.--A painful affection of the stomach, involving the sensory nerves; paroxysmal in character; caused by various sources of irritation, and not associated with any discoverable organic lesion; feeble heart action and symptoms of collapse.

Osteopathic Etiology.--Of most importance to the osteopath are the lesions of the ribs and vertebrae found in the splanchnic region, involving the sensory nerves to the stomach. Sensory nerves to the stomach are from the sixth to the ninth dorsal inclusive, the sixth and seventh supplying the cardiac end, the eighth and ninth the pyloric end. The eighth and ninth ribs anteriorly are oftentimes involved.

It occurs mostly in women, especially those who are weak, anemic and constipated, and those who are given to worrying. It is also found in women subject to menstrual derangement, and more frequently in brunettes than in blondes; it is occasionally found in healthy and stalwart men. This disease may set in as early as puberty, but is especially frequent and severe about the menopause. General nervous depression, gastric ulcer and cancer, malaria, anemia, dietetic errors, rheumatic or gouty diathesis excessive secretions of hydrochloric acid are all causes of gastralgia.

Symptoms.--The most characteristic is a sudden seizure by paroxysms of severe pain in the epigastrium, radiating to the back and around to the lower ribs. It is of an intermittent, paroxysmal character, and may be due to malaria, but vertebral and rib lesions are paramount. The pain is usually relieved by pressure and by taking food or warm, stimulating drinks. Rarely, nausea and vomiting and nervous symptoms (globus hystericus and unnatural hunger) are found. The attack is independent of the taking of food, and varies in duration from a few minutes to an hour or more. Sometimes the pain subsides gradually and the patient is much exhausted, or the attack may cease suddenly without other symptoms. There may be vomiting, eructation of gas or watery fluid, or a discharge of a large quantity of pale or reddish urine.

Diagnosis.--This affection is to be differentiated from intercostal neuralgia, ulcer, cancer, gastric crises of locomotor ataxia, biliary and intestinal colic. In intestinal neuralgia the pain is not so severe, but of longer duration and follows the course of an intercostal nerve. In gastric ulcer the pain is more continuous; there are constant dyspeptic symptoms, made worse by eating, and often tenderness and vomiting of blood. In cancer, the age, history, constancy of pain, which is increased by eating (in some cases the pain is relieved by taking food), the cachexia, hematemesis, tumor and the visible effects on the general health, distinguish it from gastralgia. Examination will generally discover a different seat of pain in gall-stone colic and there is almost always jaundice. In locomotor ataxia, absence of the patellar reflex, Argyll-Robertson pupil, loss of coordination, and paroxysmal pain in other parts of the body will distinguish the gastric crises of tabes from the simple gastralgia. In intestinal colic the pain is usually localized about the umbilicus and radiates in various directions; besides, deep pressure over the umbilicus relieves the pain.

Prognosis. Never proves fatal. Perfect recovery is usually accomplished.

Treatment.--Relief can be given by thorough inhibition of the splanchnics on each side of the spinous processes of the vertebrae anywhere from the fourth to the tenth dorsal, generally from the sixth to the ninty. Areas of contracted muscles will indicate region for treatment. If impairment of the vertebrae or ribs can be found, the treatment indicated is correction of such displacements. Inhibition of the vagi is occasionally of some aid in relieving the pain and freeing the stomach of any irritating material, by relaxing the pylorus and thus allowing the passage of such matter into the duodenum. In relieving pain in the stomach by inhibiting the vagi, more relief can usually be given by way of the left vagus than by the right. Stimulation of the vagi increases the peristaltic action of the stomach, while stimulation of the splanchnics lessens the peristalsis.

Pressure upon the epigastrium commonly gives relief, but in a few cases pressure is unbearable. Proper care should be given the bowels as intestinal dyspepsia may produce gastralgia. In these cases of intestinal dyspepsia that disturb the stomach, constipation is usually present and a thorough irrigation of the colon at bed time will be beneficial. Absolute rest and attention to the diet in severe cases is necessary.
 

GASTRIC ULCER

This is an ulcer apparently arising without an exciting cause. It undoubtedly follows impaired nutrition of a limited area of the mucous membrane of the stomach, which is destroyed by the action of the gastric juice; the latter being highly acid. These ulcers are usually single and are found in the stomach and in the duodenum as far as the papilla duodenalis. The splanchnics are invariably involved in gastric ulceration.

Osteopathic Etiology and Pathology.--As in various stotmach disorders, lesions of the middle and lower dorsal vertebrae are found. Oftentimes there are lesions of the ribs, corresponding to the middle and lower dorsal region. The ribs may be affected at both the anterior and posterior ends. Especially the anterior ends of the eighth and ninth ribs are likely to be involved. If they are at fault, the immediate locality is sensitive to pressure. The posterior ends of the ribs in the region of the fifth to eighth are apt to be luxated. Other cases present upon examination a slight kyphosis of the dorsal vertebrae. This would probably produce stasis of the blood-vessels and a nervo-muscular atony of the walls of the stomach, consequently weakening the various coats of the stomach. Occasionally the vagi nerves are affected by the upper cervical vertebrae.

