The Practice of Osteopathy

Dedicated
To the Memory
of
Andrew Taylor Still

First Edition	1899
Second Edition	1902
Third Edition	1906
Fourth Edition	1920

PART FIRST

What Hippocrates was to the Allopath, what Hahnemann was to the Homeopath, Andrew Taylor Still is to the Osteopath, and it is safe to say that when another century shall have rolled away, his fame will be equal to that of either. That he is a maker of history, even the most skeptical will admit. His teachings are revolutionary but are borne out in fact, and on that as a foundation, is built the superstructure of the young therapeutic giant—Osteopathy.

It would be of great interest to trace the history of the first inception of the thought that drugs were not only unnecessary but harmful, then view the struggle to grasp something tangible to take their place, then see the development of the idea that the human body has within it all that is needed for its upbuilding and repair until he came to this fundamental: “The power of the artery must be absolute, universal and unobstructed or disease will result. The moment of its disturbance means the period when disease begins to sow the seeds of destruction in the human body; and in no case can it be done without a broken or suspended current of arterial blood,” capped by the epoch-making discovery of the cause for this interrupted flow of the blood stream—the theory of obstruction by anatomical displacement. It is the only theory of the etiology of disease that will stand the test of science and its acceptance and practice means a revolution in the field of therapeutics.

As it is, he sets the exact date, June 22, 1874, when the light dawned and he saw the outline of his great philosophy—Osteopathy. Then came the years of adversity and struggle. With the eye of a prophet he saw the future of that philosophy, and with the firmness of a Spartan has defended it since birth. It must be a separate, distinct system. Outside the fact that it was to heal the sick and was founded on a knowledge of anatomy and physiology it had nothing in common with existing schools, and if it were ever to grow it must be alone, for his brother practitioners would have none of it and if left to their tender mercies it would have “died a-borning.” Even had it been taken up the result would have been the same for they would never have fully developed it. And so through the lean, terrible years he struggled, buoyed by the faith of a discoverer, urged on by love of this child of his brain, fanatical in his determination to win. And win he did for it was vouchsafed to him in his vigorous old age to sit on his hearthstone and see the results of his work, his struggle and his faith. It is something to know that his fame has circled the earth, to be honored and sung by millions; a boon not accorded many a sage or philosopher. Not only has the public accepted it but the medical profession is making tardy but forced recognition of certain cardinal principles of osteopathy by using them, but, of course, without credit.

Osteopathy has been defined as “that science or system of healing which emphasizes, (a) the diagnosis of disease by physical methods with the view of discovering, not the symptoms but the cause of disease in connection with misplacements of tissue, obstruction of the fluids and interference with the forces of the organism; (b) the treatment of disease by scientific manipulations in connection with which the operating physician mechanically uses and applies the inherent resources of the organism to overcome disease and establish health, either by removing or correcting mechanical disorders and thus permitting nature to recuperate the diseased parts, or by producing and establishing antitoxic and antiseptic conditions to counteract toxic and septic conditions of the organism or its parts; (c) the application of mechanical and operative surgery in setting fractures or dislocated bones, repairing lacerations and removing abnormal tissue growths or tissue elements when these become dangerous to organic life.”[1] In a word, osteopathy is adjustment and the osteopath is an anatomical engineer who knows what is wrong and has the ability to correct it. Dr. Still changed diagnosis from guess work to fact and on it his fame may well stand, for when the cause of the disease was found, treatment was easy. He has ever emphasized the necessity of thorough examination and correct diagnosis. All treatment must be based on the definite, specific object to accomplish certain definite, specific things.

“Osteopathy would expound and apply the true philosophy of manipulation. While the hands are used, it is not this alone and chiefly that distinguishes its method of operation, but the idea and purpose that lie behind manipulation.”[2]

All manipulators are not osteopaths any more than all butchers are surgeons. The need for deep study of the subject is apparent from this characteristic statement of Dr. Still’s: “Osteopathy is a science; not what we know of it, but the subject we are working is deep as eternity. We know but little of it. I have worked and worried here in Kirksville for twenty-two long years, and I intend to study for twenty-three thousand years yet.”[3] This brings us to the point of the relations of osteopathy with other manipulative forms of treatment. They are not many, for Gerdine,[4] in closing a long article on the “Physiological Effects of Mechanical Therapeutics” says: “I have striven to show that in no way is Osteopathy similar to massage either in theory or practice if Osteopathy is conceived of, according to its founder, Dr. A. T. Still, as a system of healing in which a definite lesion in form of a bony displacement is the causative factor and a removal of the same, the curative factor in disease.”

The fact that use is made of the hands to the extent it is by both osteopaths and masseurs or Swedish movement operators gives rise to the mistaken idea of similarity in treatment.

“The essential distinction,” says G. D. Hulett, “between Osteopathy and all other systems of healing based on manipulation, clusters around the etiology of disease. While these other systems, as indicated at least by their practice, look at disease from a peripheral standpoint, osteopathy views it from a central standpoint.”[5]

Massage is a small branch of manipulative therapeutics, but conceding that it is perfect and scientific it can only resemble osteopathic treatment in one ramification of osteopathic practice, viz: relaxation of muscles.

The fact that massage is often employed by osteopaths in connection with their work shows the limitations of that form of treatment. Says McConnell[6]: “In the human body, as in any delicate, complicated mechanism, there is mechanism within mechanism; and, in order to obtain certain mechanical effects, many times there is required a series of complicated movements, all of which bear a ratio one to the other according to the energy utilized and the mechanical principle involved.” No other form of manual treatment takes this principle of mechanics into consideration. It is possible, as Gerdine points out, for an undeveloped osteopath to practice massage under another name. That the two should be confounded before the public is due to his ignorance and not from any fault of the system. Massage is a valuable aid in the treatment of disease but it is not Osteopathy.

“In the bright lexicon of osteopathy there is no such word as rub[7].”

Osteopathy in its relation with medicine has little in common. From the beginning, its founder realized their paths should run divergently, so the first step, its teaching, must be considered from a different viewpoint. To quote from an address by Teall[8]: “But to adequately teach osteopathy a vast amount of original work must be done. Anatomy is anatomy but there is a vast difference in its application. Physiology must be taught to mean something more than an interesting phenomenon. Pathology has an unfilled gap between cause and effect which must be bridged. The post-mortem has a great story to tell but an osteopath must tell it. A slide of degenerated tissue under the microscope is of interest, but why the degeneration? It is described at length by the authorities, but the reason for the causes and morbific changes are not carried out. Obstetrics along strictly natural and physiological lines insuring both mother and babe against injury; gynecology, minus the knife and plus common sense; all these, and more must be put into shape to teach the osteopathic student. The archives of osteopathy were empty ten years ago. There was no precedent to follow and the ideas in teaching which had prevailed for centuries dominated. All this is changed. The colleges teach the science along strictly osteopathic lines, making the application of the truths which have escaped the notice of centuries of investigation.”

All schools recognize the wonderful recuperative power of nature, as this from the introduction of a standard allopathic text book will show[9]: “There is no scientific dogma better established than this: that the living organism is in itself adequate to the cure of all its curable disorders. This natural law sustains the medical skeptic in his infidelity, enables the homeopath to report his sugar cures, and helps all physicians out of more close places than they are generally willing to acknowledge.” But at times, as all will agree, nature is not able to overcome its maladies and assistance is needed. Here, again, is a divergence as to the method and character of that assistance. There is no system so trivial or absurd which cannot point to its cures, but a school of medicine should have a settled system with established methods of procedure. This is not true of any school employing drugs as its principal therapy. In the President’s annual address at Cleveland he says[10]: “The observant reader of the progressive medical press is struck at once by the unsettled condition in the field of modern therapeutics. The trend is emphatically away from drugs. But, in the effort to get away from medicine, the medical investigator has wandered far afield, cutting loose from nature and resorting to the artificial.” It is the last paragraph of the extract quoted which particularly emphasizes the point of divergence, natural versus unnatural methods. It must be understood at once that the osteopath admits the reality of drug action for “there is no doubt that the pharmacopeia records many drugs whose action is rapid and effective so far as securing activity or decrease of secretion is concerned, but the element of danger, i. e., their destructive power is great. Oftentimes their power does not stop at the point desired or limit its effect to the therapeutic action sought[11].” This point of unreliability of the drug is emphasized by the following from recognized medical authority[12]: “We give drugs for two purposes: (1) To restore health directly by removing the sum of the conditions which constitute disease. Here we act empirically with no definite knowledge—often indeed with little idea of the action of our drugs, but on the ground that in our hands or in the hands of others they have restored health in like cases. (2) To influence one or more of the several tissues and organs which are in an abnormal state so as to restore them to or toward the normal; with the hope that if we succeed in our purpose recovery will take place. The purpose we effect by means of the influence which the chemical properties or drugs exert on the structure and function of the several tissues and organs. Minute information, therefore, of the nature of drugs and their action is essential for their proper employment.” Osteopathy brings into action the latent or stagnant forces of nature by specific methods which are usually reliable. Naturally there being such a wide difference in theory of the cause of disease it would be also shown in diagnosis as well as treatment. The most striking points to the layman in medical procedure are: first, wide difference in the system of diagnosis and in its findings by physicians of the same school; second, the great variance in remedies employed by different physicians of the same school for the same disease.

Osteopathic diagnosis is so physical in its character, depending upon actual conditions found and not upon the subjective symptoms alone, that the same patient examined by a number of experienced osteopaths will be given the same diagnosis, and he will also be able to detect in each the same effort to correct in all their technique. All the methods of physical diagnosis are used plus the distinctive osteopathic procedure. Results wherever used bear out the effectiveness of the system.

The osteopath must and does consider the necessity of surgery, but his effort is always to prevent the operation if possible. There can be no doubt that surgery is carried to extremes and there is a strong sentiment growing that much of it is unnecessary. Says Homer Wakefield, M. D.[13]: “It is to the everlasting disgrace and mortification of the medical man that the wealthy classes who are continually under the observation and direction of eminent men, in dietary, and all life habits, in health as well as in sickness, are not only the very ones who develop appendicitis and most largely go to operation, but are almost exclusively those who attain to this distinction.” The operations of today are wonderful and the surgeon shows great skill and genius in their performance, but great as he is in these matters how infinitely greater is the man who can prevent them. The need of the osteopath today is to be trained to recognize surgical conditions and neither allow surgery unnecessarily nor make the more terrible error of not acting soon enough. Where surgery is a necessity there is always an etiological factor to be considered. The cause of the manifestation not always being removed what is to prevent a recurrence or serious sequela in spite of the operation? “The specialist ... if he has wit enough to read the lesson presented to him, that it is not sufficient to remove an ovarian tumor, e. g., and that if nothing is said at the same time or subsequently as to the causes which induced it, a positive damage may be done to the woman, who may, therefore, while considering herself cured, proceed to manufacture one on the other side, or may find herself in a few years suffering from cancer in the stump of the previous one[14].” And so the combination of osteopathy with surgery may be necessary that the cause shall be removed. Osteopathic treatment before operations in reducing congestions and inflammations, also in toning the nervous system, is particularly efficacious while the after treatment gives gratifying results. In fact, the two go hand in hand when conservatism rules both.

That diet should receive particular attention from the osteopath is not strange, for his veneration of nature peculiarly fits him to realize the necessity of correct feeding. Probably no subject is more discussed or presents a wider range of opinion than diet. There is overfeeding and underfeeding; long intervals and short between feedings. There is the no breakfast and no supper plan, mixed diet and the vegetarian, uncooked foods, and one exclusively of milk, anything you want so long as you are hungry but chew it well, etc., ad. lib. All are represented by osteopaths in their following as they are from other professions, but probably this would more nearly represent the views of them as a school. In health, first, most people eat too much and do not thoroughly masticate and insalivate. This applies to all stations of society. Second, meat forms too large an item in the daily dietary. Third, there is not enough variety and the ration is not well balanced as to elements. Fourth, not enough care is used in preparation of foods. In illness, first, the stopping, complete or partial, of food until the system can take care of it; second, the giving of easily digested foods. The man who avoids violent extremes in diet as well as in other habits of life will usually last longest. It is to be hoped that some rational system can be evolved on which all factions may agree, for the present confusion of authorities is bewildering. The osteopath gives attention to hygiene, sanitation, exercise, environment, mental attitude, etc., as they may affect the welfare of his patient.

Osteopathy can cure all curable diseases, for the same forces which will overcome one malady will overcome another when set in motion. Forces that produce a diseased condition will it normalized restore the established type.

---

Osteopathic etiology and pathology constitutes the most interesting chapter of osteopathic science. The primal divergence of the osteopathic schools from previous systems is to be found in the osteopathic interpretation of disease causes and processes, and not in osteopathic therapy as some may think. Osteopathy makes claim to an independent school because it possesses a distinct etiology, pathology, diagnosis and treatment. Thus osteopathic practice is not a mere method, but instead a system, a school, a science.

At no period of medical history have physicians of the older schools felt more keenly the futility of medical methods and the lack of an all-embracing principle of medicine than at the present. A recent writer[15] who claims to have discovered a principle that encompasses the entire field of medicine, says: “We found, we may say, that the backbone of medicine was the absent factor, and that if the patient labors of so many great minds had not proven as useful in the development of practical medicine as they should, it was because they lacked such a fundamental framework to afford a fixed nidus for each discovery, wherein its true relation to other discoveries would at once become evident.”

Since the conception of osteopathy its fundamental framework has not changed one iota as to principle, although the application of the principle has been greatly elaborated. When Dr. Still proclaimed that “the rule of the artery is supreme” he gave utterance to a basic physiological truth. But when he demonstrated that osseous and other anatamo-mechanical lesions disturbed the artery and caused disease, and that readjustment of the anatomical cured the disorder, thus allowing the physiological to potentiate and revealing that the living body contains all the attributes of a vital and physical mechanism, did his teaching contain the germ of a comprehensive philosophy; this gave osteopathic science a “backbone” with a consequent fixed nidus for all existing facts and future discoveries. And thus, it should always be emphasized that mechanical readjustment of the component parts of the vital body is the eternal keynote of the osteopathic school of healing.

The Osteopathic Lesion.—Broadly speaking a lesion is “any morbid alteration in a tissue whether attended by a recognizable structural change or not; but especially a change in which the continuity of some of the tissue elements is broken in upon.[16]” There are several kinds of lesions expressing the tissue involved, character of degeneration, locality of same, etc. But upon analyzing the medley of arbitrarily defined lesions the fact will be evident that much of medical etiology and pathology has not been logically and consistently sifted and arranged; and moreover, it will be found the cause of causes of many diseases is unknown.

Herein, arises the great significance of the osteopathic lesion, for the lesion alters the very governing and controlling tissues of the body, viz., the nervous tissue and the vascular channels. Hulett[17] defined the osteopathic lesion as “any structural perversion which by pressure produces or maintains functional disorder.” The constant maintenance of the structural perversion will, also, cause organic disease, although it is granted that functional disorder must necessarily result prior to any organic change.

The osteopathic conception of a lesion, functional and organic disorder caused by pressure from disturbed structures, does not bring us into an absolute new field. Medical literature of all ages contains references to diseases caused by pressure of tissues on nerves, blood vessels, or other channels. But the osteopathic idea is an absolutely new one in the application of this principle universally. It simplifies and makes uniform the arbitrariness of present semeiology.

Thus the osteopathic idea that many diseases originate, primarily, from anatomically malaligned, malpositioned, or malrelated tissues causing a blockage of vital processes, immediate or remote, is a theory inclusive of disturbances to all tissues. This principle is fundamental and is supported by the physiological truth that uninterrupted vital channels preserve health; moreover clinical and experimental data, as will be shown later, substantiate this fundamental. It at once places interpretation of a lesion in an entirely new light from preconceived concepts, and is analogous to and co-extensive with etiology and pathology.

Etiological Factors.—The osteopath believes in the potency of inherited and environmental influences. There can be no question that a few diseases and certain disease tendencies may be inherited, the principle feature, however, from the standpoint of heredity is, various organs and tissues have less vital resistance. These should not be confounded with congenital weaknesses and diathetic tendencies.

Environmental influences are very important factors. One’s surroundings and daily habits in the home, shop, or office count for much in the aggregate. Food, drink, air, rest, sleep, clothing, exercise, mental attitude, etc., are all factors in the sum total of health, and consequently ill health may be traceable to their abuse. In fact, all hygienic and sanitary measures are duly considered by the osteopath. Various abuses, over use, and disuse of the functions will certainly be followed by physiological discord.

The germ theory contains much truth, but in the very large percentage of cases where the micro-organism is a factor its significance is only of secondary consideration. Immunity and resistance comprise an important part of the health problem, of which the intact anatomical is of first consideration. Usually the micro-organism plays the role of an exciting and determining factor; before it can multiply and grow there must be a field that is first nutritionally disturbed. Nutrition of the tissue is the one great point always to be considered. The constitution of an individual is the pivot about which predisposing, environmental, and exciting factors of disease center. Health represents the integrity of the artery as well as a maintenance of that master tissue, the nervous system, and anything that produces or influences, directly or indirectly, a disturbance of physiological functioning borders on the pathological.

Hence the osteopath recognizes many of the common medical causes of disease, but reserves the privilege of rearranging their relative positions, for the osteopathic cause of disease greatly modifies their value.

Osteopathic Etiology distinctively emphasizes structural derangements and perversions. Of first importance, owing to static requirements, is the osseous lesion. This lesion is represented by any abnormal change of position or relation of the many bony constituents of the body. The framework of the body is subject to not only any and every physical violence of any mechanism, but moreover being the corporeal foundation of a vital mechanism is subject to both direct and indirect biochemic changes and influences.

Thus the osseous lesion is caused (a) by traumatism, e. g., strains, falls, blows, etc.; (b) indirectly by atmospheric changes, over and violent exercise, the slumped posture, debilitating habits, etc., through the media of muscle changes and imbalance; (c) by nutritional effects disturbing the elements of bony tissue; (d) by ligamentous change such as thickening of a capsular ligament; (e) by infections; (f) compensatorily and reflexly through the media of body distortions and muscular irritability or debility, e. g., an innominate lesion may be compensatory to a lumbar curvature, dietetic errors may cause dorsal muscular irritation and contraction produce a constant osseous lesion which in turn may result in chronic indigestion.

The pathological changes in the osseous lesion are commonly one of structural derangement, deviation or complete displacement. The vertebral segments are of primary consideration owing to their important relations to the spinal nerves, spinal cord centers and sympathetics; the ribs owing to the close sympathetic and spinal nervous relations; and then other osseous tissues, as the innominata, clavicles, etc., depending upon their importance to contiguous vessels, nerves and organs. It should always be remembered and emphasized that mechanical changes of the anatomical structures is the primary essential in osteopathic etiology; this is the one great inception of pathological variations from the distinctively osteopathic conception, which the osseous lesion typifies. Consequently the osseous lesion factor is actually a luxation (complete, or partial, even to a very slight degree), or malalignment of the bony constituents, which by virtue of their physical malposition impinge or irritate contiguous tissues. The essential test is the functional one, movement. The degree of involvement may be one of many gradations ranging from a slight malposition or impaction to a marked deviation or firm anchorage.

Second in importance from the static requirement of support is the muscular lesion though from the standpoints of movement and dynamics it is often of the first consideration etiologically. Many interosseous lesions are the result of spastic involvement of deep seated spinal muscles, of fibrotic changes and of tensions and weaknesses that either establish a rigidness of the segments, compromising nervous stimulus or vascular channel, or produce an imbalance of muscular tone and tension. In the latter instance some type of sidebending-rotation osseous lesion occurs, commonly anchored within the physiologic movements of the spine. The muscular lesion may be an actual dislocation of either muscle or tendon, but rarely. Commonly it is a contracted, or tensed, or contractured muscle. The muscle, also, may be diseased either from primary or secondary causes through nutritional and infectious sources and thus be an etiological feature.

The muscular lesion is caused, (a) by direct or indirect violence the same as the osseous lesion; (b) by atmospheric influences; (c) by slumped posture, debilitating habits and various errors of living; (d) infections; (e) by reflex irritations; (f) by compensatory changes; (g) by disease causing hypertrophy or atrophy; and, (h) secondary to osseous lesions, being the result of impingement to the muscles’ nervous control. The tensed or stretched muscle may result from a separation of the points of origin and insertion.

Herein the fundamental osteopathic concept is the resulting affection due to the physical encroachment, directly or indirectly, of the muscle tissue upon vascular channel or nerve fibre, or the effect upon the movement or alignment of the osseous tissue.

Muscular contractions, displacements, and tensions play a most important part in acute disorders, although muscular lesions that are secondary to other lesions are usually taken into account when treatment is given. Muscular lesions affect, (a) blood and lymph vessels; (b) nerve fibres. Muscular contractions, especially, impede mechanically the return of the venous blood to the heart. The lesions to the nerves may be manifested in innumerable ways, depending upon the location of the muscle and the function and distribution of the nerve affected.

Then there is the relaxed, overstretched, and atonied muscle. This condition results as a secondary effect to mechanical strains, these being so severe and constant as to cause direct stretching and possibly tearing of the muscle fibres. This should be distinguished from the exhausted or debilitated muscle, e. g., as found in neurasthenia and anemia.

Diagnostically there are, (a) contractions of more or less area, due to atmospherical changes; (b) the deeply seated contractions involving a very small area, caused by vertebral and rib lesions; (c) contractions due to reflex disturbances; (d) contractions caused by postural effects and deformities; (e) contractions from spasms of the blood vessels as a result of nervous irritations; (f) contractions due to toxicity of the blood. All of these characteristic muscular lesions give a direct hint as to both etiology and prognosis.

Third, the ligamentous lesion, as a lesion per se, is usually of secondary importance to the osseous lesion. In chronic cases affections of the capsular ligament and muscular fibrosis commonly maintain malalignment or rigidness. There are two features that should be noted in particular when considering this lesion; first, thickenings and adhesions; and, second, relaxations.

The tone and integrity of the ligaments cannot but be of vital concern to the stability, suppleness, and adaptability of the bony framework in all physical movements. No matter how slight the osseous lesion may be the ligament must of necessity be involved. The osseous derangements are either a source of irritation to the ligamentous tissue, resulting in congestion and inflammation and hence thickening and adhesions, or else the ligaments are so strained and tensed that in time atony may occur. Probably, in a fair percentage of atonied cases the first disturbance to the ligament is one of irritation and congestion, and from long continued involvement irritation is supplanted by debility.

Consequently the primary consideration of the ligamentous lesion from the etiological standpoint is the character of the tissue (ligament) changes. This, also, gives us a direct hint that is of the utmost value in prognosis. The independent displacement of a ligament is rare, thus ligamentous lesions from the viewpoint of purely physical displacements are secondary to if not an actual part of the osseous lesion. Ligaments, when displaced or tensed, readily impinge or irritate contiguous tissues, but the original cause of the structural perversion is commonly either the osseous or muscular lesion. Hence, whatever factors enter into the production of these lesions will at least indirectly produce the ligamentous lesion.

Fourth, the visceral lesion is frequently overlooked as being of much moment as an osteopathic lesion. Visceral displacements acting as a source of functional and organic annoyance on the physical plane (structural perversion which produces and maintains pressure) alone are not in the least uncommon.

Any or all of the abdominal viscera, or even the organs of the thorax, may be displaced (physically) pathologically. Actual displacement of the viscus is a prolific source of distinct disorders and many obscure symptoms. True it is the organs are most frequently displaced from indirect causes, but nevertheless the actual physical malposition is in turn a primary cause of still another train of symptoms and diseases.

Visceral lesions are caused by, (a) vertebral lesions; (b) postural defects; (c) direct violence; (d) nutritional disorders; (e) childbirth; (f) unhygienic measures (tight lacing, heavy skirts, etc.); (g) congenital weakness.

From the displaced heart due to valvular and debilitating influences to the displaced liver, the stomach, the kidneys, the intestines, the ovaries, and the uterus, may arise a source of direct or indirect irritations, a train of apparent or masked symptoms, or a group of nutritional disturbances that include an extremely important chapter in etiology. Moreover not only may one organ alone be involved but several may be displaced or prolapsed as a whole as in splanchnoptosis; and even these in turn may be the direct cause of further organic displacements as the abdominal viscera prolapsing upon the pelvic organs. Here is a very fruitful field for the diagnostician, for to separate cause from effect requires keen perception, an acute sense of touch, and above all, most careful weighing of all the factors that enter into the maze.

Fifth, the composite lesion is not always recognized as an extremely important osteopathic factor. By composite lesion is meant a structural lesion that primarily includes the osseous, muscular, and ligamentous tissues as a whole. This may be termed a lesion en bloc or en masse.

Composite lesions are of exceedingly frequent occurrence. Indeed, many composite lesions are overlooked and instead of treating the en bloc disturbance as a consistent whole the component factors are treated separately with no concern or attention to the whole.

Postural defects are excellent types of the composite lesion. The various curvatures, the tilted pelvis, etc., are representative of the composite lesion. Etiologically, pathologically, diagnostically, and therapeutically the contour of the spine and ribs, the relation of the innominata to the sacrum and spine, and the symmetry of the body generally should be recognized and appreciated. The relation of the part to the whole and of the whole to the part are of vital etiological concern. An incipient curvature may be easily overlooked, a pendulous abdomen neglected, and a slipped innominatum passed unnoticed wherein as a result the entire vertebral column is malaligned in relation to the physiological curves or to the perpendicular line of gravity.

Frequently attempts are made to correct individual lesions when attention should be directed to the composite lesion and vice versa, e. g., a displaced rib is usually dependent upon a corresponding vertebral lesion, and thus the transverse plane or section of the body should be considered as a whole. A single lesion may be dependent upon a composite lesion or a composite lesion dependent upon one or more single lesions. A slipped innominatum or a disordered hip joint may bring about a strain to a greater or less section of the spinal column, or a twisted vertebra may cause a curvature, whereas on the other hand postural defects may cause a strain at its maximum focal point resulting in over-stretching and relaxing of ligaments so that an osseous lesion results, or a spinal curvature cause an innominatum displacement. Thus there is a constant establishing of equilibrium, physically and physiologically, through the medium of compensation, but at some phase of the change there are apt to be pathological phenomena resulting, and very frequently physiological harmony is not reestablished but instead irritation, debility and other disease symptoms are constant effects until relieved.

Consequently osteopathic etiology is many sided and complicated. To know whether an osseous, ligamentous, muscular, visceral, or composite lesion is primary or secondary, compensatory, reflex, predisposing, or exciting, requires a command of theoretical knowledge backed by much actual clinical experience.

In noting the above distinctive osteopathic etiologic features the student should not lose sight of the constitutional status of the patient which may be modified by inherited, congenital, diathetic, and environmental influences, all of which go to make up the predisposition of the individual and have an important relation to osteopathic factors. Then it should be recalled that disease processes may be of insidious progress, and the products and effects of pathologic changes accumulative.

In the etiologic study the osteopathic characteristics have been designated structural maladjustment, although at the same time not losing sight of the angle that the body is not only a physical mechanism but also a vital organism. Structural perversions characterize the osteopathic distinction when dealing with the physical body, and remembering the vital or biochemic mechanism, mental attitude, diet, hygiene, etc., are not forgotten. To retain or attain health, thorough appreciation of both the physical and vital mechanisms should be kept in view, for there is both an independent and dependent interaction on the part of each. The living body being an entity premises a system of therapeutics both physical and vital, that acts in direct accord and harmony with physical laws and physiological functioning.

Osteopathic pathology deals with the distinctive osteopathic lesion as a factor in production and maintenance of disease. Then the province of pathology is, first, to determine whether the lesion is in reality an etiologic factor; second, the immediate character of the lesion disturbance; and, third, how organic life becomes involved.

Inspection, palpation, clinical results, dissection and laboratory experimentation include the methods employed to prove that the lesion is of practical consequence. That the lesion is an etiological factor can be known only through clinical and experimental proof; the immediate character of the lesion disturbance can be determined by dissection; and how organic life becomes involved requires the summation of histological, physiological and pathological data.

The following outline assumes that the reader is familiar with anatomy, physiology and pathology. Osteopathic pathology does not add to medical pathology an absolutely new pathology in all of the present known numerous details, but instead interprets much of clinical pathology anew, and furthermore it presents absolutely new data that is exclusive, but germane to the present general medical and surgical fields.

Nervous tissue and arterial blood are the master tissues, the controlling and governing factors in health, and disturbances of these tissues are necessarily the cause of ill health. The rule of the artery and the control of the nerve must continue uninterruptedly in order that physiological functioning remains intact. The body should be looked upon as a being complete, no more or less, each tissue and organ essential to the whole and the organism as a whole essential to every part. This is fundamental and germane to a living structure, and hence disturbance to the governing and controlling tissues, the nerves and vascular channels, must necessarily cause a break in the concatenation and disease must logically follow.

Thus in the osteopathic pathology we look to those influences that primarily disturb the nerve or artery, study the disease process or extension from inception to effect and from primary lesion to morbid results, and note action and interaction of tissue upon organ and organ upon organ.

That all parts of the body are in intimate and dependent relations each with the other through the media of the nervous and endocrine systems is a well known fact based upon histological and physiological grounds. The neurone being the physiological unit implies that any disturbance to the cell quickly disturbs any or all of its processes. It may be said that “nervous tissue is dependent for its integrity upon two things, blood supply and trophic influences. The nerve cell is solely dependent on a proper supply of blood, and dies when this is withdrawn. But the nerve fiber is more dependent on the trophic influence of the cell of which it is a prolongation. It dies when cut off from the cell but it can get along for a time with but little direct blood supply. On the other hand, if the nerve fiber is injured it reacts on the cell, leading to a partial but curable degeneration of the cell body.”[18] Here is the immediate pathologic key to many diseases. Whatever cuts off or obstructs the artery leading to the cell is a primary etiologic factor; this then leads to degeneration of protoplasmic processes and axone. It should be carefully noted that if the obstructed blood vessel is one to the nerve fiber only the resultant partial injury to the cell is curable.

“When an axone degenerates the retrogressive process involves not only the main axone, but also its terminals, together with the collaterals belonging to it with their terminals.”[19] This is an exceedingly important link in the explanation of osteopathic pathology, that distant organs may be affected by the osteopathic lesion. Moreover, “degenerations of a secondary character may occur in those systems of neurones which are more or less dependent upon the peripheral sensory neurone system for their impulses.”[20] This is equally true with the central motor neurone, or any neurone. It shows how far-reaching a degenerative process and its effects may be. It further makes clear that nerve intactness is directly and absolutely dependent upon a normal circulation, and that it is self-evident any blockage either to blood vessels or to neurones will vitally affect those tissues that govern and control the life processes of the body. The integrative action of the nervous system is one of the outstanding facts of physiology.

The above is presented so the student may see how osteopathic spinal lesions, if deeply seated and effective enough, can involve remote tissues and organs. No one will doubt that fractures and complete dislocations of the spinal column will seriously affect visceral life, or a prolapsed kidney will be a cause of nutritive disturbance, or a displaced uterus the cause of ovarian congestion, or a dislocated hip the cause of atrophy of the leg muscles, but it has remained for the osteopath to offer proof that slight misplacements of the vertebræ or ribs, incipient curvatures, postural defects, slight deformities, and unsymmetrical bodies are of sufficient etiological importance on the physical plane to affect neurone integrity and obstruct artery courses, and thus organic life.

The question at once arises, what is the immediate or direct effect upon blood vessel or nerve of the osseous, ligamentous, muscular, visceral or composite lesion? The osseous lesion will be taken as a type. The direct effect is usually one of hyperemia or ischemia, generally the former, for as physiologists and clinicians observe irritation commonly precedes debility. In the vertebral and rib lesions there may be direct pressure upon the spinal nerve at its spinal foramen exit or on the sympathetic chain directly contiguous to the heads of the ribs. This causes congestion, inflammation, ecchymosis, and degeneration of the nerve fiber, followed by macroscopic and microscopic changes as connective tissue proliferations, arterial scleroses, etc. Or, as seems probable in experimental work, the inception of the pathology may be frequently the result of blockage to nervous stimuli, which when maintained affects the efferent vasomotor, secretory, trophic and other fibers so that circulation and nutrition are definitely involved.

Thus the cells so sensitive to altered vascular changes are directly and remotely affected, and disease characteristics dependent upon structure and function of tissue, and degree of irritant are evident. This can vary, in degree only, with the muscular lesion that involves collateral spinal cord circulation, the visceral lesion that irritates sympathetic life, or the composite lesion that deforms or perverts structure en masse.

But is the physical noxa as potent an etiologic factor as the chemical or bacteriologic? Adami[21] informs us whether an irritant is physical, bacterial or chemical, no satisfactory distinction can be founded on the duration of the irritation; that a local irritation of the nervous system may lead apart from “direct reflex action, to changes of nervous origin, in the region of the injury and in the reflexes affecting associated regions, the higher centers; and through them the system at large, may become affected by paths that it is not always easy to trace.” Again he says that “centrifugal impulses alone, apart from any local injury, may originate a succession of phenomena of inflammation in a part.” And “in all probability a nervous and central origin must be ascribed to some, at least, of the sympathetic inflammations seen to occur in areas supplied by the other branches of a nerve supplying a part primarily inflamed; and again in areas supplied from the same region of the brain or cord as the inflamed organ.” Other inflammatory changes, of course, may occur independently of centrifugal nervous influences, and the vessels react independently of central influences.

This, then, presents a situation postulated thus:

1. The body follows definite structural relations and is influenced by mechanical arrangements in its morphology.

2. The integrity of tissue depends upon structural freedom of nutritive courses.

3. The above predicates a structural etiology as exact and precise as structural relations are important to nutrition.

What proof, then, of the foregoing have we to offer?

First, the clinical proof. Clinical results have been obtained in tens of thousands of cases that include disease of various types and lesions, and of all sections and organs of the body. The art of osteopathy has been perfected in many of its details, based upon actual experience and splendid results. The cure of the patient is paramount to all other consideration, and whereas the osteopathic school has been shown a superior system it logically follows on a priori grounds that relief and cure of suffering is of the first and final importance.[22]

Were it not for clinical results no new system of therapeutics could withstand criticism and calumny and finally triumph and be publicly, legislatively, and scientifically recognized.

Second, the autopsy proof. Many dissections have been made and autopsies held with the view of discovering the character and the potency of the osteopathic lesion. This very important work has borne out the osteopathic theory of disease. Vertebral and rib displacements have been noted, corresponding ligamentous tissues thickened, associated nerve tracts and vascular channels disturbed, and finally the related organ found diseased.[23]

Third, the experimental proof. Experimental proof appeals, logically, to the scientific mind. This proof[24] is being gradually developed.

Experimental investigation has been successfully carried out upon numerous animals. The experiments conclusively prove that not only spinal inhibitory and stimulatory manipulations (mechanical) are productive of immediate physiological changes in the viscera, but that the structural anatomical lesion or noxa is an important factor in the etiologic field. Pathological changes in several organs directly follow the artificially produced vertebral and rib lesions, showing beyond doubt the reality and effectiveness of the osteopathic lesion. This emphasizes the point that centrifugal impulses originate an inflammation in a previously healthy and uninjured tissue or viscus. And as “inflammatory phenomena may be sympathetically developed in regions innervated from the same area in the brain or spinal cord” it remains to prove the actuality of vertebral and rib lesions, i. e., structural perversions really affect contiguous nerve courses and vascular channels; and this has been demonstrated in laboratory experiments and at the autopsy. Consequently the vertebral, rib, or other lesion may be an important etiologic factor either to the nerve strand from cord or brain to viscus or from viscus to cord or brain.

Dr. Still says in his Autobiography that “all nerves depend wholly on the arterial system for their qualities, such as sensation, nutrition and motion, even though by the law of reciprocity they furnish force, nutrition and sensation to the artery itself.” It matters little in this outline whether obstruction to nervous integrity is by way of an impinged artery or by direct pressure, or both, or otherwise, for the primary consideration is the noting that the osteopathic lesion is a real and potent factor of disease. Sajous[25] informs us that “a neurone is directly connected with the circulation (via neuroglia-fibril) by one or more of its dendrites, which serve as channels for blood plasma,” that a neurone receives its nutrition directly from the general circulation, and that from the axone the blood passes into a lymph space connected with a vein. Thus in reality a part of the circulatory system is that of the entire cerebrospinal system.

The student is referred to the various publications of the Research Institute and Deason’s Physiology for experimental data confirming the validity of the osteopathic theory, although it should be emphasized that clinical evidence is quite conclusive. Malalignment injuries of the vertebral articulations, for example, ranging from imbalance of muscular tension to infections, is certain to result in some type of rotation and sidebending of the segments to an extent that apposition is compromised and abnormal anchorage supervenes. There are many factors of the pathology: muscular tension and fibrosis; damaged ligaments, particularly the capsular; interference of nervous stimuli, blockage of impulse directly and reflexly as shown by pathologic involvement in cord centers and sympathetic ganglia, and in certain cases direct obstruction of nerve fibers as revealed by Wallerian degeneration; involvement of circulation as shown by damage to blood-vessels, local edema and local acidosis, and effect upon local tissue respiration and drainage. Through a combination of these various factors circulation, nervous equilibrium and chemism of related parts are involved, both anatomical and physiologic balance is upset, and resistance of corresponding viscera affected. Reciprocal innervation and the axone reflex are also disturbed, all of which are important predisposing causes that disturb resistance of tissues and organs, upset their correlated mechanisms and render active various possible infections and toxins that otherwise a normal circulation, nervous and endocrine systems, and oxygen supply would rapidly and successfully combat and restore the organism to normal. Thus from the practitioner’s standpoint there are three points to always keep in mind: readjustment of the lesion; correction of the forces, habits, environment, etc. that produce the lesion; and hygienic attention of the body after lesion adjustment in order that normal condition may be maintained. A thorough study of the physiologic movements of the spine is a prerequisite to an understanding of the various possible abnormal appositions, though it should be appreciated that these movements are not consonant or applicable to many abnormal conditions. Pathology reveals many gradations and combinations not found in normal conditions. Frequently the key of a successful technique rests upon an understanding of the individual make up of the interosseous lesion.

It has not been the purpose of this section to go into details but rather to follow logically an outline of osteopathic etiology and pathology. The various details will be found in the osteopathic works on Principles as well as in the experimental articles referred to. It should be understood that the osteopath believes thoroughly in vis medicatrix naturae whether the indications are for stimulation or inhibition or for the basic readjustment. Generally speaking, however, therapeutic philosophy resolves itself (ultimately) into the principle that a cure depends upon giving an impetus to impaired, habitual and latent forces, which in the osteopathic field implies fundamentally adjustive manipulation whereby the resultant impetus or physiological stimulus is initiated.

In a word, osteopathy premises that the body is a vital and physical mechanism subject to derangements, structural alterations, and functional changes, as results of violence on the mechanical plane, as well as disturbances on the psychic and biochemic planes. Hence, osteopathic philosophy is inclusive of preventive, palliative and curative measure.

---

In osteopathic diagnosis the spine is the first and greatest object of interest, for on the result of its examination will depend the treatment to be given which is in turn hoped to bring about recovery.

As it is the structure on which rests the weight of the body the practiced eye is able to detect at a glance, by the poise and gait of the patient, if there is an abnormal condition affecting any considerable area of the spinal column. It is well to observe these points, especially in the female, before having them prepare for examination, as it will often give a clue to sources of trouble through faulty carriage, improper dress, particularly corset and shoes. Slight changes of gait, unnoticed by the patient may be of great aid in determining the beginning of disease in the spinal cord.

No osteopath is justified in accepting a patient who will not permit every examination deemed necessary, as remote and obscure lesions are frequently the cause of disease, so preparation of the patient for the first scrutiny is of importance. This cannot be made with the patient fully clothed, as visual observation is second only to the touch in making one’s deductions. Neither can palpation be made through more than one thickness of clothing with accuracy, and examination next to the skin is always preferable. This need in no way ever cause complaint, for with the use of a loose fitting short kimono, with all outer clothing removed except the knit undergarment, and with skirt bands loosed, a complete survey of the whole dorsum from occiput to coccyx can be had without the slightest unnecessary exposure. It is well to remember that the patient has come for help and the osteopath is not justified in sacrificing thoroughness for any exaggerated feelings of modesty. With tact and care in the use of the garments the most sensitive ones need feel no hesitation in coming for treatment.

A complete history of the case should be taken before the examination begins, former methods of treatment, symptoms, environment, etc., as it will aid in the final conclusions. It is well to have blanks for keeping records of all cases.

Probably the most comfortable manner to begin physical examination is to seat the patient on a table squarely with hands placed upon the knees, then raise the garment and expose the whole back. Begin by noting the texture of the skin, if it is clear, pigmented, blotched, or has eruptions. Try the capillary reflex by pinching or stroking quickly with the finger tips or the blunt end of a pencil. Find if it is moist or dry and also outline the areas of changed temperature, if any. Then observe the general contour of the spine with the patient sitting upright, to find how near it is to the normal body curve.

Occasionally having the patient alternately sit and stand will, by comparison, throw light upon the condition. With the patient bending forward place the hands on the crest of the ilia and see if they are of equal height.

Occupation may result in over development of one side or there may be congenital asymmetry[26]. Note position of the scapulæ and habit of posture in sitting and standing.