It is more common in the female sex between the ages of fifteen and forty, but it occasionally occurs in children and in adults up to sixty years of age. It is frequent among servant girls and men who follow the trade of shoemaking, tailoring, weaving or any pursuit in which the costal cartilages are pressed against the stomach. It may be due to mechanical injury in cases where there is feeble nutrition and the over-acid gastric juice digests a limited spot of the mucous membrane, thus forming an ulcer; or to over-distention of the stomach, interfering with its nutrition, and thus allowing the gastric juice to act. It may be caused by anemia, disorders of menstruation, burns of the integument, heart disease and Bright's disease. Syphilis and tuberculosis are also predisposing causes. Thrombosis and embolism are also the causes of a number of cases. Thrombi, caused by obstinate vomiting, form in the nutrient gastric arteries and the circulation being thus impeded, favors the solvent action of the gastric juice. These ulcers often occur in connection with diseases of the heart and blood-vessels, giving rise to emboli which form in the gastric arteries that have lost their tone. Duodenal ulcers are not as common as the gastric, and affect males more frequently. They are associated with the same causes that produce the gastric.

Pathologically, the ulcer is round or oval, usually situated in the posterior wall of the pyloric portion, near the lesser curvature. It gives the stomach a punched out appearance, having sloping, clear cut sides, conical shape and a blunt apex. They are usually single, but a series of ulcers is not uncommon. The floor of the ulcer is usually smooth and may be formed of any of the coats of the stomach, usually the muscular. It may also be formed by an adjacent organ to which the stomach has become attached. The ulcer is usually small, but may reach an enormous size. In the majority of cases where the ulcers are deep and perforate the coats of the stomach, adhesions take place between the stomach and adjacent organs, especially with the pancreas and left lobe of the liver. When the ulcer is situated on the anterior wall of the stomach it may perforate and excite fatal peritonitis, for adhesions do not so readily take place as when the ulcer is situated in the posterior wall.

There may be erosioins of the blood-vessels, causing fatal hemorrhage. Small aneurisms are sometimes found in the floor of the ulcer. The ulcers may burrow into the adjacent organs, invading the pericardium, spleen, pancreas, left lobe of the liver, gall-bladder, lungs, left ventricle, omentum or pleura. The vessels invaded are the gastric artery of the lesser curvature, the splenic artery from the posterior wall, the hepatic artery and, rarely, the portal vein. In case of a duodenal ulcer, the pancreatic or duodenal artery may become invaded. There may be fistulous communication with the colon or duodenum, and even a gastrocutaneous fistula may form in the umbilical region.

Symptoms.--The general symptoms of ordinary dyspepsia occur. The most prominent and constant symptom is pain with tenderness. This varies greatly in character, from a mere burning or gnawing which is relieved upon taking food, to the characteristic or typical pain of ulcer, which comes on in paroxysms of the most intense gastralgia shortly after eating. The pain is not alone in the epigastrium, but radiates to the back and sides. The pain is usually increased by pressure, but slight pressure often brings relief. Tenderness on pressure is a very common symptom, and this requires the patient to wear the waist-band very loose. It is necessary to exercise care when examining for painful points, for too great pressure may produce perforation. The tender point is usually an inch or two below the ensiform cartilage. Old ulcers of long duration with thickened bases may be recognized by the touch, feeling like tumors that are due to inflammatory thickening of the tissues.

Hemorrhage occurs to a greater or less degree in nearly all cases. Vomiting of pure red blood, which is unaltered and profuse, is characteristic of ulcer. In cases of profuse hemorrhage, quite black blood is found in the stools. Syncope may follow, and rarely death. Intense anemia may result from the frequent recurrence of these hemorrhages. Ulcers may remain entirely latent, or there may be symptoms of dyspepsia of various grades and loss of weight from the prolonged dyspepsia. Perforation occurs in about six and one-half per cent of all cases, though this is not necessarily fatal. The acute perforating form occurs most frequently in women.

Diagnosis.--Hemorrhage with the gastralgia attack is the most characteristic symptom. This, with the other symptoms already named, make the diagnosis of ulcer conclusive. It is frequently impossible to diagnose between gastric and duodenal ulcers, as the symptoms resemble one another so closely. Gastric ulcer is sometimes confounded with gastralgia, gastric cancer, chronic gastritis, occasionally with gall-stone colic, rarely with intercostal neuralgia and the gastric crises of locomotor ataxia. In gastralgia the general health of the patient is less frequently impaired, there is less dysmenorrhea and chlorosis, and the pain is generally relieved upon taking food. Pressure always relieves the pain and there are longer intervals between the attacks, while in ulcer there is pain upon pressure between the attacks. Gastric cancer usually occurs after forty, and the history, extreme emaciation and cachexia, palpable tumor, absence of hydrochloric acid, presence of lactic acid, and coffee-ground vomit differentiate it from ulcer. In chronic gastritis there is absence of vomiting of blood, tenderness diffused more in the back, no constant pain, gastric acidity less than normal, and symptoms of indigestion are persistent and well marked. In gall-stone colic the presence of jaundice, sudden onset, sudden termination, congestion and tenderness of liver make the diagnosis clear. In intercostal neuralgia there may be pain in the epigastrium and slight symptoms of dyspepsia. On examination the pain will be found to follow the courses of an intercostal nerve and tender points will be found along its course. In gastric crises of locomotor ataxia the patient has the appearance of fairly good health, the acidity of the gastric juice is wanting, and the distinctive symptoms of this disease are present.