Before taking up the subject of a critical examination of each vertebra there are certain points it will be well to consider. It is easy to know instantly, without counting, the number of the vertebra causing the lesion if these landmarks are remembered: First, the spine of the third dorsal is on a level with the spine of the scapula. Second, the spine of the seventh dorsal is on a level with the inferior angle of the scapula. Third, the spine of the last dorsal is on a level with the head of the last rib. It will save much time for the busy osteopath to have these well in mind.

The pathognomonic symptoms of the osteopathic lesion are: (a) maladjustment; (b) contracted muscles; (c) tenderness; (d) limited movement. To these might be added changes in local temperature and disturbance of function, but the former is not constant and the latter may be remote. Here the primary lesion is considered, for an osteopathic lesion may be, also, secondary or compensatory. Forbes speaks of compensatory changes as being an important diagnostic sign.

Diagnosis of the position of a vertebra is sometimes difficult to the beginner from its having longer or shorter spines than normal. Horsley speaks of the occasional congenital absence of a spinous process. They may be bent laterally, upward or downward and thus have all the appearances of a marked displacement, while occasionally the body itself seems much at fault. These present what might be termed normal abnormalities and make it necessary for the osteopath to be very sure of his diagnosis before attempting to correct what is not abnormal, for disappointment, at least, and injury, perhaps, may follow.

To avoid mistake, carefully palpate the transverse processes and determine if they are at right angles with the adjoining normal spine. In the cervical and lumbar vertebræ it is possible to reach the tips of the transverse processes, and on moderate pressure, if a lesion exists, pain will be elicited. Further, where tenderness is associated with other diagnostic points it can be safely assumed that a lesion exists, and by outlining the suspected vertebra with the finger and localizing the sensitive spot one can be sure of the point of greatest irritation and the character of the displacement. Associated also with these signs will probably be evidence of congestion, such as thickened tissues, contracted muscles, etc.

After having examined the condition of the spinal column thoroughly by inspection, begin at the first dorsal and examine the spinal column down to the sacrum. Place the middle and ring fingers over the spinous processes and stand directly back of the patient and draw the flat surfaces of these two fingers over the spinous processes from the upper dorsal to the sacrum in such a manner that the spines of the vertebræ pass tightly between the two fingers, thus leaving a red streak where the cutaneous vessels press upon the spines of the vertebræ. In this manner slight deviations of the vertebræ laterally can be noted with the greatest accuracy by observing the red line. When a vertebra or a section of vertebræ are too posterior a heavy red streak is noticed and when a vertebra or vertebræ are anterior the streak is not so noticeable. Thus when suspicious points are noticed a special examination of the localized point can be given. This examination simply takes into consideration the contour and superficial condition of disordered portions of the spinal column. In a few cases such an examination will not be necessary, for the symptoms and signs of the disease will be so clearly manifested that one’s attention will be called directly to the cause. Still, great care should be taken in the majority of cases, as the osteopath finds causes of disease remote from the seat of complaint. We must always bear in mind the significance of reflex stimuli and sympathetic radiation.

In making a critical and exhaustive diagnosis of the spinal condition after the foregoing general examination has been made, it will be best to have the patient lie on the side upon the operating table. When the patient is in this position a more thorough examination can be made, as then the spinal muscles are not contracted unless abnormally so, for when a person is in the upright position muscles are continually contracting first on one side and then on the other, as one of their functions is to act as a support in keeping the spinal column erect. The patient lying on his side, the physician should then stand in front of him and reach over upon the back and make a thorough examination of the affected portions of the spinal column, chiefly through the dorsal and lumbar regions.

Consideration should be given the contraction of the muscles along the back, chiefly the deeper layers of muscles. It may even be necessary to relax some of the muscles before a thorough examination of the vertebræ can be made. From a pathological point of view too much stress should not be put upon the contracted state of the muscles; although in a number of instances the contracted muscles may be the primary cause of the patient’s trouble; especially so when the affection is due to atmospheric and other changes. Contraction of the muscles may be secondary to the lesions presented in the bony frame work. For instance, a dislocated vertebra may be the cause of an irritation to the innervation of certain muscles along the spinal column and thus cause them to contract. Still, we must not lose sight of the importance of the contracted muscles from a diagnostic point of view. They are oftentimes prominent signs that a lesion exists in the immediate region and are thus faithful guides in locating the cause of diseases.

In closing the general consideration of the spinal column it is well to emphasize the importance of training the faculties to grasp at a glance the story told by the back as a region, instinctively placing the proper value on each physical sign and weaving them into a composite whole so that the patient’s condition stands out a vivid picture on the osteopath’s mind. When this is accomplished the more detailed observations are but incidental. Relative to the examination of the spinal column Clark[27] says: “To the osteopathic physician, the most important part of the human body is the spinal column. By its changes in contour and condition the various visceral diseases can be diagnosed, in most cases. I believe that every disease is characterized by extreme changes or signs, and I further believe that every chronic visceral disorder is manifest by changes in the spinal column that can be, by the practical eye and touch, readily interpreted. In short, there are various signs along the spinal column that point out the weakened or diseased parts of the body. This method of diagnosing disease, that is by noting these spinal changes, is distinctly osteopathic, and I believe the time will come when it will become such an exact science that the character of the spinal change or lesion is diagnostic not only of the viscus affected, but the way it is affected.”

Regional examinations and diagnosis will now be taken up.

Neck, Head and Face.—To make a thorough diagnosis of the condition of the cervical vertebræ probably requires more skill and a more acute sense of touch than of any other region of the body. The irregularities and variations of the cervical vertebræ, the numerous muscles and the passage of many vessels through the neck are very liable to mislead one.

One may examine the cervical vertebræ by having the patient either lying down or in a sitting posture. The former position is preferable, as then the muscles of the neck are passive, and besides it is much easier to relax the muscles if such should be necessary. Also one has better control of the field of examination.

It is undoubtedly best for the student when learning to examine the cervical vertebræ to first examine along the base of the skull the condition of the occipital muscles (after the patient has assumed the dorsal position upon the treating table) for any contractions; for if disorder exists in the upper five cervical vertebræ the condition will be manifested by contraction of muscular fibres along the base of the occipital bone. The muscles of the occiput are supplied by fibres from the posterior branches of the upper five pairs of spinal nerves, and if lesions exist to these upper nerves a contracted state of more or less extent of the occipital muscles will occur, no matter how slight the lesion. Thus the examiner after locating contracted fibres under the occiput has a direct clue to lesions existing somewhere in the upper five cervical vertebræ. After locating these contracted fibres of the occipital region and then still keeping the finger upon the contracted muscular fibres and following them downward until the contractions are lost and seem to enter the spinal cord, one has then located the exact point of disorder that is causing the irritation to the muscular fibres involved, and most probably the cause of the affection from which the patient is suffering, i. e., provided one has reason to suspect the trouble is in the cervical vertebræ. Simply follow the contracted muscular fibre downward until it seems to enter the spinal cord and there one will find a lesion. After the osteopath has become expert in diagnosis this will not be necessary unless he has to make a very fine diagnosis or unless he is examining a stout neck where it is hard to examine through the heavy muscles. With this method one has a firm, flat, broad surface to work on (the occipital bone) making it very easy first to locate contracted muscles and second to trace the course of contracted muscles and thus find the disorder. Otherwise the beginner is apt to get confused by trying to examine the condition of the cervical vertebræ. Later, when a student becomes more expert such a procedure will rarely be necessary only in cases that require special work in the examination.

When the point of disorder has been located the diagnosis as to the exact character of the maladjustment has to be determined. The abnormal position of the vertebra, tenderness at the point involved, local contracted muscles, and limited motion are the four diagnostic points, although the temperature of the affected part as compared with the general cutaneous temperature and the state of the local vascular channels (blood and lymphatics) will occasionally be of aid.

Owing to the irregularity of the spinous processes of the cervical vertebræ in regard to their length, great care has to be taken in the examination. Probably there is no other region of the body that will tax the patience of the osteopathic student so much in his practical work as making a diagnosis of disorders in the cervical spine. It requires patient and persistent work to become a fair diagnostician of the cervical region, and it will take much experience to become expert in both the examination and treatment.

One can depend that lateral deviations of the spinous processes are abnormal in most instances. Placing the finger upon the spinous processes of two consecutive vertebras the student can readily tell whether or not there is any lateral displacement; but telling as to other features is impossible as the spinous processes vary greatly in length. When a vertebra is lateral, a slightly twisted condition will be felt by the finger when placed upon and between the two spinous processes.

To elicit the various degrees and combinations of rotation and sidebending one should depend upon the symmetry of the transverse processes. Reaching anterior to the sternocleidomastoid muscle, or better still, pushing the cleido muscles forward and reaching posterior to them upon the transverse processes, a very fair examination can then be given the vertebras. When the vertebras are deranged, especially anteriorly or posteriorly, that is the apposition of the articular facets, a slight elevation will be felt, possibly not any larger than a very small pea, either the anterior or posterior aspects of the transverse processes, depending upon which way the vertebræ are deranged. Remember that accompanying this slight elevation will be degrees of sensitiveness of the vertebra at the point deranged. In cases where the vertebra is lateral a slight eminence will be noted along the outside of the process. Commonly disordered vertebræ are not entirely deranged in one direction but are oftentimes slightly rotated, so we may find them dislocated antero-laterally or in various combinations of sidebending-rotation. Several consecutive vertebras may be deranged in like manner of direction; this condition is chiefly found in pathological curves of the spinal column. Probably the most common general lesion is a strained condition of several consecutive vertebræ, each one being nearly intact but all of them as a whole somewhat strained or twisted. Thus there are many pathological states to take into consideration, although it is not surprising to the osteopath when he realizes that many of our pains and aches are due to anatomical derangement. Frequently bending the head strongly forward and downward, or downward pressure with slight rotation will produce pain at the point of lesion.

Subdislocations of the atlas are probably among the most common lesions presented to the osteopath. Owing to the articulation of the atlas and occipital bone being an anatomically weak point and the neck muscles being exposed constantly to atmospheric changes, besides the articulation between the head and neck receiving the brunt of many jars, falls and strains, the atlas is especially susceptible to derangements. On account of the intimate relation of the atlas to the superior cervical ganglion of the sympathetic and to the vertebral blood vessels it is certainly very necessary that the atlas should be well taken care of. No other tissue maintains such a significant position in relation to the blood and nerve supply to and from the brain. To diagnose correctly the position of an atlas and to be able to correct it is undoubtedly one of the most essential achievements of the practitioner of osteopathy.

The most common disorders of the atlas are anterior and lateral displacements. Next in order come “rotary” lesions of the atlas, i. e., where the atlas has been deranged diagonally or simply twisted. It may also be luxated anteriorly and laterally, or posteriorly and laterally, etc. A posterior derangement of the atlas is comparatively a rare disorder, although owing to the many lesions that are found in atlases one has, during the course of a year’s practice, several to correct. The atlas may occasionally be slightly tipped laterally, anteriorly, or posteriorly, and in a few cases it may be somewhat impacted against the occipital bone. Many times when the atlas is displaced the axis is also deranged on account of the close relation between the atlas and axis by the odontoid process of the axis.

To examine the atlas the patient may be either in the sitting or dorsal posture; it matters but little which position is taken. Possibly the dorsal position is better, as then the neck muscles are more relaxed and if necessary an examination of the cervical spine, below the atlas, can easily be made.

By placing the middle finger of either hand on the transverse processes of the atlas when the patient is in the sitting posture, or the thumbs on the transverse processes when the patient is in the dorsal posture and comparing the two sides, undue prominence of one side or the other can easily be noted. Remember the transverse processes of the atlas are slightly above and posterior to the angle of the inferior maxilla. Always, in examining one side of the patient, compare it with the other; it may save considerable embarrassment. One side may seem abnormal when by comparing it with the other side, both sides may be found the same and still be normal. With the fingers still on the transverse processes note the distance between the process and angle of the jaw, besides take into consideration the tenderness of the locality, and, also, what is of essential importance in all interosseous lesions, its articular range of movements. There should be room enough (approximately) to just comfortably wedge the end of a medium sized middle finger between the transverse process of the atlas and the angle of the inferior maxilla when both are normal. Thus with the fingers on the transverse processes an expert will be able to readily determine whether or not an atlas is lateral or anterior. If an atlas is posterior the distance between the angles of the jaw and the transverse process will be increased, besides the atlas will be quite prominent posteriorly. In conjunction with the abnormality of the tissues (prominence or depression of the bone and state of the muscles) the sensitiveness of the locality is extremely significant.

Outside of displacements of the atlas, a lesion between the axis and third cervical is most common; following next in frequency are lesions of the skull and atlas. By that is meant where all the cervical vertebræ are intact as far as their individual relation is concerned, but the skull is forward, backward or lateral upon the spinal column. This condition occurs quite frequently. To determine its condition the same methods are employed as in diagnosing a deranged atlas; for if the dislocations exist between the atlas and skull the same diagnostic points are presented as far as the skull is concerned as when the atlas, or atlas and axis, are dislocated from the occipital bone or from the axis or third cervical. Following the preceding examinations, additional examination will have to be made to see whether or not the atlas is intact with the vertebræ below. If the atlas is found to be intact with the vertebræ below and lesions are presented between the atlas and the skull, then the disorder must be between the atlas and the skull and nowhere else. Occasionally there are cases where the skull is so far posterior upon the spinal column that the angles of the jaw strike against the transverse processes of the atlas when the jaw is opened widely.

Derangement of the muscles of the anterior and lateral regions of the neck are common. Especially are contractions of the muscles on either side of the larynx liable to occur. In examining the cervical region do not pay too much attention to the superficial muscles, but examine carefully the deeper muscles. It is from these that impingements of nerves and constrictions of vessels are likely to take place in the contracted fibres. Also, imbalance of muscular tension may be the source of the resulting malalignment. In examining for contracted muscles do not gouge into the muscle nor grasp the muscle roughly, but bear down lightly (inhibitory) upon the muscles and then gradually exert firmer pressure. By carefully and firmly exerting pressure over muscular areas the deep muscles can then be felt beneath the superficial ones. Otherwise when the muscles are manipulated severely the superficial ones will contract to such an extent that the deeper ones cannot be felt. The muscles contracting on either side of the larynx tend to draw the larynx downward and thus there may arise a source of irritation. The various muscles contracting in the antero-lateral region of the neck are very often the source of chronic irritations of the pharynx or throat. The omo-hyoid muscle may become contracted and cause slight traction on the hyoid bone and thus produce an irritating cough. To examine the muscles of the neck thoroughly it is best to have the patient flat upon the back, for then all the normal muscles are relaxed.

Lesions quite frequently occur in the temporo-inferior maxillary articulation. The lesion may be either unilateral or bilateral, more commonly the former. The disorder usually consists of a relaxation of the muscles and ligaments about the articulation which allows a slight but perceptible dropping of the inferior maxilla on the side involved. In other cases there may be presented a spasticity of tissue, while in still others some degree of joint infection may be found. Lesions of this articulation particularly impinge upon fibres of the fifth cranial nerve. The points of diagnosis are clicking and tenderness at the articulation. These two points are the symptoms of which the patient complains; those noticed by the osteopath are a slight deviation of the jaw to one side or the other when the jaw is opened and a flinching of the patient due to tenderness when pressure is exerted over the articulation of the jaw. When the physician places his fingers around the jaw, anterior to the angles, and the thumbs over the bridge of the nose, having patient open the mouth, at the same time exerting pressure with the fingers and thumb, a sharp click may be elicited by the return of the jaw into its articulation.

In disease of the scalp the condition of the muscles of the scalp should be taken into consideration. The muscles are usually found contracted. The contraction of the muscles is generally due, as well as the disease of the scalp, to derangement existing in the posterior branches of the upper five pairs of the cervical spinal nerves.

In the neck, anteriorly the hyoid is the only bone to consider. It is easily palpated by standing at the head of the table and with the second finger of each hand outline both ends to ascertain its relation with the thyroid cartilage. Note carefully any contracted tissue or glandular enlargements which might cause undue tension. The tilting of either end of the hyoid from these contractions is productive of much throat irritation. At the same time the larynx may be examined. It may be prolapsed, causing irritation of the laryngeal group of nerves. The thyroid and cervical glands should be palpated for enlargements, and all the muscles and ligaments for contractions. Externally the tonsil may be felt by deep pressure in front of the angle of the inferior maxilla.

The Ribs.—Under the osteopathic diagnosis of the ribs will be included the examination of the clavicle and sternum. To be able to diagnose intelligently, the position of the ribs in detail is very necessary to the osteopath. Many of the diseases of the heart and lungs, besides a large number of the diseases of the digestive tract, may be traced to a deranged rib; also, occasionally diseases of different regions of the head and neck may be due to dislocated ribs. In making a thorough examination of the ribs each rib should be carefully noted as to its position. The ribs may be examined when the patient is sitting up; but it is better to have the patient flat upon the back and especially so if the floating ribs are to be carefully examined, because the muscular tissues of the side if contracted will interfere with the diagnosis. In many instances the rib lesion is secondary to a vertebral subluxation.

An expert osteopathic diagnostician will be able to detect at once by a single passage of the hands down over the ribs if there are any disorders of them. In passing the flat of the hand, especially the flat part of the fingers over the ribs, carefully observe if the intercostal spaces are too narrow or too wide, and if any of the ribs are unduly prominent or depressed. If an intercostal space is too narrow it shows that the ribs on either side of the intercostal space are too close together. Then the question arises, which one of the ribs is crowding upon the intercostal space, or whether both of the ribs are crowded together. Usually when the sternal end of the rib is displaced upward, the involved rib is prominent and when displaced downward the rib is depressed. Thus it is commonly easy to diagnose which is the involved rib. Besides finding an abnormal position of the rib there will be more or less tenderness over the rib. Finding a rib prominent or depressed and tender is generally quite conclusive that the rib is displaced. Then the range of movement as expressed through the sense of resistance is a helpful guide in diagnosis.

If a typical rib is placed upon a flat surface and one end of it is depressed the other end will be elevated and vice versa. This peculiarity holds true as well when the ribs (typical) are dislocated in the living body. If the anterior end is elevated the posterior end is commonly depressed and vice versa. Care should be taken in examining the first rib and the false ribs, for in these ribs this peculiarity is not found.

As a whole a very complete diagnosis can be made of the condition of the ribs by examining the anterior part of the thorax, although it is always best to examine along the angles of the ribs if for nothing more than to confirm the diagnosis made at the sternal ends. Still it must be remembered that the preceding only holds good when the entire rib is dislocated. Many times simply one end of the rib is deranged and the other end is practically intact.

Besides careful examination of the sternal end of the rib, attention should be paid to the condition of the costal cartilages. The costal cartilages may become deranged at either the articulation with the rib or with the sternum. The same rule holds good when the costal cartilages are dislocated as when the ribs are dislocated, i. e., when the cartilages are prominent, they are usually displaced upward and when depressed the cartilage is displaced downward toward its neighbor.

One is apt to think that a rib is only dislocated at its vertebral end. Although lesions of the vertebral end are generally of greater significance as far as the etiological factors are concerned, still the sternal end of the rib must not be overlooked. In examining the vertebral end of a rib attention should be paid the angles of the ribs, for at the angles a better opportunity for examination is given on account of the prominence. It will be necessary in many cases to find out whether or not the vertebral end of the rib is lying between the transverse processes instead of in front of them. In many severe lesions of the ribs the vertebral end of the rib is dislocated upward or downward from the transverse process of the vertebra and lies between the transverse processes of the vertebræ above and below its attachment. This certainly requires considerable skill in the diagnosis, for oftentimes the point to be found is barely an eighth of an inch in diameter. It is usually best before making such a close examination to relax the tissues well over the field of examination.

The ribs as a whole may be too transverse or too oblique upon one side. This is chiefly found in pathological curves of the spine, but still such conditions may exist where there are severely contracted muscles, especially in some cases of paralysis. Thus the contour of the ribs must be taken into consideration by comparing one side with the other.

In examining the first rib an examination somewhat different from the other ribs should be given. It is best to have the patient assume a sitting posture; then place the middle fingers of each hand upon the first ribs near their centers and compare one with the other. Also note the difference of the spaces between the ribs and clavicles. Generally the first rib is dislocated upward, rarely downward. Besides finding an abnormal prominence or depression of the rib at its center considerable tenderness will be noticed. Examinations of this region are every day experiences with the osteopath.

When diagnosing the position of the floating ribs it is best to have the patient lie flat upon the back with the thighs flexed upon the abdomen, so that the tissues about the lower ribs may be entirely relaxed. Then by placing the flat of the fingers carefully over the ribs the outline and position of them can be easily discerned. The floating ribs are oftentimes found deranged and are the source of a great deal of suffering through the iliac regions. These ribs may become dislocated from the vertebral ends and drop down obliquely toward the iliac crest, or else the free end may become locked beneath the rib above. Occasionally both ends of the rib drop down quite perceptibly and consequently is the cause of considerable distress. In such instances the rib is depressed inward so that the normal contour of the lower thorax is lost.

An examination of the clavicle should be carefully made. Always compare the clavicle with its fellow and examine thoroughly its articulation with the sternum as well as at the acromial prominence. Often the sternal end of the clavicle is slightly dislocated posteriorly to the sternum; although it may become completely luxated. The acromial end may be dislocated upward or downward.

In examining the sternum special attention should be given the articulation of the manubrium and gladiolus. This is due to the crowding anteriorly of the articulation of the sternal parts. Normally until well along in adult life there should be some movement here due to its membranous attachment. Occasionally the ensiform cartilage is turned inward, producing a tender point, but this rarely occurs. Also the articulation of the cartilages in the region of the eighth, ninth, and tenth ribs may be found considerably deranged, causing local tenderness and even stomach trouble.

Dorsal and Lumbar Spinal Region.—With the patient sitting on the table abnormal deviations can be readily noted. There may be lateral swerves, from muscular weakness, or unilateral tension, involving the whole spine or less, or a reversal of natural curves, i. e., the spine depressed anteriorly between the shoulders and posteriorly in the lumbar making the straight spine. There may be, also, an exaggerated normal curve in the dorsal region producing a kyphosis with a compensatory lordosis in the lumbar region sufficiently great to change its relations with the pelvis. By the method previously given, now outline the spinal column for lateral and bilateral scoliosis. These, frequently, are at their incipiency, and to the casual observer would pass unnoticed. It is well to make an outline of the spine before beginning treatment, and at times following, that progress may be observed. A simple method is lead tape which can be had from any plumber shop and can be molded to the deformity and traced on paper together with date of examination. H. F. Goetz has perfected an appliance for outlining and recording these deviations. Observe well the ligaments, as well as extent of joint movement, under deep palpation; from irritation they may become thickened and more or less fill the spaces about the spines and transverse processes, causing a rigid, smooth spine.

To make a detailed examination the patient should be stretched out on one side upon a treating table, although the general examination may be sufficient. Then, standing in front of the patient and reaching over him, a most careful diagnosis can be made. Do not stand back of the patient as the flat of the fingers can not be used to advantage in outlining the different vertebræ. The various contracted muscles that may be found along the spinal column will be of valuable aid in locating derangements of the vertebræ and vertebral ends of the ribs. By using contracted muscles along the spinal column as a guide for locating lesions, reference to the large superficial muscles is not made, but to the small areas of contracted fibres of the deep muscles. It is the deep muscles that become more or less contracted, and even fibrotic, when lesions of the vertebræ and ribs exist. The superficial muscles are generally contracted by atmospheric changes, slumped postures, wrong habits, etc., and are not generally the result of disorders in the osseous system. The preceding points in regard to contracted muscles cannot be too carefully observed for there is a tendency among many osteopaths to treat the contracted deep muscles as primary lesions in nearly every case. Remember that if they are not due to the motor nerve fibres of the muscles being irritated by the spinal lesion, or to a reflex stimulus, or to a compensatory change, that although the muscular tension may be the inception of the almost certain interosseous lesion, still the leverages secured through bony adjusting are very essential not only in correcting the osseous malposition but in loosening and releasing fibrous muscles and thickened ligaments.

Thorax.—Examination of the thorax as a region has been largely gone over in speaking of the ribs and their sternal attachment, cartilages, sternum and the clavicles, but its appearance as a whole should be carefully noted for it will be a valuable aid in diagnosis. Deviations from the normal, such as the emphysematous or barrel-shaped chest in asthmatic affections, or chronic cough, or accompanying kyphosis, the flat chest and its association with phthisis, the rachitic, etc., should be considered. Spinal deformities are reflected in the thorax by marked changes in contour, such as elevations and depressions corresponding to the spinal changes. These result in marked interference with the thoracic organs and in young subjects are of particular interest. Rib changes are frequently the result of vertebral deviations.

Abdomen.—The position for examination of the abdominal viscera is usually with the patient supine, head slightly elevated, knees drawn up partially and supported to relieve any muscular strain, and with the hands at the sides. In this position complete relaxation is obtained. Observe any enlargements from gas, fluid, or tumor, muscular changes, color, etc. The patient may, also, be placed upon the side, and in the knee-chest position for further verification of the diagnosis. Where the abdominal wall is much relaxed, or there is a pendulous abdomen with enteroptosis, there will be found a change of relations of the viscera by these different positions, allowing them to be palpated in another position. When there is marked tenderness it is often possible to go deeper with less discomfort with the patient in the knee-chest position. The Trendelenburg position may also be utilized. Where ascites is suspected palpation should be made with the patient in various positions in order to note changes of location of the fluid. Frequently much can be learned by inspection with the patient standing. Clues to visceral disturbance can often be had by tracing the nerve connection from the spinal lesions to the suspected part.

In examining the liver care must be taken that any gouging or severe bruising of the organ does not take place. The liver can be outlined by percussion and also by palpation of its lower and inner borders Congestions, atrophy, enlargement or hardening should be noted, also any change in position.

A rather complete examination can be given the biliary tract from the gall-bladder to the duodenal orifice of the biliary duct. By a careful inhibitory pressure over the duct the outline of the tract can be discerned providing the patient is not too stout. When the tract is swollen considerable tenderness will be present. The patient will complain of a stabbing or piercing pain upon pressure and manipulation if the duct is inflamed.

Usually the tenderness is greatest nearer the duodenal orifice. The duodenal orifice is about one and one-half inches diagonally downward to the right from the umbilicus. In cases of impacted gall-stones the osteopath as a rule has very little trouble in locating the stone.

The spleen may be percussed and when in a markedly enlarged condition its lower border can be palpated. Great care must be used in the latter condition as there is danger of rupture.

In examining the stomach the usual methods of inspection, palpation, percussion, analysis of the contents, etc., are employed.

Palpation and manipulation over the intestines are practiced a great deal by the osteopath in various intestinal diseases. By his educated sense of touch he is usually able to locate at once any impactions of fecal matter. Such impactions are generally found in the ilio-cecal and sigmoid regions. In the various acute obstructions from invagination, tumors, twists, adhesions, spasticity, knots, etc., many times one is able to readily locate the seat of the disturbance. There is one point to specially emphasize; that is, do not overlook prolapsed regions of the intestines; such occur frequently and are a source of considerable distress, especially constipation. Simple manipulation will never do much good, neither will spinal treatment or injections, as a rule. A specific treatment must be given and, that is, after locating the exact point of prolapse, to reach carefully beneath the fold and replace it.

In emaciated subjects the kidneys can be readily located, and in a few instances when they are diseased one can feel the contracted tissues about them. Be very careful not to injure the capsule about the kidney. Do not punch or gouge them in the least; but locate the kidneys by a careful inhibitory palpation.

Lumbar and Pelvis.—The intimate relation between the lumbar spine and pelvis make a consideration of them as a region necessary. Outside of ordinary curvatures involving both the dorsal and lumbar regions there are certain conditions which involve but one structure and require careful differential diagnosis to determine whether the lumbar or pelvis is at fault. In the former the fifth vertebra is a weak point and is most frequently at fault. The deviations are usually a sidebending and frequently accompanied with some rotation. Occasionally a malstructure of the lower lumbar or pathologically relaxed ligaments will approximate the spines and be misleading as to the real condition. A rotation or lateral tilting of the fifth lumbar may have the effect of elevating the crest of the ilium so that the innominatum would appear involved. There will be a difference in the length of the legs, angles of feet when patient is lying on the back, anterior spines out of line and tenderness of the muscles attached near them. However, other diagnostic points of innominate lesions, i. e., tenderness of symphysis and sacro-iliac articulation, and prominence of the posterior spine, will be lacking. Marked deviation of other lumbar vertebræ may produce practically the same effect, but the lesion will be so apparent that there will be no doubt as to the cause.

To be able to diagnose accurately and intelligently the pelvic region requires nearly as much skill as in examining the cervical region. The pelvic bones are liable to many subdislocations, especially in the female. However, it should be remembered that many apparent innominate lesions are secondary or compensatory changes due to lumbar lesions. The pelvis as a whole may be tipped anteriorly or posteriorly upon the spinal column. It also may be twisted or rotated laterally upon the spinal column. The most common lesions are subluxations of an innominatum forward, backward, upward, or downward, or various combinations of these displacements, such as a tipping forward and downward of an innominatum, or a tipping backward and upward, but these combinations do not always exist in the manner given. As a rule when the ilium is anterior, the ischium posterior, then the innominatum as a whole is downward; when the ilium is posterior, the ischium anterior, then the innominatum as a whole is upward. This is only a rule, there are exceptions to it; for in some few cases when the ilium is anterior, the ischium posterior, the innominatum may be higher, and when the ilium is posterior and the ischium anterior the innominatum may be lower.

To be able to diagnose such derangements will require skill and practice; still there are symptoms and signs that are characteristic of such disorders. In examining the pelvic bones have the patient flat upon the back at first. Be sure he is flat upon the back for a very slight variation may make considerable difference in the relation of the pelvic bones, one to the other, so far as the diagnostic points are concerned. Then go to the feet of the patient and grasp the ankles firmly, rotate laterally both legs, first to one side and then to the other, as well as pull and push both limbs slightly, and then bring the heels together directly in the median fine of the body and compare the length of the limbs at the heels. If there is any disorder whatever in one innominatum, and the thigh muscles have been relaxed thoroughly by the preceding movements and the heels are brought together in the median line of the body, a difference in the length of the limbs will readily be observed at the inner malleoli or the heels. For if the ilium is forward the ischium must be backward and as a rule the innominatum is thrown downward, thus causing an apparent lengthening of the limb which will be noticed by comparing the heels; if the ilium is backward the ischium must be forward and as a rule the innominatum is then upward, causing an apparent shortening of the limb on the affected side. A very slight variation in the pelvis will make considerable difference in an apparent lengthening or shortening of the limbs. Such conditions are generally met with several times a day by osteopaths. The object of the lateral rotary movement and the pushing and pulling of the limbs is to make sure that all the thigh muscles are thoroughly relaxed, for it is a very easy matter for contracted muscles in one thigh to produce an apparent shortening of the limb. Also be very careful in comparing the length of the two limbs at the heels where they come together that they are exactly in the median line of the body, for if they should be to one side or the other, however slightly, there would be an apparent lengthening of the outer limb as compared with the limb near the median line. While the patient remains flat upon the back it is a good plan to compare the anterior spines of the ilia. It may be readily noticed that one is higher or more depressed than the other, which will help to confirm the diagnosis. It is a good plan also to have the patient sit up squarely upon the table and compare the crests and posterior spines of the ilia; thus one may be seen to be higher than the other. Then, also, note the angles of the feet when patient is supine; an everted foot usually means that the limb is shorter due to the tilted pelvis; the opposite is commonly true when the foot is inverted. However, this is not an absolute rule. Care should be taken in differential diagnosis of possible old fracture of leg, of infantile paralysis, of asymmetry, etc.

There are three diagnostic points exclusive of all other signs that are quite conclusive when coupled with the preceding examination. If an innominatum is dislocated or subdislocated there will be tenderness over the symphysis pubis on the side affected, tenderness over the ilio-sacral articulation on the side affected, and tenderness along the crest of ilium where the abdominal muscles are attached. When tenderness is found at these three points it is quite conclusive that the innominatum is deranged, for at the symphysis pubis and ilio-sacral articulation tenderness must exist if the innominatum is disturbed, and by a change in the crest of the ilium the abdominal parietes will be affected, provided they are not too much debilitated. Marked tenderness of the external cutaneous nerve as it passes over the crest of the ilium below the anterior spine will be noticed on the unaffected side (Dr. Still). There will be, on rectal examination, marked tension of the tissues on the affected side. Possibly the patient may complain of pain exclusively in one side along the pelvis and limb which will be a leading symptom telling which side is affected.

Additional diagnostic signs will be rigidity of muscles along the ilio-sacral articulation and abnormal prominence or depression of the ilium at its articulation with the sacrum, depending upon which way the innominatum has slipped. Considerable deviation of the pubic bones may be noticed. The pubic bone on the side affected may be either thrown upward or downward.

Radiographs have repeatedly revealed subluxations of the innominate bones in many instances. This is certainly quite conclusive in confirmation of the osteopathic ideas in regard to the pelvic bones becoming dislocated.

Sacrum.—Examination of the sacrum is best made with the patient lying on the side, with the osteopath standing in front and with the hand palpate its posterior surface. In the sitting posture its relation with both innominates can be determined. It is displaced posteriorly but seldom, the most frequent being anterior, downward, and a combination of the two. In the anterior conditions tenderness at the sacro-iliac articulations is a good point, but it must not be confounded with an innominate lesion. The downward displacement is shown by comparison with the lower lumbar vertebræ. Observe the relation between the two, as a change in contour of the spine will also change the angle of the sacrum and vice versa.

Coccyx.—With the patient and operator in same position as for the sacral examination outline the coccyx, as to first, contour; second, rigidity; third, sensitiveness. If abnormalities are detected go to the other side of the table and with a well lubricated index finger palpate its anterior surface. Changed contour, displacements, and old fractures can be readily determined. The most common deviation is anterior at its union with the sacrum. The lateral form generally resulting from muscular contraction is next, with posterior but seldom. “If the lower part of the sacrum is rotated backward, the sacro-coccygeal articulation or angle is affected or becomes more acute, since the tip of the coccyx is not displaced, but held in position by structures attached to it. If the sacrum is displaced downward the effect is about the same. Often this sort of sacral lesion is mistaken for an anterior luxation of the coccyx.”[28] Remember that normally there should be some movement of the coccyx. It has a fibro-membranous articulation.

Uterine, ovarian and rectal examinations are largely of the same nature as those given by other practitioners, although osteopaths find that oftentimes other practitioners are mistaken in regard to the etiology of many diseases to which these organs are subject.

Arms and Legs.—There is comparatively little that is exclusively osteopathic in regard to the diagnosis of disorders of the arms and legs. One important feature that the osteopath finds in examining the arms and legs is that many of the disorders supposed to originate in the affected member are found to be caused from vertebral or rib dislocations. Innominate and lumbar lesions are particularly fruitful sources of trouble in the legs and feet. Always carefully examine the spine in the region of innervation to the arms and legs when they are affected. The shoulder and hip joints, as well as all joints, are subject to partial dislocations. Many times when pain or other symptoms are presented in the arms or legs the trouble is at the shoulder or hip joint or in the spinal column. There are two regions that are very apt to be overlooked in the examinations of the arms and legs and they are the elbow joint and the fibula. The small bones of the ankle and wrist as well as of the foot and hand are subject to many dislocations which are easily discerned upon examination and often overlooked. Special emphasis should be given in regard to many supposed diseases of the knee joints which are really caused by lesions in the spine or at the hip joint.

Everyone is of the opinion that to forecast the probable result of a disease is one of the most difficult problems the physician has to meet. To state the duration, course, and termination of an attack of disease as presented by its nature and symptoms implies an accurate knowledge of both disease processes and changes, and an insight into the individual’s idiosyncrasies backed by ripe clinical experience. And after each of these factors has been carefully considered to balance one against the other, nothing short of superhuman knowledge may present a sufficient insight in order to render an accurate prognosis. A prognosis represents the culmination of one’s learning, an understanding of disease characteristics, and an insight into temperament.

C. M. T. Hulett[29] says: “Only when we can know all the conditions, causative and sequential, with their possible complications and terminations, together with a full history of therapeutic results in a large number of similar cases, and carefully analyzing and weighing these various elements, are we prepared to really make a prognosis.” Nettie H. Bolles[30] writes as follows: “The prognosis depends upon the cause of the disease, the possibility of removing the cause, or the likelihood of recurrence of causes, and the chances of avoiding such recurrence. The circumstances to modify the outlook are various and deserve careful consideration.” It is not the purpose here to go into the many essential details, for that would mean an outline and forecast of all disease processes, and the effect of numerous extenuating circumstances. The medical profession have been gathering data for these three thousand years and prognosis with them is still inaccurate and incomplete. Osteopathic science will add just so much to the accuracy of prognosis as the sum total of the knowledge displayed in the fields of osteopathic etiology, diagnosis, pathology and therapeutics. Suffice it to give here a few salient practical hints as noted in the osteopathic treating room and at the bedside.

Osteopathically it may be said that prognosis depends, first, upon the true conception of osteopathy; second, upon the relative value of all factors pertaining to health and disease; and, third, upon the skill (technique and native ability) of the osteopath. The first and second being granted, the third includes a remarkably practical and pregnant field, for in no school does the physician get into as close touch and understanding of the actual condition of the patient’s disorder as in the osteopathic. Although the fundamentals and principles of the osteopathic conception of diseases are really broad, liberal, and all-inclusive, still owing to the fact that each individual (and thus each disease) is more or less a law unto himself should there not be absolute tables and prescriptions to be governed by; remember, however, this does not imply our fundamentals are not basic or our principles are not truths, but rather the application and execution of the same are as varied as the individual’s constitution, temperament, and disease. Herein rests the really difficult practical consideration of etiology, pathology, diagnosis, treatment, and prognosis. In other words, if the diagnosis and treatment are accurate the result rests entirely with the patient.

First, too much emphasis cannot be placed upon the fact that prognosis is dependent upon the osteopath—his education, training, ability, experience, and technique. One’s fitness is most important. And fitness and personality complement each other. An osteopath may know theory and still not be practical; still one cannot be practical unless he knows theory.

Second, osteopathic treatment frequently changes the usual course of acute disease. It is well known that many diseases have a certain regular course in their history. Many times the osteopath will be able to abort, lessen the severity, or cut short the ailment, thus changing the recognized symptoms and termination.

Third, the knack of treatment, or knowing how to treat, not only one region of the body but all regions, not only one temperament but all temperaments.

Fourth, the preparatory treatment before correcting the lesion. Prevention, palliation, or cure, and thus prognosis, may be dependent upon a necessary preparatory treatment. Here is where a study of the patient’s temperament is very essential.

Fifth, a prolonged treatment may defeat one’s purpose. As a rule a comparatively short, thoroughly indicated, specific treatment is best.

Sixth, much, relative to prognosis, can be told by the tone of the vertebral ligaments. When a lesion corrects too easily or does not remain well in place it shows a lack of tonicity on the part of the ligaments and muscles. Improvement is in direct ration to the increase of tonicity.

Seventh, special care should be taken with the irritable spine. This spine commonly precedes the debilitated spine. Unless precaution is taken to apply inhibition before treating specifically a cure may be prevented or at least the disorder prolonged.

Eighth, relaxation of muscles is not always essential, although the lack of it may prevent the correction of primary lesions. The relaxation should be carried out with care in order that all shock and irritation may be kept at a minimum.

Ninth, needless stretching, traction, extending, rotation, and snapping of the neck is not only useless but may be positively dangerous. Rarely is it necessary to go through the above “movements” as many are accustomed to do.

Tenth, it may be necessary, but not always, to give as additional treatment, after the anatomical defect has been specifically treated, a certain amount of stretching and moulding of the parts.

Eleventh, owing to the close personal relations of physician and patient, personality has a powerful influence on prognosis.

Twelfth, too much emphasis cannot be placed upon the uselessness and injurious effects of over and misapplied treatment.

All of the above have a positive bearing on prognosis. The osteopath should study his technique well. He will find that it gradually changes and improves from year to year. In a word, as he gains in experience he will become more skillful by giving careful attention to the development of the sense of touch, by noting the resistance of the tissues, and a score of details that are very hard to describe but the sum total of which determines and indicates the successful osteopath.

Another practical point that bears upon prognosis as well as upon the health of the osteopath is the manner of giving treatment. First, the height of the treating table should correspond to the height of the practitioner. The table should be made for the practitioner and not the practitioner fitted and warped according to a certain table. Second, give part of the treatments on a treating stool. Here there is greater freedom of movement on the part of the patient, hence greater and more effective leverage can be obtained. Suit your treatment to the patient, not your patient to the treatment. Third, make your weight count for energy expended in the treatment. As soon as one set of muscles become tired substitute another set, e. g., the back muscles and the arms, the arms and the hands. Fourth, whenever possible substitute the weight of the patient for expended energy. Fifth, when lifting keep the spinal column straight; do the bending of the body at the knees. Hence a better treatment and a more favorable prognosis, and besides that new occupation neurosis, the “osteopathic back,” will be materially lessened in both severity and frequency.