Prognosis.--Guardedly favorable; many cases are cured; others terminate in fatal hemorrhage or perforation followed by peritonitis.

Treatment.--In gastric ulcer, rest in bed is important. Great care must be taken with the diet of the patient. The secretory and motor functions of the stomach should be rested as much as possible. Milk is probably as good food as any; let the patient have an ounce or two every two hours. If the stomach needs complete rest, rectal alimentation is to be employed. In that case, care must be taken not to tax the power of the lower bowel too greatly; four ounces of milk every five hours will be sufficient. When the patient is convalescent, beef juice, gruels and eggs may be substituted.

The pain can be lessened by thorough inhibition of the splanchnics and the vagi. Hot applications over the stomach will be helpful. Vomiting may be an annoying symptom, in which case thorough work at the fourth and fifth dorsals (best on the right side), or inhibitory treatment of the vagi will usually relieve it. Lavage of the stomach is good in some instances.

Everything should be done to build up a healthy stomach. If the stomach disorder is secondary, it will be necessary to relieve the primary disorder first. When otherwise, primary trouble will be found with the innervation of the stomach; and as in other stomach diseases, lesions are commonly found from the fourth to the sixth dorsal vertebra, or slightly lower, or else in the atlas or axis, involving fibres to the pneumogastric.

Hemorrhage of the stomach, hematemosis, may be a troublesome symptom, and is a condition in some cases hard to overcome. Surgical assistance should be immediately considered. Rest in bed is absolutely necessary. The treatment of hemorrhage of the stomach is through the splanchnic and vagi nerves, to relieve the pressure in the affected blood-vessels. Swallowing pieces of ice, cold over the stomach, treatments of the cervical region, heat to the legs, and a bandage around an arm or leg will be of aid.

In all cases of gastric ulceration, careful attention should be given to vaso-motor control of the stomach by the splanchnics; to the condition of the anterior ends of the eighth and ninth ribs, with their cartilages, and to the careful removal of any lesions that may exist to the vagi nerves.
 

GASTRIC CANCER

Osteopathic Etiology and Pathology.--Little is definitely known in regard to the cause of cancer. Senn (Pathology and Surgical Treatment of Tumors, p. 23) says: "A tumor never originates, do novo, but is always an integral part of the organism, the product of tissue-proliferation from a matrix of embryonic cells....The structure and character of a tumor depend upon the stage of the arrested cell growth and the embryonic layers from which the matrix is derived."

Adami (Allbutts System of Medicine, Vol. I, p. 113) in speaking of inflammation, continues the thought that "neoplasms as a class, whether malignant or benign, not improbably develop as a consequence of some irritation having an intensity just sufficient to induce cell proliferation, and continued for a time sufficiently long to impress upon the cells of the affected tissue the habit of rapid multiplication." With this an accepted theory as to cancer formation, there is no difficulty in supplying the irritating cause for in our osteopathic experience cancers seem to be due to an irritating lesion to the various tissues, as the displacement of some tissue interfering with a nerve by irritating the whole or part of its rifbres, or to obstruction of a vascular channel, as a vein or lymphatic duct. Probably vaso-motor or trophic nerves may be impaired by lesions and thus involved the tissues suppleid by these nerves, no matter how remote from the lesion. These are doubtless the predisposing causes of cancers, by lowering the vitallity of involved tissues. Possibly micro-organisms are important exciting factors. Gastric cancers are usually found in the male sex in adult life. Ulceration of the stomach, and possibly heredity, are predisposing causes.

After the uterus, the stomach is the organ most likely to be affected by cancer. Cancer of the stomach is usually primary. Eighty per cent occur at the pylorus. Epithelioma and soft cancer are the most common varieties.

Dilatation of the stomach occurs, especially if the cancer is at the pylorus and causing obstruction. The stomach is usually reduced in size, and thickening and hardening of the tissues take place. The lymphatic glands adjacent to the stomach are infiltrated. Perforation into an adjacent organ may occur, as into the transverse colon or small intestine, or even into the peritoneum, causing peritonitis.

Symptoms.--Gastric cancer develops insidiously and progressively with all the general symptoms of dyspepsia, besides continued pain and tenderness. Pain and vomiting occur immediately after eating if the cancer is at the cardiac orifice, and a few hours after eating if at the pyloric. the vomit often contains dark, "coffee-ground" material, due to hemorrhage, the blood being altered by gastric juice. Free hydrochloric acid is absent from the gastric juice, and there are anemia, emaciation, edema of the ankles, presence of a tumor in the ipigastrium not moving with inspiration, and involvement of the superficial lymph glands, especially the supra-clavicular and inguinal glands. Lactic acid is present. Jaundice may occur if the liver is large. The urine is often scanty and may contain albumin. The duration is from one to two years.