---

The technique of treatment is, in a sense, a personal factor, for it is a well known fact no two osteopaths treat just alike. Nevertheless, the principles of technique are constant and universally applicable, and he who applies them with specificity manifestly secures the best results, and exhibits a technique that is finished and characteristically osteopathic. General manipulations are not essentially osteopathic, although by employing them a few definite results may be obtained; still such technique should not be classed as distinctive osteopathic therapy. Every case is a law unto itself and must be studied individually in order to be able to understand it perfectly. So much depends upon the ability of the osteopath in the treating of a case, that in order to meet the indications intelligently he must have command of the various anatomical details of the body, not only in his mind but upon his finger tips.[31]

The sense of touch should be very acutely developed and this requires months of persistent, practical experience. A carefully educated sense of touch is the keynote to both osteopathic diagnosis and operative technique. From the very nature of the osteopathic conception—the physical body viewed as a mechanism whose disordered or diseased conditions demand anatomical readjustment—it is imperative that a delicate and educated sense of touch be acquired in order to logically and successfully apply its tenets. Proficiency means not only being able to note certain small physical irregularities, and various degrees and areas of muscular contractions, and variations in body temperature, but the extent and state of vital resistance, that is, tissue condition, and the feeling of organic resistance, e. g., the heart, lungs, liver. These are the special features wherein osteopathic fingers detect disease causes and traces. To know the difference between normal and abnormal structural deviations and distortions, as well as organic changes, requires an accurate, detailed knowledge of anatomy and pathology with a systematic daily education of the sense of touch; but to realize, appreciate and know by tissue resistance feeling that nutritional condition is improving requires much more practical experience.

Thus two very practical points should be taught to and thoroughly impressed upon every osteopathic student: First, the sense of resistance of the tissues. This gives us an absolute clue to the vitality of the patient. As has been stated, there is a vast difference between the feel, the sense of resistance, of normal and abnormal tissues; for instance, a normal muscle and a contractured muscle, a normal liver and a congested liver, a normal intestine and a prolapsed intestine and these differences comprise innumerable gradations.

Second, the receptivity of the patient to treatment. This is dependent upon the vitality of the tissues. The sense of resistance to touch gives us an important diagnostic clue; the receptivity of the patient to treatment tells us much as to prognosis. After a few treatments the receptiveness will be positive or negative; that is, the patient is, or is not, responding to treatment. Consequently the receptivity of the patient usually tells much as to the state of nutrition.

Definite principles should be followed when applying the technique, for the osteopathic lesion is a “structural perversion,” thus indicating mechanical readjustment for its correction. The time is coming when the technique will be taught graphically and mathematically. This would not be a difficult thing to do, and it could not but prove invaluable aid to the student. He can then the more readily and comprehensively grasp the principles involved. To resolve and illustrate manipulative readjustment to and by the principles of mechanics would add considerable to osteopathic development. For example, how nicely the correction of certain innominata maladjustments illustrates the principle of the wheel and axle. Vertebral and rib displacements when readjusted make application of the principles of the simple machines. We are gradually approaching a more comprehensive understanding of the physiologic movements of the spine and of the etiologic role of muscle tension. This is part of the foundation work. Great care must be exercised in correlating this data with the individual case, for in therapy we are dealing with abnormalities—not alone normal physiologic changes. If our distinctive dynamics and therapeutics were taught in this manner the average osteopath would be more specific and comprehensive in his work and as a consequence more scientific. And consequently the principles involved in each and every case would stand out clearly. Hence diagnosis would be more exact, routine pommeling discarded, and better all around technique executed.

Two general rules are applicable to all dislocations, whether partial or complete: 1. Exaggerate or increase the dislocation. This is to relax the tissues about the dislocated articulation and to disengage the articular points that have become locked. 2. Reduce the dislocation by retracing the path along which the parts were dislocated. Hence to correct a lesion, for example, a vertebral lesion: (1) Exaggerate the lesion. (2) Place the fingers of the hand that are not employed in exaggerating the lesion over the extended portion of the lesion. (3) Extend the region that is flexed when the lesion was exaggerated. (4) When the lesion is being extended produce traction and slight rotation of the region. (5) At the same time extension, traction and rotation is being produced push in upon the extended portion of the lesion. To this might be added for sake of clearness and greater assurance of success: (a) Be positive the focal point absolutely corresponds to the lesion, or else most if not all of your effort will be useless. (b) Just before reaching the maximum of exaggeration have your fingers correctly placed for the readjustment, and at the very moment of maximum exaggeration or just a fraction of a second prior begin to correct or readjust, or else you will lose the vantage gained and the operation will probably be a failure. (c) The general traction and rotation are to aid in unlocking the lesion, not to readjust as some may think. Inhibiting and releasing the soft tissues, such as spasms, contractions and contractures of muscles, and stretching thickened and adherent ligaments is very important preliminary work. Then, next to securing exact leverages an essential point is to maintain the release or exaggeration until the readjusting step is incepted. In other words, coordination of all factors is the desideratum. The lack of this is the cause of many failures. Hot fomentations frequently assist in relaxing irritable and spastic soft tissues. This, however, is but a preliminary measure. All rough handling, needless snapping of parts, and excessive rotation and stretching are not only apt to tighten the lesion more, shock the system and irritate the parts, but it may be absolutely dangerous.

It should not be forgotten that the osteopath includes many measures in his treatment of various diseases, as nursing, dieting, hygiene, sanitation, hydrotherapy, antidotes, antiseptics, etc., and does not depend upon readjustive manipulation alone, although correcting disordered anatomical structures and perversions are paramount in the treatment.

The General Treatment.—A general treatment but accentuates the ignorance, in a majority of cases, of many so-termed osteopaths. It is a deplorable fact that there is a tendency among some osteopaths to give general treatments in every case presented. The only explanation of such a procedure that one can think of is a lack of conception as to what osteopathy really is. To give a general treatment in every case is not only actually detrimental to the patient but it is the height of folly on the osteopath’s part, for it gets him into a slovenly habit of procedure from both scientific and curative points of view, besides giving the outside world an impression that osteopathy is but little different from massage and Swedish movements instead of skillful, mechanical engineering of the human body. But a “general treatment” is not to be confused with definite attention to be a series of more or less interrelated lesions. The essential point is to normalize the body when and where distinctly indicated and after a skillful manner.

A general treatment, broadly speaking, should be given only under three conditions: (1) Constitutional diseases that are to be treated symptomatically. (2) Certain anemic cases. (3) When one is ignorant of the real cause of the disease. Each of these conditions is self-evident why a general treatment should be given. A fourth might be added, for those individuals who think they are not getting value received unless they are treated from head to foot. Such patients are usually ignorant of the philosophy of osteopathy and it is the osteopath’s duty to teach them differently.

The general treatment consists in stretching the spinal column from the atlas to the coccyx and relaxing all contracted muscles along both sides of the spinal column, besides giving special treatment to the cervical region, between the scapulæ, the splanchnics and internal and external rotation of the legs. It is no wonder that fake osteopaths do cure a case occasionally. They are quite certain to correct some disorder by pulling and hauling a patient around in such a manner. Still on the other hand they are very likely to do injury to the patient. Those who claim that no injury can come from osteopathic treatment are mistaken. One can injure a person by treatment if he is not careful. It does not stand to reason that the most delicately constructed mechanism should stand any amount of manipulation and misdirected force that may be given it.

Positions of the Patient and Physician in Treating.—The position of the patient when a treatment is given depends altogether upon the affection to be treated. Probably about one-half of the cases can be treated to advantage upon a table, the remainder sitting on a stool. Many osteopaths treat nearly all their patients upon a table. It is much better to change back and forth, because to correct a certain disorder may be hard upon the table, but will be comparatively easy when the patient is on a stool, and vice versa. Besides, constantly changing back and forth rests a physician greatly.

Learn to treat in various positions, because it will be impossible to have all cases assume a certain position when being treated; and especially in treating acute cases one is obliged to suit his treatment to the patient and not the patient to the treatment. There is also a tendency for one to get into slovenly habits of treating when patients are all placed practically in one position, and certainly one cannot treat all cases in one position to equal advantage. Also learn to treat as well with one hand as the other. Many times one will be in such positions that equal use of either hand will be required. Carefully educate the sense of touch in both hands.

Another point should receive consideration: learn to shift the strength exerted in treating from one set of muscles to others. For example, when one is standing for a long time he will continually shift his weight from one limb to the other. In the same manner in treating use the strength of the hands awhile, then the arms, then the muscles of the back, then the weight of the body, etc.; all in such a manner that there is a constant change by utilizing certain groups of muscles for the same work, as well as utilizing the weight of the body of both physician and patient to advantage. It rests a physician greatly and thus allows him to perform a maximum amount of work with a minimum amount of strength and labor.

It is frequently an advantage to the physician to treat upon the nude skin, thus preventing the fingers from becoming tender. Gowns can be easily made that open down the back so that the patient does not have to disrobe.

The Neck and Head.—In the treatment of the neck the patient may assume the sitting posture or lie flat upon the back. The latter is preferable, as then one has complete control of the neck and head. Absolute control of a part is always necessary and when this is secured the dangers are reduced to a minimum, provided always that reasonable discretion as to the amount of strength, is used. Before correcting the various deviations of the cervical vertebræ it is usually best to thoroughly relax all the muscles, superficial and deep, about the field of operation. In relaxing muscles three methods may be employed. The muscle may be firmly grasped and manipulated until relaxed, or a firm pressure may be exerted upon the muscle and thus inhibit its nerve force until the muscle relaxes, or the muscle may be longitudinally stretched. The second method is comparatively slow and is usually given in acute cases where the patients are so weak and exhausted that they cannot stand any severe manipulation. This method, however, has certain advantages when employed as a preparatory step in interosseous adjustments, though steady traction accompanied with slight rotation, if precisely localized, has many advocates.

In relaxing muscles by manipulation, grasp firmly the belly of the muscle and draw outward on the muscle several times until it relaxes. If the patient is sitting, place one hand upon the head of the patient or about the chin in such a manner that complete control of the head is maintained throughout the procedure; then with the fingers of the other hand upon the contracted muscular fibres a manipulating or kneading of the muscle can be given. It is best to flex the neck and head to the side where the contracted muscles are, so that a better hold of the muscle may be maintained; then by a series of flexions and extensions with manipulation of the contracted muscles outward, results can be readily obtained. When the patient is lying on the back the physician may stand to one side of the patient’s head and with one hand on the forehead of the patient and the other hand around the opposite side of the neck, a rotary motion of the head and neck, which is equal to flexion and extension in the sitting posture, may be given by the hand on the frontal region while the other hand relaxes the muscles; or the osteopath may stand at the head of the patient and with either hand on the side of the head and neck of the patient a series of rotary movements of the head and neck may be given with manipulation of first one side of the neck and then the other; the hands and fingers being placed in such a manner that when the fingers of one hand are relaxing the muscles on its side the other hand is executing the movements of the head and neck, each hand continually alternating in the work. This latter method requires some practice in order to do the work readily and successfully, for quite a variety of movements are required.

In the former method after one has worked on one side he is obliged to change to the other side and go through the same process. Movements may also be given to stretch the contracted muscles, thus overcoming the contraction and producing relaxation of the muscles.

After having relaxed the muscles over the field of operation, correcting the vertebræ will generally be easier to accomplish. In readjusting an atlas it matters but little whether the patient is sitting up or lying down. A firm hold of the atlas can be gotten in either instance. In correcting the middle and lower cervical vertebræ it is best to place the patient upon the back.

In correcting dislocations, as heretofore suggested, two general rules should be followed: (1) Exaggerate or increase the dislocation. This is to relax the tissues about the dislocated articulation and to disengage the articular points that have become locked. (2) Reduce the lesion by retracing the path along which the parts were dislocated. One can readily see that a dislocated ball and socket joint could be reduced only by the dislocated bone retracing the path by which it left its socket, for the capsular ligament would at once prevent its returning to the socket by any path other than that taken when dislocated. This applies to all dislocations to a greater or less extent.

After locating the exact position of the abnormal vertebra the first rule is applied, i. e., exaggerating the lesion by flexing the head in the opposite direction to which the vertebra is dislocated. Then with one or two fingers placed firmly upon the side of the vertebra in the direction dislocated, so that when the proper time comes the vertebra may be pushed or slightly rotated back into its normal position, with the other hand produce flexion of the neck, so that the angle of flexion is exactly over the involved vertebra; next produce slight traction, so as to be sure that the articular points will be disengaged; and then with rotation and extension of the head to a normal or upright posture, at the same time pushing in on the disordered vertebra, are the movements to be executed in reducing a dislocated vertebra. It takes considerable practice to be able to correct a vertebra and to know when it is corrected. The amount of force applied varies greatly in different cases. Cases of recent subdislocation require but little force unless there is marked spasticity of tissue, while in long standing cases many times the amount of force required is about all that one wishes to exert. As a rule in many chronic cases it is better to give a series of preparatory treatments in order to reduce muscle fibrosis and thickening of capsular ligament. Remember that often it is a slight rotary movement or twist given that aids the most in executing rule second. No matter to what position a vertebra is rotated or side-bent the principles applied are the same in each case.

Be very careful when flexing, extending or rotating the neck that too much strain is not brought to bear upon the ligaments. Some osteopaths seem to take delight in rotating and flexing the neck to a great degree. It is a dangerous procedure and moreover does not accomplish anything in particular. It should be kept in mind that osteopathic treatment is scientific and not a number of general movements of various regions of the body. Locate the lesions exactly and then a specific treatment can be given in every instance. To illustrate the treatment according to the preceding rules we will assume that a certain cervical vertebra is anterior, say the fourth cervical. This means that there is an interosseous lesion between the fourth and fifth. The inferior articular processes and facets of the fourth have slipped upward and forward on the opposing facets of the fifth. First, hyperextend the head in such a manner that the fulcrum comes exactly over the displaced articulating planes, thus throwing the fourth vertebra still more anterior, or in other words, exaggerating the lesion or increasing the space anteriorly between the fourth and fifth cervicals, so that when the head is flexed forward and pressure is exerted upon the anterior part of the vertebra (body or transverse process) the vertebra will have room and release enough to occupy its normal position. Second, when the head is hyperextended place a finger anterior to the transverse process of the dislocated vertebra and with the other hand around the head, that is producing the hyperextension, throw the head forward with slight traction and rotation and at the same time push posteriorly quite strongly upon the dislocated vertebra. Follow out the same principles in all cases, no matter in which way the vertebræ are deranged.

There are several methods of applying the underlying principles of adjustment. Relaxation and leverages may be secured in various ways. Preciseness, expeditiousness and skillfulness can be attained only by considerable personal experience.

In cases where the lesion is between the skull and atlas have the patient sit on a stool with the back part of his head against your chest, and reach around the head with one hand under the chin; then with the other hand around the transverse processes of three or four upper cervical vertebræ pull the spinal column toward the median line, while at the same time lifting up on the skull with the other hand and throwing the skull toward the median line. The object of lifting up on the skull is to relax and disengage the articulations, by inhibition, traction and rotation, between the occipital bone and atlas. This is one method applicable to the various lesions of the occiput, which are of frequent occurrence.

In treating the pharynx, tonsils and larynx, outside of correcting spinal lesions, an anterior treatment to these organs is very effective. Examine the deep muscles beneath the angle of the jaw when the pharynx and tonsils are involved; and when the larynx is affected note the condition of the muscles on either side of the larynx. After locating deeply seated contracted muscles in the region of the angle of the inferior maxilla place the fingers over the contracted tissues, and then by a downward, inward sweeping motion toward the median line the muscles may be readily relaxed. When treating the larynx relax the tissues on both sides by an upward, inward movement. These treatments are very effectual when applied directly to the disordered tissues.

Attention should also be given to the lymphatics. In simple infections treat the glands very lightly but attempt to break down the surrounding edematous barrier. Release all the tissues down to and including clavicles, first ribs and pectoral and axillary regions.

To treat slight lesions of the inferior maxillary articulation, stand at the head of the patient when he is lying down and hook the fingers about the jaw just in front of the angles, and with the thumbs over the bridge of the nose have the patient open the mouth while considerable force is exerted against his effort. This reduces any slight dislocation of the inferior maxilla. When the jaw is completely dislocated place a piece of wood or hard substance between the molars and exert pressure upward and backward on the chin. If the dislocation is bilateral work on one side at a time.

The object of treatment to the face is to stimulate or inhibit points of the fifth nerve that come near the surface (see neuralgia of fifth nerve). While the patient is lying flat upon the back carefully stimulate these various points, especially the supraorbital and nasal, with a downward and outward movement, or inhibit as indicated.

In treating the scalp relax the muscles over the scalp thoroughly. This is secondary treatment to correcting the innervation to the scalp at the upper four or five cervical vertebræ.

In cases of pharyngitis, tonsillitis, croup, hay fever, etc., an effective local treatment may be given through the mouth upon the soft and hard palate. Introducing a finger into the mouth clear back upon the roof of the soft palate, and with a downward and backward sweeping movement from the median line on either side toward the tonsils, considerable relief can be given the patient. This treatment relaxes the tissues, relieves the congestion, and gives a stimulating treatment to the local nerves. A treatment of the same nature may be given over the hard palate to affect the palatine nerves, especially in hay fever, when the itching of the palate and sneezing are extreme. In cases of young children it is best to protect the finger by wrapping a piece of cloth around it.

An osteopath should never give a manipulation or movement unless he understands why. Just as soon as one gives general imitating movements, from that moment his work is not that of a scientific osteopath, but of a Swedish movement curist and masseur and a poor one at that. The osteopath’s work is to locate the anatomical derangement and correct it, as a mechanic would adjust any disordered mechanism. General treatment amounts largely to naught, although in some few instances it is of benefit.

To give a detailed description of the treatment of all lesions that may be found in the cervical vertebræ would be impossible in this sketch; only a general survey of the work can be given. Each case calls for special treatment, but the same general principles are applicable in each case. If there is any one thing that should be eliminated from osteopathic treatment it is those mechanical routine movements of rotating, flexing, extending, and various Swedish-movement-massage-like manipulations that certain osteopaths give in each and every case. It shows that they are imitators and do not have a correct conception of osteopathic therapeutics. True it is, that routine movements will have stimulating and other effects upon the system. But does the body require such treatment? Is it lack of exercise on the part of the patient? If it is, then let the patient exercise himself. You do not want to lower yourself to be a mere “engine wiper,” or an exerciser. If it is not the lack of exercise and the system is in need of certain treatment, then seek the cause and apply a specific treatment. Do not hide behind generalities.

The Ribs.—In correcting dislocated ribs many methods may be employed, but all are subject to the same principles as given under the treatment of the neck and head.

One of the best methods to correct typical ribs is to have the patient upon the side with the side of the affected ribs upward. Find out exactly the nature of the dislocation, i. e., what is the relation of the dislocated rib to the other tissues. Note whether the rib is upward, downward, inward or forward, locate exactly the dislocated rib. Then, while standing back of the patient, place your fingers upon both ends of the rib. Place your fingers in such a manner that when the proper time in the procedure arrives, all that will be necessary will be to push the ends of the rib into their articulations. For instance, if the rib is raised anteriorly and lowered posteriorly, you will place the fingers on the sternal end, above the affected rib and the fingers on the vertebral end, below the rib, so that when the rib has been released from its abnormal position it may be slipped into normal position. After having placed the fingers in the exact position necessary, have an assistant take the arm and draw it obliquely across the face, while at the same time the patient takes a forced inhalation. The object of drawing the arm across the face and the deep inhalation is to exaggerate the lesion—to draw the ribs out of their locked position—so that the fingers upon either end of the rib may push the rib into normal position. Drawing upon the arm raises all the upper ribs as well as the dislocated typical rib, principally by the use of the serratus magnus; also inhalation has an effect to throw the rib outward and upward and thus away from its articulation. Thus after the lesion has been increased sufficiently to loosen the rib from its abnormal position, the arm is relaxed, the patient exhales, and the fingers upon the ends of the rib correct the dislocation. This treatment is used to the greatest advantage when there is a dislocation of a typical rib; it can be given while the patient is lying down or sitting up, although the former position is preferable.

An excellent method, when the sternal end of the rib is dislocated is to have the patient sit upon a stool with his back toward the physician; then by placing the knee in the back (while standing up, or easier still for the physician to sit upon an operating table back of the patient) over the vertebral end of the rib so that the rib may be held rigid posteriorly, reach around with one hand over the dislocated end of the rib and place the fingers upon the rib in the direction dislocated; so that when the rib is sufficiently released from its abnormal position it can be readily pushed into place; then with the other hand under the axilla of the arm on the affected side, pull up and back on the shoulder, so that the rib may be pulled away from its sternal articulation; and at the same time have the patient take a deep inhalation so as to aid in throwing the rib outward, upward and away from its sternal attachment; then when the end of the rib has been released sufficiently, relax the hold underneath the axilla, have the patient exhale, and slip the rib into its normal position by the fingers over the end of the rib. This is an excellent method. It is easy to give and does the work admirably.

Practically the same procedure may be gone through when the vertebral end is dislocated, by changing your position to the front of the patient, but there is danger of the knee slipping off from the sternum during the operation and injuring the ribs. Several other treatments may be given to correct dislocations of the vertebral ends of the ribs. For example, while the patient remains sitting the osteopath stands in front of the patient and reaches around both sides upon the angle of the ribs; then with an outward and upward movement of the fingers upon the angle of the ribs, they are pulled away from their locked position and allowed to slip into normal articulation. This treatment is applicable only when the ribs are dislocated downward, but it is one of the best treatments for such cases.

Another method oftentimes employed in correcting dislocations of the vertebral end of the ribs is to have the patient lie flat upon the side with the affected side upward; then by flexing the arm on the forearm and placing the elbow against the chest or abdomen reach over the patient upon the angle of the dislocated rib and pull it away from the vertebra; when it is pulled away from the spinal column sufficiently, push upward or downward on the angle of the ribs, as the case may demand. The elbow placed against you gives complete control of the patient and aids, by your weight, in throwing the rib upward or downward.

A treatment somewhat like the preceding one which is commonly employed, is to reach underneath the patient’s upper arm, when he is lying upon his side, with the arm extended upward across the face; then by placing the fingers of the hand underneath the patient’s arm over the angles of the affected rib or ribs and reinforcing the hand by the fingers of the other hand an upward, outward and rotary movement can be given the ribs, which pulls them out of their abnormal position and allows them to return to their normal articulations.

An effectual treatment to spread and raise the upper ribs is to have the patient flat upon the back, and with the fingers of one hand underneath the angles of the ribs and the other hand upon the elbow of the patient’s arm of the same side throw the patient’s arm across the chest transversely and bear down upon the elbow, at the same time spring upward and outward on the angles of the ribs with the other hand. By throwing the arm across the chest and bearing down upon the elbow a strong leverage can be obtained upon the upper ribs, especially those between the scapulæ. This treatment is very efficacious in certain lung and heart diseases.

Still another method of adjusting ribs is to have the patient flat on his face upon an operating table with the arms hanging down on both sides of the table and a small pillow or folded blanket beneath the upper part of the chest; then standing beside the table, or better still, with one foot upon a low stool and the knee of the other limb upon the table in such a manner that one is directly over the patient’s dorsal region one is then in a position to have full control of the vertebral end of the ribs. If the ends of the ribs are displaced downward, placing the thumbs over the angles of the ribs and pushing upward and outward on the angles, the ribs can be very readily crowded into position. If the ribs, especially between the scapulæ, are dislocated in any direction, they may be quite readily corrected by placing the hand over the shoulder posteriorly and throwing it outward and upward and away from the spinal column in such a manner that the ribs are pulled away from the abnormal position; then upon relaxing the hold upon the shoulder with the one hand, the fingers of the unemployed hand may push upward or downward, as the occasion requires, on the angles of the affected side so that the ribs may be slipped into place.

Many times one is obliged to treat the ribs of one side as a whole. In such instances the ribs are almost invariably thrown downward except on one side of scoliosis of the dorsal region. Several methods may be employed to raise the ribs. Probably the best method is to have the patient upon the side and with one hand upon the angles of the ribs and the other hand holding the wrist of the upper arm of the patient, an upward lifting movement is given both upon the angles of the ribs and upon the arm of the patient while the patient inhales. The work upon the angles of the ribs is to raise the ribs directly; the work upon the arm is to raise the ribs indirectly, principally by the use of the serratus magnus. Another effective treatment is to have the patient upon the back and with one hand over the anterior ends of the ribs and the other hand over the angles of the ribs an upward movement is given them by springing the ends of the ribs toward each other and by strong inhalation on the part of the patient. This treatment is most effective where the false ribs are at fault and especially in case of hemiplegia. While the patient is upon the back an assistant may take hold of the arm and draw it upward over the head of the patient, producing considerable additional upward tendency of the ribs, and the physician giving the same treatment of the ends of the ribs as before; or the physician may take an arm in one hand and raise it above the head of the patient and with his other hand around the angles of the ribs, and the patient inhaling deeply, the ribs may be raised.

A treatment used a great deal in raising the ribs as a whole is to have the patient sit upon a stool, and reaching around the patient from the front, place the fingers upon the angles of the ribs and raise them upward on both sides at the same time. This treatment can also be given by standing behind the patient and reaching around upon the anterior ends of the ribs and lifting upward while the patient aids you by deep inhalation. Remember that many times the ribs are drawn downward by contraction of the muscles, due to atmospherical changes and slumped postures. One should begin at the upper ribs in all treatments where the ribs are to be raised, as a whole, and work downward.

To correct the first and the floating ribs a different treatment has to be given than the foregoing.

An upward displacement is the most common lesion of the first rib. To correct such a dislocation, have the patient sit upon a stool and with one hand pull the head to the opposite side in order that the lesion may be exaggerated by traction of the lateral muscles of the neck (principally the scaleni) upon the rib; this disengages the rib from its abnormal position; then with the fingers of the other hand upon a point midway of the ends of the rib, exert a downward pressure at the moment the extended head is relaxed describing a short arc. But don’t relax head until readjusting pressure is exerted upon rib. If the patient is unable to sit up, and it is not best to give the foregoing treatment, have the patient flat upon the back, with one hand take hold of the arm on the affected side and pull down and out upon the shoulder so that the rib may be somewhat drawn away from its articulation and released from its position; then with the fingers of the other hand upon the center of the rib, or its highest point, press downward when the hold upon the arm is being relaxed. Correction of an upper displacement of the first rib is an every day occurrence. Downward dislocation of the first rib, is rare. To reduce this dislocation, place the thumb beneath the vertebral end of the rib, and with the other hand lift up strongly on the shoulder from beneath the axilla, at the same time exerting pressure upward with the thumb on the end of the rib.

The floating ribs may be dislocated obliquely downward, or the free end of the rib may be caught underneath the end of the rib above. In either case, in order to correct the displacement, place the patient upon the back with the thigh on the affected side flexed upon the abdomen so that the tissues about the field of operation are relaxed; then bear down carefully but firmly over the free end of the rib with the fingers until one finger can be hooked underneath the end of the rib; then with the other hand over the vertebral end of the rib, have the patient take a deep breath, at the same time springing the ends of the rib toward each other, thus relaxing the rib from its locked position; then have the patient exhale quickly and at the same time spring the rib into its normal position. It oftentimes requires repeated trials, especially in stout persons, and quite often the operation is painful to the patient. It is necessary that one should understand this operation thoroughly, as it is one of the most common treatments in osteopathic practice. The floating ribs are very liable to dislocations and may be the cause of many pains in the side, disturbances of the vessels as they pass through the diaphragm and inflammation in the iliac region. A palliative treatment may be given the floating ribs by having the patient lie flat either on the back or on the side; then place the hand near the vertebral end of the ribs and raise them upward while the patient takes a deep breath.

Treatment of lesions between the manubrium and gladiolus are best given by placing the patient with the face downward upon the operating table, and having the articulation of the manubrium and gladiolus just over the edge of the table. An assistant should hold the patient firmly upon the table while hyperextension or flexion, as the case may require, with traction, is exerted upon the head, neck and shoulders, and manipulation of the articular points is given to reduce the dislocation. The same principles are employed here as in correcting lesions elsewhere.

Correction of the cartilages along the sternum is very easily accomplished by having the patient sit upon a stool and the osteopath standing behind the patient places a knee in the back; then reaching around with one hand over the cartilages and the other hand underneath the axilla, execute the same movement as given in correcting dislocations of the sternal ends of the ribs.

A treatment sometimes used to release a depressed condition of the cartilages of the false ribs is to stand behind the patient while he sits upon a stool and reach around him with fingers underneath the cartilages and raise them upward as he inhales. By having the patient take a deep breath and then exhale quickly while the fingers are over the cartilages a much better grasp of them can be obtained. This treatment should be carefully given, as there is danger of tearing the cartilages loose from the ribs.

The Dorsal and Lumbar Spinal Regions.—Here, as in other regions of the body, before an attempt is made to correct the vertebræ the muscles should be thoroughly relaxed. One of the easiest methods to relax the muscles is to have the patient lie upon the side, and then by standing in front of the patient and reaching over him with the fingers upon the contracted muscles an upward and outward rotary manipulation is given; or the patient may sit upon a stool while the physician stands in front with the arms around the patient and the fingers over the contracted muscles manipulating them upward and outward. Another very easy method is to stand behind the patient while he sits upon a stool and place a thumb over the contracted fibres, with the other hand underneath the axilla lifting the shoulder upward and backward so as to favor a relaxation of the muscles, while the thumb manipulates them.

In relaxing the muscles of the lumbar region have the patient on the side upon the table; then flex the thighs upon the abdomen with your weight against the knees so as to control all movements of the patient; reach over the patient with the fingers upon the contracted tissues and manipulate them outward and upward on either side until they are relaxed. A method sometimes employed to relax the muscles of the dorsal, lumbar and sacral regions is to place the patient flat on his face upon the table; then by pushing up on the muscles from above downward with the flat of the hand they are easily relaxed. This treatment should be especially given when the patient’s muscles are contracted by atmospherical changes and from standing in one position for a long time. When the muscles of the back are contracting they draw downward and many times draw the ribs with them, as well as tensing the tissues over the sacral foramina and obstructing or irritating the sacral nerves. By using the modern table longitudinally relaxing, or stretching, the lumbar and dorsal musculature saves considerable strength and effort of the physician.

To correct vertebral lesions of the dorsal region the same rules should be followed as in treating lesions of the cervical vertebræ. Treatments may be given with almost equal ease whether the patient is lying on the side or sitting up.

To illustrate the treatment of the dorsal region when the patient is lying down, assume that there exists a lateral lesion, combined rotation and sidebending, between two vertebræ; if the lesion is below the seventh dorsal use the legs as a lever, and if the lesion is above the seventh dorsal use the head and neck as the lever. Have the patient lie upon the side toward which the lesion is pronounced, either reach under the neck or around the limbs with one hand, and with the other hand upon the lesion bend the head and neck or the thighs in such a manner that the angle of the flexion is directly over the break in the spinal column; this is to exaggerate the lesion; then by lightly lifting up on the neck or limbs and with a slight rotation of this lever the flexed parts should be extended, at the same time exerting pressure with the hand over the lesion in such a manner that the vertebra is pushed forward toward its normal position.

Practically, the same treatment is given when a patient is sitting up, with the exception, of course, that the limbs cannot be used as levers. Lesions of the dorsal region or even the lumbar region can be corrected while the patient is sitting up. By this method considerable lifting is done away with. In fact, the weight of the patient can be used to great advantage by substituting it for one’s strength. No matter in what direction the lesion is, the physician reaches around the patient’s shoulders so that he just holds the weight of the patient from falling to one side or the other; thus with one hand manipulating the lesion the other arm is around the patient guiding the weight of the body in flexion, rotation and extension. It is not always necessary to lift up on the patient but just let the weight of the patient act as strength applied to the power arm. Always make it a point when working upon dislocated vertebræ in any region that just as soon as one has obtained a slight movement in the lesion do not attempt to correct it any more for the time being. A slight movement toward the right direction may be all that is necessary to relieve the ill effects of the lesion. In fact it might be impossible to get the lesion anatomically correct as the shape of the vertebra may have conformed in a greater or less extent to its abnormal position.

An excellent method to correct the various combinations of rotation and sidebending of the third to ninth dorsals is to have the patient sit up with the physician either sitting or standing, depending upon height of seat, back of the patient. Have the patient lean back until head is supported upon shoulder of physician, and the anterior and posterior musculature of torso, abdomen and pelvis are thoroughly relaxed. Reach around the patient’s chest with one arm, the hand of which is placed beneath the axilla. The thenar eminence of the other hand is placed upon the posteriorly prominent transverse process of the lesioned segment. Then with careful hyperextension, traction, and rotation and, sidebending of the torso, the anchorage is released, care being taken that localization is exact; this moment of coordination is accompanied with a thrust of the thenar eminence upon the transverse process. Relaxation, leverages and thrust must be precise and thoroughly coordinated.

To reduce vertebræ that are deviated anteriorly in the dorsal region, especially between the scapulæ, is often a hard matter. A satisfactory method is to stand behind the patient, while he is sitting upon a stool, and reach around both sides of him upon the sternal ends of the ribs corresponding to the anterior vertebræ; then have the patient relax with the head upon the chest, and at the same time take a full inhalation while pressure is exerted posteriorly upon the sternal ends of the ribs. The object of this method is to pull back the rigid ribs (the lungs being filled with air) which are attached to the anterior surfaces of the transverse processes of the vertebræ, and thus upon the anterior vertebræ pushing them posteriorly; all of the muscles of the body being quite passive and the head relaxed on the body, a separation of the vertebræ is accomplished, thus favoring a crowding posteriorly of the subdislocated vertebræ.

To correct vertebræ of the lumbar region is on the whole much easier than in the dorsal region. Here the legs can be used as levers to great advantage. By the same method of flexion, rotation, and extension, as employed in the dorsal region when the patient is lying on the side, the result can generally be obtained.

Sidebending is the most common single lesion of the lumbar vertebræ, though there may be some rotation at the lumbo-sacral juncture. Occasionally malformation is found at the fifth. To correct the lumbar lesions the following method is often used: place the patient upon the side of the rotation or sidebending with knees flexed, buttocks well back and entire spinal column straight. Next bring torso and head, with spine straight, well forward to edge of table. Then with hand upon ilium tilt it slightly forward, and with other hand upon shoulder rotate entire spine, including head, so that spine is locked and the point of localization exactly corresponds to the lesions. This brings the spine back to nearly a straight position. Next, after a moment or two of tension-relaxation, either thrust back upon the shoulder or forward upon the ilium. Again exactly coordinating localization, relaxation and leverages is the key of the method.

The Abdomen.—Direct treatment of the abdomen is given in many diseases of its organs. The patient should lie flat upon the back, the legs flexed upon the thighs and the thighs flexed upon the abdomen, so that the abdominal muscles will be thoroughly relaxed; and then the various organs of the abdomen can usually be manipulated with ease. Remember that in many diseases of the abdominal viscera the treatment of the splanchnics and vagi will be the primary treatment rather than direct abdominal treatments.

In treating the liver directly, the ribs over the liver should be raised and separated, and the lower border of the liver manipulated directly, as considerable therapeutic results can be obtained, particularly when the liver is congested and enlarged. Manipulation of the bile ducts is very essential in many liver diseases. The treatment relieves congestion of the ducts and removes any collections of mucus in the ducts due to the congestion, as well as freeing obstructed flow of bile. The manipulation should be a deep, downward one, directly over the path of the ducts (from about the cartilage of the ninth rib to the duodenal orifice of the biliary tract, the latter being about one and one-half inches diagonally downward and to the right of the umbilicus). Be very careful when first manipulating, and bear down lightly over the duct so that the structures superficial to it may be relaxed as the duct is deep below the surface of the abdomen. Usually the gall-gladder can be emptied by light pressure over the skin above the cartilages of the eighth, ninth and tenth ribs. The light manipulation acts, probably, by way of the spinal segment, as a stimulus to the dilators of the sphincters of the gall-bladder. Very likely through reciprocal innervation relaxing the sphincter of the bile duct will contract fibres of the gall bladder.

Manipulation of the stomach has considerable effect in strengthening its circular fibres and toning up the coats in general. In cases of gas formation, the gas in some instances may by manipulating over the stomach, be forced through the cardiac or pyloric orifices.

Direct treatment over the spleen by raising the eighth, ninth, tenth and eleventh ribs of the left side is effectual in congestion and enlargement of the organ.

In thin subjects the kidneys can be treated directly by pressing down carefully but deeply over the kidneys, and lightly crowding them upward and outward. This treatment also has some effect in relieving contracted tissues about the renal vessels and kidneys.

Treatment to the intestines through the abdomen is an effective treatment. In the various obstructions to the intestines, constipation, etc., the direct work is essential. Treatment of the intestines is to correct any abnormal position that they may have assumed, to relieve constrictions of the gut caused by contracted tissues, to relieve impactions and adhesions, to increase peristalsis and to tone up the intestinal coats in general. The treatment consists in a manipulation of the intestines, especially in the right and left iliac fossæ, and the pelvic colon, ascending colon and duodenum, as impactions and prolapses of the gut are more liable to occur at these points than in any other locality. In manipulating the intestines, work for a definite purpose and not give a general kneading treatment unless the walls of the abdomen and the coats of the intestines are weakened; in the latter case the spinal treatment is the primary one. In treating over the iliac region, draw upward and inward on the folds of the gut. It is claimed by some authorities that nerves pass from the cutaneous surface of the abdomen directly to the intestine by way of the peritoneum; if such is the case, manipulation of the abdominal walls would have direct effect upon these nerve fibres. The abdomen may be treated when the patient is sitting up, but the treatment is not satisfactory. (See Prolapsed Organs).

The Pelvis.—The treatment of the pelvis is easy, but the difficult work is in making a diagnosis of the position of the pelvic bones. The pelvis is especially apt to become deranged by jars and falls. Some of the most successful osteopathic results have been obtained in correcting the pelvic region.

To relax the muscles over the pelvis, the patient should be on the side or upon the face; then relax the muscles by manipulating them upward, chiefly those over the sacral foramina. It is a good rule to adjust the lumbar first owing to release secured to the nerves supplying pelvic muscles and also to the fact that many pelvic distortions are secondary or compensatory to lumbar lesions. The easiest method to correct the innominata is to have the patient lie upon his side; then by standing in front of the patient slip one hand between the thighs and grasp around the tuberosity of the ischium, and with the other hand upon the crest of the ilium, the innominatum can be moved upward or downward and forward or backward (wheel and axle principle). Simply pulling or pushing upon these two points in whatever direction necessary is all that is required providing the soft tissues are thoroughly relaxed. By having the patient flat upon the back practically the same treatment can be given, but not to so great an advantage. In cases where the ilium is posterior and the ischium anterior, the physician may stand back of the patient, while he is lying upon his side, and place one knee against the sacrum and with one hand upon the ilium, with the other take hold of the ankle of the affected side (the involved side being uppermost in all cases where the patient is lying upon his side); pressure can be exerted upon the ilium and the limb pulled backward, thus correcting the derangement. This treatment should be avoided as much as possible, as there is considerable danger of pulling back too severely and injuring the patient; the lever is long and the amount of force exerted upon it cannot be judged precisely.

Another method is, with the patient on the back, flex and evert the knee to the side so the side of the foot lies flat on the table. Grasp the ankle with one hand and with the other on the crest of the ilium of the opposite side then, by pushing down firmly on the knee the articulation is gaped and at the same time the operator pushes with his body against the knee with a sharp thrust. This may have to be repeated a few times before the articulation is released and if one is keen he will easily detect the slight concussion carried down the femur as the adjustment takes place. This will correct a forward and downward innominate. For an upward and backward one, place the patient in exactly the same position and go through the same motions except that the knee is pulled toward the operator. If the desired “chug” is not felt and adjustment is not definite, the leg may be pulled down rather smartly by the ankle to a parallel with the other. This is a technique that is easy, both for the patient and operator, and will correct any but the most stubborn.

In the case of a greatly relaxed and atonic condition of the ligaments of the pelvis much trouble is experienced, often, in making the adjustment permanent. Many suggestions have been made and most of them useless but, probably the use of a belt of non-elastic webbing about two inches in width buckled tightly around the pelvis just below the anterior spines will do as much as anything and is a procedure well to follow in all such cases. Where there is a pendulous abdomen a support in the shape of a simple belt which should be so fitted as to act as a sling will transfer the weight of the abdominal viscera from the muscles, already stretched and atonic, to the belt and put the burden over the sacrum. This prevents the pulling of the innominatum in lesion again. Overcorrection is suggested as a means on the ground that it sets up irritation and induces fibrous ankylosis and for the same reason W. W. Howard places his patient prone and with thumb works the ligaments associated with the joint until they are thoroughly inflamed. The patient is then put in bed a few days and after the inflammation has cleared up the ligaments will be found to have shortened.

To correct a rotary lesion between the pelvis and fifth lumbar the patient should be placed upon the side, and with the body held firmly, the pelvis can be forced backward or forward as the occasion demands. (See Coccyx).

The Legs.—The origin of many symptoms manifested in the legs, as in the arms, are due to spinal lesions corresponding to the region of innervation to the affected tissues. The derangements of the pelvic bones are a frequent source of symptoms that are referred to the legs and feet. The osteopath finds that a slight dislocation of the hip may occur which is especially likely to affect the knee. This partial dislocation is apt to be an upward-posterior one; the head of the femur resting in the upper and posterior part of the acetabulum. Many diseases of the legs and feet are due to local displacement of the bones. The method of treatment is the same as given in surgical works. (See Sprains).