Diagnosis.--The differential diagnosis of gastric cancer from ulcer, gastralgia and chronic gastritis is made under gastric ulcer.

Prognosis.--While the prognosis is unfavorable, life may be prolonged by the use of proper food, cleansing the stomach, attention to the general health of the patient and surgical measures.

Treatment.--Try to locate the cause by a thorough examination of the dorsal vertebrae and ribs; these should be carefully examined to locate lesions that might occur in the splanchnic and vagi nerves and thus affect the blood and lymphtic supply to the stomach. In view of the fact that considerable progress has lately been made in the early diagnosis of gastric cancer (see late works on diagnosis), whenever there is the least suspicion of cancer, thorough chemical and microscopic analysis of the stomach contents should be made. In this way early and satisfactory surgical interference may be resorted to. Although in several cases osteopathic treatment has proven beneficial, still, at the present time, early and radical surgical measures should rule.

Great care should be taken in the preparation of food. Artificially digested foods should be used so that the labor of the stomach may be diminished, and if necessary the patient should be fed rectally, that the stomach may be rested entirely. The stomach should be washed out with tepid water once a day or every other day. The best of care of the general health must be taken, and all stimulants prohibited.
 

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; from hypertrophic thickening (simple or cancerous) and congenital and pressure strictures from without by a tumor or a floating kidney. In the latter case the 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 lessened acidity of the vomited mass. 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 out. 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 tympanitic 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.

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 fibres of the splanchnic nervs or through fibres 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 fibres 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 fibres of the stomach, mainly the circular fibres. 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 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 enlarge. (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 process of the body is impaired at its very beginning.

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.
 

GASTROPTOSIS AND ENTEROPTOSIS (See special article, Prolapsed Organs, Part I)

(Glenard's Disease)

Definition.--A downward 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. Other causes are muscular strain, repeated pregnancies, tight lacing and malnutrition. A downward displacement of the floating ribs, and a consequent prolapse 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 varius 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) prolapssed as a consequence, but all of the abdominal viscera and the parietes of the abdomen are also prolapsed and crowded down upon 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.

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 atonized viscera and abdominal parietes. Direct treatment over the abdomen help 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. The diet of the patient should be nutritious. In a few cases a supporting bandage will give some relief.

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 necesssary proceeding, and to be performed twice daily on retiring and before rising. Of equal importance with the osteopathic treatment, will 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 aabdominal contents towards the diaphragm, in regular series. These exercises must be faithfully performed and continue 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 conscientioiusly, 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

(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 toxic 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 often produce intense intestinal catarrh. 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 acute diarrhea. 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. This is a very common cause. Infectious diseases, through their specific poisons, as cholera, dysentary 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 profound 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 vertebrae 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, vaso-motor or secretory fibres 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 than 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 vaso-motor paresis of the intestinal vessels, producing an outflow of the serum.

The intestinal condition is one of hyperemia. 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 of the large and small bowels become unnaturally distinct. These enlargements may become filled with pus, forming abscesses which rupture, leaving an ulcer. Peyer's patches may be prominent also.

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 portions of undigested food, flakes of mucus, columnar epithelium and mucous cells, micro-organisms, oxalate of lime and cholesterin. 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. 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. The general health is greatly disturbed, and the patient suffers from anemia, emaciation, weakness and depression of spirits.

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 boraborygmi and thin, soupy stools, mixed with much mucus. If the lower portion of the bowel is involved there may be marked tenesmus.

Duodenitis is usually associated with acute gastritis, and, if the inflammation extends into the bile duct, there is jaundice; in these cases the urine may be bile-stained.

Prognosis.--Favorable if early and prompt treatment is employed.

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 helpful. The spinal column should be examined, especially on the left side fom the fifth dorsal down to the coccyx. The vertebrae may become displaced and cause diarrhea, by derangement of the vaso-motor 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 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 vertebrae and ribs are the essentials of treatment for diarrhea. Inhibition of the lower dorsal and lumbar is very effective; it dilates the mesenteric vessels by way of vaso-motor fibres, and thus controls secretions and lessens peristalsis. This has been clearly proven in the osteopathic experimental work of Burns and Pearce.

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. The liver should be kept active, for although the bile is a natural purgative, it is also an antiseptic to the intestinal contents and thus prevents decomposition and possibly a diarrhea. Treatment of the vagi 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
(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 slight chronic lesions of the lower ribs or lower dorsal or lumbar vertebrae. 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 palor, and the patient becomes emaciated, gloomy and irritable.

Mucous Colitis, or Membranous enteritis 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. Mental emotions and worry, sometimes errors in diet, or dyspepsia bring on the attack. 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 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 ileocecal, hepatic flexure, transverse colon, splenic flexure, sigmoid flexure, and rectal regions. The first 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 weater 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 (Von Noorden, Colitis, 1904) 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 entero-colitis.
 

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, with enlargement of the lymph follicles. In fact, the same changes take place as those described in the cnteritis of adults.

Symtoms.--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 disease may set in abruptly with vomiting, purging, griping pains and fever which rises rapidly to 103 or 104 degrees, 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 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 very 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.
 

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 entero-colitis.

The pathological changes are identical with the morbid anatomy of catarrhal gastritis and enteritis. The serous discharges and rapid collapse are due to the intense irritation of the sympathetic system.

Symptoms.--The disease is of sudden onset, setting in with incessant vomiting, which is excited by any attempt to take food or drink. The stools are copious and frequent, at first containing some offensive fecal matter, brown or yellow in color, later becoming thin, watery, serous and odorless. There is decided fever, reaching as high as 105 degrees; the temperature should be taken in the rectum, as the axillary temperature may be three or more degrees below that of the rectum. The pulse is rapid and feeble, ranging from 130 to 160. There is marked prostration from the onset, with pinched features, hollow eyes, depressed fontanelles, cold surface and ashy pallor. 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 great elevation of internal temperature. In other cases there are restlessness, convulsions and coma. As there is no cerebral lesion, this condition is, no doubt, due to toxic agents absorbed from the intestines.

Diagnosis.--This is not difficult, as the constant vomiting, the frequent watery discharage, rapid emaciation and prostration, and the hyperexia 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 absolutely cleanliness are of great importance. Thorough ttreatment 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 bettter still, wrapping the child in cold, wet sheets, will reduce the hyperexia.

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 ENTERO-COLITIS

In this form of diarrhea 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. Lesions in the spine occur from the eleventh dorsal to the fourth lumbar.

The mucous membrane is congested and swollen, 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 infiltraiton and thickening into the submucous and muscular coats, followed by induration of the tissue, producing abnormal rigidity.

Symptoms.--The disease may be a sequela 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, and are passed without pain. 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, 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.

Diagnosis.--Entero-colitis 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, hyperexia and an early collapse.

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. When the ileum and colon are involved, disorder is usually present at the third and fourth lumbar vertebrae, 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.
 

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, ashen 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 gastrointestinal 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 the abdomen.

The vomiting is relieved principally at the fourth and fifth dorsal vertebrae 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.

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

Osteopathic Etiology.--Lesions of the splanchnics, causing irritation of the sensory nerves to the intestines, are the most common causes. The splanchnics also contain inhibitory and vaso-motor nerves to the intestines. Indigestible food, flatulency and impaction of feces oftentimes produce intestinal colic. Foreign bodies, intestinal worms, abnormal amounts of bile discharged into the intestines, and reflex causes from diseases, as from the ovaries, uterus, liver, spine, etc., will produce the disorder; also lead poisoning, syphilis, rheumatism, locomotor ataxia, chronic malaria and hysteria.

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 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. 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 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.

Prognosis.--Most favorable. Rarely a case terminates fatally.

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. If disorders of the spinal volumn 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 merely a reflex sign and is one instance that goes to prove a double conductivity of nerve force, or, 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 readily 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 be controlled (sensory nerves), 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 the third lumbar; if in the colon, at the third to the fifth lumbar; and if in the rectum at the sacral and coccygeal nerves. Occasionally the duodenum and jejunum are reached by nerves as high as the fifth dorsal (usually vaso-motor 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 (vaso-motor nerves).

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. 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.

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 formation are absorbed. Additional treatment to the lower dorsal vertebrae and lower ribs to relieve nerve lesions may be indicated.

As stated in the etiology of intestinal colic, the splanchnic nerves contain not only sensitive fibres to the intestines, but motor and vaso-motor fibres 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. The diet should always be regulated for a few days at least.
 

CONSTIPATION (See Philosophy and Mechanica. Principles of Osteopathy, p. 190)

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 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 constipaton 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 the majority of cases lesions will be found in the vertebrae 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 infrequent 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, 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 effects 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 vertebrae are at fault. Constipaton 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 vaso-motor, motor and secretory nerves of the intestines may be affected by various lesions. The vaso-motor 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 r eason offered as to why this is so. 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 considers 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 fibres of the vagi, occur occasionally. Stimulation of these fibres 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, 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 haphazard 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 of the fingers 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 (Journal of Osteopathy, May, 1900) 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 regioins 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.

Direct treatment to the liver and biliary ducts is necessary in many cases, as the bile is the natural purgative; 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. 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. An enema (For points on enema, see treatment under Intestinal Obstruction) occasionally is indicated and is a great aid when used, particularly in cases of paralysis of the intestines and in impactions. Correct breathing is beneficial.

Treatment of the Constipation of Infants.--Repeated small enemata at a fixed hour each day are probably the best treatment, as the proper manipulation, with regard to method and amount of force necessary, is impossible to be judged properly. Two ounces of tepid water at a time should be injected. Massage to the abdomen will be useful, as will slight dilatation 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.
 

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 and strictures and tumors.

Strangulation.--This is the most frequent cause of acute obstruction of the bowels. There may be strictures 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 the mesentery or abdominal wall and thus form a ring through which the gut may pass and become strangulated.