A general treatment of the legs and thighs is oftentimes necessary; it consists of flexing the thighs quite firmly upon the abdomen, and executing thorough external and internal rotary movements of the thighs and legs. In a few cases both limbs are flexed strongly at the same time upon the abdomen. After giving these movements manipulation over the saphenous opening and beneath the popliteal space is performed. This general treatment tends to increase the circulation of the entire limb and to relax thoroughly all contracted fibres.

The Arms.—In treating the arms, care has to be taken that the affection is not due to spinal derangements; otherwise the arms are manipulated according to the disorder. Complete dislocations of the shoulder comes under the province of surgery. Many times the osteopath locates slight or incomplete dislocations of the shoulder. Partial dislocations of the shoulder are generally anterior. (See Sprains).

In cases where pain exists in the shoulder or arm, outside of locating the cause in the shoulder joint, the affection may be due to fibres contracting over the coracoid process, or a dislocation of the second or third rib, and in some instances the clavicle is deranged. Special care should be given to a possible bursitis and tendo-synovitis. Occasionally muscular fibres may slip out of the bicipital groove. Dislocations of the bones of the arm are treated according to surgical methods. The pains and various troublesome symptoms that may be manifested in the fingers or the hands are oftentimes caused by slight dislocations of the elbow, shoulder, ribs, or vertebræ, as low as the sixth to eighth dorsals.

The coccyx.—The coccyx, owing to its exposed position and rather unstable attachment, is subject to many injuries; more indeed than come to notice. Its injury results in many local and general disturbances owing to its close relation to the sympathetics. Successful treatment of deviations often bring startling results. They may be divided into fractures and displacements.

In complete or partial fracture of the coccyx, as well as in dislocation, if the patient can be seen with reasonable promptness after the accident much can be done for relief of the pain and the prognosis is good for complete recovery.

Examination should be made externally and internally and after the condition is diagnosed about the same procedure is indicated for any of the conditions. With the patient on the left side introduce the right index finger, well lubricated, into the rectum and carefully relax all tissue within reach of the tip. If there are spasms of the coccygeal muscles, inhibition of the anterior nerves will quiet them. When this has been done place the left index finger externally along the body of the coccyx and holding it firmly both within and without release it longitudinally and then adjust. After this has been done it is well to hold it there until all danger of returning spasm, which might displace it again, is over, when the finger can be withdrawn.

The pain following will depend on the severity of the injury, but will keep up more or less constantly for several days. When severe, relief is often given by introducing the finger and relaxing contracted tissue which is pulling it from its position. Hot water bags placed next to the part will be of benefit. The bowels should be kept confined for forty-eight hours if possible in cases of fracture. Watch carefully the progress of union that the bones are in situ so there will not be deformity.

In diagnosing the first injury be sure that there is no splitting of the first segment or splinters which may require surgical interference. In old cases of fracture where there is complete bony ankylosis it is not justifiable to attempt any change, but where there is motion and a fibrous union, after preparatory treatments about one week apart, it can usually be replaced. Look well to any muscular contractions which might interfere with it. Force must never be used nor any attempt to replace until it has been first released from its articular attachment. In the various forms of displacement the same technique applies as in fractures, or the finger and thumb of one hand may be used, the tip of the finger internally at the sacro-coccygeal articulation and the thumb externally at the same point. Complete control of the part is secured in this manner. Great care must always be used in treatment of any displacement of the coccyx. Contractions of its muscular attachments will often cause deviations in contour. Removal of the irritation and relaxation will allow it to assume its normal position.

The sacrum.—Adjustments of the sacrum as distinguished from the ilium in strictly innominate lesions are not many. When posterior with the patient on a stool the knee of the osteopath coveted by a pillow and placed against the sacrum and both hands grasping the anterior borders of the ilia, strong traction will move it into position. In a downward displacement with the aid of an assistant from behind holding the crests of the ilia firmly as the patient sits on the table, the osteopath in front clasping both arms about the patient and with a rocking motion from side disengages the sacrum and at the same time lifts it into position.

For anterior displacements use the technique described in replacing upward and backward innominate dislocation first right side and then left, which will result in correcting the lesion.

The preceding osteopathic technique includes a few of the treatments given by the osteopath. Although many osteopaths use methods not given here, those outlined are sufficient for illustrative purposes. A point which cannot be too thoroughly impressed upon the student is that osteopathic treatment is in reality constructive work, that is, readjustive, not only in detail, but in viewing the body structure as a whole. Detailed readjustment is an essential, still do not lose sight of the relation of the part to the whole. In our distinctive work anatomical construction is the basis of physiological function, although physiological stimulus is essential to anatomical development.

How often to treat.—How often to treat a case depends entirely upon the nature of the disease from which the patient is suffering. Just as in giving drugs the frequency of treatment is entirely dependent upon the seat of the disease and its severity. Acute cases require a thorough treatment at least once daily, and many times in severe cases the treatment has to be repeated several times daily. In subacute and chronic cases, as a rule, treatment should not be given as often as in acute cases; possibly once a day, but usually alternate days is better. In office practice cases are commonly treated two or three times weekly. Still it is better not to treat some cases oftener than once a week.

There is more danger in treating too often and too long than in not treating often enough. The distinctive work of an osteopath is to correct disordered anatomical structures; and when a certain derangement has been corrected the tissues should have rest and plenty of time for repair. When treatments are given often, it simply keeps the tissues in an irritated state and nature does not have time to heal the diseased tissues. Always make it a point at each treatment to correct some definite lesion, and when the work is accomplished let the parts alone until the tissues have recovered as much as possible from the effects of the previous treatment before another treatment is attempted. The reason why some cases do not get cured under osteopathic treatment is simply because the osteopath keeps the diseased tissues in an aggravated state by the constant treatment so that they do not have the least chance to heal; the physician is thus adding irritation to the disease.

It is only by experience that one can tell how often to treat. Each case is a special study; what would be quite sufficient for a certain individual with a given disease would not be at all suitable for a second individual with the same disease. As in drugs what is suitable for one person would not be adapted to another, because the make up of each individual is entirely different; but here the parallelism diverges, for in drugs there is a foreign agent introduced into the system, while in osteopathic treatment the curative agent is entirely harmonious with the idiosyncrasies of the individual. It is for this reason that experience in practice is so essential.

Most cases should not be treated, as a rule, after a meal unless the patient is suffering from some digestive disturbance; for treating other regions of the body outside of the digestive tract causes more or less stimulation of the parts treated and thereby draws blood away from the organs of digestion. Cases of disordered brain circulation, where the patient is unable to rest or sleep at night, should be treated at about their retiring time so that the circulation of the body may be equalized, thus giving the patient undisturbed rest.

To show in a practical way the methods of experienced osteopaths in this matter G. J. Helmer[32] is quoted: “I submit the following table to illustrate the frequency of treatment in one hundred cases taken from my practice: one case three times per week, sixty-three cases two times per week, twenty-two cases one time per week, nine cases once every two weeks, five cases once every four weeks. Comparing the present with the past, I find I am lengthening the time between treatments with much better results.”

Another very practical side of the question and one which will be greatly appreciated by the patient, is the lessened cost for the same result in the less frequent treatments, as well as the saving in time. With the loss in going to the office, rest after treatment, not to mention possible wait while there, three times weekly represents more time than the average person can well spare and not infrequently will deter him from continuing. More especially is this true of those coming from a distance.

Length of Treatment and Overtreatment.—Naturally the length of treatment depends upon the case at issue and nothing more. There is no reason why any two cases should be treated for the same length of time unless they present identical lesions and then the personal equation of the two might present such a wide difference of aspect as to forbid such a proceeding.

The question of time has no place in the matter, save that it must not exceed physiological limits and be sufficient for the needs of the case. The patient should understand at once that it is to accomplish a specific purpose that the treatment is given, just as definite as a surgical or dental operation, and when the work is done it is time to stop. He would hardly be attracted to the dentist who guaranteed to use forty-five minutes in extracting a tooth. Good judgment is required in this as in all matters pertaining to osteopathy. There is a generally expressed opinion among the older osteopaths, based on experience, that: first, a short specific treatment is productive of best results and, second, treatments given under high tension when quick work is necessary are most satisfactory. Long treatments are debilitating and over stimulation amounts to inhibition. Further, in a long treatment it is necessary to go over the whole body, thus dispersing the vital forces (which have been stimulated for healing and upbuilding the pathological area) to parts not involved, thus defeating the very purposes intended. Dr. Still always advocated and gave the short, specific treatment.

The point always to be considered is the individual characteristics of the patient, and effects of the first treatment should be carefully observed. After a patient has been under treatment for any considerable time it is well to give him a vacation from treatment, and it is remarkable what improvement will be shown at times by such a measure and how seldom he will lose ground. Dr. Still presented this subject vividly as follows: “To treat the spine more than once or twice a week and thereby irritate the spinal cord, will cause the vital assimilation to be perverted and become death producing by effecting an absorption of the living molecules of life before they are fully matured and while they are in the cellular system, lying immediately under the lymphatics. If you will allow yourself to think for a moment of the possible irritation of the spinal cord and what effect it will have on the uterus, for example, you will realize that I have told you a truth. Many of your patients are well six months before they are discharged. They continue treatment because they are weak, and they are weak because you keep them so by irritating the spinal cord.” It is not a rare experience for a patient to leave apparently with little or no improvement only to report a complete recovery a little later.

Misapplied Treatment.—Probably in spinal treatment more risks are taken than in any other region of the body. To us as a school it is by far the most important and interesting area we have to treat, consequently it is not surprising that various general treatments and methods have been devised with the idea of getting quicker and easier results. Herein lies the danger outside of mistaken diagnosis, for short cut treatments can never take the place of time and skill. Technically speaking, if one thoroughly understands the philosophy of osteopathy and is conversant with the underlying principles of its therapeutics, there is absolutely no danger of even the slightest injury. It is the one who takes chances by not properly diagnosing and by not being cautious enough with delicate persons when applying his treatments that is apt to overstrain some tissue or organ and otherwise do bodily harm. Of the treatments considered dangerous not one of them is without merit if judiciously applied, but unfortunately in many cases they are in general and indiscriminate use. It is well to remember that we are moving structures which have never been moved before and that time enough has not elapsed to observe what the ultimate result may be. Again, in adjusting a subluxation of the spine do not forget that the force necessary for that adjustment, if misapplied, is sufficient to produce a lesion, and there is no doubt that this has happened. Your patient’s interests are above everything and must never be sacrificed for any reason whatever, so if at any time there is uncertainty always give the patient the benefit of the doubt. On the other hand the osteopath must have the courage of his convictions and fortunately when these are coupled with good judgment the results are all that could be desired. The following should be used with great caution if used at all:

First, Indiscriminate stretching of the spinal column with the aid of an assistant. It is not good osteopathy although there are some cases where it may be beneficial. While not specially dangerous, generally, in delicate patients, elderly people, arteriosclerotic conditions, and in some stages of Pott’s disease it is absolutely contraindicated. Moreover in most spinal cases except impacted vertebræ and symmetrical curvatures the stretching of the vertebral ligaments locks the lesion firmer.

Second, Extreme rotating of the cervical region. This cannot be considered good treatment in any case with the exception of the muscle stretching. On the contrary it is dangerous; first, it is not osteopathy for it is not specific; second, the nervous shock is severe, an important consideration in delicate people; third, the cervical ligaments become stretched and the vertebræ are easily displaced, while damage to a diseased vertebra, an aneurism or in arteriosclerosis would be irreparable. No other region of the body should have greater care in treatment than the neck.

Third, Hyperextension of the spine with the patient on his face. This treatment is rarely indicated. In fact, it is barbarous and a relic of an early day. Possibly more cases have been injured by this treatment than all others combined.

Fourth, Rough separating of the vertebræ and ribs while the patient is on his face. This is a most excellent treatment in many cases, but great judgment is necessary. Delicate patients, heart disease, and necrosed vertebræ and ribs should be carefully excluded.

Fifth, Innominate adjustments such as placing the patient on the side and putting the knee against the sacrum while grasping the leg at the knee. Or, the placing of the patient face down with one hand on the sacrum and the other holding the knee. In both these there is a tremendous leverage and in the latter the strain is at the lumbar rather than where needed. There are other unnecessarily risky methods for this operation, while it is easy to perform in most cases and without danger.

Sixth, Abdominal treatment gives wonderful results when intelligently applied, but it may be productive of great harm in conditions of tumors, malignancy, and pus formations.

Misapplied treatment is always dangerous, no matter to what part of the body given, and it is proof of wrong diagnosis when given. As a rule treatment is given without proper diagnosis in such cases, so a misapplied treatment has two interpretations—first, ignorance; second, laziness. In the former lies the greater danger for ignorance coupled with force and lack of skill is an appalling combination.

Cases are frequently reported where tumors have passed from the vagina, rectum, nose, etc., the osteopath thinking it was the result of good treatment, without considering that it was simply the breaking of a long pedicle with great danger from hemorrhage. The greatest care should be exercised in treating cases where aneurism, osteomalacia, and arteriosclerosis are present, also in the leg treatment of tabes dorsalis and in the weak, thin ribs of elderly people and those with a gouty or rheumatic diathesis. Imagine treating an abscess directly, yet it has been done, as have varicose veins with the terrible danger of rupture and embolism. Aneurisms have been ruptured in the same way.

One could go on indefinitely with this subject, but to sum up: if the osteopath is not familiar with the feel of the living anatomy in its giving and resisting under treatment both in health and disease and does not know his osteopathy, nothing can prevent him doing harm. A successful practitioner means an understanding of pathology, then experience plus common sense.

---

“Osteopathic spinal centers” was a term commonly used in the early period of osteopathic development. From the facts, first, that a few centers have been actually determined in the cord, viz., genito-urinary, vasomotor, etc.; second, that the innervation from the spinal segment to various thoracic, abdominal and pelvic viscera correspond with a considerable degree of accuracy to certain vertebral sections, and third, displacements of tissues of the spinal column affect viscus integrity, depending upon the locality of the structural perversion as to the organ involved and is a clinical observation of great import, arose the misnomer “osteopathic centers.” For one to ask what “centers” should be “treated” in this or that disease shows a lack of the conception of osteopathy as if he asked what “movements” to give when “treating” a certain disorder. It is as unosteopathic, as it is unscientific, broadly speaking, to suppose osteopathic technique implies the application of movements to certain nerve centers.

“Osteopathic stimulation” is another term loosely used without extensive clinical experience to support it. Mechanical stimulation is frequently utilized in the physiological laboratory. But to employ it extensively and comprehensively in the treating room or at the bedside the therapeutic potency of it will be found wanting; that is, to employ it to the exclusion of that most important basic treatment, readjustment, is a great mistake.

Clinically, the pathologically slowed heart may be stimulated by a stimulus to the cervical sympathies, the gall-bladder emptied by a stimulus near the costal cartilages of the ninth and tenth ribs (this is probably via the spinal segments), etc. Normally, these organs and others may be temporarily stimulated. Experimentally, Burns[33] of Los Angeles and Pearce[34] of San Francisco have shown the potency of osteopathic mechanical stimulation. For example, stimulation (mechanical) in the middle and lower dorsal regions irritates and increases peristaltic action and vaso-constriction in the stomach and intestines.

Likewise the term “osteopathic inhibition” has not always been scientifically employed. Mechanical inhibition is probably used less frequently than stimulation but still it is of more importance. Probably the true interpretation of considerable of so-termed stimulatory and inhibitory efforts, is simply one of normalization of tissues, physiologic equilibrium resulting from such changes.

Clinically, to relax contracted muscles by inhibition, to relieve neuralgia by impinging nerve courses, to relax the cardiac orifice of the stomach by pressure at the ninth or tenth dorsal vertebra on the left side, etc., are excellent examples of the therapeutic value of inhibition. Experimentally Pearce and Burns produced the opposite results to that of stimulation. Inhibition in the middle and lower dorsal region caused relaxation of the muscles of both the stomach and intestines, decreased peristalsis, and caused dilatation of the blood vessels.

The employment of stimulation and inhibition rounds out to a certain extent our therapeutics, that is, makes it more practical and specific. We should not, however, over-rate the relative value of stimulatory and inhibitory treatment as compared with the readjustive treatment. Not but what the former is of considerable practical importance, but the point to be emphasized is that it gives a scientific demonstration of how pathological effects result, if long continued, from the various osteopathic lesions. In a word, it shows the physiological process from cause to effect, or rather a step in the beginning pathological (perverted physiological) in many disturbances.

Therapeutically, all will agree with Cherry[35] that “stimulation and inhibition should be employed in all forms of acute disease as palliative measures until such time as the primary lesion may be removed.”

As a preparation for adjustment of any bony lesion there is no question but that simple inhibition for a brief time in the area will bring about relaxation of soft tissues in a much more satisfactory manner than the usual massage like method. McPherson, Montreal, has developed a technique of sacral pressure which he uses exclusively in his practice. Without going into the merits of his theory there is no doubt that inhibition at the second and third sacral will bring about relaxation of the muscles of the lower trunk in a most gratifying manner. Another thing, if there is difficulty in introducing the finger in making either a vaginal or rectal examination, a minute’s pressure at these points will, in most cases, cause the sphincter to relax so as to cause no discomfort to the patient. This pressure will, also, have a great effect on the hypogastric plexus and the pelvic organs.

Readjustment or adjustment is many times particularly emphasized in this work as the key to osteopathic therapeutics.

If the theory of readjustment can not stand the most searching tests of science osteopathy will have to be relegated to a most subservient place, on a par with massage, Swedish movements, and various medical gymnastics. Consequently the readjustment theory is again referred to, and especially so when the subjects of osteopathic centers, stimulation and inhibition are outlined.

No doubt many stimulatory (so-called) and general treatments exert their greatest influence by inadvertently readjusting tissues. Then how much more effective would the readjustment treatment be if applied intelligently. In certain acute disorders, e. g., “colds,” immediate relief is often obtained by relaxing muscles through either stimulation or inhibition; in reality the final result, as far as the muscle is concerned, is one of readjustment. Likewise in stretching and rotation of tissues and sections of the body the effect may either be stimulatory or inhibitory, and still it may be, also, readjustive.

After all has been said the ultimate physiological effect of any of these treatments, if of any therapeutic value, must be one of stimulation to a part or to the body generally. But there is a vast difference between physiological stimulation and the one method of obtaining the same termed mechanical stimulation. It is not the purpose here to enter into anything like an exhaustive survey of stimulation and inhibition but simply to outline a few practical hints on the relative values. Everyone is aware that overstimulation is equal to inhibition, and even applying it to very delicate subjects the therapeutic end we may wish to obtain may be lost and as a consequence the patient exhausted; whereas at the same time readjustment possibly could have been employed and real permanent effects secured.

So we should whenever possible utilize the basic principle of our therapeutics, readjustment, for this represents in the majority of cases, first, permanent results; second, a saving of much time, and third, less exhaustion on the part of both patient and physician.

McConnell[36] has shown in his series of laboratory experiments on animals the reality and potency of the readjustment fundamental. The effect of malaligned vertebræ and ribs upon contiguous vascular channels and nervous tissues, not only affects immediate skeletal muscles by simple contractions but even produces interstitial myositis. Through narrowing of the intervertebral foramina and tension upon the fibrous tissue anchoring the spinal nerve in its exit, and through pressure and strain on the sympathetics in contact with the heads of the ribs, which are secured there by the parietal layer of the pleura, organs in corresponding cavities become diseased. Some of the diseases produced in the series of experiments were catarrhal and parenchymatous changes in the stomach and intestines, congestion of the liver and spleen, acute nephritis, goitre, inflammation of the lymphatics, edema of the cornea, and degenerations of nervous tissues. Still too much emphasis should not be placed upon the narrowing of the foramen for certain pathologic changes are shown to be due to other conditions than Wallerian.

The osteopath, as stated, may inadvertently correct osteopathic lesions. Vis medicatrix naturae undoubtedly corrects many osteopathic lesions; this is evident from the fact that many bodily strains, sprains, and injuries are overcome naturally or involuntarily, that is, without any voluntary assistance from an osteopath. On the other hand all osteopathic lesions are not due to outside influences or forces, e. g., in pneumonia the severely contracted dorsal muscles often partially dislocate the vertebral ends of the ribs and thus increase the seriousness of the disease; and this is true in many acute conditions wherein visceral changes will reflexly contract spinal muscles and also through these contractions produce osseous lesions. Here is where osteopathic treatment in acute diseases will not only correct the primary lesion but also these secondary ones and thus abort, or shorten, or lessen severity, or prevent complications of the disease. But it should always be borne in mind that when certain disease processes occur it will take a definite time at best for curative changes to predominate. In other words pathological changes are just as real and potent as physiological facts or anatomical data and the character of the same should always be considered.

Consequently in readjustment work a distinctive etiology and pathology has to be taken into account. The color, contour (whether the lesion is simply a local one or there is a composite or group lesion), condition (irritation, debility, contractions, and tenderness), and movement of the several regions, and the spine as a whole should be noted. And the student should always keep in mind that the osseous vertebral lesion may be, (a) a twist between two vertebræ (this generally means a rotation of one section of the spine on another section), (b) malalignment of several vertebræ (the composite or group lesion), or (c) the impacted or strained lesion, (this is a lesion that Clark attaches considerable significance to, wherein there is injury to the articular surfaces and ligaments without osseous derangement, followed by exudation and other inflammatory products, limited motion, etc.).

It is extremely important that the osteopath should be thoroughly conversant with the regions where he may affect the vasomotor nerves to various tissues and organs. Many anatomical derangements undoubtedly involve the vasomotor nerves, and it is therefore necessary to know where they may be affected. The following table is taken mostly from the physiology of Landois and Stirling, but many of the statements have been noted at various times; it is, therefore, impossible to give full credit.[37]

The vasomotor center is in the medulla, consequently the osteopath gives cervical treatment to influence this center. Treatment of the upper cervical region has undoubtedly a marked effect in tending to equalize the vascular system of the body, when it is disturbed.

Head.—The cervical sympathetic for the same side of the face, eye, ear, salivary glands, tongue, etc., and possibly the brain. Lesions are found in all the tissues about the cervical region, but usually in the vertebræ, which influence these nerves. Deep contracted muscles oftentimes involve them. The spinal vaso-constrictors for the vessels of the head are from the first five or six thoracics. Many lesions are located in the upper five or six dorsal vertebræ, or corresponding ribs, that have apparently a direct influence upon the vessels of the head. Not only congestive headache and congestion of the brain tissues are influenced by lesions in this region, but disease of the eye, ear and face occasionally arise from such derangements. It is always best when the head, neck or even the arms are involved, to examine carefully this region. Vaso-dilator fibres for the face and mouth are found from the second to the fifth dorsals; these fibres unite almost entirely with the trigeminus, and pass from the superior cervical ganglion of the sympathetic, to the ganglion of Gasser. This fact is of great importance to the osteopath, for oftentimes when inflammation of the face and mouth occurs, lesions may be located along the upper dorsal vertebræ or ribs, or in the deeply contracted muscles of this region. Observation revealed in several cases of erysipelas that the causative lesion was located in the upper dorsal region; and the cases were cured by correcting these lesions, thus showing that probably the vasomotor nerves were the seat of the trouble. Other dilator fibres arise apparently in the trigeminus, for stimulation of this nerve between the brain and Gasser’s ganglion causes dilatation of the vessels of the face. The lingual and glosso-pharyngeal nerves are the dilators of the lingual vessels. The sympathetic and hypo glossal are the constrictors; these arise in the sympathetic and reach the nerves by way of the superior cervical ganglion. Stimulation of the cervical sympathetic causes constriction of the retinal vessels. This point is extremely interesting to the osteopath, because diseases of the retina and optic nerve are oftentimes due to subluxated cervical vertebræ, usually the atlas or third cervical. The retinal fibres leave the sympathetic at the superior cervical ganglion and pass along the communicating ramus to the ganglion of Gasser, from whence they reach the eye through the ophthalmic branch of the fifth nerve, the gray root of the ophthalmic, the ganglion and the ciliary nerves. Almost all the fibres to the anterior part of the eye are found in the fifth nerve; this, also, is another important point for the osteopath’s consideration. Cases of conjunctivitis, keratitis, corneal astigmatism and diseases about the eyelids and tear ducts are usually caused by lesions to the fifth nerve, due to a deranged atlas or third cervical. The vaso-dilators for the anterior part of the eye, and also dilating fibres to the iris may be affected at the first and second dorsals. This point is also taken advantage of by the osteopath, for lesions of these fibres occur oftentimes at the upper dorsal. It is claimed that important fibres that aid in the control of the metabolism of the retina, may be affected at the fourth and fifth dorsals.

Lungs.—Reflex constriction by stimulation of the intercostals, central end of the sciatic, abdominal pneumogastric and abdominal sympathetic. There is not a rich vasomotor supply.[38] The essential feature to the osteopath is that the vaso-constrictors to the lungs and bronchial tubes are very likely to be interfered with by rib and vertebral dislocations, from the second to the seventh dorsals, inclusive, but chiefly at the third, fourth and fifth. The heaviest innervation being from the third, fourth and fifth spaces, probably explains why asthma is often due to a dislocation of the third, fourth or fifth rib.

Heart.—First to fifth thoracic via ganglion stellatum and inferior cervical ganglion. Vasomotor fibres to the coronary arteries are found in the vagi.

Intestines.—Sympathetic, chiefly through the splanchnic nerves. Vaso-constrictors of the jejunum from the fifth dorsal down, for the ileum slightly lower and for the colon still lower. There are none below the second lumbar. Dilators are present in the same sheath, but more abundant in the last three dorsals and the upper two lumbars; all probably end in the solar and renal plexuses.

Receptaculum Chyli.—Stimulation of the splanclinics causes dilatation.

Liver.—The splanchnics chiefly on the right side. The vagus contains vaso-dilators. There are also fibres from the inferior cervical ganglia of the sympathetic.

Kidneys.—Vasomotor nerves from the sixth dorsal to the second lumbar, but principally from the ninth to twelfth dorsals, inclusive. In the large majority of kidney diseases, lesions are found from the tenth to the twelfth dorsals. Stimulation of the sciatic centers causes contraction. There are also fibres from the superior cervical ganglion.

Spleen.—Vasomotor fibres are in the splanchnics, third dorsal to third lumbar, principally, on the left side. There are some fibres direct from the brain. Stimulation of the vagi contracts the spleen.

Portal System.—Fifth to ninth dorsal.

Generative Organs.—For Fallopian tubes, uterus, vagina, vas deferens and seminal vesicles, vasomotor fibres are found in the lower dorsal, and the second, third, fourth and fifth lumbar nerves, principally.

Coccyx and Immediate Region.—Third lumbar down.

Back Muscles.—Dorsal Posterior branches of the lumbar nerves and intercostal nerves. These nerves arise from the gray ramus of the corresponding sympathetic ganglia.

Arm.—From the brachial plexus, the sympathetic, inferior cervical ganglion and first thoracic ganglion, and sometimes lower.

Leg.—Second dorsal down, the sciatic and crural nerves, and the abdominal sympathetics.

Inhibition of various regions along the spinal column is frequently given by the osteopath to lessen pain. It is only a temporary or palliative treatment, but many times gives great relief. One should inhibit usually over tender points and contracted muscles. These (tender points and contracted muscles) are signs to the osteopath that disturbances exist at these points. The following table is taken from Quain, which is Head’s classification:

Heart.—First, second and third dorsals.

Lungs.—First, second, third, fourth and fifth dorsals.

Stomach.—Sixth, seventh, eighth and ninth dorsals. Cardiac end from sixth and seventh. Pyloric end from ninth.

Intestines.—(a) Down to upper part of rectum, ninth, tenth, eleventh and twelfth dorsals. (b) Rectum, second, third and fourth sacrals.

Liver and Gall-bladder.—Sixth, seventh, eighth, ninth and tenth dorsals.

Kidney and Ureter.—Tenth, eleventh and twelfth dorsals. Upper part of ureter, tenth dorsal. At lower end of ureter, first lumbar tends to appear.

Bladder.—(a) Mucous membrane and neck of bladder; (first) second, third and fourth sacrals; (b) over distension and ineffectual contraction, eleventh and twelfth dorsals, and first lumbar.

Prostate.—Tenth, eleventh (twelfth) dorsals. First, second and third sacrals, and fifth lumbar.

Epididymis.—Eleventh and twelfth dorsals and first lumbar.

Testis.—Tenth dorsal.

Ovary.—Tenth dorsal.

Appendages, etc.—Eleventh and twelfth dorsals, first lumbar.

Uterus.—(a) In contraction, tenth, eleventh and twelfth dorsals, and first lumbar. (b) Os uteri; (first) second, third and fourth sacrals (fifth lumbar very rarely).

Other points are used by the osteopath to relieve pain of certain regions, for such the reader is referred to the article on neuralgia; besides many tender points are found along the spine by the osteopath, where inhibition gives relief to the patient, provided such points have a connection with the case in question.

Hot fomentations if property applied, through reciprocal relationship of the nervous system, are of value in relieving pain, releasing spastic musculature and normalizing visceral function. Frequently, in both acute and chronic cases, this is an excellent preparatory measure, to be followed by careful adjustment. It will be recalled that the functional test, movement of a vertebral lesion is of primary consideration.[39]

---

Any deviation of two or more consecutive vertebræ from the normal curves of the spinal column is usually termed by the osteopath a pathological curvature. Of the common pathological curvatures of the spinal column there are found: (1) scoliosis or lateral curvature, (2) kyphosis, or excurvation, an antero-posterior curve with the convexity backward, and, (3) lordosis, or incurvation, an antero-posterior curve with the convexity forward.

Osteopathic Etiology.—Of primary importance in the causation of pathological curvatures of the spinal column, are injuries to the spine, such as strains, falls, blows, and various physical forces, acting directly or indirectly, as injuries to the chest, pelvis and limbs. The osteopath in his daily work finds more curvatures, as well as acute and chronic diseases, resulting from some simple injury to the spine, as a slip, strain or twist, than from any other cause. The dire effects of any violence to the spinal column cannot be overestimated.

Among predisposing causes may be mentioned, continued ill health, general weakness, rapid growth, rachitis, tuberculosis, etc. Any habitual one-sided position may result in a curvature. An injury to the chest, adhesions from pleuritis, chronic liver disease, obliquity of the pelvis producing unequal length of the legs, carrying heavy weights on one side, and various morbid growths of the chest and abdomen, may all produce curvatures. Many cases are found in school children who are growing rapidly, and whose muscular strength and development do not keep pace with their growth. Unilateral atrophy of the muscles, due to central changes or overuse, may be the cause of deviations of the spinal column. Sacro-iliac disease in some instances is a potent factor. Thus there may be a great variety of causes productive of the incipiency, and the spine being strained or irritated at a single point and in a certain way gradually develops a curvature. Every spinal and innominate lesion should be considered as a potential cause for a curvature.

Scoliosis.—This is the most common spinal deformity and is characterized by lateral deviation from the median line. In most cases the curve is to the right in the upper dorsal region, with a compensatory curve in the opposite direction in the lumbar region. The curve being to the right in the majority of cases, is probably due to the fact that most people are right-handed.

Morbid Anatomy.—The vertebræ in the region involved are rotated so that their spinous processes point toward the concavity of the lateral curve. The bodies of the vertebræ on the side next to the concavity are thinner, due to absorption; the intervertebral discs are made thin on the same side by pressure and absorption. The ribs are considerably distorted, depressed on the concave side and prominent on the convex side. The ligaments on the concave side are contracted, and stretched on the convex side. The muscles on the concave side are more or less contracted, and on the convex side they are stretched, causing atrophy and fatty infiltration of their tissues.

Kyphosis.—This may be a slight posterior curve really amounting to nothing, or it may be a very grave pathological condition as in Pott’s disease. Therefore it is very necessary that one should make a most careful diagnosis (see Pott’s disease).

The most common causes of kyphosis are Pott’s disease, rachitis, occupation, general weakness, rheumatism and old age.

In Pott’s disease, the posterior curve is characterized by a sharp angle, and by the spine being very rigid. This, taken in conjunction with the history and other symptoms should be sufficient to enable one to make a diagnosis. Radiographic examination should be made.

The condition of round shoulders, which in time produces marked kyphosis, is rarely a habit as it is usually termed. In nearly every case it indicates either a weakness of the back muscles or, what is more apt to be the cause, a strained posterior condition of the dorsal vertebræ, commonly of the lower dorsal region.

Morbid Anatomy.—In mild cases there is simply a relaxation of the ligaments of the vertebræ and a separation of the laminæ and spinous processes. In severe forms there may be absorption of the anterior portion of the intervertebral discs and the bodies of the vertebræ (Pott’s disease).

Lordosis.—This may be a congenital condition, especially when occurring in the lumbar region. Anterior curves of the spine are generally found in the lumbar or cervical regions, but occasionally occur in the dorsal region, causing the spinal column to be more or less straight, and thus weakening the individual. This curve is commonly compensatory to kyphosis, hip-joint disease and congenital dislocations of the hip.

Treatment of Spinal Curvatures.—The treatment of pathological curves of the spinal column, by osteopathic methods, has been highly satisfactory to both osteopath and patient. The success of the osteopath in these cases has been due to his comprehensive and exact knowledge of each vertebra, and of the spinal column in general. He recognizes curvatures that the ordinary practitioner, and it is safe to say the orthopaedic specialist, would not even notice or recognize. On account of the highly developed sense of touch of the osteopath, he is capable of detecting the slightest deviation of one vertebra from another, and of the spine in general from the normal. Thus by the uniqueness and peculiarity of his work he is capable, not only of discovering a curvature, but also of reducing a curve when found.

The work consists of, first, relaxing any muscles that may have become rigid over the seat of the curve. Then follows a treatment to each vertebra involved, by attempting to replace it, and treatment to the curve in general by springing it toward its normal position. At each treatment effort should be made to accomplish something toward correcting the spine; too many treatments are given in a “general” way, and being unspecialized amount to nothing. One must become familiar with the exact location of each vertebra involved, to attempt a correction of a curvature intelligently. Upon this one point it is impossible to speak too strongly, for a great many treatments have been wasted and improvement of cases retarded by not paying enough attention to the details of the diagnosis, either from pure slothfulness or from an imperfect conception of osteopathy. Corrective exercises are always of value in addition to treatment.

These remarks refer to incipient and certain moderate curvatures. In other cases radical measures (Abbott) should be employed if age and conditions permit. Remember, however, that the practitioner in his daily work of adjusting the many combinations of rotation and sidebending lesions corrects innumerable actual and impending curves.

Lateral curvature in the dorsal region is undoubtedly the hardest to correct on account of the ribs, which complicate the condition. A marked curve in the dorsal region is sure to be accompanied by a dislocation of the vertebral end of one or more ribs. Treat each distinct lesion separately, follow by general stretching, replacing and molding of the tissues. A good method to stretch tissues and adjust a moderate lateral curve is to utilize the swing, or in lieu of this have the patient stand just at arm’s length from the wall with concave side toward the wall with straight arm at right angles and palm resting against the wall. Stand in front of patient whose feet are firmly on the floor and reach around with both hands upon the spine. As the patient sidebends toward the wall it tends to correct the deformity, so if the operator coordinates his adjustment with that lateral movement of the patient, precise fulcra can be obtained and a certain, definite correction secured. The significance rests with the stretching of tissues and the definite fulcra obtained, thereby securing a maximum sidebending and rotation toward correction.

The dislocation of an innominate sometimes complicates matters, but is a simple point to remedy, and should not be overlooked.

The correction of a curvature presents a special study to the osteopath, whether it be scoliosis, kyphosis or lordosis, and special rules cannot be laid down for treatment. Cases of rare occurrence are what might be termed “symmetrical” curves; i. e., no vertebra presents separately a marked lesion, the column on the whole being simply bowed. Such cases can be treated by springing back the spinal column, and by the use of methodical exercises. Unfortunately most curvatures are characterized by various lesions between the vertebræ, and thus each lesion requires special work.

In simple curves the use of braces, jackets, and the various mechanical appliances are of very little use to the osteopath, in fact, more harmful on the whole, than beneficial. Naturally they would apply to a “symmetrical” curve, or where the patient is too weak to sit or walk, but they can be of very little use to the average patient, in place of correct osteopathic treatment. Mechanical appliances confine the movements of the patient, interfere with the development of the muscles, and impinge to a greater or less extent the spinal nerves. Due attention to hygienic surroundings and diet are certainly of aid. Proper exercises and occupation for the sufferer should be advised. Special care should be taken in examining (radiographic) for infectious lesions (arthritis).

Straight Spine is a term used particularly by osteopaths for a condition seldom recognized by orthopedic surgeons. The following is from H. W. Forbes[40]: Straight spine is “a departure from the normal in the conformation of the chest; characterized anatomically by bilateral diminution in size, decrease in the antero-posterior diameter, relative increase in the transverse diameter and flattening of the anterior and posterior walls; characterized clinically by diminution of respiratory capacity, lowered lung and heart resistance, impaired general nutrition and predisposition to neurosis.

“Of the many possible manipulations that may be used to lift and overcome the morbid bend of the ribs I will attempt the description of but one.

“Relax the musculature of the back and chest. Rotate, flex and extend the dorsal spine. Examine all the ribs on each side and loosen any that do not move freely. Having done this, the patient is prepared for the specific treatment. Have the patient sit on a stool and lean forward on a table. Have him separate the elbows, flex the forearms, place one hand over the other and his forehead on the hands. Tell him to relax all the muscles of the shoulders and arms and to breathe deeply without using the muscles. After a few trials he is able to fully expand his chest without contracting the muscles connecting the upper extremity with the trunk. The physician then takes a position at side (either side) of the patient and places the weight of his trunk on the ribs of the side he is on, a little external to their angles. He passes his arms around the patient’s body; the arms passing across the front of the chest are carried around far enough to allow the hand to be placed on the ribs just external to their angles. The other hand is placed on the top of this one. In this position the physician’s body on one side, and his hands on the opposite, occupy similar positions. The patient is now told to inspire deeply and at the same time to relax the shoulder muscles, as before instructed. As the chest expands drop the weight of the trunk on one side and make pressure forward (forward meaning toward the anterior surface of patient’s body) with the hands on the other side. This lifts the ribs to a greater extent than the patient unassisted could lift them. At the end of inspiration and during the first third of expiration the chest is compressed laterally. The compressing force, if applied correctly, will fix the ribs in a position of less obliquity and will also correct the increased lateral bending of them. The dorsal spine becomes more convex posteriorly at the moment of lateral compression of the thorax, if correctly made. Great force should not be used at the beginning. Repeat the manipulation five to twenty times each treatment. Give treatment three times a week. A similar movement may be given on the table.

“The greater number of flat chests in patients under thirty years of age may be corrected. If the patient is above thirty, although complete correction may not always be accomplished, the results are satisfactory. Two to six months treatment is required.”

A “typhoid spine” comes as a sequel to typhoid fever. There is constant pain, tenderness along the lumbar region and rise of temperature. The pain is generally increased when the spine is moved forward or sidewise. Such a condition is clearly understood by the osteopath. There are always found distinct vertebral lesions along the region that is tender on pressure. In fact these very lesions may have been the predisposing cause of the attack of typhoid fever. The treatment is rest and the indicated manipulation to correct the derangements. It is of great interest to note that where the typhoid patient is treated osteopathically the condition just described seldom results. Observations by C. M. T. Hulett confirm this statement.

The Neurotic Spine may be the result of injury but the subject is usually of a nervous, neurasthenic type. It occurs from the age of puberty to adult, much more often in females than males.

The patient has dull pain in the back of the neck or in the lumbar or sacral region, complains of a constant tired feeling and often of a sharp neuralgic pain in certain parts of the spine. Generally there is a drooping posture in the upper dorsal with shoulders thrown forward, which is a sign of weakness. There is extreme tenderness along the spine and usually the pain is confined to the sensitive places.

Treatment consists of a constitutional toning up, and increasing muscular strength through judicious exercise. The posterior curve may be pushed toward the median line by laying the patient on the face; also with the knee in the back and the flat of both hands on the sternal ends raise the ribs; or by the arms making use of the pectoral muscles accomplish the same result. Deep breathing is also effective. Relief can usually be given and a cure will depend upon the patient’s general condition.

The Hysterical Spine is usually considered the same as the neurotic spine, but there are many cases which have the sensitive spine without being hysterical. There is more deformity usually present, particularly in the lumbar region. Probably there will be a history of some injury.

The treatment is to correct the curvature and build up the general health. These conditions are stubborn and progress is slow. In both the neurotic and hysterical spines the ligaments of certain areas will be found atonied and relaxed. This is especially noticed upon attempting to spring a group of vertebræ when all of a sudden the section relaxes. In either of these spines the lesions will irritate or obstruct nervous courses, produce venous stagnation or arterial starvation, and disturb lymph channels. H. F. Goetz has observed that in functional nervous diseases the dorsal spine is flat, while in visceral displacement the dorso-lumbar spine is posterior.

The Spine of the Aged wherein is found stooped shoulders and a rigid spinal structure, can be distinctly improved by slow, cautious traction. This tones weakened muscles, releases contractures, separates the compressed intervertebral discs, and definitely tones the viscera. Careful work is imperative.

---

An article on Pott’s disease does not really come within the province of a practice of medicine. Still it will be acceptable to the practitioners and students of osteopathy, as one of the objects of osteopathic work is to improve, not only medical and obstetrical practice, but also surgical practice, and besides the osteopath will have many cases of spondylitis to treat. “Pott’s disease, or caries of vertebral bodies, was first described by Percival Pott in 1779. It consists of a destructive ostitis affecting the spongy tissue of one or more of the bodies of the vertebræ. The ostitis is tuberculous, and is similar in character to tubercular ostitis seen in the epiphysis of the long bones. Owing to the superincumbent weight of the head and shoulders pressing upon the carious vertebral bodies, the spine and trunk become peculiarly and characteristically distorted. The morbid process is limited, as a rule, to the bodies; the transverse, articular, and spinous processes are rarely primarily affected.” (Park).

The first consideration in the treatment of Pott’s disease is rest. If the disease is a progressive one, rest in bed in the recumbent position is necessary. Naturally, the object of the treatment is to secure resolution of the tubercular ostitis as soon as possible. To do this, careful manipulative treatment should be applied to the diseased vertebræ. The treatment must not be harsh, for there would be danger of greater irritation to the parts, and possibly infected particles from the destroyed tissue might gain entrance to the vascular system. The osteopath must be extremely careful how he manipulates the spinal column in Pott’s disease. The object of the manipulation is not primarily to overcome the deformity, as some may think such an act possible, but to separate the vertebræ enough to allow a freedom of the circulation, and to remove impingements of the nerve tissue. It is impossible to overcome the deformity to any extent when part of the body of the vertebra is destroyed; but if one could treat the case at the incipiency, most probably deformity would be prevented. There is another danger in treating cases too severely, and that is causing exhaustion of the patient. Treat the spinal column not only to separate each articulation slightly, but to carefully crowd the diseased vertebræ toward their normal position. When the disease is in the dorsal region, considerable attention has to be paid to the ribs, as they are invariably involved when the spinal curvature is great. Hence it is necessary to treat each rib separately, and try to correct them at least, and remove any obstruction to nerve fibres or vessels that may be found. One of the strongest arguments against the indiscriminate use of braces, jackets and various mechanical appliances in spinal deformities, is that they tend to straighten the spine, by simply crowding the vertebræ and ribs as a whole into place, besides interfering with the cutaneous circulation. The osteopath should realize that each vertebra and rib has to receive special treatment, in order to correct the spinal column, and that mechanically exerting pressure upon all the vertebræ at one time tends to lock the vertebræ and ribs all the more securely. It is like trying to correct a certain subdislocation of the cervical vertebræ by pulling and twisting the neck instead of applying specific treatment—the lesion is all the more firmly fastened. Young, in his Surgery, makes this observation: “Like chronic abscess or chronic bone disease, this affection has its origin in the fact that the tissues of the anterior parts of the bodies of the vertebræ have been partly deprived of their nutrition because of luxated ribs or subluxated or twisted vertebræ.”

After the tissue destruction has been limited, and the deformity corrected as much as can be, an ankylosis should be secured if possible. Promotion of ankylosis depends altogether upon the preceding treatment—rest and an improved nutrition of the parts. A truss or brace, if correctly applied, is often beneficial in such cases. The treatment of spinal abscesses is entirely in accordance with surgical treatment.

In all cases the general health of the patient has to be well taken care of. The osteopath must not be over zealous for quick results. It takes many months to perform a cure; however, there is always a tendency toward a cure. Treatment of the spinal muscles and of the limbs, and pure air, sunlight, massage and good food are very necessary.

---

A postural defect is any abnormal position, congenital or acquired, of the body, assumed in sitting, standing or walking. This leads to a symmetrical development, causes structural changes, and as a sequel, disturbance of function and organic life results.

Defects in posture are of very common occurrence. A perfect posture, in fact, is somewhat rare. Considerable is being accomplished, especially of late years, by the laity through various physical methods and exercises to correct the many defects of position in sitting, standing and walking. The originators of the many so-termed systems of exercises have gone so far as to even advertise to cure various diseases of the body as well as attempting to improve the normal tissues and structure.

Exercises, undoubtedly, have their place, particularly in the life of those of sedentary habits. Most of us do not exercise enough, neither do we as a rule get enough fresh air and pure water. But there are many defects of the anatomical that mere gymnastics can not adjust. And there are still other defects that gymnastics may decidedly aggravate. In these cases the mechanism of the body has become so deranged and disturbed that nothing short of actual readjustment can be effective.

In the consideration of postural defects there are a few points that should be particularly emphasized. First, these defects may not only be the result of laziness or carelessness, but of more frequent occurrence is some previous strain or injury to the spinal column or other parts of the body framework. Some defect of position or symmetry of the body may easily follow as a result. Here gymnastic work may reduce the defect to a minimum, but rarely can the compensatory forces of nature entirely obliterate the structural disorder, unless assisted by actual, specific readjustment. Second, in the examination and treatment of the patient due attention should be given the symmetry and figure of the body as a whole so that relation of the part to the whole and vice versa may be rightly proportioned. Remember that the spinal column is only one part of the body outline, thus one should consider the transverse section of the body in relation to the spinal column and not the spinal column alone. In a word, correction of postural defects implies both structural rearrangement and molding of the contour. Do not make the mistake, for example, when correcting a deformity that involves the chest, of paying attention to the spine alone, but take into consideration the thorax as a whole of which the spine is only a part.

Round Shoulders are a defective posture with which everyone is familiar. How many children have escaped the parents’ criticism to sit, stand, and walk erect? And not a few of the afflicted have not succeeded after persistently doing their best.

Round shoulders or stoop shoulders are commonly attributed to indifference. Probably a few cases are due simply to laziness and indifference, and others may be carelessness, and usually when they arrive at an age where pride of their physical demeanor and powers enters as a life factor, the child soon overcomes the postural weakness. With still others the correct, persistent physical training, as exemplified in military schools, will readjust the defect. But there is a class, and by far the largest, where round shoulders are a very real and active weakness of the physical body. And the weakness is not primarily in the shoulders as nearly everyone thinks. The stoop is a result. The origin is in the lower dorsal spinal column. Here will be found a posterior curvature that involves nearly the entire dorsal and lumbar areas. This is the real, the original cause of the larger number of round shoulders.

This backward curve of the spinal column, instead of the forward curve as it should normally be at the waist, obliterates the brace or truss of the spinal column that is so essential in maintaining an erect posture of the shoulders. It allows the individual to “fall into his stomach,” to drop the shoulders, and as a consequence the chest cavity is depressed. The spine is one continuous backward bow, and when he does try to sit straight, and it is always with a constant effort, the normal, the physiological curves of the spine are not apparent.

First, then, there is a spinal weakness in the region of the innervation to the digestive organs. Indigestion of various forms is a common accompaniment. Second, there is lessened lung and heart capacity. The ribs are depressed, interfering with perfect aeration and elimination on the part of the lungs and with normal activity and tone of the heart muscles. Phthisis is predisposed. Is it any wonder the child’s blood is impoverished and anemia results from the insufficient aeration and poor digestion and assimilation? Costogenic anemia may also be a result. And, third, the shoulders are “round” from the spinal weakness and flattened chest, really an effect; but while the most noticeable, it is the least serious.

It is evident from careful observation and study of these cases that the treatment resolves itself into the treatment of a posterior spinal curvature. Shoulder braces, steel braces and jackets, and casts have very little place, if any, although there may be diseased bone of such character and severity that a cast will be necessary; this, however, would refer to treatment of Pott’s disease and similar conditions.

Hence, the treatment is, first to replace and readjust the malaligned vertebræ. There must be an actual physical manipulation in order to correct the vertebræ at fault. This is the essential, and by far the primal, treatment for the key to the truss or brace that holds and retains the body in an erect position is then replaced.

Second, raising the depressed ribs. Remember the depressed ribs are dependent upon the spinal condition. The thorax should be treated as a comprehensive whole, not the spinal column alone.

Third, exercises are a valuable aid. The individual’s part is as necessary, in a way, as the physician’s, for in order to accomplish the maximum there should be consistent and appreciative work on the part of the patient. Holding the shoulders back, the head erect and the chin in, drawing the abdomen in and up, all with deep breathing by the use of the chest muscles, the patient will be able to retain the correction obtained during treatments. “Setting up” exercises are helpful. Developing the muscles of forced expiration is excellent. Thus the patient must be conscious of the work required of him and act in concert with the physician. Minute instruction on the requirements of each case is demanded.

Good food, pure water, and fresh air are necessary, particularly in the anemic. Right living and correct environment are always in order.

Under this heading may come a variety of conditions affecting one or both shoulders causing much distress and, at times, total disability. The conditions may be the result of direct injury to the joint, systemic, or from spinal lesions. Anatomically the shoulder offers frequent opportunity to injury as it has the greatest range of motion of any joint, is least secure in its articulation, and is most vulnerable from location. Once the shoulder has been dislocated it is rarely back to normal functioning again as this injury tears the capsular ligament and stretches the structures in relation. Many times there is only a subluxation in which the head of the humerus is driven upwards in the fossa, usually from a fall or blow on the point of the elbow. As a rule, after such an accident, the only thing done is to rest the joint and apply a liniment and, after a time, begin the use of the arm. It is, however, painful and to save himself, the patient each time restricts movement until he reaches a point where he is unable to dress without assistance. It is then found that normal motion is reduced fully one-half and even this will be accompanied by pain on movement and in bed. A radiograph will, usually, show the condition. Articular crepitus and fibrous adhesions are present while the adjoining structures have undergone changes so that a reduction is impossible without certain preparation. Very often a trivial cause will disable a joint; a sudden movement which finds the muscles about the shoulder unprepared and the resulting lesion is so slight as to, often, defy detection. At first there will be swelling and pain but, in time, it settles down to a limited motion with more or less distress.

Bursitis.—This is a condition in which the subdeltoid bursa is involved or where there have been a number of bursæ formed from overuse of the joint. One authority reports as many as twenty-five in a shoulder. There may be, also, tenosynovitis primarily or from extension. These conditions may not be easily diagnosed at first.

Brachial neuritis (chronic) beginning with or without an acute attack is usually from a cervical lesion involving the brachial plexus but most frequently it is the 5th and 6th cervicals at the origin of the circumflex nerve. From this the deltoid is particularly affected and its contraction leads to pressure on the nerve and subsequent partial or complete paralysis. Brachial neuritis is found in an increasing number of osteopathic practicians and is the result of overwork of the arms and to strain of the upper dorsals and lower cervicals. There are contractions of structures about the joint constantly limiting motion and pain when a strain is put on them.

Many methods for the treatment of the conditions described have been employed, all involving the same principle but none of them systematized. C. H. Spencer has worked out a technique which, while originally intended for bursitis, has been found well adapted to all conditions described. It gives a stretching of all structures and gradually breaks up adhesions, both in the joint and in the tendon sheaths, so there is no resulting irritation which could easily result if suddenly done. His technique is[43]:

“First: The patient on the side, the affected shoulder up; operator facing the patient, places one hand on the top of the shoulder, does nothing more than fixing it; with the hand grasping the forearm above the wrist, push the elbow backward, the arm parallel to and almost in contact with the body, then pull forward in the same plane. Second: Elevate the elbow with the hands of the operator in the same position as before, carry the elbow in as wide a circle as possible. Third: With the hands still in the same position, extend the forearm with traction; carry it as high in front of the patient as possible. The foregoing are designed to relieve the congestion about the shoulder, bring pressure to bear on the subdeltoid bursa and moderate traction on the supraspinatus, infraspinatus, subscapularis, teres minor and major, latissimus dorsi and the tendon of the biceps. These manipulations will be all that is possible in the more aggravated cases for some considerable period of time. As the tenderness subsides, the second group may be cautiously started, the hands in the same position as above noted, with the arm extended as nearly as possible at right angles with the body, carry the arm in as wide a circle as the pain will permit. Again, with the arm flexed at the elbow, one hand of the operator on the point of the shoulder and the forearm of the patient across the forearm of the operator, the other hand of the operator resting on the point of the patient’s elbow, push down toward the middle line of the body and carry the elbow toward the head. Then flex the arm and place the back of the hand behind the patient, flexing the shoulder in front with one hand grasping the point of the elbow and pull forward. This group of movements accomplishes with greater force the same ends obtained in the previous, and the first in this group is the most effective in overcoming swelling of the subdeltoid bursa. Direct manipulation of the muscle masses and this bursa is desirable from the first.” It will be noticed in all these movements that the joint is protected by one hand of the operator while the other is grasping the arm of the patient. This is desirable as it makes the technique absolutely safe. An additional treatment will be found very effective, especially where the deltoid is involved. With the patient on the well side, facing the operator, locate the quadrilateral space which is bounded by the subscapularis above, the teres minor below and the long head of the biceps medially and the surgical neck of the humerus externally, and the circumflex nerve can be easily palpated along with the artery. If these structures are stretched and the deltoid lifted from the shoulder it will be found to free the action of both nerve and artery, one supplying the joint with nutrition and the other innervating it.

Certain conditions for which these movements are contraindicated arise and the following differential points by H. Glasscock are well to remember[44]: “Rheumatism: Fever in the joint, with redness, swelling and other joints involved. Tuberculosis: Daily temperature and other tubercular foci. Neuritis: Pain in the neck and shoulder muscles, also near insertion of deltoid and in the forearm, particularly musculo spiral. Pain worse at night. No pain on movement. No swelling. Bursitis: No pain in neck. Pain in anterior and posterior part of joint and on motion. Pain near insertion of deltoid. Arm held close to the body, motionless. Infection: Chill, limited motion, severe pain with temperature. Dislocation: Deformity with preternatural mobility. Dislocation of acromio-clavicular joint: Tenderness over articulation. Arm cannot be raised beyond right angle with the body, but elbow may be brought across the chest with external rotation of arm and raised perpendicular with the body without pain.” The infected joint should never be manipulated and all conditions showing swelling, redness and pain on touch should be viewed with suspicion. Remember that all other conditions will almost invariably have vertebral lesions, primary or secondary and a permanent result will depend upon their correction.

A hip that is prominent and larger than its fellow is of frequent occurrence. It may not be necessarily conducive to a defect in posture, but it often is. The female is more frequently afflicted with this anatomical irregularity than the male. In the first place, the female pelvis is not so stable and rugged as the male pelvis, i. e., a mechanical wrench or fall will more easily displace the relative position of the tissues in the female. Then, in the second place, the dress of the woman accentuates irregularities of the figure, so that possibly in some instances the defect, from a diseased or deformed point of view, is more apparent than real. But of still more importance is the fact that many cases of a prominent hip are due to a lateral curvature of the lumbar spinal column. Lumbar curvatures are of common occurrence in the woman; first, the spinal column is not so strong as in man, simply on account of the physique not being so robust; second, modern dress constricts the waist by the use of corsets and many waist bands, and the weight of heavy skirts upon the waist, hips and abdomen; and, third, severe strains from childbirth. Care should be taken that there is no congenital abnormalities of the lumbar spine, or that congenital asymmetry of one-half of body, or trunk or leg is not present.

Thus the principal cause of a prominent hip is the lateral lumbar curvature. This, through compensatory action, renders the hip on the concave side prominent and high, while the hip on the convex side is depressed and less pronounced in appearance. Dressmakers and tailors are all too familiar with this feature of the irregularly outlined figure, and, consequently, have to resort to “padding” to round out the symmetry of the body. The mere irregularity of the figure, unfortunately, is by far the less serious part of the defect. Many ailments and diseases can be readily and directly traced to this. Not that the prominent hip itself necessarily always plays a leading part, but rather the lumbar curvature is the cause of very much suffering and misery. To enumerate the many disorders that arise from malaligned lumbar vertebræ may be unnecessary but a few will be given. A point to be emphasized is that the prominent hip often plays the role of a sign or symptom, or an effect, that an ailment or disease may be elsewhere.

In the female one of the most common causes, if not the most common cause by far, of disorders of menstruation, whether painful, profuse, or irregular, is irritation or obstruction of the lumbar spinal nerves due to lumbar curvatures. It is well known the lumbar spinal nerves control, to a large extent, the pelvic organs; consequently the osteopath pays particular attention to this area. Then certain intestinal disorders, such as appendicitis, typhoid fever, dysentery, rectal diseases, owe their origin to predisposing lesions here; also, bladder ailments, and sexual diseases of men, and many affections of the legs, as sciatica, varicose veins, etc.

In a number of instances the prominent hip will be due to a displaced innominatum. Then a lumbar curvature will result as a compensatory condition. This reverses the compensatory act as heretofore referred to; the prominent hip, in this instance, is the cause and not the effect. To diagnose which is cause and which is effect will frequently require considerable technical knowledge and experience. The slipped innominatum then produces symptoms and disorders directly from its changed anatomical relations; the points of diagnosis are given in the chapter on Diagnosis. The prominent hip can easily be detected when the subject sits down upon an even, firm surface, or stands up, and the one side is compared with the other. In some cases where the prominent hip is due to a lumbar curvature, and the prominence is a secondary feature, the legs will be found uneven in length, but not always, for the lumbar curvature may straighten out when the patient lies flat upon the back. To diagnose the cause from effect and to differentiate the maze of signs and symptoms that may be present is not always easy even for the skilled practitioner.

The correction of a prominent hip is not ordinarily a difficult matter. In the cases where lumbar vertebræ are principally at fault, and these include the greater number, the problem is one of correcting the spinal curvature. Lumbar curvatures are the easiest of any of the curvatures to correct, for one is not hampered by the rib articulations, and the lumbar section presents an area where a leverage can readily be obtained. Where the innominatum is primarily at fault it is simply a matter of readjusting this, with probably some attention to the lumbar region. Care should be taken that the prominent hip is not caused by a tubercular sacro-iliac disease, by hip-joint disease, by a dislocated hip, or by an overlapping of thigh or leg bones from fracture.

Standing erect will, of course, be a valuable help, for standing with the weight on one foot will tend to make the hip on that side more prominent. But generally the reason why one favors a certain side is because the other side is weaker; a weak back, a slipped innominatum, or an injured leg are common causes. There are many cases where the skirts will have to be considerably altered after the hips have been made symmetrical.

The pendulous abdomen is another defect that is all too common. A great many people have prominent abdomens because they do not stand properly, but a pendulous or prominent abdomen is not necessarily synonymous with a stout abdomen. They attempt to stand erect by drawing the shoulders back and extending the abdomen. If they would hold the head erect and the chin in, with the shoulders back and the chest forward, and draw the abdomen inward and upward, their figures and physiques would undergo shortly a wonderful transformation. These directions also apply to pregnant women. Drawing the abdomen upward and inward will at first require considerable effort. It certainly will not be an involuntary act for the first few days.

The sagging of the abdomen not only causes an unsightly appearance but results in great relaxation of the abdominal muscles, interferes with digestive functions, displaces the pelvic organs, and weakens the action of the lungs and heart.

The laxity of the abdominal muscles allows the abdominal organs—the intestines, stomach, kidneys, etc.—to displace downward. This tends to indigestion, constipation, inactivity of the liver, etc., and causes a score of reflex symptoms. The organs become simply weakened from a lack of proper tone. This is a frequent cause of nervous prostration. Also it is one of the common causes of prolapsed and displaced pelvic organs, because the abdominal organs sag down upon them and the pelvic organs thus receive the brunt of the gravitative effect. Internal local treatment of the pelvic organs can only be a makeshift in these cases. The lungs and heart are weakened because the abdominal organs are dragging on the chest, the lungs can not aerate the blood freely owing to the abdominal weight and to the blood being obstructed in passing from the abdominal organs through the liver to the heart and lungs. The heart is handicapped in its work through lessened chest capacity and obstructed circulation. Just “suck” up the abdominal organs and see how much easier it is to expand the chest and to breathe.

There are other causes for a pendulous abdomen, such as a weakened spinal nerve supply to the abdominal muscles and organs. The weakened nerve supply may cause a loss of tone to the abdominal organs themselves, so that certain organs, as the stomach and intestines, become dilated and prolapsed; to the ligaments, and to the tissues and organs as a whole so that they become gravitated.

Through childbirth muscular fibres of the abdominal walls often rupture, leaving scars and a relaxed condition. Actual ruptures, hernia, of the abdominal muscles occur and cause a pendulous abdomen. Then there are cases of obesity where the pendulous abdomen is a symptom.

Much can be done with all of these conditions through osteopathic work; the patient must also help himself. The center of gravity of the body must be changed, and kept changed; correct posture and a constant effort will accomplish considerable. The “setting up” military exercises are excellent. Even in some cases of obesity the abdominal prominence can be markedly lessened by careful exercising and keeping the abdomen drawn in so that the abdominal muscles, the diaphragm, and the chest may be strengthened. For the relaxed, flabby abdomen, self manipulation of the weak muscles when lying on the back will materially aid.

Undoubtedly, the great percentage of postural defects, or slumped states, are dependent, directly or indirectly, upon weaknesses in the spinal column. As was seen, round shoulders, the prominent hip, or the pendulous abdomen, are often initiated by spinal deviations and deformities, so naturally spinal column curvatures are a most fruitful source of direct defects of posture.

It is somewhat uncommon to find an anatomically true spinal column, although this does not preclude that one’s posture is defective, for often through pride and effort one may consciously overcome a defective posture.

It is the purpose here to offer a few suggestions relative to the development of a greater symmetry of the body. Nearly every one is more or less interested in physical exercises and development. And especially to those of sedentary habits do means and methods of exercise appeal. Curiously enough, in a way, nearly every layman looks upon defects in posture, symmetry and stature as an effect arising from lack of, or improper, exercise. He seems to be imbued with the idea that the body in most instances is practically permanent in construction and when irregularities in figure occur certain exercises will correct the defect. Thus have individuals been prone to look upon osteopathy as a method of passive exercises. Osteopaths should believe most thoroughly in exercising, personal hygiene, etc., but the idea of osteopathic manipulation is primarily one of anatomical reconstruction, and not muscular development alone. The work of the osteopath is to readjust or to re-mold the body framework and the many tissues that clothe it so that normality of function may predominate. The manipulation is not routinism but mechanical rebuilding of the tissues so that perfect freedom of vital forces may be forthcoming.

The spinal column presents the most frequent as well as many extremely interesting phases for re-correcting work. The number of abnormalities as to contour to which it is subject are many and varied. Emphasis should be placed upon possible congenital abnormalities and developmental defects as sources of certain derangements. Any variation or combination of variations with the normal or physiological curves constitutes an abnormality or pathological curve. And as a consequence defective posture, unless thoroughly compensated, is readily initiated. Not only may the normal curves be exaggerated, lessened, eliminated or reversed, but lateral and rotary curvatures are of frequent occurrence.

Curvatures involving the cervical region to the extent of producing noticeable defects of posture are principally lateral deviations of several vertebræ. Wry-neck is probably the most noticeable disturbance. The head and neck being drawn and slightly twisted to one side is a defect that is both noticeable and painful. Another common source of postural affection is an exaggerated forward curving of the neck vertebræ. This produces a stooped appearance of the neck.

The dorsal vertebræ are often curved backward too far. This produces roundness with too decided a fullness of the upper back and shoulders. The chest may be somewhat flattened as a secondary effect but not necessarily so. Neither are the shoulders what may be termed “round shoulders,” still such a condition may occur, for “round shoulders” are more often caused by a backward swerve of the column at the waist line. There is often a shortening of the anterior structures which pull the point of the shoulders forward. Forcing them backward will aid in correcting the fault. The dorsal vertebræ may be forward from what is termed a “straight” spine; this results in an exaggerated “braced” back position. Then lateral curvatures of the dorsal spine are common, which in time may develop into a rotary curvature; that is, the vertebræ are actually rotated on their axes. Lateral curvatures of the dorsal spine are slow and difficult to correct, for the ribs complicate matters very materially. Then, also, the vertebræ are apt to be deformed.

Curvatures of the lumbar spine, whether posterior, lateral or anterior, are common. Both dorsal and lumbar curvatures, as any one can readily see, are extremely common sources of postural defects. Erect positions of the body are maintained through the support of the dorsal and lumbar vertebræ. Stooped shoulders, one shoulder lower than its fellow, sitting humped over, sitting on the sacrum instead of squarely on the buttocks, the prominent hip, standing first on one foot and then on the other in order to rest the back, and the many allied variations of incorrect postures are largely dependent on the condition of the lumbar and dorsal spines.

It is not to be supposed that the above defects are the only ailments and disturbances that spinal curvatures cause, for, indeed, the defective posture may be by far a minor consideration. Disorders of body functions and affection of organic life itself are very often traced to the malaligned vertebræ.

The causes of spinal curvatures are many, but without question one of the most common causes is mechanical wrenching or twisting of the column from falls, jars, etc. Often the strain or sprain of the sections are readjusted through the inherent powers of the body, but there is a point where vis medicatrix naturae requires extraneous help to correct the perversion; and, naturally, such aid, by virtue of the cause of the disturbance, should be physical force mechanically applied. Other causes of spinal curvatures are contractions of muscles on one side of the column or paralysis of the muscles on one side; in either instance, muscular action is greater on one side than the other, which easily results in a curvature. This imbalance of muscular tension, whether due to the above or other sources such as overfatigue or various deleterious habits, is a prolific source of lesions. And among still other causes may be noted, bone diseases of the spinal column, compensatory deformities, and constitutional weakening and irritating diseases. Also, some occupations predispose to certain curvatures.

One can readily see that the treatment which is directed specifically to the cause of the vertebral deviation would be the most scientific. This is just what osteopathic work implies, direct readjustment of the sections at fault—not exercises, or routine stretching, or braces; although these latter methods may in some cases have their place as secondary aids. Of course exercises are usually physiological and may be employed, in many instances, as an auxiliary. Care should be taken to eradicate infectious foci when present.

Where curvatures are extreme, complicating and deforming the ribs, and absorbing the bodies of the vertebræ so they become wedge-shaped, and resulting from abscesses, no one can expect within reason to absolutely correct the posture. Some aggressive work can be accomplished, but a perfect symmetry will not be forthcoming. It may be well to emphasize again that where the ribs are involved the osteopath is not contending with the deformity of the spinal column alone, but in addition the entire transverse area of the body. (See also Spinal Curvatures).

Conclusion.—In concluding this rapid survey of a number of postural defects the principal lesson to be drawn is not one of developing the physique and thus perfecting a better posture, so much as curtailing and eliminating insidious beginnings of disease. These little ailments and deformities, of which postural defects may be the most noticeable, are so often the inception of more serious disorders. The anatomical structure being maladjusted, -aligned, or -positioned, easily and readily leads to consequences that require much time and patience to overcome.

Poise of body represents much to every one. Poise or correct posture coupled with careful and methodical exercise and correct breathing are material aids in constructive development, as well as in eliminating disease, for not alone may abdominal, pelvic and thoracic integrity be benefited, but the upper respiratory tract may be toned.

The most important goal that osteopathic science and art is striving for is that of a fully developed and rounded out prophylaxis or preventive treatment. When the public realizes that the proverbial ounce of prevention is an established medical reality then it can truly be said our science has reached its ultimate good. To those who are familiar with osteopathic theory, facts, and development, it is an open secret that this school holds the key to successful preventive treatment. The time is rapidly approaching when the actual lessening of diseases will be an established fact. Then will be the universal practice of the layman going periodically to his osteopath to see if there are any small or insidious beginnings of disorder or disease.

Not only must the many deleterious habits and errors of the daily regimen be corrected, but after environmental, physiological and structural adjustment, in so far as possible, has been attained, a daily regimen to maintain the normal should be instituted.

---

Prolapse of various organs or tissues are among the very common ailments that afflict all classes. Prolapse of the stomach, a kidney, the uterus, or the rectum is a familiar term to every one. But this condition may also rest with the intestines, the liver, an ovary, or even the heart.

Outside of injuries, congenital weaknesses, and so-termed surgical disorders, there are commonly two constant forces predisposing to prolapsed organs, viz: gravitation and weakened innervation; the one, of course, is a constant factor in either health or ill health, the other is dependent upon acquirement. Here the latter, or acquired nervous weakness, will especially demand our attention.

Where tissues are torn or lacerated, or congenital malformations are present, or tissues are weakened from ulceration and with a resultant scar tissue, or certain tumors are present, the disorder must be amenable largely to surgical measures if at all.

The perpendicular position of the body favors a decided gravitation of the abdominal and pelvic organs. This gravitative effect being a constant one, many methods, both surgical and mechanical, have been devised to hold in approximate and relative position certain organs and tissues that may be prolapsed. But it is well known that outside of a certain few instances where surgical measures are clearly indicated the prevalent use of braces, bandages, supports and the like are usually poor makeshifts.

The one great feature in these cases is that tonicity to organs and supporting muscles and tissues is more or less impaired. The tissue atony may vary from mere weakness to actual tearing and separating of the fibres. The indications in the cases about to be described are to stimulate a lowered nerve supply and to increase a lessened blood supply; if this can be accomplished, supporting muscles, ligaments and other tissues will be able to restore the prolapsed organs to normal positions, thus improving functions and eliminating disease symptoms.

In discussing the prolapse of the following organs, perhaps it should be noted here that all of the abdominal organs may be prolapsed as a whole. The intestines, stomach, liver, kidneys, etc., may actually prolapse together. This is more apt to occur in persons whose abdominal walls are thin and flabby. In women pregnancy is a common cause. When the abdominal organs have gravitated, the pelvic organs, also, are very likely to be disturbed and displaced; in fact, the pelvic organs are frequently disordered this way.

Dilatation of the stomach is a much more common and serious affection than prolapse of the stomach, although usually the two are associated. Prolapse, or ptosis, of the stomach means simply a downward displacement of the organ. This is apt to take place in those cases where all of the abdominal organs have gravitated. There is invariably some dilatation of the organ as well.

Weakness of the abdominal walls and of the supports of the stomach constitute the principal causes of the prolapse. Spinal deviations that impinge or obstruct the nerve strands (or obstruct the blood and lymph supply to these strands) to the supporting stomach tissues is the most frequent cause of the ailment. General debilitating diseases, as anemia, cancer, etc., are indirect causes of weakened organs with consequent displacements.

In dilatation of the stomach the condition may be either acute or chronic. The former is found where immense amounts of food or drink have been introduced.

One of the principal causes of chronic dilatation is some obstruction to the opening from the stomach into the intestine, so that the stomach contents do not pass readily into the bowel. This leads to chronic disturbances of the stomach walls, and the food remaining in the stomach somewhat indefinitely weights down and stretches the walls of the stomach. The obstruction may be a tumor, or some stricture or adhesion from scar tissue resulting from ulceration or inflammation. The treatment of these cases comes within the province of surgical interference rather than other methods.

The second important cause of chronic dilatation is muscular weakness of the walls from poor nerve supply. This is a common cause and osteopathy is very successful in curing these cases. The splanchnic nerves are below normal, usually from a slight lateral or posterior spinal curvature. The nerve force to the walls of the stomach not being normal causes atony of the muscles and dilatation results. This nervo-muscular atony, also, results from a chronic catarrh, or from a general nutritional disorder as tuberculosis or anemia. The treatment of the former would imply direct correction of nerve and blood supply with attention to diet; the latter can be cured only through relieving the nutritional disorder of which the stomach condition is a symptom.

Dilatation of the stomach is most common in people of middle age or older. The disease is usually easily diagnosed. The symptoms may not be indicative of the trouble beyond showing that the stomach is disturbed. Indigestion, uneasiness, and nausea are common. Vomiting of large quantities of material from the stomach is likely to occur. The patient is generally emaciated, the skin is dry, the bowels constipated, and the urine scanty.

The diagnosis, as a rule, is not hard to make. Through the media of inspection, palpation and percussion, the careful osteopath will have little trouble to determine the size of the stomach. Kemp’s[45] distinction between gastroptosia and dilatation of the stomach is as follows: “In dilatation the lesser curvature retains its relation to the diaphragm. The distance between the lesser and the greater curvature is increased, but the lesser curvature still maintains its relation to the diaphragm, with the exception that the pyloric end may extend farther over and somewhat farther down.” Another instructive point relative to diagnosis the above authors make is the importance of the splashing sound. Owing to the fact that the stomach in health closes concentrically about its contents and thus adapts itself to the volume of ingesta, no splashing sound can be elicited. Three different degrees of relaxation are diagnosticated as follows: “Splashing sound, which can be elicited only during the normal period of digestion, means simple atony; splashing sound produced after the legitimate time of digestion has expired means motor insufficiency; and splashing sound produced in the morning, after the night’s fasting, before liquid or food has been introduced, may mean stagnation, dilatation of the stomach, as understood by most writers.” (For a more complete outline see Dilatation of the Stomach. The object of this section is to present an outline of prolapsed organs as a whole, and to refer especially to the effectiveness of osteopathic treatment in this condition).

This is a disease where osteopathy has been particularly successful in not only relieving distressing symptoms, but in actually curing the disorder. This refers to the nervo-muscular atony type, for where there is obstruction due to stricture or tumor of the pylorus, resulting in stomach dilatation, the treatment, from the very nature of things, must be largely surgical. Stomachs that have been dilated and prolapsed several inches have been entirely restored to function and organic integrity. To cure these cases is a matter of stimulating nerve control and blood supply to the stomach tissues, and, often of greater importance, removing spinal impingements to the stomach nerve fibers, thus allowing nature to fully assert herself. In reality, outside of so-termed surgical cases and other cases where the stomach dilatation is merely a symptom of general nutritional disorder, the primary treatment, by far, is the spinal one. Treatment over the stomach is a decidedly beneficial treatment; it aids materially in toning both abdominal and stomach muscles; still this is mostly a secondary treatment.

Dieting is essential. Careful dieting lessens the tendency to catarrhal inflammation and reduces the work of the stomach to a minimum. Still, nourishing food is necessary and the dieting can easily be carried to an extreme. Liquids should not be taken freely. Fatty and starchy foods should be eliminated. Give the patient food at short intervals. Various nutritious meats are excellent.

In dilatation, and also general abdominal relaxation, daily abdominal treatments may be indicated. If the relaxation is pronounced, keeping the patient in bed with thorough spinal treatment two or three times a week, daily abdominal treatment, having the patient exercise abdominal parietes by drawing the walls in and up, upper thoracic breathing, and frequent feeding will accomplish comparatively quick results. The progress of each case depends very materially upon the general health, the physical status of other tissues, constitution, inheritance, environment, age, etc. Some cases will yield in two or three months, others will require two or three years in order to obtain the greatest possible benefit.

A prolapsed kidney is often termed a floating kidney, or movable kidney, or dislocated kidney. It is of common occurrence, especially in thin persons. Some authorities state that one woman out of every four has a floating kidney. It is more common in women than in men, and among the working class than other classes.

The condition is usually an acquired one, following severe strains from lifting, falls, injuries, etc. It is claimed by some that a floating kidney arises from congenitally weakened and relaxed tissues about the kidney, that is, the tissues that keep the kidney normally at anchorage. Thus a congenital looseness of the kidney would easily be a predisposing cause whence mechanical violence, repeated pregnancies, an enlarged liver, or tight lacing would act as an exciting cause. Undoubtedly in some instances there is a congenital predisposition, the peritoneal fold attaching the kidney to the spine being loose and the capsule of fat retaining the kidney being scanty, but osteopathic experience has amply demonstrated that the tissues anchoring the kidney may in many case become atonied and relaxed from lower dorsal spinal lesions. Rarely is a case presented to an osteopath that does not exhibit two apparently characteristic causative features, viz: spinal irregularity in the lower dorsal spine, and constriction of the zone about the waist, i. e., dropping and constricting of the floating ribs. Furthermore, correction of these lesions will almost invariably lessen the mobility of the palpable kidney.

The symptoms of a floating kidney are many and variable. The kidney may be slightly movable or it may be so loose that one can easily grasp it through the walls of the abdomen. Most of the symptoms are of a nervous reflex nature. Indigestion, which is likely to be very persistent, flatulency, heart palpitation, painful menstruation, irritable bladder, etc., are the most common symptoms. Still, blueness, depression and morbidness are frequently present. The most distressing direct disturbance is the feeling of weight in the abdomen, especially on standing, running or lifting. Sometimes the ureter becomes twisted and severe pain, colic and even collapse occurs. (Dietl’s crisis.)

The diagnosis of a dislocated kidney is not a particularly difficult matter. A little experience coupled with a delicate sense of touch will usually readily detect abnormal mobility of the kidney. A point to always remember is that the kidney normally descends about one-half an inch with each inspiration. Care should be taken not to mistake a floating kidney for a movable spleen, although this is not likely, as the shape of the spleen is different.

The treatment of a movable kidney under osteopathic measures is usually successful. In the first place a number of cases require but little attention, simply toning up the general health, and especially directing attention to the abdominal walls and organs. There are a number of cases where the kidney prolapse is incidental to general abdominal laxness and weakness. In more severe cases, treating the spine, raising the floating ribs, carefully manipulating over the abdomen, keeping the bowels open, and lessening liver congestion should it arise, will suffice; in fact, will remedy a good percentage of the cases. With others, a well fitting, medium width, elastic bandage with pad underneath will be beneficial. In these cases the patient should be taught how to treat the abdominal organs, to manipulate the abdominal walls, and to replace the prolapsed kidney; particularly after going to bed this can be done successfully by the patient and will prove a decided help in obstinate cases.

Surgical measures for fixing the kidney should seldom be resorted to. If the patient will live a careful life, avoid unduly straining himself, keep the bowels normal, and have the anatomical lesions corrected, he will come very near being entirely relieved, if not absolutely. Surgical measures are not always a success. Surgeons are not operating for this disorder so often as in past years. (See Movable Kidney—Diseases of the Kidney.)

This is commonly termed a floating liver. There is prolapse of the organ as well as its being abnormally movable. It is not of frequent occurrence; women suffer from it much oftener than men.

Normally, the liver is partially held in place, in the concavity of the diaphragm, by a number of peritoneal folds. The attachment of these ligaments is to the spine and the diaphragm; their principal function is to prevent extended lateral movements. Of greater importance in supporting the liver in a normal position is the integrity of the abdominal walls, and the position of the stomach and intestines. If the abdominal walls are of normal tone the liver is very apt to be in correct position. And the rest of the abdominal organs, especially intestines and stomach, act as a cushion support. Often when the liver is displaced the remaining abdominal organs are, also, out of normal position and relation to each other; in fact, general prolapse of the abdominal viscera is a frequent cause of liver prolapse. An additional support of the liver is a certain cohesion of the liver and diaphragm, and the elastic traction of the lungs.

Foremost among the causes that predispose to inelastic and atonied abdominal walls are spinal irregularities, deviations, and curvatures, which impinge nerve force and obstruct blood supply. These same lesions weaken ligamentous supports of the liver and lessen tonicity of the other abdominal organs, so that local or general displacements are readily forthcoming. Strains, injuries, frequent pregnancies, etc., also act as causes that weaken the supports of abdominal tissues and organs. In a word it is very often the pendulous abdomen that is the immediate cause of a floating liver.

It is very rare to find the liver displaced to the lower region of the abdomen. The ptosis is usually somewhat slight. The organ generally rotates on descent, the right lobe being the lowest portion, owing to the attachment of a ligament, the ligamentum teres, to the umbilicus. Probably in some cases there is a congenital tendency to relaxation of the ligaments, and, thus violent exertions and atonic and flabby abdominal walls and diaphragm are secondary but important factors.

The principal symptom of a floating liver is a tumor in the right side, which may be low down. Palpation will usually determine this. Then the abdominal walls are flabby. Pain and bearing down of the right side are common. There is apt to be considerable indigestion. Various reflex symptoms are often present. The floating liver will seem larger than normal, as the liver is below the costal arch and much of it can be felt. Percussion will be of value in determining the extent of the disorder.

Much can be accomplished by treatment, especially where the displacement is of a lesser degree. Correcting the spinal lesions, toning up the abdominal walls and diaphragm, and replacing the displaced organs will be extremely effectual. The abdominal bandage may be of service. Certainly abdominal exercises will be beneficial.

A point to remember is, stimulation over the abdomen beneath the right costal arch will cause the liver to contract and retract. This is of considerable osteopathic note. The liver will often recede at least a half an inch. This is a liver reflex (Abrams).

Prolapse of the bowels, as a whole, or, more frequent still, of a part, is undoubtedly the most common form of organ prolapse. The intestines are so situated that they readily feel the effect of gravitative influences, of atonic and anemic states, and of weaknesses and disorders of other abdominal organs.

Spinal irregularities come first as potent causes of bowel prolapse. The spinal nerves to the supports of the intestines, to the muscular coats of the intestines, and to the abdominal walls, are obstructed in their normal activity, and consequently those tissues to which these nerves are distributed are affected. Wasting diseases, as anemia, consumption, cancer and the like predispose to intestinal atony.

The severe mechanical wrenches, strains, frequent pregnancies, tight lacing, heavy skirts, large abdominal tumors, obesity, cause more or less general or local weakness.