Strangulation may take place in 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 tube and diaphragmatic hernia may be other causes. An external 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 of a stoppage of the 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 and the middle and inner layers increase in length at the expense of the outer layer. This produces compression and inflammation 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 thrown out which may cause the layers of gut to adhere, so that the invaginated portion cannot be drawn out. 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 descends into 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 a 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 by 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 gallstones, enteroliths, lumbracoid 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 (Diseases of the Intestines, Vol. 1, p. 240) 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 dilatation 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. Bandel speaks of a case diagnosed as brain fag which was accompanied by increasing prostration and weakness to the point where a fatal issue was feared It was in reality a colon impacted throughout its entire ength. Absorption was so great that the colon could be outlined by discoloration of the skin. Quick recovery followed the unloading of the bowel. The heart may be affected by weight upon the vessels, gastric disturbances and signs of autointoxication from absorption may appear.

Dilatation of the sigmoid flexure, especially when 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 are of much less importance than the other causes of acute obstruction, but they are common causes of chronic obstruction. Occasionally a stricture may be spastic, due to vertebral lesions. Paralysis of a section of the intestine may take place.

Strictures may be: (1) Congenital, commonly causing complete occlusion, as is seen in the imperforate anus, and defective union between the duodenum and pylorus. (2) Cicatricial stenosis, from ulceration produced by dysentery, typhoid fever, tuberculosis and syphilis. (3) New growths, from any of the benign tumors or from malignant tumors, chiefly cylindrical epithelioma about the sigmoid flexure. Tumors external to the bowels or in the pelvis may cause intestinal obstruction by compression.

Symptoms.--Acute Obstruction.--Constipation, nausea, vomiting, and pain are the four important symptoms. 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; 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, or the sufferer gradually regains health.

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. Intestinal obstruction may be confounded with tumors, 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 discharge and cachexia will be important symptoms.

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. 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. The nutrition of the patient is best retained by rectal injections of food.

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 most impactions it is important to get the water into the ascending colon, as that is their usual location. For that purpose nothing is better than a steel sigmoid irrigator. This is shaped somewhat like the letter S and 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 bowl 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, then 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 Trendelenberg 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.
 

APPENDICITIS

Appendicitis is an inflammation of the appendix vermiformis. In a number of cases the cecum and surrounding tissues are involved (typhilitis, perityphlitis). The vaso-motor nerve supply comes from the lower three dorsals and the 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, by vertebral derangements or sub-dislocations 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 (The Lancet, (London,) Oct., 1904) 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. This is in keeping with the ideas of Dr. Still, who has 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 lymphatics 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 (Philosphy of Osteopathy, p. 226) suggests that the appendix has a sphincter, also the power to contract, dilate or shorten, should any foreign substance enter, and he has worked with this idea in view with uniform success. 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 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 pyrogenes aurei, 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 vertebrae 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 superior 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 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.

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 micturation. 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 with nausea and vomiting, fever, and local tenderness present in all cases may indicate a wide-spread infection of this membrane." (Osler). He also says local signs are not so trustworthy as the general symptoms.

There is liability to relapses in appendicitis. 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 n the right iliac region are three symptoms that together almost positively indicate appendicitis. 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 ililum. 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 Widala 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 (The Vermiform Appendix and Its Diseases, p. 711) 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 the 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* 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.

Treatment,--Confine the patient in bed at once. Cases have undoubtedly been lost by not enforcing this point. Attempt 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 vertebrae. If the case is seen at the beginning of the attack, thorough manipulation over the right iliac fossa and local application of ice are indicated. 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 impactions 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 nor 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 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. H. Wakefield (Cyclopedia of Practical Medicine, June 1906) says he has never had a case go to operation or fail of recovery. He lays particular stress on keeping the bowel open, non-irritation by drugs, and avoidance of easily fermenting foods as prophylaxis, and among other directions in treatment, "Well adapted massage and kneading over the visceral region are of service in hastening the return to normal."

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 (Journal of the American Osteopathaic Association, Dec., 1903) 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.
 
 
DISEASES OF THE LIVER AND BILE DUCTS

There are several diseases of the liver and bile ducts, such as carcinoma of the biliary tract, stenosis of the ducts, pylethrombosis, fatty liver, perihepatitis, etc., purposely left out, as they are either of rare occurrence in which there has been no osteopathic experience, or else almost wholly require surgical interference. The osteopath has had, on the whole, excellent results in the treatment of liver diseases; yet no one can expect to accomplish the impossible or get good results when the liver (or any other organ) is so organically changed that very little normal tissue remains. 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 vaso-motor fibres. Displacements 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 arterial, passive when venous.

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 vertebrae and ribs, irritating vaso-motor nerves, are important. Habitual constipation, malaria, heat and arrested menstrual epoch, and infectious fevers are also causes of the active form.

Passive hyperemia is due to obstructions of the venous circulation. Valvular heart disease is the most common cause. Lung diseases, as emphysema or cirrhosis; obstruction to the vena cava or causes interfering 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 vaso-motor 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).
 

SIMPLE CATARRHAL JAUNDICE

Definition.--Jaundice due to inflammation of the terminal portion of the common duct, not the result of impacted gallstones. The bile is retained and absorbed.

Osteopathic Etiology and Pathology.--A frequent 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 may be a cause. 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.

Diagnosis.--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 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. 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.