The pendulous abdomen, from wrong or careless posture, and exclusive of other causes, is a common source of general bowel displacement. This form of disorder, besides being unsightly, favors abdominal stoutness. There are a number of instances where simply voluntarily holding or “sucking” the abdomen into place, until it becomes strong enough to support itself, has reduced one’s weight by five, ten or fifteen pounds. These were cases where most of the adipose tissue was about the abdomen. Thus exercising and toning the abdominal organs by keeping them in normal position rectified a dormant blood and lymph circulation, which was followed by absorption of the abdominal stoutness.

Congenital weaknesses are to be considered in many cases. The muscular ligaments may not be developed, the mesenteric attachments may be too long, and various other abnormalities may result from congenital disturbances.

Of particular local interest to the osteopath, outside of the bowels dislocating as a whole, are: first, the hepatic flexure; second, the ileo-cecal region; third, the sigmoid flexure; fourth, the rectum; and fifth, hernias. Each of these sections are of separate interest and will be considered presently.

The symptoms are extremely variable. Constipation, a feeling of discomfort in the bowels, nervousness, depression, lassitude and anemia are frequent. Colicky pains in the intestines, indigestion, hysteria at times, are also among the symptoms. In reality a great variety of symptoms may be present. The patient is likely to be emaciated. In some cases exhaustion is marked.

Diagnosis, as a rule, is not a difficult matter. The various neurasthenic symptoms in a lean patient with constipation, indigestion, and stomach and intestinal distress would lead one to suspect intestinal displacement. The outline or contour of the abdomen will often reveal the character of the trouble. The atonic, thin and relaxed walls of the abdomen may readily give view of the displaced organs. Then careful examination by palpation and percussion will help very materially in the diagnosis. Radiographic examination is a decidedly helpful diagnostic method.

The hepatic flexure is frequently prolapsed. The bowel (colon) ascends from below upward to beneath the costal arch and then angles sharply into the transverse colon, which extends directly across the abdomen to the left side. The ligaments that support this flexure are apt to become weakened or stretched and allow a descent of this section of the bowel, which is followed by constipation, indigestion, etc. The ligament especially involved is the colo-hepatic ligament. The duodenum may require attention. This can be raised by getting beneath it where the organ descends alongside of the ascending colon. The effect of treatment is to release tension of the duodeno-hepatic ligament which is closely associated with the portal vein, hepatic artery and bile-duct.

The ileo-cecal region is an area that readily becomes congested and catarrhally inflamed, especially from constipation or impaction at this point. The section often becomes atonic and prolapsed with resultant clogging of fecal matter. Owing to the close proximity of the vermiform appendix, appendicitis frequently results from the above condition. The osteopath can do much in these cases of appendicitis. Lesions are invariably found in the lumbar vertebræ or the floating ribs are depressed.

The sigmoid flexure is also frequently prolapsed. The fecal mass often becomes impacted here, owing to a settling or prolapse of this part. In some cases the prolapse is so marked that it extends to the rectum below and drags on the splenic flexure above.

Lumbar and innominate lesions are the usual causes, although, it seems in a number of instances, that relaxed walls of the abdomen cause a “contraction of the diaphragm resulting in kidney displacement and followed by intestinal prolapse.” The vertebral lesions, probably, first weaken the muscular coat of the bowel, then, second, the bowel supports (other than its own inherent tonicity) and the abdominal walls.

Prolapse of the rectum is of such separate importance that it will be but partly outlined here. As stated above, a source of rectal displacement arises from the section of the bowel above settling downward and ultimately causing invagination of one or more coats of the rectum. Dislocation of the coccyx is a potent cause of rectal disorders. Lumbar lesions, especially twists between the fourth and fifth, and fifth and sacrum are common causes of rectal weaknesses. Slips of the innominata are other causes of prolapse.

Osteopathy has had marked success in these cases. Cures may result from a single treatment to readjust the coccygeal displacement or temporarily relieve excessive physiological activity by dilating the rectal sphincter, or the treatment may demand a number of months’ work in correcting general abdominal prolapse. Raising the sigmoid is effectual.

A hernia is “the protrusion of a loop or knuckle of an organ or tissue through an abdominal opening.” Two of the common hernias of the intestines are inguinal and femoral. These conditions are most often acquired from severe straining, so that a loop of the bowel protrudes through a weakened and stretched area of the abdominal walls, though there is reason to suspect that congenital defects are often predisposing factors.

Mention of the hernia is here made because, in a way, it is a form of bowel prolapse; that is, a limited form, and osteopathy contains certain possibilities for a successful treatment. Hernia has always been looked upon as purely a surgical disorder; i. e., remediable by surgical measures only. Where a truss has failed to give relief surgery has been resorted to. This is true in most instances, but where the hernia is in the incipiency careful abdominal exercises (this should be carried out with great care, for severe exercise may produce a hernia or increase one already existing), massage to the tissues about the hernia, attention to the bowels, and spinal stimulation corresponding to the weakened tissue, and avoidance of strains may strengthen the tissues materially about the hernia.

Occasionally a loop of the intestine will prolapse into the cul-de-sac back of the uterus. A heavy dragging pain low down in the center of the abdomen and constipation or complete obstruction are the pronounced symptoms. Careful lifting of the loop of bowel by pressure within the vagina and traction from above with a hand outside, with the patient, on her back, with buttocks elevated, gives speedy relief.

The treatment of the prolapsed bowels represents those measures that will replace and keep in position the displaced organs. Naturally, the spinal and abdominal treatment comes first; this strengthens intestinal ligaments, tones intestinal muscles, and contracts the abdominal parietes, and at the same time the bowels are regulated, digestion and nutrition improved, and the general health built up. In some cases abdominal supporters will be of value. In a number of instances attention to chest mobility and diaphragm tonicity will be of value. Right living, which is represented by proper diet, sufficient outdoor exercise and regular habits, is invaluable.

The really specific treatment is to correct spinal, rib and innominate deviations and abnormalities. But direct local work will be, in many instances, necessary. General abdominal manipulation is good, but this should be supplemented by careful local treatment. The hepatic flexure requires a direct stimulating and replacing treatment. The ileo-cecal section should be raised, stimulated and emptied of the fecal mass. Direct upward manipulation of the sigmoid flexure in the left iliac fossa and of the splenic flexure beneath the left costal arch is extremely efficacious. Care must be taken not to bruise the parts. Getting beneath the prolapsed area and gently and intelligently raising the bowel so that it is emptied, toned up, and vascular congestion relieved, are the indications. This requires careful work and the necessity of gentleness can not be emphasized too much. Still in all of this treatment we should never forget the absolutely essential spinal readjustment.

Rectal prolapse requires lacol internal treatment, external tissue correction, especially of the coccyx, an innominatum or the lumbar spine, and, of much importance, deep, careful and thorough work over the sigmoid section.

Cases of bowel prolapse are every day experiences with the osteopath. The osteopathic treatment is of great value in these and a successful issue is very often the result. Cases of pendulous abdomen, of obstinate constipation, of chronic indigestion, of many nutritional disorders, of feeling pain, weight or dragging, locally or generally, in the abdomen, are very apt to be in persons suffering from prolapsed intestines.

A number of cases of bowel prolapse are associated with general prolapse of abdominal organs; that is, displacement of the stomach, kidneys, liver, spleen, etc. This general condition is termed enteroptosis or Glenard’s disease. It usually requires several months to treat it successfully. These patients are neurasthenic, malnourished, and often hysteriacs. The symptoms from which they suffer are innumerable. Mechanical weaknesses, lowered vitality, poor innervation and blood supply, and auto-intoxication are causative factors.

Prolapse of the uterus is of common occurrence. The prolapse may be incomplete or complete; the latter when the organ is presented to the external world. Of special interest are those affections exclusive of surgical cases. Ptosis of the abdominal organs upon the pelvic organs is a common cause of uterine prolapse. The abdominal prolapse crowds uterine space, congests the uterus, weakens the ligaments, and drives the uterus downward as a wedge.

Lumbar spinal curvatures are frequent causes of prolapse, as well as other displacements of the uterus. In this region vasomotor nerves to the pelvic organs make their exit, and, consequently congestions, inflammations, and weaknesses of supports are results. Also, slips of the innominata disturb the pelvic circulatory balance. Weakness of the uterine support from below, the vaginal walls and perineum, most often arises from lacerations at childbirth. Still, the vaginal walls may become relaxed through other causes. Tumors and extreme congestions are causes of prolapse. Heavy lifting is quite a frequent source of uterine displacements. Osteopathy is very successful in uterine prolapses; that is, any displacement of the uterus not of a surgical character. Correction of the external causes comes first. Then local treatment to replace, tone, and relieve congestion, and break up adhesions is necessary. The external treatment is usually the primary treatment. Local work is not always necessary. Lacerations and other surgical indications, of course, require surgery.

The ovaries may be prolapsed, the left much oftener than the right. When prolapsed, it drops backward, downward and inward.

Ovarian congestion, tumor, retroverted or retroflexed uterus, tubal disease, and pregnancy are among the principal causes. Back of these congestions, tumors and uterine displacements, are the osteopathic causes, particularly spinal and rib lesions from the ninth dorsal downward. Specific lesions at the ninth and tenth dorsals and corresponding ribs, affecting directly ovarian tissues, and lumbar and innominate lesions and abdominal prolapse disturbing uterine and tubal tissues, are the most frequent osteopathic causes. A retroverted or retroflexed uterus is often found. Uterine displacements bear down upon the ovary and cause its descent, and also disturb ovarian circulation.

As has been stated, the left ovary is more apt to be displaced than the right. This is owing to the absence of a valve in the ovarian vein on the left side, and also, this vein opens at a right angle into the renal vein; this anatomical feature easily leads to passive congestion of the ovary, and thus to diseases of the organ. Then the rectum is on the left side and large fecal masses are apt to crowd against the ovary, which tends to its displacement.

Thus it is readily seen that osteopathic treatment is very applicable to ovarian displacement unless the indications are surgical. A more or less constant burning or sharp pain in the ovarian region, with probably some feeling of weight, profuse and painful menstruation, depression, irritability, etc., are diagnostic. However, a local examination will reveal the status of the ovarian position and congestion.

The same treatment as in other organ prolapse is indicated: toning weakened tissues, relieving congestions, replacing organ, with careful attention to the bowels and the general health. There are no tissue disorders of any part of the body wherein osteopathy is more thoroughly indicated and the results more generally satisfactory than in prolapse. And especially should it be remembered that in prolapse of various organs many vague intestinal and pelvic disorders and even ureteral and bladder disturbances may be traced to bowel dislocations and excessive kidney mobility in which osteopathic measures are often successful.

Conclusion.—The purpose of this section on Prolapsed Organs has been to supplement the various articles on Dilatation of the Stomach, Movable Kidney, etc., with an outline that may include relaxation of a part or of the whole of the abdominal viscera. The physician is all too prone to simply note the most offending or conspicuously disturbed organ instead of carefully analyzing all the features, great and trivial, that may be either apparent or marked. A general relaxation of the abdominal and pelvic organs may be found, and a nearly complete restoration take place under treatment, but still a lacerated perineum may have to be repaired before a cure is completed. Or it may be in a general abdominal ptosis that a floating kidney will resist all measures for restoration, short of surgery, and before much improvement can be obtained the kidney will have to be stitched into place. An enlarged liver may crowd the kidney out of place or a transverse colon may prolapse and drag on contiguous tissues and still the annoying symptoms be referred elsewhere. Then the primal point of general relaxation may not be in one organ, but there may be a simultaneous displacement of several.

The thorax itself may be distorted from various diseases so that the chest is narrowed, the diaphragm displaced with consequent descension of the abdominal organs, and from the latter a displacement of the pelvic.

“Far down displacement, marked changes of form, and real disfigurements of the stomach are found in some cases of kyphosis and scolio-kyphosis.”[46] The osteopath will not only find this true in some cases, but in many cases, although he recognizes as causative factors injuries to the spine causing curvatures and postural defects as prolific sources of abdominal relaxation.

“Glenard’s whole theory of splanchnoptosia is based on the relaxation of the suspensory ligaments of the intestines, especially that of the transverse colon; and Stiller, the discoverer of the floating tenth rib, says that splanchnoptosia is a descent of the atonic stomach, of the colon (especially the transverse portion), of the kidney (the right or both kidneys), exceptionally of the liver or the spleen. A descent which has been developed mostly in tender age, in consequence of general relaxation, especially of the peritoneal suspensory ligaments in individuals with congenital general dyspeptic neurasthenia, tender muscles, lean habit, and slender bone structure, manifested in a higher degree by a floating tenth rib.” Stiller observed that when there is a floating tenth rib there is a displaced stomach and a floating kidney, although it is not found in every case, but never missing if the case is pronounced. The tenth ribs in these cases have only a ligamentous fastening and are as freely movable as the eleventh and twelfth.

That abdominal relaxation plays a very important part in many diseases of the abdominal and pelvic organs, in cardiac and pulmonary affections, disturbs the circulation in the legs, and is the source of many reflex affections no one can gainsay. The osteopath should always pay particular attention to tonic condition of the abdominal viscera, for relaxation of the suspensory tissues and walls, and atony and sluggishness of the organs are frequently paramount etiological factors. And the osteopathic treatment is the remedy par excellence.

---

Various skin diseases have been treated osteopathically with varying success. So much depends upon the cause of the disturbance and its removal, in skin diseases, that the cure does not rest so much with the mere treatment, as with the necessary skill in locating the disturbing factor. One has to be continually on his guard to locate external irritations and disorders of the digestive and genito-urinary tracts. A great deal depends upon the avoidance of external influences; eating nutritious food and having an unobstructed circulation. The leading object of osteopathic treatment is to free the circulation and thus promote a healthy and unobstructed flow of blood; in no other class of diseases is this more essential than in skin diseases. After the removal of cutaneous irritations and the correction of internal disorders, the cure of the case depends upon the removal of constrictions to the cutaneous blood-vessels. The osteopath corrects the lesions found, relaxes the muscles thoroughly and stimulates the circulation to the parts involved, and promotes a healthy activity of all the excretory organs. When the upper part of the body is affected, lesions are generally found at the atlas and axis, and when the lower part of the body is affected, lesions at the fifth lumbar are of common occurrence, although lesions may be located at various points corresponding with the seat of disturbance. The constant use of hot baths will be found a helpful measure in many skin diseases. But use of soap must be considered as too much alkali will neutralize the oil of the skin and cause undue dryness, but bran may be substituted to advantage. Cleanliness is necessary but the result sought is, also, flushing the cutaneous vessels. There are many cases where a specific vertebral lesion will cause, through the peripheral nerves, a cutaneous irritation with intense itching and discomfort. This, in turn, produces an exudate with or without a crust and a condition results which is not amenable to any local or constitutional treatment but an adjustment of the lesion will in most cases bring immediate relief. Application of this principle will aid greatly in treatment of any skin disease. In no disturbance of health is it more necessary to find the cause than in skin disease and once found to apply specific treatment.

Eczema is frequently met in osteopathic practice. It is the most common form of skin disease, comprising nearly one-third of all these disorders. For a differential diagnosis of the several varieties the student is referred to special texts. It is well to remember that the same underlying causes may be basic to the various forms, for several varieties may occur at the same time or one variety pass into another, though commonly one form is more prevalent. The limbs, face and genitalia are the most common sites, though the eruption may occur on various parts of the body.

Etiology includes a number of factors, constitutional and local. Dietetic errors, indigestion and faulty elimination comprise the principal underlying causes, often manifested through absorption of toxins and leucomains. In fact any disorder of the abdominal viscera, organic or functional, may be a predisposing factor, likewise various disorders of the pelvis, tuberculosis, diabetes, anemia, etc. should be considered. So-called gouty and rheumatic tendencies may be the constitutional basis.

The many osteopathic lesions play a very important role in lowering not only systemic resistance but of local tissue as well. This feature can not be over-emphasized.

Then local irritants, mechanical, chemical and thermal, are not to be neglected. These are usually of secondary importance. Micro-organisms are probably a complicating factor after the lowered resistance has been established. Vasomotor neurosis, through constitutional defects, toxins and the very significant osteopathic lesion, is probably an essential part of the pathogenesis.

Treatment is usually successful if the various etiologic factors are eradicated. Early treatment is very important. If the disorder is of more than local significance change the entire daily regimen of the patient. Diet, outdoor exercise and sufficient sleep should be definitely regulated. A certain amount of general treatment to improve digestion, assimilation and elimination is imperative. An unbalanced diet and over eating must be corrected. In certain moist types, eliminating fatty foods will be helpful, while in dry forms the starches and sugars should be reduced.

If there is an underlying disease this should be remedied if possible. Particular attention should be paid to constipation.

Common sense in diet, rest, change of environment and free elimination, coupled with due attention to the osteopathic lesions, will cure the vast majority of cases. The greatest difficulty arises where there is some underlying disease. The parts should be protected against irritation such as dirt, cold, soap, and too much water. Meddlesome local treatment is to be guarded against. A simple application is boric acid, rice-flour or cornstarch, or where there is much itching add carbolic acid to the saturated solution of boric acid. Substitute bran for soap for cleansing purposes.

Herpes Simplex, fever-blister, or “cold sore” comprise two principal varieties: herpes facialis and herpes genitalis. The first occurs upon or near the lips, face, neck or ears. When the herpes is on the tongue or the mucous membrane within the mouth it is commonly termed “canker sores.”

Herpes genitalis is located on the prepuce, glans penis or farther back upon the penis. In the female the labia majora and minora and vestibule are the usual locations. Lack of cleanliness, sexual excitement and adherent prepuce are causative factors, though predisposing factors such as faulty circulation and disturbed innervation are to be considered.

In “cold sores” there is often some gastro-intestinal disturbance, especially intestinal stasis, cold in the head and other infections that supply toxins which irritate the nerves. No doubt there are underlying osteopathic lesions that lower the local nerve resistance or block the impulses such as vertebral and inferior maxillary lesions. The predisposing disturbance is probably due to the Gasserian ganglion.

Cold winds and excessive exposure to the sun’s rays will effect the tissues over the mental and infraorbital foramina, tensing the muscles and irritating the nerves at these points. On palpation they will be found sensitive. Frequent rotary motion by tip of finger over foramina will open them and allow congestion to drain.

Herpes Zoster, or shingles, is an acute inflammatory disease characterized by groups of small vesicles, usually along the course of the intercostal nerves on one side of the body. Before the vesicles appear there is more or less severe neuralgia. The eruption is unilateral, very rarely bilateral. The nearby lymphatics are usually enlarged.

Though the intercostal nerves are the ones most frequently involved, still the lumbar, thigh, trifacial and other cutaneous nerves may be affected.

The most common lesion is an inflammation of the posterior spinal ganglion which usually involves the fibers of the entire nerve. Inflammation of the nerve outside of the ganglion will cause the disorder. Toxins from various infectious sources are often exciting causes. Vertebral and rib lesions are always found; and where the Gasserian ganglion is involved lesions of the inferior maxilla and upper cervical vertebræ are predisposing factors. Thus osteopathic lesions from traumatism, cold and wet, and imbalance of muscular tension are important. Exudates, tumors, pleuritic and pulmonary affections are to be considered as possible sources.

Treatment.—Adjust vertebral lesions and carefully raise and separate ribs if intercostals are affected. Look after vertebral origin of any other nerve or nerves if otherwise. Local application of talcum or starch or boric acid will generally be sufficient.

Urticaria, hives or nettle rash is a common affection often due to some derangement of the digestive tract. This may be a mechanical irritation or of a toxic nature. Every one is familiar with the various foods that are apt to cause the hives, shell fish, strawberries, cheese, pork, oatmeal, mushrooms, etc.

The irritation may be a reflex one from the visceral disturbance; also, there may be irritation of the pelvic organs that would give rise to the trouble. It is well known that certain drugs will produce urticarial eruptions. There are cases where the irritation is simply local due to the nettle, mosquito bites and wasp stings.

In chronic cases intestinal stasis, nervous exhaustion and nephritic diseases are important.

No doubt osteopathic lesions frequently determine the location of the wheals. These lesions affect the innervation and thus establish a basis for the reflex vasomotor effect. This is in the nature of spasm of the cutaneous vessels quickly followed by dilatation with exudation of serum. The irritant probably acts on the walls of the blood vessels.

Treatment consists of thoroughly emptying the bowels by warm water enema, correcting the diet, toning the viscera and adjusting the osteopathic lesions. Thorough attention to the patient’s environment, daily habits and occupation are of value. Warm soda baths will relieve the itching.

Acne is a common skin disorder that is characterized by an inflammation of the sebaceous glands of the nature of papules, tubercles or pustules. The face, shoulders, chest and back are the regions usually involved. It generally, appears about puberty. Blackheads is the starting point; these are accompanied with greasy skin and dust, and influenced by micro-organisms and more or less intestinal disorder.

The general or systemic health no doubt affects the local disorder, as in many skin diseases; for various intestinal derangements as indigestion, constipation, etc.; pelvic and menstrual irregularities; general ill health; anemia, etc. affect circulatory, glandular and nervous integrity. Any disturbance of normal elimination is important.

The treatment consists of careful attention to the general health and to the local innervation of the face or region involved. Measures that tone the bodily organs such as outdoor life, regular habits, plenty of sleep and correct diet are important. In some cases the X-ray is of value.

---

An affection produced by exposure to excessive heat. Two varieties are recognized; heat exhaustion and thermic fever.

Heat Exhaustion.—This is caused by prolonged exposure to high temperatures, combined with physical exertion. Fatigue, overeating, alcoholic drinking, and poor sanitation predispose. This may occur without exposure to the direct rays of the sun, the heat being artificial, or in mid-summer, in close, confined rooms the same result will be produced. There is vasomotor paralysis, the surface of the body is usually cool, the temperature may be as low as 95 degrees F., while the pulse is small and rapid.

Sunstroke or Thermic Fever.—This is usually caused by prolonged work under the direct rays of the sun in a humid, very hot and sultry atmosphere. This is caused by the action of the heat upon the heart centers producing a paralysis of those centers.

Pathologically, rigor mortis develops early and is marked. Putrefactive changes appear early, owing to the high temperature of the cadaver. The various organs are deeply congested, the venous engorgement is extreme in the cerebrum. There is rigid contraction of the left ventricle; while the right is dilated and filled with blood. The blood is fluid and dark. Parenchymatous changes take place in the liver and kidneys.

In heat exhaustion with lowered temperature there is a paralysis of the vasomotor center in the medulla, and the heat is dissipated more rapidly than it is produced. In thermic fever the heat regulating centers become paralyzed by the action of the excessive temperature and more heat is produced, and less dissipated than normal.

Symptoms.—Heat Exhaustion.—This may occur gradually or suddenly with a severe attack of faintness, pallor, dizziness, headache, cold perspiration and sometimes blindness as the first symptoms. Consciousness is rarely entirely lost. In severe cases there is more permanent collapse. The pulse is rapid and feeble and there is great restlessness and delirium. Under prompt treatment mild cases may recover in a few hours, while in extreme cases death may occur almost at once from heart failure.

Thermic Fever.—In some cases the patient is struck down, becomes quickly unconscious, and may die within an hour, or death may be almost instantaneous. In other cases there is pain in the head, oppression, dizziness, nausea, vomiting and sometimes diarrhea or frequent micturition. Soon unconsciousness sets in, the face is flushed, the eyes injected, the breathing labored and there is a temperature of from 105° to 110° F. The pulse is full and rapid, the skin hot and dry and the pupils are contracted. There is usually complete relaxation of the muscles, and in some cases there is twitching and jactitation. Epileptiform convulsions are rare. In fatal cases the coma deepens, the pulse becomes feeble, rapid and irregular, the breathing hurried and shallow and death occurs in a few hours. Favorable cases are indicated by a fall in the temperature and by the return of consciousness. In these cases recovery may be complete. In some cases the patient may never be able to stand even moderate degrees of temperature, which often produce excitement, headache and pain in the cervical region. Failure of the memory, and the loss of power to concentrate the mind are sometimes sequelæ. Meningitis, epilepsy and insanity are also sequelæ.

Diagnosis.—This presents little difficulty. The history and circumstances preceding the attack are very important in making the diagnosis. The diagnosis between heat exhaustion and sunstroke fever is readily made. In heat exhaustion the temperature is lowered, the pulse is feeble, consciousness is rarely completely lost; in sunstroke fever the temperature is extremely high, there is usually complete unconsciousness, and the pulse is full and rapid.

Prognosis.—This should be guarded, depending upon the severity of the case.

Treatment.—In cases of heat exhaustion remove the patient to a shady place and apply water to the face, chest and spine. Thoroughly treat the upper cervical region, in order to control the impaired vasomotor centers and nerves. If the temperature is below normal a hot bath should be given. Keep the heart and lungs stimulated.

In sunstroke, place the patient in a recumbent position and loosen all constricted clothing, and stimulate the heart’s action. The high fever is to be met promptly. Place the patient in a bath of water, to which add ice freely. The patient may also be rubbed with ice, and ice water enemata may be employed. The muscles of the neck will be found contracted, probably due to cerebral hyperemia. A thorough relaxation of these muscles will be of great aid in equalizing the vascular system. It is a good plan to thoroughly relax all the muscles along the spinal column for the same purpose. When the temperature nears normal the baths should be stopped. After the temperature has been reduced place the patient upon a cot with ice to the head. The cervical treatment should be repeated as often as necessary. The diet of the patient should be liquid for a few days. Plenty of water and stimulation of the kidneys and bowels will be found beneficial. The sequelæ are to be treated according to the condition. Much can be done for the sequelæ of heat exhaustion and sunstroke. Lesions will be found corresponding to the regions involved. Deep contracted muscles are common.

---

PART SECOND

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

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

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

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

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

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

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

Two points should always be remembered relative to fever:

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

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

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

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

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

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

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

(Enteric Fever)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Ague)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Breakbone Fever)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Bloody Flux).

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

(Bacillary Dysentery)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Lock-jaw)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

C. A. Whiting in Clinical Osteopathy says:

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

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

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

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

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

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

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

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

(Scrofula)

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

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

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

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

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

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

The affection often runs a slow course.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Prognosis.—Generally very unfavorable.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

By George M. McCole

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Throat was always examined. This is an important point.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

---

By Edgar S. Comstock

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

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

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

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

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

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

(Smallpox)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Vaccination and smallpox never prevent.	Smallpox may closely resemble chicken pox; especially mild cases.
Age—usually before puberty, may occur in adults.	Usually after puberty (many exceptions.)
Initial stage practically absent.	Initial stage severe, even in mild cases.
Temperature,—no remission on onset of rash.	Typical remission and secondary fever.
White cells normal or decreased.	Leukocytosis.
Prodromal rash very exceptional.	Prodromal rash quite frequent.
Vesicles in crops.	Vesicles never in crops.
Vesicles rarely shotty.	Vesicles, following macules, are hard and shotty.
Rash Evolution,—	Rash Evolution,—
Very rapid, vesicles on first or second day.	Much slower, vesicles on seventh day.
Eruption is universal, successive crops, most abundant on back, begins on body, less on face, scalp, hands and feet.	Development progresses downward, face first, then wrists, trunk, arms and lastly legs. Less on trunk.
Vesicle is superficial and fluid transparent.	Fluid pearl-colored and NOT transparent. Thicker covering.
Halo (areola) usually absent.	Areola is marked.
Involution is quite rapid.	Involution is slow.

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

I.	Variola Vera.		a. Discrete.
			b. Confluent.
II.	Variola Hemorrhagica.		c. Purpura variolosa (black smallpox)
			d. Variola hemorrhagica pustulosa.
III.	Varioloid.		e. Smallpox modified by vaccination or partial immunity.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Vaccinia; Cow-pox)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Scarlatina)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3. Strawberry tongue is constant.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nephritis is most common in the second and third weeks of the illness, but may develop later. In all cases where any symptoms of nephritis appear, light or severe, the patient must be confined to bed for at least four weeks, and kept on a milk diet. All irritants must be absolutely avoided. Hot baths should be given twice daily to increase the sweat and the urinary functions, the bath lasting half an hour and the patient kept afterward between blankets. Treat thoroughly, daily, the splanchnic and renal areas, paying particular attention to the tissue conditions in the lower dorsal region.

In the milder cases, the urine contains albumin and a few tube casts, very rarely blood, and edema is slight or transient. Though the patient improves, he remains pale and there is a slight trace of albumin in the urine for months. If recovery does not take place, then chronic nephritis becomes established.

In the more severe cases there may be a puffy appearance of the eyelids, slight edema of the feet, urine diminished in quantity, smoky, containing albumin and tube casts. The kidney symptoms dominate, dropsy persists and there may be effusion into the serous sacs. The condition may become chronic, the patient may succumb to uremia, but in the majority of cases recovery takes place.

The nephritis may be hemorrhagic, in which the urine is suppressed or there may be a very small amount of bloody fluid laden with albumin and casts; constant vomiting and convulsions follow and the patient dies with symptoms of acute uremia.

Other complications are arthritis, malignant endocarditis, severe toxic myocarditis and acute phlegmonous inflammation, the last three of which are usually fatal. Chorea is a fairly frequent nervous complication. The mental symptoms are mania and melancholia. Progressive paralysis of the limbs with wasting, may simulate infantile paralysis. The fever may persist after the eruption disappears and the child remain in a septic state (scarlatinal typhoid).

Relapses are rare. Scarlatina may coexist with almost any other acute infection. It lowers the resistance of the body to disease and is often followed by other acute infections or by tuberculosis. Therefore the necessity of care during the entire convalescent stage.

(Rubeola; Morbilli)

Definition.—Measles is an acute infectious, contagious, erythematous disease, occurring in epidemics, characterized by an initial coryza, bronchial catarrh and an eruption of a general maculopapular type; also by the presence of Koplik’s buccal spots.

Etiology.—Predisposing Influences: The chief predisposing factor in measles, as in all other contagious diseases, is a lowered resistance in which some structural or functional change has taken place that reduces the functional activity of the body’s inherent protective agencies. These predisposing factors may be classed under three heads, namely; (a) structural, (b) environmental, (c) dietetic. Under the first we find structural disturbances in the upper cervical area affecting the functional control of the nose, throat and head, as well affecting the thyroid and its internal secretions: structural disturbances in the upper and mid-dorsal areas affecting the vasomotor control to the head, neck, and chest, thereby perverting nutrition to all these structures and rendering them more susceptible to the infective organisms; also the dorsal lesions disturb the functional integrity of the lungs and heart, with the result of disturbed respiration and circulation, both of which are vital factors in body resistance: we also find structural lesions in the lower dorsal region, affecting the function of the kidneys and their elimination and the function of the adrenals and their internal secretions. Under the second or environmental, we have unsanitary and unhygienic conditions, exposure to sudden changes of temperature, wet clothing, fatigue, etc., all of which produce secondary structural lesions and the effects above mentioned. Under the third or dietetic classification, we have the errors of diet so common in children and adults as well; such as too much candies and other sugars, also too much starches, as well as over eating and unbalanced diet.

Measles prevails in all climates and attacks all races, the Negroes appearing to suffer more severely than the whites and to be more subject to complications. Outbreaks are more common in winter and spring, but occur at all seasons. The disease is particularly a children’s disease but adults may contract it if not protected by an attack in early life, and with adults the disease frequently manifests the more aggravated forms. It is more common after puberty than scarlet fever.

Exciting Cause.—While the disease is probably produced by a micro-organism, it has not yet been demonstrated. Inoculation experiments upon human beings have shown the presence of the infecting principle in the blood, in the tears, in the secretions of the nasal, pharyngeal and bronchial mucous membranes, and in the contents of vesicles occasionally present. Inoculation with the epithelial scales thrown off at the end of the disease has been unsuccessful. Ordinarily the transmission of the disease takes place through the breath or the nasal and bronchial secretions. The disease may be carried by a third person or by fomites. The infecting principle is intensely active, but not so tenacious nor persistent as scarlet fever. Measles is communicable throughout its entire course from the earliest appearance of the coryza. The individual predisposition toward measles is apparently so general that few, upon exposure, escape it, though we have observed cases where children have been directly exposed and who were immediately thereafter put under osteopathic care and did not develop the disease. Second, or even third, attacks may occur at intervals of some years, but these are unusual. Sporadic cases do occur and are often the starting points for epidemics. Extensive outbreaks occur at intervals of five or six years.

The incubation period is from seven to eighteen days, usually about ten days.

Symptoms.—Prodromes are common, usually consisting of loss of appetite, restless sleep, fretfulness, and often feverishness. There are three stages, (a) Invasion, (b) Eruption, (c) Desquamation.

(a) Stage of Invasion. The prodromal symptoms are intensified. There is often chilliness but seldom distinct chills. The temperature rises, often reaching 102 to 104 degrees, upon the first and second day. It then falls one degree or more to rise again upon the appearance of the eruption. Nausea, vomiting and headache are often present. The tongue is furred. With these symptoms coryza has developed and is sometimes intense, often simulating severe influenza. Irritation and smarting of the eyelids, lachrymation, photophobia, persistent sneezing, running of the nose, sore throat, discomfort in swallowing, hoarseness, and cough, at first of a croupy character, appear in rapid succession and with varying intensity. These initial catarrhal symptoms are characteristic and occur in the mildest cases in which chilliness, fever and the associated signs of the reaction of the organism to general infection are not observed. The vessels of the conjunctivæ are injected, the eyelids swollen, the nasal mucosa tumid and reddened. The mucous membrane of the mouth and throat is erythematous, while upon the soft palate and the roof of the mouth, and particularly upon the buccal mucous membrane, are to be seen pin head or split pea sized, circumscribed, round or irregularly shaped reddish blotches slightly or scarcely at all raised above the surrounding tissues, usually discrete, but sometimes confluent. This eruption also shows itself in the larynx and is undoubtedly the cause of the croupy cough and other throat symptoms. In a strong light there may be seen upon some of the spots on the mucous membrane of the cheeks and lips minute bright whitish, or bluish-white flecks which are called Koplik’s Spots. These spots appear early and soon disappear, and as they are not found in any other disease they are of value in the early diagnosis of measles. The duration of this stage is usually three or four days; rarely it is shorter or it may be as long as a week.

(b) Stage of Eruption. On about the fourth day the temperature again rises, increasing as the rash develops, often to 104 or 105 degrees and reaching its maximum about the sixth day when it usually falls by crisis; followed on the seventh or eighth day by normal temperature. The pulse-rate increases with the fever, often reaching 140 or higher. The eruption usually appears on the fourth day, and shows first about the hair line on the forehead, spreading to the face, chest, trunk and the arms and legs. The eruption is attended by itching and burning, and completely develops in from twelve to thirty-six hours, the catarrhal symptoms persisting during this time. During this time, in the more severe cases, delirium or stupor may be present, and the patient complains of sore throat and general discomfort, and is restless and wakeful. Usually upon the second or third day of the eruption, great and rapid amelioration of all these symptoms takes place and the fever falls to normal or subnormal. When the eruption is fully developed the individual spots are irregularly circular or oval, and differ greatly in size, averaging about the size of a split pea. The eruption is unevenly set, but usually close together and sometimes confluent, especially on the face, buttocks, hands and feet. Frequently they take on a crescentic arrangement and the spots are circumscribed, the intervening skin being normal or slightly hyperemic.

About the ninth day the rash begins to disappear, on the face first, then the neck and the rest of the body in about the same order as the eruption appeared. The skin takes on a yellowish discoloration and the rash disappears in a bran-like desquamation which lasts several days to a week. In the beginning of the stage of eruption, and in many cases throughout its course, the skin is moist and often bathed in free perspiration. At the height of the eruption the superficial lymphnodes of the neck, and elsewhere, are often slightly swollen and tender.

(c) Stage of Desquamation. The fine branny scales of desquamation are often so fine as to be easily overlooked. This process occupies about a week. The catarrhal symptoms in uncomplicated cases gradually disappear, so that, by the end of the second week from the initial coryza, convalescence is fully established. The cough frequently persists and is of a bronchial nature. Epistaxis is common at the height of the attack. Relapses of measles are extremely rare. Diarrhea is apt to occur at some time during the attack, without any particular significance.

Varieties.—Atypical cases may occur but are not common. They are as follows: (1) Morbilli Papulosi, development of distinct papules, hard to the touch but not extending deeply into the skin. (2) M. Vesicular; a vesicular form. (3) M. Sine Exanthema, cases in which the eruption does not appear, but general symptoms and coryza are present. (4) M. Sine Exanthema, in which the mucous membranes are not involved.

Variations in constitutional symptoms.—(1) M. Afebriles, rare cases in which there is no rise of temperature. (2) M. Hemorrhagica. This is the malignant form and in it the organism is unable to withstand the intensity of the infection and death takes place in the course of two or three days after sustained hyperpyrexia, profound adynamia, or hemorrhages into the skin and mucous membranes. These malignant forms are very rare in private practice, but they occasionally occur in asylums and in the fierce epidemics of camps, and were common in the first outbreaks among the natives of the Fiji Islands, where measles prevailed as a scourge. Death may occur before the rash appears or a few papules may show themselves upon the forehead and wrists. This is also known as black measles, and it is characterized by convulsions, delirium and coma, petechiæ, bleeding from the mucous surfaces and profound constitutional depression. The patient is rapidly exhausted, the pulse frequent and thready, the skin pale and cold, and death occurs. (3) Adynamic measles is a serious type in which the symptoms are grave from the onset but without hemorrhages and a typhoid status is early present.

Complications.—In the absence of complications, measles is comparatively a benign disease, but these complications are frequently enough present to place measles among the more serious diseases of childhood. The ordinary complications are due to the extension or intensification of the catarrhal processes peculiar to the disease.

(1) Otitis media is quite common, and may result in perforation of the tympanic membrane and permanent impairment of the hearing; or lead to sinus thrombosis, meningitis, or abscess of the brain. (2) Bronchopneumonia is the most common complication. (3) Purulent conjunctivitis may occur and in neglected cases infiltration and ulceration of the cornea. (4) Catarrhal laryngitis is a frequent complication. (5) Pseudo-membranous type is very uncommon but very dangerous. (6) Edema of the glottis is not common but does occur. (7) Diphtheria is much less common in measles than in scarlet fever. The high death rate of measles is due to the bronchopneumonia complication in which the lesions become extensive, the symptoms become urgent and a large proportion of these cases die. (8) Acute enterocolitis is a frequent and serious complication. (9) Gangrenous stomatitis occurs in young and debilitated children, and in girls gangrene of the pudenda occur during convalescence with greater frequency than in other infectious diseases.

Sequelæ.—The more common sequelæ are chronic local inflammations, conjunctivitis, otitis, nasal catarrh, laryngitis, and bronchitis. Tuberculosis is a common sequel.

Diagnosis.—During an epidemic, coryza, persistent sneezing and fever are suspicious. The appearance of the eruption on the third or fourth day upon the mucous membrane of the mouth and throat, and Koplik’s spots are positive.

Measles is often confused with 1. Rubella or German measles, 2. Variola, 3. Typhus Fever and 4. Scarlet Fever, which see. Occasionally drug exanthems are confused with measles. These may be caused by salicylates, antipyrin, quinine, turpentine or copaiba. These rashes are not accompanied by fever or throat symptoms unless they have been given to allay these very conditions.

Treatment.—Measles is so often a serious disease that it should not be attended with carelessness as it so often is, but the best of care and attention given. Parents should be informed of the danger of complications and of the absolute necessity of proper care and attention.

As soon as a susceptible individual is exposed to the measles, he should be immediately isolated, watched and corrections made of any dietetic errors, unsanitary conditions or structural lesions that may exist. He should be protected from sudden atmospheric changes and carefully watched for the first symptoms of the prodromal coryza.

On the appearance of the prodromal, or invasion symptoms the patient should be put to bed in an isolated, well ventilated room of as nearly constant temperature as is possible, from which all hangings, rugs and unnecessary furniture have been removed. The windows must be shaded to protect the eyes from direct or strong light, and any artificial lights in the room must also be well shaded.

The cases can usually be easily handled by careful, well-directed osteopathic treatments. In the manipulative treatment we must pay especial attention to the muscular and other soft tissue conditions in the suboccipital region, over the transverse processes of the upper four or five cervical vertebræ, under the angle of the lower maxilla and the lateral cervical tissues to remove any obstructions to the circulation and nerve control of the head and throat; see that the muscles in the lower cervical and upper dorsal areas are kept well relaxed, and articulation of these vertebræ, the upper three ribs and the clavicles are kept free; remove all lesions in the mid-dorsal area, whether muscular or otherwise, to prevent involvement of the lungs or heart, and to keep up function of the respiratory and circulatory systems; treat and keep normal the tissues and the articulations at the kidney and adrenal center, 11th and 12th dorsal; raise the ribs and keep them freely movable, this especially for the bronchial cough. Painful manipulations should be avoided and are not necessary. Dr. Still said, “The arms must be raised and the axillary region freed and kept so.” During the acute stage two or three treatments per day are advisable. Do not treat severely or to cause discomfort to the patient. Best results are obtained in the gentle, but thorough, treatments.

In the beginning of the case have the bowels cleansed with an enema, and then careful attention must be constantly given to the bowels and kidneys. The bowels can be kept open by manipulations and diet. The diet should be light and easily digested; during the fever it is best to withhold all food but give plenty of water. Follow fast with fruit juices and then the light diet.