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 fibres 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. When all of the muscles of the hepatic region have been carefully relaxed and softened, a thorough examination can then be made of the vertebrae and ribs that might embarrass the innervation or vascular supply of the liver. Lesions of the vertebrae 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 has been practiced. The cold is supposed to excite peristalsis of the gall-bladder and ducts and thus aid in the expulsion of the mucus. 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 albumen and pressed beef juice. After the pain, vomiting and fever subside, the diet can be gradually increased.
 

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.

Osteopathic Etiology.--There are two forms of jaundice, hepatogenous--caused by a suppression of the function of the liver cells, as found in acute yellow atrophy, malaria, pernicious anemia and certain fevers; and hematogenous--due to disintegration of the blood. The supposed cause of the latter form has recently been found to be of rare occurrence, if ever present; that is, the hematogenous form is also due to obstruction.

There are various causes of jaundice. The immediate cause is a deposit of pigment in the skin. 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 vertebrae and the ribs from the sixth to the eleventh, will affect the liver markedly by lowering the blood pressure in the liver, so that the tension in the smaller bile ducts is greater than in the blood-vessels. Also, lesions at these points may cause inflammation and tumefaction of the bile ducts.

Symptoms.--Hepatogenous.--This form may be found at all ages, usually though in children. 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 ey Sweating is common and localized in the abdomen and palms of the hands. The secretions are colored with the bile pigment. It may be noticed in urine before being apparent in the skin or conjunctiva. The perspiration is colored, rarely the saliva, tear and milk are colored, and oftentimes the expectoration is tinted.

As very little bile passes into the intestine, the feces are pale gray or slate gray color and usually fetid and pasty. The bowels are generally constipated, but diarrhea may occur, owing to decomposition resulting from absence of the natural antiseptic ingredient. Other symptoms may be associated with the gastrointestinal 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 often occur 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 trapesius muscle.

Various cerebral symptoms may be present, as great depression of spirits, irritability, headache and vertigo. Vision is variously affected. Owing to the ingredients of the bile gaining entrance to the blood, grave nervous symptoms occasionally are manifested, as sudden coma, delirium and convulsions, attended by fever, rapid pulse and dry tongue--the symptoms of the so-called "typhoid state."

In the hematogenous form the destruction of blood is due to some toxic agent. The feces are not clay colored and the urine is less stained with bile. Among the diseases causing this form are acute yellow atrophy, yellow fever, bilious fever, typhus and typhoid fevers, pyemia and snake poison.

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. The hematogenous form usually terminates fatally, owing to the disease causing it

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.
 

ABSCESS OF THE LIVER

Abscess of the liver is a diffused or circumscribed inflammation of the cells of the liver, resulting in suppuration.

Suppuration within the liver, in the parenchyma or blood or bile passasges, may be produced by various causes. The amoeba coli of dysentery is occasionally transferred from the intestines into the liver. Traumatism is sometimes the cause. Foreign bodies and parasites, such as gall-stones; retained bile, which causes suppuration of the bile passages; hydatid cysts; and in rare cases, foreign bodies (as a needle or fish bone from the stomach) pass into the liver, and lodging there are the exciting causes of an abscess. Septic emboli.--Nearly all the abscesses of the liver may be traceable to microbic origin. They may come through the hepatic artery, but more often reach the liver through the portal vein, which brings septic emboli from ulcers of dysentery, typhoid fever, typhlitis, or from gastric ulcers. There may be an embolus which arises in the left heart, reaching the liver through the hepatic artery. Even a non-infectious embolus may be the cause of an abscess by coming in contact with pyemic organisms brought to the liver through other channels and lodged there. These emboli generally originate in the lungs and left heart or arise beyond if they are small enough to pass through the capillaries of the pulmonary artery. In fact, these embolic or pyemic abscesses may be caused by infection in the area of the systemic circulation and carried through the portal vein or hepatic artery. The emboli may even, instead of passing through the lungs, reach the liver through the inferior vena cava. Much more commonly, however, infection is brought through the portal vein from ulcerative infections of the bowels in dysentery, appendicitis, rectal affections, abscesses of the pelvis and sometimes after typhoid fever. These conditions produce a purulent inflammation of the portal vein (suppurative pylephlebitis).

Pathologically, the right lobe is the most frequent seat of abscess, more toward the convexity than toward the concave side. The abscess may be single or multiiple and varies in size. It may be very small, or it may convert the whole right lobe into an abscess cavity. The liver is proportionately enlarged and rarely the abscesses communicate with one another. Although the liver is enlarged, the external appearance may be unchanged, but if the abscess is near the surface there may be a prominence and fluctuation may be recognized. Sometimes the liver adheres to the viscera or abdominal wall. The walls of the abscess cavity are usually ragged and have no definite limiting membrane; but in chronic cases the abscess wall may be firm and thick. Septic or pyemic abscesses are always multiple. The liver is uniformly enlarged and on section there may be found what looks like solitary abscesses, but it will be found upon examination that they communicate and that probably the entire portal system in the liver is involved.

Symptoms.--Hepatic abscess is marked by fever, high in the evening and low in the morning, resembling very much intermittent or remittent fevers. There are pain, usually in the hepatic region, chills, sweats, and slight jaundice, marked jaundice being rare. Emaciation is a common symptom. The liver becomes enlarged and if the abscess is near the surface there may be bulging and fluctuation, limited tenderness and throbbing. This enlargement is usually upward into the mammary and midaxillary regions rather than downward, and is most marked in the right lobe. It is not entirely due to the presence of pus, but also to the swelling of the cells and to hyperemia. Constipation may occur or there may be diarrhea, which is important in the diagnosis as amoebae are found in the stools. The abscess may burst into the lungs, pleura, intestines or stomach or it may perforate externally, occasionally breaking into the pericardium.

Diagnosis.--Abscess of the liver may be mistaken for intermittent fever, or typhoid fever. Then it is sometimes confounded with the intermittent hepatic fever of gall-stones or impacted calculus, but in that case there will be a history of hepatic colic, and jaundice is much more marked. It should be remembered that abscess of the liver is usually secondary to dysentery, or suppurative disease in some part of the body, as from ulceration of the rectum or stomach.

Prognosis.--Generally unfavorable, but modern surgical measures have reduced the mortality.

Treatment.--The treatment is largely surgical, but cures can at times be performed by thorough treatment of the dorsal liver splanchnics, and by treatment of the pneumogastric, as it contains a great many of the vaso-motor nerves to the liver. The phrenic and the sympathetic, by way of the inferior cervical ganglion, form part of the innervation of the liver. The case must be watched most carefully. To determine the cause will be the most valuable aid in deciding on the treatment required. Use care in regard to diet.
 

HEPATIC CANCER

Hepatic cancer occurs next in frequency to that of the uterus and stomach. Severe subdislocations of the vertebrae and ribs corresponding to the liver splanchnics are usually found on examination. These lesions affect the vaso-motor nerves to the blood-vessels or lymphatics of the liver, or possibly the trophic nerves to the liver tissues are involved. Traumatism and mechanical obstructions are also important. Certain micro-organisms are possibly exciting factors. Heredity may be a cause. The disease may be secondary by extension from other organs. Carcinoma, which is comparatively common, is generally secondary in the liver. It is usually found in males between the fortieth and sixtieth years.

Pathologically, the chief forms of cancer of the liver are the nodular and massive. The nodules in the nodulary form vary in sizes from one-fifth of an inch to two inches in diameter and are found throughout the entire organ. They are opaque, of a yellowish white color, and the superficial ones may occasionally be felt through the abdominal walls. The nodules are both primary and secondary. In the massive form the lesion is one large cancerous mass, sometimes as much as six inches in diameter, and of a grayish white color. This form is primary.

The primary form of cancer starts in the liver cells and thus a stroma of independent growth is added. The secondary form results from emboli, usually through the portal vein, but occasionally through the hepatic artery, and thus the liver cells become affected. In time the hepatic cells undergo atrophy caused by the pressure of the new growth. The portal circulation becomes blocked, owing to compression and atrophy of the branches of the portal vein, while the branches of the hepatic artery are enlarged and permeate the new growth. Sarcoma is a secondary involvement.

Symptoms.--The enlargement of the liver, and increased nodules may be present upon examination. Other symptoms are loss of appetite, nausea, dyspepsia, flatulency, constipation, epigastric fullness and tenderness over the hepatic region. Pain is a common symptom. Fever rarely occurs. There are jaundice, a cold, dry skin, with emaciation and characteristic cachexia.

Diagnosis.--The age, history, cachexia, enlargement of the liver, with nodules, pain, tenderness and a rapid course are the points of differentiation. Diagnosis has to be made from pyloric, intestinal, and kidney tumors, gall-stone impaction, liver abscesses and echinococcus cysts.

Prognosis.--Terminates in death after a course of a few months to a few years.

Treatment.--Indications for treatment are to relieve the suffering of the patient, and if a careful study of the case is made and thorough, persistent treatment is given, life can be consideraably prolonged. The suffering can be at least lessened by early symptomatic treatment.
 
 
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. The abuse of spiritous 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 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 death 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 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.--In the most extreme cases of this 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 sllight jaundice appears at the onset, which gradually deepens until it is intense and persistent. Occasionally there is fever. There is neither ascites, hemorrhage nor enlargement of the spleen, but there is enlargement of the liver with tenderness; there being apparently no hyperemia of the stomach or bowels. The urine is often bile-stained, but of normal quantity. It is likely to run a rapid course. On examination the liver is smooth and round and can be felt below the ribs.

Diagnosis.--In atrophic 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 slightly 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 casees the disease cana 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 out-door 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.
 

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 vertebra, 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 changes 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 lilkely 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 vaso-motor nerves of the portal system (fifth to last dorsal) should be treated thoroughly.
 
 
ACUTE YELLOW ATROPHY OF THE LIVER

Definition.--A disease characterized by marked jaundice with rapid destruction and general inflammation of th hepatic cells (the size of the liver being markedly reduced), and by great disturbance of the nervous system.

Etiology and Pathology.--This disease is of rare occurrernce and more frequently found in women than in men. It seems to be assoc