The temperature is usually controlled by treatment, but if it remains high for some time and if the physician cannot reach the patient, the nurse should be directed to give a tepid sponge bath of ten to twenty minutes duration, and repeated at intervals of two or three hours. Also the tepid enema will often reduce the temperature.

For the itching of the skin, a tepid bath with water at 100 degrees given twice daily should be used, the patient dried carefully, and an application of olive oil, cold cream, liquid albolene, or a two per cent menthol salve, rubbed over the entire body will give relief.

The cough is best relieved by thorough treatment of the anterior thoracic regions and the correction of any upper rib or clavicular lesions. Keeping the air of the room moist with vapor is agreeable to the mucous membranes. The dropping of a few drops of eucalyptus oil in the boiling water produces a very soothing vapor.

If the eyes are much involved, they should be bathed every hour or two with a three per cent solution of boric acid, using cotton which is immediately destroyed after use. Dark glasses in a well ventilated room is better than an unaired darkened room.

The nose and mouth should be carefully cleansed at regular intervals and the cloths burned. The throat should be carefully examined daily at first, and at least every other day later, until the case is discharged. The conditions of the lungs must be observed by daily examinations, and the lung and bronchial areas should be daily treated to prevent the possibility of respiratory involvement.

If rash is slow in appearing and the temperature is high, a hot bath (105 to 110 degrees) for three to five minutes will often bring out the rash and relieve the more serious symptoms. During convalescence the patient must be protected against cold. Recovery is hastened by the continuation of treatment during convalescence and treatment given should be indicated by the symptoms present.

Prognosis.—Practically all uncomplicated cases recover. In the hemorrhagic and adynamic types, the majority succumb. One attack usually confers immunity. Sequelæ are frequent under the “old school” treatment, but are infrequent under careful, conscientious osteopathic treatment and careful nursing.

“In and of itself measles is usually not particularly serious, but the after effects are so far-reaching and so serious that students of the history of medicine rank measles third among infectious diseases for causing death. During recovery from measles the patient stands in special danger from pneumonia, and pneumonia following measles is more dangerous than uncomplicated pneumonia. There is a considerable length of time during which he is particularly susceptible to tubercular infection. This is so often insidious, and its evidences are so obscure, that by the time the disease has fully developed, one may have forgotten the mild attack of measles which really paved the way for the serious malady.”—C. A. Whiting.

(German Measles; Rubeola notha; Rotheln; Epidemic Roseola)

Definition.—A specific acute, contagious, infectious, eruptive disease, characterized by a diffuse maculopapular eruption and swelling of the superficial lymphatic glands. It is attended by a mild fever, suffused eyes, mild cough, slight sore throat but no catarrh, a macular rose-red eruption of the throat accompanied by the swelling of the cervical lymph glands and by a rose-red eruption of irregular size and shape appearing on the first day of the disease.

Rubella, in some ways, resembles scarlet fever and also measles and was at one time considered a hybrid of the two. It is now known to be an independent disease.

Etiology.—The exciting cause, or the infective principle, has not yet been discovered. The disease is probably carried by fomites, is readily transmissible, attacks children especially, and usually occurs in epidemics, though sporadic cases are frequently found. The epidemics usually occur at intervals with several years intervening, during which time there are comparatively few cases. Persons of all ages are susceptible unless having acquired an immunity through an attack of the disease at some former time. Rubella does not confer immunity against any other disease, as scarlet fever or measles, nor do these diseases confer immunity against rubella. One attack of rubella confers immunity against any succeeding attacks.

The incubation period is from five to twenty-one days and is without symptoms.

The predisposing factors are the same as in measles or other infectious or contagious diseases.

Symptoms.—Invasion Period. This stage is usually of very short duration, lasting from a few hours to perhaps two days. The initial symptoms are usually mild, being a sudden chilliness, but not chills; mild fever of about 100 degrees; a slight headache; mild sore throat; swollen cervical and post auricular lymphatic glands; little or no coryza; sometimes slight pains in the back and legs; and the macular rose-red eruption in the throat which is constantly present. Often the initial symptoms are so mild that the presence of a disease is not recognized until the eruption appears, which usually occurs on the first day and rarely not until the fourth day.

Eruption Period.—The rash, which consists of round or oval reddish spots about the size of a split pea, mostly discrete, but sometimes confluent, and surrounded by areas of hyperemic skin, usually shows first upon the face and follows a wavelike progression over the body and limbs. The rash usually begins to fade upon the face before it has appeared upon the last affected areas, and usually remains in one region from a few hours to a half day. It extends over the entire body in from twenty-four to thirty hours. Occasionally the skin is so hyperemic in extensive tracts that the rash more resembles scarlet fever rather than measles. The crescentic arrangement of the papules usually seen in measles can not be made out in rubella. In the course of two or three days the rash disappears with very fine desquamation, leaving a faint pigmentation, which remains for a short time. Slight etching usually accompanies the rash.

Relapses are rare and complications infrequent. There are no special sequelæ, but albuminuria, bronchitis and pneumonia have been noted. Although one attack usually confers immunity, second attacks have been reported, which may have been real second attacks or the first attack may have been an error in diagnosis.

Diagnosis.—Early or sporadic cases may present great difficulty in diagnosis, but when an epidemic is present diagnosis becomes much easier. The direct diagnosis of the disease rests upon the very mild nature of the disease, its short initial onset, the character of the eruptions and the early enlargement of the glands with the absence of severe throat symptoms and coryza.

Rubella is frequently mistaken for mild cases of measles or scarlet fever. Unlike measles, it does not have the prominent catarrhal symptoms, the higher fever, the crescentic grouping of the eruption and Koplik’s sign. In measles the adenitis is not so severe as in rubella, and especially are the suboccipital and post-auricular glands involved in rubella. Scarlet fever has a very sudden onset with severe symptoms, a very sore throat, the characteristic tongue and the peculiar rash, all of which are decidedly different from rubella. In the latter stages the character of the desquamation is also a distinguishing feature.

Treatment.—Patient should be kept in a properly heated and well ventilated room, being careful that no draughts chill the patient, and should remain in bed for at least two days. Patient should be isolated. Treatment should be directed to the upper cervical, mid-dorsal and lower dorsal areas to keep normal the function of the internal secreting mechanism, and to normalize and keep normal the respiratory and circulatory systems. Treat carefully to upper lymphatics, working around the enlarged glands and not directly over them. Watch the excretory functions and keep them active by judicious measures. If annoying itching occurs, the hot bath followed by being wrapped in a soft warm blanket will usually relieve. Daily tepid sponging should be given and if hot bath does not relieve itching an application of olive oil or cold cream will often relieve. Diet should be reduced and regulated according to age of patient and severity of the case. Usually the above is all that is indicated, but if more severe symptoms present themselves vary your treatment according to the symptoms present.

Prognosis.—Recovery is the general rule. Relapses sometimes occur, and are usually much more severe than the initial attack. The symptoms are often more severe in adults than in children. Like measles, this disease seems to lower resistance to other infections, and therefore especial care should be taken to protect the patient from exposure to other diseases for some time after recovery from rubella. See that the patient is built up constitutionally after recovery by plenty of fresh air, suitable exercises and good food.

(Chicken Pox)

Definition.—Chicken pox is an acute, specific, contagious, slightly febrile, eruptive disease, usually of childhood, affecting the whole organism through the blood. It is an epidemic disease that spreads rapidly, is highly contagious but not inoculable, and confers immunity.

History.—Varicella was first recognized about 1553 and was distinguished from smallpox by Trousseau.

Etiology.—The agent that causes the disease is not known; the disease usually affects children under ten years of age, but does occasionally attack adults. It bears no relation to variola, except the very slightly similar eruption. It is transferred by direct personal contact, by the air or by a third person. It is infective from the first symptoms until all the crusts have disappeared. Although the disease usually occurs in epidemics, frequently we see sporadic cases.

As in all other contagious or infectious diseases the predisposing causative factors are those conditions which lower the resistive powers of the body, such as fatigue, improper diet, exposure to sudden temperature changes and imperfect elimination of the body wastes. The structural lesions found as predisposing factors are contractured muscles of the neck and behind the jaw, and muscular and interosseous lesions of the upper cervical, mid-dorsal and dorso-lumbar areas, also of the clavicle and upper ribs.

Symptoms and Diagnosis.—There are three stages to the disease: (1) Incubation, (2) Prodromal, (3) Eruptive.

1. Incubation Period.—This period lasts about fourteen days though it may vary from seven to seventeen days. During this period there is practically no symptomatology except perhaps the last two or three days, when the child shows evidence of a little excitability and irritability. Often on the day before the first noticeable symptoms the child appears even more active than usual.

2. Prodromal Stage.—Prodromal symptoms are not common and usually last but about twenty-four hours. The first noticeable symptom is the irritability of the patient, which is followed by a temperature, usually 99° to 101°, which temperature persists during the course of the disease. There are sometimes thirst, anorexia, constipation, seldom vomiting, and a furred tongue. Some cases have been observed to have the following as prodromal symptoms, but these we believe are usually due to concurrent conditions that exist at the time of the infection: delirium, convulsions, angina, conjunctivitis, dysphagia, bloody vomiting and stools, and an initial erythema, usually scarlatiniform.

3. Eruptive Stage.—The eruption comes within twenty-four hours and is often the first symptom that is noticed. It appears first as hyperemic macules and then rose colored papular spots, somewhat comparable to the typhoid roseola and not hard. These papules rapidly become raised, flattened, ovoid, pin-head to pea-sized vesicles containing a fluid at first watery and then pearly. They disappear on pressure. The vesicles mature within twenty-four hours, are very superficial, and leave a slight areola about them, which is not inflammatory as in smallpox. The eruption appears first on the chest and then on the neck, face, scalp, and then trunk and limbs in the order named. The eruption is most abundant upon the back, and over the entire body they may number anywhere from eight to many hundred and are usually scattered.

The vesicles are not umbilicated, but some may have slightly depressed centers, are discrete, and appear in successive crops which require from three to six days to complete. Pustulation and hemorrhage into the vesicle rarely occur. On the third or fourth day yellowish-brown crusts form and gradually disappear. Scars may result from scratching or infection. By the fifth day we may find all stages of the eruption because of the appearance of the successive crops. There may be an efflorescence upon the mucous membrane of the oral cavity and of the pharynx causing slight difficulty in deglutition.

The itching may be more or less intense. As scratching may cause pitting it should be guarded against. The fever which is usually slight may persist during the entire eruptive stage, but if it is high and persists as high temperature it suggests complications. Muscular tension of the cervical muscles, especially those in front, and around the angle of the inferior maxilla are usually found, and often the clavicles are bound down, and relation of ribs is disturbed. Ulceration sometimes follows scratching, and even gangrene may appear around the vesicles in debilitated children, especially those who are tubercular or congenitally syphilitic. It is apt to be fatal in these cases. Complications of tubular nephritis, which occurs within two weeks; cardiac hypertrophy; uremia; otitis media; and bronchial affections, are sometimes met with.

Treatment.—Isolate patient so as not to come in contact with other children. The younger children should be put to bed until the crusts have formed; older children may be allowed to be up around the room if their cases are light. Pay particular attention to the muscular lesions of the neck, lower maxilla, mid-dorsal and dorso-lumbar regions, keeping them relaxed by gentle relaxing treatments. A general systemic treatment is soothing and helps to prevent complications.

“Be very careful and very thorough in your neck adjustments. Loosen the atlas and axis and draw forward the inferior maxilla from its pressure upon the vessels and nerves back of its angle. Draw the hyoid bone forward and secure good circulation of blood throughout the entire cervical area.”—A. T. Still.

Give treatment at the 4th and 5th dorsals to stimulate the superficial circulation and thus increase elimination through the eruption as well as the sweat glands. Remember the eruption is the expression of the body’s attempt to eliminate the toxins within.

Keep the bowels active by splanchnic and abdominal manipulations and by laxative diet. If bowels are persistently inactive use enemata. Diet should be bland and easily digested. During fever, diet should be liquid or better restricted, giving only water in abundance.

During the eruptive stage do not use tub baths. Daily tepid sponges with either plain water or boric acid solution answers both as an antiseptic wash and bathing. After the daily sponging, and as often as necessary to control itching, anoint with a 10% boric acid ointment or with carbolized vaseline. If scratching can not be controlled, the hands should be tied in muslin bags. As in smallpox the ultra-violet rays seem to irritate the eruptions and to increase the tendency to scarring, therefore the windows and lights should be screened with a dull red material.

Prognosis.—Invariably favorable unless complications set in, which is seldom. Recurrences are very rare.

Prophylaxis.—The child should be kept in quarantine for three weeks or until the skin is entirely clean.

(Mumps; Epidemic Parotiditis)

Definition.—Mumps is an acute, infectious, contagious disease, occurring in limited epidemics, and characterized by inflammation of the salivary glands, particularly the parotid, swelling slight fever and pain over the involved glands. There is special liability to orchitis or to mastitis.

Etiology.—Predisposing Factors: Mumps is peculiarly a disease of childhood and adolescence, not being common in infancy or after the twentieth year. It affects boys nearly twice as often as girls. Mandibular and upper cervical lesions, both of the interosseous and soft tissue types, are undoubtedly potent predisposing factors, as they obstruct and interfere with nerve and circulatory function to the glands affected. Also any condition which lowers the child’s resistance to infections makes them more susceptible to this disease than to any other, these conditions being fatigue, exposure to dampness and sudden weather changes, dietetic errors, etc. The cases are more numerous in the spring and autumn seasons. Extensive epidemics are infrequent, but do occur in reformatory institutions and children’s homes. It is much more widespread in large cities than in the country or villages.

Exciting Cause; The specific cause has not been demonstrated. The disease is usually transmitted by direct contact, but there are instances where it has been transmitted by a third party or by fomites. There are two views as to the mode of infection; the first being that the active principle travels along the course of the salivary ducts from the mouth to the glands, probably most often through the duct of Stenson to the parotid gland. This is the most generally accepted theory. The second is that the infection is a general one to which certain structures are more susceptible, principally the salivary glands, and the parotid in particular.

Symptoms.—The period of incubation is from fourteen to twenty-one days. Prodromes are usually absent, though in the more severe cases constitutional disturbances, with chilliness, vomiting and mild fever may precede the local inflammation. In the milder cases the local swelling may be the first manifestation of the disease. The temperature is usually moderate but may rise to 103 or 104 degrees in the more severe cases. The left side is more often affected than the right. The disease is characterized by a feeling of tension with soreness just below the ear. Soon a slight swelling may be observed directly under the ear and in the course of forty-eight hours it reaches its maximum size. The parotid gland becomes greatly enlarged and the adjacent tissues of the neck and face become tense and edematous. The skin becomes hard and glossy and usually white in color because of the obstruction to the circulation from pressure. The swelling is between the angle of the jaw and the mastoid process, pushing the ear upward and its lobule is pushed sharply outward. In the majority of cases the other side becomes affected in two or three days, but sometimes the spread of the disease to the other side is delayed for several days, and occasionally the other side escapes the infection. Frequently the swelling of the other side is so slight that it is only recognized by the closest scrutiny. Infrequently the submaxillary glands become affected without involving the parotid glands, but these cases are rather rare.

The patient is usually unable to open the mouth without considerable pain; acids, and rarely sweets, produce spasms of the jaw muscles; speech and even deglutition are difficult; the salivary secretions are usually increased but quite frequently they are decreased. The breath is foul and the tongue is furred. The mucous membrane of the cheek and pharynx are reddened and there may be a slight angina.

The spine shows subluxations of the upper cervical area, particularly of the atlas and axis, also upper rib lesions and upper dorsal lesions are frequently found. The lesions of the second and third dorsal, and their ribs, are most frequently found when the submaxillary gland is involved.

The symptoms persist from six to fourteen days, when the swelling disappears and the patient regains normal health. Orchitis occurs in about one-third of the cases after puberty. In infancy and childhood it is extremely rare. Usually one testicle is involved, and is characterized by weight, swelling and pain in the scrotum. The testicle may become greatly enlarged when the pain becomes intense. Atrophy may result and if both testicles are affected the loss of reproductive ability may result. In females, usually after puberty, the breasts may become enlarged and tender, pain and tenderness of one or both ovaries, hematoma of the labia, or a vulvovaginal discharge may occur. However these complications are very rare. As a rule the patient is not very sick and relapses are very uncommon. The attack confers immunity which is practically permanent.

Diagnosis.—Under ordinary conditions, especially during an epidemic, the diagnosis of mumps is very easy. The swelling in front of and below the ear, with the displacement of the lobule outward is quite indicative of mumps. The relative rapidity with which the swelling appears, develops and subsides is characteristic of mumps. In acute cervical adenitis the swelling is below the angle of the jaw and does not at any time correspond with the outline of the parotid gland. In Hodgkin’s disease, which is a chronic affection of the lymphatic glands, the salivary glands are not involved.

Treatment.—The patient should be kept away from other children, and should remain in a well lighted, well ventilated room of even temperature, and if the temperature is high or moderately high he should be kept in bed.

The correction of all interosseous lesions is indicated, especially of the upper cervical area, though the second and third dorsal should be given attention because of the influence of these dorsal nerves upon the submaxillary glands. Also correct upper rib lesions that may exist. As mumps is an infective disease the channels of elimination should be watched and stimulated. Build up the body resistance by treatment at the mid-dorsal area to affect circulation and respiration; and lower dorsal area to affect kidney and adrenal function. Watch the bowels and keep this avenue of elimination functioning freely, using enemata if necessary.

The diet should be liquid, of fruit juices, thin gruels, milk and plenty of water. Tepid sponging allays the fever and restlessness. Relaxation of the deep muscles of the neck and shoulders will do much to make the patient comfortable, also the muscles under the angle of the jaw. A very gentle relaxing of the tissues around the gland itself, by crowding them toward the gland, assists in relieving the tension by securing a better venous and lymphatic drainage.

Hot applications to the swollen glands will give a considerable relief; these may consist of hot fomentations, hot salt bag, electric heating pad, hot water bottle, etc. The mouth is kept in good condition by the use of a mild antiseptic mouth wash.

Orchitis should not occur if the boy is kept warm and in bed. If it does occur the best treatment is relaxation of the lower dorsal and upper lumbar spinal muscles, rest in bed, support and protection of the scrotum with cotton wool, cold applications, correction of any bony lesions affecting the pelvic viscera.

If mastitis occurs, rib lesions will be found and should be corrected, as they are probably the predisposing factor to this complication. Treatment would consist of correction of these lesions, if it can be done without irritating the inflamed glands. The manipulation of the surrounding tissues, with gentle crowding of the normal tissues toward the inflamed glands, without exerting any pressure on the gland itself, is helpful and comforting. Free tissues back to the axillary lymphatics.

Prognosis.—The outcome is usually favorable. In the rare fatal cases, meningitis is the usual cause of death. Under osteopathic care the duration of the swelling, fever and pain is usually greatly lessened.

Quarantine of twenty-four days is necessary.

(Pertussis; tussis convulsiva)

Definition.—It is a specific, epidemic, infectious, contagious disease affecting the respiratory organs, characterized by a cyclic course, a severe convulsive cough, paroxysmal, with the characteristic “whoop.”

Etiology.—It usually occurs in children, most frequently during the fourth year, and extremely seldom after the twentieth year. It appears to be slightly more frequent among girls, and most cases occur in March and April. Pertussis is highly contagious, being carried by direct contact and by fomites. The Bordet and Gengou bacillus is the specific cause. This is found in the sputum most abundantly during the first week, the most infectious period, and becomes gradually less. One attack usually confers immunity.

The incubation period is from seven to ten days. The patient may be considered non-infectious five weeks after the first whoop.

Lesions of the cervical and upper dorsal vertebræ and of the first, second and third ribs, affecting the vagi, the phrenic, the sympathetic, the recurrent laryngeal or the vasomotor nerves predispose to the disease.

The bacteria were found by Mallory and Horner to be characteristically between the cilia of the trachea and the bronchi. They interfere, mechanically, with the movements of the cilia, preventing the normal removal of secretions.

Symptoms.—The disease is divided into three stages: 1. The catarrhal stage, which lasts one to two weeks; 2, the spasmodic stage, three to six weeks; 3, the declining stage, three weeks.

The Catarrhal Stage: Characterized by headache, photophobia, conjunctivitis, coryza and a cough which becomes drier and harder toward the end of this stage. Often the invasion is insidious and sometimes well marked with a temperature of 100° to 102°. Frequently this stage cannot be differentiated from a “hard cold,” except toward the end of the stage when the cough becomes worse instead of better, and the child will seek some support to steady itself during the coughing paroxysm. Also the eyes will water freely during the coughing spell and the child will not be able to “get his breath” between coughs, but will have a number of coughs without inhaling.

One to two weeks.

The Spasmodic Stage: This stage dates from the “first whoop.” The fever now usually ceases, unless there are complications. The cough becomes paroxysmal, consisting of a succession of fifteen or more short, rapid expiratory puffs with no intervening inspirations, immediately followed by a deep, loud inspiration, which is the characteristic “whoop,” and is due to the partial closure of the glottis. Each paroxysm is composed of three or more such spells, the last one often followed by the expectoration of a small plug of mucus or by vomiting. During the paroxysm the facies presents a swollen, dusky appearance, eyeballs protruding, eyes reddened, and puffy, pinkish lids. The child is well except for the paroxysm, which has an aura, tickling in the larynx, thoracic constriction, a creeping sensation, when the child attempts to brace himself, or runs in terror for support. The “whoop” is a deep, singing or whistling inspiration which is absolutely characteristic. During the cough the child’s body is bent forward and he is perfectly helpless, often passing urine and feces involuntarily. Cyanosis often occurs from the strain.

After the attack patient regains control of himself, the respiration is fast, and there is fatigue, sweating and often pain in the abdomen from the strain of coughing. During the severe cough petechiæ of the forehead, ecchymosis of the conjunctivæ, epistaxis, bleeding of the external auditory meatus or from the frenum of the tongue may occur. Ulcer of the frenum of the tongue is quite common. The parosyxms vary from four to a great many per day, averaging about twenty.

Three to six weeks, usually four weeks.

The Terminal or Declining Stage: This stage is longer in proportion in the mild cases. The paroxysms occur at longer intervals, are of shorter duration and of less intensity, the catarrhal symptoms are more marked, the expectoration becomes thinner, fluid, mucopurulent, and looser. The “habit cough” may follow. It is during this stage that complications are most likely to occur, therefore it is the most dangerous.

Complications.—Catarrhal inflammations are common in the initial stage. Bronchopneumonia is the most frequent and severe complication. Lobar pneumonia, exudative pleurisy, endocarditis, pericarditis, meningitis and nephritis are infrequent complications. Spasms of the glottis in nervous or scrofulous children is largely nocturnal, and may cause death from asphyxia even in the lightest cases. Hemorrhages may occur in the skin, conjunctivæ, nose, throat, ears or cerebrum. The writer knows of one case where death was sudden from a cerebral hemorrhage in an apparently mild case. Other complications are cardiac dilatation, emphysema, bronchiectasis, pneumothorax, aneurysm hernias, muscular ruptures, and visceral prolapses.

Spasmodic cough from diseased bronchial glands very closely resembles whooping cough. Barthez and Sannee give the following differentiation:

Whooping Cough	vs	Enlarged Glands
1. Contagious, epidemic.		Isolated, not contagious.
2. Three periods, 2nd parosyxmal.		No distinct periods.
3. Paroxysmal cough with whoop, vomiting, viscid expectoration.		Paroxysms without whoop, expectoration or vomiting.
4. Respiratory sounds normal.		Signs of enlarged glands sometimes present.
5. Respiration normal in interval; apyrexia if simple.		Asthma in some cases, febrile movements, sweats, wasting, etc.
6. Voice natural.		Voice sometimes changed.
7. Acute.		Chronic.

Treatment.—Isolation of patient in well ventilated, sunny room where there is plenty of fresh air day and night is essential. Children exposed to infection should be disinfected and isolated for three weeks, as the disease can not be diagnosed during the catarrhal stage. If case is at all severe, patient should be put to bed.

Cases receiving early treatment are sometimes aborted. Treatment of the whole respiratory tract with correction of vertebral and rib lesions, and relaxation of the contracted muscles should be given. Treatments for the first few days should be at least twice per day. Pay especial attention to the vagi and phrenic nerves. Lesions of the first and second ribs will affect the recurrent laryngeal nerves which will aggravate the cough. The muscles of the shoulder girdle are always very tense and should be kept well relaxed, as should the subscapular muscles. Frequently after treatment the child will have a coughing spasm and raise large quantities of mucus, after which there will be no more spasms for several hours.

Children who play and live out of doors get along best. To support the diaphragm and abdominal muscles from the strain of coughing a muslin bandage tightly pinned about the trunk is very valuable, a pad being placed over the stomach under the bandage. In a very young child instruct the nurse to strongly flex thighs on abdomen during the severe coughing. Inhalations of steam from water with a very few drops of eucalyptus oil in it often relieves the first tickling sensations.

If cyanotic symptoms appear they may be relieved by raising the ribs, especially those over the heart; by relaxing the subscapular muscles; and by supporting the heart by application of cold cloth over the heart. Elevating the abdominal viscera and diaphragm is, also, of distinct benefit.

The diet should be nutritious and easily digested, restricted to liquids during the fever. The child should be warmly clad and protected from drafts. The excretory systems should be kept active by plenty of water drinking and by diet. Treatment should be continued during the terminal stage to prevent the possible complications. Irritants, as beef-tea, stimulants, dry bread, cookies and overfeeding, provoke coughing and vomiting. Food should be given at frequent intervals in concentrated form—gruels, milk with lime water, zwieback in milk, eggs, meat juice, etc. Older patients tolerate more solid food.

Prognosis.—With the complications, this is the most fatal of the acute infections under five years of age. Infants and little children should receive special care. Ordinary uncomplicated cases are favorable for recovery. The prognosis depends upon the age and strength of the patient, the severity and number of the paroxysms, and the presence or absence of complications. No recurrence is to be expected.

Death is due to spasm of the glottis or to extensive subdural hemorrhage, occurring chiefly in the children of the poor and in delicate infants.

Prophylaxis consists of isolation, disinfection of sputum and final fumigation of the premises. Children should be protected from exposure to infection from whooping cough. It must be realized that it is a very serious disease.

---

Definition.—Inflammation of the mouth.

Etiology.—Chemical, mechanical, thermal or parasitic irritations; secondary to disorders of the gastro-intestinal tract, scarlet fever, measles and variola; cachexia, due to such diseases as cancer and phthisis; dentition; artificial feeding; hot weather and poor hygienic surroundings are the most common causes. Lesions to the innervation and vascular supply of the mouth are found, principally, in the upper cervical vertebræ, occasionally in the upper dorsal vertebræ and corresponding ribs.

Varieties.—Catarrhal, aphthous, ulcerative, parasitic, gangrenous.

Etiology.—Most common in infants and children. Hot and irritating substances; secondary to diseases of the stomach, to measles, scarlet fever and variola; difficult dentition; alcoholic or tobacco excesses.

Hazzard says in all cases of stomatitis “there is generally lesion to the bony or other tissues in the cervical region (sometimes also in the upper dorsal), which deranges vasomotor control of the tissues of the mouth and tongue, obstructs venous return, weakens the tissues and lays them liable to the effects of some particular irritant, local or in the system, but there is, generally, lesion affecting the gastro-intestinal tract which is the real underlying cause of the trouble.”

Symptoms.—Diffuse, red swelling of the mucous membrane, heat and pain in the mouth, increased flow of saliva, fetor of breath, restlessness and languor. In children there is a disinclination to nurse and a slight fever may be present. The sense of taste is blunted and there is commonly a bitter taste in the mouth. The neck glands are enlarged.

Treatment.—Removal of the exciting cause is the most important point in the treatment. Good hygienic conditions must be enforced. The mouth should be kept clean. Wipe it out at frequent intervals with a soft piece of absorbent cotton and cold water. A borax solution is frequently used. Attention should be paid to the diet and secretions. Light but thorough treatment of the upper cervical region is to be given, with careful attention to the tissues about and below the angles of the jaw, so that the innervation, blood and lymphatic supply may be equalized.

(Canker)

This disease is characterized by little, painful, grayish-white spots upon the superficial layer of the mucous membrane. They consist, primarily, of an exudate of fibrin and wandered-out leucocytes. It is principally a disease of childhood. Among the common causes are difficult dentition, disorders of digestion and uncleanliness of the mouth, such as neglect to cleanse the child’s mouth after nursing. It may be a symptom of measles or of local diseases.

Probably the innervation to the region of the little grayish-white spots or canker is obstructed at some points by a disordered tissue. The lesion may be mechanical or it may arise from a disordered digestion. If one is able to locate such a lesion and remove it, a cure will be hastened. The seat of the infection is the internal surface of the cheeks, gums, roof of the mouth, tongue and lips.

Symptoms.—There is redness of the mucous membrane of the mouth, followed by the appearance of the vesicles with a red areola. Pain in the mouth and an increased flow of saliva occur. Mastication, deglutition, and even speaking, may be painful. This condition is followed by sleeplessness, feverishness, diarrhea and fetor of the breath.

Treatment.—Removal of the cause, as in other varieties of stomatitis, is paramount. Give attention to the food. The milk should be sterilized. The disordered digestion should be corrected at once. All secretions must receive prompt attention. The child should be nursed at regular intervals. Locally, keep the parts clean and carefully treat the innervation.

This is a disease of children, although it may not be limited to them, as it occasionally occurs in epidemics and affects all ages. It occurs chiefly in the families of the poor and in places where the hygienic surroundings are bad, the food poor and personal cleanliness lacking. It may begin as an aphthous stomatitis. Often sufferers from severe, acute diseases are subjects of attack.

Symptoms.—The gums of the lower jaw are chiefly affected. They are at first congested, swollen and bleed readily. Pain is increased by mastication and deglutition, the mouth is hot, the breath fetid, the saliva dribbles and the digestion and bowels are disordered. The ulcers may appear at various points upon the cheeks, lips and tongue; the deposit is yellowish-gray.

In the more severe cases the gums are spongy and the teeth are loosened. In proportion to the constitutional disturbances, fever and enlargement and tenderness of the submaxillary glands occur. Even necrosis of the bone may follow.

(Thrush)

The exciting cause is a fungus known as Laccharomyces albicans. It is claimed that a catarrhal stomatitis is the soil upon which the fungus develops. Parasitic stomatitis is chiefly a disease of nursing children and is promoted by unhygienic conditions. It is seldom seen after ten years of age, occurring in adults only in the last stages of consumption, cancer, and severe chronic diseases.

Symptoms.—Upon inspection there are seen numerous milk-white elevations. These appear first about the angles of the mouth, soon extending to all parts of the mouth, and in a few cases, even to the pharynx and to the esophagus. When removed bleeding points are left. The general symptoms of stomatitis are present—pain upon mastication and swallowing; fetid, hot breath; increased saliva; increased temperature; restlessness; swollen lips and disordered digestion occur.

Diagnosis.—The microscope will remove all doubt as to the nature of the affection. In aphthous stomatitis the ulcers are preceded by the formation of vesicles.

Prognosis.—Is favorable in the majority of cases.

Treatment.—Hygienic measures, absolute cleanliness, correction of the disorders of the gastro-intestinal tract and local treatment as in other forms of stomatitis, is the required treatment. A boric acid solution will be found beneficial.

---

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Spasm of the Glottis)

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

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

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

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

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

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

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

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

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

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

(False Croup)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The duration varies from a few hours to several days.

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

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

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

---

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

---

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

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

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

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

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

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

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

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

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

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

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

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

Atrophic emphysema is a senile change.

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

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

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

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

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

(Croupous Pneumonia)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Catarrhal Pneumonia)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Fibroid Induration)

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

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

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

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

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

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

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

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

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

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

Treatment is the same as in the beginning of pneumonia.

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

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

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

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

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

---

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

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

(Fibrinous or Plastic Pleurisy)

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

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

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

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

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

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

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

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

Symptoms.—The onset may be abrupt with a chill, severe pain in the side and fever. With few exceptions the disease comes on insidiously, pain in the side being the first symptom. The pain is sharp and cutting and is aggravated by breathing or coughing. There is moderate fever, the temperature ranging from 102 to 103 degrees F. Dyspnea may be present at the onset. This is due to the fever and pleuritic pain. When the fluid is effused slowly, dyspnea may be absent except on exertion. It is most marked when the effusion has developed rapidly. As the effusion accumulates and the inflamed surfaces separate, the pain diminishes and, as a rule, soon disappears.

Physical Signs.—Immobility and bulging of the affected side, depending on the amount of exudation. The intercostal spaces are obliterated. The apex beat of the heart is displaced. Upon palpation the limited movement of the chest is more accurately determined. Tactile fremitus is largely diminished. The position of the heart’s impulse can be readily located by palpation. Displacements of the liver and spleen can be felt through the abdominal walls. At first the percussion notes are impaired and later there is dullness which gradually rises as the fluid increases. The upper line of dullness is not horizontal when the patient is in the erect posture, but is higher behind than in front. Above the effusion in the sub-clavicular region, percussion gives a tympanitic note, the so-called Skoda’s resonance. In moderate effusions the level of dullness often changes with the position of the patient. Early in the disease a friction rub can usually be heard. As the fluid accumulates, the breath sounds become weak, distant and may have a tubular or bronchial quality. Vocal resonance is usually lessened. There may be bronchophony, or it may manifest a nasal or metallic quality, resembling somewhat the bleating of a goat (Lænnec’s egophony). X-ray examination should be made.

Duration.—The course is extremely variable. The fever is due to inflammation and may last for two or three weeks, when it may subside. The cough and pain disappear and the effusion, which is usually slight in these cases, may be absorbed quickly. In cases where the effusion is poured out rapidly it may be absorbed just as quickly. In cases where the effusion is poured out slowly or where the effusion reaches as high as the fourth rib, recovery is usually slower. Large effusions may persist without change for months and finally the case may become subacute or chronic. This is particularly true of tuberculous cases.

Prognosis.—This depends largely upon the cause; on the whole, prognosis is favorable. Death is a rare termination of serofibrinous effusion; death may, however, occur suddenly without sufficient lesions to explain the cause. The exudate may become purulent.

An early treatment and rest in bed with a liquid diet are the measures to be employed at the beginning of the attack. Pay particular attention to any primary disease and to the general health. Rarely is there any difficulty in locating certain predisposing causes of the disturbance. Then often a rib or corresponding vertebra is badly subdislocated over the seat of the disease. The sympathetic and phrenic nerves are involved through the intercostal and phrenic nerves. A careful examination of the side of the affected chest should be made, as there may be more or less obstruction of the intercostals and the internal mammary arteries from their branching of the aorta and subclavian vessels. A dislocation of the first or second rib may affect the subclavian vessels and their branches markedly; although all the upper ribs and the thoracic muscles should be examined carefully for derangements which would affect these blood-vessels and produce an exudation. Ice-bags upon the chest, as in pneumonia, may be used. Limiting the movements of the chest with a bandage or adhesive strips will give considerable relief.

When the effusion has taken place, carefully raising and spreading the ribs with attention to special points of involvement, will at times cause absorption of the fluid. The daily amount of liquid food should be greatly lessened with a view of depleting the blood serum from various tissues; thus the serum collecting in the pleura, which is a lymph space, will also be absorbed. Treatment of the bowels, kidneys and skin, so that they may be rendered active, will aid in the depletion of the blood serum.

It may be necessary in some cases to aspirate, especially if other methods fail and if the effusion is large. The points of operation are in the mid-axillary line at the sixth interspace or at the angle of the scapula at the eighth interspace. In puncturing, the needle should be held close to the margin of the upper rib so as to avoid the intercostal artery. Withdraw the fluid slowly and if faintness is produced, desist.

Empyema should be treated surgically. Simply tapping is rarely sufficient. A free incision, as in abscess, and thorough drainage should be made. Care must be taken that the drainage tube is large enough.

“In cases of pleurisy the axilla and the inner arm may be tender and painful; this is due to the pleuritic inflammation being carried by the way of the ‘nerve of Wrisburg.’

“The pleuritic pain in the costal muscles compels restricted movement of the ribs and also limits the respiratory function of the diaphragm. These painful cramps and stitches are independent of the pain arising alone from the inflamed pleural surface, and the diminution of the respiratory movements is due to a particularly contractured state of the muscles of the chest as is demonstrated by the fact that the patient can not draw a long breath; hence one may reasonably conclude that nature has so distributed nerves to the pleura as to enable that serous membrane to control the muscles which create movements of the adjacent costal surfaces and thus insure its quietude during the stages of inflammation or repair.” (Ranney).

Definition.—Chronic inflammation of the pleural layers. There are two forms, exudative and dry or plastic pleurisies.

Chronic Pleurisy with Effusion.—This may follow an acute serofibrinous type. Some cases develop very slowly. In most cases in children, the fluid changes to pus early in the disease. The fluid may remain for months without changing to a purulent character. In such cases the character and physical signs do not differ from those in acute serofibrinous pleurisy.

Chronic Dry Pleurisy.—These cases originate in two ways:

First, this may succeed pleural effusion when the fluid portion of the exudate is absorbed and the pleural layers are opposed. They are separated only by fibrinous elements that become organized into firm connective tissue. This process goes on at the base, principally, which, if it follows the acute form, produces but slight flattening, but if it succeeds the chronic form or empyema, the extent of retraction and flattening will be marked. Calcification may occur in these firm, fibrous membranes and occasionally little pouches of fluid are found between the false bands.

Second, a large number of cases are dry from the onset. This condition may follow directly acute plastic pleurisy. It may be of tuberculous origin or it may set in without any acute symptoms. No matter how slight the plastic exudate may be, it invariably tends to become organized, thus producing adhesion of the layers. This is undoubtedly the result when the pleurisy is primary or secondary. The adhesions are generally circumscribed. When the adhesions are of tuberculous origin they may be locally confined to one pleura or they may be bilateral. In these cases both the parietal and costal layers are thickened, and embodied in the thickened pleura are found firm fibrin masses and small tubercles.

Occasionally, vasomotor symptoms arise in chronic pleurisy, especially in cases of tuberculous origin, and are probably due to the involvement of the first thoracic ganglion. These almost invariably mean that there is a displacement of the first, second, or third rib. Unilateral flushing or sweating of the face or dilatation of the pupil are frequently noticeable.

Symptoms.—Definite symptoms are rarely present. In some cases the physical signs are quite pronounced, while, on the other hand, they may be entirely negative. In mild cases there may be slight immobility of the affected side with feeble breath sounds. In other cases there may be very full chest expansion while the breath sounds are feeble. In a large number of instances the physical signs are quite distinct. There is displacement of the viscera, retraction of the chest walls, curvature of the spinal column and dropping of the shoulders. There are feeble breathing and creaking, leathery friction sounds. Dullness is found at the base.

Treatment.—The treatment of chronic pleurisy is largely that of acute pleurisy. Gymnastic and methodical breathing exercises should be employed in helping to correct the thoracic walls. Care must be taken not to injure the chest and pleura if adhesions have formed. Surgical work may be necessary in some cases.

The vasomotor symptoms that are sometimes manifested in chronic pleurisy and are claimed to be due to involvement of the first thoracic ganglion, are an interesting feature to the osteopath. Such cases would probably present to the osteopath a marked lesion of the upper dorsal vertebræ or the second or third rib. These vasomotor symptoms are also found in pleurisy associated with tuberculosis of the apex of the lung.

The osteopath frequently treats these cases and he should be cautious about over-treating or straining the chest wall. The adhesions are persistent and often there is more or less pain, so care must be exercised when attempting to structurally readjust. Do not expect to completely relieve every case, but nevertheless there are few cases but that can be benefited. Occasionally the pain alone is due simply to pleurodynia.

---

Definition.—An increase in the amount of blood to the vessels of the kidney. It is active hyperemia when there is arterial congestion, passive hyperemia when there is venous congestion.

Osteopathic Etiology and Pathology.—Active hyperemia may be caused by injuries to the renal splanchnics, especially the tenth to twelfth dorsal segments; injuries over and to the kidneys; exposure to cold when the body is very warm; poison given, as diuretics; eruptive fevers and pregnancy, or follow genito-urinary operations. Passive hyperemia may be caused by obstructive diseases of the general circulation, as chronic heart, lung and liver diseases, or by pressure on the renal veins by tumors, growths and the pregnant uterus. Thrombosis of the renal veins may produce passive hyperemia, but rarely.

Pathologically, in active hyperemia the kidney is swollen and slightly enlarged. Upon removal of the capsule, the kidney is found to be brown and mottled. On section the parts bleed freely, the Malpighian bodies are distended, and microscopical examination shows a cloudy swelling of the renal epithelium. In passive hyperemia the kidney is swollen, hard, firm and of a bluish red color. Later there is an overgrowth of connective tissue and some infiltration between the tubules. The Malpighian bodies occasionally become shriveled and the renal epithelium fatty.

Symptoms.—In active hyperemia the urine is scanty, of high specific gravity and of high color, containing some albumin and casts. Pain is experienced over the loins, following the course of the ureters, and the bladder is irritable. There are headache, nausea and vomiting. When from infection, fever may be present.

In passive hyperemia the symptoms are primarily those caused by the disease producing the disorder. There is weight over the loins and dropsy. The urine is diminished, of high specific gravity, highly colored, albuminous and occasionally shows a few hyaline casts.

Prognosis.—Active hyperemia.—Usually favorable if it can be treated in time. If prolonged, acute nephritis may develop. Passive hyperemia.—Depends on the cause. If the disease is prolonged, it terminates in interstitial nephritis.

Treatment.—Active hyperemia.—Absolute rest and thorough treatment to the renal splanchnics and treatment over the abdomen to the kidneys directly by carefully raising them. Adjust the lower ribs if found lesioned. Water should be drunk liberally and the patient encouraged to use vapor baths. Favorable hygienic surroundings, warmth and good food are indispensable. Warm applications over the loins are helpful.

Passive hyperemia.—The treatment largely depends upon the cause, but too much importance cannot be given to the treating of the vasomotor fibers of the kidneys from the eighth dorsal to the first lumbar. Textbooks state that the vasomotor fibers to the kidneys are from the ninth to the twelfth dorsal vertebræ, inclusive, but osteopathic experience shows we can affect vasomotor fibers slightly higher. Treatment here has a distinct effect on the blood pressure within the glomeruli. The renal epithelium is extremely sensitive to circulatory changes. Even the compression of a renal artery for only a few minutes causes marked disturbances. Hence any irritation or obstruction to the vasomotor innervation of the renal blood-vessels may result in serious conditions. The superior cervical ganglion of the sympathetic and the sciatic center have important bearing on the secretions of the kidney, through vasomotor fibers. Due attention should be paid to the bowels, and the patient required to take plenty of rest and a light diet.

(Acute Bright’s Disease)

Definition.—An acute, inflammatory process affecting the epithelium of the uriniferous tubules and due to the action of cold or toxic agents upon the kidneys, as well as to injuries to the renal splanchnics; is characterized by certain nervous symptoms with fever, dropsy, and scanty and highly colored urine. This inflammation involves more or less the whole kidney.

Osteopathic Etiology and Pathology.—This disease is caused by exposure to cold and wet while the body is warm and perspiring. Excessive use of alcohol may be a factor. May be caused also by infectious diseases, such as scarlet fever, diphtheria, measles, smallpox, acute tuberculosis and others; also by certain specific poisons which are eliminated by the kidneys, as turpentine, chlorate of potash, carbolic acid, phosphorus, ginger, cantharides and oil of mustard; also by pregnancy, as this is supposed to compress the renal veins, or through toxic agents. Syphilis may be an underlying cause. Blows and injuries to the back at the tenth, eleventh and twelfth dorsals are frequently the cause. Lesions are found from the sixth dorsal to the fourth lumbar. The lower three ribs may be at fault, while the innominate and muscular contractions have been found to be pathological factors. Lordosis may be a contributing cause. Loudon places considerable importance on cervical lesions and McConnell believes vasomotor disturbance plays an important causative role in the disease.

Pathologically, at times the kidney alteration may be so slight as not to be recognizable by the naked eye, the appearance varying according to the stage and severity of the disease. The kidneys become enlarged, engorged and of a bright red color, and later have a mottled appearance; and when the capsule, which is non-adherent, is stripped off, the kidney is found to be soft and inelastic. In most of the cases in which the disease is due to toxic agents brought to the kidney through the blood-vessels, the glomeruli suffer first. The epithelium of the glomeruli and tubules is the seat of cloudy swelling and, in the later stages, of fatty change and hyaline degeneration. The tubules are clogged by altered cells, leucocytes and blood-corpuscles. In mild cases the interstitial tissue is simply inflamed, but in all cases it becomes more or less mixed with leucocytes and red blood-corpuscles. Osteopathic lesions produced upon animals in the region of the ninth to the twelfth dorsal, resulted in acute nephritis. The autopsy findings were distinctly typical.

Symptoms.—The onset is usually sudden, with moderate fever, pain in the back in the lumbar region and over the kidneys and following the ureters. Nausea and vomiting may be present. Dropsy soon appears, beginning with slight swelling or puffiness in the face below the eyes, later showing itself in edema of the abdominal walls and extremities. Uremic symptoms may develop. The urine is characteristic; is diminished in quantity and of high specific gravity; at first the sediment is copious and reddish brown in color, becoming less in amount and of high color. This sediment contains casts of the uriniferous tubules, free blood, epithelial cells, uric acid and urates. There are large quantities of albumin in the urine.

The presence of albuminous matter in the urine, even in large quantities, is not sufficient evidence to warrant a diagnosis of Bright’s disease nor is the amount a guide as to the severity of the case, for grave conditions often show a slight amount (Loudon).[98]

Diagnosis.—The general symptoms may be very slight, for the most severe cases may manifest slight edema of the feet, or there may be only the puffiness under the eyes and of the eyelids. In such cases the diagnosis must depend upon examination of the urine. With previous history, suddenness of the attack and character of the urine, ordinarily the diagnosis will be quite easy.

Prognosis.—Although this disease is generally grave, the prognosis is favorable and the majority of cases recover under judicious treatment.

Treatment.—Cases of acute nephritis require rest, quiet and warmth. Many cases recover under these conditions alone. It is absolutely necessary, however, that these conditions exist no matter what other treatment is used. A thorough treatment to the renal splanchnics cannot be overestimated for it is here (tenth to twelfth dorsal, inclusive) that a majority of the lesions producing acute nephritis occur. Besides correcting the vertebral and rib displacements in this region, a very effective treatment is to have the patient lie flat upon the back and then the osteopath, reaching around the patient with the fingers of one hand on either side near the spines of the lower dorsal vertebræ, raise the patient so that the entire body, except the shoulders and the feet, are lifted clear of the bed. Thus the treatment springs the spine anteriorly and produces a marked effect upon the kidneys through the renal vasomotor nerves. Occasionally lesions in the upper cervical region interfere with the normal activity of the renal nerve fibers passing to the kidneys by way of the superior cervical ganglion of the sympathetics.

Another very effectual treatment for the kidneys is treating them through the abdomen by a careful pressure upon the kidneys through the abdomen on either side of the umbilicus, thus lightly working each kidney outward and upward. This treatment relaxes any tissues about the blood-vessels, nerves and lymphatics to and from the kidneys that may be contracted and thus aids in establishing a normal activity of the involved organs. It also helps in relaxing tissues about the ureters and prevents the clogging up of the latter with debris. Bandel and Stearns report cases in which an impacted colon was an important factor in this particular.

The above means have for their object the direct relief of the congestion of the kidney. This is further aided by keeping the bowels active, which supplements the action of the kidneys, and by increasing the activity of the skin. This also aids in relieving dropsical effusions. The hot pack, in which the patient is wrapped in a wet sheet and then covered by a number of blankets, is an exceedingly good method to relieve the kidneys of some of the work and lessen their congestion, besides arresting uremic intoxication. This can be repeated daily if necessary. Where there is dropsy and scanty urine, the indications are to increase the secreting action of the kidney; besides treatment through the renal splanchnics, which contain the vasomotor nerves of the kidneys, stimulating treatment to the vagi will help to increase the urinary secretion. Hot fomentations, placed directly over the region of the renal splanchnics, is a valuable aid in cases which do not respond quickly to osteopathic stimulation. Treatment of the liver is important. Injections of cold water into the intestines will tend to stimulate the secretion of the kidneys, but this should be used with the greatest caution; in some cases tepid water would be better (see uremia).

The diet of the patient with acute nephritis is important. Give food that is easy of digestion and which contains a minimum amount of nitrogen. The stomach is quite likely to be irritable, consequently food that is adapted to it should be selected. Milk and weak animal broths are undoubtedly the best foods. The return to a solid diet, especially of meat, should be very slow. Suitable adjuvants to the milk diet are rice and farinaceous preparations. Loudon[99] recommends complete withdrawal of all foods for twenty-four to forty-eight hours and the reducing of nitrogenous foods to a minimum; a diet of milk and cream after the fast, followed by cereals and broths, then eggs and fish until albumin disappears from the urine. Alkaline mineral waters are useful to help maintain an alkaline urine, thus tending to withdraw exudates. The patient should be treated daily at first and later on every other day, for case reports show frequent treatments hasten recovery.

For treatment of acute uremia in Bright’s disease, see uremia. Complications should be treated as affections independent of the renal disorder.

Definition.—A chronic inflammation of the kidney, involving the epithelium, glomeruli and interstitial tissue, characterized by dropsy, increasing anemia, albuminous urine and acute uremia.

Osteopathic Etiology and Pathology.—It may be the result of acute nephritis. It follows the same diseases as already mentioned in acute nephritis. More often it follows the same diseases as already mentioned in the acute form, syphilis, tuberculosis, purulent conditions, focal infections (streptococcus), alcohol, scarlatina and pregnancy contributing the greater number. It is more common in the male sex and in early adult life. Habitual exposure to cold and dampness; chronic lesions of the spine, chiefly in the lower dorsal region, are causative factors.

Pathologically, the large white or a yellowish white kidney is the most common kidney lesion. In this form the kidney is enlarged, often to twice its normal size, is smooth, and the capsule very thin. The tubes, on microscopic examination, are found to be choked with broken down granulated epithelium and fibrinous casts. The capillaries show hyaline changes. The interstitial tissue is increased everywhere, but not to an extreme degree. Catarrhal swelling and hyperemia (to a slight degree) are found in the pelvis of the kidney.

In the second stage—that of the small white kidney—there is a reduction in the size of the organ, due to the destruction of the renal epithelium and the contraction of the overgrown connective tissue. Some hold that this may be a primary, independent form and not always preceded by the large white kidney. The organ is pale in color, rough and granular, the capsule being thickened and somewhat adherent. There is an accumulation of fatty epithelium in the convoluted tubules, constituting marked areas of fatty degeneration and giving the organ a white or whitish yellow appearance. It is this which gives the name of small granular fatty kidney to this form. There are extensive interstitial changes, degeneration of tubules and destruction of great numbers of the glomeruli.

Chronic hemorrhagic nephritis is a variety associated with this stage. The organ is enlarged, and scattered throughout the cortex are found brown hemorrhagic foci due to hemorrhages into and about the tubes. Otherwise the changes are similar with those found in the first form.

Symptoms.—It usually begins as a chronic affection and the symptoms slowly become apparent. Failing health and loss of strength, dyspepsia and anemia, waxy appearance with puffiness of the face, dropsy and increased arterial tension with hypertrophy of the left ventricle, gradually make their appearance. Uremic symptoms are common, while dropsy is marked and persistent. Vomiting and sometimes profuse diarrhea occur; in fatal cases there is sometimes found to be ulceration of the colon. The urine, as a rule, is diminished in quantity, is often very scanty, although it is frequently normal in color and appearance. There is an abundance of albumin, heavy sediment, hyaline and granular tube casts, epithelium from the kidneys and pelvis, leukocytes and often red blood-corpuscles. If fatty degeneration takes place, there will be fatty casts and oil globules. In the later stages the urine is abundant, low specific gravity, considerable albumin, and many casts.

Diagnosis.—In the inflammatory stage, where there is enlargement of the kidney, extreme pallor, scanty urine, albumin, and tube casts, history of infections, pregnancy, or exposure to cold and wet, and lesions in the lower dorsal region, the diagnosis is clear.

Prognosis.—Always give a guarded prognosis; relapses are frequent, but cases have been cured. There is always a tendency for the subchronic forms to become chronic.

Treatment.—The treatment requires persistent work, especially over the renal splanchnics, and strict attention on the part of the patient to hygienic principles. The lower dorsal lesions are very apt to be refractory owing to extensive fibrotic changes of the deep muscles and capsular ligaments. But repeated effort will usually secure results. Care should be taken as to exposure to cold and overexertion. The quality of the blood should be improved, as it is anemic and contains various toxic products. Strict attention should be paid to the diet. Iron is largely used for anemic conditions, but this principle we hold to be wrong. It is not more iron that is wanted, but an ability of the system to assimilate the iron which it has. Relative to diuretics von Noorden says: “It would be the greatest paradox to economize the renal work to the utmost in one direction (diet, sweating, etc.) and on the other hand excite them to increased activity by means of the strongest stimulants we possess, (drugs). I regard such prescribing as radically wrong.” The diet should be carefully selected and of minimum amount. The pure milk diet is undoubtedly the best. The use of meat seems to favor uremic convulsions.

The digestive organs should be kept in as good condition as possible, particular attention being paid to the liver and bowels. The use of suitable clothing is important; wool should be worn next to the body. The skin is a powerful adjuvant to kidney elimination, and the suppression of the action of the skin throws extra work on the kidneys. Possibly stimulation of the lung function would aid in the elimination. Rest, with a proper amount of fresh air and outdoor exercise, is essential.

In conditions calling for attention to the skin and bowels the treatment will be the same as in acute parenchymatous nephritis. There is a ganglion on each side of the umbilicus within a radius of an inch that sends fibers to the kidneys (Dr. Still). Just what is the function of these ganglia is unknown. The treatment of the complications is independent of that for the renal trouble. For direct treatment to the kidneys see acute Bright’s disease.

Definition.—A chronic inflammation of the kidney in which there is reduction in its size due to an extensive destruction of the tubular substance, with an overgrowth, and later a contraction, of the connective tissue elements. Cardio-vascular changes, arteriosclerosis and cardiac hypertrophy are usually associated.

Osteopathic Etiology and Pathology.—Osteopathic lesions to the renal splanchnics are important predisposing causes. The disease may follow parenchymatous nephritis; or it may be caused by a continued passive congestion due to valvular heart disease. Gout; cystitis (often following gonorrhea), the inflammation extending up the ureters to the kidney; heredity; old age; long continued worry, anxiety or grief; chronic alcoholism, overeating; syphilis; tuberculosis; focal infections, especially of streptococci; chronic mineral poisoning (as from lead), and alterations in the renal ganglionic centers are causes. It chiefly occurs in males during middle life.

Pathologically, both kidneys are involved (although one may be more affected than the other), and reduced in size, often to less than half their normal size. After removing the capsule, which is thickened and adherent, the surface is found to be uneven, or granular and containing small cysts. The kidney is hard, tough and resistant, the color varying from a darkish brown to a yellowish gray. The cortical portion is especially reduced in size. On microscopic examination, the connective tissue appears greatly increased; this contracts, compressing the tubules and blood-vessels, causing their destruction. There is general arterial sclerosis, and the left side of the heart is hypertrophied. There are frequent nasal and retinal hemorrhages, due to the brittleness of the arterial walls which predispose them to rupture; hence, apoplexy is a frequent termination. The ganglionic centers, being interfered with, undergo fatty degeneration and atrophy. There are marked retinal changes—retinitis, fatty degeneration of the retinal tissues and sclerosis of the nerve fiber layers.

Symptoms.—The onset is insidious. In most cases the symptoms are latent. The general health is disturbed; there are frequent micturition, gastric disturbances, tense and bounding pulse, hypertrophy of the left ventricle, high blood pressure, disorders of vision, sleeplessness, headache, furred tongue, slight swelling of the feet, dry skin, scurvy and shortness of breath. The urine is increased in quantity, of acid reaction, light in color, low specific gravity, with a small amount of albumin, a few hyaline casts, and some epithelial cells. There is increased thirst and the patient may have to urinate two or three times during the night. There is well marked mucous cloud, slight sediment, and as the disease advances the urine may be diminished, the albumin increased and the casts become more numerous, while occasionally blood cells will be found.

Much importance should be attached to the blood pressure condition.

Diagnosis.—The early stages are not always recognizable. Later, while there is high arterial tension, thickening of the arterial walls and marked hypertrophy of the heart, the urine should be examined very carefully both night and morning, as the diagnosis will greatly depend upon the condition of the urine, which is increased in quantity, of low specific gravity, with a trace of albumin, narrow hyaline and pale granular casts, making the diagnosis usually easy.

Prognosis.—It is generally incurable, but favorable so far as the power to prolong life is concerned, provided the diagnosis be made early in the case, and the patient lives a quiet life. The case usually terminates with convulsions, coma and death. Apoplexy is frequently associated with chronic nephritis. In all forms of chronic nephritis some intercurrent infectious disease is quite possible, which is apt to be serious owing to the cachectic state.

Treatment.—The dietetic and hygienic treatment is the same as in chronic parenchymatous nephritis. The nerve and vascular supply to the kidneys should be treated as in acute parenchymatous nephritis. Freedom from worry and overwork, and if possible change of climate, should be prescribed. Frequent bathing, with friction of the skin, should be insisted upon and the bowels kept regular by a treatment of alkaline water. In all kidney cases special attention should be given the liver. The alkaline water is a good diuretic; besides it flushes the kidneys and helps to remove the debris.

These cases invariably present a rigid spine which should be carefully but thoroughly treated, traction being one of the methods that give comparatively quick and excellent results. Overcoming spinal immobility, correction of the dorsal area, attention to the chest rigidness, and frequently raising the abdominal organs will often considerably reduce the blood pressure.

The accidents and complications which so often endanger the patient, must be treated as they arise.

Definition.—A pathological state of the kidney in which there is a peculiar infiltration into the kidney structure of an albuminoid material of a waxy appearance.

Etiology and Pathology.—This is associated with Bright’s disease and other wasting diseases. It is most frequently caused by profuse and long continued suppuration, especially of the bones, by syphilis, tuberculosis, cancer, lead poisoning and gout.

Pathologically, the kidney is large and pale, but it may be normal in size or even small, pale and granular. The capsule is not adherent, the surface of the kidney, after removing the capsule, is pale and anemic. On section the cortex is seen to be enlarged. It is homogeneous, anemic, pale, waxy and resisting. On microscopic examination there is found to be an infiltration of a homogeneous or wax-like material. This progresses until all parts of the organ are infiltrated. As the result of this pressure the structures of the kidney undergo an atrophic degeneration, the kidney becoming contracted, smaller, rough and even distorted in shape. The cortex becomes narrowed and the capsule adherent. If a section of an amyloid kidney be stained with a solution of iodine, numerous mahogany red points appear.

Symptoms.—There are similar changes in the liver, spleen and often the intestinal canal. There is a profuse, watery diarrhea, due to amyloid changes in the intestinal canal, with loss of flesh and strength, edema of the lower extremities, and ascites. There is an increased flow of pale, watery urine, of low specific gravity; albumin is abundant and usually hyaline, often fatty or finally granular tube casts occur.

Prognosis.—As a rule the prognosis is decidedly unfavorable and it must be controlled by the disease with which it is associated.

Treatment.—The primary disease demands attention, otherwise the measures of treatment indicated are those of chronic parenchymatous nephritis, with special attention to the general health and surroundings of the patient. Give a generous diet and be persistent with the treatment.

Pyelitis is inflammation of the pelvis of the kidney. When a suppurative inflammation extends into the interstitial tissue of the organ, it produces a condition called pyelonephritis. The inflammation usually starts in the pelvis of the kidney, the infection being carried there either by the circulation or the urinary tract, but it soon involves the rest of the kidney. Pyelitis is usually secondary to some other conditions such as urethritis, cystitis, or ureteritis. “Infection of the kidney rarely takes place through the blood and only when the vital membrane of the kidney is impaired.” It may start from within the organ in the interstitial tissue, caused by infectious embolism or traumatism, or the tubules may become obstructed by concretions.

Osteopathic Etiology and Pathology.—Retained decomposed urine due to pressure upon the ureters by tumors or bladder disease; calculus concretion, kinked ureter, displaced kidney, traumatic agencies, as falls, blows, strains, kicks or penetrating wounds; nephritis, pregnancy, cold and wet, are causes. Pyelitis may follow cystitis, the inflammation extending up the ureters to the pelvis of the kidney and thence to the substance of the organ, inducing pyelonephritis. Tuberculosis, focal infections, and intestinal disorders (colon bacillus), are other causes. Lesions from the ninth dorsal to second lumbar or lower, and malnutrition are predisposing factors.

Pathologically, the mucous membrane of the pelvis is usually the first affected, the inflammation generally extending from below upward. It is swollen and sometimes visibly congested and of a gray color. The pelvis and calyces are more or less dilated, while the papillæ are flattened. There is a gradual dilatation of the calyces and atrophy of the kidney substance, until the whole organ may be converted into a pus sac. If complete obstruction occurs, the fluid portion may be absorbed and the pus become inspissated and cheesy. The ureter is often dilated. In tuberculous pyelitis the apices of the pyramids are also invaded, the kidney substance is broken down and the result is the same. In the pyelitis caused by cystitis, the infection passes up the tubules or is carried by the lymphatics. The abscesses extend along the pyramids, burst through the papillæ and calyx into the pelvis of the kidney, and thus also the kidney becomes a purulent sac.

Symptoms.—Pain and tenderness over the region of the kidney first appear. In a few cases cystitis will be the only symptom. The suppurative stage is marked by high fever and a chill or a succession of chills. The general condition of the patient denotes prolonged suppuration. There is failure of health and more or less wasting and anemia. The urine is characteristic, contains pus, which varies in quantity greatly, and where only one kidney is affected, may be suppressed for a time and there will be a sudden outflow of the pus, due to the breaking of the sac. Blood is also very constant, but hardly ever of sufficient quantity to be seen by the naked eye. The urine is usually diminished in quantity and the color pale; the specific gravity is low on account of the small amount of urea present. The reaction of the urine is acid. Pus and blood render the urine slightly albuminous. Casts from the kidney, and even portions of the kidney, may be present.

Diagnosis.—From nephritis by the absence of much albumin, tube casts and dropsy. From cystitis, by the history, lumbar pains and acid urine. In cystitis the urine is always alkaline. From perinephritic abscess, by the absence of edema over the lumbar region. The urine may be normal and there are lumbar pains and hectic fever. In tuberculous pyelitis there is a history of tuberculosis in other organs and there are tubercles in the urine. Malaria or typhoid may be suspected. The X-ray and cystoscope should be employed. An exploratory incision may be necessary.

Prognosis.—Depends altogether on the cause and extent of kidney involvement. In simple cases and some tubercular, recovery may occur, although there is a tendency in all cases for the disease to become chronic.

Treatment.—Depends upon the cause, but thorough treatment along the lower dorsal, the lumbar and sacral regions will be of considerable benefit in controlling the catarrhal process in the kidney, its pelvis, the ureter and the bladder. If pathology permits, gently raising the kidneys, ureters and neighboring organs, knee-chest position, will materially assist circulation and drainage. Fresh spring waters for diluents and restricting the diet to light food, preferably milk, are indicated. Rest is important and warm applications locally are sometimes helpful. The general health must be carefully watched as there is always considerable drain upon the system. A timely operation may materially lengthen the life in many cases. Attention to the bladder, urethra and prostate is necessary.

The name applied to a series of manifestations resulting from the retention of poisonous materials in the blood, which should have been removed by the kidneys. Uremic symptoms may occur any time during an attack of nephritis. In chronic cases it seems likely that extensive destruction of renal tissue is the principal factor that leads to the toxemia. They may also occur when the circulation of the blood in the kidneys is interfered with or the ureters are obstructed. They are not due alone to the urea (which is found to be increased in the blood), but more probably several poisons that are retained in the blood. Traube’s theory is that acute cerebral edema with anemia accounts for the symptoms. Halbert says: “A more recent and more plausible claim is to the effect that a poison is developed in the body as the result of nephritis,” for retention of effete matter or ligation of renal arteries and ureters or impaired renal activity does not fully explain the cause of the stupor, coma, convulsions, sometimes paralysis, and gastro-intestinal disorders.

Symptoms.—Loss of appetite, nausea, vomiting, headache and drowsiness are the initial symptoms. Headache is usually at the back of the head and may extend down the neck. The next symptom is coma, alternating with convulsions which may range from only a slight twitching to violent epileptiform spasms. These spasms may occur without the slightest warning and are often followed by blindness which may last for several days. These attacks of coma and convulsions are sometimes ascribed to localized edema of the brain.

Transient paralysis is also due to congestion or edema of the brain and it may be of the cord. There may be mania which comes on abruptly, although the delirium is not at all violent, while profound melancholia may be found. There may be nervous symptoms develop, such as numbness in the hands and fingers, itching of the skin and cramps in the muscles—especially those of calves of the legs. Pulmonary symptoms are sometimes continuous—dyspnea, paroxysmal dyspnea and Cheyne-Stokes’ breathing. These attacks of dyspnea may be as distressing as true asthma. Cheyne-Stokes’ breathing may be present without coma.

Uncontrollable vomiting may set in with great abruptness, followed by hiccough and purging. There may be a catarrhal or diphtheritic inflammation of the colon with diarrhea. The breath has a urinous odor and the tongue is often very foul. The pulse is slow and full, with a temperature below the normal, although during convulsions the pulse may become rapid and the temperature rise. Occasionally there are atypical forms of uremia which may be very confusing and obscure.

Diagnosis.—The history, subnormal temperature, the urinous odor of the breath, high arterial tension and increased second sound of the heart will distinguish the condition. Feeling of numbness, palpitation, headache, restlessness, mental wandering are not infrequently early symptoms. The phenolsulphonephthalein test for the secreting power of the kidney, and the examination of the urea in the blood are of great aid in diagnosis.

Prognosis.—Extremely grave, but one should always be very careful in his prognosis, for there is a possibility of recovery, even after the most serious symptoms have been manifested.

Treatment.—As impermeability of the kidneys produces uremia, by not allowing the various poisons to be eliminated by the renal path as they should be, the treatment must be applied directly to the kidneys. Elimination is demanded and if treatment through the abdomen to the kidneys directly and to the renal splanchnics does not bring about prompt and thorough elimination of the intoxicating properties, the bowels and skin must be made active. The vapor or hot air bath or hot pack should at once be used. An ice-bag to the head will be beneficial. An increase in the quantity of urine may be brought about by the displacement of a part of the mass of blood, which is in relative stagnation in certain parts of the vascular system. Forcing it into the main circulation in order to increase the pressure within the vessels of the kidney, is the treatment indicated. This great stagnant mass of blood is found in the arterial capillaries of the portal system in the liver and splenic tissues and should be manipulated into the general circulation in order to increase the arterial tension of the kidneys and thus favor elimination. The treatment should mainly be applied to the vasomotor nerves of the portal system, from the fifth to the ninth dorsal, and directly over the abdomen, liver and spleen.

The introduction of water, from 110 degrees to 120 degrees, or even 150 degrees, into the colon by means of injections, is useful; warm irrigations increase renal secretion, bowel action and sweating with a decrease of tension. Cold drinks will stimulate the abdominal vessels and induce absorption of a certain quantity of water to still further increase diuresis. Cold irrigation increases blood pressure temporarily, but later it lessens the pressure; it should be used only with great caution. Milk is one of the best drinks to be used. Secretions of the liver must not accumulate. The bile must be expelled so that its toxicity will not be added to the other poisons.

The food of the patient is an important matter. A milk diet is best; avoid meat and nitrogenous foods and any food that leaves much residue. In this way the nutrition of the patient is kept up with a minimum of urea formation and, besides, there will be very little intestinal putrefaction. Emergency measures not mentioned above are repeated high normal salt enemata (two to three pints), the alcohol sweat and venesection (about one pint). When the attack is broken the condition resolves itself into the renal disorder, generally acute Bright’s disease.

This disease illustrates one phase of the uselessness of drugs; for when the impermeability of the kidney has become such that it ceases to have the power of eliminating toxic substances formed by the organism, there is then retained the medicinal substances. The kidney is as impermeable for therapeutic poisons as for the natural poisons and the employment of toxic medicines in such cases has often no other effect than to bring an association of medicinal intoxication with an uremic.

Renal calculi are concretions formed by precipitation of solids derived from the urine, and are found in the kidney or its pelvis. If large, they are called stones; the smaller masses are known as gravel or sand, according to their size. When the stones attempt to pass through the ureters, it brings on an attack of renal colic; rarely are they voided without this symptom.

Osteopathic Etiology and Pathology.—The affection occurs at all ages, more commonly, however, in children and in old people. The male sex is more liable than the female. Sedentary habits, gout and excessive meat eating are predisposing causes. Heredity seems to be a predisposing cause in some families. Inflammation of the pelvis of the kidney, caused by derangement of the ribs and vertebræ of the tenth, eleventh and twelfth dorsals or first lumbar, is an important etiological factor.

Pathologically, the chemical varieties are:

(1) Uric acid and urates are the most common. The stones are usually smooth or lobulated; are hard and of a reddish color. Usually in these stones, both uric acid and urates are to be found. This material may be passed in the form of sand or large stones. The sediment in the urine may be the nuclei of the stones; as may foreign matters, such as the mucus or desquamated epithelium caused by the inflammation of the pelvis of the kidney, blood clots, or, in fact, any foreign matter that may reach the urinary passages. Individuals passing a small amount of urine, and old people are the principal subjects. “As a consequence of concentration and high acidity of the urine, the uric acid and urates are readily separated in solid form and held together by the albuminous matrix.”

(2) Phosphatic Calculi are white in color, soft and mortarlike. They are composed of phosphate of lime, ammonia and magnesium phosphate. These are found more often in the bladder than the kidney. Disease of the bladder is the cause.

(3) Oxalate of Lime are a mixture of oxalate of lime and uric acid. They are dark in color, very hard and uneven, with hard, pointed projections. On account of their uneven shape they have been named mulberry calculi. These stones produce great pain as they pass through the ureters.

There are other concretions of rare occurrence.

Symptoms.—There is pain in the back in the region of the kidneys with more or less tenderness. The pain may be severe and paroxysmal. There may be bleeding, which is seldom profuse; this will give the urine a smoky hue, but may be present to such a small degree as to be only apparent by the use of the microscope. The stone may obstruct the ureter and cause pyonephrosis or hydronephrosis. Pyelitis of a catarrhal character is common. In pyelitis there may be intermittent fever of several degrees, then sweating. There may or may not be pus in the urine.

Renal Colic is caused when the calculus attempts to pass through the ureter so that ureteral spasms result. The stone, however, may become lodged at the entrance to the ureter. There is a sudden onset and great pain which starts in the back, radiating downward into the groin, down the side of the thigh and into the testicle and glans penis. The testicle is often retracted, the face pale, the features pinched, and there is frequently vomiting. There are cold sweats and the pulse is weak. The paroxysm may last only a few minutes or extend over several hours. If uric acid is found, it points to uric acid or oxalate of lime calculi and the urine is acid in reaction. If alkaline phosphatic stones may be suspected, examination of the urine directly after the attack aids greatly in diagnosis, for at other times the urine is usually negative.

Diagnosis.—Biliary Colic.—The jaundice in biliary colic comes on very soon after the obstruction begins. The stools are without bile and the pain extends from the right hypochondriac region to the upper abdomen and the right shoulder. The urine is negative and a stone may be passed in the stools. Renal colic is often simulated when the ureter is obstructed from any cause whatever. It may be compressed from a floating kidney or tumor, or obstructed by a clot of blood, fragments of hydatid cysts or plugs of mucus. Lumbo-abdominal neuralgia, intestinal colic, and renal tuberculosis may simulate renal colic. The X-ray plate is of decided value.

Prognosis.—As complications may arise, it is best to give a guarded prognosis, but the prognosis is generally favorable. It is a disease that is very apt to recur when strains or falls affect the innervation to the kidney, but many cases have been permanently cured. If the stone is large, its passage along the ureter may prove fatal unless surgical interference is instituted at once, but if it is renal sand it may be easily voided in the urine and thus the prognosis will be favorable.

Treatment.—Treatment should be given toward overcoming the cause producing the calculi, which will often be found at the tenth rib. Treat the kidneys thoroughly, both through the renal splanchnics and directly through the abdomen, anteriorly. But direct abdominal treatment should be given very cautiously. Treatment here corrects disorders and seems to release some solvent that acts upon the various forms of calculi and disintegrates the ones already formed and prevents the formation of others. Possibly this solvent is an internal secretion of some gland; possibly like the splenic secretion is to the biliary calculi (Dr. Still.). Dr. Still held that one of the functions of the suprarenal capsule was to prevent the formation of these concretions.

In the uric acid tendency, the free use of alkaline mineral waters for the solution of uric acid may be helpful. Much may be done by dieting. The amount of nitrogenous food should be limited, eating a minimum amount of meat and using plenty of milk and vegetables. In the phosphatic tendency, diluted drinks freely used are helpful. Meats are indicated. Milk and vegetables should not be used freely as they tend to make the urine alkaline. In all instances care of the general health and avoidance of beer drinking and excessive meat eating are demanded.

During an attack of renal colic, when a stone had lodged in a ureter, one may be able, by very careful manipulation, to aid the stone in its progress downward, (somewhat after the manner of manipulating gall-stones), but do not delay surgical measures too long. By inhibiting the nerve force of the spinal nerves along the lumbar and sacral regions (chiefly tenth dorsal and first lumbar), relief may be given. The nerves of the ureters are derived from the inferior mesenteric, spermatic and pelvic plexuses. Employ the hot bath; this may relax the spastic condition. Cloths wrung out of hot water and applied locally are of aid. Occasionally a change of posture will give relief. Even inversion of the patient is sometimes followed by immediate cessation of the pain. The patient may drink freely of hot lemonade or water. An anesthetic may be of aid in the manipulation of a renal calculus in the ureter, as the anesthetic will relax the tissues over the abdomen, making it much easier for one to get near the impacted calculus, but be cautious. Morphine may be necessary. During the intervals the patient should lead a quiet life and avoid sudden exertions of any kind. It is important to keep the urine abundant, consequently have the patient drink a large quantity of distilled water. “Renal calculus is brought about by lesions affecting the suprarenal capsule of the kidney, or spinal lesions from the tenth dorsal to the first lumbar, affecting the lower ribs.”

This means a distinctly mobile condition of the kidney (almost always acquired, but may be congenital), due to the lax condition of the tissues which support it and to the elongation of the renal vessels which allow the kidney to move in certain directions. Rapid loss of tissue that absorbs the fat surrounding the kidney is a cause. There are almost invariably lesions in the dorso-lumbar region that predispose to an abnormal mobility of the kidney. These lesions undoubtedly weaken the innervation to the surrounding and supporting kidney structures. A posterior spine, with consequent downward and constricting displacement of the floating ribs, is common, although lateral and anterior spines (dorso-lumbar region) may be found. Strains, heavy lifting, and various violent exertions are important exciting factors. Tight lacing, pregnancies, an enlarged liver and gastro— and enteroptosis are also important factors. This condition is found more commonly in women, and undoubtedly is a frequent cause of direct, gastro-intestinal, reflex, and obscure disturbances. There are very different degrees of mobility in different cases. It may be so slight as hardly to be recognized or so great that it can easily be felt by the hand through the abdominal walls, resembling a movable tumor in the abdomen.

Symptoms.—Often there are no noticeable symptoms. Sometimes when the displacement and mobility of the kidney are most marked, the reflex symptoms are not noticeable. The right kidney is the one usually affected, on account of its relation to the liver which moves during the respiratory act. Usually there is pain in the lumbar region and the patient experiences a heavy, dragging pain in the abdomen, which especially manifests itself while standing and walking. There may be intercostal neuralgia. Various colicky and other gastro-intestinal pains, and nervous symptoms as neurasthenia, melancholia, hysteria and headache are common. There may be obstinate indigestion, palpitation of the heart, flatulence and cardialgia; also, an irritable bladder, due to pressure. At times the kidney becomes tender and swollen as a result of twisting of the renal vessels or of the ureter (Dietl’s crises), causing engorgement of the organ; this may be associated with agonizing pain and symptoms of collapse. Hydronephrosis may be manifested.

Diagnosis.—The shape of the tumor, marked mobility, and lessened resistance on percussion of the renal region will make the diagnosis. The disorder very rarely proves fatal. In doubtful cases utilize the X-ray.

Treatment.—Many cases rarely give trouble directly, but may be a source of reflex and obscure symptoms. Attention to the general health of the patient and persistent treatment of the dorso-lumbar region greatly strengthen the relaxed tissues about the kidney and cure a number of cases. Having the patient attempt to replace the organ after he goes to bed will be of value. Treatment of the abdomen to strengthen the walls and lessen any liver congestion and to keep the bowels active is very beneficial. Teach the patient how to stand and walk correctly, especially holding the abdomen in and up. A liberal diet to the point of increasing the weight is worthy of trial. The use of supports is not always satisfactory. Surgical treatment for fixing the kidney is of permanent value, but do not advise operation unless absolutely indicated. (See Prolapsed Organs, Part I).

To determine the presence of a movable kidney, it is best to have the patient in the dorsal position, the head slightly lowered and the abdominal walls relaxed by flexing the thighs moderately upon the abdomen. Then with the left hand in the lumbar region behind the eleventh and twelfth ribs, and the right hand in the hypochondriac region, the kidney can usually be detected after full inspiration followed by complete expiration; or, have the patient in a standing posture with the body bent slightly forward and the hands placed upon a table, then perform bimanual palpation; or, perform the manipulation in the knee-elbow position. When in this position (knee-elbow), if the kidney has become dislodged, a resonant note will be obtained by percussion over the normal location of the kidney.

---

Cystitis is an inflammation of the mucous membrane of the bladder. Retention of the urine; foreign bodies, such as stones, in the bladder; the use of dirty catheters; exposure to wet and cold; injuries to the bladder and over the pubes; irritations to the sacral nerves; spinal lesions in the dorsal enlargement of the cord; innominate lesions; irritating drugs; enlarged prostate and urethral strictures are the principal causes of cystitis. The disease may be secondary to fevers, infectious diseases and inflammation of adjacent organs. A displaced uterus may produce a chronic irritation of the bladder.

Pathologically, there is hyperemia of the mucous membrane of part or of the whole of the bladder, with redness, congestion and edema. The secretion of mucus that covers the mucous membrane is of a dirty gray color. If the congestion is very extensive, a bursting of the capillaries may take place. In a few cases the neck of the bladder and the urethra, where it passes through the prostate, is involved. In chronic cases the mucous membrane becomes thickened and covered with patches of false membrane. The muscular coat of the bladder becomes hypertrophied and the veins tortuous.

Symptoms.—The onset may be sudden with rigors and fever, but in many cases a frequent desire to micturate will be the first symptom. This is followed by tenderness and pain over the bladder and contiguous parts, loss of appetite, depression and sleeplessness. Tenesmus of the bladder, caused by a spastic condition of its muscles, and a burning along the urethra are usually present. The urine is alkaline in reaction and contains pus, epithelium and blood.

Diagnosis.—The diagnosis is usually easy. Pyelitis causes pains in the lumbar region and along the ureters and there is a frequent desire to urinate. The bladder is not subject to spasms and the urine is of an acid or neutral reaction.

Prognosis.—In many cases the prognosis is favorable, but in cases of long standing and in hypertrophy of the bladder, prognosis must be guarded.

Treatment.—Rest in bed with strict attention to diet is necessary. Milk is the best food and avoid highly seasoned articles and acid foods. The use of plenty of pure water is helpful to dilute the urine, and if necessary the bladder should be washed out carefully. If the case is severe, emptying the bladder several times a day with a catheter will be necessary. Always be careful about the cleansing of the instruments. Warm applications over the pelvic region will be comforting to the patient. Lifting the abdominal viscera from the bladder is of assistance. The patient may be placed in the knee and chest position for this or the usual method employed.

Treatment to the second, third and fourth sacral nerves controls the neck of the bladder, and strong inhibition will generally control the spasms of the sphincter. The fundus of the organ is supplied by sympathetic fibers from the pelvic plexus. Direct treatment over the bladder, if applied carefully, will act on the terminal fibers of the sympathetic. Lesions to the nerves of the sphincter of the bladder oftentimes occur between the fifth lumbar and sacrum, also from a displaced innominate. Such lesions are apt to be found in cases of incontinence of urine. The lesion to the vertebra is usually a lateral one.

Thorough treatment to the genito-urinary center (lower dorsal and upper lumbar) will also be of aid. In males direct treatment of the prostate gland is occasionally important as is also the plexus of nerves at the trigone of the bladder. In treating the prostate gland introduce a finger into the rectum and work about the base of the gland to relax the tissues, and thus remove obstructions of the vascular, lymphatic and nervous structures to the gland. Do not work too much upon the gland itself (commonly once a week or ten days), as it may irritate, but release surrounding edema. Also treat the innervation at the eleventh and twelfth dorsals, fifth lumbar, and first, second and third sacrals. Spreading the ischii will occasionally be beneficial; this tends to release the anterior commissure where it is attached to the symphysis.

Follow the above with a “general treatment” in order to secure a general systemic reaction. This is of value in all infectious disorders.

It is important in young boys to examine the condition of the penis in bladder diseases. The prepuce may become adherent or other irritations may be found that are a source of disturbance to the bladder, or even to the kidneys, on account of the intimate connection of the sympathetic system in this region and the relation of one organ to another.

An irritable bladder is usually due to disorders of nearby tissues, especially the urethra, vagina, uterus and rectum.

Enuresis, exclusive of paralysis, is frequently due to some local mechanical disturbance. Nocturnal enuresis or bed wetting is caused by lower dorsal and lumbar lesions (especially the fifth lumbar), displacements of the innominate, or phimosis, hooded clitoris, contracted meatus, highly acid urine, worms, lack of discipline, etc. The patient is usually neurotic, which demands attention to the neuromuscular system of the entire body. Care of the general health and habits is important. Constipation may be present.

---